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 CSKKKIGHX DEPOSIT, 
 
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PLATE I 
 
 Lichen planus. 
 
 Pagi 81 
 
DISEASES OF THE SKIN 
 
 THEIR PATHOLOGY AND 
 TREATMENT 
 
 BY 
 
 MILTON B. HARTZELL, A.M., M.D., LL.D 
 
 PROFESSOR OF DERMATOLOGY IN THE UNIVERSITY OF PENNSYLVANIA 
 
 51 COLORED PLATES AND 242 CUTS IN THE TEXT 
 
 PHILADELPHIA & LONDON 
 J. B. LIPPINCOTT COMPANY 
 
 1917 
 
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 >Mzs 
 
 COPYRIGHT, 1917, BY J. B. LIPPINCOTT COMPANY 
 
 DEC 19 (317 
 
 Electrotyped and Printed by J. B. Lippincott Company 
 At the Washington Square Press, Philadelphia, U. S. A. 
 
 ©CI.A479589 
 
TO 
 
 THE MEMORY OF MY FATHER 
 
 EZEKIEL HARTZELL, M. D. 
 
 I DEDICATE THIS BOOK 
 
PREFACE 
 
 This treatise, which is based very largely upon the author's own ex- 
 perience as a worker and teacher in this special department of Medicine 
 for more than twenty-five years, has been prepared as a text-book for the 
 student of Medicine, as a practical guide for the general practitioner in 
 the recognition and treatment of diseases of the skin and as a work of 
 reference for the dermatologist. 
 
 In the preparation of the work the author has not only drawn upon his 
 own experience, but, in order to present the views held by the most eminent 
 authorities, he has made liberal use of the standard treatises of other 
 authors, both American and European, and he desires here especially 
 to acknowledge his indebtedness to those two monuments of industry 
 and learning, La Pratique Dermatologique and Mracek's Handbuch 
 der Hautkrankheiten. 
 
 While the author has endeavored to fully present the views held by his 
 co-workers in this very active field of medical research, he has not hesi- 
 tated to express his own when they differed from those generally accepted ; 
 and when he has thus differed it was because he believed his experience 
 justified it. 
 
 A not inconsiderable experience in general medicine extending over 
 some years has especially enabled the author, as he believes, to survey the 
 subject from the view-point of the general practitioner as well as. from 
 that of the specialist, and, keeping the special needs of the former promi- 
 nently in mind, he has endeavored to describe the numerous varied and 
 ever-varying symptoms of cutaneous disease lucidly and concisely, 
 avoiding overelaboration and at the same time omitting nothing of 
 real importance. 
 
 Considerable space has been given to the subjects of etiology and 
 pathology, since a knowledge of these must lie at the foundation of all 
 rational treatment and prophylaxis ; indeed, without such knowledge treat- 
 ment is a mere blind groping in the dark and prophylaxis a vain delusion. 
 In the sections devoted to treatment every effort has been made to 
 include all the remedies and methods of treatment of approved value and 
 especially those which the author's own experience has led him to rely 
 upon. The manner of using local remedies has been gone into at consid- 
 erable length, since success or failure depends quite as much upon the 
 manner of their employment as their selection ; indeed, an indifferent 
 remedy used with intelligence is frequently more efficacious than the best 
 used without attention to apparently unimportant details. 
 
 Recognizing the great aid to be derived from well-made illustrations, 
 liberal use has been made of the author's own large collection of photo- 
 graphs, a considerable number of them color photographs, which represent 
 
vi PREFACE 
 
 cutaneous eruptions with an accuracy and fidelity to nature quite unat- 
 tainable in any other form of illustration. A very considerable number of 
 photomicrographs have been introduced which the author hopes will aid 
 materially in the elucidation of the text devoted to pathology. 
 
 In conclusion the author desires to express his great appreciation of the 
 liberality and unvarying courtesy of the publishers, the J. B. Lippincott 
 Company. 
 
 M. B. H. 
 Philadelphia, October, 1917. 
 
CONTENTS 
 
 Chapter Page 
 
 I. Anatomy i 
 
 II. General Symptomatology 17 
 
 III. General Etiology , 24 
 
 IV. General Pathology 29 
 
 V. General Diagnosis 35 
 
 VI. General Therapeutics 38 
 
 VII. Congestions — Hypercmic 48 
 
 VIII. Inflammations — Exudationes 51 
 
 IX. Inflammations Due to Vegetable Parasites 308 
 
 X. Inflammations Due to Animal Parasites 437 
 
 XI. Hemorrhages — Hemorrhagic 461 
 
 XII. Hypertrophies — Hypertrophic 469 
 
 XIII. Atrophies — Atrophic 520 
 
 XIV. Anomalies of Pigmentation — Anomalic Pigmentationis 530 
 
 XV. New Growths — Neoplasmata 544 
 
 XVI. Neuroses 625 
 
 XVII. Diseases of the Appendages— Morbi Appendicium 634 
 
ILLUSTRATIONS 
 
 PLATES 
 
 PAGE 
 
 I. Lichen planus Frontispiece 
 
 II. Psoriasis 97 
 
 III. Erythematous eczema 119 
 
 IV. Erythematous and vesicular eczema 119 
 
 V. Eczema rubrum 121 
 
 VI. Eczema rubrum with crusts 121 
 
 VII. Eczema rubrum with chronic leg ulcer 121' 
 
 VIII. Squamous and fissured eczema 121 
 
 IX. Eczema of the beard 146 
 
 X. Seborrhceic dermatitis ., 149 
 
 XL Herpes simplex 154 
 
 XII. Chronic pemphigus , 180 
 
 XIII. Raynaud's disease 204 
 
 XIV. Dermatitis factitia 221 
 
 XV. Lupus vulgaris (elbow) 236 
 
 XVI. Initial lesion of syphilis. Maculopapular syphiloderm 268 
 
 XVII. Late squamous syphiloderm of the palm. 270 
 
 XVIII. Ulcerating syphilitic gummata 293 
 
 XIX. Granuloma fungoides 323 
 
 XX. Granuloma fungoides 325 
 
 XXI. Erythematous lupus 325 
 
 XXII. Variola. Varicella 373 
 
 XXIII. Scarlet fever 382 
 
 XXIV. Measles 388 
 
 XXV. Favus of the scalp 398 
 
 XXVI. . Ringworm of the scalp 407 
 
 XXVII. Ringworm of the beard 410 
 
 XXVIII. Ringworm of the thighs. Eczemated ringworm of the toes 412 
 
 XXIX. Deep ringworm 415 
 
 XXX. Scabies . 444 
 
 XXXI. Scabies 444 
 
 XXXII. Purpura simplex 461 
 
 XXXIII. Circumscribed scleroderma 506 
 
 XXXIV. Xanthoma tuberosum 581 
 
 XXXV. Colloid degeneration of the skin , 585 
 
 XXXVI. Epithelioma 598 
 
 XXXVII. Sycosis vulgaris 676 
 
 XXXVIII. Acne vulgaris . 693 
 
 XXXIX. Acne vulgaris 693 
 
 XL. Acne rosacea 702 
 
 TEXT CUTS 
 
 1. Section of the epidermis and upper portion of the corium 2 
 
 2. Cells of the rete mucosum, the so-called " prickle cells " 3 
 
 3. Tactile corpuscles 6 
 
 ix 
 
t ILLUSTRATIONS 
 
 4. Smooth muscles and hair follicles of scalp II 
 
 5. Sweat-gland 12 
 
 6. Spiral portion of sweat-duct in epidermis 13 
 
 7. Erythema multiforme, papular variety 52 
 
 8. Erythema multiforme (erythema iris) 53 
 
 9. Dermographism 59 
 
 10. Urticaria pigmentosa 62 
 
 11. Urticaria pigmentosa 64 
 
 12. Dermatitis exfoliativa 68 
 
 13. Desquamation following recurrent scarlatiniform erythema 74 
 
 14. Prurigo nodularis 81 
 
 15. Lichen planus. Unusually profuse eruption 82 
 
 16. Lichen annularis , 83 
 
 17. Lichen planus discoides 84 
 
 18. Lichen planus. Lines of papules occurring in scratch-marks 85 
 
 19. Lichen planus. Band-like distribution 86 
 
 20. Lichen planus 88 
 
 21. Lichen simplex chronicus (lichenification), thigh, inner surface 92 
 
 22. Pityriasis rubra pilaris 94 
 
 23. Pityriasis rubra pilaris 96 
 
 24. Psoriasis 97 
 
 24a. Psoriasis 100 
 
 25. Psoriasis (recent papule) 102 
 
 26. Pityriasis rosea 114 
 
 27. Eczema craquile , 122 
 
 28. Eczema rubrum, scrotum 126 
 
 29. Vesicular eczema 130 
 
 30. Eczema rubrum, leg 131 
 
 31 . Dermatitis seborrhoeica, sternum 150 
 
 32. Dermatitis seborrhoeica, axilla, 151 
 
 S3. Dermatitis seborrhoeica, lips 152 
 
 34. Herpes simplex facialis 155 
 
 35. Herpes zoster. Unusual location 160 
 
 36. Thoracic herpes zoster (shingles) 161 
 
 2,7. Herpes zoster arsenicalis — lichen planus 162 
 
 38. Herpes zoster. " Ballooned " epithelial cells 164 
 
 39. Pompholyx • 168 
 
 40. Dermatitis herpetiformis. Erythematous and vesicular type 170 
 
 41. Dermatitis herpetiformis, annular patches of vesicles 172 
 
 42. Dermatitis herpetiformis, circinate bullous type (pemphigus circinatus) . . 173 
 
 43. Dermatitis herpetiformis (herpes gestationis) 174 
 
 44. Chronic pemphigus 181 
 
 45. Pemphigus vulgaris 182 
 
 46. Pemphigus vegetans, negress 184 
 
 47. Bleb of pemphigus 186 
 
 48. Bleb of pemphigus vegetans 187 
 
 49. Pemphigus vegetans. Section of vegetation from groin 188 
 
 50. Impetigo contagiosa 192 
 
 51. Impetigo contagiosa circinata • 193 
 
 52. Bockhardt's impetigo J 94 
 
 53. Dermatitis repens 198 
 
ILLUSTRATIONS xi 
 
 54. Dermatitis vegetans 199 
 
 55. Infectious multiple gangrene — forearm \ 202 
 
 56. Bacilli in multiple gangrene of skin 203 
 
 57. Dermatitis venenata 211 
 
 58. Dermatitis venenata 213 
 
 59. Arsenical keratosis 215 
 
 60. Arsenical pigmentation 216 
 
 61. Bromide eruption (bromoderma) leg resembling late pustular syphiloderm 217 
 
 62. Bromide eruption (bromoderma) 218 
 
 63. Dermatitis factitia 222 
 
 64. Granuloma pyogenicum, thumb 235 
 
 65. Granuloma pyogenicum 236 
 
 6 ' > Lupus vulgaris 237 
 
 68. Lupus vulgaris, thigh 238 
 
 9 [Lupus vulgaris 239 
 
 71. Lupus vulgaris, forearm „ , 240 
 
 J2. Lupus hypertrophicus 240 
 
 72- Lupus vulgaris 242 
 
 74. Tuberculosis verrucosa cutis, back of hand 249 
 
 75. Tuberculosis verrucosa cutis (negro) . ., 250 
 
 76. Tuberculosis verrucosa cutis 252 
 
 yj. Papulo-necrotic tuberculide 254 
 
 78. Erythema induratum, with papulo-necrotic tuberculide 258 
 
 79. Lichen scrofulosorum „ 262 
 
 80. Multiple benign sarcoid 266 
 
 g ' >• Initial lesion of syphilis 268 
 
 83. Erythematous syphiloderm 271 
 
 84. Papular syphiloderm 272 
 
 85. Circinate papular syphiloderm 273 
 
 86. Annulo-papular syphiloderm (secondary) 274 
 
 87. Sycosiform syphiloderm 275 
 
 88. Miliary papular and pustular syphiloderm 2j6 
 
 89. Pustular syphiloderm 279 
 
 90. Miliary pustular syphiloderm 280 
 
 91. Miliary pustular syphiloderm 281 
 
 92. Varioliform syphiloderm 282 
 
 93. Pustular syphiloderm 283 
 
 94. Large papulo-pustular syphiloderm 284 
 
 95. Flat condylomata 287 
 
 96. Nodular syphiloderm 288 
 
 97. Ulcerating nodular syphiloderm 289 
 
 98. Nodular syphiloderm 290 
 
 99. Nodular syphiloderm (late) 291 
 
 100. Circinate squamous syphiloderm 291 
 
 101. Squamous syphiloderm (late) 292 
 
 102. Multiple ulcerating syphilitic gummata 294 
 
 103. Vegetating syphilitic papule 299 
 
 104. Lepra tuberosa 310 
 
 105. Lepra, maculo-ansesthetic 313 
 
 106. Macular leprosy 314 
 
xii ILLUSTRATIONS 
 
 107. Lepra, maculo-anaesthetic 315 
 
 108. Anaesthetic leprosy; contraction of fingers, so-called leper claw 316 
 
 109. Lepra ansesthetica 317 
 
 no. Bacillus leprae 319 
 
 in. Granuloma fungoides , 324 
 
 112. Tumor formation with ulceration; total loss of hair of scalp, brows and 
 
 beard 325 
 
 1 13. Blastomycosis cutis 328 
 
 1 14. Blastomycosis cutis 329 
 
 115. Blastomycosis cutis, blastomyces 330 
 
 116. Blastomycosis cutis . . . 330 
 
 117. Blastomycosis cutis 331 
 
 1 18. Actinomycosis ^37 
 
 119. Oriental sore 345 
 
 120. Rhinoscleroma 356 
 
 121. Lupus erythematosus. Mild type 358 
 
 122. Lupus erythematosus , 359 
 
 123. Lupus erythematosus, scalp 360 
 
 124. Lupus erythematosus 364 
 
 125. Pellagra 367 
 
 126. Pellagra 368 
 
 127. Pellagrous dermatitis 370 
 
 128. From smallpox 374 
 
 129. Varicella 395 
 
 130. Favus 400 
 
 131. Favus. Achorion Schonleinii 402 
 
 132. Favus 403 
 
 133. Ringworm of the scalp 407 
 
 134. Ringworm, scalp. Trichophytosis capitis 408 
 
 135. Ringworm of the beard 410 
 
 136. Ringworm. Trichophytosis corporis 412 
 
 137. Ringworm. Infection from cat 413 
 
 138. Ringworm of the body 414 
 
 139. Tinea cruris (ringworm of the thigh) 415 
 
 140. Ringworm of the axilla 416 
 
 141. Deep ringworm 417 
 
 142. Ringworm of the scalp 418 
 
 143. Ringworm of the scalp 419 
 
 144. Epidermophyton inguinale 422 
 
 145. Tinea cruris 423 
 
 146. Trichophytosis 4^3 
 
 147. Deep trichophytosis 4 2 4 
 
 148. Trichophytosis profunda 4 2 5 
 
 149. Tinea imbricata 43 2 
 
 150. Mycelia in tinea imbricata 433 
 
 151. Pediculus capitis 437 
 
 152. Ovum pediculus capitis 438 
 
 153. Pediculus corporis 439 
 
 154. Pediculosis corporis 440 
 
 155. Pediculus pubis 44^ 
 
 1 56. Scabies 445 
 
 1 57. Acarus scabiei 446 
 
ILLUSTRATIONS xiii 
 
 158. Burrow of scabies 447 
 
 159. Larva migrans 459 
 
 160. Keratosis senilis — epithelioma 472 
 
 161. Keratosis senilis 473 
 
 162. Keratosis pilaris 475 
 
 163. Keratosis follicularis (Darier's disease) 478 
 
 164. Keratosis follicularis (Darier's disease) 479 
 
 165. Darier's disease (keratosis follicularis) 480 
 
 166. Hereditary keratosis of the palms and soles 483 
 
 167. Keratosis of the soles (following eczema) 484 
 
 168. Ichthyosis simplex 494 
 
 169. Ichthyosis • 495 
 
 170. Verrucae digitatae 499 
 
 171. Verrucae planar 500 
 
 172. Circumscribed scleroderma (morphoea) 507 
 
 173. Cutis verticis gyrata 519 
 
 174. Dermatitis chronica atrophicans 521 
 
 175. Vitiligo 534 
 
 176. Vitiligo, following psoriasis 536 
 
 177. Tinea versicolor 540 
 
 178. Microsporon furfur 542 
 
 179. Epithelioma (molluscum) contagiosum 545 
 
 180. Epithelioma (molluscum) contagiosum 546 
 
 181. Epithelioma (molluscum) contagiosum 547 
 
 182. Epithelioma (molluscum) contagiosum. Section of a two-lobed tucsior... 548 
 
 183. Epithelioma (molluscum) contagiosum 549 
 
 184. " Molluscum bodies " 550 
 
 185. Epithelioma (molluscum) contagiosum 550 
 
 186. Trichoepithelioma (benign cystic epithelioma) 552 
 
 187. Trichoepithelioma • 553 
 
 188. Syringocystoma . . . 554 
 
 189. So-called syringocystoma 555 
 
 190. Adenoma sebaceum 558 
 
 191. Lymphangioma 560 
 
 192. Lymphangioma circumscriptum 561 
 
 193. Fibroma molluscum 563 
 
 194. Keloid 566 
 
 195. Keloid (negro) 567 
 
 196. Hypertrophic scar (scar keloid) following a burn , 568 
 
 197. Keloid, back (followed burn with a cupping-glass) 569 
 
 198. Granuloma annulare 572 
 
 199. Granuloma annulare 573 
 
 200. Lipoma 576 
 
 201. Xanthoma tuberosum 583 
 
 202. Colloid degeneration of the skin . . . 585 
 
 203. Naevus vascularis occupying the hand, forearm and a part of the upper 
 
 arm 588 
 
 204. Naevus pigmentosus 593 
 
 205. Naevus pigmentosus 593 
 
 206. Hairy naevus (naevus pilosus) 594 
 
 207. Naevus unius lateris 595 
 
 208. Flat, smooth pigmented naevus 596 
 
xiv ILLUSTRATIONS 
 
 209. Naevus unius lateris 597 
 
 210. Epithelioma ( rodent ulcer) 599 
 
 211. MorphcEa-like epithelioma 600 
 
 212. Morphcea-like epithelioma 601 
 
 213. Epithelioma baso-cellulare 605 
 
 214. Paget's disease 608 
 
 215. Paget's disease of the buttocks 610 
 
 216. Paget's disease of the breast 611 
 
 217. Idiopathic multiple hemorrhagic sarcoma 619 
 
 218. Multiple pigmented hemorrhagic sarcoma 620 
 
 219. Leukaemia cutis 622 
 
 220. Leukaemia cutis 623 
 
 221. Onychogryphosis 635 
 
 222. Syphilis of the nails 638 
 
 223. Onychomycosis, ringworm of the nails 640 
 
 224. Ringworm of the nail, thumb 640 
 
 225. Ringworm of the nails 641 
 
 226. Trichorrhexis nodosa 647 
 
 227. Monilethrix 649 
 
 228. Monilethrix 650 
 
 229. Lepothrix, axillary hair 653 
 
 230. Lepothrix 654 
 
 231. Alopecia areata (in brothers) 663 
 
 232. Ringed hair 671 
 
 233. Dermatitis papillaris capillitii (acne keloid) 674 
 
 234. Dermatitis papillaris capillitii 675 
 
 235. Sycosis vulgaris 677 
 
 236. Lupoid sycosis 678 
 
 237. Comedo 688 
 
 238. Acne vulgaris 694 
 
 239. Acne vulgaris 697 
 
 240. Paraffin acne 706 
 
 241. Acne varioliformis . 707 
 
 242. Hydrocystoma 720 
 
DISEASES OF THE SKIN 
 
 ANATOMY AND PHYSIOLOGY OF THE SKIN 
 
 CHAPTER I 
 
 ANATOMY 
 
 The skin is an elastic membrane of variable thickness covering 
 the entire body. It varies in color from the pinkish-white of the Euro- 
 pean through various shades of brown to the black of the African, 
 the variations in color depending chiefly upon the amount of brown 
 pigment present. Even in the white races there is considerable pig- 
 mentation, which is more marked in particular localities, such as the 
 axillae, the areola of the nipple, the external genitalia, and the eyelids. 
 It is not perfectly smooth, but is marked by numerous furrows and 
 ridges which divide its surface into small lozenge-shaped areas, or, 
 upon the palms and soles, produce peculiar patterns, each individual 
 having his own special pattern. About the joints where the skin is 
 subject to extensive movement these are much more marked than in 
 other situations. It is to be regarded not simply as a protective 
 membrane, but as an organ of great complexity, abundantly pro- 
 vided with blood-vessels, lymphatics, nerves, having certain append- 
 ages, such as the sweat- and sebaceous glands, the hair and nails, 
 and having certain functions the proper performance of which is 
 more or less necessary, not only to the maintenance of the health 
 of the skin itself, but to the health of the individual. It is divided 
 into three parts, which are, beginning with the surface, the epidermis, 
 the corium, and the subcutaneous connective-tissue ; the two former, 
 while closely united, are yet quite distinct the one from the other 
 in structure and origin, the epidermis being derived from the ecto- 
 derm, while the corium is of mesoblastic origin (Fig. i). 
 
 The epidermis is composed of four layers of epithelial cells, more 
 or less distinct, which are, proceeding from without inwards, the corne- 
 ous layer or stratum corneum, the clear layer or stratum lucidum, the 
 granular layer or stratum granulosum, and the stratum germinativum, 
 also known as the rete mucosum, the rete Malpighii, or the prickle-cell 
 layer. This last layer is the actively growing part of the epidermis 
 and is the most important portion of it. 
 
 The stratum corneum or horny layer (see Fig. I, s. c.) is of variable 
 thickness. In certain regions, such as the palms and soles, it is very 
 much thicker than upon the trunk. According to locality, it is com- 
 posed of a few or many layers of flat, quite elongate, translucent cells, of 
 horny material from which the nuclei have disappeared, although here and 
 
 1 
 
2 DISEASES OF THE SKIN 
 
 there remains of a nucleus may be perceived in some of the cells of the 
 lowest layer. The cells of this layer are being constantly exfoliated 
 and as constantly renewed from below. Its function is chiefly, if 
 not exclusively, a protective one, protecting the soft mucous layer 
 which lies beneath it. 
 
 Immediately beneath the stratum corneum are two or three rows 
 of flat, clear cells — the stratum lucidum — which in sections of the 
 skin appear as a narrow, bright band separating the stratum corneum 
 above from the stratum granulosum below. This layer is practically 
 a part of the corneous layer. 
 
 Fig. i. — Section of the epidermis and upper portion of the corium. 5. c, stratum corneum, horny- 
 layer; 5./., stratum lucidum, clear layer; s. g., stratum granulosum, granular layer; r.m., rete 
 mucosum; c, corium; s.d., upper portion of sweat-duct. 
 
 The granular layer, which in stained sections (see Fig. i) of the 
 skin is one of the most conspicuous layers of the epidermis, consists 
 of two or three rows of elongated oval cells lying horizontally, con- 
 taining rather ill-defined, imperfectly staining nuclei, in the proto- 
 plasm of which are numerous granules. The nature of these granules 
 is still a matter of some debate. It is supposed by some investigators 
 that there are two substances — eleidin, which exists as, droplets of 
 fluid in the cell, and keratohyalin, a solid substance exhibiting the 
 reaction of hyaline material. It seems most likely that there is a 
 
ANATOMY 3 
 
 single substance, keratohyalin, which is fluid or solid according to 
 the age of the cell, and that the appearance of this material in the 
 cell is a part of the process of cornification. 
 
 The stratum germinativum, or, as it is more commonly called, 
 the rete mucosum (Fig. i), is the thickest of the layers of the epi- 
 dermis and is composed of oval, polygonal, and columnar cells with 
 large round nuclei, the oval cells being situated in the upper part, 
 the polygonal in the middle and lower portions, while the columnar 
 cells form a single row, the basal-cell layer, standing more or less 
 at right angles to the undulatory line separating the epidermis from 
 the papillary layer of the corium. The cells of this portion of the 
 epidermis are connected with one another by slender protoplasmic 
 
 Fig. 2. — Cells of the rete mucosum, the so-called "pnckle-cells." Note fine intercellular filaments. 
 
 bridges (Fig. 2) which give them, when seen in profile, the appear- 
 ance of being covered with small spines like a burr, and for this 
 reason they are sometimes spoken of as prickle-cells. The cells of 
 this layer contain numerous fine fibres running in various directions 
 in those centrally situated, but in the columnar cells they pursue a 
 course parallel with the long axis of the cell. These fibres, which 
 were designated protoplasmic fibres by Kromayer, are supposed by 
 Weidenreich to form the intercellular bridges which connect the cells 
 of this layer. Between the cells of the basal layer, starting at the 
 junction of the epidermis with the corium, are numerous fine spiral 
 fibrils. These fibres, which require special methods of staining to 
 demonstrate them, were first described by Herxheimer and are con- 
 sequently known as Herxheimer's spirals. Although most abundant 
 
4 DISEASES OF THE SKIN 
 
 in the lowest parts of the epidermis, they may, under certain patho- 
 logical conditions, extend up to and within the horny layer, accord- 
 ing to Eddowes. The nature of these spirals is somewhat uncertain ; 
 Herxheimer thought they represented juice channels; Eddowes re- 
 gards them as fibrin, while Kromayer thinks he has demonstrated their 
 protoplasmic nature. 
 
 The corium (Fig. i, c), derma, or true skin, as it is sometimes called, 
 lies immediately below and in contact with the epidermis, sharply 
 separated from it by an undulatory line. It is composed of coarse 
 bundles of interlacing fibrous tissue, collagen, surrounded by finer 
 elastic fibres composed of elastin, and a moderate number of con- 
 nective-tissue cells, most abundant in the neighborhood of the larger 
 vessels. It contains blood-vessels in abundance, nerves, lymphatics, 
 hair follicles, sebaceous glands, and muscles. It is divided into two 
 parts — the pars papillaris, the portion immediately underlying the 
 epidermis, and the pars reticularis, the deeper portion — these two not 
 being separated by any sharp line of division, but passing insensibly 
 into each other. The pars papillaris is made up of numerous small 
 nipple-like elevations which fit into corresponding depressions on the 
 under surface of the rete mucosum. Most of these papillse are provided 
 with blood-vessels running parallel with their long axis and termi- 
 nating in capillary loops. A lesser number also contain nerve-endings 
 in the shape of tactile corpuscles. The number, size, and arrange- 
 ment of these papillse vary greatly according to location. Upon the 
 palms and soles they are arranged in curving lines, while upon the 
 finger-tips they form oval patterns of concentric lines which, owing to 
 the fact that no two individuals have precisely the same pattern, 
 are employed under certain conditions for purposes of identification. 
 
 In the pars reticularis the bundles of fibrous tissue are coarser 
 than in the papillary portion and form a looser mesh-work. Imme- 
 diately beneath the pars reticularis, and practically forming a part 
 of it, is the subcutaneous connective-tissue or stratum subcutaneum. 
 In this portion of the derma the meshes formed by the fibrous tissue 
 are large and usually contain a considerable number of fat-lobules. 
 The sweat- or coil-glands, some of the hair papillse, and the Pacinian 
 corpuscles are found in this portion of the derma. 
 
 In those regions where the fat is abundant it forms the pannicu- 
 lus adiposus. 
 
 The skin contains a brown pigment, melanin, which in the white 
 races is much more abundant in some regions than in others, such as 
 the genitalia of both sexes and the aieola of the nipple in women. 
 It occurs as yellowish or brown granules, which in white-skinned 
 individuals are found almost exclusively in the lowest layer of cells 
 of the rete, but in the negro are present in all parts of the rete up to 
 the stratum corneum. Scattered pigmented cells are also present in 
 the upper portion of the corium. 
 
 Blood-vessels. — The skin contains numerous blood-vessels which form 
 
ANATOMY 5 
 
 two horizontal plexuses, a superficial and a deep one. The former, lying 
 just beneath the papillary layer of the corium, sends minute capillary loops 
 to the papillae, while the latter, composed of much larger vessels and 
 lying much deeper in the subcutaneous tissue, supplies the sebaceous 
 and sweat-glands and the hair papillae. The epidermis is without 
 blood-vessels. 
 
 The lymphatic circulation of the skin consists of an extensive 
 arrangement of channels without special walls, the so-called juice 
 spaces of Unna, and lymphatic vessels lined with endothelium. The 
 juice spaces are found between the cells of the rete mucosum, in 
 the papillae, about the excretory ducts of the sweat-glands, the seba- 
 ceous glands, hair follicles, about the fibres of the corium, and the 
 muscles. The lymphatic vessels form plexuses corresponding in a 
 general way with the blood-vessel plexuses. The lymph flows from 
 the apices of the papillae into the epidermis and returns by way of 
 the interpapillary prolongations of the rete. 
 
 Nerves. — The skin contains many nerves both of the medullated and 
 non-medullated varieties. The trunks which supply the skin accompany, 
 for the most part, the larger vessels situated in the subcutaneous tissue, 
 and give off branches which ascend through the corium, supplying in 
 their course upwards the various glands, muscles, and hair papillae 
 found in this structure, and forming a fine network of nerve-fibres 
 immediately beneath the epidermis, from which fine fibrils penetrate 
 the rete. The medullated nerve-fibres end in certain peculiar corpuscles, 
 of which there are three principal varieties — the corpuscles of Krause, 
 the corpuscles of Meissner, and the Pacinian corpuscles or corpuscles 
 of Vater. 
 
 The corpuscles of Krause (Kolbenkorperchen) are globular or 
 ovoid bodies surrounded by a connective-tissue capsule having two 
 or three layers composed of flat cells and containing an inner bulb 
 penetrated by a nerve fibril or fibrils which have lost their medulla. 
 These bodies are found on the glans penis, the clitoris, the inner 
 surface of the prepuce, the mucous membrane of the lips, the tongue, 
 and conjunctiva of the lids. 
 
 The corpuscles of Meissner and Wagner, tactile corpuscles (Fig. 3) 
 (Tastkorperchen), are oval bodies surrounded by a thin, occasionally 
 laminated capsule, the surface of which is transversely striated. These 
 bodies receive medullated nerves, which on entering the corpuscle 
 lose their medulla and divide up into numerous fine branches which 
 present irregular or spindle-shaped thickenings or swellings, and which 
 form an irregular network within the corpuscle. They are found in 
 the papillae of the corium, most, abundantly on the palms of the 
 hands and soles of the feet, each papilla containing usually one, but 
 sometimes several, corpuscles. 
 
 The Pacinian corpuscles, or corpuscles of Vater, are the largest of 
 the corpuscular nerve-endings, being visible to the naked eye. They 
 are ovoid or pear-shaped bodies, found most abundantly in the skin 
 
6 
 
 DISEASES OF THE SKIN 
 
 of the finger-tips, but are present also upon the palms and soles, 
 the backs of the hands and feet, upon the upper extremities, the 
 nipples, and the genitalia. They are situated in the deepest part of 
 the reticular portion of the corium and in the subcutaneous connec- 
 tive tissue. Like the other nerve corpuscles, they are surrounded by 
 a laminated capsule composed of many concentric layers of connec- 
 tive tissue, within which is a central core containing the terminal 
 
 nerve-fibre, which loses its medulla on 
 passing from the capsule into the core. 
 The terminal nerve-fibre passes through 
 the centre of the corpuscle, in the 
 direction of its long axis, terminating 
 at the distal pole in a club-shaped 
 thickening, or, what is less frequent, 
 dividing up into two or three small 
 branches with slightly thickened ends. 
 Each corpuscle is supplied with blood 
 by two or three small vessels which 
 enter it usually at the poles and divide 
 into a fine vascular network under the 
 external layer of the capsule. 
 
 Still another form of nerve end- 
 organ, situated in the lowest portion 
 of the corium and in the subcutaneous 
 tissue, has been recently described by 
 Ruffini. These are spindle-shaped 
 bodies composed of connective tissue 
 and elastic fibres running in the direc- 
 tion of their long axis. 
 
 Each of the corpuscles is provided 
 with a single nerve branch which enters 
 at the side, or, less frequently, at the 
 end, and divides up within the connec- 
 tive tissue to form an anastomosing 
 network of fine fibres upon which are 
 numerous swellings (Rabl, Mracek's 
 Handbook). The blood supply is ob- 
 tained from a rich capillary network which covers the surface but does 
 not penetrate the interior of the organ. 
 
 As "touch-cells," Merkel has described certain oval nucleated cells 
 found in small numbers only in the epidermis and upper portion of 
 the corium ; these he regards as nerve-cells which are connected with 
 nerve-fibres. Krause, however, does not consider them as in any 
 way connected with the nerves, but as epidermis cells which have 
 undergone mitosis. They are found in those localities where tactile 
 corpuscles are few, as the skin of the abdomen, although Kolliker found 
 them upon the finger-tips and upon the soles. The real nature of these 
 cells is still a subject of debate. 
 
 Fig. 3. — Tactile corpuscles. 
 
ANATOMY 7 
 
 Muscle. — Both striped and unstriped muscles are present in the skin. 
 The former are found chiefly in the face and neck as scanty fibres which, 
 taking their origin from more deeply-seated muscles, are distributed 
 to the lips, nose, eyebrows, and chin. These are analogous to the 
 muscles which exist in certain of the lower animals by which exten- 
 sive movements of the skin may be produced. 
 
 The unstriped or smooth muscles exist as fasciculi associated with 
 the hair and glands or as membranous expansions in the scrotum, 
 forming the tunica dartos, in the areola of the breast, and in the 
 nipple, the last arranged as circular bundles. The unstriped muscles 
 connected with the hair follicles, named arrectores pilorum, usually 
 arise by several small fasciculi from the papillary layer of the corium, 
 and are inserted in the side of the hair follicles, which they join at an 
 acute angle about the level of the hair papilla, including in the angle 
 thus formed a sebaceous gland. Within and around these muscles 
 are numerous elastic fibres by which they are connected with the 
 fibrous bundles of the corium and subcutaneous connective tissue. 
 Contraction of the arrectores pilorum causes that peculiar condition of 
 the skin known as cutis anserina, or "goose skin," and the erection 
 of the hair such as is seen in some of the lower animals when enraged. 
 Owing to their situation in the angle between the muscle and the 
 hair follicle, the sebaceous glands are compressed by the arrectores, 
 which thus serve as expulsors of the sebum ; and they also serve 
 by their contraction and relaxation to regulate the amount of blood 
 in the vessels of the corium. 
 
 Pigment. — The color of the skin, while due in some part to other 
 causes, depends chiefly upon the presence of a yellowish-brown granular 
 pigment, melanin, contained in the cells of the epidermis, especially 
 in those of the lowest layers of the rete, although in the dark races 
 and in certain pathological conditions pigment-bearing cells are found 
 in the upper part of the corium as well. In the white races the 
 pigmentation of the skin is not uniform, but varies considerably in 
 different parts of the body, being most marked in the axillae, in the 
 nipple and its areola, the external genitalia, and about the anus. Ac- 
 cording to most authors, pigment granules are never present in the 
 cells of the horny layer of the epidermis, even in the dark races, there 
 being only a slight diffuse discoloration of these ; but Rabl found 
 them in the corneous cells of the nipple of a nursing woman. In 
 fair skins it is found almost exclusively in the basal cells of the rete 
 mucosum deposited about the nucleus, but in dark skins several rows 
 of cells contain pigment scattered throughout the body of the cell, 
 this pigmentary deposit showing as a dark-brown undulatory line 
 following the contour of the papillary layer of the corium. The origin 
 of melanin is still a matter of debate. Some investigators (Aeby, 
 Riehl, Ehrmann) maintain that it is carried from the corium and 
 subcutaneous tissues to the cells of the epidermis by certain pigment- 
 containing cells, chromatophores, while others (Jarisch, Schwalbe) 
 believe that the pigment is formed in the epidermal cells themselves. 
 
8 DISEASES OF THE SKIN, 
 
 The experiments of Karg, while not conclusive, would seem to favor 
 the former view. This investigator, who transplanted white skin 
 into the skin of the negro, found large branched cells at the boundary 
 line between the corium and the epidermis, which, sending long proc- 
 esses upward into the spaces between the epidermal cells, transferred 
 pigment to them so that at the end of six weeks the transformation 
 of the white into black skin was complete. The function of this pig- 
 ment is without doubt to protect the skin from the injurious effects 
 of the actinic rays of light, and it is greatly increased in quantity in 
 parts exposed for any length of time to the rays of the sun, of the 
 electric arc light, and to the X-rays. 
 
 Hair is present upon all parts of the skin except the palms and 
 soles, the dorsal surface of the terminal phalanges of the ringers 
 and toes, and the penis. There are three quite distinct varieties: 
 long, soft hair, such as is found upon the scalp, in the axilla, and 
 upon the pubes ; short, stiff hair found in the eyebrows, eyelashes 
 (cilia), in the nostrils (vibrissas), and in the external auditory meatus; 
 and soft, fine, for the most part unpigmented, hair or down designated 
 lanugo, present upon the face outside of the bearded region, the 
 trunk, and extremities. 
 
 The hair is contained in tube-like depressions extending deeply into 
 the corium and subcutaneous tissues, lined with epithelium, known 
 as hair follicles, each follicle containing, as a rule, one hair, but not 
 infrequently two, three, or more. The portion which projects be- 
 yond the mouth of the follicle is known as the shaft, while that within 
 the follicle is called the root, terminating in a swollen extremity, the 
 hair bulb, which surrounds the hair papilla at the bottom of the fol- 
 licle. It is composed of three parts — the cortex, the cuticle, and the 
 medulla, this last being absent in the lanugo hair and in the free 
 extremity of the long hair. The cortex, which forms the principal 
 part of the hair, is composed of slender bundles of long spindle-shaped 
 horny cells, usually without nuclei, whose long axis corresponds with 
 that of the hair, frequently containing granules of dark pigment. 
 
 In the lower portion of the root the cells of the cortex are less 
 elongate, contain nuclei, and are softer, owing to less complete corni- 
 fication, and, as one approaches the bulb, the cells become oval or 
 polygonal, resembling those of the rete mucosum of the epidermis. 
 
 The cuticle of the hair (cuticula pili), which covers it, consists 
 of thin, translucent, irregular quadrilateral cells without nuclei, which 
 overlap one another like tiles on a roof, their free borders projecting 
 at a slight angle and directed toward the end of the hair. 
 
 A medulla is present, as a rule, only in the thicker hairs, being 
 absent in the foetal and lanugo hairs, and it is occasionally absent 
 even in the hair of the scalp. It consists of clear, nucleated cubical 
 cells contained in a central canal, and extends from the bulb to within 
 a short distance of the free end, where it disappears. These cells 
 contain a few granules of keratohyalin and of pigment and numerous 
 air vesicles which give to the marrow, black by transmitted light, 
 
ANATOMY 9 
 
 a lustrous white appearance when viewed by reflected light. In the 
 upper portion of the hair the cells of the medulla undergo atrophy, 
 the nuclei disappear, and air vesicles appear between the cells as 
 well as within them. 
 
 The hair follicle, in which the hair is contained, may be regarded 
 as an invagination of the epidermis into the corium. It is a narrow 
 tube composed of connective tissue lined with epithelium, with a 
 funnel-shaped mouth, slightly constricted some distance below the 
 external opening at the point where the sebaceous-gland duct opens 
 into it, with a bulbous expansion at the bottom into which projects 
 the hair papilla. The connective-tissue portion of the follicle is de- 
 rived from the corium and consists of two layers — an external layer 
 in which the fibres run parallel with the long axis of the follicle, and 
 an internal one in which the fibres are arranged circularly around it 
 and contain numerous rod-shaped nuclei. In the lower half of the 
 follicle the inner fibrous layer is separated from the epithelial lining 
 by a thin, transparent membrane, the vitreous membrane, which in- 
 creases in thickness as the bottom of the follicle is approached, then 
 becomes thinner until it disappears completely at the base of the 
 papilla. The internal surface of this membrane, or the one turned 
 toward the epithelial lining of the follicle, presents numerous trans- 
 verse ridges or furrows which fit into corresponding depressions and 
 elevations in the basal layer of the epithelial cells. 
 
 The epithelial lining of the follicle is continuous with the epidermis, 
 and down to the neck of the follicle, the point where the sebaceous 
 glands open into it, is identical in structure with it, but at this point 
 the stratum corneum and the stratum granulosum disappear. It is 
 divided into two layers or sheaths, the external root-sheath and the 
 internal root-sheath. The external root-sheath is a continuation of 
 the rete Malpighii of the epidermis and is composed of nucleated polyg- 
 onal cells resembling the cells of that portion of the epidermis. Its 
 thickness diminishes as the bottom of the follicle is approached until, 
 at the base of the papilla, it may contain but a single row of cells. 
 Unna has proposed to call this the "prickle-cell layer of the hair 
 follicle" instead of external root-sheath. 
 
 The inner root-sheath, closely connected with the external sheath, 
 extends from the neck of the follicle to the neck of the hair papilla, 
 and is composed of three layers of cells more or less distinct — an 
 outside layer, the layer of Henle, consisting of a single row of polyg- 
 onal nucleated cells ; a middle layer, the layer of Huxley, in which 
 the cells are also polygonal and contain granules of keratohyalin ; 
 and an inner layer, the cuticle of the follicle, consisting of elongate 
 cells which have their long axes transverse to the axis of the follicle, 
 and which, as they approach the follicular neck, become more or less 
 oblique and interlock with the cells of the cuticle of the hair shaft. 
 The cells which compose the several layers of the inner root-sheath 
 ur.dergo cornification as they near the mouth of the follicle, become 
 mo-e elongate, and lose their nuclei. 
 
10 DISEASES OF THE SKIN 
 
 The papilla which occupies the bottom of the follicle is a pear- 
 shaped projection composed of connective-tissue fibres from which 
 the hair is produced, the medulla growing from the top, while the 
 cortex of the shaft is produced by the sides. According to Rabl, 
 hairs which show a strongly growing medulla are seated upon papillae 
 which have pointed tops, while the lanugo and hair in which the 
 growth of the medulla has come to a standstill are found on papillae 
 with rounded tops. 
 
 The follicles may occur singly or in small groups, the latter being 
 the usual arrangement upon the scalp. They are never placed at right 
 angles to the skin, but more or less obliquely, extending to a depth 
 varying from 2 to 7 mm., in the case of the strong hairs, down into 
 the subcutaneous tissue, while the lanugo hair does not reach below 
 the corium. 
 
 Sebaceous Glands. — All hair follicles, practically without exception, 
 are provided with glands, known as sebaceous glands, which secrete a 
 fatty substance, the sebum, which is discharged into the follicle, or, in some 
 instances, directly upon the skin, and serves to lubricate the hair and the 
 skin. The number occurring within each follicle varies from two to six 
 or eight. 
 
 They occur in several forms, the simplest being a rather short 
 pyriform tube lined with epithelium, while those connected with the 
 follicles of well-developed hairs, such as the hairs of the scalp, are 
 racemose glands with a variable number of lobules, and a duct through 
 which the sebum is discharged into the follicle some distance below 
 its mouth. In the case of the lanugo hairs, the gland is often quite 
 as large and well developed as the follicle, the hair occupying the 
 excretory duct of the gland which opens directly upon the surface. 
 They are provided with a connective-tissue covering derived from 
 the corium, which is lined with a thin membrane, the membrana pro- 
 pria. The lobules have no lumen, but are filled with epithelial cells, 
 the most external layer of which, cubical in shape, with a round or 
 oval nucleus and granular contents, are seated upon the membrana 
 propria. Those occupying the more central part of the lobule are 
 polygonal in shape and contain a clear protoplasm in which are minute 
 drops of fat, the amount of fat increasing as the centre of the lobules 
 is approached. Among the largest and most complex of these glands 
 are those found upon the nose ; they are frequently quite large and 
 contain many lobules. The ducts are lined with several layers of epi- 
 thelium which are continuous with the rete mucosum lining the mouth 
 of the follicle (Fig. 4). 
 
 While occurring for the most part as appendages to the follicles, 
 they are also found in regions where hairs do not exist, such as the 
 border of the lips, the inner surface of the prepuce, the glans penis, 
 and the nipple and its areola; these discharge their secretion directly upon 
 the cutaneous surface. 
 
 The largest glands are found in the free borders of the eyelids 
 
ANATOMY 
 
 11 
 
 and are designated by a special name, the Meibomian glands. The 
 sebaceous glands found on the glans penis and on the inner surface 
 of the prepuce are known as Tysonian glands. 
 
 Sweat-glands. — In addition to the sebaceous glands the skin contains 
 another form of gland, known variously as coil-glands, sweat-glands, or 
 sudoriparous glands (glandulse sudoriparse). These are found in great 
 
 Fig. 4. — Smooth muscles and hair follicles of scalp. 
 
 numbers in the meshes of the reticular portion of the corium and in the 
 subcutaneous connective tissue. 
 
 The glands, which are globular in shape, are made up of coiled 
 tubules surrounded by an external layer of connective tissue and elas- 
 tic fibres the inner surface of which forms the membrana propria, 
 and an inner layer of smooth muscle fibres upon which is seated a 
 single layer of cylindrical epithelial cells. There are two kinds of coil- 
 
12 
 
 DISEASES OF THE SKIN 
 
 glands, distinguished from one another chiefly by their size, but also 
 by slight differences in structure. The large glands are found in the 
 axilla, the areola of the nipple, around the anus, and in the external 
 auditory meatus, the largest in the first-named situation, where they 
 form an almost continuous mass. 
 
 Unlike the small glands in which the lumen of the tubules is of 
 fairly uniform size, the large glands show constrictions and dilatations 
 and those of the axillae short tubular branches with blind ends. 
 
 The glands which occur in the lids, which are also known as the 
 glands of Moll, are so modified in shape that they present a spiral 
 
 FlG. 5. — Sweat-gland. 
 
 arrangement instead of a coil, and they empty into the hair follicles 
 instead of upon the surface, unlike the other coil-glands (Figs. 5 and 6). 
 The excretory duct is smaller in diameter than the secreting tubules 
 of the gland. It is lined by two rows of cubical or cylindrical epi- 
 thelial cells, the inner row of which is covered by a delicate membrane, 
 the cuticula, and in the corium is surrounded by a continuation of the 
 membrana propria of the gland and a thin layer of connective tissue. 
 Upon entering the epidermis, which it always does at an interpapillary 
 depression, it loses its membrana propria and connective-tissue cover- 
 ing, retaining only the epithelial lining in which the cells become 
 flatter as the surface of the epidermis is approached. In the corium 
 the duct is straight, or sometimes slightly undulatory, but upon enter- 
 
ANATOMY 
 
 13 
 
 ing the epidermis it assumes a markedly spiral course, terminating 
 in a funnel-shaped opening, the sweat-pore, around which the cells 
 are arranged concentrically. The secretion of the coil-glands is in 
 most instances a watery fluid, the sweat or perspiration ; but those 
 found in the external auditory meatus, the glandular ceruminosae, secrete 
 a fatty material, the cerumen. 
 
 The nails are horny, translucent plates covering the dorsal sur- 
 face of the distal ends of the terminal phalanges of the fingers and 
 toes. They are approximately quadrilateral in shape, convex from side 
 to side, the free distal end projecting slightly beyond the finger-pulp, 
 while the lateral and proximal borders are contained in a groove, the 
 nail groove, the fold of skin forming this groove being designated 
 the nail fold. 
 
 
 
 Fig. 6. — Spiral portion of sweat-duct in epidermis. 
 
 They present three quite distinct divisions : A convex free margin, 
 which projects beyond the finger-tips and is an opaque white ; the 
 body, which is translucent, pink in color, and covered with fine longi- 
 tudinal striae; and a small semilunar area at the posterior border, the 
 lunula. The posterior border or root of the nail is covered over by 
 a narrow fold of the epidermis, the eponychium. 
 
 The nail bed, upon which the body of the nail rests, is divided 
 into two portions, a posterior portion, the matrix, from which the 
 growth of the nail takes place, and a larger anterior portion, the nail 
 bed proper; it is composed of epidermis, corium, and subcutaneous 
 connective tissue. The epidermis has neither a corneous nor granu- 
 lar layer, and corresponds to the mucous layer of the skin. The 
 corium beneath the matrix presents numerous small papillae without 
 
14 DISEASES OF THE SKIN 
 
 any definite arrangement; anterior to the lunula there are no papillae, 
 but these are replaced by numerous fine longitudinal ridges running 
 parallel with the long axis of the phalanges. The connective tissue 
 of the nail bed is usually free from fat and consists of fasciculi, which, 
 starting from the periosteum of the phalanges, diverge in a fan-like 
 arrangement to all parts of the nail bed. The nail bed is liberally 
 supplied with blood through numerous capillary loops. 
 
 The nail substance is composed of nucleated polygonal cells re- 
 sembling the cells of the corneous layer of the epidermis. Quite fre- 
 quently they contain minute air vesicles, and when a considerable 
 number of cells adjoining contain such air vesicles they give rise to 
 the opaque white spots which are often seen in the nails. 
 
 PHYSIOLOGY 
 
 The skin performs a variety of functions more or less important 
 to the general economy. First, it serves in a purely mechanical way 
 as a protective covering. The firm and elastic corium and the subcu- 
 taneous connective tissue with its cushion of fat serve admirably 
 to protect the underlying organs and tissues from external violence. 
 The impervious and insensitive horny layer of the epidermis serves 
 to protect the skin itself from injury by the innumerable chemical 
 and physical irritants with which it daily and hourly comes in con- 
 tact, acts as a barrier to bacterial invasion, and, aided by the fat 
 which it contains, derived from the glands of the skin, it prevents 
 undue loss of the fluids of the body by evaporation and the excessive 
 loss of heat which such evaporation would bring about. The pigment 
 contained in the upper portion of the corium, and more particularly 
 in the epidermis, serves to protect it from the frequently injurious 
 effects of the actinic rays of light. 
 
 The skin, through the sebaceous and coil-glands, performs im- 
 portant secretory functions. 
 
 The sebaceous glands secrete a fatty substance, the sebum, which 
 constantly anoints the hair and skin, and serves, together with the 
 secretion from the coil-glands, to keep the latter soft and pliable. 
 In the glands it exists as a thick, oil-like fluid, but in the excretory 
 ducts it is of much firmer consistence and may be readily expressed 
 from them as a butter-like mass. It is of somewhat uncertain composi- 
 tion, containing glycerin fats, fatty acids, cholestenn, soaps, and 
 drops of fat mixed with epithelial debris. The secretion of sebum is 
 a continuous one. 
 
 The coil-glands are usually spoken of as sweat-glands or sudorip- 
 arous glands, since they are for the most part concerned in the pro- 
 duction of the sweat; but certain of these, as has already been pointed 
 out, such as those in the external auditory meatus, produce a fatty 
 secretion. The sweat is a watery fluid composed of a little more than 
 99 per cent, water and about 0.9 per cent, solids, and usually acid in 
 
PHYSIOLOGY 15 
 
 reaction, although not infrequently alkaline, the reaction changing 
 from acid to neutral or alkaline in the excessive secretion induced arti- 
 ficially and under a variety of other circumstances. The solids of the 
 perspiration consist of inorganic alkaline salts, chiefly sodium chloride, 
 small quantities of earthy phosphates and iron oxide, and organic 
 substances, the chief of which is urea, and volatile fatty acids, such 
 as formic acid, acetic acid, butyric and propionic acids. In patho- 
 logic conditions in which the secretory function of the kidneys is 
 much impaired, leading to suppression of urinary excretion, the coil- 
 glands may vicariously assume the function of the kidneys, when the 
 amount of urea in the sweat is considerably increased. The secretion 
 of the sweat is not a continuous one, but varies greatly according to 
 a number of circumstances. It is chiefly dependent upon nervous 
 influences transmitted through nerve-fibres which are abundantly dis- 
 tributed to the glands, the centres for which are situated in the ante- 
 rior horns of the spinal cord. It is likewise influenced by muscular 
 activity, temperature, and a few drugs, the chief of which is pilo- 
 carpine. 
 
 As the result of the early investigations of Simon, Kolliker, and 
 Meissner and the later studies of Unna, it seems to be pretty certain 
 that the sweat-glands also secrete fat at times, if not continuously. 
 
 The skin possesses the power to absorb various substances when 
 brought into contact with them. The horny layer of the epidermis, 
 anointed as it is by the fatty secretion of the glands of the skin, 
 presents an effective barrier under normal conditions to the absorp- 
 tion of watery fluids, but when this is removed, and the rete mucosum 
 is laid bare, absorption takes place quite readily, so that various chemi- 
 cal substances in watery solution may thus be introduced into the 
 system. Fats, solid or fluid, are taken up by the skin, especially when 
 pressure is employed, and various substances, when mixed with these, 
 may be made to enter the system. These probably pass through the 
 skin chiefly by way of the excretory ducts of the glands. 
 
 Various gases and volatile substances are absorbed by the skin 
 with more or less readiness. 
 
 Through its permeability by gases and vapors, the skin also per- 
 forms a respiratory function, oxygen being taken up, and C0 2 and 
 water being given off. As compared with the lungs, however, the 
 interchange of gases is very slight, only about one one-hundred-and- 
 twenty-seventh (1/127) as much oxygen being taken up by the skin 
 as by the lungs, while the C0 2 varies from 1/25 to 1/92 of that ex- 
 creted by the pulmonary surface. The amount of water given off 
 by the skin is greatly in excess of that given off by the lungs, being 
 about twice as much (Kreidl, Mracek). 
 
 One of the most important functions performed by the skin is 
 that of the regulation of the temperature of the body. Through it 
 the animal heat is maintained at a constant figure. When the exter- 
 nal temperature rises, the blood-vessels of the skin dilate through 
 
16 DISEASES OF THE SKIN 
 
 the vasomotor centres, and the quantity of blood thus brought to the 
 surface is greatly increased, and heat is lost by radiation. The activity 
 of the coil-glands is greatly increased at the same time and the evapo- 
 ration of the perspiration very materially helps in the dissipation of 
 bodily heat. When the external temperature is lowered, the blood 
 recedes from the skin, and radiation from it is greatly lessened, thus 
 conserving the animal heat, since the skin itself is a poor conductor 
 of heat. The contraction and relaxation of the smooth muscles of 
 the skin likewise influence the amount of blood in it, and consequently 
 the dissipation of heat. 
 
 No less important than the regulation of bodily temperature are 
 the functions which the skin performs as an organ of sensation. It 
 was formerly supposed that the various sensations experienced through 
 the skin were simply qualitative variations of a single sense — that of 
 touch; but the studies of Blix (1883) and Goldscheider (1885) have 
 shown conclusively that the nerve end-organs contained in the skin 
 vary much in the manner of their response to stimulation, some re- 
 sponding only to touch, others to heat and cold, and still others to 
 pain, each requiring its own special stimulus, responding to no other. 
 Thus we have in the skin tactile sensibility, temperature sensibility, 
 pain sensibility, each of these having its own special nerve end-organs, 
 through which these various sensations are produced. 
 
CHAPTER II 
 
 GENERAL SYMPTOMATOLOGY 
 
 Diseases of the skin may be accompanied by both constitutional 
 and local symptoms. The former are frequently absent, but when 
 present differ in no respect from the constitutional symptoms which 
 accompany general and visceral diseases and, therefore, need no 
 special description ; but the local symptoms present a special group 
 of morbid phenomena peculiar to the skin and must, on that account, 
 be specially considered. 
 
 The symptoms of disease of the skin are of two kinds, viz., objec- 
 tive symptoms, those which are perceived by the sight and touch of 
 the patient or other observer, and subjective symptoms, or those which 
 are perceived by the patient alone, upon whom we must depend for 
 a knowledge of their existence and character. 
 
 The objective alterations, which occur upon the skin as the result 
 of pathological processes and commonly called eruptions or efflores- 
 cences, are made up of various lesions which are divided into two 
 classes — primary and secondary lesions. The former are among the 
 early symptoms and are those which give to each disease its special 
 characters, without which it cannot exist, while the latter, usually, but 
 not always, the result of the former, may or may not be present in any 
 given case. A thorough acquaintance with the primary lesions is of 
 the utmost importance, indeed it is necessary for any intelligent com- 
 prehension of cutaneous diseases — it is the very A B C of the subject. 
 
 The primary lesions of disease of the skin are : Maculae (spots, 
 stains ; Fr., Taches ; Ger., Flecken) ; Papulae (papules ; Ger., Knotchen) ; 
 Pomphi (wheals, urticse ; Fr., Plaques ortiee ; Ger., Quaddeln) ; Vesic- 
 ular (vesicles; Fr., Vesicules ; Ger., Blaschen) ; Bullae (blebs, blis- 
 ters; Fr., Bulles; Ger., Blasen) ; Pustulse (pustules; Ger., Pusteln) ; 
 Nodulse (nodules, tubercles ; Fr., Tubercules ; Ger., Knoten) ; Tumors 
 (phymata; Fr., Tumeurs ; Ger., Geschwulste). 
 
 Macules are variously sized and shaped, more or less definitely 
 circumscribed changes in the color of the skin, which are neither 
 elevated above nor depressed below the surrounding healthy skin; 
 they are visible, but not palpable lesions. They are of various colors, 
 presenting various shades of red and brown and combinations of these, 
 yellow, black, and white. They vary in size from a mere dot up to 
 the size of the hand and even larger. They are produced by a great 
 variety of causes. A large number are the result of hyperemia, active 
 or passive ; these are bright red or violaceous, and disappear tem- 
 porarily under pressure ; they may be caused by permanent dilatation 
 of the capillaries of the skin, as in the so-called port-wine stain ; they 
 may be the result of hemorrhage into the skin, as in purpura, when 
 2 17 
 
18 DISEASES OF THE SKIN 
 
 they undergo the changes in color peculiar to extravasated blood and 
 cannot be made to disappear by pressure. Yellowish, brown, and 
 even black, macules occur as the result of abnormal deposit of pig- 
 ment in the skin, a familiar example of this lesion being the ordinary 
 freckle ; pigmentary macules also frequently follow the eruptions of 
 syphilis, lichen, or long-continued inflammation, especially upon the 
 lower extremities, or prolonged venous stasis. White macules result 
 from pigment atrophy, such as occurs in vitiligo. 
 
 Papules are small, circumscribed, solid elevations of the skin, 
 usually more or less firm to the touch, with flat, rounded, or acumi- 
 nate summits and round or angular bases. They are red, yellow, 
 or brown in color, or may be the color of the normal skin. They 
 vary in size from a pin-point to a split pea and may be due to morbid 
 changes in the epidermis, in the corium, in the hair follicles, and in 
 the sebaceous and sweat-glands. They may be the result of inflamma- 
 tion, as in eczema, and may undergo further transformation into vesi- 
 cles or pustules ; they may result from the retention of secretion 
 (sebum), as in milium and comedo; from abnormal production and 
 accumulation of cornified epithelium, as in keratosis follicularis ; from 
 hemorrhage. Exceptionally the summit may show a central depres- 
 sion, as in the papule of lichen planus. The duration of these lesions 
 varies greatly — they may run an acute or chronic course, or they 
 may be permanent. Not infrequently they are accompanied by sub- 
 jective symptoms, the most frequent being itching of varying degrees 
 of severity. 
 
 Wheals are circumscribed, flat elevations of the skin, varying in 
 size from a small pea to the palm of the hand, and even larger, the 
 larger wheals being formed, usually, by the coalescence of a number 
 of smaller lesions. They vary in color from a whitish pink to crim- 
 son and, under moderate pressure, show quite white against the pink 
 of the normal skin. They present a great variety of shapes — round, 
 oval, gyrate, and not infrequently linear, these last resembling a 
 stroke with a whip-lash. They are accompanied by burning and itch- 
 ing, frequently extreme. One of the most striking features is the 
 extreme suddenness with which they frequently appear and disap- 
 pear, individual lesions lasting but an hour or two, and sometimes but 
 a few minutes ; exceptionally they are more permanent, lasting some 
 days. Occasionally they are of unusual size, as large as a small egg; 
 these so-called "giant" wheals are usually hemispherical in shape and 
 not infrequently are the color of the normal skin. The wheal is an 
 angioneurotic phenomenon, the result of a sudden circumscribed 
 oedema taking place in the upper portion of the corium. It usually 
 disappears without leaving any trace, but may be followed by slight 
 transient pigmentation, or, as in urticaria pigmentosa, considerable 
 pigment may be left, which disappears only after the lapse of a con- 
 siderable time. These lesions are seen in urticaria, in the sting of 
 the nettle, and after the stings and bites of insects. 
 
GENERAL SYMPTOMATOLOGY 19 
 
 Vesicles are rounded or acuminate, occasionally umbilicated, ele- 
 vations of the epidermis, varying in size from a pin-point to a small 
 pea, filled with transparent or turbid fluid, usually, but not always, 
 serum. They may contain fluid from the beginning or they may 
 begin as papules, fluid appearing only after some hours ; they may 
 contain but a single cavity or they may be multilocular. They may 
 be discrete or they may occur in small groups or variously-sized 
 patches in which the lesions tend to become confluent. When very 
 numerous and closely aggregated they may coalesce, so that the epi- 
 dermis is elevated over considerable areas, and bullae, or blebs, are 
 formed. Spontaneous rupture of their walls frequently occurs, and 
 the escaped serum dries into yellowish crusts ; or the fluid in them 
 may be absorbed without rupture and the epidermic covering desqua- 
 mate. Through secondary infection of their contents they are often 
 transformed into pustules. They may be seated in any portion of 
 the epidermis, immediately beneath the horny layer or deeper in the 
 rete mucosum. They occur in many inflammatory diseases of the 
 skin, such as eczema, when they are seated upon an inflammatory 
 base, or they may result from the retention of sweat, as in sudamen, 
 or from dilatation of lymph-spaces, as in lymphangioma circumscrip- 
 tum. Their course is, with but few exceptions, acute, and when a 
 symptom of inflammation they are usually accompanied by more or 
 less severe itching and burning. 
 
 Blebs, or bullae, are elevations of the epidermis varying in size 
 from a pea to an egg, filled with fluid which is usually transparent, 
 straw-colored serum. They may contain turbid sero-pus, pus, or 
 blood mixed with serum or pus. They are usually hemispherical in 
 shape, with tensely distended walls, which do not, as a rule, tend to 
 spontaneous rupture, but they may be irregular in shape and may 
 be only partly filled, with flaccid walls which easily break. They 
 usually rise abruptly from apparently normal skin, but may be sur- 
 rounded by a slight areola, especially when their contents are puru- 
 lent. As a rule they are not accompanied by any decided subjective 
 symptoms, but exceptionally itching and burning are present. The 
 anatomical seat of the bleb varies somewhat. 
 
 The effusion of fluid may take place immediately beneath the horny 
 layer of the epidermis, which then forms the roof of the bleb, in the 
 deeper portions of the rete mucosum, or between the epidermis and 
 the papillary layer of the corium ; in the last-named case the entire epi- 
 dermis, which is stripped off bodily from the underlying papillae, forms 
 the roof of the bleb. 
 
 Blebs occur in pemphigus, of whjch they are a characteristic feat- 
 ure, in dermatitis venenata, in dermatitis herpetiformis, and in other 
 inflammations of the skin. 
 
 Pustules are elevations of the epidermis containing pus. They 
 vary in size from that of a small pea to a thumb-nail, are usually 
 rounded, but may be flat, acuminate, or umbilicated. They are usually 
 
20 DISEASES OF THE SKIN 
 
 surrounded by an inflammatory halo and are often accompanied by 
 more or less induration of their bases. They may begin as pustules, 
 but are frequently preceded by papules or vesicles, from which they 
 develop. They are accompanied by tenderness and pain, but itching 
 is an infrequent symptom. They pursue an acute course and may 
 terminate in discharge of their contents with the formation of thick 
 yellow, greenish, or blackish crusts, or they may dry up with moder- 
 ate crusting. Occasionally ulceration takes place beneath the crusts. 
 When the inflammation is severe, and the corium is involved to any 
 depth, scarring follows. Pustules may be seated in the epidermis, 
 in the sebaceous glands, as in acne, or in the hair follicles, as in 
 sycosis. They occur in acne, in syphilis, in variola, in ecthyma, in 
 which disease they are frequently followed by permanent scarring. 
 They are also seen in eczema, scabies, and other inflammations of 
 the skin, in which they usually disappear without leaving any trace. 
 
 Nodules, or tubercles, are circumscribed, usually firm, elevations 
 of the skin, varying in size from a split pea to a hazelnut. They 
 may be the color of the normal skin or various shades of red, and 
 are usually rounded in shape. They differ from papules not only 
 in being larger as a rule, but by being more deeply seated, and are 
 much less frequently caused by inflammation. They are seen most 
 commonly in the infectious granulomata, such as syphilis and tuber- 
 culosis, when they are usually a brownish or yellowish red, and in 
 the new growths, both benign and malignant, such as fibroma, carci- 
 noma, sarcoma. They pursue a varied course. They may be absorbed, 
 they may undergo ulceration, or they may remain unchanged for 
 months or years. 
 
 Tumors are more or less definitely circumscribed swellings, vary- 
 ing in size from a pea to a fist, which may have their origin in any 
 portion of the skin or its appendages. They are firm or soft, accord- 
 ing to their composition, and are usually globular in shape. They may 
 be attached to the skin by a broad, flat base, sessile, or they may 
 be attached by a pedicle. They are most frequently new growths, 
 benign or malignant, resulting from the hyperplasia of some of the 
 elements of the skin or its appendages ; they may be produced by the 
 retention of the secretion of a gland, as in the so-called wen or 
 steatoma. Their causes are many and various, and their evolution 
 is usually slow, but exceptionally may be quite rapid. 
 
 The secondary lesions are: Squamae (Scales; Fr., Squames ; Ger., 
 Schuppen) ; Crustse (Crusts; Fr., Croutes ; Ger., Borken, Krusten) ; 
 Excorationes (Excoriations; Fr., Excorations ; Ger., Hautabschurfun- 
 gen) ; Rhagades (Fissures ; Fr., Fissures ; Ger., Rhagaden, Hautschrun- 
 den) ; Ulcera (Ulcers ; Fr., Ulceres ; Ger., Geschwiire) ; Cicatrices 
 (Scars; Fr., Cicatrices; Ger., Narben). 
 
 Scales are laminated masses of horny epithelial cells which are 
 being cast off from the epidermis, having lost their attachment to it 
 through some morbid condition of the skin. They are of various 
 
GENERAL SYMPTOMATOLOGY 21 
 
 sizes and vary in color from silvery white to yellowish or grayish 
 white. They may be fine and bran-like, furfuraceous, as in the desqua- 
 mation which follows measles, or they may form extensive sheets, 
 as after scarlatina, or they may occur in thick laminated plates, as 
 in psoriasis. They may be readily detached or firmly adherent; they 
 are usually dry and brittle, but they may be greasy ; they vary much 
 in amount, in some instances being cast off in great quantities. They 
 are usually the result of inflammation, but may result from an ab- 
 normal dryness of the skin. They occur in a great variety of dis- 
 eases of the skin, such as psoriasis, ichthyosis, eczema, the vegetable 
 parasitic diseases, and some of the exanthemata. 
 
 Crusts are masses of dried exudate or other product of disease. 
 Their presence is, with few exceptions, indicative of the preexistence 
 of moisture of some sort upon the skin. They are usually composed 
 of dried serum, pus, or blood, occasionally of a mixture of sebum and 
 epithelial scales, as in seborrhoea, and in a few instances they are 
 made up almost entirely of vegetable fungi, as in favus. They may 
 be quite thin, or form thick masses with uneven surface, or they 
 may be laminated like the shell of an oyster, as in the rupial crusts of 
 syphilis. They are yellow, greenish, brown, or black in color. Those 
 formed of dried serum are quite light yellow in color; those composed 
 of pus are yellow or greenish-yellow, while a dark-brown or blackish 
 color usually indicates a considerable admixture of blood. 
 
 Excoriations are superficial losses of substance rarely extending 
 deeper than the rete mucosum of the epidermis. They are the result 
 of mechanical injury to the skin, usually inflicted by scratching with 
 the nails or rubbing, or are the product of traumatism. They exhibit 
 a variety of forms, dependent upon the mode of production ; when 
 due to scratching with the nails they are punctate or linear in shape ; 
 when the result of friction, they are usually irregular in outline. Their 
 surfaces are frequently moist from oozing of serum or blood, which 
 dries into thin reddish or brownish crusts. Quite frequently secondary 
 infection takes place and suppuration occurs, with more or less in- 
 flammation of the skin and the formation of pustules. Excoriations 
 are common lesions in many itching diseases, such as eczema, pruritus, 
 pediculosis, and their form, distribution, and localization afford valu- 
 able aid in diagnosis. 
 
 Fissures are linear cracks in the skin, of variable length, usually 
 limited in depth to the epidermis, but sometimes extending down 
 into the corium. They occur most commonly in the natural furrows of 
 the skin in parts subjected to movement, as the palms and soles and 
 the fingers and toes ; they are also/ frequently seen at the angles of 
 the mouth and about the anus. They are especially apt to occur in 
 such diseases as impair the elasticity of the skin through inflamma- 
 tory thickening, hence are often observed in chronic eczema, psoriasis, 
 and other inflammatory diseases, accompanied by infiltration of the 
 skin. They may ooze and often bleed, and are frequently quite pain- 
 ful, interfering seriously with the movement of the parts affected. 
 
22 DISEASES OF THE SKIN 
 
 Ulcers are circumscribed losses of substance in the skin extending 
 through the epidermis into the corium or deeper, the result of dis- 
 ease. They vary in size from that of a small pea to the palm of the 
 hand, and even larger. They may be round, crescentic, kidney-shaped, 
 or serpiginous, with sharp-cut, infiltrated, elevated, or overhanging 
 edges. They may be shallow, involving only the upper portion of 
 the corium, or they may be deep, extending through the entire thick- 
 ness of the skin into the subcutaneous tissue. They are accompanied 
 by more or less discharge of serum, pus, or blood, which frequently 
 dries into thick crusts, covering the ulcer. They are usually tender 
 and painful, but these symptoms may be entirely absent, the patient 
 experiencing but little subjective discomfort. Their course may be 
 acute or chronic, although it is most commonly the latter. Ulcers 
 occur in a large number of diseases of the skin, in the infectious 
 granulomata, such as syphilis, tuberculosis, lepra, and in the malig- 
 nant new growths, such as carcinoma and sarcoma. They are com- 
 mon lesions on the lower extremities, where they are frequently the 
 result of varicose veins and of long-standing eczema; they may also 
 occur as the result of defective innervation, the so-called trophic ulcer. 
 They heal with the formation of scars. 
 
 Scars or cicatrices are new formations, composed of connective tis- 
 sue, which follow and replace losses of substance, the result of disease 
 or injury, extending into the corium or deeper. They are of all sizes 
 and shapes, according to the lesions which have preceded them. They 
 are red or pink when recent, but are white and glistening when old. 
 They may be smooth and level with the normal skin, or they may 
 be depressed and pit-like, or elevated, with uneven nodular surface ; 
 they may be soft and pliable or hard and unyielding. Occasionally 
 they undergo contraction, producing great deformity ; they may like- 
 wise undergo more or less marked hypertrophy, forming disfiguring 
 growths known as keloid. Although scars usually follow some solu- 
 tion of continuity, they may result from the absorption of pathological 
 tissue which has taken place without any previous breach in the skin. 
 They are composed of connective tissue and contain neither papillae, 
 hair follicles, nor glands. Usually there are no subjective symptoms, 
 but occasionally they are accompanied by itching or pain and tender- 
 ness. A knowledge of scars is frequently of much service in diagnosis, 
 since a number of diseases, e.g., syphilis, produce scars which are more 
 or less characteristic. 
 
 The foregoing primary and secondary lesions are the elements out 
 of which are made up the numerous eruptions characteristic of dis- 
 eases of the skin, and these exhibit a great variety of combinations, 
 which, with the type of lesion, give to each disease its peculiar stamp. 
 An eruption may contain but a single form of lesion, when it is 
 spoken of as a uniform eruption, or several types of lesion may co- 
 exist to form a multiform or polymorphous eruption. The manner 
 in which the lesions are arranged varies greatly ; they may be isolated 
 
GENERAL SYMPTOMATOLOGY 23 
 
 or discrete ; may be arranged in solid rounded or discoid patches 
 with well-defined borders, or in irregular patches with margins which 
 gradually fade away into the surrounding normal skin ; they may occur 
 in rings, forming annular patches, or in segments of a circle which may 
 join to form gyrate figures ; or, lastly, they may be scattered about over 
 the surface without any definite arrangement. The various patches 
 which go to make up an eruption may exhibit more or less symmetry 
 in their arrangement and distribution, both sides of the body being 
 affected in an equal degree and presenting the same arrangement of 
 the lesions, as is frequently seen in psoriasis. Eruptions may be 
 unilateral or bilateral, general or universal, the term general being ap- 
 plied to those eruptions in which all regions of the skin are affected, 
 but in which areas of normal skin are present, while the term uni- 
 versal is applied to those in which no portion of the skin is free from 
 disease. They may be limited to certain regions, affecting these ex- 
 clusively or in large part, while the remainder of the body remains 
 free. 
 
 The distribution and arrangement of eruptions is largely condi- 
 tioned by the anatomical structure of the skin, by the distribution of 
 its nerves and blood-vessels. What has been described by Simon 
 as the cleavage of the skin, the direction which the fibres of the corium 
 take in various regions, plays an important role in this respect. Certain 
 affections, such as herpes zoster and unilateral naevi of a certain type, 
 follow the distribution of nerve branches, while the distribution of 
 the terminal capillaries without doubt frequently determines the 
 configuration of eruptions. 
 
 SUBJECTIVE SYMPTOMS 
 
 The subjective symptoms of diseases of the skin are itching, burn- 
 ing, formication, tingling, and pain ; less frequently, increased sensi- 
 bility, hypersesthesia, or more or less complete loss of sensation, 
 anaesthesia. These vary greatly in degree, and may be entirely ab- 
 sent, many diseases of the skin occasioning the patient no physical 
 discomfort, or they may be of such severity and of such a character 
 as to produce the greatest distress. The commonest of all the sub- 
 jective symptoms is itching, which may be present in all degrees of 
 severity ; it may be a slight and occasional sensation, or may be so 
 severe and long-continued as to drive the patient beyond all self- 
 control in his efforts to relieve it. Severe itching is far more intoler- 
 able than pain, a fact seldom realized by any but the sufferer. Pain 
 occurs with a fair degree of frequency in cutaneous diseases, espe- 
 cially in inflammations of the deeper parts of the skin resulting from 
 local infections, and in some of the malignant new growths. 
 
CHAPTER III 
 
 GENERAL ETIOLOGY 
 
 The causes of disease of the skin are exceedingly numerous and 
 of the most varied character. They may exist within the organism 
 itself and be produced by it as the result of disturbed function or 
 abnormal metabolic processes. They may gain access to it from 
 without, or they may be and remain wholly external to it, producing 
 only local alterations. Not infrequently the morbid changes in the 
 skin are but a part of some general disturbance — symptomatic dis- 
 eases ; or they may be limited to the skin alone — idiopathic diseases of 
 the skin. 
 
 Certain conditions, both within and external to the body, while 
 not directly productive of pathological alterations in the skin, favor 
 its occurrence, and the importance of these varies greatly. Some of 
 them are a necessary prerequisite, certain affections, although not 
 directly produced by them, being unable to occur without their co- 
 operation ; while others are of comparative insignificance or even of 
 doubtful influence. These indirect or predisposing causes of disease 
 are : climate, season, race, heredity, age, sex, occupation. They all 
 exercise more or less influence upon the incidence of cutaneous dis- 
 eases, and in respect to some of them it is not always possible to deter- 
 mine whether they exert only a predisposing effect or are the actual 
 direct causes of disease. 
 
 Climate exerts a decided predisposing influence upon cutaneous 
 diseases. Certain affections, particularly those due to parasitic organ- 
 isms, are much more frequently seen in the tropics than in temperate 
 climes ; certain of them are confined to these regions, and for that 
 reason are called tropical diseases, while others, which, in temperate 
 regions are comparatively insignificant affections, take on greatly in- 
 creased virulence when transferred to the tropics. 
 
 Many diseases of the skin exhibit a more or less marked seasonal 
 predisposition ; examples of this are erythema multiforme, which is 
 much more common in the spring than in other seasons of the year; 
 herpes zoster, likewise, is seen much oftener in the spring and autumn ; 
 while certain forms of eczema and pruritus appear with the advent 
 of cold weather, to disappear more or less completely in the summer. 
 
 Although little is known that is definite about the influence of 
 race upon the occurrence of cutaneous disease, yet it exerts an un- 
 doubted effect. It has long been observed that fibrous overgrowth, 
 such as keloid and related affections, is much more common in the 
 negro than in the white races, while psoriasis, a common affection in 
 Europeans, is quite unusual in the negro. 
 
 Heredity has long been regarded as an undoubted factor in pre- 
 24 
 
GENERAL ETIOLOGY 25 
 
 disposing to disease, but it has lost much of its importance in this 
 respect in recent years, owing to the rapid increase in exact knowl- 
 edge concerning the causes of disease in general. Much of what was 
 formerly looked upon as the result of heredity is now known to be 
 the result of prolonged contact with affections feebly contagious. It 
 would be an error, however, to deny to this factor considerable im- 
 portance in predisposing to certain affections, such as ichthyosis, 
 xeroderma pigmentosum, and, perhaps, psoriasis. 
 
 Age plays an important role in the occurrence of many affections 
 of the skin. It is a well-known fact that certain diseases, like ring- 
 worm of the scalp, are confined to childhood ; that certain others, like 
 lupus vulgaris, almost always begin in this period of life, but con- 
 tinue in later years, while others, like epithelioma, are seen as a rule 
 only after middle age. Although we are well aware of the influ- 
 ence of age upon the occurrence of disease of the skin, we are prac- 
 tically without any definite information to explain it. 
 
 Sex influences, sometimes very markedly, the occurrence of cuta- 
 neous disease, directly through peculiarities of anatomical structure 
 and physiological function, and indirectly through occupation and so- 
 cial customs. Sycos,is, for anatomical reasons, is a disease of men 
 exclusively, while Paget's disease, although occasionally seen in men, 
 is practically a disease of women. Certain affections, like acne vul- 
 garis and acne rosacea, experience a more or less marked exacerbation 
 at the menstrual period, while others, such as herpes gestationis (der- 
 matitis herpetiformis) and chloasma, are peculiar to pregnancy. 
 
 Idiosyncrasy. — There is no doubt that idiosyncrasy, individual sus- 
 ceptibility to certain agencies which are innocuous to the majority 
 of individuals, has a considerable share in predisposing to cutaneous 
 disease as well as to disease of other organs and tissues. Examples 
 of such susceptibility are by no means rare, being within the expe- 
 rience of every observer; they are observed in connection with a 
 great variety of foods and drugs, plants and chemical substances, and 
 the like. The nature of this susceptibility is as yet unknown, but 
 recent observations make it extremely likely that it is largely, if not 
 altogether, a manifestation of anaphylaxis. 
 
 Food and clothing are to be reckoned among the agencies which 
 predispose to disease of the skin. These agencies, too, are at times 
 directly provocative of disease. Insufficient food, or food of improper 
 character, may so interfere with the general nutrition as to seriously 
 diminish the skin's power of resistance to morbific agencies. Certain 
 articles of food in certain individuals may act as powerful toxic sub- 
 stances producing various eruptions. 
 
 Underwear made of wool in many individuals causes a most annoy- 
 ing and persistent itching, and, indirectly, through the dyes which 
 they contain, clothing may be the source of extensive and persistent 
 inflammations. 
 
 Occupation must be included among the influences which predis- 
 
26 DISEASES OF THE SKIN 
 
 pose to, or directly cause, disease of the skin. Indeed, it frequently 
 plays a most important role in this respect. Many trades lead to 
 disease of the skin through the unhygienic surroundings which are 
 more or less inseparable from them, or, what is much more frequent, 
 through the immediate and prolonged contact with chemical sub- 
 stances injurious to the skin employed in them. These latter form 
 a large and most important group of diseases and are known as trade 
 dermatoses. Examples of disease thus produced are extremely numer- 
 ous and are met with in a great variety of occupations: makers of 
 artificial flowers, dyers, tanners, candy-makers, photographers, metal 
 polishers, as well as workers in many other trades of a similar kind, 
 are more or less subject to inflammations of the skin as the res.ult 
 of their calling. 
 
 Disease of the skin occurs as the direct or indirect consequence of 
 a considerable number of constitutional and visceral diseases. Dis- 
 ease of the kidneys, of the liver, of the gastro-intestinal tract, of the 
 thyroid and adrenals, of the nervous system, diabetes, rheumatism, 
 and gout, are frequently accompanied by disturbances in the skin 
 which can be traced with more or less certainty to the internal disease 
 with which they are associated. In some of these, for example, the 
 inflammations which are so frequently complications of glycosuric 
 diabetes, the relationship is readily demonstrated, but in others the 
 demonstration is much less satisfactory, and the relationship ib* still 
 largely a matter of theory and speculation. In a small proportion of 
 cases of chronic nephritis, particularly chronic interstitial nephritis, 
 in which the excretory function of the kidneys is greatly damaged, 
 pruritus and eczema occur, which are presumably the consequences 
 of defective elimination by the diseased kidneys. The furuncles, car- 
 buncles, and other infections which are frequent occurrences in saccha- 
 rine diabetes are the indirect result of the saturation of the skin with 
 sugar, making it an especially favorable soil for the growth of micro- 
 organisms, while the genital eczemas, which are quite common, are 
 the direct result of contact with the saccharine urine. 
 
 Disease of the liver, especially when it is accompanied by jaundice, 
 may occasion severe pruritus ; and xanthoma, when at all extensive, 
 is very frequently associated with chronic jaundice. 
 
 That there is a more or less intimate relationship between gastro- 
 intestinal disease and disease of the skin has long been observed, but 
 we are still lacking exact information, for the most part, concerning 
 the precise nature of this relationship, which is, without doubt, a 
 very complicated one. The several forms of acne, urticaria, some 
 eczemas, and pruritus, are examples of cutaneous disease which are 
 frequently associated with, and more or less markedly influenced by, 
 diseases of the stomach and intestines. A very curious and interesting 
 relationship has been observed to exist between cancer of the stomach 
 and liver and acanthosis nigricans, a curious pigmentary affection of 
 the skin. 
 
GENERAL ETIOLOGY 27 
 
 Rheumatism and gout have long been regarded as frequent and 
 important factors in the causation of cutaneous diseases, but it is 
 becoming more and more doubtful whether these altogether deserve 
 their evil reputation. As to the former affection, there seems to be 
 but little doubt that it is frequently associated with certain forms of 
 eczema which may alternate with the ordinary joint symptoms of 
 the disease, but there is just as little doubt that a considerable number 
 of so-called gouty eczemas have nothing whatever to do with gout. 
 As to rheumatism, the association of certain erythemata, such as 
 erythema multiforme, with pain and inflammation of the joints, and 
 the occasional association of psoriasis with a chronic arithritis, are 
 quite commonly regarded as pointing to a rheumatic origin of these 
 affections; but it is well to remember that not every arthritis is rheu- 
 matism ; indeed, it is pretty certain that these joint affections are not 
 rheumatism. Upon the whole, the evidence that rheumatism, properly 
 so-called, plays any considerable role in the production of disease of 
 the skin is, to say the least, unconvincing, in the author's opinion. 
 
 Disease of the ductless glands, such as the thyroid and the supra- 
 renal capsule, by causing alterations in the quality or quantity of the 
 so-called internal secretions, must be reckoned among the causes of 
 morbid conditions of the skin. The profound alterations in the nutri- 
 tion of the skin and its appendages, which occur in myxcedema and the 
 extensive pigmentation of the skin and mucous membranes in Addi- 
 son's disease of the suprarenal capsules, are examples of the close rela- 
 tionship between disease of such glands and disease of the skin. 
 
 The list of diseases of the skin due to microorganisms of various 
 kinds is already a considerable one, and is constantly growing. 
 
 In some of these — syphilis, leprosy, and the exanthemata — the erup- 
 tive symptoms are but a part of a general infection. They are sympto- 
 matic eruptions, while in others, as in sporotrichosis and rhinoscleroma, 
 the skin alone is invaded and the disease remains a strictly local one. 
 In a few instances the organism produces at one time a general, at 
 another a local, infection, examples of such being the bacillus tuber- 
 culosis and the blastomyces, both of which may at times cause a 
 general infection with cutaneous lesions, at others strictly local symp- 
 toms. Certain fungi belonging to the order of moulds, such as the 
 trichophyton, the achorion, the microsporon furfur, give rise to a 
 group of diseases commonly designated vegetable parasitic diseases, 
 which are always purely local affections. Diseases of the skin may 
 likewise arise from the invasion of animal parasites, such as the acarus 
 scabiei, the several varieties of pediculi, and a few other animal organ- 
 isms of less frequent occurrence. 
 
 On account of its exposed situation, the skin is especially liable to 
 disease from traumatism and from mechanical and chemical irritants 
 of the most varied kind. The former is a common source of disease. 
 The slight injury inflicted upon the skin by scratching, when long 
 continued, is a frequent source of morbid change; the slight abrasions 
 
28 DISEASES OF THE SKIN 
 
 which the skin so frequently suffers are quite commonly the starting point 
 for eczemas and chronic ulcers, particularly in those debilitated by im- 
 proper living, disease, or age. 
 
 Mere mechanical pressure, when long continued in the same region, 
 may lead to pathological change in the skin, as in the corns and cal- 
 losities which occur so frequently upon the soles from pressure of ill- 
 fitting shoes, and upon the palms from pressure of some implement 
 used in the daily work. 
 
 Although not commonly regarded as an irritant, water frequently 
 acts as such upon the skin when applied often or for prolonged pe- 
 riods. Eczema of the hands is a common affection in washerwomen 
 and others whose occupation compels them to immerse the hands fre- 
 quently and for hours in water. Its injurious effects upon a skin 
 already eczematous are well known to every dermatologist and fre- 
 quently to the patient. 
 
 A considerable number of plants, such as the so-called poison ivy 
 (Rhus toxicodendron), the primrose (Primula obconica), and some 
 other varieties of the primula, contain substances which are violently 
 irritating to the skins of many individuals, producing severe and extensive 
 dermatitis. The chemical rays of light are likewise capable of exciting 
 inflammation of the skin, and of causing other morbid changes, some of 
 them of a quite special character ; for example, the alteration in the 
 process of keratinization often followed by epitheliomatous change, as seen 
 in the so-called sailor's skin. Exposure to the X-ray and radium, espe- 
 cially the former, produces a dermatitis with which we have become only 
 too familiar in the last few years. This dermatitis may vary from a mild 
 and transient erythema to complete destruction of the skin, and in the 
 chronic forms arising from repeated exposures may terminate in epithe- 
 lioma with all its disastrous consequences. 
 
CHAPTER IV 
 
 GENERAL PATHOLOGY 
 
 The pathology of the skin does not differ in essentials from the 
 pathology of the internal organs of the body. Since the skin responds 
 to morbific influences in the same manner as other tissues, and brings 
 to its defence against disease the same agencies, the same morbid proc- 
 esses, anaemia, hyperemia, inflammation, hypertrophy, atrophy, are 
 observed in it as in the viscera. But while the pathological processes 
 in the skin and the mechanism of their production are similar to those 
 which take place in diseases of the viscera, the tissue alterations which 
 result from these are frequently different, largely, but not exclusively, 
 because of peculiarities of anatomical structure and physiological func- 
 tion. The histopathology, therefore, of cutaneous disease frequently 
 presents important variations from that of other tissues. 
 
 The epidermis may undergo hypertrophy, either as a whole or in 
 some one of its component layers. Hypertrophy of the stratum cor- 
 neum or horny layer, designated hyperkeratosis, is a common patho- 
 logical condition. It may be a congenital and generalized affection, 
 as in ichthyosis, or it may be acquired and limited to circumscribed 
 areas, as in callosities and cutaneous horns. There is not only a more 
 or less marked increase in the number of the horny cells, but they have 
 undergone a qualitative alteration ; owing to an increase in the keratin 
 they are firmer than normal and have lost to some extent their cohe- 
 siveness, so that they may be easily separated. Circumscribed hyper- 
 keratoses are extremely common lesions, and result from a variety of 
 causes. Lesions of this kind are frequently seen upon the palms 
 and upon the soles, in the former as the result of pressure from the 
 use of certain tools, in the latter from ill-fitting shoes. They may 
 result from the ingestion of certain drugs, such as arsenic, which pro- 
 duces peculiar, corn-like lesions upon the palms and soles, and from 
 senile change in the skin — as in the so-called senile keratosis. It is 
 an interesting and important fact that epithelioma is prone to follow 
 certain circumscribed hyperkeratoses, especially those following the 
 prolonged use of arsenic and the senile form. Hyperkeratosis may 
 exist alone or be associated with other morbid conditions. In angio- 
 keratoma, in addition to the increase in the horny layer, there is 
 likewise an increase in the blood-vessels of the papillae of the corium ; 
 and keratosis of the palms and soles is frequently associated with a 
 marked hyperidrosis of these regions. Hyperkeratosis may occur in 
 the hair follicles and about the orifices of the sweat-ducts. 
 
 In a number of affections of the skin, chiefly inflammatory in char- 
 acter, cornification takes place imperfectly. The nuclei of the horny 
 cells do not completely disappear, as under normal conditions ; there 
 
 29 
 
30 DISEASES OF THE SKIN 
 
 is an absence of keratohyalin granules and a diminution of cohesion 
 between the cells, so that desquamation readily takes place, and small 
 collections of leucocytes are frequently present between the cells. This 
 condition, which is known as parakeratosis, is always preceded by 
 pathological alterations in the rete mucosum and is observed in eczema, 
 psoriasis, and some other affections with desquamation or scaling. 
 Anomalous forms of cornification occur in the disease first described 
 by Darier under the name of follicular vegetating psorospermosis and 
 in epithelioma (molluscum) contagiosum. In the former certain of 
 the horny cells about the mouths of the follicles are transformed into 
 large round bodies with a double wall resembling certain protozoa, 
 for which they were at one time mistaken. 
 
 Hypertrophy of the rete mucosum, acanthosis, occurs both as a 
 benign and a malignant process. In the former, while the cells are 
 increased in number, they still retain the ordinary characteristics of 
 the cells of this layer, but in the latter the overgrowth is accompanied 
 by alterations in the cells themselves ; they lose their intercellular 
 fibrils so that they are no longer connected with one another ; they 
 become smaller and round or oval instead of polygonal, and undergo 
 various forms of degeneration with frequent cell-inclusions. In ma- 
 lignant overgrowth of the rete the columnar basal layer of cells no 
 longer forms a sharp dividing boundary between the epidermis and 
 the corium, but is invaded and broken up by the multiplying altered 
 cells from above and by leucocytes from the corium below. 
 
 Circumscribed hypertrophy of the rete may occur as a congenital 
 affection, as in soft nasvi, or as an acquired condition, as in warts and 
 condylomata. In certain affections having their seat in the corium, 
 such as the infective granulomata, tuberculosis, syphilis, and leprosy, 
 extensive overgrowth of the rete, resembling in many particulars ma- 
 lignant hypertrophy, occurs. Long branching processes composed of 
 epithelium extend down deeply into the corium, but the cells usually 
 retain their special characters. Extensive diffuse acanthosis frequently 
 occurs in inflammations of the skin, such as eczema and psoriasis, 
 often accompanied by hyperkeratosis, or still more frequently by 
 parakeratosis. 
 
 Atrophy of the rete mucosum may occur as the result of pressure 
 from within or without. It may occur as an idiopathic affection asso- 
 ciated with atrophy of other parts of the skin, and is frequently the 
 result of advancing years, when it is known as senile atrophy. The 
 thickness of the layers of epithelial cells is diminished, sometimes 
 greatly, and the interpapillary prolongations are markedly shortened 
 so that the undulatory boundary between it and the corium approaches 
 a straight line. 
 
 In a large number of inflammatory conditions of the skin, such as 
 eczema, herpes, and the various forms of dermatitis arising from con- 
 tact with chemical substances and plants, oedema of the rete mucosum 
 
GENERAL PATHOLOGY 31 
 
 takes place, which, when considerable, frequently leads to the for- 
 mation of lesions peculiar to the skin and mucous membranes, known 
 as vesicles. This oedema may be either intercellular, intracellular, or 
 both. In the former the fluid distends the intercellular spaces to form 
 unilocular cavities which may become multilocular by the coalescence 
 of several adjoining lesions. They are filled with serum and a variable 
 number of polymorphonuclear leucocytes with, in certain bullous dis- 
 eases, such as dermatitis herpetiformis and pemphigus, a considerable 
 number of eosinophiles. In the intracellular oedema the cells them- 
 selves are filled with fluid and contain small cavities which coalesce 
 to form multilocular vesicles. Both forms of oedema and both varie- 
 ties of vesicles frequently occur together. The multilocular form of 
 vesicle is best seen in the vesicles of variola and varicella. 
 
 In the vesiculation which occurs in varicella, variola, and herpes 
 zoster, a peculiar alteration of the epithelial cells about the sides and 
 bottom of the lesions takes place, which transforms them into large, 
 round or pear-shaped bodies frequently with double-contoured walls 
 and a cavity filled with large round nuclei varying in number from 
 five or six to a score or more. The " ballooned " cells of herpes zoster 
 were regarded at one time by PfeifTer as a form of protozoon, and the 
 probable cause of that disease ; their epithelial nature, however, has 
 been definitely established by numerous observers, although the 
 exact nature of the degeneration is still undetermined. 
 
 The situation of vesicles varies considerably. They may be im- 
 mediately beneath the horny layer of the epidermis or anywhere be- 
 tween the horny layer and the papillary layer of the corium. 
 
 Bullae, or blebs, may be regarded as exaggerated vesicles, since 
 the mechanism of their production is practically the same as that of 
 the latter. The roof of the bleb may be composed of the stratum 
 corneum only, or it may consist of the entire thickness of the epidermis 
 which has been lifted en masse by exudation from the papillae of the 
 corium. Lesions of this sort are present in pemphigus, dermatitis 
 herpetiformis, and in the severe forms of dermatitis resulting from 
 external irritants, such as certain plants like the Rhus toxicodendron 
 and many chemical substances. In the bullae of pemphigus and of 
 dermatitis herpetiformis, many eosinophiles are commonly present. 
 
 Pustules differ but little, if at all, in their structure from vesicles. 
 Indeed, a vesicular stage often precedes the pustules, the fluid con- 
 tents being clear or only slightly turbid at first, becoming purulent 
 later. In certain cases, however, the pustular lesion begins as such, as 
 in certain forms of impetigo (Bockhart's impetigo). 
 
 In dermatitis, inflammation of the skin, the pathological changes 
 which take place in the corium are for the most part similar to those 
 which occur in inflammation of other tissues — dilatation of the blood- 
 vessels, with exudation of plasma and leucocytes. The cellular exudate 
 is usually most abundant in the neighborhood of the vessels, the hair 
 follicles and the sweat-glands ; less frequently it is uniformly dis- 
 
32 DISEASES OF THE SKIN 
 
 tnbuted throughout the corium. It is composed of polymorphonuclear 
 and small mononuclear cells, some of which are lymphocytes and 
 others are probably derivatives of the connective-tissue cells, although 
 there is considerable difference of opinion concerning the nature and 
 origin of the small, round mononuclear cells. 
 
 Other types of cell are present in certain diseases which have more 
 or less special significance. One of the most important of these, pres- 
 ent especially in chronic inflammations in infective granulomata and 
 certain malignant affections, is the plasma-cell. This is a large, round, 
 frequently cuboidal cell with a large, round or oval nucleus eccen- 
 trically situated. In certain affections, such as syphilis and Paget's 
 disease, these cells may be very numerous, forming the principal part 
 of the exudate ; their origin is still a matter of dispute. 
 
 A more or less considerable increase in the number of " mastzellen " 
 occurs in a number of diseases of the skin. These, which are normally 
 present in small numbers in the corium, are large, round, oval, spindle- 
 shaped, and frequently branched cells in the protoplasm of which are 
 numerous basophilic granules. In urticaria pigmentosa the cellular 
 exudate is made up almost entirely of these cells. Their exact signifi- 
 cance is still quite uncertain. 
 
 Giant-cells of the Langerhans type are met with in the corium in 
 the various forms of tuberculosis of the skin so constantly as to be 
 a characteristic feature of this affection, but their presence is by no 
 means to be regarded as certain proof of the tuberculous character 
 of the tissue in which they are found, since they are seen, although 
 much less frequently, in others of the infective granulomata, syphilis, 
 lepra and blastomycosis. Other types of giant-cell in which the nuclei 
 are centrally instead of peripherally situated, the so-called chorio- 
 plaques, are found likewise in some of the infective granulomata, such 
 as lepra and yaws. 
 
 The fibrous elements of the corium, the collagen, may undergo dif- 
 fuse hypertrophy, as in scleroderma and elephantiasis, or there may 
 be a circumscribed increase of these, as in keloid. Atrophy of the 
 collagen occurs in many cutaneous affections. 
 
 The elastic fibres of the corium, so far as our present knowledge 
 goes, are not subject to hypertrophy, but more or less atrophy takes 
 place in many diseases. It disappears in the area occupied by the 
 cellular infiltration about malignant growths, such as carcinoma and 
 sarcoma, and is absent in atrophic scars. Rupture of the elastic fibres 
 may occur from over-distention of the skin, as in the striae atrophicae 
 of pregnancy. 
 
 Both the cellular and fibrous elements of the corium may undergo 
 various forms of degeneration, such as fatty, hyaline, colloid, and 
 myxomatous degeneration, which do not differ essentially from those 
 occurring in other tissues. Fatty degeneration of the connective- 
 tissue cells of the corium is one of the principal pathological changes 
 present in xanthoma tuberosum, while the same process, affecting 
 
GENERAL PATHOLOGY 33 
 
 the muscle-cells of the lids, is present, according to Pollitzer, in xan- 
 thoma planum. Colloid or hyaline degeneration takes place in the 
 cells of a number of affections which have their seat in the corium, 
 such as syphilis, rhiaoscleroma, and diseases attended by suppuration. 
 
 Colloid degeneration of the fibres of the corium has been observed 
 chiefly in connection with so-called colloid milium. 
 
 Myxomatous degeneration occurs in various new growths, both 
 benign and malignant, and in myxcedema. 
 
 In many diseases of the skin the fibrous and elastic elements, the 
 collagen and elastin, undergo degeneration, which causes them to 
 lose their normal affinity for acid dyes and to become basophilic ; the 
 collagen is transformed into collacin and collastin, the elastin into 
 elacin. This degeneration may very well be demonstrated in the senile 
 skin by the use of appropriate staining methods. Our knowledge, 
 however, of these degenerations is still very incomplete. 
 
 Quantitative and qualitative alterations of the pigment of the skin 
 occur as an accompaniment or sequel of many cutaneous affections, 
 usually associated with other pathological changes of various kinds, but 
 in a few instances alone. The pigment is of two sorts, viz., an iron- 
 containing one, always pathological, composed of yellow crystalline 
 granules, hcematoidin, and dark amorphous granules, hemosiderin, 
 and an iron-free pigment, melanin, which exists normally in the skin in 
 certain regions. Pigmentation from deposit of haematoidin and hsemo- 
 siderin in the tissues follows extravasation of blood, such as occurs 
 in purpura and after contusions, when it is usually of short duration. 
 It also occurs as a sequel of long-standing inflammations accompanied 
 by venous stasis, such as chronic eczema of the lower extremities, espe- 
 cially when associated with varicose veins, when it is apt to be per- 
 manent or of long duration. A more or less general pigmentation of 
 the skin, due to haemosiderin, occurs in bronze diabetes (haemo- 
 chromatosis). 
 
 The origin of melanin is still a matter of debate. There are two 
 theories concerning its derivation, one that it is derived from the 
 haemoglobin, the other, that it is the product of epithelial cells in the 
 epidermis. Hyperpigmentation due to an increase of melanin accom- 
 panies or follows many affections of the skin, such as certain forms 
 of chronic eczema, lichen planus, and neurofibromatosis (von Reckling- 
 hausen's disease). It occurs to a marked degree in certain naevi and 
 malignant neoplasms, such as melanosarcoma and pigmented epithe- 
 lioma, which, as a rule, exhibit extraordinary malignancy. It accom- 
 panies or follows certain general diseases, such as Addison's disease 
 and syphilis. 
 
 Hyperpigmentation may result from the ingestion of certain drugs, 
 such as arsenic, which produces a diffuse, more or less general dirty 
 brown discoloration of the skin when given in considerable quantities 
 for a length of time. Arsenical pigmentation is apt to be most marked 
 in regions subjected to mechanical irritation or inflammation. 
 3 
 
34 DISEASES OF THE SKIN 
 
 Pigmentation of an entirely different kind may result from the 
 deposit of metallic particles in the skin following the continued use 
 of certain salts of the metals, such as nitrate of silver, which produces 
 a slaty blue discoloration. 
 
 In all the various forms of hyperpigmentation the pigment occurs 
 as golden-brown to dark brown amorphous granules which are most 
 abundant in the lower layers of the rete mucosum, especially in the 
 basal or columnar cells. They may be so abundant as to completely 
 obscure the outlines of the cells containing them. Pigment granules 
 are also present lying free between the epithelial cells in the inter- 
 cellular spaces, and in certain stellate cells, the so-called melanoblasts 
 of Ehrmann. The papillary layer and upper portion of the pars 
 reticularis of the corium also contain pigment, but rarely in quantities 
 comparable with that present in the epidermis. 
 
 Absence, or a marked decrease of pigment, occasionally occurs as 
 an inherited congenital defect, as in albinism, or it may occur in circum- 
 scribed areas as an acquired condition, usually preceded by a tem- 
 porary increase, as in vertiligo. 
 
 According to Ehrmann, hemosiderin is found only in the con- 
 nective-tissue spaces and secondarily in the leucocytes, while melanin 
 is situated within the epithelial cells and in the melanoblasts. 
 
CHAPTER V 
 GENERAL DIAGNOSIS 
 
 An accurate diagnosis must of necessity precede the rational treat- 
 ment of cutaneous, as well as of visceral disease, and this can only be 
 arrived at by careful and methodical examination, not only of the 
 disease under consideration, but of the patient as well. If we are to 
 avoid error and arrive at trustworthy conclusions, a certain orderly 
 procedure should be observed. 
 
 The examination, when possible, should be made by daylight, since 
 most colors are altered by artificial light, and some, such as yellow, 
 may not be visible at all, unless the light is quite white, like the electric 
 arc light. Every portion of the eruption should be seen, since to exam- 
 ine but a part of it is to invite error, for the same eruption may, and 
 frequently does, exhibit marked differences according to locality. 
 One should not be satisfied with the patient's statement that all of the 
 eruption is precisely like that exposed to view ; one should see for 
 himself. Not only should the whole eruption be examined, but in 
 doubtful cases the entire cutaneous surface should be subjected to 
 careful scrutiny ; in no other way can one so quickly and certainly 
 learn its extent, distribution, and localization. Not infrequently faint, 
 but entirely characteristic, lesions may be present of which the patient 
 is entirely unaware, or which, for some reason, he desires to conceal. 
 Indeed, it is an excellent rule at the first visit to strip the patient, if it 
 is a man or child. Of course, when the patient is a woman we must 
 often be satisfied to inspect the skin in sections. 
 
 Age, sex, race, occupation, habits of life, should all be carefully 
 noted, since these frequently have an important bearing on the 
 diagnosis. 
 
 Age. — A considerable number of diseases occur far more frequently 
 in childhood than in adult age, and some are practically confined to 
 this period of life. The exanthemata, impetigo contagiosa, and ring- 
 worm of the scalp are diseases of childhood, while lupus vulgaris, and 
 some others of the tuberculous affections of the skin, although not 
 limited to this period, usually have their beginning before puberty. 
 On the other hand, acne vulgaris is practically never seen before 
 pubertv, and epithelioma is uncommon before forty years of aee. 
 
 Sex. — For purely anatomical reasons, sycosis, both the parasitic 
 and non-parasitic varieties, is exclusively a disease of the male sex, 
 while Paget's disease, impetigo herpetiformis and chloasma are so 
 rarely observed in the male as to be practically affections of the female 
 sex. A certain variety of dermatitis herpetiformis, herpes gestationis, 
 as its name indicates, is confined exclusively to women. 
 
 Race. — Keloid is far more frequently seen in the negro than in 
 
 35 
 
36 DISEASES OF THE SKIN 
 
 the white race, while psoriasis is extremely uncommon in the pure- 
 blooded negro. Multiple hemorrhagic sarcoma of the skin exhibits an 
 extraordinary predilection for the Hebrew race. 
 
 Occupation. — Those exposed to contact with the innumerable 
 chemical substances used in the various arts and trades are much more 
 likely to suffer from dermatitis and eczema than those whose occu- 
 pation does not so expose them. Those whose occupation exposes 
 them to the rays of the sun and to the wind are much more apt to suffer 
 from certain degenerative changes of the skin leading to malignant 
 disease. 
 
 The patient's habits, especially as to his eating and drinking, also 
 largely influence his liability to certain diseases, such as acne rosacea, 
 pruritus, and those affections like ecthyma which depend upon sec- 
 ondary infections. 
 
 The character of the primary lesions should be carefully noted, i.e., 
 whether they are macules, papules, vesicles, pustules or blebs, and 
 they must be carefully distinguished from secondary lesions. The 
 character of the primary lesions may best be observed in those of recent 
 origin and when the eruption tends to occur in patches in which the 
 individuality of the lesions is lost, in the discrete lesions about the 
 border of the patch or some little distance from it. 
 
 In studying any eruption it should be noted whether it is a uniform 
 one, i.e., that composed of but a single kind of lesion, as in lichen planus 
 and psoriasis, or whether it contains several varieties of lesion, as in 
 scabies and eczema. The distribution, arrangement, localization and 
 evolution are all matters of more or less significance in diagnosis. For 
 example, a vesicular eruption distributed over the course of the brachial 
 plexus, or over the intercostal nerves, arranged in groups, is distinctive 
 of herpes zoster. A multiform eruption between the fingers, on the flex- 
 ures of the wrists, on the anterior fold of the axillae, and, in the male, 
 upon the shaft of the penis, is almost certainly scabies. 
 
 The presence or absence of secondary lesions, such as crusts, scales, 
 excoriations, should be noted. The presence of crusts is almost always 
 indicative of precedent moisture, serum, pus, or blood, while excoria- 
 tions, especially linear ones, point unerringly to the existence of more 
 or less severe itching, and their localization often affords a clue to the 
 nature of its cause. 
 
 Not only should the history of the disease under immediate con- 
 sideration be carefully gone into, but, what is just as important, indeed 
 sometimes more so, the patient's previous medical history should be 
 carefully considered, not only as to previous cutaneous diseases, but as 
 to the constitutional affections from which he may have suffered. 
 The presence or absence of the same or other cutaneous affections in 
 other members of the family or household should be inquired into with 
 a view to learning whether heredity or contagion plays any part in his 
 disease. Inquiry should be made as to whether he has had treatment, 
 local or internal, before coming under observation, and, if so, what has 
 
GENERAL DIAGNOSIS 37 
 
 been the nature of it, and more especially what drugs, if any, have been 
 taken internally. One should always be on the lookout for drug- 
 eruptions which may complicate the diagnosis greatly. Eruptions are 
 frequently greatly altered by local applications employed by the 
 patient himself, or ordered by the previous medical adviser, which fre- 
 quently mask the original disease by an artificial dermatitis. Under 
 such circumstances the original affection only becomes manifest after 
 the artificial condition subsides, either from judicious treatment or 
 spontaneously. 
 
 While the history of the case is without doubt often of great 
 assistance in arriving at a correct diagnosis, it is almost as often of no 
 use or, worse, misleading. Since patients are rarely accurate obser- 
 vers; since they often have notions of their own, which are erroneous 
 concerning the nature and origin of their maladies and which materially 
 influence their statements ; and since they not infrequently endeavor 
 to mislead the physician when they suspect their affection to be of 
 venereal origin, or when they are the subjects of hysteria, the exercise 
 of a rational skepticism in the matter of histories is much to be preferred 
 to a too easy credulity. 
 
 Valuable information may occasionally be obtained from an in- 
 spection of the mucous membranes adjoining the skin, more especially 
 in cutaneous syphilis. The nature of a doubtful or only faintly visible 
 eruption may at once be made plain by the finding of a mucous patch 
 on the labial or lingual mucous membrane or a flat condyloma at the 
 verge of the anus. 
 
 The employment of tuberculin after the methods of von Pirquet 
 and of Morro is often of great use in the recognition of the tuberculous 
 affections of the skin, and complement fixation (Wassermann test) 
 is always to be employed in obscure or suspected syphilis of the skim 
 Although far less useful than the Wassermann reaction, intradermic 
 injections of luetin, killed cultures of the spirochseta pallida are also 
 useful, especially in the diagnosis of late cutaneous lesions of syphilis. 
 
 The microscope is an invaluable aid in the diagnosis of cutaneous 
 maladies, but its successful use demands not only a thorough knowl- 
 edge of microscopic technic, but an extensive acquaintance with the 
 histopathology of the skin. With the aid of local anaesthesia, it is 
 entirely practicable to excise small portions of diseased tissue and 
 subject them to microscopic study, a method of diagnosis frequently 
 of the greatest value, and one which should be employed in all doubtful 
 and obscure cases. The examination, however, of crusts and scales 
 and hair for the vegetable parasites requires only the most elementary 
 knowledge of the use of the microscope. 
 
 The recently employed intracutaneous injection of certain soluble 
 proteins promises to add a diagnostic procedure of value in certain 
 inflammations of the skin, more particularly certain eczemas and 
 urticaria and other affections exhibiting angioneurotic phenomena. 
 
CHAPTER VI 
 
 GENERAL THERAPEUTICS 
 
 Since pathological processes and the mechanism of their production 
 .are essentially the same whatever the tissue involved, and since the 
 many causes of disease produce their effects in practically the same 
 manner in diseases of the skin as in diseases of the internal organs, 
 the same general principles which govern the treatment of the latter 
 apply to the treatment of the former. The chief difference between 
 the therapeutics of cutaneous maladies and the therapeutics of general 
 diseases lies in the fact that in the former our remedies are very fre- 
 quently applied directly to the diseased parts. Internal remedies are, 
 in the great majority of cases, given in diseases of the skin, not for their 
 direct effect upon the cutaneous disease, for a comparatively small 
 number of drugs are capable of exerting any curative effect in this 
 manner, but for their effect upon either the system at large, or upon 
 the functions of the various organs with disease of which cutaneous 
 affections are so often directly or indirectly connected. It should be 
 constantly borne in mind that there are just as few specifics for diseases 
 of the skin as for other diseases. 
 
 In many affections, perhaps in most, both local and internal reme- 
 dies are indicated, and frequently both are equally valuable. It should 
 be remembered, however, that a large number of cutaneous affections 
 are strictly local diseases, in no way dependent upon general con- 
 ditions, and therefore curable, if curable at all, by local treatment. 
 Under such circumstances, of course, internal treatment is useless and 
 may be harmful. 
 
 Since, as has already been pointed out, diet is frequently the direct 
 and still more frequently a contributing cause of many affections of the 
 skin, this should be regulated with care. It is useless to prescribe 
 lotions and ointments for an acne rosacea, even the most effective, if 
 the patient is permitted to indulge in sweets, pastry, tea and coffee and 
 alcoholic drinks, and the vulvar eczema which occurs in a glycosuric 
 woman will be treated in vain so long as sugars and starches form a 
 part of her diet. As is well known, shell-fish, strawberries, pork, honey 
 and other articles of food may, in certain individuals, give rise to urti- 
 caria, and these are, of course, to be rigidly excluded from the diet of 
 those who suffer from this affection. Recent studies make it seem 
 most probable that food allergy, or protein sensitization, plays a very 
 important role in certain inflammatory affections of the skin, especially 
 those associated with angioneurotic symptoms. In acutely inflamma- 
 tory conditions of the skin, especially when large areas are involved, 
 the diet should be of the simplest kind : meats should be taken in great 
 38 
 
GENERAL THERAPEUTICS 39 
 
 moderation, and oftentimes a liquid diet will be found best, with plenty 
 of milk, while tea, coffee and alcohol are best omitted altogether. 
 
 The gouty and the rheumatic who suffer from diseases of the skin, 
 especially the former, should carefully observe a regimen suited to 
 those conditions. 
 
 After all, however, there are many affections of the skin in which the 
 diet is a matter of no importance. 
 
 Attention should be paid to the patient's clothing, especially the 
 underwear, which may directly cause certain disturbances, either be- 
 cause of the material of which it is composed or because of the dyes 
 with which it is not infrequently colored. Infants are often too 
 warmly clothed, so that the skin is continually bathed in perspiration 
 and the sweat-glands are constantly over-stimulated, producing a con- 
 dition known as miliaria. Many individuals find woollen underwear 
 intolerable, many cases of the so-called winter itch being nothing more 
 than the irritation produced by woollen undergarments, and in inflam- 
 matory diseases wool should not be worn next to the skin. 
 
 Internal or Constitutional Treatment. — In the internal treatment of 
 diseases of the skin the same drugs are, for the most part, employed as in 
 the treatment of other affections and for the same reasons — to control 
 inflammation, to relieve pain or other distressing sensations, to combat 
 infection by destroying or neutralizing the effects of pathogenic organisms. 
 There is a large number of drugs which are useful in diseases of the skin, 
 and a small number have a more or less direct effect upon this tissue. 
 Alkalies, such as the citrate or the acetate of potash, are remedies fre- 
 quently found useful in extensive inflammations of the skin accompanied by 
 itching or burning, or in those accompanied by symptoms of gout or 
 rheumatism. They should be given in considerable doses, sufficient to 
 produce and maintain alkalinity of the urine, but their administration 
 should not be continued for too long a period without interruption, as 
 they are likely to produce gastric disturbance and anaemia when given 
 over long periods. 
 
 Laxatives and cathartics form a most valuable group of remedies in the 
 treatment of many affections of the skin, and are especially useful in 
 eczema and acne. The saline laxatives may be most conveniently and 
 agreeably administered in the shape of some one of the many waters 
 which are to be found in the market. Fractional doses of calomel fol- 
 lowed by a laxative are often of the greatest use in eczema, especially the 
 eczemas of children. 
 
 The preparations of iron are frequently of service in diseases of the 
 skin when these occur in anaemic subjects, and in such affections as are 
 accompanied or followed by general debility. 
 
 Quinine is of great use in a number of cutaneous affections, such as 
 pemphigus, exfoliative dermatitis, lupus erythematosus, in those accom- 
 panied by evidences of malarial infection, and as a general tonic. 
 
40 DISEASES OF THE SKIN 
 
 Cod-liver oil is a remedy of decided value, especially in children 
 whose nutrition is impaired. In pustular eczema of children, asso- 
 ciated with enlargement of the lymphatic glands, it is a remedy of 
 undoubted value. It is also capable of rendering decided service in 
 those forms of acne characterized by deep-seated violaceous lesions, 
 slow in course, which occur in those with pale doughy skins and swollen 
 glands. It was regarded by Hebra as a specific in lichen scrofulosorum. 
 
 The iodides of sodium and potassium are of especial value in the 
 skin lesions of late syphilis, but are of little if any use in the early erup- 
 tions, a fact of which the majority of physicians seem to be unaware, if 
 one may judge from the frequency with which they are prescribed 
 in the secondary period of this malady. They are also sometimes 
 of decided value in psoriasis, but only when given in large doses. 
 
 While mercury displays its remedial value in diseases of the skin, 
 chiefly in those due to syphilis, it is often of decided use in other 
 affections. In many cases of eczema accompanied by constipation and 
 coated tongue, fractional doses of calomel, or blue pill, followed by 
 a saline, will often be accompanied by benefit. 
 
 Remedies which diminish intestinal putrefaction, such as salol, 
 salicylate of bismuth, creosote, guaiacol, or betanaphthol, are given in 
 those affections which are attributed to absorption of putrefactive 
 products from the intestinal tract. It seems doubtful, however, 
 whether these are of very much value. 
 
 Among all the drugs which have been employed internally in the 
 treatment of diseases of the skin, arsenic for a long time held the first 
 place. Its history as a remedy in diseases of the skin practically began 
 with the opening of the last century, and for years it was regarded 
 as a remedy which could be given with advantage in every affection 
 of the skin. Its popularity began to decline in the last quarter of the 
 past century, owing, no doubt, to the great influence of Hebra, who 
 criticised the use of it in every cutaneous disease, and at the present 
 time its use is very much restricted as compared with that of fifty years 
 ago. Even yet it is the one internal remedy to which the general 
 practitioner is apt to have recourse in a very large number of diseases 
 of the skin. In eczema, an affection in which it was at one time largely 
 employed, its use is of doubtful efficacy. I£ useful at all, it is only 
 in the dry scaly forms with thickening and scaling, and should never 
 be employed in the acute forms or when an acute exacerbation is pres- 
 ent. In psoriasis it is often remarkably effective, causing the eruption 
 to rapidly disappear, but it is not curative, nor does its continued use 
 prevent relapses. In pemphigus, in lichen planus, in dermatitis her- 
 petiformis, it is often of great use. It may be given in a number of 
 forms — as arsenic trioxide, the solution of potassium arsenite (Fow- 
 ler's solution), the solution of sodium arsenate, cacodylate of soda, 
 atoxyl and salvarsan (arsenobenzol). Cacodylate of soda and atoxyl 
 
GENERAL THERAPEUTICS 41 
 
 are especially adapted to hypodermatic use. By the use of these last 
 two, enormous amounts of arsenic may be introduced into the system 
 without toxic effect, but it is doubtful whether, except in certain specific 
 diseases, they produce any therapeutic effect which cannot be obtained 
 by the use of the older preparations. While undoubtedly a most 
 useful drug in a limited number of diseases, it must not be forgotten 
 that its prolonged use is not unattended by untoward and even danger- 
 ous effects. The long-continued use of arsenic produces marked pig- 
 mentation of the skin and a peculiar form of keratosis, usually confined 
 to the palms and soles, which may become the seat of epithelioma in 
 time. The most effective way to administer this drug is by hypoder- 
 matic injection, or, as in the case of arsenobenzol, intravenously. 
 
 Antimony has been employed in the treatment of inflammatory 
 affections of the skin, especially when the symptoms of inflammation 
 are acute. According to Ringer, Murrell and Nunn, it exerts an effect 
 similar to arsenic upon the epidermis. Its use is contraindicated in 
 the debilitated, as it is a powerful depressant. Quite recently it has 
 been found to exert a specific effect upon certain infections of the skin, 
 such as oriental sore and closely related tropical diseases, due to the 
 organism described by Leishman. It is used as tartar emetic and given 
 intravenously. From a recent experience the author is inclined to 
 believe that it may also be used locally with good effect in such 
 maladies. 
 
 Phenol, the various salicylates, and salicin are internal remedies of 
 decided value, especially the two latter, in affections such as psoriasis, 
 lichen planus and pruritus, salicin being perhaps the most valuable of 
 the three, since it may be given in larger doses for considerable time 
 without disturbing the stomach or producing other untoward effects. 
 
 Acetanilid, antipyrin, and phenacetin are frequently of decided 
 service in relieving itching and burning in such affections as urticaria 
 and pruritus ; indeed, in the former they often afford great, although 
 often only temporary, relief. 
 
 Sulphur has long had a great reputation among the laity as a remedy 
 in diseases of the skin, but it is more than doubtful whether it deserves 
 an important place among the useful internal remedies. Its internal 
 administration is, however, highly recommended by Crocker in hyperi- 
 drosis and other eruptions connected with sweating. Sulphide of 
 calcium, which was recommended by Ringer and others as a remedy 
 in furunculosis and other diseases accompanied by the formation of pus, 
 is, in the author's experience, a useless drug. Ichthyol and thiol, which 
 owe whatever therapeutic properties they possess to sulphur, have 
 been recommended by Unna and others for a great variety of cutaneous 
 affections, but the disagreeable odor of the former and the doubtful 
 efficacy of both limit their use decidedly. 
 
 Some of the ductless glands, such as the thyroid and the adrenals, 
 either in substance or as extracts, are useful to a limited degree in 
 
42 DISEASES OF THE SKIN 
 
 dermatological therapeutics. The former produces marvellous results 
 with which all are acquainted, in myxcedema. It has also been used 
 with occasional good effect in psoriasis and scleroderma. 
 
 The hyperdermatic injection of suspensions of killed microorgan- 
 isms, such as the bacillus tuberculosis, staphylococci, streptococci, 
 bacillus acne, and other organisms concerned in the production of 
 cutaneous infection, according to the method of Wright has, in recent 
 years, been attended occasionally with brilliant results, but these 
 results are far from uniform, most probably because our knowledge 
 concerning the etiological relationship of many of these organisms 
 to the diseases in which they are found is still inexact. The method, 
 erroneously called vaccine treatment, is one of considerable promise, 
 although it has thus far fallen short of expectations. Suspensions 
 made from the organism obtained from the patient's own lesions, so- 
 called autogenous vaccines, are much to be preferred to the stock 
 vaccines, but, no doubt, when our knowledge of the infecting organ- 
 isms is more exact, the latter will be found quite as effective as the 
 former. The diseases in which this method of treatment has been 
 found useful are furunculosis, acne, and sycosis vulgaris. Doubtless 
 this list will be greatly increased in the near future. 
 
 Within the past five years injections of serum, obtained from other 
 individuals, or from the patient's own blood (autoserum), have been 
 employed in a number of affections, such as pemphigus, dermatitis 
 herpetiformis, especially herpes gestationis, chronic urticaria, psoriasis, 
 chronic eczema, and some other chronic itching diseases, with asserted 
 remarkable results (Veiel, Linser, Spiethoff, Riibsamen, Gottheil and 
 Satenstein, and others). Foreign serum, especially horse serum, has 
 been employed in hemorrhagic purpura with occasional beneficial re- 
 sults, but in most instances it has failed. The results of serum therapy 
 are of such uncertain character that the whole matter must for the 
 present be regarded as still in the experimental stage. The with- 
 drawal of the blood, the preparation of the serum and its injection 
 should be carried out with strict asepsis. From 20 c.c. to 60 c.c, and 
 even more, are injected intravenously at each injection. 
 
 External or Local Treatment. — The direct application of remedial 
 agents to the diseased parts, external treatment, plays a most important 
 role in the treatment of diseases of the skin. Even in those affections in 
 which internal remedies are of most importance, the use of local appli- 
 cations will also frequently be found indispensable, not only for the relief 
 of symptoms, but as an important aid to cure. Many diseases of the skin 
 yield more or less readily to local remedies, and in many more both local 
 and internal treatment are requisite to recovery. It is in the use of local 
 remedies that dermatological therapeutics differ from the therapeutics 
 of constitutional and visceral diseases, and success in their employment 
 is largely a matter of experience, so that, other things being equal, 
 he will best succeed with these who has had the largest experience in 
 their use. 
 
GENERAL THERAPEUTICS 43 
 
 In applying remedial agents to the skin, many and various vehicles 
 are employed, such as baths, washes or lotions, ointments or salves, 
 dusting powders, pastes, varnishes, soaps, gelatins and plasters, and 
 the selection of the vehicle in any given case is, by no means, a matter 
 of indifference; indeed, it is oftentimes secondary in importance only to 
 the selection of the remedy to be incorporated with it. 
 
 It should always be borne in mind that the therapeutic effect of 
 many external remedies, like that of many internal ones, varies greatly 
 according to the dose. Weak preparations of salicylic acid act as a 
 stimulant to keratinization, strong ones are keratolytic, softening the 
 horny layer of the epidermis and causing its exfoliation. Menthol 
 ointment, two or three grains to the ounce, is markedly sedative, and 
 especially useful in pruritic diseases, while one containing ten or 
 fifteen grains is decidedly irritating. 
 
 In the treatment of acute inflammations of the skin washes or 
 lotions, as a rule, will be found to be more agreeable to the patient, 
 and at the same time more effective than ointments, while in chronic 
 affections, attended by considerable tissue-change, the reverse is usually 
 true. Exceptions, however, are not infrequent. 
 
 Baths may be employed in diseases of the skin for the purpose of 
 removing such pathological products as scales and crusts in order 
 to facilitate the application of local remedies. When used for this 
 purpose, they consist of plain water, or water to which some alkali, 
 such as bicarbonate of soda, or biborate of soda, has been added, the 
 latter being preferable when the accumulation of scales or crusts is at 
 all considerable. The indiscriminate use of baths in acute inflamma- 
 tory affections of the skin is often injurious, although the first effect 
 may be agreeable. Baths to which bran, starch, or other mucilaginous 
 substance has been added are frequently employed as palliatives in 
 inflammatory affections attended by itching and burning. The con- 
 tinuous bath in which the patient is immersed for several hours or even 
 days at a time is useful in extensive inflammations of the skin, as in 
 pemphigus and extensive burns. 
 
 It is frequently necessary to remove scales and crusts from the 
 skin before local treatment can be properly employed — to apply an 
 ointment or lotion to a surface covered by thick crusts for the pur- 
 pose of influencing the diseased skin beneath is futile. Water, either 
 warm or cold, alone or with soap, is frequently sufficient, but in many 
 inflammatory affections, such as eczema, the application of soap and 
 water is frequently harmful and should be avoided when possible. In 
 certain situations, such as the scalp, it may be difficult to remove the 
 accumulation of crusts and scales by simple washing without first 
 softening these. For this purpose we may employ starch poultices 
 made with a saturated solution of boric acid, or the liberal application of 
 bland fats, such as olive oil, oil of sweet almond or some one of the 
 petroleum fats, such as vaseline or cosmoline. Where a considerable 
 surface is involved, a prolonged tepid bath of plain water or, better, 
 
44 DISEASES OF THE SKIN 
 
 one made slightly alkaline by the addition of three or four ounces 
 (90.0 or 120.0) of sodium bicarbonate or borax to thirty gallons (120 
 litres) of water may be used with good effect. 
 
 Dusting powders are composed of various vegetable and inorganic 
 powders, such as starch, lycopodium, oxide of zinc, subcarbonate or 
 subnitrate of bismuth, or talcum. The inorganic powders are prefer- 
 able usually to the vegetable ones, because they do not readily undergo 
 decomposition in the presence of heat and moisture. These are em- 
 ployed as protectives in inflamed conditions of the skin, or as absorb- 
 ents, and may be used either alone or combined with medicinal 
 substances, such as various antiseptics like boric acid, salicylic acid, 
 or with sedatives such as phenol or menthol, when it is desired to allay 
 itching and burning. To obtain the best results from the use of. such 
 powders they should be liberally applied. 
 
 Lotions or washes are aqueous or alcoholic solutions, usually the 
 former, of various medicinal substances which are applied to the dis- 
 eased parts by mopping or spraying and then allowed to evaporate. 
 To apply them on lint or gauze, which is then covered over with a 
 bandage or some impervious covering, such as paraffined paper or 
 oiled silk, is to misuse them, since it defeats one of the purposes for 
 which they are used, viz., cooling by evaporation. They are no longer 
 lotions, but fomentations. The addition of insoluble powders, such 
 as oxide of zinc or subnitrate of bismuth, is often desirable, since these 
 form a protective covering after the evaporation of the water and prolong 
 the effect of the substance in solution, or the lotion may be immediately 
 followed by the application of a dusting powder. While often a most 
 useful form of local application, their effect is usually much less lasting 
 than other local remedies, such as ointments, and is also quite super- 
 ficial. They are indicated chiefly in acute affections and those in which 
 the tissue changes are superficial, and are employed for their cooling 
 or sedative effect, or as astringents, stimulants and antiseptics. 
 
 Salves or ointments are more largely used as local remedies in 
 diseases of the skin than any other form of application, and are, all in 
 all, the most useful form of local medication. They are composed of 
 a great variety of medicinal agents incorporated with some fatty base, 
 and according to the purpose in view they are merely protective or 
 astringent, sedative, stimulating, parasiticide, or alterative, and the 
 effect may be greatly varied merely by the manner in which they are 
 employed. 
 
 If they are to be used simply as a protective, they should be bland, 
 of rather firm consistence, and should be applied with very gentle 
 friction, either directly to the skin, or, if the parts are sensitive, they may 
 be spread upon lint or gauze and gently laid upon the diseased area. 
 
 If it is desired to affect the deeper portions of the skin, they should 
 be thoroughly rubbed in, not merely smeared over the affected parts. 
 A large number of fatty substances are employed as bases for oint- 
 ments and it is by no means an unimportant matter what particular 
 
GENERAL THERAPEUTICS 45 
 
 base is employed in a given case. When penetration is desired one 
 of the best bases is lard, but it has the disadvantage, common to many 
 animal fats, that it readily becomes rancid and is then an irritant. 
 Mineral fats, such as are obtained from petroleum, have the very 
 great advantage over those of animal or vegetable origin in that they 
 are unalterable, but most of them have a low melting point, so that they 
 readily become soft when applied to the skin and are absorbed by 
 clothing or bandages. Lanolin, or wool fat, adeps lanse, a cholesterin 
 fat largely employed in recent years, may be made to penetrate the 
 skin quite readily, but is too viscid to be used alone. When combined 
 with some soft fat, such as lard, or with an oil, such as oil of sweet 
 almond, or lard oil, it forms an excellent ointment base when it is 
 desired to produce a deep effect. As a rule the best ointment bases 
 are obtained by combining two or more fats. 
 
 Quite recently an admirable ointment-base, known as eucerin, has 
 been introduced by Unna. It is a derivative of wool fat, adeps lanae, 
 but lacks the objectionable viscid quality of that fat. It is entirely 
 odorless and may be made to penetrate the skin very readily. The 
 author has used it extensively in the past two or three years and finds 
 it especially adapted for use upon the scalp ; indeed, it is one of the 
 very best bases for ointments to be used in this region. 
 
 The following may be mentioned as examples of soothing and pro- 
 tective ointments to be employed alone or as vehicles for more active 
 remedies : Unguentum Aqua Rosae, which is one of the most elegant 
 and agreeable of all ; Unguentum Zinci oxidi, diachylon ointment, or 
 a substitute composed of equal parts of lead plaster and cosmoline. 
 The zii'c ointment of the Pharmacopoeia may be advantageously re- 
 placed by one containing two drachms (8.0) of oxide of zinc to six 
 drachms (24.0) of the Unguentum Aqua Rosas, being far more soothing 
 than the official ointment. 
 
 A very valuable modification of the ointment is the pastes which 
 are much more adhesive, form a better protective covering than the 
 former, and act to a limited extent as absorbents. They contain con- 
 siderable quantities of stearate or oxide of zinc, subcarbonate or sub- 
 nitrate of bismuth, or talc combined with starch, gum, or dextrin, and 
 some fatty base. To these, various active medicinal substances, such 
 as salicylic and boric acids, tar, resorcin, ichthyol, and many others, 
 may be added as indicated. They should not be applied to parts 
 covered by hair unless first shaved and should be removed once a day 
 by the application of some fatty substance, such as vaseline, olive oil or 
 oil of sweet almond; soap and water only make them more adhesive. 
 One of the most frequently employed is one devised by Lassar and 
 lenown by his name ; the formula is as follows : 
 
 B. Arid, salicylic gr. x (0.65) 
 
 Pulv. amyli, 
 
 Pulv. zinci oxidi aa 3ii (8.0) 
 
 Petrolat Bss ( 16.0) 
 
 M. 
 
46 DISEASES OF THE SKIN 
 
 Pastes, as a rule, are not suitable when there is free oozing. It is 
 difficult to apply them to moist surfaces and they do not adhere. 
 
 Glycerin is a valuable addition to washes and salves when suffi- 
 ciently diluted, making them much less drying; undiluted, it is quite 
 irritating to the skin. When combined with a considerable proportion 
 of gelatin it forms the so-called glycogelatins which, solid when cold, 
 become quite fluid when warmed, so that they may be readily applied 
 to the skin with a flat brush. When it is desired to give them con- 
 sistency, powders, like oxide of zinc, in varying proportions are added. 
 These are a useful form of application when it is desired to employ 
 a dressing which affords the utmost protection to the diseased surface, 
 and which may be left undisturbed for a considerable period. They 
 may have a variety of drugs, such as sulphur, ichthyol, calomel, am- 
 moniated mercury or chrysarobin, added to them, according to the indi- 
 cations of the individual case. When it is desired to remove them this 
 may be readily done by the use of hot water. 
 
 Varnishes are of two kinds — those soluble in water, which are com- 
 posed of gum, such as tragacanth or gum arabic, or bassorin, with 
 glycerin and water, and those, like collodion and solutions of gutta- 
 percha, which are insoluble in water. These, like the glycogelatins, 
 may be medicated in a variety of ways. 
 
 Plasters are employed to a limited extent when it is desired to avoid 
 the use of greasy applications or to produce a more continuous impres- 
 sion upon the affected parts as well as to protect them. While they 
 are convenient and cleanly, they labor under the disadvantage common 
 to all fixed dressings — that they cannot be altered in composition and 
 proportion to suit the individual case. Useful forms of plaster are the 
 salve muslins, mulls, and plaster mulls introduced into dermatological 
 therapeutics by Unna. These are cleanly and effective, but are open 
 to the same objection that other forms of plaster are. They are medi- 
 cated with salicylic acid, tar, salts of mercury, oxide of zinc and a 
 great variety of other medicaments in varying strengths. 
 
 Soaps are useful in the treatment of diseases of the skin as detersives 
 or as vehicles for various medicinal agents. As a detersive and stimu- 
 lant in various diseases of the skin, sapo viridis, soft soap, which con- 
 tains a large amount of potash, is frequently useful, but owing to the 
 large amount of free alkali in its composition it must be used with 
 caution, otherwise it produces a considerable degree of irritation, 
 removing the protective horny layer of the epidermis. In recent years 
 it has been endeavored to lessen the irritating effects of soap by adding 
 an excess of fat, producing so-called " superfatted " soaps. These are 
 medicated with salicylic acid, tar, resorcin, ichthyol, thymol, sulphur, 
 phenol and various mercurial salts. While soaps are convenient, they 
 can by no means replace ointments. They are of use chiefly in parasitic 
 diseases, such as scabies, and in diseases of the scalp. 
 
 The following is a brief list of some of the more important remedies 
 
GENERAL THERAPEUTICS 47 
 
 employed in the treatment of diseases of the skin arranged according 
 to their therapeutic effect: 
 
 Protectives. — Simple ointments composed of bland fats (lard, lano- 
 lin, petrolatum) and oils (olive oil, oil of sweet almond, oil of sesami) ; 
 dusting powders ; plasters. 
 
 Astringents. — Acetate of lead ; acetate and chloride of aluminum ; 
 tannic acid; sulphate of zinc. 
 
 Sedatives and Antipruritics. — Carbolic acid ; menthol ; resorcin ; 
 coal-tar; hydrocyanic acid (dilute); weak alkaline solutions; dilute 
 acetic acid. 
 
 Keratoplastic Agents (those which favor keratinization and healing 
 of the epidermis). — Salicylic acid (when used weak) ; resorcin (in mod- 
 erate strengths); sulphur; tar; tumenol ; formaldehyde; chrysarobin ; 
 salts of mercury. 
 
 Keratolyti: Agents (those which soften the horny cells of the 
 epidermis and cause its exfoliation). — Salicylic acid (one of the most 
 important) ; resorcin (when used in considerable strength) ; acetic acid. 
 
 Antiseptics and Parasiticides. — Carbolic acid ; salicylic acid ; resor- 
 cin ; salts of mercury, both the soluble and insoluble ; sulphur ; tar ; 
 formaldehyde ; naphthol. 
 
 Caustics. — Caustic potash; caustic soda; chloride of zinc; pyro- 
 gallol (especially useful in the treatment of flat superficial epithelioma) ; 
 arsenious acid (very effective in malignant growths, but extremely 
 painful) ; acetic and trichloracetic acids (superficially acting) ; nitrate 
 of silver; chromic acid; solid carbon dioxide (carbon dioxide " snow," 
 very useful when a superficial effect is desired with but little scarring) ; 
 liquid air. 
 
 The various forms of radiant energy, such as concentrated light, 
 the X-ray, and the emanations from radium, form a most useful group 
 of remedial agents in the treatment of many diseases of the skin. They 
 are especially valuable in the treatment of new growths, both benign 
 and malignant, and of the infectious granulomata, such as tuberculosis. 
 The X-ray is likewise frequently of great service in chronic eczema, 
 with much thickening, in acne, sycosis, and in the treatment of ring- 
 worm of the scalp. Of these, the X-ray is probably the most useful 
 to the dermatologist, but it is a remedy potent both for good and evil 
 and should accordingly be used with care and discrimination with a full 
 appreciation of its powers ; otherwise much harm may result from its 
 use. Electrolysis, the high-frequency current, and the violet ray also 
 find a l'.mited use in the treatment of diseases of the skin. 
 
CHAPTER VII 
 
 CONGESTIONS— BYPERJEM1JE 
 
 ERYTHEMA SIMPLEX 
 
 By erythema is meant simply redness of the skin, the result of con- 
 gestion or over-fulness of the blood-vessels. This redness may affect 
 an entire region, may be limited to variously-sized, ill-defined, or well- 
 circumscribed patches, or may occur as small spots or macules, varying 
 in size from that of a hemp-seed to a pea, when it is often designated 
 roseola. In simple hyperemia the redness can be made to disappear 
 completely under pressure, but immediately returns when the pressure 
 is removed. The skin may be unduly warm to the touch and the 
 patient may experience more or less heat or itching, or subjective 
 symptoms may be entirely wanting. The entire group of hyperaemic 
 erythemata are essentially mild inflammations of the skin and might 
 with entire propriety and accuracy be described under the title 
 dermatitis. 
 
 Two classes of erythemata are recognized — the idiopathic, or those 
 in which the skin affection exists independently of any other, and the 
 symptomatic, in which the eruption is but a part of a general affection 
 or the result of disturbance in some other organ. 
 
 The idiopathic erythemata are for the most part the result of local 
 conditions, such as heat, cold, traumatism, or contact of the skin with 
 irritants such as various poisonous plants or chemical substances. 
 
 The symptomatic erythemata are, for the most part, toxic manifes- 
 tations and are usually part of a general infection, such as the roseola 
 of typhoid and of syphilis, the erythematous eruptions which some- 
 times accompany or precede cholera, variola, and other general 
 infections. Or the toxic substance may be absorbed from the gas- 
 trointestinal canal, as in the erythemata which accompany gastric 
 disturbances in young children. 
 
 There are a number of clinical varieties of idiopathic erythema 
 which are classified chiefly according to their causes. 
 
 Erythema Caloricum. — Under this term are included those forms 
 of erythema due to exposure of the skin to heat. A common form of 
 this variety of erythema is sunburn, erythema solare, although to be 
 quite accurate this is due to the combined effect of heat and the chemi- 
 cal rays of light. With the disappearance of the redness more or less 
 pigmentation, so-called tanning, remains. 
 
 Erythema ab Igne. — Prolonged exposure to artificial heat, as of the 
 fire, will produce a retiform erythema which in time is followed by 
 pigmentation presenting a similar net-like arrangement. This variety 
 of erythema is seen most frequently upon the lower extremities of those 
 who are in the habit of toasting their shins before an open fire or by 
 
 48 
 
CONGESTIONS 49 
 
 sitting close to the stove. It may also follow the prolonged applica- 
 tion of the hot-water bag, one of the most marked examples of the 
 affection which the author has ever seen having been produced in this 
 manner in the sacral region. The pigmentation, which follows the 
 erythema, is frequently mistaken for a syphilitic symptom. 
 
 Erythema Traumaticum. — Mild injuries of the skin, such as follow 
 pressure or friction, may produce an erythema. 
 
 Erythema Venenatum. — Exposure to contact with poisonous plants 
 and many chemical substances, such as dye-stuffs, or medicinal sub- 
 stances used as local remedies, may produce an erythema which, unless 
 the exposure is short, usually passes into a dermatitis. 
 
 Erythema Pernio. — Exposure to cold in the young and old with 
 feeble circulation produces an erythema situated upon the extremities, 
 especially upon the toes, heels, and outer sides of the sole, less fre- 
 quently upon the nose and ears. The affected regions are usually a 
 dusky red or bluish red, and itch and burn to a marked degree, espe- 
 cially when the parts become warm. The affection usually disap- 
 pears in warm weather more or less completely, to recur with the 
 return of cold weather year after year. Exceptionally, inflammation, 
 vesiculation, and even ulceration, may occur as the result of neglect, 
 or from rubbing of the shoe. Those who suffer from this form of 
 erythema usually have a sluggish peripheral circulation, as shown by 
 dusky extremities which may become quite livid when cold. 
 
 In the treatment of pernio effort should be made to improve the 
 circulation in the affected parts by the application of stimulating 
 lotions and liniments, such as soap liniment; by alternate immersion 
 in hot and cold water, and protection by warm clothing. Duhring 
 found a lotion containing five grains (0.32) each of sulphate of zinc and 
 sulphuret of potash to the ounce (32) of water a useful application. 
 Tinctura iodi, painted on lightly once a day, is useful ; or 25-50 per cent, 
 ichthyol solution may be applied in the same manner. When the parts 
 are lightly frosted, Lapatin has advised the application, once a day, 
 for three or four successive days, of equal parts of dilute nitric acid 
 and peppermint water. If the parts are severely frozen, they should 
 be kept away from the fire, and efforts to restore the circulation be 
 made by friction with snow, when this is obtainable. 
 
 Erythema intertrigo, or simply intertrigo, chafing, occurs upon 
 opposed skin surfaces and is the combined effect of heat, moisture, 
 and friction. It occurs in the axillae, the groins, between the but- 
 tocks, on the inner surfaces of the thighs, and beneath the breasts in 
 women; in fat subjects, especially in infants, it occurs likewise in 
 the flexures of the joints. The skin is bright red at first, and later 
 becomes moist with maceration of the corneous layer of the epidermis. 
 There is a variable amount of tenderness with heat. If neglected, or 
 if injudiciously treated, a true eczema is likely to follow. It is usually 
 much worse in warm weather, when it may be the source of much 
 annoyance to stout subjects. 
 4 
 
50 DISEASES OF THE SKIN 
 
 The disease is produced by purely local conditions, and is the 
 result of heat, moisture, and friction combined. It may result from 
 neglect in infants, especially in the region of the buttocks and groins; 
 or, on the other hand, from too frequent bathing. 
 
 It is to be distinguished from eczema by its limitation to those 
 regions in which opposed surfaces of the skin are in contact, and by 
 the absence of itching and infiltration of the skin. In infants it is 
 to be differentiated from syphilitic erythema, which is likely to occur 
 in this region, by the usually darker hue of the redness, its limita- 
 tion to the buttocks, and the absence of syphilitic lesions elsewhere. 
 
 In the treatment of intertrigo the parts should be mopped frequently 
 with a saturated solution of boric acid, and afterwards freely powdered 
 with a dusting powder composed of equal parts of talc, oxide of 
 zinc, and boric acid. Or, in regions where there is an abundance of 
 perspiration, a powder containing one per cent, of salicylic acid will 
 be found serviceable. The opposed surfaces should be kept apart by 
 lint or gauze, or, as suggested by Unna, by thin bags made of cheese- 
 cloth or other loose-meshed cloth filled with a dusting powder such 
 as has been given above. Occasional applications of weak astringent 
 lotions containing acetate of lead, sulphate of zinc, or aluminum acetate 
 are at times useful. In infants particular care should be taken to 
 remove soiled napkins at once, and to keep the parts thoroughly dry 
 by the liberal application of a dusting powder. As a rule, salves 
 should not be used, although an exception may be made in favor of 
 the so-called pastes which contain a large quantity of powder. 
 
CHAPTER VIII 
 
 INFLAMMATIONS— EXUDATIONES 
 
 ERYTHEMA MULTIFORME 
 
 Synonyms. — Erythema exsudativum multiforme (Hebra) ; Fr., 
 firytheme multiforme. 
 
 Definition. — An acute inflammatory disease of the skin distin- 
 guished by an eruption composed of a variety of lesions, such as 
 macules, papules, nodules, and, less frequently, vesicles and bullae, in 
 varying combination and arrangement. 
 
 Symptoms. — The attack usually begins abruptly without premoni- 
 tory symptoms, although in a small number of cases there are headache, 
 malaise, and slight fever for some hours before the appearance of 
 the eruption; and in rare instances there is considerable elevation of 
 temperature, amounting to io2°-io3° F., with muscular and joint pains 
 and swelling of the joints, the eruption appearing only after twenty- 
 four to thirty-six hours. As its name indicates, the eruption presents 
 considerable variety in the type of lesions and their arrangement. 
 
 In the commonest form of the disease the eruption consists of a 
 variable number of, at first bright red, later violaceous, macules and 
 flat papules, the latter frequently exhibiting a small central punctum 
 which later may become a decided depression, occasionally transform- 
 ing the larger papules into ring-shaped lesions. The eruption shows 
 a decided predilection for certain localities, such as the backs of the 
 hands (the most frequent site), the extensor surface of the forearms, 
 the sides of the neck over the sterno-mastoid muscles, about the elbows 
 and knees, and the tops of the feet. Much less frequently the erup- 
 tion occurs upon the trunk, where it is most apt to be of the macular 
 type (Fig. 7). 
 
 The macules occasionally undergo involution in the centre, while 
 they continue to spread peripherally, forming well-defined rings, ery- 
 thema annulare. New macules may appear in the centre of these 
 rings, which undergo the same development, and in this manner sev- 
 eral concentric rings arise of different colors, the new ones bright red, 
 the older ones bluish or greenish, erythema iris (Fig. 8) ; or several 
 spreading rings may join to form gyrate figures, erythema gyratum. 
 The eruption may consist of a variable number of variously sized, 
 round, or irregularly shaped patches with somewhat elevated borders, 
 erythema marginatum. All these varieties of macular eruption are 
 seen most frequently upon the trunk. 
 
 Somewhat exceptionally, the inflammatory process may go on 
 to the production of sufficient exudation to form vesicles, or blebs, 
 erythema vesiculosum, erythema bullosum, situated, in most cases, 
 upon the hands and forearms, a variety occurring comparatively fre- 
 
 51 
 
52 
 
 DISEASES OF THE SKIN 
 
 quently in newly arrived immigrants. The vesicles may be arranged 
 about the borders of erythematous patches forming rings, herpes cir- 
 cinatus ; or there may be several concentric rings of vesicles, herpes 
 iris. Subjective symptoms are often entirely absent, but itching, vary- 
 ing from slight to severe, is present in a certain number of cases. 
 
 In rare cases the mucous membrane of the lips and of the cheeks 
 may also be attacked. 
 
 The number of the lesions and the extent of the eruption vary 
 considerably. In the maculopapular form the number of macules 
 and papules is usually quite limited. There may be no more than 
 a dozen of papules on the backs of the hands, with a few on the sides 
 of the neck ; but occasionally there may be scores of them covering 
 
 %k^ v ;sM^M. 
 
 Fig. 7.— Erythema multiforme, papular variety. 
 
 the hands and the forearms, the sides of the neck, the forehead, and 
 cheeks. In the various macular forms, occurring for the most part 
 on the trunk, the greater part of this region may be covered, although 
 here, too, the patches may be quite limited in number. 
 
 In rare cases the eruption, instead of being on both sides of the 
 body, may be confined to a limited area on one side. In a case under 
 the author's observation in the University Hospital it was limited 
 to the inguinal region of the left side, the lesions being of the maculo- 
 papular type and typical in every respect. There were frequent recur- 
 rences, three or four each year, for several years. 
 
 In mild cases of the papular type new lesions usually continue to 
 appear for two or three days, and the attack ends in a week. In the 
 
INFLAMMATIONS 
 
 53 
 
 severe forms there may be a number of crops coming out irregularly, 
 prolonging the disease to two or three weeks. In rare instances the 
 affection may last for months, or even several years, erythema perstans 
 (Kaposi, Stelwagon). 
 
 In a certain small proportion of cases the eruption is accompanied 
 by pronounced constitutional disturbance, sometimes of a serious 
 character, with visceral symptoms. Osier has reported a considerable 
 series of cases in which, along with a characteristic eruption, there 
 were nausea, vomiting, gastro-intestinal pains, and diarrhoea, with 
 occasional bloody stools. 
 
 Recurrences are very common in all varieties of the malady, espe- 
 cially so in the papular form, and not very infrequently there are 
 
 Fig. 8. — Erythema multiforme (erythema iris). 
 
 several attacks a year. In a young woman, under the author's care 
 some years ago, there had been an attack every year in the spring for 
 sixteen years. 
 
 Etiology. — Age and season are common predisposing causes. It 
 is quite infrequent in childhood and old age, but occurs most frequently 
 in youth and young adults. It is much more common in the spring 
 and autumn than at other seasons, although it may occur at any time 
 of the year. Sex is without any appreciable influence upon its occur- 
 rence. 
 
 The association of the eruption with painful and occasionally swol- 
 len joints in a certain proportion of the cases inclines many authorities 
 to regard the affection as of rheumatic origin ; but it need hardly be 
 pointed out that there are many kinds of arthritis which have nothing 
 to do with rheumatism. There is no satisfactory proof, in the author's 
 
54 DISEASES OF THE SKIN 
 
 opinion, of its rheumatic origin. A perfectly typical erythema multi- 
 forme is occasionally produced by certain drugs and sera, such as 
 antipyrin, the salicylates, the iodides, copaiba, and antitoxin. The 
 author has seen a most characteristic eruption follow the ingestion of 
 copaiba. It is occasionally observed in septic conditions, and is then 
 apt to be quite extensive in its distribution. 
 
 Crocker observed the papular variety to follow irritation of the 
 extremities from exposure to cold, to the sun, and to sea-winds; but 
 these could hardly have been anything more than predisposing factors. 
 
 Pathology. — The preponderance of evidence is greatly in favor of 
 the' view that erythema multiforme is of toxic character ; and it is 
 altogether probable that diverse toxins are concerned in its produc- 
 tion, a view to which its occurrence after drugs and sera lends much 
 support. Its occasional association with septic conditions seems to 
 make it likely that it may also at times be the result of infection. 
 
 Erythema multiforme, urticaria, and purpura are apparently closely 
 related affections, and at times seem to alternate with one another 
 in the same subject. It therefore seems quite probable that they are 
 due to similar or perhaps identical causes, and that the mechanism 
 of their production is much the same. 
 
 The histological features are those of a dermatitis. The papillae 
 of the corium are ©edematous and wider than normal, and their vessels 
 are dilated and surrounded by a more or less pronounced exudate of 
 lymphocytes, polynuclear leucocytes, and not infrequently a few red 
 cells which give to the papules their characteristic crimson or bluish 
 color. In the epidermis, in which the changes are of a secondary 
 character, the cells of the rete are somewhat swollen, and the inter- 
 cellular spaces are enlarged and contain a small number of leucocytes. 
 In the vesicular and bullous forms all these alterations are much more 
 pronounced. The rete contains intercellular cavities rilled with serum 
 and leucocytes, and in the bullous form the horny layer, or the entire 
 epidermis, is lifted up from its attachment to the papillary body by 
 an abundant exudation of serum. The contents of the vesicles and 
 blebs are usually sterile, but sometimes contain staphylococci. 
 
 Diagnosis. — The multiform character of the eruption; the bright 
 red color which shortly becomes bluish ; the frequent presence of a 
 central point or depression in many of the papules ; the pronounced 
 preference for the backs of the hands ; the absence or trivial character 
 of the subjective symptoms, in most cases; and the decided tendency 
 to recurrences, are the characteristic features which distinguish it from 
 other eruptions. 
 
 It is most likely to be mistaken for urticaria, especially if itching 
 is present; but the bright red or violaceous color of the papules, the 
 presence of a central depression in many of them, and more particu- 
 larly their persistence, in marked contrast to the evanescence of the 
 urticarial wheal, serve to distinguish it from that affection. 
 
 The frequently multiform character of the eruption and the large 
 
INFLAMMATIONS 55 
 
 size and color of the papules, the absence of marked itching, and its 
 characteristic localization upon the backs of the hands sufficiently 
 distinguish it from papular eczema. 
 
 The bullous form is to be distinguished from pemphigus and the 
 bullous variety of dermatitis herpetiformis. Both the latter are chronic 
 diseases, and dermatitis herpetiformis is attended, as a rule, by vio- 
 lent itching. Erythema multiforme is practically always an acute 
 affection, and seldom itches to any extent. It must be admitted, how- 
 ever, that in its beginning stage dermatitis herpetiformis may resemble 
 bullous erythema multiforme sufficiently to make a positive differen- 
 tial diagnosis between the two possible only after a period of obser- 
 vation. 
 
 A certain degree of resemblance may at times exist between ery- 
 thema multiforme and erythema nodosum, but the lesions of the 
 latter are decidedly larger than those of the former, are situated, in 
 most cases, over the front of the leg, and are often very sensitive or 
 painful. 
 
 Prognosis and Treatment. — With the exception of the cases accom- 
 panied by visceral symptoms and those of septic origin, the prognosis 
 is always favorable. In the cases with visceral complications, and 
 in those of septic origin, grave symptoms may arise, followed at times 
 by a fatal issue. As already observed, recurrences are common, and 
 the disease may appear year after year, sometimes several times a 
 year. 
 
 The disease is probably but little influenced by any form of treat- 
 ment. In cases of average severity the administration of a saline laxa- 
 tive and the application of a lotion of phenol, one per cent., or of 
 menthol, five per cent., in thirty per cent, alcohol, if itching is present, 
 will usually be sufficient. When muscular and arthritic pains are 
 associated with the eruption, salicylate of soda, aspirin, or salicin may 
 be given with advantage in moderate doses. In those with visceral 
 complications or of septic origin, salicylate of quinine should be given 
 in considerable doses. Villemin regarded iodide of potassium as a 
 specific, but it is more than doubtful whether it exercises any appre- 
 ciable effect. For the prevention of recurrences the salicylate of soda, 
 salol, or salicylate of quinine in moderate doses may be given inter- 
 mittently for some time ; but it must be confessed that these frequently 
 fail to prevent them. 
 
 ERYTHEMA NODOSUM 
 
 Synonyms. — Dermatitis contusiformis ; erythema contusiforme ; Fr., 
 £rytheme noueux; Ger., Knotenerythem. 
 
 Definition. — An acute inflammatory disease characterized by pain- 
 ful nodes situated, in most instances, upon the legs over the tibia. 
 
 Symptoms. — It usually begins abruptly with some constitutional 
 disturbance — headache, muscular and joint pains, the latter at times 
 
56 DISEASES OF THE SKIN 
 
 quite pronounced, and fever. After some hours, or, less frequently, 
 after a day or two, bright red, ill-defined, round or oval spots appear 
 upon the legs, usually over the tibia, wHich are quite sensitive, and 
 upon palpation are found to be deep-seated nodes. These, after a day 
 or two, as they approach the surface, present some elevation and in- 
 crease in size until they become as large as a small nut, or, excep- 
 tionally, as large as a pigeon's egg. Bright red at first, within two 
 or three days they become bluish, later greenish, and finally brownish, 
 presenting the changes in color shown by an ordinary bruise, hence 
 one of its names, dermatitis contusiformis. At first they are quite 
 firm, but later, when fully developed, they are somewhat soft and 
 elastic, and upon palpation frequently give a sensation of fluctuation 
 like an abscess, which they may resemble somewhat; but suppuration 
 rarely occurs, although it has been noted by a few observers. The 
 number on each leg varies from two or three to a dozen or twenty ; 
 but as a rule they are present in moderate numbers. Occasionally 
 they occur upon the forearms, usually upon the outer side ; and, quite 
 exceptionally, they are seen upon the face. In rare instances they 
 have been seen upon the mucous membranes of the mouth and pharynx, 
 and Cott has reported a case in which they were present upon the 
 tracheal mucosa, giving rise to alarming dyspnoea. In exceptional 
 cases the constitutional disturbance is pronounced, the temperature 
 reaching 104 or 105 ° F. ; and hemorrhage may occur in the nodes, 
 giving them a crimson or purplish color, which does not disappear 
 under pressure. 
 
 Occasionally mixed cases occur, in which, along with the usual 
 nodes upon the legs, there is a papular eruption on the backs of the 
 hands characteristic of erythema multiforme. Such cases go far to 
 support the contention of those who regard the malady as a variety of 
 the latter. 
 
 The duration of an attack varies from ten days to two or three 
 weeks, but it is not very rare to see it last five or six weeks, new 
 nodes appearing every few days. Second attacks are quite unusual,, 
 although not exactly rare. 
 
 Etiology. — Erythema nodosum occurs most frequently in the sec- 
 ond and third decades, and is decidedly uncommon at both extremes of 
 life. Women are much more frequently its subjects than men, accord- 
 ing to Mackenzie, in the proportion of five to one. In a series of 108 
 cases this same author found the disease so frequently associated with 
 arthritis, sore throat, endocarditis, and other symptoms commonly at- 
 tributed to rheumatism that he concluded that it was, in most cases, 
 if not invariably, a rheumatic affection ; but it is hardly necessary to 
 point out that rheumatism is a very elastic term applied to a number 
 of affections which are quite unrelated so far as their causation is 
 concerned. Other factors which are regarded as directly causative 
 or predisposing are malaria, exposure to cold, and damp and unhy- 
 gienic surroundings. In a considerable number of instances, much too 
 
INFLAMMATIONS 57 
 
 large to be the result of mere coincidence, it has been observed in 
 connection with tuberculosis, and in a small number in the secondary 
 stage of syphilis. 
 
 Very recently Rosenow has found in the nodes a polymorphous 
 diplococcus, usually in pure culture, which, when injected into the 
 dog, the rabbit, and guinea-pig, exhibits a marked affinity for the 
 subcutaneous tissues, where it produces localized hemorrhages, fol- 
 lowed by migration of leucocytes and enlargement of the regional 
 lymph-glands. He regards this organism as the cause of the affection. 
 
 Pathology. — Erythema nodosum is regarded by many authorities 
 as simply a variant of erythema multiforme, and there is apparently 
 very little doubt that the two are closely related. The occurrence of 
 mixed cases in which symptoms of both are present simultaneously 
 affords strong proof in support of this view. It is regarded by most 
 recent authors as an infection, and the findings of Rosenow, above 
 referred to, seem to confirm this, although these still await the con- 
 firmation of other investigators. It seems not at all improbable, how- 
 ever, that a similar, if not identical, eruption may be produced by 
 more than one kind of infection. There is strong evidence that it 
 is in some manner related to tuberculosis and occasionally, perhaps, 
 to syphilis. 
 
 The histological changes are those of inflammation, and are much 
 the same as those found in erythema multiforme. The changes in the 
 epidermis are slight — some swelling of the cells, with dilatation of 
 the lymph spaces, and an increased number of mitoses. In the papil- 
 lary body and in the corium the vessels are dilated and surrounded 
 by an abundant exudation of leucocytes. According to most authori- 
 ties, there is more or less diapedesis of red blood-cells, which accounts 
 for the changes in color which the nodes exhibit ; but Unna has never 
 found extravasated blood. He attributes the discoloration to the 
 breaking up of haemoglobin in the vessels and its absorption by the 
 tissues. 
 
 Diagnosis. — The lesions of erythema nodosum are to be distin- 
 guished from bruises, from abscess, and from syphilitic gumma. 
 
 Their number and symmetrical distribution, with the constitutional 
 symptoms which are usually present in some degree in the beginning, 
 differentiate them from the first. The local symptoms are usually 
 much more pronounced in abscess, and this is rarely present in such 
 numbers as the nodes. The multiplicity of the lesions, their tender- 
 ness, and rapid change in color distinguish them from syphilitic gum- 
 mat a. 
 
 Prognosis and Treatment. — The prognosis is always favorable, the 
 affection running a course of two or three weeks in most cases, al- 
 though it may be prolonged to five or six. In rare cases, as already 
 noted, the constitutional symptoms may be quite severe. 
 
 The treatment is altogether symptomatic. We know of no reme- 
 dies which directly influence the course of the disease. In all but the 
 
58 DISEASES OF THE SKIN 
 
 mildest cases, the patient should be put to bed, and if the pain in the 
 nodes is at all severe the legs should be elevated. A mild laxative 
 should be given and the diet somewhat restricted. Salicylate of soda, 
 aspirin, or salicin should be given in moderate doses. Locally, lead- 
 water and laudanum should be applied on gauze, or a mixture of 
 ichthyol in water, one part of the former to three of the latter, may 
 be applied with a camel's-hair brush twice or three times a day. 
 
 URTICARIA 
 
 Synonyms. — -Hives, Nettlerash ; Fr., Urticaire ; Ger., Nesselaus- 
 schlag, Nesselsucht. 
 
 Definition. — An inflammatory disease of the skin distinguished by 
 an eruption of whitish, pink, or red elevations known as wheals, which 
 are usually quite evanescent, and are accompanied by severe itching 
 and burning. 
 
 Symptoms. — The attack usually begins quite suddenly with the ap- 
 pearance of a variable number of wheals, and in a certain proportion 
 of cases with some gastric disturbance, such as nausea, vomiting, and, 
 exceptionally, with some elevation of temperature. In a considerable 
 number of cases, however, the eruption is the only symptom. The 
 wheals vary in size from that of a small pea to the palm of the hand, 
 are round or irregular in shape, sometimes serpiginous, and quite often 
 linear, the last looking as if produced by the stroke of a whip-lash. 
 The number of the lesions and extent of the eruption vary greatly. 
 There may be less than a half-dozen wheals limited to a certain local- 
 ity or scattered about in various regions, or there may be hundreds of 
 them covering a considerable part of every region of the body. One 
 of their most striking and characteristic features is their evanescence. 
 They usually last but a short time, from a few minutes to an hour or 
 two, and then disappear, leaving no trace of their existence. They 
 may appear with extreme rapidity, covering the greater part of the 
 skin within a few minutes. 
 
 The eruption is by no means limited to the skin, but attacks the 
 mucous membranes of the lips, the tongue, the larynx, and even the 
 bronchi. The lips when attacked are often greatly swollen, and the 
 tongue may be so swollen as to protrude from the mouth. When the 
 larynx is invaded there is more or less dyspnoea, and with the involve- 
 ment of the bronchi the breathing becomes markedly asthmatic. 
 
 In exceptional cases a small vesicle may appear upon the top of 
 the wheal ; or, still less frequently, the exudation may be so great as 
 to produce blebs or bullae (urticaria vesiculosa, urticaria bullosa). In 
 rare instances the wheals are purplish, owing to hemorrhage into 
 them (urticaria hemorrhagica, purpura urticans). 
 
 More or less itching, burning, and tingling accompany the erup- 
 tion, and are frequently of the most distressing character, driving the 
 patient to desperation in his efforts to obtain relief. In women and 
 children a highly nervous condition may result. 
 
INFLAMMATIONS 
 
 59 
 
 In many cases wheals may be artificially produced by stroking 
 the skin with some blunt object, such as the end of a pencil, or with 
 the nail. Such stroking produces at first a red streak with a white 
 centre, which, within some minutes, becomes a well-developed linear 
 wheal, which may last from twenty minutes to a half hour. This 
 condition, known as urticaria factitia, or dermographism, autographism 
 (Fig. 9), also occurs in other itching affections, such as pediculosis 
 corporis, scabies, and eczema. As it is often discovered by accident, 
 
 Pig. 9. — Dermographism. Letters and figures appeared about fifteen minutes after rubbing with 
 the end of the handle of a pen-knife and lasted about a half-hour. Patient had an eczema of the face 
 and neck. 
 
 the susceptibility is no doubt present in many cases of these diseases 
 without being discovered. 
 
 Although the wheals usually last but a short time, a few hours 
 at most, cases occur in which theylast for some days, or even a month 
 or more (urticaria perstans). 
 
 In much the larger proportion of cases, urticaria is an acute affec- 
 tion, lasting a few days or a week ; but it also occurs as a chronic 
 malady, lasting months or years. As in the acute variety, the individ- 
 ual wheals are of short duration, but new ones are constantly taking 
 
60 DISEASES OF THE SKIN 
 
 the place of the old ones, and the affection is thus greatly prolonged. 
 The patient is rarely quite free from eruption, there being a few wheals 
 present in one locality or another continuously, and acute exacerba- 
 tions occur from time to time, in which the number of lesions is greatly 
 increased, with a corresponding increase in the itching and burning. 
 These exacerbations may, in exceptional cases, exhibit a remarkable 
 periodicity. In a case under the author's care for a considerable time, 
 a furious outbreak occurred every afternoon about five o'clock for more 
 than five years. 
 
 In children, especially in those ill-nourished and badly cared for, 
 an affection known as papular urticaria (urticaria papulosa), also as 
 lichen urticatus, occurs which differs from other forms of urticaria. 
 The eruption begins as hemp-seed sized, firm, pink or red wheal-like 
 papules, which, however, do not disappear in a short time like the 
 ordinary wheals, but persist as papules for days, or longer. These 
 papules itch severely, and as the consequence of scratching most of 
 them are covered with a small blood-crust. The eruption is most 
 abundant upon the extremities, although by no means limited to these, 
 and disappears largely in cold weather, to reappear with the return 
 of warm weather. With some other writers, the author is inclined to 
 regard this as related to mild prurigo rather than to urticaria. 
 
 Etiology.— The sting of plants, such as the nettle; the bites and 
 stings of certain insects, such as the mosquito, the flea, the bedbug; 
 and contact with certain hairy caterpillars and the jelly-fish, are fre- 
 quently enumerated as among external causes of urticaria; but, while 
 it is true that these produce wheals, they do not cause urticaria — the 
 presence of a few wheals from such causes does not constitute an attack 
 of urticaria. 
 
 The most frequent cause of urticaria is the ingestion of certain 
 articles of food, such as strawberries, shell-fish (such as crab, lobster, 
 less frequently oysters, clams), veal, pork, honey, eggs, but, in addition 
 to taking such foods, there is necessary a certain predisposition on the 
 part of the individual, since many, in fact most, persons may partake 
 of them without any ill-effects. Many drugs may, in predisposed sub- 
 jects, produce an attack. Antipyrin, the salicylates, the iodides, quinine, 
 and many others are occasionally followed by urticaria. It frequently 
 follows emotional disturbance. The author has seen a most extensive 
 eruption follow the embarrassment of an interview with a stranger, the 
 whole body being covered with wheals within five minutes. 
 
 Malaria is likewise to be regarded as an occasional cause. The 
 author has seen an instance in which an eruption of wheals occurred 
 every other day, the attacks ceasing promptly with the administration 
 of quinine, and H. C. Wood has recorded a similar case. 
 
 It occasionally precedes or accompanies other affections of the 
 skin. Prurigo usually begins as an urticaria in infancy, and it occurs 
 with a fair degree of frequency in certain cases of dermatitis her- 
 petiformis. 
 
INFLAMMATIONS 61 
 
 In women functional or organic disease of the generative apparatus 
 may produce it. In the classical case recorded by Hebra an attack 
 invariably followed the introduction of the uterine sound, and Spencer 
 Wells observed it in one case after every introduction of the vaginal 
 speculum. 
 
 It has been noted to follow the puncture or rupture of a hydatid 
 cyst, the fluid escaping into the peritoneal cavity. 
 
 Pathology. — Recent investigations make it altogether probable that 
 urticaria is to be regarded as an anaphylactic phenomenon in most 
 cases, if not invariably the result of a hypersensitiveness on the part 
 of the subject to certain proteins, or to other substances, such as drugs, 
 which may behave like proteins. 
 
 The urticarial wheal is the product of a marked circumscribed 
 cedema. By most authorities it is regarded as a vasomotor phenomenon 
 resulting from the irritation produced by some toxin in the circulation. 
 Vidal, who examined sections of a wheal excised during life, found the 
 superficial and deep network of vessels dilated and gorged with blood 
 with no alteration of the vessel-walls. Around the vessels and 
 lymphatics were many leucocytes, and collections of these were 
 scattered throughout the entire thickness of the corium. There 
 was also a slight emigration of leucocytes into lower layers of the 
 epidermis. 
 
 Unna, in the wheals produced by the sting of the nettle, found an 
 enormous dilatation of the lymph-spaces and vessels most pronounced 
 in the neighborhood of the deep vascular network. The white color of 
 the wheal was due to the venous stasis present which compressed the 
 capillaries, driving out the blood. He found no leucocytes nor other 
 signs of inflammation and regards the process as a very acute spastic 
 cedema. 
 
 Gilchrist, who studied the wheals of factitious urticaria excised 
 at varying intervals after their production, found decided evidences of 
 inflammation — emigration of polymorphonuclear leucocytes, lympho- 
 cytes, and fragmentation of nuclei. 
 
 Diagnosis. — The urticarial wheal is such a very characteristic lesion 
 that when present the diagnosis of urticaria may be made with the 
 greatest ease. But it very frequently happens that one is called upon 
 to make the diagnosis when the eruption has for the time disappeared. 
 The evanescent character of the eruption, the severe itching and burn- 
 ing which accompany it, often with swelling of the lips or the lids, the 
 white color of the wheals which the patient often describes as blisters, 
 and their frequent linear shape, together with the knowledge that the 
 patient has eaten strawberries or shell-fish, will usually enable the diag- 
 nosis to be made without difficulty. 
 
 Prognosis and Treatment. — The prognosis in acute urticaria is 
 always favorable, the attack seldom lasting more than a few days and 
 often only a few hours. It is otherwise, however, in the chronic 
 variety. This may persist for many months or several years with in- 
 
62 DISEASES OF THE SKIN 
 
 complete intermissions, in spite of the most careful attention to the 
 patient's diet and mode of life, and cause him extreme distress. 
 
 In an acute attack, if the patient is seen sufficiently early, and it is 
 probable that it is due to the taking of some article of food, such as 
 shell-fish, the stomach should be emptied by an emetic, or if some time 
 has already elapsed since the meal, hourly doses of a tenth of a grain 
 (0.006) of calomel, until ten have been taken, should be given, followed 
 by a brisk cathartic. For the relief of the itching, lotions of phenol, 
 one to two per cent.; of menthol in alcohol, one-half to one per 
 cent. ; of thymol, one-half per cent. ; of chloral hydrate, two to three 
 per cent. ; of sodium bicarbonate or sodium biborate, one to two per 
 cent.; dilute acetic acid, two per cent., will be found more or less 
 useful. Dusting powders composed of talcum and stearate of zinc, or 
 subnitrate or subcarbonate of bismuth, with one-half per cent, of 
 menthol added, will often prove useful if liberally applied. The diet 
 should, of course, be carefully regulated to prevent relapses and new 
 attacks. 
 
 In chronic urticaria the patient's diet should be carefully and 
 minutely supervised and the possible hypersusceptibility to certain 
 proteins be determined by a rigid analysis of his dietary, or by the 
 epidermic inoculation or intradermic injection of soluble food proteins. 
 In the author's own experience, however, food is much less frequently 
 the etiological factor in the chronic form than in the acute variety. 
 The bowels should be kept freely open, preferably with some saline, 
 and occasional short courses of small doses of calomel should be given. 
 In the gouty, alkaline waters, especially Vichy, should be freely given 
 and a suitable regimen adopted. Patients with diabetes or uterine 
 disease should have treatment appropriate to these affections. 
 
 Intestinal antiseptics, such as salol, guaiacol, or the salicylate of 
 bismuth, are at times serviceable and have been highly commended by 
 Crocker. In a number of instances the administration of thyroid gland 
 has been followed by decided relief. In a case under the author's 
 care at the present time, which has lasted for four or five years, this 
 has been decidedly useful, much more so than the many other reme- 
 dies tried. Acetanilid with bicarbonate of soda, in doses of four or five 
 grains (0.26 or 0.32), or phenacetin in the same dose, will often afford 
 considerable relief to the itching, although these have no curative 
 effect. Calcium chloride, in doses of ten to twenty grains (0.65 to 
 1.30), several times a day, has been recommended by Wright, but 
 the author has found it disappointing after a considerable experience 
 with it. 
 
 Atropin or hyoscin hydrobromate will occasionally afford relief from 
 the itching, but the effect of these upon the mucous membranes makes their 
 prolonged use undesirable. 
 
 Locally, the same lotions and dusting powders may be used as in 
 the acute form. These are much more agreeable and usually much 
 more effective than ointments. 
 
Fig. io. — Urticaria pigmentosa. 
 
INFLAMMATIONS 63 
 
 URTICARIA PIGMENTOSA 
 
 Synonym. — Xanthelasmoidea (Tilbury Fox). 
 
 Definition. — A chronic affection distinguished by an eruption 
 resembling urticarial wheals, which is more or less persistent and 
 pigmented. 
 
 Symptoms. — The disease begins in most cases early in life, usually 
 within the first six months, and is characterized by an eruption of 
 papules and maculopapules, varying in size from that of a hemp-seed 
 to a pea, at first pinkish red or yellow in color, resembling the wheals 
 of urticaria and, like those, coming out rapidly, ordinarily in a few 
 hours. It may appear on all parts of the skin, is usually symmetrically 
 distributed and is most abundant first upon the trunk, next upon the 
 extremities and last upon the palms and soles, where it is rare. Occa- 
 sionally it also occurs upon the mucous membranes of the mouth and 
 pharynx. New lesions appear from time to time, while the old ones 
 become less prominent and more pigmented. Occasionally some of the 
 papules exhibit a vesicle upon the summit in their early stages, but this 
 is decidedly uncommon. More or less itching, as a rule, accompanies 
 the eruption, but in many cases this is not a pronounced symptom and 
 may disappear entirely in the later stages. Quite commonly factitious 
 wheals appear, and the old lesions become distinctly red and elevated 
 when rubbed or irritated in any manner. Whil^-as a rate, the erup- 
 tion shows no definite arrangement, it is occasionally noted to follow 
 a linear distribution upon the sides of the thorax, in the direction of 
 the intercostal spaces, or occurs in ill-defined patches. The lesions 
 are often very numerous and may cover a large part of the skin 
 (Fig. 10). 
 
 Unlike ordinary wheals, they do not disappear in a little while, 
 but remain for weeks or months, changing in color from pink to vary- 
 ing shades of brown and becoming flatter, with a finely granular or 
 wrinkled surface. They may then remain for years, with but little 
 change in appearance. As altogether exceptional, Hallopeau has re- 
 ported a case in which small white cicatrices replaced the lesions. 
 
 It usually disappears spontaneously about the time of puberty, but 
 it may last much longer. Morrow observed an instance in which it 
 had lasted thirty years or more. 
 
 Duhring recognized two types of the malady, one a persistent urti- 
 caria with pigmentation, the other, resembling xanthoma multiplex, 
 in which the papules are distinctly yellow, the xanthelasmoidea of 
 Tilbury Fox. Crocker describes three types : a nodular, or xanthelas- 
 moidea form, a macular in which there is little more than pigmentation, 
 and a third mixed type in which the lesions are both nodular and 
 macular. 
 
 Etiology and Pathology. — In the great majority of cases the disease 
 begins in infancy, usually in the third or fourth month. ^ Crocker saw 
 one in which it was noticed at birth. Exceptionally it begins after 
 puberty. 
 
64 
 
 DISEASES OF THE SKIN 
 
 Elliot has reported a case in which it appeared first at twenty-seven 
 years of age, and the author has very recently seen one in which it 
 began at twenty-three. It is decidedly more frequent in males than in 
 females. Six out of eight cases observed by Crocker occurred in boys. 
 The direct cause is altogether unknown. 
 
 The epidermis shows but little change beyond an abnormal amount 
 of pigment in the basal-cell layer of the rete mucosum. In 1887 Unna 
 announced that the cellular exudate present in the papillary and sub- 
 papillary portions of the corium was composed almost entirely of 
 
 Fig. 11. — Urticaria pigmentosa. Broadening of the rete mucosum with vacuolation of some of its cells 
 
 numerous "mastzellen" in corium. 
 
 " mastzellen," an observation abundantly confirmed since by other 
 observers. These cells are arranged in rows and columns between the 
 collagen fibres of the corium and are large and frequently cubical in shape 
 instead of elongate, owing probably to pressure. This " mastzellen " exu- 
 date is wholly characteristic of the disease. According to Unna it is 
 limited to the papillary body, but subsequent observations have shown that 
 it may extend well down into the corium. According to Gilchrist the 
 apparently sound skin contains an abnormal number (Fig. n). 
 
INFLAMMATIONS 65 
 
 Diagnosis. — The disease is readily recognized in most cases, but 
 the author has recently seen one case in an adult male with numerous 
 papules the size of a shot, which resembled very closely the maculo- 
 papular syphiloderm ; but a history of a duration of a year or more 
 and a biopsy confirmed the diagnosis of pigmented urticaria. The 
 early appearance of the eruption in infancy, the presence of wheals 
 followed by persistent pigmentation, and its great chronicity are the 
 characteristic features. 
 
 Prognosis and Treatment. — The affection usually lasts for many 
 years, but, as already observed, tends to disappear about the time of 
 puberty. In most cases the subjective symptoms are so slight as to 
 occasion but little annoyance. Its course is altogether uninfluenced by 
 treatment. If itching is at all pronounced, lotions of carbolic acid or 
 of menthol may be used. 
 
 CEDEMA ANGIONEUROTICUM 
 
 Synonyms. — Acute circumscribed cedema; Angioneurotic oedema; 
 Giant urticaria; Quincke's disease. 
 
 Definition. — An affection distinguished by circumscribed painless 
 swellings of the. skin coming on suddenly and of short duration. 
 
 Symptoms. — This affection was first described by Milton under the 
 name of giant urticaria, and later cases have been reported under 
 the name of acute circumscribed or angioneurotic cedema by 
 Quincke, Striibing, Osier, the author, and a number of others. 
 It is characterized by the sudden appearance of ill-defined swell- 
 ings on various parts of the cutaneous surface, most frequently 
 the face, varying in size from a nut to an egg. These are usually 
 the color of the normal skin, but may be pink or bright red, are 
 rather firm, do not pit on pressure and, as a rule, are unaccompanied 
 by any subjective symptoms beyond a slight feeling of stiffness or 
 tension. In a considerable proportion of cases their appearance is 
 accompanied by nausea, vomiting, abdominal pain or other symptoms 
 of gastro-intestinal derangement, but these are often entirely absent. 
 The duration of the swelling is usually short, frequently only a few 
 hours, and, as a rule, less than twenty-four. The number present at 
 any one time is usually quite small, as a rule not more than two or 
 three, and not infrequently but a single one. The mucous membranes 
 of the tongue, the soft palate, and the larynx may be attacked, and when 
 the swelling occurs in the last situation it may give rise to the most 
 urgent dyspnoea, and may cause death from suffocation. In a case 
 observed by Striibing the dyspnoea became so alarming that prepara- 
 tions were made to do tracheotomy. In a certain number of cases the 
 attacks recur with great regularity, coming on at a definite hour. In 
 one observed by Matas the attacks came on every day between eleven 
 and twelve o'clock. They frequently occur at night, the patient at 
 retiring presenting his usual appearance, but arising in the morning 
 with an eye completely closed or most of the features obliterated by 
 5 
 
66 DISEASES OF THE SKIN 
 
 a formless swelling of the face. In a patient under the author's obser- 
 vation for some months the attacks invariably occurred at this time. 
 Occasionally the extremities may be the seat of swellings, but the trunk 
 is rarely affected. In a large proportion of the cases the oedema con- 
 stitutes the only symptom, but occasionally ordinary wheals, such as 
 those seen in urticaria, are present or alternate with it. 
 
 The course of the affection is an eminently chronic one, usually 
 continuing for months and even years, the interval between the attacks 
 varying from a few weeks to a month or more. 
 
 Etiology and Pathology. — The causes are, in a way, much the same 
 as those of urticaria, although it is much less frequently due to ingesta 
 than the latter. In certain individuals cold, as a cold bath, or washing 
 with cold water, will produce it, especially in regions where there is an 
 abundance of loose connective tissue, as the lids, the prepuce, and the 
 scrotum. The studies of Striibing, Osier, and Schlessinger show that 
 heredity plays an important role in its production, these authors having 
 noted its occurrence in one or more members of certain families for 
 several generations. Osier has reported the history of a family in 
 which it was present in five generations, including twenty-two mem- 
 bers. It is an angioneurosis closely related to urticaria and. like that 
 affection, probably an anaphylactic manifestation. 
 
 Diagnosis. — The diagnosis is usually readily made. The sudden 
 appearance of the swellings, usually in the face, the occasional involve- 
 ment of the mucous membranes, the short duration of the lesions and 
 the usual absence of any marked subjective symptoms, such as itching, 
 burning, or pain, serve to distinguish it from other affections of the skin. 
 
 Prognosis and Treatment. — The course of the affection is usually 
 a very chronic one, but little influenced by treatment. As already 
 observed, sudden death may occur from oedema of the glottis. 
 
 The diet should be carefully supervised, excluding such articles 
 of food as strawberries, shell-fish, cheese, and pork; in other words, 
 the diet should be the same as in chronic urticaria, at least until it is 
 definitely ascertained that the malady is in no way dependent upon 
 ingesta. In the author's own experience the daily use of a mild saline 
 laxative and small doses of sodium salicylate have given the best results. 
 
 Calcium chloride or lactate may be tried, in doses of 10 to 15 grains 
 (0.65 to 1.0), three or four times a day. Osier has observed great 
 improvement follow the prolonged use of nitroglycerin. 
 
 DERMATITIS EXFOLIATIVA 
 
 Synonyms. — Pityriasis rubra (Hebra) ; Fr., Dermatite exfoliatrice ; 
 Erythrodermie exfoliante (Besnier). 
 
 Definition. — An acute or chronic, in most cases the latter, inflamma- 
 tory disease, distinguished by intense redness and abundant desqua- 
 mation affecting the greater part or the whole of the skin. 
 
 Under the term dermatitis exfoliativa a number of inflammatory 
 affections of the skin are included which have in common the symptoms 
 
INFLAMMATIONS 67 
 
 of redness, abundant exfoliation of the epidermis and universal dis- 
 tribution. While the different members of this group resemble one 
 another quite closely in their clinical symptoms, they differ consider- 
 ably in their course arid termination, and are probably, for the most 
 part, wholly unrelated etiologically. Certain of them are primary 
 diseases, others are secondary to other inflammatory affections, such 
 as eczema, dermatitis, or psoriasis, of which they may be the terminal 
 stage or the sequel. The exact relationship of these to one another 
 is still undetermined. Crocker was of the opinion that all were only 
 varieties of one disease, while others regard the pityriasis rubra of 
 Hebra as an independent affection quite distinct and apart from the 
 rest (Jadassohn). 
 
 There are two principal types of the affection, viz., the Wilson- 
 Brocq type, which may be acute or chronic, primary or secondary, and 
 the Hebra type, pityriasis rubra. Other forms are the dermatitis 
 exfoliativa neonatorum described by Ritter, and the epidemic derma- 
 titis described some years ago by Savill. Recurrent scarlatiniform 
 erythema is regarded by Brocq and other French authors as belonging 
 in the same category, but will not be considered here. (Vid. Erythema 
 scarlatiniforme.) 
 
 Symptoms. — The primary form of the Wilson-Brocq variety begins 
 with redness of the skin, either diffuse or in patches, which steadily 
 spreads until, within two or three days, or it may be two or three 
 weeks, the greater part or the whole of the cutaneous surface is covered. 
 In a considerable proportion of the cases there is some constitutional 
 disturbance — headache, malaise, and fever, the last sometimes consider- 
 able — which usually disappear within a day or two, but may continue for 
 a considerable time, as a daily evening rise of temperature. Shortly 
 after the appearance of the redness, or almost immediately, scaling 
 begins on the reddened areas, which are soon covered with abundant 
 thin papery scales of considerable size. Upon the palms and soles the 
 scales are thick and large, or the horny layer of the epidermis may 
 come off almost entire. The scalp is covered with scales and the 
 hair is dry. When the disease is fully developed the skin is intensely 
 red and dry and covered with thin scales, like tissue-paper, which are 
 constantly cast off in great abundance, and as constantly renewed. 
 Several handfuls of scales may be gathered in the patient's bed every 
 day, and the carpet around him is covered with them every time he 
 removes his clothing. The hair becomes thin and the nails are lustre- 
 less, ridged transversely, and sometimes shed. When the disease has 
 lasted for some time, the skin may lose its bright red color and become 
 a slate-blue or quite brown, owing to pigmentation (Fig. 12). 
 
 When it occurs as the terminal stage or the sequel of eczema or 
 psoriasis, the primary affection, retaining for a time its usual characters, 
 spreads, either as the result of an acute exacerbation, or slowly without 
 any special increase in the severity of the symptoms, until the entire 
 surface is involved. It then assumes the features of a universal der- 
 
68 
 
 DISEASES OF THE SKIN 
 
INFLAMMATIONS 69 
 
 matitis with abundant scaling and loses altogether its original charac- 
 teristics. In the cases which follow eczema there may be some 
 thickening of the skin and slight moisture in places at times. 
 
 While in most cases the eruption is universal, leaving no part of 
 the skin unaffected, it may very exceptionally remain limited to certain 
 regions, as the extremities (Crocker, Stelwagon). 
 
 Itching is present in the majority of cases and varies from mild 
 to severe ; the patient is very sensitive to cold and usually complains 
 much of chilliness. 
 
 In severe cases of long standing the mucous membranes of the 
 mouth and the conjunctiva may be inflamed. Swelling of the lym- 
 phatic glands is occasionally present. 
 
 The duration of the malady varies from five or six weeks to many 
 months or years. In the latter case there may be occasional remis- 
 sions or complete intermission for a variable period. Relapses are 
 not uncommon. 
 
 The general health may remain quite unaffected, although in long- 
 standing cases the general nutrition fails eventually and the patient 
 may fall an easy victim to some intercurrent disease. Secondary infec- 
 tions, such as furuncles and abscesses, are not infrequent complications. 
 
 According to Crocker, it runs a much more acute course in children, 
 in whom it is rare, than in adults, is accompanied by severe constitu- 
 tional symptoms and may terminate fatally. 
 
 In pityriasis rubra, a very rare malady, the skin is bright red and 
 covered with thin papery scales which are usually smaller than those 
 present in other forms of exfoliating dermatitis. Its earliest stage 
 rarely comes under observation, but in two cases which Kaposi saw it 
 began with redness in the axillae, groins, and popliteal spaces, which 
 gradually spread to the rest of the skin. In the course of some months 
 the redness and scaliness have invaded the entire surface. At first the 
 patient's general condition is but little affected, and the skin retains its 
 flexibility and elasticity, but in the course of years it shows thickenings 
 in places and later becomes darker, begins to atrophy and shrink ; the 
 mouth can no longer be opened widely, ectropion of the lower lids 
 occurs, the fingers are in a condition of partial flexion, and over the 
 larger joints and bony prominences it is red, tense and shining and 
 ulceration from pressure occasionally takes place. The hair and nails 
 are also affected ; the scalp is dry and covered with fine bran-like scales 
 and the hair is dry, lustreless, and scanty, while the nails are yellow, 
 brittle and ridged transversely. 
 
 The general condition is for a time but little altered, but eventually 
 the patient becomes marasmic and dies of exhaustion, or from some 
 intercurrent affection. 
 
 Etiology. — Males are much more frequently affected than females, 
 and it occurs most frequently between the ages of forty and sixty, 
 although it is seen in a considerable proportion of cases earlier. It is 
 rare in childhood. In primary cases of the Wilson-Brocq type the 
 
70 DISEASES OF THE SKIN 
 
 direct cause is altogether unknown. It has been observed compara- 
 tively frequently in association with gout, rheumatism and chronic 
 alcoholism, but there is no reliable evidence that these are anything 
 more than possible predisposing factors. In the secondary forms, 
 eczema, psoriasis and, in rare instances, lichen planus directly precede 
 it, and it has been observed after the dermatitis produced by irritating 
 ointments, such as mercurial ointment and chrysarobin or arnica. 
 
 As has been shown by Jadassohn, Mueller and Kanitz, tuberculosis 
 is present in a considerable proportion of cases of the Hebra type, pity- 
 riasis rubra. Brusgaard has reported a case of universal exfoliating 
 erythrodermia resembling pityriasis rubra in which tubercles contain- 
 ing tubercle bacilli were present in the papillary and subpapillary 
 portion of the derma. 
 
 Pathology. — There is but little doubt that dermatitis exfoliativa 
 represents a symptom-complex of varied origin. The primary forms 
 are, in all probability, the result of a toxaemia of varying kind, while 
 the secondary varieties are the result of local irritation occurring in 
 subjects with a special predisposition. Pityriasis rubra is possibly 
 a manifestation of tuberculosis, but the proof of this still awaits more 
 extended observation and study. 
 
 All those who have studied the histopathology of the malady are 
 practically agreed as to its inflammatory character, but the accounts 
 differ a good deal as to the details of the histological changes present. 
 No doubt many of these differences are due to differences in the stages 
 at which the studies were made, and perhaps not all were studying the 
 same affection. It is altogether likely that the secondary forms, such 
 as follow eczema, for example, present features not found in the disease 
 when it is primary. 
 
 Pathological alterations are present in both the epidermis and the 
 corium, the former being secondary to the latter. The changes in the 
 epidermis consist of a slight widening of the rete and alterations in 
 keratinization, as shown by a diminution or entire absence of the 
 granular layer and retention of the nuclei of the cells of the horny 
 layer (parakeratosis). 
 
 The papillae of the corium are somewhat oedematous, their vessels 
 and those of the subpapillary network are dilated and surrounded by 
 an exudation of leucocytes, connective-tissue cells and " mastzellen." 
 In advanced stages there is atrophy of both the epidermis and the papil- 
 lary body — the former is narrower than normal and the latter has 
 entirely disappeared. 
 
 Diagnosis. — When fully developed the affection presents a picture 
 readily recognized. The intense redness of the skin, the abundant and 
 continuous desquamation, and the wide distribution of the eruption 
 involving the whole surface of the skin, are altogether characteristic. 
 In universal eczema, which is rare, there is usually more or less thicken- 
 ing of the skin, the scaling is much less abundant and oozing and 
 crusting occur in places. It is to be remembered, however, that derma- 
 
INFLAMMATIONS 71 
 
 titis exfoliativa may follow an extensive eczema. Psoriasis is rarely 
 universal, the scaling is much thicker and is laminated. In its very 
 early stages it may be confounded with recurrent scarlatiniform ery- 
 thema, but its prolonged course and the frequent previous existence 
 of an extensive eczema or psoriasis and the absence of a history of 
 repeated attacks which characterize the latter will serve to distin- 
 guish the two. The distinction between the erythrodermic stage of 
 granuloma fungoides and pityriasis rubra may at times be very difficult 
 and even impossible for a time. In a case of the former, under the 
 author's observation for a number of years, the appearance of the 
 tumor stage was preceded by a typical exfoliative dermatitis lasting 
 for eighteen months. 
 
 Prognosis. — The course of all forms of the disease is, in most cases, 
 a more or less prolonged one, although exceptionally it may run an 
 acute course of some weeks and then end in recovery, or, in rare cases, 
 may terminate fatally. In the majority of cases of the Wilson-Brocq 
 type, recovery takes place after some months, but relapses are not 
 uncommon and the affection may last for an indefinite period. In pity- 
 riasis rubra the prognosis is unfavorable, the disease continuing for 
 years and eventually causing the death of the patient. All the cases 
 seen by Hebra and Kaposi ended fatally, but more recent observations 
 have shown that the affection is not invariably fatal. 
 
 Treatment. — Patients usually do much better if kept in bed. They 
 should have plenty of easily digestible and nutritious food, and should 
 abstain from tea and coffee and alcoholic beverages. Quinine is prob- 
 ably the most useful internal remedy and is especially indicated in the 
 cases with fever (Crocker). Mook advocates very large doses, 30 to 80 
 grains a day (2.0 to 5.30). Opinions differ a good deal about the 
 usefulness of arsenic, but the majority of authorities agree that it is of 
 little use in most cases, and may be harmful. If useful at all, it is so 
 chiefly in the latter stages. Its uselessness in pityriasis rubra has been 
 pretty definitely proved. Kaposi saw recovery take place in this 
 affection after the internal administration of carbolic acid. 
 
 Frequent warm baths, weakly alkaline or with starch, bran or 
 gelatin added, followed by inunctions of some bland ointment, such as 
 equal parts of lanolin and vaselin, or cold cream, will often afford 
 much relief. Engman and White advocate the application of a dusting 
 powder to the entire surface, in quantities sufficient to keep the skin 
 dry, as the best form of local treatment, the former recommending corn- 
 starch, the latter borated talcum. 
 
 DERMATITIS EXFOLIATIVA EPIDEMICA 
 
 Synonyms. — Epidemic eczema; Dermatitis epidemica ; Savill's dis- 
 ease. 
 
 In 1892 Savill reported an epidemic of a previously undescribed 
 form of dermatitis, which occurred in several of the Poor Law Infir- 
 maries of West London. His account of the affection was based upon 
 
72 DISEASES OF THE SKIN 
 
 165 cases under his observation in the summer and autumr of the 
 previous year. Similar epidemics have since been observed in London 
 (Crocker), and a few sporadic cases have been seen in America by 
 Fordyce, and Colby and Winfield. 
 
 Savill defined the disease as " a contagious malady in which the 
 main lesion is a dermatitis, sometimes attended by the formation of 
 vesicles, always resulting in desquamation of the cuticle, usually accom- 
 panied by a certain amount of constitutional disturbance, and running 
 a more or less definite course of seven or eight weeks." 
 
 Symptoms. — The affection occurs under two forms, viz., a moist 
 form resembling eczema, and a dry form resembling pityriasis rubra. 
 It begins as patches of small red papules which appear first, in most 
 cases, upon the upper extremities and the face. These spread and new 
 patches appear until the greater part or the whole of the skin is covered 
 with the eruption (in one-half of Savill's cases it was universal). In 
 the moist form the papules are succeeded by vesicles in the course of 
 two or three days which soon rupture or dry up and are followed by 
 desquamation. In the dry form no vesicles appear, but the papules are 
 followed directly by desquamation. In a small number of cases the 
 first manifestation of the disease was an erythema resembling the papu- 
 lar form of erythema multiforme. At the acme of the attack the skin 
 is very red, decidedly thickened and covered with an abundance of 
 epidermic scales. In all the severe cases the lingual mucous mem- 
 brane is inflamed, and there is conjunctivitis with loss of the hair and 
 nails. After a course lasting six or eight weeks, the redness subsides, 
 the scaling grows less, the skin becomes smooth but still thickened and 
 more or less pigmented. The subjective symptoms are itching and 
 burning pain, which may be at times extreme. In most cases there is 
 considerable prostration, and in the later stages some elevation of 
 temperature, varying from 99 to ioo° F. Diarrhoea is a common 
 symptom, and albuminuria occurs in a large proportion of the cases 
 with extensive eruption. Crocker noted enlargement of the occipital 
 and submaxillary glands in several of his cases. Boils and carbuncles 
 are common sequelae. 
 
 Etiology and Pathology.— In the great majority of cases the patients 
 are past middle life and many of them are between sixty and seventy 
 years of age. Children, however, are occasionally attacked. Crocker 
 saw a case in a boy eleven years old. Men are more frequently affected 
 than women. There is apparently but little doubt about its contagious- 
 ness. Its rapid spread and the occasional occurrence in nurses and 
 attendants cannot readily be explained in any other way. 
 
 Risien Russell found in the scales and fluid from unbroken vesicles 
 a diplococcus resembling the staphylococcus pyogenes albus, but dif- 
 fering from that organism by certain cultural peculiarities. Inocula- 
 tion experiments with this organism, however, were negative. Eche- 
 verria, studying the histology of the affection in Unna's laboratory, 
 found that it differs altogether histologically from chronic eczema, 
 
INFLAMMATIONS 73 
 
 but, like that affection, belongs to the catarrhs of the skin, more par- 
 ticularly to the parakeratoses. It is especially distinguished by a peculiar 
 form of degeneration of the nuclei of the cells of the prickle-cell layer 
 which he designates " peridiaphania " of the nuclei. 
 
 Diagnosis. — As already observed, the moist cases bear some resem- 
 blance to eczema, the dry ones to pityriasis rubra, but it differs mark- 
 edly from both these by its epidemic occurrence, contagiousness and 
 self-limited course. It differs very decidedly from eczema by the much 
 more pronounced thickening of the skin, the more abundant exfoliation 
 and the occurrence of death in a considerable percentage of the cases. 
 
 Prognosis and Treatment. — In about thirteen per cent, of Savill's 
 cases death occurred usually from exhaustion. In some other locali- 
 ties the mortality was much lower, as low as five per cent. (Crocker). 
 Relapses are frequent and second attacks occur occasionally. 
 
 The course of the malady is but little influenced by treatment, gen- 
 eral or local. The same local remedies are indicated as in other forms 
 of exfoliating dermatitis — mild antiseptic ointments, or, better, dry 
 treatment with dusting powders, such as the borated talcum. In a 
 few instances the spread of beginning patches was apparently checked 
 by painting them with collodion or tincture of iodine (Crocker). 
 
 ERYTHEMA SCARLATINIFORME 
 
 Synonyms. — Erythema scarlatinoides ; Desquamative scarlatini- 
 form erythema; Recurrent scarlatiniform erythema; Dermatitis scarla- 
 tiniformis recidivans. 
 
 Definition. — An affection distinguished by an eruption resembling 
 the eruption of scarlatina. 
 
 Symptoms. — Erythema scarlatiniforme is characterized by a bright- 
 red, usually diffuse, but occasionally somewhat punctiform, rash resem- 
 bling, as its name indicates, the rash of scarlet fever. While the erup- 
 tion may occupy any portion of the skin, it is seen most frequently upon 
 the trunk, which it may cover entirely, or in part only as ill-defined 
 patches of varying size. The face is affected only infrequently. Its 
 appearance is usually accompanied by slight, exceptionally considerable 
 elevation of temperature with chilliness and malaise. After a duration 
 of two or three days, it begins to fade and is followed by desquamation, 
 usually of a branny character, sometimes quite abundant, lasting from 
 five to eight days, the amount and duration depending upon the inten- 
 sity of the eruption (vid. p. 75). 
 
 In a rarer and more severe type, which, on account of its marked 
 tendency to recurrences, is known as recurrent scarlatiniform erythema, 
 the symptoms are usually much more pronounced. An attack usually 
 begins with chilliness, nausea, headache and fever, which precede the 
 eruption by some hours. The eruption is usually quite extensive, 
 covering the entire trunk, or, at times, the entire cutaneous surface, 
 is accompanied by considerable itching and burning and is followed 
 
74 
 
 DISEASES OF THE SKIN 
 
INFLAMMATIONS 75 
 
 by an abundant desquamation beginning about the third or fourth day, 
 occasionally with shedding of the hair and nails (Fig. 13). 
 
 In this variety there may be many recurrences, but there is a decided 
 tendency for the attacks to grow milder with each recurrence. In a 
 marked case under the author's observation for a considerable time, 
 in which there were many attacks, this progressive diminution of the 
 severity of the symptoms was a very noticeable feature. 
 
 Etiology and Pathology. — Although not yet actually proved, there 
 is little doubt that this scarlatiniform erythema is a manifestation of 
 a toxaemia which may be produced by toxins of diverse kinds. It is, 
 at times, observed in connection with other diseases of a general char- 
 acter, as a symptom of some general infection, such as rheumatism, 
 syphilis, variola, and sepsis. It is occasionally produced by the inges- 
 tion of certain drugs, such as quinine, belladonna, the various com- 
 binations of salicylic acid, and by the injection of various sera em- 
 ployed therapeutically. In these last, idiosyncrasy plays a prominent 
 part, since the eruption can be produced only in certain individuals. 
 
 According to Leloir and Vidal, Brocq and other French dermatolo- 
 gists who have specially studied the affection, the recurrent form should 
 be separated from the ordinary variety, not only because of the pro- 
 nounced tendency to recurrences, but because it probably is due to 
 different causes. 
 
 A study of sections of the skin from the author's case above re- 
 ferred to show r ed a pronounced parakeratosis, the horny layer being 
 held in place only by a few greatly elongated slender corneous cells. 
 The stratum granulosum had almost entirely disappeared, being repre- 
 sented by a few cells scattered here and there at the extreme margin 
 of the rete. The rete mucosum showed but little change beyond a 
 slight increase in width, and vacuolation of a few of its cells. The 
 most notable change was seen in the papillary layer of the corium. 
 In this there was a considerable round-cell exudate situated along the 
 margins of the papillae and around the vessels. In places this exudate 
 was so abundant as to obscure the line of demarcation between the 
 papillae and the overlying rete. 
 
 Diagnosis. — The malady is to be distinguished from scarlatina, 
 which it at times resembles very closely, by attention to the following 
 points : the eruption is in most cases diffuse instead of punctiform like 
 the eruption of scarlet fever, and if punctiform, it is only so in the 
 beginning, usually becoming diffuse after a little time. It begins upon 
 the trunk and is often limited to that region. Sore throat is, in the 
 great majority of cases, absent, and if present is slight. The so-called 
 strawberry tongue is never present. Desquamation begins earlier than 
 in scarlet fever, as early as the second or third day. There is no his- 
 tory of contagion, no nephritic symptoms, and in many instances a 
 history of several, sometimes many, attacks. 
 
 Treatment. — The treatment is largely symptomatic and expectant. 
 Some restriction of the diet and the administration of a saline laxa- 
 
76 DISEASES OF THE SKIN 
 
 tive are all that is necessary in many cases. If there is much itching 
 and burning, a dusting powder of talc and bismuth subcarbonate, with 
 one per cent, of menthol, may be used, or a lotion of carbolic acid, 
 one per cent., with two or three per cent, of glycerin. In the recur- 
 rent variety a careful search should be made for the possible cause. 
 The diet should be carefully looked after and the possibility of its 
 drug origin should not be overlooked. 
 
 DERMATITIS EXFOLIATIVA NEONATORUM 
 
 Synonyms. — Keratolysis neonatorum ; Ritter's disease. 
 
 Definition. — A dermatitis accompanied by exfoliation occurring 
 within the first few weeks after birth. 
 
 This rare affection was first described by Ritter, in 1878, his de- 
 scription being based upon the observation of 297 cases seen in the 
 Prague Foundling Asylum within a period of ten years. 
 
 Symptoms. — It begins with an erysipeloid redness in the face, 
 usually about the mouth, and spreads thence to the neck, trunk, and 
 extremities. The skin is swollen and slightly translucent at first, and 
 the horny layer of the epidermis, loosened from its attachment to the 
 lower layers, may be readily pushed off or wrinkled up by the fingers 
 or by friction of the clothing. Within a few days it dries up and 
 exfoliates. In places flaccid bullae, with very scanty fluid contents, 
 are formed, which soon dry into thin, rather greasy crusts. When 
 fully developed the skin is covered with scales and in places with thin 
 crusts, beneath which it is red and dry or slightly moist. About the 
 mouth radiating fissures form, and the lips are swollen, the lids are 
 covered with scales, so that the eyes cannot be fully opened, and the 
 mucous membranes of the mouth, nose, and the conjunctivae may share 
 in the inflammation. The disease is most pronounced in the face and 
 on the trunk, the extremities being comparatively little involved. It 
 is rare in the first two or three days after birth, most frequent in the 
 second week, and infrequent after the fifth. It lasts from eight to 
 ten days in mild cases, and from three to four weeks in the severer 
 ones. The disease is usually afebrile in uncomplicated cases, but 
 digestive disturbances are common and pulmonary complications occa- 
 sionally occur. Furuncles and abscesses are frequent sequelae. 
 
 When recovery takes place, the redness gradually diminishes, the 
 scaling grows less and less, and finally disappears, the first signs of 
 recovery appearing in the regions first attacked. 
 
 Etiology and Pathology. — Ritter regarded it as a pysemic affection, 
 an opinion shared by Escherich. Kaposi thought it due to an increase 
 of the physiological exfoliation which occurs in young infants. Luith- 
 len is inclined to regard it as a toxic erythema. In a number of the 
 reported cases it began with blebs like an acute pemphigus, assuming 
 the features of an exfoliative dermatitis later (Knopfelmacher and 
 Leiner, Hedinger). In several instances it occurred in two or more 
 
INFLAMMATIONS 77 
 
 children cared for by the same nurse, an occurrence indicating the 
 possibility of its transmission from the sick to the well. Indeed, there 
 is considerable evidence of a convincing character, which is increas- 
 ing, that it is closely related to, if not identical with, the so-called 
 pemphigus neonatorum, an affection which the author, along with a 
 number of other authors, believes is nothing more than impetigo con- 
 tagiosa occurring in new-born infants. Winternitz, Hansteen, and 
 Dalla Favera found the staphylococcus, the first-named, in the blood, 
 in the crusts, and the secretion. Riehl found a fungus characterized 
 by a long and slender mycelium in the scales, but this finding has not 
 been confirmed by others. 
 
 The histopathology, as described by Winternitz, Luithlen, and 
 Dalla Favera, does not differ essentially from that of other forms of 
 exfoliative dermatitis. The horny layer of the epidermis is wanting 
 in many places, lost through exfoliation. The rete is increased in 
 thickness chiefly by oedema, shows numerous mitoses, and contains a 
 number of leucocytes. In places where blebs have formed the upper 
 layers of the rete are separated from the deeper ones by fluid exuda- 
 tion. The papillary layer and subpapillary portions of the corium are 
 cedematous, the vessels dilated and surrounded by a more or less 
 abundant exudate of leucocytes, connective-tissue cells, and consider- 
 able numbers of "mastzellen." 
 
 Diagnosis. — The rapidly spreading redness, the extensive exfolia- 
 tion, and the patient's age are quite characteristic features. Attempts 
 to differentiate it from the pemphigus of the new-born are usually 
 futile and superfluous, if, as seems probable, the two affections are 
 identical or variants of the same disease. 
 
 Prognosis and Treatment. — The prognosis is very unfavorable, a 
 large proportion of the infants dying. One-half of all Ritter's cases 
 terminated fatally, but these were all foundlings. 
 
 Especial attention should be given to the nourishment of the infant 
 and the preservation of the bodily heat. Locally, mild antiseptic oint- 
 ments should be applied to the inflamed parts, or, what is probably 
 better, the skin should be abundantly covered with some dusting pow- 
 der, such as borated talcum, as recommended by White in the treat- 
 ment of the exfoliative dermatitis of adults. Tamm obtained unusually 
 good results from the dry treatment, using xeroform, a compound of 
 bismuth tribromophenate. 
 
 PRURIGO 
 
 Synonyms. — Fr., Strophulus prurigineux ; Ger., Juckblattern. 
 
 Definition. — An extremely chronic inflammatory disease, beginning 
 in very early life, characterized by an eruption of small papules, the 
 color of the skin or pale red, accompanied by violent itching. 
 
 Symptoms. — Two varieties of the malady are usually recognized, 
 viz., a mild form, Prurigo mitis (Prurigo of Willan), and a severe 
 form, Prurigo ferox, Prurigo agria (Prurigo of Hebra). These differ 
 
78 DISEASES OF THE SKIN 
 
 from one another only in degree, not in any essential feature. The 
 affection begins in the great majority of cases in infancy or early child- 
 hood, with an eruption of papular wheals (papular urticaria, lichen 
 urticatus), accompanied by itching. After a variable period these are 
 succeeded by small, at first very little elevated, papules the color of 
 the skin or pale red, which are accompanied by severe and more or 
 less continuous itching. As the result of scratching, many of the 
 papules are capped by a small blood-crust and after a while become 
 more prominent. The eruption is most abundant upon the extensor 
 surfaces of the extremities, more so upon the forearms and legs than 
 upon the upper arms and thighs, and in mild cases may be limited 
 to these regions. In the severe form it also occurs upon the trunk, 
 especially upon the sacrum and buttocks. The palms and soles, the 
 flexures of the elbows, popliteal spaces, and the scalp remain free 
 even in the severe forms of the disease. In the mild cases the face 
 escapes completely, but may show a moderate eruption in the severe 
 ones. In prurigo ferox the eruption is very abundant and extensive, 
 covering the greater part of the cutaneous surface, and the itching 
 is of the most distressing character. The skin is dry and harsh, the 
 hairs broken off by continuous rubbing. There is more or less pro- 
 nounced pigmentation and numerous small scars, which have fol- 
 lowed the superficial wounds inflicted by scratching. Secondary 
 changes of an inflammatory character are frequent. Small furuncles, 
 pustules of an impetiginous or ecthymatous character, the result of 
 infection by the nails, and oozing or crusted eczematous patches, are 
 common. A noticeable and characteristic feature is enlargement of 
 the lymphatic glands, which, in the inguinal region, may form nodular 
 masses as large as an egg, or larger. 
 
 The course of the malady is extremely chronic. In the severe form 
 it continues throughout the patient's life. The symptoms usually un- 
 dergo some amelioration in warm weather, with a corresponding ag- 
 gravation in the winter. The type of the disease is usually determined 
 by the character of its beginning. The cases characterized by mild 
 symptoms in the early stages are likely to remain mild, while the 
 severe type usually begins as such. 
 
 Etiology. — Prurigo is a disease of the poor, of those who receive 
 insufficient or improper food and live under unhygienic conditions. 
 It is common in parts of central Europe, especially in Austro-Hungary, 
 but is fortunately very rare in the United States, where the native 
 cases are of the mild type. It begins, in the great majority of cases, 
 in infancy or early childhood, but that it does so invariably, as was 
 maintained by Hebra, has been disproved by later observers. Crocker 
 saw it appear as late as at twelve years of age. Ehlers saw "many 
 cases" in which it first appeared between ten and fifteen years of 
 age, and a few between fifteen and thirty. Men are much more fre- 
 quently affected than women, according to Ehlers's statistics, more 
 than twice as often. The primary cause is quite unknown. 
 
INFLAMMATIONS 79 
 
 Pathology. — The pathology and pathogenesis of the disease are 
 still matters of debate. Hebra regarded the papule as the primary 
 lesion, but Auspitz and, much more recently, Ehlers believed the pruri- 
 tus to be the primary symptom, considering the papule the product 
 of the scratching. Ehlers based his opinion on the fact that after 
 the papules have been made to disappear by baths and ointments the 
 itching still persists. There is no doubt that in most cases the malady 
 begins with urticarial symptoms, much too frequently to be a mere 
 coincidence, as Ehlers believes. 
 
 The histological features of the papule of prurigo are a spastic 
 oedema of the cutis, with a moderate perivascular cellular exudate, 
 swelling of the papillae, and, in the prickle-cell layer of the epidermis, 
 small circumscribed areas of softening which in prurigo ferox become 
 cavities containing epithelial debris. The erector pili muscles are 
 more or less thickened (Unna, Holder). While the histological changes 
 are described by many authorities as practically the same as those of 
 papular eczema, Unna could find no resemblance between the papule 
 of prurigo mitis and the papule of eczema. 
 
 Diagnosis. — Prurigo is to be distinguished chiefly from papular 
 eczema and, in the early infantile stages, from urticaria. It differs 
 from the former by the uniformly papular character of the eruption, 
 by its extreme chronicity, by the great severity of the itching, and 
 by the occurrence of lymphatic gland enlargement. It differs from 
 urticaria by the appearance of small, pale papules, sooner or later, 
 which do not exhibit the transient character of the urticarial wheal. 
 It is sometimes confounded with long-standing scabies, but is readily 
 distinguished from that affection by the absence of the characteristic 
 burrows and the differences in the distribution of the two eruptions. 
 The presence of an eruption will serve to distinguish it at once from 
 pruritus, a disease with which it was formerly confounded. 
 
 Prognosis and Treatment. — The affection is curable in the early 
 stages, but relapses are frequent. When the malady is thoroughly 
 established, or of the severe type, it is practically incurable, although 
 even in these much may be done to alleviate the symptoms. 
 
 The patient should have an abundance of easily digested, nutritious 
 food, and should be placed under the best hygienic conditions. Fer- 
 ruginous tonics and cod-liver oil are frequently of decided service. 
 Cannabis indica, either the tincture or solid extract, is occasionally 
 of decided service in allaying the itching, Crocker especially commend- 
 ing its use. Kaposi occasionally observed a decided improvement of 
 the symptoms from the internal use of carbolic acid in considerable 
 doses. Pilocarpin, hypodermatically, has been employed with occa- 
 sional good effect. 
 
 Warm baths, either plain or made alkaline by the addition of bicar- 
 bonate of soda or borax, and baths containing starch or bran are use- 
 ful. These should be used in conjunction with ointments of menthol, 
 one-half to one per cent., or of phenol, two to three per cent. In 
 
80 DISEASES OF THE SKIN 
 
 using the latter, care should be taken when applying it to large areas 
 that toxic effects are not produced by absorption. A favorite remedy 
 with Kaposi was an ointment of naphthol, five per cent., in adults, 
 one to two per cent, in children. This is to be rubbed in every evening, 
 and every second day a bath with sulphur-naphthol soap should be 
 taken. Ointments of tar, of resorcin, and of salicylic acid are also of 
 more or less use at times. 
 
 PRURIGO NODULARIS 
 
 Synonyms. — Multiple tumors of the skin, accompanied by intense 
 itching; Persistent Papular Dermatosis; Lichen Obtusus Corneus; 
 Urticaria Perstans. 
 
 Definition. — A rare chronic inflammatory disease characterized by 
 intensely itching papules or nodules. 
 
 Symptoms. — This affection was first described by Hardaway, in 
 1880, and a very limited number of additional cases have since been 
 observed and reported under various titles by Johnston, Schamberg, 
 and Hirschler, Brocq, C. J. White, Hartman, and a few others. 
 
 It is characterized by small to large pea-sized, and occasionally 
 larger, rather flat, discrete papules or nodules, which are at first smooth 
 and pinkish in color, but later are covered with an adherent scale, and 
 become violaceous or brownish. Many of the lesions show a well-marked 
 central depression or umbilication, and occasionally a small vesicle on 
 the summit. Intense itching accompanies the malady, limited, as a 
 rule, to the nodules, but occasionally affecting other parts of the skin. 
 It is an extremely chronic affection, lasting for years, and when the 
 nodules have once been fully developed they show but little or no 
 perceptible change for months (Fig. 14). 
 
 Etiology and Pathology. — With the exception of one or two doubt- 
 ful cases, the disease has been seen in adult females only. Nothing 
 is known about its direct cause. 
 
 As may be readily inferred from the number of titles given it, 
 there is great uncertainty concerning the exact nature and place of 
 the malady. Those who have studied its histopathology (Heitzman, 
 Johnston, Schamberg and Hirschler, C. J. White) are agreed as to its 
 inflammatory character. The horny layer of the epidermis is greatly 
 thickened, and there is a more or less pronounced increase in the 
 breadth of the rete. In the papillary and reticular portions of the 
 corium there is an exudation of round cells, most abundant about the 
 vessels. Schamberg and Hirschler found enormous numbers of "mast- 
 zellen" in their cases. In Johnston's case there were minute vesicles 
 in the central portion of the prickle-cell layer of the rete, and a cellular 
 exudate about the nerve-branches in the corium, as well as about the 
 vessels. 
 
 Diagnosis. — The large size and discrete character of the nodules, 
 the very chronic course, and the intense itching are so characteristic 
 
INFLAMMATIONS 
 
 81 
 
 of the affection that no difficulty is likely to be experienced in the 
 diagnosis. 
 
 Prognosis and Treatment. — The prognosis is very unfavorable as 
 regards a cure. As already observed, it pursues an extremely chronic 
 course, lasting for many years. It is extremely rebellious to treat- 
 ment, but temporary relief is afforded by baths and the use of lotions 
 or ointments of menthol or carbolic acid. No internal treatment has 
 been found of any use. 
 
 r ^ ■ • - 7 
 
 Fig. 14. — Prurigo nodularis. 
 
 LICHEN PLANUS 
 
 Synonyms. — Lichen ruber planus ; Lichen psoriasis. 
 
 Definition. — An acute or chronic, usually the latter, inflammatory 
 disease distinguished by an eruption of small red or violaceous, flat- 
 topped, shining papules with angular bases, many of which present a 
 shallow central umbilication (Plate I). 
 
 This affection was described in 1869 by Erasmus Wilson as identi- 
 cal with the lichen ruber of Hebra, and it is still described by most 
 German authors as a variety of that disease. The studies of Robinson 
 published in 1883 and in 1889 have quite conclusively demonstrated, 
 6 
 
82 
 
 DISEASES OF THE SKIN 
 
 however, that it is related to lichen ruber neither histologically nor 
 clinically, and it is regarded by most American and English writers 
 as an independent disease. 
 
 El 
 
 Fig. 
 
 -Lichen planus. Unusually profuse eruption. 
 
 Symptoms. — The eruption consists of small, discrete, pinkish, red, 
 or yellowish-red, flat papules with glazed tops and angular or polyg- 
 onal bases, which, as they grow older, usually become a dull crimson 
 or a bluish-red. At first smooth, and in many instances slightly umbili- 
 
INFLAMMATIONS 
 
 83 
 
 cated, they are sooner or later covered with a thin, whitish epidermic 
 scale, which is usually adherent, so that it cannot be brushed off. 
 Many of the papules show grayish or whitish points and lines, a symp- 
 tom to which attention was called by Wickham, who considered it 
 pathognomonic and therefore of much value in diagnosis. The papules 
 are at first discrete and seldom increase much in size after their ap- 
 pearance, but, as new lesions continue to appear between the earlier 
 ones, elevated and circumscribed patches are frequently formed, viola- 
 
 FlG. 16. — Lichen annularis. 
 
 ceous in color and covered with a fine adherent silvery-white scale, in 
 which it is no longer possible to distinguish the individual papules. 
 As a rule the eruption is symmetrically distributed, but it may be uni- 
 lateral or limited to a single region (Fig. 15). While it usually shows 
 no definite arrangement, it sometimes occurs as rings, or semicircles 
 (Fig. 16), or sharply marginate disks with depressed centres (Fig. 17) 
 (lichen annularis). The larger rings are composed of a number of 
 discrete and confluent nodules, but the small ones arise through the 
 central atrophy and peripheral extension of single lesions. Not very 
 infrequently it assumes a linear arrangement, the eruption under such 
 circumstances occurring along the course of a superficial scratch (Fig. 
 
84 
 
 DISEASES OF THE SKIN 
 
 18) (lichen linearis). In rare instances it is distributed over the course 
 of some nerve trunk, such as the sciatic nerve, forming long band- 
 or ribbon-like patches (Fig. 19) several inches wide. Although it 
 may occur in any region, it shows a preference for certain localities, 
 such as the flexor surface of the wrists, a common site, of the fore- 
 arms and the anterior surface of the knees and legs. It varies greatly in 
 extent. At times it is limited to a few scattered, discrete papules sit- 
 uated on the wrists, forearms, and legs, or to a single small patch ; 
 at other times it is widespread and occupies the greater part of the 
 skin. When the papules disappear they usually leave slightly atrophic 
 spots and pigmentation, which varies from a pale sepia to dark brown 
 and which usually persists for some months, sometimes for many 
 
 Fig. 17. — Lichen planus discoides. 
 
 months. There is usually more or less itching, and sometimes it is 
 so severe as to cause the patient great distress. 
 
 In a certain proportion of cases the mucous membranes of the 
 mouth, the glans penis, and the labia are affected, usually coincident- 
 ally with the skin, but in exceptional cases alone. In these situations 
 the papules, constantly moist, are white instead of red, and are 
 less elevated than those upon the skin. Upon the tongue they are 
 frequently arranged symmetrically upon both sides of the median line, 
 sometimes as a small patch occupying the centre of the organ. Upon 
 the cheeks they are apt to be situated in the interdental space, forming 
 slightly elevated white linear patches upon both cheeks. Upon the 
 glans penis and the labia the lesions are white, as upon other mucous 
 membranes, but upon the former, when it is habitually uncovered, 
 they are pink in color, approaching in appearance the cutaneous lesion; 
 in this situation the eruption occasionally occurs as very slightly ele- 
 vated small rings. 
 
INFLAMMATIONS 
 
 85 
 
 As a rule the malady pursues a chronic course, lasting from a few- 
 months to a year or two. Exceptionally it occurs as an acute affec- 
 tion, either beginning as such or as the sequel of the chronic form. 
 
 Fig. 18. — Lichen planus. Lines of papules occurring in scratch-marks 
 
 rounded instead of flattops. 
 
 of the papules with- 
 
 in the acute cases the eruption appears suddenly and spreads rapidly, 
 covering the greater part of the skin in the course of a few days. 
 The papules are usually bright red, quite small, and very numerous, 
 
86 
 
 DISEASES OF THE SKIN 
 
 and more or less pronounced constitutional disturbance, with some 
 elevation of temperature, is present in the severer cases. Such cases 
 
 Fig. 19. — Lichen planus. Band-like distribution. 
 
 may run a rapid course, the eruption disappearing at the end of a 
 few weeks, or they may assume the chronic form and last for months. 
 
INFLAMMATIONS 87 
 
 Variations from the ordinary type of eruption are occasionally 
 met with. Although in the vast majority of cases the eruption is 
 strictly papular from the earliest to the latest stages, in rare instances 
 vesicles and blebs appear at some time in the course of the affection, 
 as in the cases reported by Kaposi, Unna, Leredde, and others. At 
 first there was an inclination to attribute such atypical lesions to arse- 
 nic, which is employed frequently in the treatment of the malady, but 
 it was soon shown that they also occurred in those who had not had 
 any arsenic. In a series of seventeen cases collected by Whitfield, 
 nine had no arsenical treatment. 
 
 Under the name lichen ruber moniliformis, Kaposi has described 
 an extraordinary case in which the eruption, consisting of pea-sized 
 nodules, formed thick bands looking like rows of beads situated in 
 the flexures of the arms and legs parallel with the long axis of the 
 limbs, and upon the abdomen and buttocks. Somewhat similar cases 
 have been described by Rona and Dubreuilh. As lichen planus erythe- 
 matosus, Crocker has described a rare form in which the papules were 
 of a deep crimson color and were very soft to the touch. 
 
 In old cases, thick, dark-red or bluish-red patches, with verrucous 
 surface covered with fine scales, occasionally appear upon the legs, 
 together with large, discrete, wart-like nodules (lichen sclerosus ; lichen 
 verrucosus). 
 
 Etiology. — The direct exciting cause of lichen planus is still un- 
 known. Its incidence is apparently uninfluenced by sex, and it is 
 most common between the ages of twenty and fifty, although it is 
 not unknown in children and the aged. In a considerable proportion 
 of cases the patient exhibits symptoms of nervous exhaustion, the 
 consequence of worry, overwork, or insufficient or improper nourish- 
 ment. Occasionally it has been observed to follow traumatism, and 
 the eruption frequently occurs in those already the subjects of the dis- 
 ease at the site of scratches or superficial abrasions. In recent years 
 the possibility of its being due to some toxin of unknown character 
 and origin has been suggested by a number of observers (Fordyce, 
 Montgomery, and Alderson). 
 
 Pathology. — Lichen planus (Fig. 20) is an inflammation having 
 its principal seat in the papillary and subpapillary portions of the 
 derma. According to Crocker, the papule is situated, in most cases, 
 if not in all, about a sweat-duct, but the observations of Fordyce and 
 other investigators have shown this to be erroneous. Pronounced his- 
 tological changes are present in both the epidermis and in the corium, 
 those in the former probably being secondary. In the epidermis there 
 is a pronounced hyperkeratosis, a decided increase in the thickness 
 of the granular layer, a broadening of -the rete (acanthosis), with inter- 
 cellular oedema, and in the later stages colloid degeneration of some 
 of the prickle-cells. The papillae and subpapillary portion of the co- 
 rium are occupied by a very dense, abundant exudate of connective 
 tissue and small mononuclear cells, which more or less completely ob- 
 
88 
 
 DISEASES OF THE SKIN 
 
 literates the interpapillary prolongations of the rete and the dividing 
 line between the epidermis and the corium. The nature of the small 
 round cells is still somewhat in doubt, but most authorities regard 
 them as leucocytes. Unna asserts that plasma and polymorphonuclear 
 cells are never present in this exudate, but Fordyce has seen both 
 varieties of cell, and Sabouraud has found occasional giant-cells which 
 he believes to be of epidermic origin. The umbilication present in 
 some of the papules is the result of the peg-like thickening of the 
 horny layer, which exfoliates and leaves a small depression. In the 
 
 
 . 
 
 
 m 
 
 Fig. 20. — Lichen planus. 
 
 regressive stages of the papule pigment granules are present in the 
 cells of the epidermis and in the corium. 
 
 Diagnosis. — Lichen planus is to be distinguished from other papular 
 affections by the flat, shining tops of the papules, the frequent umbili- 
 cation, the presence of the minute puncta and striae described by 
 Wickham, their polygonal or angular bases, and their dull crimson 
 or violaceous color. When the lesions are closely aggregated, forming 
 thick patches with a finely scaly surface, such patches may be mistaken 
 for squamous eczema or psoriasis. From these they are to be dis- 
 
INFLAMMATIONS 89 
 
 tinguished by the presence of characteristic papules about the borders 
 of the patch or some little distance away from them, and by the dif- 
 ference in the quality of the scales, which are fine and silvery-white 
 when at all abundant. 
 
 Prognosis. — Although the affection may persist for several months 
 or a year or two, recovery eventually takes place, and relapses, al- 
 though occurring, are not frequent. Even in extensive cases the 
 patient's general health, as a rule, is not affected, although when the 
 itching is severe loss of sleep may lead to neurasthenia or a decided 
 increase of this symptom when already present. 
 
 Treatment. — When the patient shows symptoms of neurasthenia, as 
 is not uncommon, he should spend considerable time in the open air, 
 have an abundance of wholesome food, with plenty of milk, cream, 
 and eggs, and should be freed from mental stress and worry as much 
 as possible. Quinine, iron, and cod-liver oil may be given in moderate 
 doses for their tonic effect. Among the internal remedies which more 
 or less directly influence the eruption, arsenic and mercury occupy the 
 first place. The former may be given as Fowler's solution, in doses 
 of from five to ten drops three times a day, or as the solution of the 
 arseniate of soda, in the same doses. Arsenic trioxide may be given 
 with advantage in the so-called Asiatic pill, each pill containing one 
 (0.065) grain of black pepper and from a twenty-fifth to a twentieth of a 
 grain (0.025-0.003) of arsenic. Mercury may be employed as the bichlo- 
 ride in doses of a twenty-fourth to a sixteenth of a grain (0.025-0.004), 
 three times a day. Donovan's solution, which combines both drugs, may 
 be given with good effect in doses of five drops three times a day. In the 
 cases in which itching is pronounced, salicylate of soda or aspirin, in doses 
 of ten grains (0.65) four times a day, will sometimes afford marked relief 
 from this most annoying symptom, or salicin, in the same dose, as recom- 
 mended by Crocker, may be given instead as less apt to disturb the stomach. 
 
 Local treatment is quite as necessary as the internal ; indeed, in 
 cases of limited extent, it may suffice to remove the eruption. Warm 
 alkaline baths, or baths containing bran or starch, are frequently of 
 use in extensive cases accompanied by itching. One of the most useful 
 lotions is the following: 
 
 R. 
 
 Liq. carbonis detergent fS i (32.0) 
 
 Phenolis 3ss (2.0) 
 
 Glycerini fS i (32.0) 
 
 Aquae q. s. ad fSiv (120.0) 
 
 M. 
 
 Sig. Apply with cotton mop three times a day. 
 
 When itching is not a prominent symptom, the phenol may be 
 omitted. A lotion of thymol containing one-half grain (0.03) to the ounce 
 (32.0) of lime water, with a half drachm (2.0) of glycerin to each ounce 
 (32.0), is a cleanly and agreeable application which frequently proves useful. 
 
 When the disease occurs in dry, scaly patches the local treatment 
 
90 DISEASES OF THE SKIN 
 
 is much the same as in psoriasis, and ointments are usually more useful 
 than washes. Oil of cade in a twenty-five per cent, ointment is an 
 effective remedy. It should be well rubbed in once or twice a day. 
 In thick, old, and dry patches the addition of two to four per cent, 
 of salicylic acid increases the efficacy of this ointment very decidedly, 
 or a ten per cent, plaster of salicylic acid may be used with good 
 effect. An ointment of chrysarobin, five to eight per cent, strength, 
 is likewise a useful remedy in the treatment of such patches. The 
 X-ray is frequently of much service, not only relieving the itching, 
 but bringing about the involution of the patch within a comparatively 
 short time. Occasionally, however, it fails. 
 
 LICHEN NITIDUS 
 
 This affection was first recognized by Pinkus as an independent 
 disease in 1901, and more fully described by him in 1907. Other cases 
 have since been reported by Arndt, Lewandowsky, Kyrle and Mc- 
 Donagh, Sutton and Bachrach. 
 
 Symptoms. — It is distinguished by an eruption of small, shining, 
 flat-topped polygonal papules, which are red, brownish, or the color 
 of the normal skin, resembling the papules of lichen planus. In the 
 great majority of cases the eruption is situated upon the penis, the 
 shaft, and the glans, but has also been seen upon the abdomen, the 
 chest, the arms, and about the anterior border of the axillae. The 
 papules are at times very numerous, covering the entire shaft of the 
 penis. No subjective symptoms of any sort accompany the eruption, 
 and the patient in consequence is sometimes quite unaware of its 
 existence. In a number of cases it was discovered accidentally when 
 examining the patient for another ailment. The course of the affection 
 is sluggish, papules coming and going for months or years. Occasion- 
 ally the eruption disappears completely. 
 
 Etiology. — Little or nothing definite is known about its cause. 
 With but a single exception, all the cases thus far observed have been 
 in males. Kyrle and McDonagh are of the opinion that the malady 
 is tuberculous, an opinion with which Sutton agrees, but animal ex- 
 perimentation has failed completely so far to support this view of 
 its causation, although the first-named authors obtained a mild general 
 reaction after an injection of tuberculin. 
 
 Pathology. — Histologically it is a granuloma presenting the struc- 
 ture of tuberculous tissue. The papules are made up of collections 
 of round, epithelioid, and giant-cells of the Langhans type, the last 
 being unusually numerous. 
 
 Diagnosis. — It is to be distinguished from lichen planus, the only 
 affection for which it might be mistaken, by its pronounced predilec- 
 tion for the genitalia, by the absence of itching, and by its histology. 
 
 Treatment. — The affection is apparently but little influenced by 
 treatment. In Sutton's case the eruption disappeared within a month, 
 
INFLAMMATIONS 91 
 
 • 
 
 -while using an ointment of salicylic acid and resorcin alternately with 
 oxide of zinc ointment ; but, as the eruption may disappear without 
 any treatment, it is uncertain how much it was influenced by the rem- 
 edies employed. 
 
 LICHEN SIMPLEX CHRONICUS (Vidal) 
 
 Synonyms. — Lichenification ; Nevrodermite circonscrite ; Prurit 
 circonscrit avec lichenification (Brocq). 
 
 Definition. — A chronic inflammatory disease characterized by 
 patches of flat, quadrangular pseudo-papules, accompanied by violent 
 itching. 
 
 Symptoms.— It begins with severe paroxysmal itching without any 
 visible alteration of the skin, confined to a limited area. After a 
 variable period a red, violaceous, or brownish-red patch, with ill- 
 defined borders, appears in the itching area, made up of closely aggre- 
 gated, square, flat papules. When the patch is fully developed it varies 
 in size from that of a coin to the palm of the hand, is usually round 
 or oval, with a border which blends imperceptibly with the normal skin, 
 its surface somewhat elevated and traversed by numerous fine lines 
 running at right angles to one another (Fig. 21), producing flat, 
 quadrangular elevations resembling superficially the flat-topped pap- 
 ules of lichen planus. These elevations, however, are not true papules, 
 but are nothing more than an exaggeration of the quadrilateral or 
 lozenge-shaped areas into which the skin is normally divided, pro- 
 duced by inflammatory thickening. The itching comes on in 
 paroxysms, is usually much worse at night, and is often so vio- 
 lent as to interfere seriously with the rest of the patient, who is apt 
 at times to become highly nervous or hysterical. There is often but 
 a single patch, although there may be several. The most common 
 sites are the inner and upper surfaces of the thigh and the nape of 
 the neck. 
 
 In addition to this circumscribed variety, Brocq recognizes a diffuse 
 form in which the whole of a region, such as the extremities, or a 
 considerable portion of the trunk, or even the greater part of the cuta- 
 neous surface, may be involved. 
 
 A similar lichenification is occasionally observed as a sequel of 
 chronic eczema, particularly of the papular form. The patches are 
 situated upon the sides of the neck and in the supraclavicular region, 
 in the bends of the elbows and the popliteal spaces, and exceptionally 
 on the buttocks where they meet. 
 
 Fox and Fordyce have described a lichenoid affection distinguished 
 by patches of papules in the axillary and pubic regions, accompanied 
 by severe itching, which the latter regards as probably a variety of the 
 neurodermatitis of Brocq. 
 
 Etiology and Pathology. — The circumscribed form first described 
 is much more frequent in women than in men. Indeed, almost all 
 
92 
 
 DISEASES OF THE SKIN 
 
 the cases under the author's care have been in middle-aged women. 
 Brocq believes it largely dependent upon the nervous system and a 
 symptom of neurasthenia. The direct cause is quite unknown. 
 
 There is considerable difference of opinion among authorities as 
 to the place which ought to be assigned to it among diseases of the 
 skin. By most it is regarded as closely related to chronic eczema, 
 if net simply a variant of it. The author is not inclined to accept this 
 view, but agrees with Brocq and other French dermatologists that it 
 is an independent affection. 
 
 Brocq found an increase in thickness of the rete, its interpapillary 
 prolongations greatly increased in length, and occasionally divided 
 or branched. The papillae were decidedly enlarged in all directions 
 
 Fig. 21. — Lichen simplex chronicus (lichenification), thigh, innei surface. 
 
 and their vessels and the pilo-sebaceous follicles were surrounded by a 
 considerable exudation of lymphoid cells. In the cases of Fox and 
 Fordyce the latter found an acanthosis with hyperkeratosis most pro- 
 nounced about the sweat-ducts. In the corium the most marked change 
 was a dilatation of the coils of the sweat-glands, about which there 
 was an exudation of lymphoid and plasma-cells, as well as about the 
 vessels. 
 
 Diagnosis. — The unmistakable quadrilateral shape of the papules ; 
 the localization of the patch, most frequently on the thigh or the nape 
 of the neck; the furious itching, and the very chronic course of the 
 affection, are so entirely characteristic that an error in diagnosis is 
 not likely to occur. 
 
 Prognosis and Treatment. — The affection is unusually rebellious 
 
INFLAMMATIONS 93 
 
 to treatment, and, as already observed, is of long duration. The 
 author has derived most benefit from X-ray treatment — moderate ex- 
 posures at intervals of four or five days. An ointment containing ten 
 to fifteen grains (0.65 to 1.0) each of phenol and camphor will often 
 afford marked relief from the itching; and if this is successfully com- 
 bated a long step has been made toward cure. 
 
 PITYRIASIS RUBRA PILARIS 
 
 Synonyms. — Pityriasis pilaris (Devergie) ; Lichen ruber (Hebra) ; 
 Lichen ruber acuminatus (Kaposi). 
 
 Definition. — A chronic affection of mildly inflammatory type, char- 
 acterized by small, acuminate, firm papules covered by a horny scale, 
 situated about the follicles. 
 
 First described by Devergie under the title pityriasis pilaris and 
 independently by Hebra as lichen ruber, the first recognizable case is 
 to be found in Rayer's treatise on diseases of the skin, where it is de- 
 scribed as a peculiar example of psoriasis affecting the hair follicles, 
 the particulars of the case having been communicated to Rayer by 
 Tarral, who had seen it in St. Bartholomew's Hospital. In order to 
 distinguish it from the lichen ruber planus of Erasmus Wilson, Ka- 
 posi gave it still another name, lichen ruber acuminatus. Although 
 the relationship of the disease to Hebra's lichen ruber has been the 
 subject of much discussion, it is pretty well agreed at the present 
 time that the two affections are identical, and they will be considered 
 so here, although the author formerly was inclined, for various rea- 
 sons, to regard them as independent diseases. 
 
 Symptoms. — Although it may begin, in exceptional cases, somewhat 
 abruptly, it usually appears gradually, beginning in the majority of 
 cases in the scalp, less frequently on the face, and upon the palms and 
 soles. In the scalp and face it appears as a more or less abundant, 
 fine, branny desquamation, usually accompanied by some redness in 
 the latter region, where it is most pronounced on the forehead, in 
 the brows, about the alas nasi, and, in men, in the mustache and beard. 
 On the palms and soles it begins with slightly red, scaly patches, which 
 spread until the whole region is covered with a diffuse thick scale. 
 In rare instances it appears first upon some portion of the trunk as 
 small, discrete, red, scaly papules. Shortly after its appearance in the 
 scalp and upon the palms and soles, characteristic papules appear upon 
 the backs of the hands, especially upon the phalanges, upon the ex- 
 tensor surface of the forearms, and later upon the trunk and lower 
 extremities. These papules, which are the most characteristic feature 
 of the eruption, vary in size from that of a pin-head to a hemp-seed, 
 are red or brownish-red in color, acuminate in shape, and are topped 
 by small, horny plugs or spines frequently containing a broken hair, 
 imbedded in the dilated mouths of the hair follicles. At first discrete, 
 later, by increase in numbers rather than in size, they may form cir- 
 
94 
 
 DISEASES OP THE SKIN 
 
 ZZ^U y , PatCl ? eS W ' th r ° Ugh ? rater -'ike surface, resembling 
 
 superfically patches of psoriasis. In fully developed cases the facf 
 and scalp are red and covered with fine white scale, looking at a little 
 distance as ,f powdered. Although commonly quite dry the scales 
 occasionally are somewhat greasy, like those of seborrhea, and may 
 form crusts, which upon the scalp mat the hair together. Even in 
 cases in which the scalp is markedly involved, the hair is seldom much 
 affected until late in the disease. The palms and soles are diffusely 
 thickened the nails are lustreless, brittle, and broken, and there is 
 more or less thickening of the skin in all the regions affected with 
 occasional fissnr.ng about the joints, which may interfere more or 
 less with movement. 
 
 The eruption is usually symmetrically distributed and varies a 
 good deal in extent. In mild cases it may be limited to the scalp, face 
 neck, and upper extremities. In more severe ones it may occupy the 
 greater part of the cutaneous surface. 
 
 Fig. 22. — Pityriasis rubra pilaris. 
 
 The subjective symptoms are usually slight, and in mild cases 
 may be absent altogether. There may be some itching, however which 
 in rare instances may be so severe as to interfere decidedly with the 
 patient's rest at night. 
 
 The malady pursues a chronic course and may last for an indefi- 
 nite time. It may slowly and steadily advance, or there may be periods 
 of remission or retrogression, followed by periods of renewed activity 
 in which the areas already affected are increased in extent and new 
 regions invaded. 
 
 The patient's general health, even in extensive cases, is but little 
 affected, but occasional exceptions to this rule occur (Fig. 22) 
 
 Etiology.— The cause of the malady is altogether unknown It 
 usually occurs in those who have previously shown no evidence of 
 ill-health, and is most frequent in the second and third decades of life 
 although it may occur in quite young children, even as early as the 
 first year (Whitehouse). In most instances there is no evidence that 
 
INFLAMMATIONS 95 
 
 heredity plays any role in its production, but recently de Beurmann, 
 Bith, and Heuyer have reported four cases in one family. Sex is 
 without influence upon its occurrence. Milian has recently asserted 
 that it is of tuberculous origin, basing this opinion upon clinical sta- 
 tistics and a positive reaction from injections of tuberculin obtained 
 in cases under his observation ; and other French observers — de Beur- 
 mann, Darier, Gaucher — are somewhat inclined to adopt this view. 
 Vignolo-Lutati, however, reports absolutely negative results from 
 tuberculin injections in a case studied by him. 
 
 Pathology. — Little or nothing is known about the pathogenesis of 
 pityriasis rubra pilaris. As already mentioned, it is believed by some 
 recent observers to be of tuberculous origin, but definite proof of this 
 is still wanting. 
 
 As to its histopathology, it is a hyperkeratosis, most pronounced in 
 and about the hair follicles, but not limited to these, with secondary 
 inflammatory changes in the subjacent parts of the corium. The horny 
 layer of the epidermis is everywhere increased in thickness, forming 
 in the dilated mouths of the follicles, and to a less extent in the open- 
 ings of the sweat-ducts, projecting plugs or spines which extend some 
 distance into the follicles, and there is likewise a more or less pro- 
 nounced acanthosis. 
 
 In the papillae, which are increased in length, and in the subpapillary 
 portion of the corium, there is a moderate exudation of leucocytes, with 
 a few plasma-cells and " mastzellen," and the follicle? are surrounded by 
 a similar, but more pronounced, exudate throughout their length 
 
 (Fig- 23). 
 
 Diagnosis. — The small follicular papules with horny tops, rarely ab- 
 sent from the backs of the hands even in mild cases ; the bran-like 
 white desquamation of the scalp and face, and the occasional rough, 
 scaly patches about the elbows and knees, are features which suffi- 
 ciently distinguish it from other affections. The diseases with which 
 it is most likely to be confounded are pityriasis rubra and lichen planus ; 
 but the former lacks the characteristic papules about the follicles and 
 is characterized by abundant papery scales, while in the latter the 
 papules are flat-topped, frequently umbilicated. and of a dull crimson 
 or violaceous color, altogether unlike the papules of pityriasis rubra 
 pilaris. 
 
 Prognosis. — The prognosis as to recovery is unfavorable, since the 
 disease tends to persist for an indefinite time. Improvement, however, 
 mav take place, and in exceptional cases the disease may disappear, 
 but relapses are common. As already observed, the general health 
 is usually unaffected, but it should be noted that all of Hebra's early 
 cases terminated fatally. 
 
 Treatment. — When indicated by the patient's general condition, 
 tonics, such as quinine, iron, strychnia, and cod-liver oil, may be 
 given with advantage, although these have no direct influence upon 
 the course of the disease. Pilocarpine has been recommended to re- 
 
96 
 
 DISEASES OF THE SKIN 
 
 lieve the abnormal dryness of the skin, but as its effects are only 
 temporary, and as the same result may be obtained by exercise, it is 
 better to employ the latter rather than the former. There is some 
 difference of opinion as to the usefulness of arsenic. Hebra found it 
 of the utmost value — indeed, all his cases died until he began its use, 
 but later authors have failed to obtain the same results with it, and 
 some have asserted that it is injurious. It should be reserved for the 
 later stages of the malady, since there is apparently but little doubt 
 that it may act injuriously when given early, and it should be given 
 in full doses to obtain benefit from its use. Crocker found thyroid 
 
 Pig. 23. 
 
 -Pityriasis rubra pilaris. Note increased width of the rete and horny plug, H, in mouth of 
 follicle. (Section from case under the care of Dr. H. W. Stelwagon.) 
 
 gland, beginning with five grains three times a day, and gradually 
 increasing the dose, useful when employed in conjunction with local 
 treatment. 
 
 In cases of average severity frequent alkaline baths, followed by 
 inunctions with a three per cent, ointment of salicylic acid, will be 
 found the most satisfactory local treatment. If the skin is inflamed 
 and irritable, bran or starch baths may be used. Oil of cade, in an 
 ointment such as the following, is likewise frequently serviceable : 
 
PLATE II 
 
 Psoriasis. 
 
o 
 
 y 
 
 ' 
 
 Fig. 24. — Psoriasis. 
 

INFLAMMATIONS 97 
 
 ft. 
 
 Ol. cadini f3ii (8.0) 
 
 Lanolini 3vi (24.0) 
 
 M. 
 
 Sig. Rub in after the bath. 
 
 Brocq has recommended pyrogallol, used as in psoriasis, as one 
 of the most efficacious remedies, but besides being dirty and disagree- 
 able, staining the underwear and bed-linen, its use over extensive 
 surfaces is not unattended with danger from absorption. For thick- 
 ened patches a 10 to 20 per cent, salicylic acid plaster is perhaps 
 the most efficacious remedy. 
 
 PSORIASIS 
 
 Synonyms. — Lepra; Alphos ; Ger., Schuppenflechte. 
 
 Definition. — A chronic inflammatory disease of the skin character- 
 ized by an eruption of red scaly papules and sharply circumscribed, 
 round, sometimes annular, patches, of variable size, covered with a 
 laminated, mica-like scale. 
 
 Symptoms. — The disease begins with the appearance of small, red 
 papules, which almost at once become covered with a whitish, loosely 
 adherent scale. These continue to enlarge peripherally for a variable 
 time, forming sharply limited patches, varying in size from that of a 
 large pea to a coin, and frequently much larger, which are usually 
 rounded in shape and which by coalescence with neighboring patches 
 frequently form larger ones with irregular borders. With their in- 
 crease in size the patches become somewhat infiltrated, so that they 
 project slightly above the surrounding skin even when the scale is 
 removed. If, after removal of the scale, the underlying red surface is 
 lightly scraped with the nail, a number of bleeding points appear, 
 owing to the nearness of the vessels of the papillae of the corium to the 
 surface. The eruption is invariably dry from beginning to end, and 
 is remarkably uniform in its appearance, varying less from the type 
 than almost any other affection of the skin. While the essential feat- 
 ures of the lesion vary very little, the course, arrangement, and dis- 
 tribution of the eruption as a whole present numerous variations. The 
 entire eruption may be made up of shot to pea-size scaly papules and 
 patches (psoriasis guttata et punctata) ; it may consist of a few or 
 many dime- to half-dollar-size disks (psoriasis numularis), and these 
 may coalesce to form extensive, irregularly shaped plaques the size 
 of the hand or much larger, sometimes covering a half of an extrem- 
 ity or the greater part of the trunk (-Plate II) (psoriasis diffusa). Quite 
 frequently discoid patches undergo involution in the centre and are 
 thus transformed into rings (Fig. 24), which, extending, coalesce with 
 neighboring rings, forming gyrate and serpiginous figures (psoriasis 
 circinata, psoriasis gyrata). In exceptional cases the eruption covers 
 the entire body (psoriasis universalis). 
 7 
 
98 DISEASES OF THE SKIN 
 
 The course of the eruption is somewhat variable. While it usually 
 exhibits irregular exacerbations, it frequently, after reaching a cer- 
 tain stage, remains practically unaltered for months or even years. 
 This is especially apt to be the case in so-called psoriasis inveterata, 
 in which the skin is markedly thickened, covered with abundant ad- 
 herent scales, and frequently fissured around the joints. Quite com- 
 monly the exacerbations and remissions show a seasonal variation, the 
 eruption being much worse, as a rule, in cold than in warm weather. 
 
 The mode of evolution varies a good deal. As a rule, the eruption 
 extends slowly, requiring weeks and months to reach its full develop- 
 ment; but in a fair proportion of cases it comes out quite acutely 
 and spreads over a large surface within a few days or a week. In 
 these rapidly spreading cases scaling is less noticeably laminated than 
 in the slowly extending ones, and there is frequently quite severe itch- 
 ing and burning. According to Crocker, a certain proportion of the 
 cases begins with one or two patches, "primary plaques," which re- 
 main alone for weeks or months, or even years, before new ones 
 appear. It is not uncommon for the disease to consist of a few insig- 
 nificant patches, usually situated upon the points of the elbow, for 
 many years, then, without any evident reason, a sudden exacerbation 
 occurs, new lesions appear rapidly and abundantly, until a considerable 
 part of the cutaneous surface is affected. 
 
 The disease exhibits a marked predilection for the extensor sur- 
 faces of the extremities, being very commonly found on the points of 
 the elbows and over the anterior surface of the knees ; but these re- 
 gions may escape entirely, even in extensive cases. The scalp is also 
 a favorite region, particularly on the forehead at the margin of the 
 hair and behind the ears. Indeed, the disease may be confined to 
 this region, although a careful search in the cases in which it seems 
 to be the only part affected will often reveal one or two insignificant 
 papules elsewhere, usually upon the elbows. 
 
 There is frequently a quite remarkable symmetry in the arrange- 
 ment of the eruption. The patches occupy practically the same re- 
 gions and have, in a general way, the same shape on both sides of 
 the body (Fig. 24) . Quite exceptionally it may be unilateral or limited to a 
 single region. The palms and soles are not often affected, although, 
 according to Neilsen, these regions are more frequently affected than 
 is commonly supposed. In these localities it seldom presents the cir- 
 cumscribed patches seen in other parts, but occurs as a diffuse thick- 
 ening of the horny layer, or as small scaly elevations. The face is 
 quite often exempt, even in extensive cases, and when attacked the 
 eruption is usually less marked than elsewhere, the patches being ill- 
 defined and only slightly scaly. 
 
 The nails are occasionally involved, usually along with the skin, 
 but the disease may be limited to these, at least for a time. They 
 become thickened, brittle, lustreless, and deformed, and beneath them 
 is an accumulation of dirty white scales. Neilsen asserts that psoriasis 
 
INFLAMMATIONS 99 
 
 never attacks the nails alone and never begins in these ; but this is 
 certainly an error, since we have had a case under our own observa- 
 tion in which the nails were the only part attacked for a period of 
 some months. 
 
 The amount of scaling is likewise variable. While in most cases 
 it is abundant, it may, on the other hand, be quite scanty ; in the scalp 
 it may amount to no more than a well-marked dandruff, although 
 usually quite thick in this region. Exceptionally the scales may form 
 thick, oyster-shell-like, adherent crusts (psoriasis rupioides, psoriasis 
 ostreacea). 
 
 In certain cases not very uncommon the eruption presents some 
 of the features of an eczema — the scaling is scanty, the patches are 
 not well circumscribed, and there is more or less severe itching — so 
 that it may be difficult to decide whether one has to do with a psoriatic 
 eczema or an eczematoid psoriasis. 
 
 In certain regions, as, for example, the scrotum, the inflammatory 
 symptoms are unusually pronounced. There is frequently considerable 
 swelling, with pain and tenderness, occasionally Assuring, with more 
 or less moisture. 
 
 In those the subjects of psoriasis irritation, such as may result 
 from the application of a mustard plaster, or slight traumatism, such 
 as a scratch, may be followed by a psoriatic eruption in the irritated 
 or wounded region. In all probability, some of the cases of psoriasis 
 which have been reported as following vaccination have been of this 
 sort. Former sites of the eruption are much more likely to be affected 
 in recurrences than other parts of the skin. 
 
 In the great majority of cases, when the eruption disappears no 
 trace of its existence is left, but not uncommonly a faint discolora- 
 tion may remain for a short time, or, exceptionally, a decided pig- 
 mentation may follow, this last being especially apt to occur in those 
 who have taken large doses of arsenic for some time, but not ex- 
 clusively in these. In rare cases loss of pigment (leucoderma) may 
 follow at the site of the patches, and this leucoderma may be perma- 
 nent (Hallopeau). 
 
 In a small number of cases, which is gradually increasing, epithe- 
 lioma has occurred at the site of circumscribed keratoses, but this com- 
 plication is to be regarded as the result of arsenical treatment rather 
 than as a sequel of the psoriasis. Wart-like growths have been ob- 
 served in a few instances at the site of patches, and superficial scarring 
 has been noted in a small number of cases (vid. p. 98). 
 
 Etiology. — The direct cause of psoriasis is unknown. It is slightly 
 more frequent in men than in women, the proportion of the sexes 
 being three of the former to two of the latter. The great majority 
 of cases begin between the ages of ten and forty, and almost one-half 
 before fifteen. It is uncommon before ten years of age, and decidedly 
 rare in infancy, although Rille has reported a case which began on 
 the sixth day, and Kaposi one at eight months. It almost never ap- 
 
100 
 
 DIESASES OF THE SKIN 
 
 pears for the first time after fifty, but Crocker saw it begin at eighty- 
 one and Neilsen at eighty-five. It is uncommon in dark-skinned races 
 and rare in the full-blooded negro. 
 
 Opinions vary greatly as to the possible influence of heredity in 
 predisposing to the affection, and these opinions vary all the way 
 from ascribing the chief role in its production to inheritance to deny- 
 ing its influence altogether. Most authors are agreed, however, that 
 the malady is never directly transmitted in this manner. Crocker was 
 
 Sib 
 
 m 
 
 ■■* 
 
 Fig. 24a. — Psoriasis. 
 
 quite certain that a proclivity to the affection was inherited, and the 
 author has at least once seen it occur in three generations in the male 
 line. Neilsen very pertinently remarks, however, that the occurrence 
 of the affection in several members of the same family can just as well 
 be explained by contagion as by heredity. 
 
 The affection apparently has no relationship to any definite con- 
 stitutional condition ; it occurs in those who are apparently in robust 
 health as well as in the debilitated. It has been attributed to nervous 
 
INFLAMMATIONS 101 
 
 disturbance and nervous shock, and gout and rheumatism have long 
 been regarded as having an etiological relationship to it, as to many 
 other skin affections, and with just as little foundation. In my opin- 
 ion, there is no evidence worth the name that these affections exer- 
 cise the slightest influence in producing psoriasis. The French have 
 especially called attention to its occasional association with chronic 
 arthritis, especially of the arthritis deformans type, and have made a 
 special variety of these cases (psoriasis arthritica), but the evidence 
 for a causal relationship between the joint trouble and the cutaneous 
 affection is far from sufficient to prove it. It has been noted, how- 
 ever, that the cases of psoriasis associated with chronic arthritis are 
 apt to be unusually severe (psoriasis inveterata) and to show a more 
 or less marked tendency to terminate in a dermatitis exfoliativa. 
 
 As has already been noted, slight mechanical injuries, such as abra- 
 sions or scratches, or the application of local irritants, may be followed 
 in psoriatic subjects by eruptive lesions at the site of injury or irri- 
 tation, especially if the disease is advancing. Kobner was able to pro- 
 duce eruptive designs by superficially scratching the skin of individuals 
 with psoriasis. 
 
 A number of cases have been observed to follow vaccination, the 
 eruption beginning at the point of inoculation and spreading to other 
 parts of the body. Whether these are to be classified with the cases 
 in which a local irritation simply serves to call out the eruption in a 
 subject already predisposed, or whether they are to be considered as 
 a real transference of the disease, cannot yet be definitely determined, 
 although the weight of opinion is in favor of the former view. 
 
 Under ordinary conditions psoriasis is not contagious, although 
 the view that it is due to some as yet unknown organism has many 
 supporters. Numerous attempts to transfer it by inoculation have 
 been made, in most cases with entirely negative results ; but Destot 
 apparently succeeded in transmitting the malady to himself from an 
 infant with vaccinal psoriasis. A few examples of supposed contagion 
 have been reported. Unna, for example, observed three children who 
 were supposed to have contracted the disease from a nurse with psori- 
 asis, in whose care they were. The number of such cases, however, 
 is very small, much too small to base any trustworthy conclusions upon. 
 
 Pathology. — There are many theories as to the nature and patho- 
 genesis of psoriasis, and all of them, or most of them, have, as a mat- 
 ter of course, something in their favor, but each and every one is as 
 yet nothing but a theory. The chief views as to its nature are : First, 
 that it is due to vasomotor or trophoneurotic disturbance ; second, that 
 it is an infection ; and, third, that it is a toxaemia, the result of some 
 metabolic disturbance. The author is much inclined to the view that 
 it is a dermatomycosis, an infection of the skin. While none of the 
 organisms which have been reported by various investigators from 
 time to time as the causative agent, beginning with the "epidermophy- 
 ton" of Lang, have been able to stand the test of subsequent investi- 
 
102 
 
 DISEASES OF THE SKIN 
 
 gation, yet the apparent success of one experimental inoculation, the 
 slowly growing number of cases in which vaccination seems to have 
 been the starting-point of the eruption, and the scattered cases of 
 apparent contagion from ordinary intercourse, cannot be disregarded 
 in a consideration of the causes of the disease. The manner in which 
 the eruption spreads, extending at the border and often undergoing 
 involution in the centre of the patch ; the disappearance of the spread- 
 
 
 "mm. 
 
 FlG. 25. — Psoriasis (recent papule). Note increased thickness of the horny layer of the epidermis 
 and its arrangement in lamellae with retention of nuclei in the lower layers. The rete mucosum is widened 
 and there is a moderate exudate of lymphoid cells in the papillae of the corium most noticeable at left of 
 section. 
 
 ing rings at the point of contact, as if a temporary immunity had been 
 created by the previous existence of the eruption ; the well-known ten- 
 dency of the affection to recur at the site of previous lesions; and, 
 lastly, the fact that the most efficacious local remedies are, as a rule, 
 parasiticide, are facts most readily explained by the theory of infection. 
 Pathological alterations occur in both the epidermis and the corium, 
 but there is a difference of opinion as to where these changes begin — 
 that is, whether the disease is primarily an affection of the epidermis 
 or of the papillary layer of the corium (Fig. 25). 
 
INFLAMMATIONS 103 
 
 There is a considerable proliferation of the cells of the rete (acan- 
 thosis), occurring chiefly in the interpapillary prolongations, the layer 
 of rete cells over the congested papillae being comparatively thin, so 
 that punctate bleeding from the papillary vascular loops readily occurs 
 when the scales are scratched off. Cornification of the upper layers 
 takes place in an incomplete manner ; the cells retain their nuclei, are 
 somewhat moist, so that they adhere in layers, between which are 
 small, round, and linear collections of leucocytes (parakeratosis). The 
 silvery-white color of the scales is due to the collection of air between 
 the lamellae. Owing to the interference with the process of corninca- 
 tion, keratohyalin is no longer formed, and the granular layer disap- 
 pears in consequence. 
 
 The papillae of the corium are enlarged, chiefly in the direction of 
 their length, and their vessels are dilated, more particularly the venous 
 capillaries. About the vessels, the hair follicles, and the sweat-glands 
 there is a fairly abundant round-cell exudate, consisting of mononuclear 
 and polymorphonuclear leucocytes, with a slight increase in the number 
 of connective-tissue cells. The amount of these changes is largely 
 dependent upon the age of the lesion, being most marked in the older 
 papules. 
 
 Schamberg, Kolmer, Ringer, and Raiziss, in a study of the metab- 
 olism of psoriatic patients, found a notable disturbance of protein 
 metabolism, as shown by an enormous retention of nitrogen, but their 
 findings still await confirmation by other investigators. They attribute 
 great importance to this nitrogen retention in the causation of the 
 disease. 
 
 Diagnosis. — The invariably dry character of the eruption ; the 
 abundant mica-like scales ; the almost invariably sharp circumscrip- 
 tion of the patches ; its predilection for the extensor surfaces, and fre- 
 quently symmetrical distribution, are features so characteristic of the 
 malady that the diagnosis is usually made without difficulty even by those 
 with limited experience. 
 
 The diseases with which it is most apt to be confounded are squa- 
 mous eczema, seborrhcea, especially of the scalp, lichen planus, ring- 
 worm, pityriasis rosea, and the squamous syphilodermata. 
 
 Psoriasis, as has already been pointed out, is invariably dry from 
 the beginning to the end of its course, while in eczema there is fre- 
 quently more or less discharge, or a history of its Occurrence, at some 
 time or other. The scale of psoriasis is laminated and composed 
 entirely of horny epithelium, while the scale of eczema is frequently 
 bran-like, or a mixture of crust and scale — that is, a mixture of epithe- 
 lial scales and dried discharge. The patches of psoriasis are sharply 
 marginate, while those of eczema commonly have no well-defined 
 border, but merge insensibly with the healthy skin. Psoriasis attacks 
 by preference the extensor surface of the extremities, while eczema 
 shows no such preference. In psoriasis severe itching is exceptional ; 
 in eczema it is the rule. While the differential diagnosis between 
 
104 DISEASES OF THE SKIN 
 
 psoriasis and scaly eczema may usually be made without much dif- 
 ficulty, the reverse is true when the latter affects the elbows or 
 knees, as it occasionally does ; and the distinction between the two 
 can be safely made only by a careful examination of the entire cuta- 
 neous surface, and especially of the sites of predilection of the former. 
 
 Psoriasis and seborrhcea occurring upon the scalp may resemble 
 each other quite closely, and are frequently confounded; indeed, no 
 other error of diagnosis is quite so common. Psoriasis in this region, 
 as elsewhere, occurs in circumscribed patches covered by dry, brittle 
 scales, beneath which the skin is more or less red, and in the great 
 majority of cases evidences of the disease exist elsewhere. In seborrhcea 
 of the scalp the area affected is not sharply delimited, the scales are 
 fatty or greasy, and the scalp beneath them is either of a normal color 
 or paler than in health. In seborrhceic eczema of the scalp or seb- 
 orrheic dermatitis the scales are less abundant than in psoriasis ; 
 there is usually more or less moisture beneath them, and the disease 
 of the scalp is apt to coexist with the same affection in the eyebrows 
 and other hairy regions. 
 
 Psoriasis and lichen planus resemble each other only when the 
 latter occurs in patches, but the distinction between the two is usually 
 quite easy, since the flat-topped, angular papules characteristic of the 
 latter may always be found about the border of the patch or at some 
 distance from it. The papules of psoriasis are red, while those of 
 lichen are usually violaceous, and the amount of infiltration in a patch 
 of lichen is much greater than in a patch of psoriasis. The discrete 
 papules of lichen are usually without scales, and it is only when patches 
 are formed that scaling becomes at all pronounced, while the earliest 
 lesions of psoriasis show a distinct scale. The scale of the two 
 diseases is quite different ; that of psoriasis is laminated and re- 
 sembles mica somewhat, while the scales of lichen planus are small, 
 quite white, and somewhat scanty. The distribution of the two mal- 
 adies is different, psoriasis affecting the extensor surfaces, lichen 
 the flexor surface of the extremities. 
 
 When the patches of psoriasis are ring-shaped and few in number, 
 they are sometimes mistaken by the inexperienced for ringworm or 
 tinea circinata, but in the former the scaling is quite abundant and 
 the extension of the rings much slower than in the latter. No fungus 
 can be detected in the scales of psoriasis, while in those of ring- 
 worm the spores and mycelia of the trichophyton fungus may always 
 be quite readily demonstrated. 
 
 A superficial resemblance may exist between mild cases of psoriasis 
 and extensive cases of pityriasis rosea, but the latter is an acute 
 affection, running a course of two to three weeks, while the former 
 is a chronic disease, lasting often for years. Scaling in the latter 
 is usually quite insignificant, altogether unlike the laminated scales 
 of the former. 
 
 Psoriasis with small lesions, the so-called guttate psoriasis, and the 
 
INFLAMMATIONS 105 
 
 papulosquamous syphiloderm of the secondary stage, may occasionally 
 resemble one another very closely. In psoriasis the eruption is a 
 uniform one, the lesions are all scaly papules which vary only in size ; 
 in the papulosquamous syphiloderm there are sure to be found papules 
 without scales, and here and there a pustule covered with a crust. 
 Psoriasis affects by preference the extensor surfaces and usually spares 
 the face or affects it but slightly. Syphilis affects all parts alike, occur- 
 ring quite frequently in the face, and characteristically on the palms 
 and soles, regions which psoriasis attacks only infrequently. The 
 syphilitic eruption is usually accompanied by a general adenopathy, 
 and lesions upon the mucous membranes of the lips, tongue, and 
 cheeks are often present, together with moist papules (condylomata) 
 at the verge of the anus and on the scrotum. The scaly lesions of late 
 syphilis often occur upon the palms and soles, regions which, as al- 
 ready noted, are infrequently attacked by psoriasis. 
 
 Prognosis. — The outlook as to a complete and radical cure is un- 
 favorable, although there are few cases of the disease in which the 
 eruption cannot be made to disappear for a longer or shorter time 
 by judicious treatment. Relapses occur, however, in the larger pro- 
 portion of cases at varying intervals, although it occasionally happens 
 that a period of years may elapse during which there is no trace of 
 the disease. 
 
 Treatment. — Both internal and external remedies are employed in 
 the treatment of psoriasis, and a judicious combination of both usually 
 gives the best results, although there are cases in which one or the 
 other form of treatment may be successfully employed alone. On 
 general principles the patient's general health should be carefully 
 looked after, but in many cases, if not in most, the patient's general 
 condition affords no indication for systemic treatment. In a general 
 way, everything which tends to lower the patient's vitality should 
 be avoided. Although it is the custom to regulate the patient's diet, 
 the author does not believe that any particular form of diet influences 
 the disease, either favorably or unfavorably. Quite recently it has 
 been asserted (Schamberg) that under a low protein diet the erup- 
 tion tends to disappear more or less completely. It is true that some 
 individuals, while on such a diet, apparently improve, but the im- 
 provement is usually very brief, and the eruption promptly reappears 
 after a return to the ordinary diet, and in a considerable proportion 
 of cases such a diet exerts no apparent effect upon the disease. The 
 inordinate use of alcohol is undoubtedly bad, and it should be inter- 
 dicted in most cases. 
 
 Among the systemic remedies employed in the treatment of psori- 
 asis, arsenic easily takes the first place, but it is not to be used indis- 
 criminately nor by any means in every case, since it is capable of 
 doing quite as much harm as good — indeed, more when used injudi- 
 ciously. The cases in which it acts best are those in which the erup- 
 tion is either stationary or extending very slowly, with no signs of 
 
106 DISEASES OF THE SKIN 
 
 acute inflammation and little or no itching. It should not be em- 
 ployed when the eruption is spreading rapidly, is bright red, with 
 rather fine scaling, and marked itching. In such cases it almost in- 
 variably makes the patient's condition much more uncomfortable. Not 
 uncommonly, even in chronic cases, its administration is followed 
 by a marked increase in itching, and exceptionally this increased itch- 
 ing is so severe as to make the continuance of the remedy almost 
 impossible for a time. There are many preparations of arsenic, and 
 special therapeutic properties are claimed for some of the recently 
 introduced organic arsenical compounds, but there is little or no 
 evidence that the new preparations are any more effective therapeutic- 
 ally than the old ones, although some of them, such as the cacodylate 
 of soda, are especially adapted to hypodermatic use. In order to 
 obtain satisfactory results from arsenic in psoriasis, it should be given 
 in doses as large as the patient can comfortably and safely take. Small 
 doses are of little or no use. Of course, the patient should be under 
 constant and careful supervision while taking the remedy. It should 
 always be given immediately after meals, and the liquid preparations 
 should be taken largely diluted with water, or, better, with milk, 
 in order to avoid as much as possible its local irritant effects upon 
 the gastric mucosa. Arsenic trioxide or arsenious acid may be given 
 in doses of one-twentieth to one twenty-fifth grain (0.002 to 0.003) 
 three times a day, and my own experience is much in favor of giving 
 it in combination with black pepper in the shape of the so-called 
 Asiatic pill. 
 
 Pulv. piper, nig gr. i. (0.05) 
 
 Pulv. arsenic, trioxid gr. V20 (0.003) 
 
 M. 
 
 Sig. To be taken three times a day. 
 
 This seems to be more active therapeutically than the arsenic tri- 
 oxide alone, and better tolerated by the stomach. Fowler's solution 
 (liquor potassii arsenitis) is one of the most commonly employed forms 
 of arsenic, and may be given in doses of five to ten drops in half a 
 tumblerful of water after meals. The author much prefers, however, 
 the liquor sodii arsenatis given in the same dose, since it is tasteless 
 and odorless and is apparently somewhat less irritating to the stomach 
 than the potash salt. It may be given conveniently and effectively 
 in a glass of water taken with the meals, or in milk. If the patient 
 is anaemic, either one of the above solutions may be advantageously 
 combined with the wine of the citrate of iron, giving one or two 
 teaspoonfuls of the latter as a dose. Recently the cacodylate of soda, 
 which contains as much as fifty-five per cent, of arsenic, has been 
 recommended as an especially effective arsenical preparation. It may 
 be given in doses of one-half to three-quarters of a grain (0.03 to 0.05) 
 three times a day, and even larger doses may be given without pro- 
 ducing symptoms of arsenical poisoning. When taken by the mouth 
 
INFLAMMATIONS 107 
 
 it imparts an intensely disagreeable odor of garlic to the breath, ex- 
 tremely unpleasant for those who come in contact with the patient. 
 A large experience with this preparation has convinced me that it 
 possesses no advantages over other preparations of arsenic except 
 that it is quite soluble in w T ater, making an unirritating solution par- 
 ticularly well adapted to hypodermatic administration. Atoxyl is 
 another of the more recently introduced arsenical preparations which 
 may be administered hypodermatically, but it is much too dangerous 
 for ordinary use. Certain untoward effects are apt to be produced 
 by the prolonged use of arsenic in large doses, such as pigmentation 
 of the skin and the formation of keratoses, particularly in the palms 
 and on the soles, and, since these latter are occasionally followed by 
 epithelioma, their production is to be carefully avoided. 
 
 Salicin and the salicylates, remedies which were first recommended 
 by Crocker in the treatment of psoriasis, are of considerable value, 
 but they must be given in fairly large doses in order to obtain the 
 best effect. Salicin is preferable to the salicylates because it rarely, 
 if ever, disturbs the stomach and seems to be quite as effective as 
 the latter therapeutically. It may be given in doses of from ten to 
 fifteen grains (0.65 to 1) three or four times a day, and may be in- 
 creased to twenty grains (1.50) without any untow r ard effect. It 
 seems to be especially useful in those cases in which arsenic is contra- 
 indicated — cases in which the eruption is rapidly extending and in 
 which there is considerable itching. Salicylate of soda may be given 
 in the same doses, preferably in carbonated water, to avoid upsetting 
 the stomach. Unlike salicin, it is at times quite depressing, in addition 
 to its nauseating effect. 
 
 Iodide of potassium in large doses, as advocated by Haslund, is 
 a remedy which is occasionally of service, but it should be given in 
 large doses, not less than a drachm (4.0) a day, and should not be given 
 to patients with cardiac or renal insufficiency. 
 
 The alkalies, such as potassium citrate or acetate, or the liquor 
 potassse in full doses, largely diluted with water, are sometimes of 
 service, especially in subacute cases with a spreading eruption occur- 
 ring in robust individuals, but these should not be continued for any 
 considerable period. 
 
 Other remedies which are occasionally useful, but much more 
 uncertain in their effects than the foregoing, are phenol in doses of 
 one grain (0.06) three times a day, carefully increased to three or 
 four grains (0.20 to 0.25) three times a day; turpentine, ten to thirty 
 minims three times a day, recommended by Crocker in hypersemic 
 cases ; wine of antimony in ten-drop doses three times a day in mark- 
 edly inflammatory cases occurring in robust subjects; and, lastly, thy- 
 roid gland (Bramwell). This last sometimes proves effective in cases 
 which have resisted other forms of treatment, but it should be given 
 with care, and upon the appearance of symptoms of hyperthyroidism, 
 such as vertigo, increased rapidity of pulse, and restlessness, it should 
 be suspended. 
 
108 DISEASES OF THE SKIN 
 
 The local treatment of psoriasis is no less important than the sys- 
 temic treatment, and requires even more skill and judgment. It is 
 quite possible to remove the eruption by external treatment alone, 
 and in cases in which it is not very extensive internal treatment may 
 be dispensed with, if there are any contra-indications to its employ- 
 ment. The first step in the local treatment should be the thorough 
 removal of the scales. When they are scanty, simple inunction with 
 some bland fatty substance, such as petrolatum, benzoated lard, olive 
 oil, or oil of sweet almond, may be sufficient to remove them. In 
 cases in which the scales are abundant more active measures are 
 necessary, such as prolonged immersion in a warm alkaline bath and 
 the use of the tincture of green soap. If the scales are unusually thick 
 and adherent, the wet pack may be employed. In very extensive cases 
 rubber clothing or, when an extremity is involved, a rubber bandage 
 may be used; these, by retaining perspiration, produce thorough mac- 
 eration of the epidermic scales, so that they may be completely re- 
 moved. 
 
 In mild and recent cases the use of baths, followed by emollient 
 ointments, may be sufficient to remove the eruption when employed 
 in conjunction with internal treatment, but in most cases more active 
 local treatment is required. 
 
 One of the most efficient of all the local remedies is chrysarobin, 
 which may be used as an ointment, paste, or varnish, the first being 
 the most efficacious. Certain disadvantages, however, attend its use, 
 which restrict to some extent its employment. The first and most 
 important of these is its tendency to occasionally produce a severe 
 dermatitis, which may extend far beyond the point of its application. 
 When applied to the face and scalp, a severe conjunctivitis may result, 
 and for this reason it should not be used at all in the former region 
 and only with caution in the latter. A second disadvantage is the 
 staining of the skin, hair, nails, and clothing which it causes, the last 
 being stained an indelible mahogany red. The most efficient manner 
 of applying it is as an ointment, containing from two to twelve per 
 cent. This should be thoroughly rubbed into the patches, first freed 
 of scales, once a day. Made up in a paste as in the following, staining 
 is reduced to a minimum : 
 
 Chrysarobini gr. xx-xxx (1.5-2) 
 
 Pulv. amyli, 
 
 Pulv. zinci oxidi aa 3ij (8) 
 
 Petrolati Sss (16) 
 
 M. 
 
 Sig. Apply once a day. 
 
 This paste is not quite as effective as an ointment, but it is much 
 more agreeable to use, greasing and staining the clothing much less. 
 The staining may be quite prevented by dissolving the chrysarobin 
 in liquor gutta-percha and painting it on the patches, first thoroughly 
 freed of scales, with a flat brush. It may be mixed with flexible collo- 
 
INFLAMMATIONS 109 
 
 dion and applied in the same manner ; or it may be mixed with chloro- 
 form, thirty grains (2.0) to the ounce (32.0), and painted over 
 the patches, which are then covered with collodion after the chloroform 
 has evaporated. The strength of these ointments, pastes, and solu- 
 tions must depend upon the degree of inflammation and the amount 
 of infiltration present. If the inflammation is at all acute, with much 
 itching or burning, chrysarobin should not be used at all, or at least 
 not until these have measurably subsided. In sluggish, long-standing 
 cases, with considerable thickening, the addition of two to three per 
 cent, of salicylic acid adds materially to the effectiveness of the chrysa- 
 robin applications. Should a dermatitis be produced, the use of the 
 remedy should be suspended until this subsides. 
 
 Tar is an old and valuable local remedy in the treatment of psoriasis. 
 The ordinary tar ointment of the Pharmacopoeia, unguentum picis 
 liquidae, is effective, but dirty and disagreeable, and may advantageously 
 be replaced by other tarry preparations, such as the oil of cade 
 (oleum cadini) or oil of birch (oleum rusci). These may be used com- 
 bined with some ointment-base, such as lanolin or benzoated lard, in 
 the proportion of one or two drachms to the ounce (4-8 to 32), and 
 should be thoroughly rubbed in once a day, or they may be mixed 
 with some fluid fat, such as fluid cosmoline, oil ot sweet almond, or 
 olive oil, and thoroughly rubbed into the affected areas with a flannel 
 cloth or stiff brush. In inveterate cases with much infiltration the 
 pure oil of cade or oil of birch may be employed in this manner. The 
 curative effect of the tarry preparations is materially enhanced by 
 following their application by prolonged immersion in a warm alka- 
 line bath. They are not suited to inflammatory cases, and in every 
 case it is well to use the weaker ointments at first until the patient's 
 tolerance of the remedy is ascertained. Occasionally toxic symptoms 
 result from absorption, such as nausea, vomiting, diarrhoea, strangury, 
 and blackened urine ; the appearance of these symptoms should lead 
 to the immediate suspension of the treatment. In recent years at- 
 tempts have been made to obtain a tarry preparation which should 
 have all the therapeutic value of tar without its disagreeable qualities, 
 but so far these attempts have not met with much success. Anthrasol, 
 a light-yellow, oily preparation made from tar, with a slight but not 
 disagreeable tarry odor, while useful and more agreeable, is by no 
 means as effective as the oil of cade or the oil of birch. Coal-tar 
 may be employed instead of the preparations of wood tar, but is by 
 no means the equivalent of the latter. The most convenient manner 
 of using it is in the shape of a mixture of one part of coal-tar to six 
 or eight of tincture of soap bark, known as the liquor carbonis deier- 
 cjcus; this should not be used in full strength — at least, not at first — 
 but should be diluted with three or four parts of water, or, better, 
 lime water, and should be thoroughly rubbed into the patches twice 
 a day. 
 
 A very useful and cleanly remedy is an ointment of ammoniated 
 
110 DISEASES OF THE SKIN 
 
 mercury of the strength of from five to ten per cent., or stronger; 
 it is colorless and odorless and much more agreeable to use, especially 
 on uncovered parts, than the preparations of tar and chrysarobin. 
 Owing to the danger of producing mercurialism through absorption, 
 its use should be limited to comparatively small areas. It is an espe- 
 cially useful local remedy in psoriasis of the scalp, owing to its free- 
 dom from odor and stain. 
 
 Pyrogallol, introduced as a remedy for psoriasis by Jarisch, may 
 be used as an ointment of ten per cent, strength, but it is a dangerous 
 remedy if applied to large areas, since enough of the drug may be 
 absorbed to cause serious toxic symptoms, or even death. Betanaph- 
 thol and thymol, the former recommended by Kaposi, the latter first 
 proposed by Crocker, are occasionally useful, but decidedly inferior to 
 such remedies as chrysarobin or tar, although more agreeable to use. 
 They are best applied in an ointment of from five to ten per cent, 
 strength. 
 
 The X-ray is a very effective and cleanly local remedy, frequently 
 causing the rapid disappearance of the patches, but it is no more 
 curative than other local or internal treatment, and relapses occur with 
 the same facility as after other remedies. It should be employed with 
 caution ; the exposures should be short and not too frequently repeated ; 
 and it should not be used in psoriasis of the scalp, as permanent alope- 
 cia may be produced. Exposure to sunlight and to the electric arc-light 
 likewise exerts a favorable effect upon the eruption. 
 
 PARAPSORIASIS 
 
 Synonyms. — Parakeratosis variegata (Unna) ; Lichen variegatus 
 (Crocker) ; Psoriasiform and lichenoid exanthem (Neisser) ; Derma- 
 titis psoriasiformis nodularis (Jadassohn) ; Erythrodermie pityriasique 
 en plaques disseminees, Parapsoriasis en plaques (Brocq) ; Resistant 
 maculo-papular scaly erythrodermias (Fox and MacLeod). 
 
 Definition. — A rare and extremely chronic and rebellious inflamma- 
 tory affection distinguished by an eruption composed of minute scaly 
 papules and scaly erythematous patches situated, for the most part, 
 upon the trunk. 
 
 Attention was first called to this rare affection by Unna, who, in 
 conjunction with Santi and Pollitzer, first described several cases in 
 1890, under the name of parakeratosis variegata. Other cases bear- 
 ing more or less resemblance to Unna's cases have since been described 
 under a variety of names by Jadassohn, Juliusberg, Neisser, Colcott 
 Fox and MacLeod, J. C. White, and Brocq. While all these cases 
 have certain features in common, they also present decided differ- 
 ences in many of their clinical symptoms, and while regarded by 
 most authorities at present as closely related, it is still uncertain 
 whether they are actually only variants of the same disease or dis- 
 tinct affections. Fox and MacLeod have proposed for the whole 
 group the provisional title "Resistant maculo-papular Scaly Erythro- 
 
INFLAMMATIONS 111 
 
 dermias," including under it the erythrodermie pityriasique en plaques 
 disseminees, parapsoriasis en plaques, of Brocq ; the dermatitis psoriasi- 
 formis nodularis of Jadassohn ; the pityriasis lichenoides of Juliusberg ; 
 the lichenoid psoriasiform exanthem of Neisser; and Unna's parakera- 
 tosis variegata. 
 
 Symptoms. — As may be inferred from the variety of names under 
 which the cases have been reported, the symptoms present considerable 
 variation, although certain of them are common to the whole group. 
 Following Brocq, the cases may be divided into three groups : First, 
 those which resemble in some degree psoriasis, characterized by small, 
 flat, red or brownish-red, slightly scaly papules and macules scattered 
 over the trunk and extremities, slowly spreading to new regions until 
 a large part of the skin is involved ; second, those which bear some 
 resemblance to lichen, distinguished by an eruption consisting of very 
 small, slightly scaly, red or yellowish-red papules which in time form 
 irregular or serpentine patches, which inclose areas of sound skin, 
 producing a characteristic retiform appearance. When fully developed 
 the eruption may cover a large part of the trunk and extremities. The 
 skin is somewhat thickened and varies in color in different localities 
 from yellowish-red to a pale violaceous color, producing a variegated 
 appearance (parakeratosis variegata, lichen variegatus). The third 
 form is characterized by variously sized red or brownish-red, non- 
 elevated patches covered with a fine scanty scale, which begin as small 
 red spots or patches one or two centimetres in diameter and steadily 
 enlarge and coalesce. On the back they occasionally form linear 
 patches an inch or an inch and a half wide, which follow the direc- 
 tion of the ribs, producing a streaked appearance. 
 
 Occasionally intermediate cases are observed in which, in addi- 
 tion to the scaly erythematous areas above described, patches of very 
 small scaly papules are present, such as are seen in cases of the sec- 
 ond group. 
 
 In most of the cases reported the absence of itching has been em- 
 phasized, but a few exceptions have been noted. In a case of the 
 third form in a neurasthenic man at present under the author's care, 
 considerable itching is present at night. 
 
 Etiology and Pathology. — The immediate cause of the affection is 
 altogether unknown. It is apparently decidedly more frequent in men 
 than in women, and is, for the most part, a disease of adults, although 
 Juliusberg saw a case in which it was said to have begun at seven years 
 of age. The cases, however, are as yet far too few to permit any trust- 
 worthy conclusions to be drawn concerning the factors which predis- 
 pose to it. 
 
 Brocq regards it as related, on the one hand, to psoriasis and the 
 psoriasiform "seborrheids," and on the other to lichen planus. 
 
 The histological changes are indicative of an inflammatory process 
 and are much the same in all forms, differing chiefly in degree. In 
 the epidermis there is inter- and intra-cellular oedema of the prickle- 
 
112 DISEASES OF THE SKIN 
 
 cell layer, with disturbances in keratinization leading to disappear- 
 ance, wholly or in part, of the granular layer and retention of nuclei 
 in the cells of the horny layer (parakeratosis). 
 
 The papillae of the corium are cedematous, their vessels dilated and 
 surrounded by a more or less abundant round-cell exudate. 
 
 Diagnosis. — The extremely chronic and rebellious character of the 
 eruption, its steady spread, its peculiar yellowish-red or brownish- 
 red and occasionally variegated color, and the absence of itching are 
 characteristic features. It differs from psoriasis by the scantiness of 
 the scales and their bran-like character, and by the absence of any 
 partiality for the regions affected by the latter. It may be distin- 
 guished with difficulty from the erythrodermic stage of granuloma 
 fungoides, and in at least one case was confounded with that affection. 
 
 Prognosis and Treatment. — As already observed, the affection is 
 an eminently chronic one and extremely resistant to treatment. Brocq 
 has observed benefit from the internal use of cacodylate of soda, and 
 Engman and Mook from bichloride of mercury, but others have ob- 
 served no benefit from any form of internal treatment. 
 
 Unna had some success with a strong ointment of pyrogallol, coun- 
 teracting its toxic effects by the simultaneous administration of hydro- 
 chloric acid. Brocq regards this as the most useful local remedy, 
 using a ten per cent, ointment with the addition of two and one-half 
 per cent, of salicylic acid. When using such a dangerous local remedy 
 as pyrogallol, the patient should be under constant and careful super- 
 vision lest serious toxic effects be produced. 
 
 PITYRIASIS ROSEA 
 
 Synonyms. — Pityriasis maculata et circinata; Pityriasis rose (Gi- 
 bert) ; Herpes tonsurans maculosus (Hebra). 
 
 Definition. — An acute mildly inflammatory disease characterized by 
 an eruption composed of small, red, only slightly elevated papules and 
 round, annular and elliptical, slightly scaly macules. 
 
 Symptoms. — This affection was first described by Gibert, in i860, 
 who gave it the name pityriasis rose, and later by Bazin, who gave it 
 another name, pityriasis maculata et circinata, and by Hardy, Duhring 
 Behrend, and others. 
 
 The eruption is in most cases confined to the trunk, although it 
 is not very uncommon on the neck and extremities, but is very rare on 
 the face. It begins as small pink or red papules and round or oval 
 patches which continue to enlarge for a day or two and then remain 
 stationary. The majority of the macules undergo a partial involution 
 in the centre after a short time, which transforms them into rings or 
 ellipses with a yellowish centre covered with a thin, finely wrinkled 
 scale and slightly elevated and finely scaly red borders. When fully 
 developed the patches vary in size from that of a large pea to a coin 
 and in numbers from a dozen or two to scores or hundreds, covering 
 
INFLAMMATIONS 113 
 
 the trunk, the upper arms, and upper thighs. In the cases with scanty 
 eruption the lesions may all appear within two or three days, but in the 
 more extensive cases they come out in crops for a week or longer. 
 A certain number of the lesions remain papular throughout the attack, 
 and exceptionally the papular character of the eruption as a whole 
 is quite pronounced. 
 
 As was pointed out some years ago by Brocq and repeatedly con- 
 firmed since, the disease begins in a certain proportion of cases with 
 a " primitive plaque," which usually appears upon the trunk, according 
 to Brocq somewhere near the waist-line, and, after a period varying 
 from two or three to ten days, new patches appear rather rapidly on 
 various parts of the trunk. The interval between the appearance of 
 this primitive plaque and the general eruption is occasionally quite 
 prolonged. Moingeard observed a case in which it was six weeks, 
 and the author has within a few months seen one in which it was seven 
 weeks. The proportion of cases in which it occurs is still undetermined. 
 Szaboky found it in 50 per cent, of 119 cases, while Graham Little saw 
 it only nineteen times in 174. Since it is unattended by any annoying 
 subjective symptoms which attract the patient's attention, and may 
 occur on parts not easily seen, it probably is present in a much larger 
 proportion of cases than these figures indicate. 
 
 The distribution and extent of the eruption vary considerably. 
 In the majority of cases it is found in the clavicular regions and on the 
 sides of the thorax. It is rather scanty, but may cover a great part 
 of the trunk and extend to the upper arms and upper thighs. The 
 forearms and legs are rarely affected, the face still less frequently, 
 and the hands almost never. In rare cases it may be unilateral or 
 limited to certain regions, such as the clavicular or the sides of the 
 thorax. 
 
 In most cases some degree of itching is present and occasionally 
 is very severe, causing the patient much distress. If irritating washes 
 or salves have been applied, a decided dermatitis may be produced, 
 accompanied by intense itching. 
 
 The eruption lasts from two to three weeks, the usual time, to six 
 or eight, or even three or four months in exceptional instances. 
 
 With a widespread eruption slight elevation of temperature, with 
 headache, may be present for a short time, but this is unusual. Under 
 similar circumstances the cervical, axillary, and inguinal glands may be 
 slightly enlarged (Crocker). 
 
 Second attacks may occur, but are decidedly rare, the author having 
 seen but a single example (Fig. 26). 
 
 Etiology. — The disease is seen in the great majority of cases in 
 children and young adults. It is rare in infancy and old age, but 
 Crocker saw it as early as seven months and as late as seventy years. 
 Although it is stated by some authors (Thibierge) that it is decidedly 
 more frequent in women than in men, the author's own experience 
 coincides with that of Szaboky, who found it much oftener in males than 
 8 
 
114 
 
 DISEASES OF THE SKIN 
 
 in females. It is altogether likely, however, as the statistics of Crocker 
 and Graham Little show, that sex affects its incidence very little, if 
 at all. It is apparently somewhat more frequent in the cold than in 
 the warm months. 
 
 In 1882 Vidal announced the discovery of a fungus in this malady 
 
 s 
 
 Fig. 26. — Pityriasis rosea. 
 
 consisting of extremely small spores of unequal size without mycelium, 
 surrounding the epithelial cells, to which he gave the name Microsporon 
 anamocon or dispar. This discovery was not confirmed by other in- 
 vestigators, but quite recently (1912) Du Bois has described a similar 
 organism which he has found in the scales of the patches for which he 
 proposes the name given by Vidal, Microsporon dispar. He attributes 
 
INFLAMMATIONS 115 
 
 the non-success of those who have looked for the organism to the fact 
 that they have not removed the scale with sufficient care. Unless this 
 is very carefully done, the spores are destroyed or lost. This dis- 
 covery still awaits the confirmation of other investigators. 
 
 In a few instances it has been observed in two or more members of 
 the same family, as husband and wife, mother and child, sister and 
 brother (Hyde, Crocker, Fordyce, G. H. Fox), but these are still so 
 few that they may just as well be attributed to coincidence as to 
 contagion. 
 
 Pathology. — The nature of the disease is still undetermined. Hebra, 
 Kaposi, and others of the Vienna school believed it a variety of ring- 
 worm, but as it has been demonstrated again and again that the 
 trichophyton is not present in the scales of the patches, this opinion is 
 hardly worth serious discussion. By a number of authorities it is 
 regarded as a general infection analogous to the exanthemata, or to 
 the toxic erythemata. 
 
 Notwithstanding the apparently superficial character of the macules, 
 considerable histological changes are present in both the epidermis and 
 the upper portion of the cutis. In the former there is a parakeratosis 
 with parenchymatous oedema of the rete which causes a slight increase 
 in its width. In the advanced stages of the eruption, microscopic 
 vesicles are present beneath the horny layer. In the papillae and sub- 
 papillary portion of the cutis the vessels and lymph-spaces are dilated 
 and the former surrounded by a considerable exudation of cells, which, 
 according to Unna, are almost wholly young connective-tissue cells, 
 but which according to Hollman are largely leucocytes. 
 
 Diagnosis. — The eruption is in most cases quite characteristic in 
 appearance, but is at times mistaken for seborrhoeic dermatitis, ring- 
 worm, psoriasis, and, most frequently of all, for syphilis. 
 
 Seborrhoeic dermatitis shows a decided preference for the scalp, 
 face, and on the trunk, for the sternal and interscapular regions, the 
 regions which pityriasis avoids altogether or shows no special prefer- 
 ence for. The scales are greasy and may form crusts, while those of 
 pityriasis rosea are dry and fine. Seborrhoeic dermatitis is a chronic 
 affection, pityriasis rosea an acute one. 
 
 In ringworm the patches are rarely very numerous, are situated, 
 in most cases, upon the face and other uncovered parts, spread peripher- 
 ally quite rapidly and sometimes extensively, and contain the spores 
 and mycelia of the trichophyton. 
 
 In psoriasis the patches are decidedly red and infiltrated and are 
 covered with a laminated mica-like scale much more abundant than 
 the fine scale on the patches of pityriasis rosea. The former is a 
 markedly chronic, the latter an acute, disease. 
 
 Although there is, in most cases, but little real resemblance between 
 pityriasis rosea and syphilitic eruptions, the former is quite often 
 mistaken for the latter. The color of pityriasis is a characteristic 
 salmon-pink, that of the macular and papulo-squamous syphiloderm 
 
116 DISEASES OF THE SKIN 
 
 red or brownish-red. The former never occurs on the palms and very 
 rarely upon the face, regions commonly affected by syphilis. The 
 former frequently itches more or less, the latter very rarely. The 
 syphilitic eruption is accompanied by a general adenopathy, mucous 
 patches in the mouth and about the anus, and other symptoms more or 
 less characteristic. 
 
 Prognosis and Treatment.— In most cases it is a trivial affection, 
 chiefly of importance from the point of view of diagnosis. It runs 
 a course lasting from two or three weeks to a month or more, but 
 exceptionally it may last several months. It is rarely accompanied 
 by annoying symptoms and disappears without leaving any sequelae. 
 
 Internal treatment is unnecessary and without effect upon its course, 
 although Crocker was quite convinced that salicin hastened its invo- 
 lution. Nor is there any certainty that external treatment is any more 
 efficacious, although this may be necessary for the relief of itching. 
 Especial care should be taken to avoid the use of lotions or ointments 
 which may irritate the skin, which seems to be more than usually 
 irritable. If irritated, the itching may be extremely annoying ; indeed, 
 the only cases in the author's experience in which this symptom has 
 been especially pronounced have been those which have been inju- 
 diciously treated locally. Lotions of phenol, one to two per cent., with 
 two or three per cent, of glycerin, of resorcin, one per cent., of menthol 
 and borax (vid. Eczema), may be employed when local treatment is 
 indicated. 
 
 ECZEMA 
 
 Synonyms. — Salt rheum ; tetter ; Fr., eczema ; Ger., Ekzem, nassende 
 Flechte, Salzfluss. 
 
 Definition. — Eczema is an inflammation of the skin, a dermatitis 
 characterized by a variety of primary lesions, such as redness or ery- 
 thema, papules, vesicles, and pustules, and secondary lesions, such as 
 crusts, scales, fissures, and thickening of the skin. The eruption is 
 usually a multiform one, several, indeed all, of the above-mentioned 
 lesions being present at one time or another in the course of the disease, 
 or simultaneously. Itching and burning, usually of a marked charac- 
 ter, accompany the eruption, the former being almost never absent. 
 
 If we consider the frequency of its occurrence, the distress which it 
 occasions its subjects, the difficulties which often surround its treat- 
 ment, eczema is easily one of the most, if not the most, important of all 
 the diseases of the skin. According to the statistics of the American 
 Dermatological Association, no less than 30 per cent, of all diseases 
 of the skin in North America belong in this category. No age nor 
 station in life is exempt. Infancy and old age, the rich and poor alike, 
 are its subjects. Much has been written in times past in a vain en- 
 deavor to show how eczema differs from an ordinary simple dermatitis, 
 but, as was conclusively proven by Hebra, eczema is nothing more 
 than a dermatitis, although not every dermatitis is an eczema. It 
 
INFLAMMATIONS 117 
 
 differs in no essential particular, neither as to its clinical features nor 
 its histopathology, from the inflammation of the skin which may be 
 artificially produced by many irritant substances locally applied. That 
 eczema is nothing more than a dermatitis is conclusively shown by 
 the fact that in the so-called trade eczemas a large and important class 
 which are in every particular real eczemas, differing in no discoverable 
 way from those of unknown origin, the affection is in the beginning 
 an inflammation of the skin resulting from contact with some irritant 
 substance, chemical or otherwise, which frequently runs an acute 
 course, disappearing promptly at first with the withdrawal of the irri- 
 tant, but which after repeated attacks or prolonged exposure no longer 
 disappears, even when the cause is withdrawn, but continues in- 
 definitely. The simple acute dermatitis has then become a chronic 
 eczema. And while it is true that many individuals are much more 
 prone to acquire eczema than others, exhibit an " eczematous " ten- 
 dency, it is also most probably true that every individual may acquire 
 the affection if the irritation of the skin is sufficiently prolonged or 
 often enough repeated. Bateman's definition of eczema, " a non- 
 contagious eruption, generally the effect of irritation, whether inter- 
 nally or externally applied, occasionally produced by a great variety of 
 irritants," has had nothing of real importance added to it in a hundred 
 years. 
 
 While all authors recognize an acute and a chronic form of the 
 malady, yet eczema is practically a chronic affection, pursuing a course 
 lasting months or years, during which there are frequent acute exacer- 
 bations. Indeed, the author is quite convinced that acute eczema 
 would dwindle to small proportions if care were taken to exclude the 
 action of local irritants in every case of acute inflammation of the skirt 
 presenting the symptoms of eczema. A large proportion of the cases 
 of so-called acute recurrent eczema are, in fact, cases of acute derma- 
 titis resulting from contact with some unsuspected or undiscovered 
 irritant. There are, however, certain cases of acute inflammation of 
 the skin, presenting the symptoms of eczema, in which such local 
 cause can be excluded, and for which some unknown internal source 
 must be accepted, 
 
 Symptoms. — The symptoms of eczema are those of inflammation, 
 redness and some swelling, with or without papules, vesicles or pustules 
 seated upon reddened areas, accompanied by subjective sensations of 
 itching and burning, oftentimes of the most exaggerated character. 
 The picture presented by the eruption is a constantly changing one — 
 the erythema of to-day is succeeded by a vesicular eruption to-morrow, 
 which, in turn, may be replaced by a red raw surface from which oozes 
 a straw-colored viscid fluid which dries into thick yellow crusts. Very 
 commonly, if the disease is at all extensive, several types of eruption 
 may be present on various parts of the skin simultaneously. The face 
 may present a diffuse redness with slight scaling, while the arms are 
 covered with vesicles and the legs are moist, oozing and crusted, the 
 
118 DISEASES OF THE SKIN 
 
 type of disease depending upon a great variety of circumstances, such 
 as duration, locality, and age of the patient. Certain types are much 
 less subject to variation in the eruption than others. Erythematous 
 eczema frequently remains such throughout its course and the same 
 is often true of the papular variety, while the vesicular type is apt to 
 undergo transformation into one or the other of the secondary forms 
 of the affection. It varies much in extent. It may consist of a few 
 scattered patches limited to one or two regions, or may involve the 
 entire cutaneous surface. Not very infrequently the mucous mem- 
 branes adjoining the skin, such as the conjunctiva, the vaginal and 
 rectal mucous membranes, share in the inflammation when the lids, 
 the vulva and the anus are the seat of the eczema. In vulvar and 
 anal eczemas implication of the adjoining mucous membranes usually 
 gives rise to the most intolerable paroxysmal itching, and in the latter 
 is sometimes accompanied by painful spasm of the sphincters. Con- 
 stitutional symptoms are absent in the great majority of cases, although 
 in acute attacks involving large areas there may be for the first few 
 hours a slight rise in temperature, but this is altogether exceptional. 
 
 The course of the malady is a very variable one. As has already 
 been mentioned, it may be acute, but in the vast majority of cases it is 
 a chronic affection, often lasting many months and even years, varying 
 greatly in its symptoms from day to day, often exhibiting acute exacer- 
 bations which transform it for the time into an acute inflammation, 
 these exacerbations being the result of improper treatment, scratching, 
 or, not infrequently, of some undiscoverable cause. In long-standing 
 cases the skin is frequently greatly thickened, is dry and harsh from 
 suppression of the functions of the sweat and sebaceous glands, and in 
 consequence has lost its pliability and elasticity, so that Assuring 
 readily occurs. These fissures are usually found in the normal lines 
 of the skin, especially upon the palms and soles, or about the joints. 
 
 Furunculosis is an occasional complication and adds much to the 
 patient's discomfort. In eczema of the lower extremities, particularly 
 in middle-aged individuals, chronic leg ulcer is a frequent complication, 
 especially when the eczema is associated with, or is the sequel of, vari- 
 cose veins. In extensive and very chronic cases, swelling of the lymph- 
 glands is not at all uncommon. 
 
 Four principal varieties of eczema are commonly recognized, named 
 according to their primary lesions, eczema erythematosum or erythe- 
 matous eczema, eczema papulosum or papular eczema, eczema vesic- 
 ulosum or vesicular eczema, and eczema pustulosum or pustular 
 eczema. A variable number of secondary forms are likewise recog- 
 nized, such as eczema rubrum, eczema madidans or moist eczema, 
 eczema squamosum or scaly eczema, eczema fissum, fissured eczema, 
 eczema verrucosum or verrucous or wart-like eczema, eczema scle- 
 rosum or sclerous eczema. Although there is a great diversity in the 
 clinical symptoms presented by these several varieties, it must not be 
 supposed that they represent distinct diseases— they are nothing more 
 
PLATE III 
 
 Erythematous eczema. 
 
PLATE IV 
 
 Erythematous and vesicular eczema. 
 
INFLAMMATIONS 119 
 
 than variations of the same affection, one form readily and often passing 
 into the other, and two or more forms frequently coexisting in the 
 same individual. 
 
 ECZEMA ERYTHEMATOSUM 
 
 Erythematous eczema (Plate III) usually begins quite acutely 
 with redness and swelling of the skin, the latter being especially 
 marked when it attacks certain regions, such as the lids. The skin is 
 a bright red to dull crimson or violaceous, and there is marked itching 
 and burning. The area involved varies from a small coin-sized patch 
 to the whole of a region, such as the face or an extremity, the borders 
 of the inflamed area being ill-defined, fading insensibly into the sur- 
 rounding normal skin. After a few days more or less scaling, usually 
 of a furfuraceous or bran-like character, takes place, and the skin 
 becomes harsh and dry. When the parts affected are opposed surfaces, 
 as in the region of the genitalia or beneath the breasts in women, the 
 horny layer of the epidermis is often lost through maceration and fric- 
 tion and the skin becomes bright red and moist or oozing (eczema 
 intertrigo). After lasting a week or two the redness may slowly 
 diminish, the itching and burning grow less and speedy recovery seem 
 assured, when suddenly a new outbreak occurs, and all the symptoms, 
 objective and subjective, reappear with their original severity. With 
 such exacerbations and remissions, or sometimes with but little varia- 
 tion, the disease may continue for months, or indefinitely. In chronic 
 cases the skin is dry, harsh, thick and scaly, there is a moderate amount 
 of itching and often little or no tendency to spread beyond its original 
 borders. Even after complete recovery relapses are quite common 
 upon the slightest exposure to irritation of any kind, and frequently 
 without any discoverable cause. Instead of continuing as an erythema 
 it may be transformed into one of the other types of the affection, 
 such as the vesicular, or irritated by rubbing and scratching or inju- 
 dicious local treatment, the surface becomes moist, red and oozing, 
 presenting the characters of an eczema rubrum. While less frequent 
 than some other forms, the erythematous type is a fairly common one, 
 and may occur on any portion of the skin, although it is most frequently 
 seen upon the face, especially upon the forehead and the lids. 
 
 ECZEMA VESICULOSUM 
 
 The commonest of the primary forms of eczema is the vesicular 
 (Plate IV). It usually begins with sensations of heat and itching, 
 followed speedily by redness of the skin with a moderate amount of 
 swelling, and upon the reddened surface numerous pin-head to shot- 
 sized elevations of the epidermis filled with transparent yellowish 
 serum soon appear. The vesicles may be discrete, or, as is most 
 .frequently the case, they exist in such numbers that they are crowded 
 together, forming variously sized irregular patches with poorly defined 
 margins or upon the palms where the skin is thick they may coalesce to 
 
120 DISEASES OF THE SKIN 
 
 form blebs. Owing to the thinness of their walls the vesicles are soon 
 broken by the scratching and rubbing of the patient in his efforts 
 to relieve the almost intolerable itching accompanying the eruption, 
 or, when not broken by violence, they rupture spontaneously, giving 
 exit to an abundance of yellowish, viscid serum which stains and 
 stiffens the patient's linen and dries into yellow crusts. New vesi- 
 cles constantly succeed the old and ruptured ones, or, as frequently 
 happens, these no longer form, but the inflamed skin is transformed 
 into a bright-red surface, denuded of its horny layer, covered with red 
 points from which serum constantly oozes, sometimes in such quantity 
 as to drip from dependent parts, the vesicular eczema thus passing into 
 a secondary eczema rubrum. Oftentimes the most intense itching 
 accompanies the eruption, occurring paroxysmally and driving the 
 patient to the most violent scratching and rubbing in his efforts to 
 obtain relief, which comes only after the vesicles have been broken, 
 and is usually of very brief duration, recurring with all its original 
 severity with each new crop. While the eruption may remain as it 
 began, a purely vesicular one, it much oftener exhibits a considerable 
 degree of multiformity, papules, vesicopapules and pustules coexisting 
 with the vesicles. The extent of surface involved varies from a few 
 small patches to an entire limb or the face, and while it shows no 
 marked predilection for any region, it is seen most frequently upon 
 the face, forearms, hands and feet. Upon the back of the hands it 
 occasionally occurs in coin-sized circular, rather circumscribed patches 
 which persist with great obstinacy. A common situation in infants is 
 the face, a variety known to the older authors and the laity as " milk- 
 crust." 
 
 ECZEMA PAPULOSUM 
 
 Papular eczema, the lichen simplex of the older writers, is charac- 
 terized by an eruption of pin-head sized and larger red, acuminate or 
 rounded papules, occurring discretely over considerable areas, or more 
 frequently in ill-defined, variously sized patches in which the lesions 
 are closely aggregated, producing more or less infiltration of the skin. 
 Although the lesions often remain papular throughout the entire course 
 of the disease, it is not unusual for a number of them to become vesicles. 
 Owing to the usually severe itching which accompanies the eruption, 
 many of the papules are covered with small blood crusts. The regions 
 attacked are most commonly the flexor surfaces of the limbs, less fre- 
 quently the trunk, and infrequently the face. This is one of the most 
 persistent forms of eczema, always running a chronic course. In long- 
 standing cases in which there are thickened patches of closely crowded 
 papules, a certain amount of scaling usually occurs. Exceptionally, 
 as a result of scratching and rubbing, these patches may become moist 
 and oozing, and a secondary eczema rubrum arise. With the excep- 
 tions just noted, this variety of eczema is always dry. The papules 
 usually last a considerable time and new lesions appear from time to 
 
PLATE V 
 
 Eczema rubrum. 
 

PLATE VI 
 
 Eczema rubrum with abundant crusts. 
 
 Eczema rubrum with crusting. 
 
PLATE VII 
 
 Eczema rubrum with chronic leg ulcer. 
 
PLATE VIII 
 
 Squamous and fissured eczema. 
 
INFLAMMATIONS 121 
 
 time. In certain cases not very rare, the papules are rather flat and 
 somewhat glistening, resembling somewhat the papules of lichen 
 planus, although they are rarely so well defined as the lesions of that 
 affection, and lack the violaceous hue and the central umbilication so 
 frequently present in lichen papules. 
 
 ECZEMA PUSTUT.OSUM 
 
 Pustular eczema, a much less common type than the vesicular, may 
 begin as such, or, what is much more frequent, it commences with 
 vesicles the contents of which become puriform later. In the latter 
 event the eruption is a mixed one, vesicles and pustules coexisting. 
 With the rupture of the pustules, either spontaneously or through rub- 
 bing and scratching, thick, yellowish, greenish or brownish crusts form, 
 sometimes in great quantity, beneath which the skin is red and covered 
 with an abundant seropurulent fluid. Subjective symptoms, such as 
 itching and burning, while present, are rarely so severe as in the vesic- 
 ular form. It is most commonly situated upon the scalp, less fre- 
 quently in the face, and is seen especially in children, particularly in 
 those who are ill-cared for and ill-nourished, or who show evidences of 
 tuberculous infection, such as enlarged or inflamed lymphatic glands, 
 so-called strumous subjects. When eczema attacks hairy regions other 
 than the scalp, such as the beard and, in hairy individuals, the forearms 
 and legs, it frequently assumes the pustular type, the pustules being 
 situated about the hair follicles. 
 
 While the foregoing clinical types are often well defined and well 
 differentiated from one another, it is very common to see a mixed type, 
 in which several varieties of lesion coexist. 
 
 Sooner or later in most cases, the primary lesions disappear or are 
 more or less modified, giving rise to secondary forms which differ 
 clinically more or less distinctly from the primary forms. 
 
 Eczema rubrum is one of the commonest of these secondary forms 
 (Plates V and VI). In this variety the skin is usually much thickened, 
 bright red, with scanty scales or crusts, or moist and weeping (eczema 
 madidans) , and covered with thick crusts. Acute exacerbations occur with 
 more or less frequency, accompanied by oedema, and abundant discharge of 
 viscid serum, which after a time dries into thick yellow crusts. There are 
 often much pain, itching and burning, which are always decidedly increased 
 during these acute outbreaks. While eczema rubrum may occur on almost 
 any portion of the skin, it is most often seen on the lower extremities of 
 middle-aged and elderly people, in the flexures of the forearm, and, in 
 children, behind the ears. It follows vesicular and pustular eczema much 
 more frequently than any of the other varieties. Although it is not very 
 uncommon after the erythematous form, it is quite unusual as a sequel 
 of the papular variety. On the lower extremities it is often associated 
 with the chronic leg ulcer (Plate VII). 
 
 Eczema squamosum, or scaly eczema (Plate VIII), occurs as ill- 
 
122 
 
 DISEASES OF THE SKIN 
 
 defined, red and thickened patches, covered more or less thickly with 
 whitish or yellowish scales which may be fine and bran-like and easily 
 detached or of considerable size and more or less adherent. The scaly 
 form is usually the sequel of the erythematous and papular varieties, 
 or it may be the terminal stage of a vesicular eczema or an eczema 
 
 rubrum. A common situation for 
 this form is the scalp, particularly 
 the occipital region and the nape 
 of the neck, forming in the latter 
 situation dull red or violaceous 
 dry, thick patches covered with 
 scanty bran-like scales, often ac- 
 companied by severe itching. 
 Similar patches occur upon the 
 extremities, particularly the lower 
 ones, as the sequel of papular 
 eczema. While desquamation may 
 be a transient symptom in eczema, 
 as when it is the terminal stage 
 of an acute or subacute erythe- 
 matous eczema, it is most 
 commonly associated with very 
 chronic forms with much thicken- 
 ing and a moderate degree of in- 
 flammation. A frequent locality 
 for squamous eczema is the palms, 
 where it occurs as irregular or 
 rounded, red patches, covered with 
 abundant adherent scales, and fre- 
 quently attended by Assuring. 
 
 Eczema Fissum. — In chronic 
 eczema the flexibility of the skin 
 is much impaired through diminu- 
 tion of the activity of the sweat 
 and sebaceous glands and by infil- 
 tration with inflammatory exu- 
 date, so that it frequently splits, 
 particularly about moving parts, 
 such as the joints, and upon the 
 palms and soles, forming fissures 
 which are usually, but not always, 
 in the normal furrows. These fissures are frequently quite deep, 
 and when situated upon the palms and soles add greatly to the 
 patient's discomfort, interfering seriously with the use of the hands, 
 and making walking painful. Fissures also occur at the corners 
 of the mouth and at the verge of the anus when eczema affects these 
 regions. 
 
 Fig. 27. — Eczema craquile. 
 
INFLAMMATIONS 123 
 
 Under the name of eczema craquile (Fig. 27) French authors have 
 described an unusual form of fissured eczema in which the reddened 
 skin is divided into numerous lozenge-shaped or irregularly polygonal 
 areas by superficial cracks in the horny layer of the epidermis. This 
 form often covers considerable areas, such as the trunk, or the ex- 
 tremities, and is accompanied by marked itching and burning. 
 
 Other less common secondary forms of eczema are eczema verru- 
 cosum and eczema sclerosum, both very chronic. In the former, 
 usually situated upon the legs, the skin is dull red or violaceous, dry 
 and thickened and covered with numerous slightly scaly wart-like 
 elevations, often accompanied by severe itching. In the latter, which 
 affects the palms and soles, less frequently the legs, the skin is slightly 
 reddened, hard and inelastic and rather smooth or slightly desquamat- 
 ing. More or less itching usually accompanies it. 
 
 While the primary varieties of eczema may be either acute or 
 chronic, the secondary ones are invariably of the latter form, but it 
 must be remembered that in the chronic forms of the affection, whether 
 they be primary or secondary, exacerbations are of frequent occurrence 
 during which the disease, for purposes of treatment at least, is to be 
 regarded as acute. 
 
 REGIONAL FORMS OF ECZEMA 
 
 While no portion of the skin is immune to eczema, certain regions 
 are more likely to be the seat of the affection than others, and a num- 
 ber of regional varieties are recognized in which the clinical symptoms 
 and the indications for treatment are more or less modified by the 
 locality. 
 
 Eczema frequently attacks the scalp [Eczema capitis], particularly 
 in children, and in the careless and uncleanly, and is apt to be of the 
 pustular variety. The hair is often matted together with thick yellow, 
 greenish or brownish crusts composed of dried serum, pus and blood 
 mixed with sebaceous secretion, which frequently exhale a very dis- 
 agreeable odor owing to decomposition. Pediculi are often present, 
 which in many cases, especially in children, are the primary cause, 
 especially when it is of the pustular form. 
 
 The face [Eczema faciri] is frequently the seat of eczema in both 
 children and adults. In the former it is most commonly of the vesicular or 
 pustular type, often accompanied by abundant crusting. Both are often 
 succeeded by eczema rubrum. The eruption is usually situated upon the 
 cheeks, but cases are not rare in which the entire face is covered with 
 a mask-like crust. The symptoms are much more apt to be acute than 
 in adults. In the latter the eruption is more commonly of the erythe- 
 matous variety, and is usually situated upon the forehead and cheeks, 
 although it may occupy the whole face. It is usually accompanied by 
 marked thickening of the skin, which greatly accentuates the normal 
 
124 DISEASES OF THE SKIN 
 
 furrows of the face, especially noticeable upon the forehead. While 
 the skin is usually dry and slightly scaly, scanty oozing often occurs 
 as the result of the friction to which the skin is subjected by the patient 
 in his efforts to allay the itching, which is frequently intense. Eczema 
 of the face is usually a very persistent variety in the adult. 
 
 Eczema of Lid {Eczema Palpebrarum). — Eczema may be confined to 
 the lids, in which case it is almost always of the erythematous variety. The 
 lids are dusky-red, thickened, slightly scaly, and the itching is usually quite 
 severe. Not uncommonly, partly as the result of frequent rubbing, 
 and partly by extension of the inflammation from the lids, there is 
 more or less conjunctivitis. In children inflammation of the Mei- 
 bomian glands, blepharitis, may accompany the eczema, small crusts 
 occurring about the roots of the lashes, which in long-standing cases 
 frequently fall out and may be permanently lost. Eczema of the lids 
 in adults is a most obstinate and unusually annoying affection. 
 
 Eczema of the Ears {Eczema Aurium). — Eczema of the external ear 
 is a fairly frequent topical variety, especially in children. In the latter 
 the posterior surface of the auricle and the parts adjacent are often 
 red and moist or crusted with Assuring in the furrow behind the ear 
 and at the bottom of the lobe in the notch. In adults the external 
 auditory meatus is occasionally affected. The entire auricle may be 
 swollen and reddened and is occasionally subject to recurrent attacks 
 accompanied by an eruption of vesicles and pustules, or, what is more 
 common, the affection pursues a subacute or chronic course, the ear 
 being thickened and dark red. 
 
 Eczema of the Beard {Eczema Barber). — The bearded region may be 
 attacked by eczema to which it may be confined, or it may be a part of 
 a more extensive disease. Whatever may be the particular form 
 assumed in the beginning, sooner or later pustules appear which have 
 their seat about the hair follicles. In addition to the vesicles and 
 pustules, there is commonly a considerable degree of crusting with 
 reddening and thickening of the skin. Burning and itching are usually 
 prominent symptoms. In true eczema of the beard the eruption is 
 rarely confined to the hairy region, but usually extends to the adjacent 
 smooth parts or exists elsewhere. 
 
 Eczema of the Hands {Eczema M annum). — No region of the skin is 
 more frequently attacked by eczema than the hands. For obvious reasons 
 they are the most usual site for all the forms of so-called trade eczema. 
 Every variety of the malady may occur here, but the vesicular and squa- 
 mous forms are the most frequent. The former occurs as a diffuse 
 eruption extending over the backs of the hands, sides of the fingers, 
 less frequently upon the palms, where the vesicles, owing to the thick- 
 ness of the horny layer of the epidermis, do not tend to rupture as 
 elsewhere, but appear as bluish-white grains embedded in the skin, or 
 the eruption may occur in fairly well-defined patches of varying size, 
 
INFLAMMATIONS 125 
 
 with more or less thickening and crusting. Less frequently the erup- 
 tion consists of coin-sized, circular, well-defined patches of discrete 
 vesicles which rupture spontaneously and ooze clear viscid, abundant 
 serum ; this is an especially obstinate form of the disease, recurring 
 with great persistency. 
 
 The squamous form is, in the great majority of cases, confined to 
 the palms, where it occurs as diffuse areas without definite borders, or, 
 exceptionally, as marginate scaly patches which are often quite thick 
 and not infrequently fissured. In the cases attended by much thicken- 
 ing with fissuring, the patient is often incapacitated for performing any 
 manual labor. In a considerable proportion of cases the entire palm 
 as well as the palmar surface of the fingers is greatly thickened and 
 fissured, interfering seriously with the use of the members. 
 
 Eczema of the Nails (Eczema Unguium). — Eczema may attack the 
 nails. It may be limited to these structures and the parts immediately 
 concerned in their growth, such as the nail-fold, the matrix and the 
 nail-bed, or it may occur here as a part of a more extensive eruption. 
 In eczema of the nails there is usually more or less interference with 
 their nutrition, so that they are dry, more or less roughened and de- 
 formed, their surface often presenting small pits which give them a 
 worm-eaten appearance. When the disease is part of an extensive 
 and severe eczema the nails may be lost. 
 
 Eczema of the Breasts (Eczema Matnmarum). — Eczema not infre- 
 quently attacks the nipple and areola of the breast, especially in nursing 
 women, resulting from the irritation and frequent wetting of the parts 
 by the nursling. The itching in some of these cases is most intense. 
 Care must be taken not to confound an eczema of this region with a 
 much graver malady known as Paget's disease which occurs in the 
 same region and often presents a decidedly eczematoid appearance in 
 its early stages. 
 
 Eczema of the Genitalia (Eczema Genitalium) . — One of the most 
 distressing of all the topical varieties of eczema is that which affects the 
 external genitalia. In men the disease is most commonly seated upon 
 the scrotum (Fig. 28), which is often enormously thickened and swollen, 
 red, scaling, or moist and oozing. Not infrequently, the adjacent parts, 
 such as the inner surface of the thighs, the perineum, and the under side 
 of the shaft of the penis, share in the inflammation. In eczema of the 
 vulva there is often great thickening, the parts are dull-red, dry and 
 scaly, or moist and crusted. Quite commonly the mucous surfaces of 
 the labia are likewise involved and the lower part of the vagina. The 
 itching is often atrocious, coming on in paroxysms which completely 
 over-master the patient, who, losing her self-control, violently tears the 
 skin with her nails in her efforts to obtain relief, which usually follows 
 only when free oozing takes place. Patients with eczema vulvae are 
 often reduced in time to mere neurasthenic wrecks by the loss of sleep 
 
126 
 
 DISEASES OF THE SKIN 
 
 and nervous energy. Although frequently due to other causes, it is not 
 uncommonly the result of a glycosuria, and an examination of the urine 
 for sugar should never be omitted in such cases. 
 
 Eczema of the Anus {Eczema Ani). — Eczema is frequently confined 
 to the anus, either beginning as such, or, what is quite common, having 
 its origin in a pruritus which for a time presents no visible alteration 
 of the surface. The disease is situated about the mucocutaneous bor- 
 der of the anus and on the opposed surfaces of the nates, or it may be 
 confined to the former situation. The skin is red, excoriated, often 
 moist and decidedly thickened, with frequent fissuring. Not uncom- 
 
 
 Fig. 28. — Eczema rubrum, scrotum. 
 
 monly the inflammation extends within the verge of the anus, upon the 
 mucous membrane. The itching is at times of the severest kind, fre- 
 quently paroxysmal, compelling the patient to seek relief by scratching, 
 quite regardless of time or place. When the inflammation extends 
 well within the sphincter there may be paroxysms of violent tenesmus 
 which exceptionally may necessitate division of the sphincter for its 
 relief, as in a case under the author's observation some years ago. 
 Itching is usually much worse at night, often interfering seriously 
 with sleep. 
 
 Etiology. — Eczema has no single specific cause. It is the result of 
 a great variety of causes, direct and indirect. These are internal or 
 
INFLAMMATIONS 127 
 
 constitutional, and external or local, the former being almost without 
 exception indirect or contributing causes, while the latter are fre- 
 quently directly productive of the malady. 
 
 Our knowledge of the internal causes is, unfortunately, still most 
 unsatisfactory. Indeed, it is yet largely a matter of hypothesis. While 
 many, if not most, individuals suffer at one time or another from 
 eczema, there is an enormous difference in the susceptibility of different 
 individuals to the affection, but, in all probability, this difference is 
 not so much one of kind as of degree. The cause of this difference we 
 are absolutely unable to explain. In many instances the subjects of 
 eczema are seemingly in perfect health, the most careful scrutiny failing 
 to reveal any disturbance of function or disease of viscus. On the other 
 hand, however, there is frequently disturbance of the gastro-intestinal 
 tract, often the result of improper diet, especially in the eczemas of 
 childhood. This may act as a contributing cause in one of two ways : 
 First, and most commonly, by producing certain toxic substances in 
 the intestinal canal, which, when absorbed and carried to the skin, 
 act as irritants, or, secondly, and less frequently, by interfering with 
 nutrition, and thus lowering the patient's powers of resistance gener- 
 ally. In all probability the importance of indigestion as a causative 
 factor in eczema has been greatly overrated. There is altogether too 
 much generalization on the subject and too little exact observation. 
 The studies of Hall, in regard to the relationship of indigestion to 
 eczema in infancy, have apparently shown that it is far from exerting 
 the baneful influence commonly attributed to it; in a series of cases, 
 sixty in number, it was shown that it had practically no influence at all. 
 Moreover, many individuals suffer more or less from functional dis- 
 order of the gastro-intestinal tract the greater portion of their lives 
 and never exhibit any trace of eczema. 
 
 The whole subject of food in its relation to eczema is apparently 
 about to be placed upon a much more scientific and secure foundation 
 than it has rested on heretofore. Quite recently Towle and Talbot have 
 announced that a considerable proportion of infants suffering from 
 eczema show an excess of fat or of starch in the stools, a finding con- 
 firmed by the observations of White. 
 
 White and a number of others have also found that a considerable 
 number of the subjects of chronic eczema exhibit anaphylactic reac- 
 tions to certain food substances and the inference is made that such 
 foods stand in a causal relation to the eczema. This susceptibility to 
 certain food proteins may be demonstrated by the epidermic inoculation 
 of food materials after the von Pirquet method, or by the intradermic 
 injection of small quantities of the proteins from beef, egg-albumen, 
 potato, etc., in sterile aqueous solution. A positive reaction is indicated 
 by the appearance of a papule within a half-hour or hour at the site 
 of the inoculation or injection. 
 
 These observations are not only of great scientific interest, but of the 
 greatest practical importance, if subsequent investigation shall con- 
 
128 DISEASES OF THE SKIN 
 
 firm their correctness. However, our knowledge of the whole subject 
 of protein hypersensibility is still in the formative stage. 
 
 The author should like to point out, what seems at times to be 
 overlooked, that abnormal sensibility to certain food proteins is not 
 at all the same thing as indigestibility. Many articles of food which 
 are known to exert an injurious effect upon the skin do so not because 
 of their indigestibility, but because of other totally different qualities. 
 
 There is apparently considerable evidence to show that gout is fre- 
 quently accompanied by eczema, but even this affection occupies a 
 much less prominent place among its internal causes than formerly. 
 
 In a certain proportion of cases of chronic nephritis, eczema occurs 
 as a complication, but it must be admitted that the vast majority of 
 cases of the former run their course without any manifestation of 
 the latter ever being present. 
 
 Diabetes markedly predisposes its subjects to various forms of 
 inflammation of the skin, and is especially apt to be accompanied by 
 eczema, particularly of the genital region, especially in women. The 
 saturation of the tissues with sugar makes them especially liable to 
 infections of various sorts after the slightest injury, and in the genital 
 region the saccharine urine acts as a powerful local irritant. 
 
 Hepatic disease, especially when accompanied by icterus, may 
 give rise indirectly to eczema through the scratching which results from 
 the pruritus usually accompanying the presence of bile salts in the 
 circulation. 
 
 Certain eczemas are supposed to be of reflex origin, such, for exam- 
 ple, as those associated with dentition, intestinal parasites, or disease 
 of the uterus. As to the first of these, there is, in the author's opinion, 
 no proof based upon accurate observation that it may produce eczema, 
 although existing eruptions may exhibit exacerbations with the erup- 
 tion of the teeth. 
 
 Functional derangement of the nervous system seems at times to 
 play a considerable etiological role ; but, just how it does so, or whether 
 it does so at all, is as yet largely a matter of conjecture. 
 
 Unusual dryness of the skin, either congenital (as in the milder 
 grades of ichthyosis) or acquired, as in old age, markedly predisposes 
 it to take on eczematous inflammation, especially when exposed to 
 cold. Many individuals with ichthyosis suffer every winter from an 
 eczema which persists until the return of warm weather. 
 
 External Causes. — Any agent which by contact with the skin may 
 produce inflammation is a potential cause of eczema. Hence, a large 
 number of chemical substances, drugs, dyestuffs, certain plants, such 
 as the several varieties of rhus, heat and cold, and mechanical irritation, 
 such as scratching, rubbing of the clothes, are among the many external 
 causes of the disease. The susceptibility, however, of different indi- 
 viduals varies greatly, as has already been pointed out. In one, contact 
 with such irritants is followed by a simple inflammation of the skin 
 which runs an acute course and promptly disappears with the with- 
 
INFLAMMATIONS 129 
 
 drawal of the irritant ; in another, the inflammation does not subside 
 when the skin is no longer in contact with the irritant agent, but con- 
 tinues indefinitely. It is a curiously interesting and important fact 
 that in many individuals a skin once inflamed by a certain irritant, such 
 for example as formaldehyde, becomes increasingly sensitive to this 
 irritant, so that after a time the slightest exposure is capable of calling 
 forth an inflammation, and each attack disappears less readily than 
 before until a chronic eczema is established. Examples of this are fre- 
 quently seen in the so-called trade eczemas, which occur in dyers, 
 chemists, photographers, metal polishers, etc. While it is possible 
 for an eczema to follow a single exposure to an irritant in individuals 
 with an especially sensitive skin or with a so-called eczematous ten- 
 dency, it is in the great majority of cases the result of frequently 
 repeated and prolonged exposure. Certain substances which are not 
 ordinarily regarded as irritants, such as soap and water, are frequently 
 the cause of eczema, as is often seen on the hands of washerwomen, 
 bartenders, and others whose occupations compel them to have the 
 hands wet for long periods. 
 
 Heat and cold, especially the latter, frequently act as predisposing 
 causes. In many cases eczema occurs in winter only, disappearing 
 more or less completely with the advent of warm weather. At other 
 times the reverse is true, an increase in the symptoms coinciding with 
 warm weather. 
 
 There is no conclusive evidence that microorganisms play any role 
 among the direct primary causes of eczema, but it is altogether probable 
 that the disease is frequently materially modified in its course and 
 symptoms by secondary infection with various microorganisms, espe- 
 cially the staphylococci. Bockhart, Bender and Gerlach found that 
 inoculation of the skin with staphylococci produced impetiginous and 
 pyodermic inflammations, but never eczema, but if a filtrate from a 
 bouillon culture was applied to the skin on moist warm bandages for 
 some hours a typical papular and vesicular eczema was produced, and 
 they conclude accordingly that it is the staphylococcus toxin that 
 produces eczema and not the organism itself, a distinction without a 
 difference. Cole, in a quite recent bacteriological and experimental 
 study of eczema and the pyodermias, could not demonstrate any etio- 
 logical relationship of staphylococci or streptococci to the former. 
 
 Pathology. — As has already been stated, eczema is an inflammation 
 of the skin, a dermatitis, and the pathological changes in it do not 
 differ essentially from other forms of dermatitis, such as may arise from 
 contact with irritant substances of various kinds. Changes are found 
 in both the epidermis and corium, but pathologists are not agreed as 
 to where the primary changes occur, whether in the former or in the 
 latter. Leloir and Vidal, Crocker, and others believed that the changes 
 in the epidermis preceded those in the corium. Other investigators, 
 prominent among whom is Unna, assert that the epidermis is primarily 
 affected. 
 
 As the result of a parenchymatous oedema of the prickle-cell layer 
 9 
 
130 
 
 DISEASES OF THE SKIN 
 
 of the epidermis, which has interfered with the normal processes of 
 keratinization, the horny layer presents a condition known as para- 
 keratosis, a term first employed by Auspitz. The cells of this layer are 
 moister than normal and somewhat swollen. Many of them still 
 retain more or less well-formed nuclei and between them, here and 
 there, are small collections of leucocytes. In certain areas the granular 
 layer is no longer visible, owing to the absence of keratohyaline 
 granules, the result of the interference with the normal transformation 
 of the prickle-cells. The desquamation which is a frequent symptom 
 in eczema is the expression of this parakeratosis. Owing to their moist 
 and swollen condition, the horny cells are only loosely held together 
 
 Fig. 
 
 29. — Vesicular eczema. Vesicle, V, filled with coagulated fibrin in which are a few cells, chiefly 
 polymorphonuclears. A, widened rete (acanthosis). 
 
 and readily separate from the rete in the shape of scales. In the moist 
 and oozing form the horny layer is completely lost in places, laying 
 bare the rete. 
 
 In chronic eczema of the palms and soles, especially the latter, when 
 the disease has been of long duration, there is at times an enormous 
 increase in the thickness of the horny layer (hyperkeratosis). 
 
 Owing to the oedema and multiplication of its cells, the prickle-cell 
 layer is more or less increased in width (acanthosis). The amount of 
 increase in breadth depends largely upon the duration of the disease 
 
INFLAMMATIONS 
 
 131 
 
 and is, consequently, more marked in the chronic than in the acute 
 form. In addition to the parenchymatous oedema there is also an inter- 
 cellular oedema which separates the cells and forms cavities between 
 them whose walls are formed by greatly elongated and more or less 
 degenerated epithelial cells. These cavities are the vesicles (Fig 29) 
 which frequently occur in eczema and are filled with serum, small quan- 
 tities of fibrin and a varying number of polymorphonuclear leucocytes. 
 These vesicles may form in any portion of the rete, but are usually 
 situated just beneath the horny layer. This intercellular cedema and 
 
 »* 
 
 
 »i% 
 
 Fig. 30. — Eczema rubrum, leg. Note increased breadth of rete mucosum, formation of vesicles ( V) 
 beneath horny layer, which is quite thin. Moderate round-cell exudate in the upper portion of eorium. 
 
 formation of cavities between the epithelial cells constitute the 
 * spongy transformation " of the rete of Unna. According to this author 
 the formation of the vesicle of eczema differs materially from the 
 formation of the vesicle in other vesicular eruptions, such as herpes, for 
 example. In the former, as has just been described, the vesicle is an 
 intercellular cavity, while in the latter it arises within the cell through 
 colliquation of its protoplasm, several cells uniting to form a multi- 
 locular lesion (Fig. 30). 
 
 Pigmentation of the lower layers of the rete is common in chronic 
 
132 DISEASES OF THE SKIN 
 
 cases, especially when the disease is situated upon the lower 
 extremities. 
 
 The changes in the corium are much less characteristic than those 
 in the epidermis. There is dilatation of the blood- and lymph-vessels 
 in the papillary and subpapillary layers, a more or less marked oedema 
 of the papillae, a moderate amount of cellular exudate, chiefly in the 
 immediate neighborhood of the blood-vessels, and an increase in the 
 number of connective-tissue cells. The extent and degree of these 
 changes vary decidedly according to the duration of the disease. 
 
 Beyond some swelling, the collagen fibres show but little alteration 
 and the elastic tissue is usually well preserved, except in long-standing 
 cases with much cellular exudation in which it may have completely 
 disappeared. 
 
 In eczema sclerosum and in the cases with elephantiasic enlarge- 
 ment occasionally seen upon the legs, there is a marked increase in the 
 fibrous tissue, which in the latter form leads to obstruction of the lymph 
 channels. 
 
 In verrucose eczema, always a very chronic form, there is a pro- 
 nounced inflammatory exudate in the papillary layer of the corium with 
 consequent enlargement of the papillae, which gives to the disease its 
 verrucose aspect. 
 
 Diagnosis. — The diagnosis of eczema in all its forms commonly pre- 
 sents no unusual difficulty. The violent itching which is so common 
 and often so distressing a symptom; the oozing and crusting which 
 occur in so large a proportion of cases ; its frequent localization in cer- 
 tain regions, such as the face and behind the ears in children, about the 
 genitalia and anus in adults, upon the legs in middle-aged and old 
 subjects and its chronic course in the vast majority of instances, are 
 features which are more or less characteristic, distinguishing it from 
 other cutaneous inflammations. Nevertheless mistakes in diagnosis 
 are common. 
 
 Acute erythematous eczema is likely to be mistaken for mild der- 
 matitis and is frequently confounded with the early stage of acne 
 rosacea, various forms of erythema, and with erysipelas. 
 
 A dermatitis usually runs a much more acute course than eczema, 
 is much more likely to be situated upon exposed parts, such as the 
 hands and face, and is often known to have been preceded by contact 
 with some plant or irritating chemical substance. 
 
 The earliest stage of acne rosacea which is characterized by redness, 
 at times without papules and pustules, may be mistaken for an erythe- 
 matous eczema, but the latter is not confined to the nose, cheeks and 
 chin, like the former, and is accompanied by marked itching, a symp- 
 tom usually absent in acne, or, if present, only so in a trifling degree. 
 
 The various erythemata which are at times mistaken for erythe- 
 matous eczema are as a rule very acute in their course, are apt to be 
 patchy rather than diffuse, and are rarely accompanied by severe itch- 
 ing, usually a most pronounced symptom in eczema. 
 
INFLAMMATIONS 133 
 
 There is usually but little excuse for mistaking acute erythematous 
 eczema for erysipelas, but this is a very common error. The patches 
 of erysipelas are dusky-red, with well-defined, slightly elevated bor- 
 ders and spread peripherally from a single point; the patches of ery- 
 thematous eczema are diffuse without definite margins and, as a rule, 
 with little swelling. The former is always, except in cases of small 
 extent and of the mildest character, accompanied by fever, headache 
 and other symptoms of constitutional disturbance ; in the latter these 
 are absent. 
 
 Papular eczema is to be distinguished from urticaria, lichen planus 
 and prurigo. In urticaria the lesions are wheals, whitish or pinkish 
 elevations of varying size, which are accompanied by extreme itching 
 and burning and are usually of very short duration, quite unlike the 
 papules of eczema in this respect. They are usually discrete and show 
 no tendency to form patches such as occur in eczema. 
 
 The papules of lichen planus are commonly violaceous, with angu- 
 lar or polygonal bases and flat, glistening tops, and occasionally show 
 a small umbilication ; those of eczema are red, with rounded or acu- 
 minate tops and round bases, and are never umbilicated. The patches 
 of lichen planus are usually covered with a fine, adherent, silvery-white 
 scale altogether unlike the branny scaling seen in eczema. The papules 
 of lichen planus occasionally show a marked tendency to appear in 
 scratch-marks — those of eczema never do so. 
 
 Prurigo is a rare affection in America, and usually begins in the 
 first year or two of life. The eruption is widely distributed and the 
 skin is rough and thick, presenting much greater alterations than are 
 seen in papular eczema. 
 
 Vesicular eczema may be confounded with various forms of derma- 
 titis venenata and with herpes. In vesicular eczema the inflammation 
 is rarely so acute or so severe as in dermatitis, nor is it confined to 
 exposed parts of the skin, as is commonly the case with the latter. In 
 dermatitis bullae are common when the inflammation is severe ; in 
 eczema these are infrequent. 
 
 In herpes of all varieties the vesicles are arranged in groups, in 
 simple herpes about the mouth and nose, commonly, or some other part 
 of the face, in herpes zoster over the course of a nerve. In the latter 
 there is frequently more or less severe pain. None of these symptoms 
 is present in eczema. 
 
 Vesicular eczema and dermatitis herpetiformis may at times be 
 mistaken for each other when the grouping of the eruption, which is a 
 characteristic feature of the latter, is little pronounced. Sooner or 
 later, however, the grouping becomes more definite and the eruption 
 exhibits a more or less decided polymorphism. 
 
 Pustular eczema is to be distinguished from pediculosis capitis, 
 from impetigo contagiosa, and from sycosis vulgaris. Pediculosis of 
 the scalp is frequently mistaken for a pustular eczema, and the two 
 frequently coexist, the latter often as a sequel of the former. The 
 
134 DISEASES OF THE SKIN 
 
 presence of a pustular eczema in the occipital region in children is 
 almost invariably due to pediculi. The diagnosis is of the easiest, the 
 ova being readily found. In impetigo contagiosa the lesions are usually 
 discrete, few in numbers and rapidly spread peripherally, drying into 
 thin crusts. They are situated upon the face and hands far more fre- 
 quently than elsewhere. 
 
 Pustular eczema of the beard and sycosis vulgaris may resemble 
 each other quite closely at times, but the former is diffuse and usually 
 extends beyond the bearded region, while the latter is a folliculitis of 
 the beard and is limited to it. In eczema other regions are apt to be 
 affected, and oozing and crusting are prominent symptoms ; in sycosis 
 oozing does not occur, and crusting is rarely so pronounced as in 
 eczema. In eczema there is more or less marked itching; in sycosis 
 the subjective symptoms, when present, are burning and sometimes 
 pain, but are often trivial or even absent altogether. 
 
 Squamous eczema is to be differentiated from psoriasis, seborrhcea, 
 ringworm, lupus erythematosus and from the squamous syphiloderm. 
 Squamous eczema does not often occur in sharply marginate patches, 
 while this is the rule in psoriasis ; the scales of eczema are usually much 
 less abundant than in psoriasis, nor are they laminated like those of the 
 latter. Eczema shows no predilection for the extensor surfaces of 
 the extremities, such as is frequently a marked characteristic of psori- 
 asis. Psoriasis is uncommon on the palms and soles, regions which 
 are frequently attacked by squamous eczema. Itching is present in 
 almost all cases of eczema, but is infrequent or absent altogether in 
 psoriasis. Eczema frequently is moist at some time or other in its 
 course, psoriasis never. 
 
 Squamous eczema of the scalp differs from seborrhoea of that region 
 by the dryness of the scales and the presence of symptoms of inflamma- 
 tion. In seborrhoea the scales are greasy and the scalp beneath is nor- 
 mal in color or occasionally paler than normal. Itching is common in 
 the former and infrequent or trifling in the latter. 
 
 Squamous eczema and erythematous lupus of the superficial type 
 may, in exceptional cases, resemble each other sufficiently to lead to 
 error in diagnosis. The latter is, in the great majority of cases, situ- 
 ated upon the cheeks and over the bridge of the nose, regions rarely 
 attacked by the former ; the patches are sharply limited instead of 
 diffuse, and the scaling is slight. Itching is rarely a symptom of lupus, 
 while it is the rule in eczema. 
 
 Scaly eczema of the palms and the scaly palmar syphiloderm may at 
 times present considerable similarity in their appearance, but the former 
 rarely exhibits the sharply circumscribed borders nor the circular shape 
 so common in patches of the latter. Eczema is usually bilateral, 
 syphilis unilateral ; the former is often intensely itchy, the latter rarely 
 itches at all. In eczema there is often decided thickening, and fis- 
 sures are common ; in the squamous syphiloderm there is usually but 
 little thickening or Assuring. 
 
INFLAMMATIONS 135 
 
 Eczema of the anus and of the vulva is frequently mistaken for 
 pruritus of those regions, but even a superficial examination of the parts 
 is sufficient to differentiate the two affections. The former is character- 
 ized by redness, oozing and excoriations, while in the latter itching is the 
 sole symptom. It must be remembered that eczema is often a sequel of 
 pruritus, owing to the frequently-repeated and often prolonged irritation 
 produced by scratching in the latter. 
 
 Universal eczema is at times to be differentiated from dermatitis 
 exfoliativa. The latter seldom if ever presents the thickening of the 
 skin seen in the former, and the scaling is much more pronounced. In 
 certain cases, however, a universal eczema may terminate in a dermatitis 
 exfoliativa and is then, of course, indistinguishable from it. 
 
 Eczema of the breast, when situated upon the areola and nipple, its 
 most frequent site, and Paget's disease of the same region resemble 
 each other very closely, but also present certain differences by which 
 they may be distinguished, in most cases without much difficulty. The 
 patch of eczema is rarely so sharply limited as that of Paget's disease 
 and shows no noticeable thickening. The latter presents a parchment- 
 like induration, " like a penny felt through a cloth," and after a time 
 the nipple is more or less completely destroyed or retracted, and carci- 
 noma of the mammary gland invariably occurs sooner or later. Eczema 
 occurs most commonly during the child-bearing period and in nursing 
 women ; Paget's disease usually occurs after the menopause. 
 
 The parasitic diseases — scabies, pediculosis corporis and certain 
 forms of ringworm — may at times bear a considerable resemblance to 
 eczema, but a little care in examination usually readily enables one to 
 make the differential diagnosis. 
 
 Eczema shows no special regional predilection; scabies occurs most 
 frequently upon the hands, especially between the fingers, on the flexor 
 surface of the wrists, the anterior border of the axillae, the abdomen 
 and thighs, upon the shaft of the penis and in the areola of the nipple 
 in women, and is distinguished by a pathognomonic symptom, — the 
 burrow. Moreover, there is frequently a history of contagion in 
 scabies, never in eczema. 
 
 The eruption of pediculosis corporis is practically altogether a 
 secondary to scratching and consists largely of linear excoriations 
 situated upon covered parts of the body only, in regions readily acces- 
 sible to the patient's nails, such as the shoulders, the sacral region, the 
 buttocks and the lower extremities. 
 
 Ringworm affecting the inner surface of the upper thighs and the 
 axillae often presents the appearance of an erythemato-squamous 
 eczema, or in severe cases of an eczema rubrum. Indeed, this variety 
 of ringworm was formerly regarded as a peculiar form of eczema and 
 was called eczema marginatum. It differs from eczema of these 
 regions by the rounded shape and sharp limitation of the borders of 
 the patch, and the tendency of the centre, in many cases, to undergo 
 involution while it extends at the periphery. In eczema the patches 
 
136 DISEASES OF THE SKIN 
 
 usually have ill-defined borders and show no tendency to central invo- 
 lution. In the parasitic affection the epidermophyton inguinale, a fungus 
 closely akin to the trichophyton, may be readily found in the scales on 
 the borders of the patches. 
 
 Prognosis. — In the vast majority of cases of eczema the prognosis 
 as to eventual recovery is highly favorable. It is true, however, that 
 in many cases the disease runs a protracted course, requiring months, 
 or in some instances a year or two, to recover, and relapses are common. 
 The acute forms usually respond readily to appropriate treatment, but 
 when injudiciously treated or neglected they often become chronic. 
 Long-standing cases, attended by dryness, scaling and thickening of 
 the skin, are much less readily curable than those of comparatively 
 short duration with slight or moderate structural change. Especially 
 rebellious forms are the papular, particularly when accompanied by 
 much thickening, squamous eczema of the palms and soles, and eczema 
 of the anus, scrotum and vulva. Eczema of the anus and vulva is 
 among the most obstinate and distressing of all the varieties. Vesicu- 
 lar eczema, occurring in rounded patches upon the back of the hands 
 accompanied by free oozing and crusting, is often most resistant to 
 treatment and particularly subject to relapse. Infantile eczema, 
 although relapsing frequently, is usually quite amenable to treatment, 
 and a cure, even in the most rebellious cases, may be confidently pre- 
 dicted. With the exception of chronic eczema of the legs, in which 
 permanent pigmentation frequently follows, the disease disappears 
 without leaving any trace of its existence. Scarring never occurs in 
 uncomplicated cases, even of the severest type. 
 
 The notion formerly entertained, and yet prevalent among the laity 
 and shared by some physicians, that it may be dangerous to cure a 
 chronic eczema quickly, that serious general disturbance, or even fatal 
 consequences may follow, is wholly without foundation. 
 
 Treatment. — In beginning the treatment of any case of eczema 
 every effort should be made to discover, if possible, its cause, but unfor- 
 tunately this only too frequently eludes the most careful search. In 
 those cases in which the disease is confined to uncovered parts, such as 
 the hands, neck and face, the possibility of a strictly locally-acting 
 cause, some irritant substance employed by the patient in his daily 
 work, some favorite hair-wash, or a neck fur, should never be over- 
 looked, and the most searching inquiry should always be made in such 
 cases, an inquiry often rewarded with the discovery of some local 
 irritant whose removal or avoidance is followed by speedy recovery 
 and freedom from some long-lasting eczema. 
 
 If no local cause can be discovered, the patient's general condition 
 should be subjected to a careful examination. Every organ should be 
 interrogated to ascertain if its functions are properly performed ; the 
 patient's occupation and habits should be minutely inquired -into, since 
 these often have an important bearing upon the origin of his disease. 
 His previous medical history should be carefully gone into, this being 
 
INFLAMMATION S 137 
 
 an especially important matter as showing the patient's pathological 
 tendencies. 
 
 While in many cases constitutional treatment is necessary, or at 
 least helpful, there are many others in which local treatment alone may 
 accomplish the cure and in which internal treatment is useless or of 
 more than doubtful value. 
 
 As there is no single specific cause of eczema, so there is no specific 
 remedy for it. The internal treatment is directed, not so much against 
 the eczema as against those derangements of special organs, or of the 
 general economy, which act as favoring causes of the cutaneous disease. 
 
 The diet must be regulated according to the circumstances of each 
 case. In robust, well-nourished individuals who frequently over-eat, 
 taking an excess of rich food, more or less restriction of the quantity 
 and quality of the food will frequently be advantageous, while those 
 whose nutrition is under the normal will be benefited by an increase in 
 the amount of food taken, provided it is of a kind easily digested and 
 readily assimilated. In children, even more than in adults, the diet 
 should be carefully supervised, and in bottle-fed infants this is often 
 a most difficult part of the treatment. 
 
 Certain articles, such as pork, cheese, and shell-fish, except oysters, 
 should as a rule be denied eczematous patients. The possible presence 
 of a protein hypersensitiveness should be kept in mind, and its presence 
 or absence determined by a detailed study of the patient's diet, or by the 
 employment of the cutaneous tests previously referred to (vid. Etiol- 
 ogy). If present, such foods as produce an anaphylactic reaction should, 
 as far as possible, be rigidly excluded from the dietary. As to the 
 matter of beverages he is much better without either tea or coffee, or 
 if they are taken at all, they should be allowed in moderate quantities 
 only. Alcoholic drinks are upon the whole injurious, although elderly 
 individuals, who have been in the habit of taking moderate quantities 
 of alcohol, may be permitted to continue its moderate use, whiskey 
 being the least objectionable and malt liquors and sweet wines the 
 most hurtful. Alkaline waters, such as Vichy, may often be used with 
 advantage, especially in the plethoric and in those with gouty tenden- 
 cies. The use of tobacco should be greatly restricted, especially smok- 
 ing. Inordinate use of the pipe or cigars is frequently injurious to 
 those with extensive eczema. In acute eczemas of considerable extent 
 a restricted diet is as a rule indicated, limiting especially the amount 
 of meat taken ; on the other hand, harm is frequently done by the com- 
 plete withdrawal of meats in elderly individuals suffering from eczema, 
 as is frequently advised. 
 
 In those with gout a strict regimen should be adopted, and in the 
 eczema accompanying diabetes a diet free from sugar and starches is 
 an essential part of the treatment. In patients with chronic nephritis, 
 who suffer from eczema, a restriction in the amount of nitrogenous 
 food taken, and the use of a milk diet are indicated. 
 
 The patient's underwear, especially if a child, should have attention. 
 
138 DISEASES OF THE SKIN 
 
 Woollen undergarments, as has been mentioned elsewhere, often irri- 
 tate the sound skin and should never be worn next the skin by individ- 
 uals with eczema. If for any reason it is deemed necessary that wool 
 be worn, thin cotton gauze or silk should be worn underneath it. All 
 rough edges about the underwear should be carefully looked after; a 
 collar band or a wristband frequently determines the localization of an 
 eczema about the neck or wrist. 
 
 Coming now to the medicinal treatment, much more will depend 
 upon the patient's general condition than upon the fact that he has an 
 eczema. In those who suffer from the many symptoms which are in- 
 cluded under the term dyspepsia or indigestion, such as flatulence, con- 
 stipation, heartburn and other forms of distress after eating, remedies 
 appropriate to these should be employed. For constipation, which is 
 a frequent condition, laxatives should be administered, preferably the 
 salines in the shape of some one of the bitter waters, such as Hunyadi 
 Janos, Apenta, or a pill of aloin, strychnia and belladonna, or cascara 
 may be given. Occasional short courses of fractional doses of calomel 
 followed by a saline will often be found especially useful, particularly 
 in the eczemas of children. In the latter, even when no symptoms of 
 disturbed or faulty digestion are present, small doses of calomel or 
 mercury-with-chalk given for three or four days in succession will often 
 be followed by decided improvement in the condition of the skin. In 
 those who suffer from eructations after eating, alkalies may be given, 
 such as bicarbonate of soda in compound tincture of gentian ; or some 
 bitter tonic, such as nux vomica or strychnia, either alone or with 
 hydrochloric acid, will frequently serve a useful purpose. In patients 
 with irregular attacks of diarrhoea the salts of bismuth, especially the 
 salicylate or salol, taken before meals, will be found effective. 
 
 In the anaemic, iron, either alone or with small doses of arsenic, is 
 indicated. In those who present evidence of a tuberculous tendency 
 in the shape of swollen lymphatic glands, cod-liver oil is a valuable 
 remedy, especially useful in the pustular eczemas of strumous children. 
 
 In eczema occurring in the gouty, besides the careful supervision 
 of the patient's diet and habits of life, already referred to, the alkalies, 
 particularly the salts of lithia, the salicylates and, under certain con- 
 ditions, colchicum, should be administered. 
 
 When chronic nephritis is associated with the eczema the alkaline 
 diuretics with an abundance of milk and water should be taken. 
 
 In acute eczema, especially when large areas are involved and even 
 when there are no symptoms of gastro-intestinal disorder, a brisk 
 purge given in the early stage is often of advantage. The citrate of 
 potash, or, when the excretion of urine is scanty, the acetate, given in 
 doses sufficient to make the urine alkaline and keep it so, is often 
 useful in alleviating the irritability of the skin, not only in acute 
 eczema, but in the acute exacerbations of the chronic form, but these 
 should not be continued above a week or ten days at a time. In robust 
 plethoric individuals, small doses of antimony given three or four 
 
INFLAMMATIONS 139 
 
 times a day may, in acute cases, be employed with good effect for a 
 short time. 
 
 When itching is severe and continuous, the use of some one of the 
 coal-tar analgesics will occasionally afford a certain degree of relief. 
 Phenacetin is one of the best and least harmful of these and is often 
 distinctly useful when the continuous pruritus has made sleep impos- 
 sible. The extract of cannabis indica in full doses, either alone or com- 
 bined with hyoscyamus, is likewise occasionally useful for the relief of 
 itching. Opium and its alkaloids should not be given for this purpose, 
 since in many individuals they produce itching and rarely afford relief, 
 unless given in considerable doses, a relief which may be purchased 
 by an increase in this symptom when the effects of the drug have 
 passed. 
 
 For a long period of years arsenic was regarded as a valuable 
 internal remedy in eczema, but at the present time its use is very 
 limited. There is little doubt that it is not only useless but positively 
 harmful in all the acute forms of the disease without exception. While 
 some regard it as occasionally useful in the chronic forms, especially 
 those characterized by dryness of the skin with thickening, all are 
 agreed that it is at best an uncertain remedy. Although I have given 
 it an abundant trial in former years, I have never seen any benefit from 
 it and have occasionally seen it do harm. 
 
 While a considerable proportion of cases of eczema may be quite 
 well and satisfactorily treated without the use of internal remedies, 
 few or no cases can dispense with some kind of local treatment. This 
 is frequently quite adequate for the cure and is often indispensable for 
 the relief of symptoms. 
 
 In the early stages of acute eczema, if the inflammation is at all 
 marked, lotions as a rule will be found to be better borne and to give 
 more relief than ointments, partly, no doubt, because of the cooling 
 effect produced by their evaporation. If the lotion contains only solu- 
 ble substances, it may be applied most conveniently and effectively by 
 means of an atomizer, a very cleanly and agreeable way of using such 
 remedies. If, however, it also contains insoluble powders in suspen- 
 sion, as is often the case, it should be softly dabbed on with lint or 
 absorbent cotton. 
 
 Among the many lotions which may be used with good effect in 
 acute erythematous or vesicular eczema a saturated solution of boric 
 acid, sprayed or mopped on the inflamed surface every two, three or 
 four hours, is one of the most useful. The good effect of such a lotion 
 is often materially enhanced by following it with a dusting powder of 
 talcum or one composed of equal parts of starch and oxide of zinc, or, 
 when there is discharge, as in acute vesicular eczema, a powder of tal- 
 cum two parts, and boric acid one part, may be used instead. Black 
 wash, the lotio nigra of the Pharmacopoeia, in full strength or diluted 
 with an equal quantity of lime water, is another useful lotion which 
 may be softly mopped on three or four times a day. One of the most 
 
140 DISEASES OF THE SKIN 
 
 effective applications, especially useful for the relief of the itching and 
 burning which are always more or less prominent symptoms in acute 
 eczema, is an alkaline lotion containing a small quantity of menthol, 
 such as the following: 
 
 Sodii biboratis gr. x.v (i.o) 
 
 Mentholis gr. iv. (0.25) 
 
 Glycerin . f 3 i (4.0) 
 
 Ad. destil q.s. ad iB iv (12.0) 
 
 M. Filtra. 
 
 Sig. Apply with an atomizer. 
 
 This lotion may be applied every two or three hours. 
 
 A one to two per cent, solution of carbolic acid in water, either alone, 
 or, if there is discharge, with one-half drachm (2.0) of oxide of zinc, 
 subcarbonate or subgallate of bismuth in suspension with each ounce 
 (32.0), will often be found the most effective application for the relief 
 of itching; occasionally it irritates the skin and must be suspended. 
 
 When the inflammation has somewhat subsided, mild ointments 
 may be used, either alone or in combination with some of the foregoing 
 lotions, the lotion being first applied and the ointment when the former 
 has dried. An ointment containing two drachms (8.0) of oxide of zinc 
 to the ounce (32.0) of cold cream (unguentum aquae rosse) may be 
 thus employed, or a simple paste composed of twenty-five per cent, each 
 of powdered starch and subcarbonate of bismuth and fifty per cent, 
 of petrolatum. If a paste is used, the patient should be directed to 
 remove the old application each time, before making a new one, with 
 olive oil or vaseline, not with water. 
 
 Other lotions which are more or less useful are weak solutions of 
 subacetate of lead, one part of the dilute lead water to two parts of 
 water, or a solution of resorcin three to five grains (0.20) (0.32) to the 
 ounce (32.0) of water or lime water. If the inflammation is very acute, 
 however, one of the first-mentioned lotions, especially the alkaline 
 lotion containing menthol, will be better borne. 
 
 When opposed surfaces are the seat of the eczema dusting powders 
 are frequently of use. Those composed of inorganic material, such as 
 oxide of zinc, subcarbonate of bismuth and talcum, are much to be 
 preferred to such powders as starch and lycopodium, since the latter are 
 apt when they become moist to undergo fermentation and act as irri- 
 tants. To these dusting powders small quantities of carbolic acid or 
 menthol may be added to allay itching. Their use should be preceded 
 by the application of the lotion and they should be liberally applied 
 and often. 
 
 In the terminal stages of acute eczema, when the inflammation has 
 to a considerable degree subsided, but the skin is somewhat red and 
 covered with scales or crusts, and when itching is still a prominent 
 symptom, mildly stimulating ointments are indicated. Ten grains 
 (0.65) of calomel or ammoniated mercury to the ounce (32.0) of equal 
 
INFLAMMATIONS 141 
 
 parts of vaseline and lanolin or a paste, such as has been described 
 above containing two per cent, of salicylic acid, and one-half per cent, 
 of menthol, may be used, especially when there is dry scaling with con- 
 siderable itching. An ointment containing from one to two per cent, 
 of resorcin is likewise often most useful. Great care is always neces- 
 sary at this stage to avoid irritating the skin and relighting the inflam- 
 mation by the employment of too stimulating ointments. 
 
 A very important preliminary frequently necessary in chronic 
 eczema is the removal of crusts and scales, which are often present in 
 considerable quantity, and unless removed make applications of any 
 sort nugatory, since they protect the diseased skin beneath. Such 
 crusts may usually be removed by the liberal application of some bland 
 fat, such as olive oil or vaseline liberally applied. Occasionally, how- 
 ever, they are quite adherent and cannot be easily removed ; under such 
 circumstances they may be loosened by the application of a starch poul- 
 tice made with a saturated solution of boric acid. When the inflam- 
 mation is of moderate severity, soap and hot water or tincture of green 
 soap may be employed, but these should be used only for this pre- 
 liminary cleansing, as they are, as a rule, more or less injurious to 
 eczematous skin. 
 
 Chronic eczema as a rule demands more stimulating applications 
 than the acute form, but it should always be borne in mind that 
 in many cases, although they have existed for months and even 
 years and are therefore very properly designated as chronic, exacer- 
 bations occur which for the time transform them into acute eczema, 
 which should be treated as such until the acute outbreak has subsided. 
 
 Although lotions are less generally useful in the local treatment of 
 chronic eczema than in the acute variety, they frequently serve a useful 
 purpose in relieving certain symptoms, such as heat and itching. A 
 resorcin lotion, such as the following, will frequently afford much relief : 
 
 Resorcini gr. xx to xxx (1.30-2.0) 
 
 Bismuthi subcarbonatis 3 ii (8.0) 
 
 Glycerini f3 i (4.0) 
 
 Aq. destil i£ iv (120.0) 
 
 Mix. 
 
 Sig. Apply three times a day. 
 
 When oozing is present the subgallate of bismuth may be substi- 
 tuted for the subcarbonate. 
 
 A lotion containing coal-tar, such as the following, frequently 
 affords great relief to the itching in many forms of chronic eczema : 
 
 Liq. carbonis detergentis f3 i (32.0) 
 
 Glycerini f 3 ii (8.0) 
 
 Liquor calcis, 
 
 Aq aa fS ii (64.0) 
 
 Mix. 
 
 Sig. Apply t.i.d. 
 
142 DISEASES OF THE SKIN 
 
 If the itching is unusually severe and rebellious the sedative quali- 
 ties of this lotion may be materially increased by the addition of from 
 one to two per cent, of phenol. This lotion is especially useful in the 
 dry forms of eczema, particularly the papular, but sometimes irritates 
 when the surface is raw and oozing. 
 
 Ointments and their modifications are the most generally employed 
 of all the local remedies used in the treatment of chronic eczema, and 
 the manner of their employment is almost, if not quite, as important as 
 their composition. Pastes, which are a modification of ointments, are 
 often more serviceable than the latter, since they afford better protec- 
 tion to the skin, being more adhesive, but they are not so readily 
 rubbed in. 
 
 In chronic eczema with dryness and moderate thickening an oint- 
 ment containing from 2 to 3 per cent, of salicylic acid or a paste 
 of the same strength is particularly useful. In the moist forms, how- 
 ever, it is less well borne, and should be used in a strength of not more 
 than one per cent. When itching is present, a half per cent, of menthol 
 or two or three per cent, of phenol may be added. 
 
 Acid, salicylic gr. x (0.65) 
 
 Pulv. amyli, 
 
 Bismuthi subcarbonat .aa 3 ii (8.0) 
 
 Petrolat Sss (15.0) 
 
 Mentholis gr. iii vel phenolis gr. x (0.20-0.65) 
 
 Mix. 
 
 Sig. Apply twice a day, with gentle friction. 
 
 Calomel and ammoniated mercury in ointment containing from 30 
 to 60 grains (2.0 to 4.0) to the ounce (32.0) are both useful remedies, 
 especially the latter. Of course, these are to be employed only over 
 surfaces of limited extent ; otherwise ptyalism may result. 
 
 An ointment of resorcin containing from two to three per cent, is 
 frequently a useful remedy, allaying itching and favoring keratinization. 
 It is to be used, however, with a certain degree of caution in the begin- 
 ning, since in the author's experience it occasionally irritates even in 
 moderate strength. 
 
 Tar in its various forms has long been regarded as one of the most 
 useful local remedies in the treatment of chronic eczema, and there is 
 little doubt that it frequently renders most valuable service. It is 
 often, however, a most uncertain remedy, disagreeing at times in cases 
 in which it seems to be plainly indicated. It should never be em- 
 ployed when the inflammation is acute, but should be reserved for 
 those cases in which the skin is dry, thickened, and scaly. The sev- 
 eral forms of tar employed are the pix liquida or the ordinary wood 
 tar, oil of cade, and the oil of birch. Of these the oil of cade is on 
 many accounts to be preferred. The official tar ointment of the Pharma- 
 copoeia is dirty, with a strong odor, and possesses no therapeutic prop- 
 erties superior to the other forms of tar. The oil of cade may be 
 used as an ointment or paste containing from twenty-five to fifty per 
 
INFLAMMATIONS 143 
 
 cent., or it may be applied with a brush, diluted with varying quanti- 
 ties of olive oil or oil of sweet almond, or when there is much thicken- 
 ing it may be used undiluted. 
 
 In long-standing cases attended by marked infiltration and scaling, 
 an alcoholic solution may be painted on limited areas with excellent 
 effect. The ordinary tar may be used as a lotion in the shape of the 
 liquor picis alkalinus diluted with four to six parts of water, but this 
 should be used cautiously at first, as it is a decidedly stimulating appli- 
 cation and frequently irritates. The composition of the liquor picis 
 alkalinus is as follows : 
 
 Picis liquidae f3 ii (8.0) 
 
 Potassse causticse 3 i (4.0) 
 
 Aq. destil. . f 3 v (20.0) 
 
 Dissolve the potash in the water and add the tar slowly, rubbing 
 the mixture in a mortar. 
 
 In subacute eczema the gelatins of Unna and others often afford a 
 convenient and cleanly method of applying these several remedies. 
 The formula employed by Unna is as follows : Gelatin, 15 ; glycerin, 15 ; 
 zinc oxide, 30; water, 40. To this as a vehicle may be added various 
 medicaments in varying proportions. The mixture is heated over a 
 water-bath and when it is melted is applied with a flat brush and 
 afterwards covered with a thin layer of absorbent cotton or gauze. 
 The so-called plaster mulls are likewise a convenient form of local 
 treatment, but neither these nor the gelatins are as efficacious as oint- 
 ments and pastes, although much more cleanly and convenient. 
 
 When the disease is of long standing and has resulted in thick, 
 dry patches, with a verrucous surface unusually rebellious to the ordi- 
 nary remedies, chrysarobin, in an ointment or paste containing from 
 three to five per cent., may be cautiously tried, or pyrogallol may be 
 used in a similar manner. Both should be employed, however, with 
 caution, and the latter should not be applied over any considerable 
 surface. Green soap thoroughly rubbed into such thickened patches 
 with a flannel cloth dipped in hot water may be applied daily, the 
 skin afterwards being carefully rinsed off, dried, and lint spread with 
 diachylon ointment bound upon the part. When other methods have 
 failed, the careful use of the X-ray, giving short exposures every three 
 or five days, will sometimes produce the desired result. 
 
 As has already been pointed out, the age of the patient and the 
 locality affected often make important differences in the indications 
 for the remedies to be used and the manner of their employment. 
 
 In the eczemas of infancy the diet and the condition of the gastro- 
 intestinal tract should receive special consideration. Small doses of 
 calomel, one-twentieth to one-fifteenth (0.003 to 0.004) of a grain 
 three or four times a day and continued for three or four days at 
 a time, will often be followed by prompt improvement. In acute 
 eczema nothing is more useful than the alkaline menthol lotion, the 
 
144 DISEASES OF THE SKIN 
 
 formula for which has already been given, with a half drachm (2.0) 
 of bismuth subcarbonate added to each ounce (32.0), or followed by 
 the liberal application of talcum powder. Special care should be taken 
 to prevent the rubbing and scratching of the inflamed parts, since 
 these add materially to the inflammation of the skin and prolong the 
 disease. In infantile eczema of the face a resorcin lotion such as the 
 one mentioned above is often most useful, in the strength of three 
 to five grains (0.20 to 32.0) of resorcin to the ounce (32.0). This 
 should be softly mopped on three or four times a day, and at night 
 a paste containing calomel, such as the following, may be applied: 
 
 & 
 
 Hydrarg. chlorid. mit gr . x (0 65) 
 
 Pulv. amyli, 
 
 Pulv. talci aa 3i (40) 
 
 Ung. aq. rosae 3 v i ( 24 ) 
 
 Sig. Apply at bedtime. 
 
 When the skin is dry and scaly a similar paste containing one per 
 cent, of salicylic acid and 0.5 per cent, of menthol will be found espe- 
 cially useful. 
 
 In eczema of the scalp, especially in children, crusting is apt to 
 be very abundant, owing to the matting of the hair by serum, pus, 
 and blood, and before any treatment can be effective these crusts 
 must be removed. When they are not too adherent they may be 
 removed with soap and hot water if previously softened by the appli- 
 cation of vaseline or olive oil. When thick and adherent, the applica- 
 tion of a starch poultice made up with a saturated solution of boric 
 acid is usually the most effective and agreeable way of removing 
 them. In children the hair should be cut short and kept so, since 
 this greatly facilitates the application of the remedies and prevents 
 the accumulation of crusts. One of the most generally useful rem- 
 edies is an ointment of ammoniated mercury, twenty to thirty grains 
 (1.30 to 2.0) to the ounce (32.0). If itching is a prominent symptom 
 three to five grains (0.20 to 0.32) of menthol, or ten to fifteen grains 
 (0.65 to 1.0) of phenol to each ounce (32.0), may be added to this oint- 
 ment. If the scalp is dry and scaling, oil of cade, one or two drachms 
 (4.0 to 8.0) to the ounce of cold cream or lanolin, will be found a useful 
 application. 
 
 In subacute eczema of the scalp resorcin is often a most useful 
 remedy employed as an ointment of two to three per cent, strength. 
 Crocker found iodoform one of the most efficacious remedies in all 
 forms of pustular eczema, a form particularly frequent in the scalp, 
 but its abominable, far-reaching odor practically prohibits its use in 
 private practice 
 
 The best ointment bases for use upon the scalp are cold cream 
 and a mixture of cosmoline three parts, lanolin one part. Bases con-. 
 
INFLAMMATIONS 145 
 
 taining lard usually become rancid very quickly in this region and 
 should not be employed. The pastes which are so useful in other 
 regions should not be used upon the scalp except in very small children 
 with little hair. 
 
 In eczema of the ears, especially when it affects the sulcus behind 
 the ear, some form of paste is commonly more useful than ointments ; 
 one containing fifteen to twenty grains (i.o to 1.30) of calomel, or 
 1 to 2 per cent, of salicylic acid, usually answers well. It is 
 important in such cases to keep the parts dry, which may be accom- 
 plished by the liberal application of a dusting powder such as equal 
 parts of talcum and oxide of zinc, or by keeping strips of lint back 
 of the ears. If a dusting powder is used it should not be allowed to 
 accumulate unduly, but should be gently removed once a day by the 
 free application of cosmoline or olive oil. When the auditory canal 
 is affected, ointments containing some one of the above remedies 
 may be applied on tampons of absorbent cotton or with a camel's-hair 
 brush, the ointments having been thinned sufficiently with oil of sweet 
 almond or fluid cosmoline. Very frequently the itching in the meatus 
 is intense and the inflammation is greatly aggravated by rubbing with 
 some hard substance, such as a hairpin or toothpick, which the patient 
 uses to obtain relief. Of course, this should be prohibited. For the 
 relief of this itching nothing is better than menthol, which may be 
 added to the ointment in the strength of 0.5 per cent. 
 
 In the treatment of eczema of the lids, if the inflammation is at 
 all acute, lotions are to be preferred to ointments, and special care 
 must be used to avoid irritation owing to the unusual delicacy of 
 the skin in this region. A saturated solution of boric acid in water 
 with ten to fifteen minims of glycerin to each ounce (32.0) forms a 
 valuable lotion which may be applied three or four times a day, or if 
 there is much swelling the solution may be applied continuously on 
 gauze or lint. Another useful lotion is the black wash, lotio nigra. 
 After the inflammation has somewhat subsided, these lotions may 
 be used in combination with a soothing ointment such as the fol- 
 lowing : 
 
 Bismuthi subcarb 2 drachms (8.0) 
 
 Ung. aq. rosse 6 drachms (24.0) 
 
 M. 
 
 The lotion should be allowed to dry before applying the ointment. 
 When the inflammation is subacute or chronic, mildly stimulating 
 ointments or a soft paste containing 0.5 to 1 per cent, of salicylic 
 acid or two per cent, of calomel may be used. Owing to its volatility 
 and its consequent liability to irritate the conjunctiva, menthol is not 
 so well adapted for the relief of itching in this region, which often 
 proves most annoying, but phenol should be used instead in the 
 strength of two per cent. A resorcin ointment containing one per 
 10 
 
146 DISEASES OF THE SKIN 
 
 cent, is at times useful, but should be tried cautiously at first, since 
 it sometimes irritates in this region in any strength. 
 
 In eczema of the margin of the lids a favorite remedy with the 
 ophthalmologists is the yellow oxide of mercury in an ointment con- 
 taining from one to two per cent., but other preparations of mercury, 
 such as calomel or the ammoniated mercury, are probably just as 
 useful. Crusts which adhere to the lashes are often present and should 
 always be carefully removed before applying the ointment, first soft- 
 ening them with a solution of sodium borate, three to five grains 
 (0.20 to 32.0) to the ounce (32.0) of warm water, or with vaseline 
 or oil of sweet almond. 
 
 Eczema of the beard (Plate IX), like eczema of the scalp, is often 
 accompanied by abundant crusting and is apt to be of the pustular 
 type. Much the same remedies may be employed in its treatment 
 as have been advised for the scalp, namely, ammoniated mercury or 
 calomel, but it should be remembered that the face is much less tol- 
 erant of stimulation than the scalp, and therefore the ointments should 
 be milder. In chronic cases stimulating ointments containing am- 
 moniated mercury, twenty to thirty grains (1.30 to 2.0) to the ounce 
 (32.0), or ten grains (0.65) of salicylic acid, may be used with good 
 effect, the former particularly when the disease is of the pustular 
 variety. In the dry forms with thickening and scaling, oil of cade, 
 one or two drachms (4.0 or 8.0) to the ounce (32.0), will be found 
 useful. In order to facilitate the application of the remedies and to 
 prevent the accumulation of crusts, the beard should be kept closely 
 clipped. 
 
 In ordinary eczema of the hands the usual remedies are indicated, 
 but in that rebellious form characterized by coin-sized, roundish 
 patches of rather large vesicles which soon rupture, giving exit to an 
 abundant discharge of syrupy serum, nothing is quite so effective as 
 the X-ray, giving a five-minute exposure every three or four days. A 
 lotion of resorcin, six to eight grains (0.40 to 0.50) to the ounce (32.0), 
 containing J/£ drachm (2.0) of subgallate of bismuth in each ounce 
 (32.0), is often of much service in relieving the itching and in drying 
 up the discharge. 
 
 A paste containing 1 per cent, of salicylic acid is likewise useful. 
 In scaly eczema of the palm, with thickening and fissuring, a most useful 
 application is the following: 
 
 Liquor, carbonis detergentis fS ii (60.0) 
 
 Glycerini fS i (32.0) 
 
 M. 
 
 A teaspoonful of this should be poured into the palms and thor- 
 oughly rubbed in two or three times a day, wiping off the excess with 
 a soft cloth. When the horny layer of the palm is much thickened, 
 ointments of salicylic acid, twenty to thirty grains (1.30 to 2.0) to 
 
PLATE IX 
 
 Eczema of the beard (Eczema barbae) 
 
INFLAMMATIONS 147 
 
 the ounce (32.0), or of tar, twenty-five to fifty per cent., should be 
 thoroughly rubbed in, employing as a base five parts of lard and three 
 parts of lanolin, or lanolin six parts and glycerin two. As many 
 eczemas of the hand are examples of occupational disease, it is fre- 
 quently most difficult to treat them successfully so long as the patient 
 continues at his occupation. In the case of women doing housework 
 the hands may be protected from the injurious effects of soap and 
 water to some extent by the frequent application of simple fats, or, 
 what is less to be advised, by the wearing of rubber gloves. 
 
 In eczemas affecting the nipple and areola of the female breast 
 a soft paste containing two per cent, of salicylic acid with o 5 to one 
 per cent, of menthol is a useful application. When the patient is a 
 nursing woman painful fissures of the nipple are frequently associated 
 with the eczematous inflammation ; these should be painted with tinc- 
 ture of benzoin or collodion, and a nipple shield should be used when 
 the infant is nursing. Sometimes lightly touching with the solid 
 stick of nitrate of silver or painting the fissures with a solution one 
 drachm (4.0) to the ounce (32.0), will heal them more quickly. Ex- 
 ceptionally it may be necessary to wean the infant. 
 
 In eczema of the genitalia, particularly of the vulva, examination 
 of the urine for sugar should never be omitted. When glycosuria is 
 
 P u eSe l I l\ a dlCt freC fr ° m SUgar and su gar-producing articles of food 
 should be prescribed; this is the most important part of the treat- 
 ment. Not uncommonly a vaginal discharge is the causative agent 
 Under such circumstances frequent and copious douching with a 
 saturated solution of boric acid should accompany the local treat- 
 ment. When oozing is present, lotions and dusting powders are to 
 be used rather than ointments, and when itching is a prominent symp- 
 tom, as it so frequently is, a most useful lotion is the borax and men- 
 thol lotion already described, followed by the liberal application of 
 a dusting powder containing bismuth and talc. When the acuteness 
 of the inflammation has subsided and the parts are no longer moist 
 a paste containing twenty grains (1.30) of calomel with ten to fif- 
 teen grains (0.65 to 1.0) of phenol to the ounce (32.0) may be 
 applied two or three times a day. Special pains should be taken 
 to keep the parts clean by the liberal use of some bland oil like 
 olive oil or cosmohne, since decomposition readily takes place in this 
 region. 
 
 In eczema of the scrotum, when the parts are oozing, the thighs 
 and scrotum should be kept apart by the interposition of two or 
 three layers of gauze sprinkled with a dusting powder of talc and 
 the salicylate or subgallate of bismuth. Ointments used in this region 
 should have as a base some mineral fat such as cosmoline. If made 
 with lard or other animal or vegetable fat they very readily become 
 rancid, irritating, and ill-smelling through decomposition. 
 
 In eczema of the anus much the same remedies are to be emploved 
 as about the genitalia, but owing to the heat and moisture always 
 
148 DISEASES OF THE SKIN 
 
 present in this region, and to the occasional extension of the inflam- 
 mation within the sphincter, the difficulties in the way of success- 
 ful treatment are many. The itching, which is apt to occur paroxys- 
 mally, is at times atrocious and always demands relief. A lotion which 
 I have often found most useful is the following : 
 
 Liq. carbonis detergentis i% i (32.0) 
 
 Glycerini fS ss (16.0) 
 
 Aq. camphorae q. s. ad fS iv (120.0) 
 
 M. et adde 
 
 Phenolis 3ss (2.0) 
 
 Sig. Shake thoroughly and mop on three or four 
 times a day. 
 
 This lotion may sometimes be usefully modified by substituting 
 menthol for the phenol in the proportion of a half a grain (0.03) to 
 the ounce (32.0), and by using lime water instead of camphor water. 
 A menthol and salicylic acid paste containing three to five grains 
 (0.20 to 0.30) of the former and ten grains (0.65) of the latter to the 
 ounce (32.0) often acts admirably in relieving the itching. If the 
 parts are much inflamed, the proportions of the menthol and sali- 
 cylic acid may be reduced one-half. For the relief of the pruritus 
 within the sphincter, ointments made up with lanolin should be used, 
 as the ordinary fatty bases not mixing with water are comparatively 
 ineffective upon moist mucous surfaces. In cases which have re- 
 sisted the ordinary local applications, the X-ray may be tried; this 
 sometimes affords marked relief to the intolerable itching. 
 
 In the treatment of eczema of the legs, one of the commonest local 
 varieties, the same lotions, ointments, and pastes are to be employed 
 as elsewhere, but owing to the dependent position of the parts and 
 the frequent association of varicose veins with the eczema, certain 
 auxiliaries, such as the roller bandage, or, what is much more efficient, 
 the elastic bandage, are to be employed. In acute forms occurring in 
 this locality and in the acute exacerbations of the chronic variety, 
 nothing can take the place of rest and elevation of the limb ; and when 
 the inflammation is severe, especially if it is accompanied, as is often 
 the case, by cedema, these should be insisted upon. In the subacute 
 and chronic forms, when the patient is obliged to be about, a bandage 
 of elastic webbing should be smoothly applied, stretching it suffi- 
 ciently in the application to make moderate, even pressure after 
 the ointment or lotion selected has been applied. If the parts are 
 moist, a dusting power, such as talcum, should be freely dusted over 
 the legs before the bandage is put on. Instead of a bandage, the 
 zinc-gelatine of Unna, the formula for which has already been given, 
 may be applied to the leg, alone or with the addition of one or two 
 per cent, of salicylic acid. 
 
 The chronic leg ulcer is a frequent complication of eczema of 
 the legs which often adds much to the patient's discomfort and in- 
 
PLATE X 
 
 Seborrheic dermatitis (Dermatitis seborrheica). 
 
INFLAMMATIONS 149 
 
 creases materially the difficulties of treatment. The following will 
 be found a useful ointment in the treatment of these ulcers : 
 
 Acid, salicylic gr . I0 (0.65) 
 
 Emp. plumbi, 
 
 Petrolat aa 5ss (16.0) 
 
 M. 
 
 This should be spread upon lint and applied to the surface of 
 the ulcer, first thoroughly cleansing it with a warm saturated solu- 
 tion of boric acid, twice a day. In these cases the elastic bandage 
 or the zinc-gelatin is even more necessary than in uncomplicated 
 eczema. When the ulcer is discharging an opening should be made 
 in the gelatin after it has become firm, to permit cleansing and the 
 application of the remedies. 
 
 Very often these ulcers are extremely painful, interfering with 
 the patient's rest both night and day, and the author knows of no 
 more generally useful local application for the relief of the pain than 
 a two per cent, ointment of resorcin. 
 
 DERMATITIS SEBORRHEICA 
 
 Synonyms. — Eczema seborrhceicum ; seborrhoea corporis (Duh- 
 ring) ; seborrhoea sicca. 
 
 Definition.— A chronic inflammatory disease of the skin occurring 
 as red, somewhat scaly patches, often discoid or annular in shape 
 when situated upon non-hairy parts, with a pronounced predilection 
 for certain localities, as the scalp, sternum, and interscapular region 
 (Plate X). & 
 
 In 1887 Unna proposed to include under the title eczema seborrhcei- 
 cum a number of affections of an inflammatory character more or 
 less closely associated with the sebaceous glands, which had previously 
 been described under a number of names, and which were regarded 
 as separate and distinct affections. While the views of Unna have 
 for the most part met with general acceptance, there is still some 
 dissent from including under this term all included by Unna. 
 
 Since the conditions included by Unna under the term eczema 
 seborrhceicum are for the most part inflammatory in character and 
 more or less distinct from ordinary eczema, a number of authors, 
 among them Crocker and Elliot, prefer to designate the affection 
 dermatitis seborrheica, a term which seems to be more appropriate 
 than the one originally suggested by Unna. 
 
 Symptoms.— The symptoms presented by seborrheic dermatitis 
 vary considerably, according to the region affected. On the scalp 
 it occurs quite frequently as a more or less marked scaliness, the scales 
 being fatty without any very definite signs of inflammation of the 
 underlying skin, although a careful examination of the cases which 
 are seemingly not inflammatory will often disclose small scattered 
 
150 
 
 DISEASES OF THE SKIN 
 
 areas in which the scalp is slightly reddened. In more marked cases 
 the scaling may be quite abundant, the scalp red, sometimes moist 
 and oozing slightly, with some crusting. There is usually more or 
 less itching, and when the disease has lasted for some time the hair, 
 which in the beginning was oily, becomes thin, dry, and brittle, the 
 oiliness in the early stages being due to the oily seborrhoea which often 
 accompanies the affection. 
 
 In the brows and beard, and especially in the mustache, it fre- 
 
 Fig. 31. — Dermatitis seborrheica, sternum. 
 
 quently exists for a long period as an abundant scaling, dandruff, 
 "but here, too, just as upon the scalp, there may be present the ordi- 
 nary signs of inflammation, such as redness, and, exceptionally, moist- 
 ure and crusting. There is rarely, however, even in the cases which 
 have lasted a considerable period, any noticeable thickening of the 
 skin such as occurs in ordinary eczema. Upon the smooth or non- 
 hairy parts of the face it occurs as ill-defined patches of fine scaling, 
 usually accompanied by a moderate degree of redness. In the fur- 
 row between the ala of the nose and the cheek, and extending a little 
 
INFLAMMATIONS 151 
 
 distance upon the latter, the redness is often quite marked with con- 
 siderable crusting, the crusts being fatty rather than dry and brittle. 
 Upon the trunk it exhibits a decided predilection for the sternal 
 and interscapular regions (Fig. 31), where it occurs as rather well- 
 defined, yellowish-red, rounded and not uncommonly annular patches, 
 covered with small, loosely adherent, fatty scales. At times these 
 patches exhibit a moderate amount of infiltration, although, as a rule, 
 they are but little elevated above the healthy skin. In the mildest 
 cases the eruption is confined to the sternum, and, less frequently, 
 the region between the scapulae, where it frequently exhibits a dis- 
 
 
 . ■ 
 
 . - . 
 
 W 
 
 Fig. 32. — Dermatitis seborrheica, axilla. 
 
 tinctly ring-shaped arrangement; this is the seborrhcea corporis of 
 Duhring. In exceptional cases the entire trunk may be more or less 
 involved, or it may be confined to the umbilical region. 
 
 The axillary (Fig. 32), the pubic, and the inguinal regions are 
 likewise invaded at times, and in, these regions, owing to the heat 
 and moisture normally present, there is often oozing, with more or 
 less crusting. 
 
 In children and in young adults it may occur on the upper and 
 lower lips (Fig. 33), invading, in exceptional cases, the vermilion 
 border of the lips, causing considerable exfoliation, or, in markedly 
 inflammatory cases, crusting. 
 
152 DISEASES OF THE SKIN 
 
 Unlike the ordinary forms of eczema, itching is rarely a very 
 marked symptom, although it is usually present to a moderate degree. 
 As a rule, to which there are few, if any, exceptions, dermatitis 
 seborrhceica begins upon the scalp, where it often exists for a long 
 time as excessive scaling with few or no signs of inflammation. This 
 early mild form of the malady is the seborrhcea capitis of some authors, 
 but there is no doubt that it actually represents the earliest stages of 
 what sooner or later becomes the seborrhceic eczema of Unna. 
 
 While the amount of scaling present is in most cases moderate, 
 it may, in exceptional cases, be so considerable as to resemble to a 
 pronounced degree patches of mild psoriasis. 
 
 Etiology. — While departures from the normal standard of health 
 
 may act as predisposing: 
 
 J causes of the affection, there 
 is no evidence that it is the 
 direct result of any general 
 condition. Among local con- 
 ditions which favor its occur- 
 rence are excessive heat, per- 
 p spiration, friction, woollen 
 
 . % *; underclothing, lack of clean- 
 
 *• liness, or any other source of 
 
 local irritation. These in 
 predisposed individuals fre- 
 quently exert a decided effect 
 in detei mining the origin 
 and spread of the inflamma- 
 tion. The majority of recent 
 authors, among whom may 
 
 Fig. 33. — Dermatitis seborrhoeica (involving mucous mem- K^ t-n#=>nf ir\n^rl TTnno Qnknn 
 brane of the lips as well as the skin). De mentioned Unna, SaDOU- 
 
 raud, and Elliot, are of the 
 opinion that the affection is parasitic, and a number of microorganisms 
 have been found which are regarded by their discoverers as the direct 
 agent in its production. Proof is still lacking, however, that any one of 
 these is the actual cause of the disease, although the preponderance 
 of evidence seems to be in favor of its parasitic origin {vid. Seborrhcea). 
 Pathology. — The histological changes found in dermatitis seborrhce- 
 ica are, for the most part, such as are present in the milder forms of 
 eczema. There is a disturbance of the process of keratinization (para- 
 keratosis), parenchymatous and interstitial oedema of the rete, the 
 latter usually much less marked than in ordinary eczema, and a mod- 
 erate acanthosis (thickening of the rete). A moderate amount of 
 cellular exudation is usually present in the papillary layer of the 
 corium about the vessels and in the neighborhood of the coil-glands. 
 Fat in varying amount is present in the epidermis, and less frequently 
 in the corium, according to Unna, who finds the origin of the increased 
 fat secretion in the coil-glands which show evidence of pathological 
 
INFLAMMATIONS 153 
 
 change, such as an increased number of mitoses in the cells lining 
 the ducts, together with globules of fat, and proliferation of the epi- 
 thelium lining the glands. This author found no changes in the 
 sebaceous glands. Elliot was not able to confirm Unna's findings 
 as to the infiltration of the rete and corium with fat, nor did he 
 find fat in the coil-glands or their ducts, although degenerative changes 
 were observed in them. Even in the mildest grades of the disease 
 represented by pityriasis capitis and the seborrhcea of authors, Elliot 
 found a slight cellular exudate about the vessels of the corium and 
 the hair follicles, indicating its inflammatory character, while in the 
 severer forms inflammatory changes were present in the entire cutis. 
 
 Diagnosis. — One of its most striking characteristics is its marked 
 predilection for the scalp and the sternal regions. As has already 
 been observed, it almost always begins in the former locality, spread- 
 ing thence in time to other parts ; such a predilection is shown by 
 none of the diseases which may resemble it. 
 
 It is to be distinguished from eczema of the ordinary type, pityriasis 
 rosea, ringworm, and psoriasis. 
 
 It differs from ordinary eczema by the localization already men- 
 tioned, by the usually milder degree of inflammation, the absence of 
 any considerable thickening of the skin, and by the annular and discoid 
 arrangement which it frequently exhibits on smooth or non-hairy parts. 
 Itching, which is usually a very pronounced symptom in eczema, is 
 as a rule trifling. 
 
 Pityriasis rosea and dermatitis seborrhoeica may resemble each 
 other quite closely, but the former is an acute affection, shows no 
 special tendency to occur in the face or over the sternum ; indeed, it 
 is unusual in the former region. In the former the scaling is fine 
 and dry ; in the latter, fairly abundant and fatty. 
 
 Ringworm of non-hairy surfaces may at times resemble it, but 
 the rapid extension of the patch and its speedy transformation into 
 a ring, the fine dry scales in which the trichophyton fungus is readily 
 demonstrated, are features which easily distinguish it from seborrhceic 
 dermatitis. 
 
 When the disease occupies a considerable portion of the trunk 
 and scalp and the scaling is unusually abundant, it may resemble the 
 milder forms of psoriasis, but in the latter the patches are usually 
 much more sharply circumscribed, the scales are dry, white, laminated, 
 and much more abundant. The two diseases affect different regions, 
 psoriasis occurring especially upon the extensor surfaces of the ex- 
 tremities and particularly on the elbows and knees, while, as already 
 noted, seborrhoeic dermatitis affects especially the sternal and inter- 
 scapular regions. There is likewise decided infiltration of the patches 
 in psoriasis, while in seborrhceic dermatitis this is trifling, if present 
 at all. 
 
 Prognosis. — As a rule, the malady yields quite readily to judicious 
 treatment, but relapses are common. 
 
154 DISEASES OF THE SKIN 
 
 Treatment. — Internal remedies are rarely, if ever, indicated in treat- 
 ment. If, however, the patient is anaemic or debilitated from any 
 cause, tonic remedies and such as tend to improve the general nutri- 
 tion, such as iron, strychnia, arsenic, or cod-liver oil, may be given. 
 
 The local treatment will vary somewhat, according to the region 
 affected. In the dry, scaly form affecting the scalp a lotion of 
 resorcin containing from ten to fifteen grains to the ounce of equal 
 parts of alcohol and water, with a few minims of glycerin, will often 
 prove an effective remedy. Should this be found too drying, an 
 ointment of resorcin, two to three per cent., may be substituted for 
 the lotion. In cases in which a moderate degree of inflammation is 
 present, an ointment containing twenty grains of ammoniated mer- 
 cury to the ounce is often most useful, first removing any crusts that 
 may be present, either with soap and water or with vaseline. Weak 
 sulphur ointment, ten to twenty grains to the ounce, is often an effec- 
 tive remedy, but it should be used cautiously at first, as it occasion- 
 ally irritates. In mild forms affecting the sternal and interscapular 
 regions, nothing is more effective than the zinc sulphide lotion with 
 ten or fifteen minims of glycerin to the ounce. 
 
 Zinci sulphat., 
 
 Potas. sulphuret aa gr. xl (2.60) 
 
 Glycerini 3i (4.0) 
 
 Aq Siv (108.0) 
 
 Mix. 
 Sig. Shake and apply twice a day. 
 
 When there is marked inflammation, this lotion is contra-indicated ; 
 instead a lotion of resorcin containing from five to ten grains (0.32 to 
 0.65) to the ounce (32.0) of equal parts of lime water and water will be 
 found useful. In the cases which approach in type ordinary eczema 
 the treatment is practically the same as for that affection. 
 
 HERPES SIMPLEX 
 
 Synonyms. — Herpes; "cold-sore" ; fever blister; Fr., Herpes vul- 
 gaire ; Ger., Blaschenflechte. 
 
 Definition. — An acute inflammatory disease of the skin distinguished 
 by one or more groups of small vesicles on an inflamed base, situated, 
 in most instances, in the face or upon the genitalia (Plate XI). 
 
 Symptoms. — Two varieties of herpes occur which differ from each 
 other chiefly in the regions involved, their symptoms being much the 
 same. One variety occurs in the face, hence is known as herpes facialis 
 (herpes labialis, herpes febrilis, cold-sore) ; the other affects the geni- 
 tal region, the penis in the male, the labia in the female. 
 
 Herpes Facialis (Fig. 34). — Facial herpes is distinguished by one 
 or more usually quite small groups or patches of pin-head to split- 
 pea-sized vesicles seated upon a reddened area situated at one corner 
 or other of the mouth, upon the lips at the mucocutaneous junction, 
 
PLATE XI 
 
 Herpes simplex. 
 
INFLAMMATIONS 
 
 155 
 
 and extending upon the skin, upon one ala or other of the nose, or, 
 less frequently, upon one cheek, or the ear. Frequently there is but 
 a single patch, but often there are two, three, or more, each contain- 
 ing from four or five to a dozen or more small vesicles filled with trans- 
 parent serum, which soon becomes cloudy and sometimes purulent. 
 Exceptionally the patches are comparatively large, and may contain 
 small blebs formed by the coalescence of several vesicles when these 
 are closely crowded together. In the course of three or four days the 
 vesicles dry up, forming yellowish crusts, which fall off at the end 
 of a week, leaving a reddish, sometimes faintly brownish, stain which 
 soon disappears. The appearance of the eruption is usually preceded 
 by a feeling of local heat or itching for some hours. In a considerable 
 proportion of cases the eruption ^ _ i 
 
 is preceded and accompanied in H| 
 its early stages by slight malaise, I 
 
 some elevation of temperature, I ^^ 
 
 and chilliness, hence the name I 
 "fever blister," "cold-sore," by 
 which it is commonly known; or 
 there may be slight gastric dis- 
 turbance. 
 
 Although the vast majority of 
 cases of simple herpes occur upon 
 some part of the face, it may also 
 occur upon other parts, such as 
 the trunk or extremities, and in 
 exceptional cases upon the mu- 
 cous membranes of the lips, the 
 tongue, the cheeks, pharnyx, or 
 larynx. 
 
 In a considerable number of 
 cases it exhibits a remarkable tendency to recur, often in tne same 
 situation, at intervals of some months. It is fairly common to see 
 this recurrent type in children, in whom it is apt to occur upon the 
 cheek two or three times a year for a number of years. The author 
 has had under his observation several cases in adults in which a patch 
 of vesicles recurred every few months upon the buttock, and Sequiera 
 and Adamson have made similar observations. 
 
 An epidemic form of herpes has been described by Savage, Seaton, 
 and others in which there was marked elevation of temperature, 102 
 or 103 F., accompanied by patches of vesicles in the face, or upon 
 the ears. In the epidemic reported by Savage the fever lasted four 
 days, and the attack was attended by great prostration. 
 
 A few cases of generalized herpes have been reported, but the diag- 
 nosis in some of these is open to doubt. 
 
 Herpes Progenitalis. — In this variety of herpes the eruption is sit- 
 uated upon the inner surface of the prepuce, the glans, or, much less 
 
 Fig. 34. — Herpes simplex facialis. 
 
156 DISEASES OF THE SKIN 
 
 frequently, upon the shaft of the penis in men and upon the inner 
 surface of the labia, the prepuce of the clitoris, exceptionally upon 
 the cervix uteri, occasionally upon the skin of the vulva, and at times 
 upon the inner surface of the thigh adjoining, in women. As in facial 
 herpes, the appearance of the eruption is preceded by burning or itch- 
 ing, sometimes pain, but malaise and fever, which are so common 
 in facial herpes, never occur. Upon the mucous surfaces the vesicles 
 are not transparent, as upon the skin, but appear as small white opaque 
 elevations, which are soon transformed into small shallow erosions 
 or ulcers ; but when situated upon the shaft of the penis, the vulva 
 and thighs they present the same appearances as when situated upon 
 other parts of the skin, and after a time dry up into small crusts. The 
 number of vesicles is usually small upon the prepuce and the glans— 
 there may not be more than two or three — but occasionally patches of 
 considerable size are present, varying in number from a single one 
 to three or four, and containing a considerable number of vesicles. 
 When irritated, as frequently happens, from injudicious treatment, 
 especially in men, considerable swelling, with inflammatory indura- 
 tion of the part upon which the vesicles are seated, and occasionally 
 ulceration with swelling of the inguinal glands, may occur. The sub- 
 jective symptoms are usually trifling in the male, but in women, in 
 whom it is apt to occur at the menstrual period, the amount of burn- 
 ing and pain may be considerable. Recurrences are extremely common, 
 much more so than in the facial variety. 
 
 Etiology. — There is an extraordinary variation in individual sus- 
 ceptibility to facial herpes. In certain individuals it is extremely com- 
 mon, the slightest indisposition, a coryza, or a trifling indigestion 
 being sufficient to produce it, while others never, under any circum- 
 stances, suffer from it. In certain individuals certain articles of food 
 may produce it. The author has knowledge of a case in which the 
 eating of cheese in the evening is sure to be followed by a labial 
 herpes next morning. It is a common symptom in certain acute 
 general infections, such as malaria, pneumonia, epidemic cerebrospinal 
 meningitis, and, exceptionally, in typhoid fever. Its occurrence is 
 commonly regarded as a favorable omen in these affections, but it is 
 doubtful whether it has any prognostic significance. 
 
 Genital herpes is frequently, but by no means always, preceded by 
 some venereal affection, such as gonorrhoea or the venereal ulcer, 
 and is quite common in prostitutes. In men predisposed to it coitus 
 is a frequent exciting cause, and it may follow every coitus. In women 
 it is apt to occur at the menstrual period and may be the cause of 
 much distress. 
 
 Pathology. — Herpes is, in all probability, a toxic neuritis affecting 
 the terminal filaments of a branch of a cutaneous nerve, and it is 
 extremely probable that a variety of toxic substances may cause it. 
 Its occurrence after certain foods or drugs, and its association with 
 
INFLAMMATIONS 157 
 
 certain general infections, such as have already been referred to, cer- 
 tainly afford much support to such a view. 
 
 There is a fibrinous inflammation of the upper portion of the epi- 
 dermis terminating in a coagulation necrosis of the epithelial cells. 
 The papillae immediately beneath the vesicle are cedematous, their ves- 
 sels and lymph spaces dilated, and the former surrounded by a con- 
 siderable exudation of leucocytes. 
 
 Diagnosis. — The recognition of facial herpes is usually very easy. 
 The arrangement of the vesicles in one or more well-defined groups ; 
 their situation about the mouth and the alse nasi ; the absence of 
 marked itching ; the acute course of the eruption, and the frequent 
 history of repeated recurrences, are features which distinguish it from 
 acute vesicular eczema. The absence of neuralgic pain and of any 
 definite relation to nerve-branches will serve to distinguish it from 
 herpes zoster, which is very unusual in the regions affected by simple 
 facial herpes. When simple herpes occurs elsewhere than upon the 
 face there may at times be difficulty in differentiating it from a mild 
 zoster with a single patch. 
 
 When the patches have crusted they may bear some resemblance 
 to impetigo contagiosa, but the peripheral spread of the vesico-pustules 
 of the latter, their thin, wafer-like crusts, and the appearance of new 
 lesions at short intervals, often from auto-inoculation, soon differen- 
 tiate the two affections. 
 
 Herpes occurring upon the prepuce (herpes praeputialis) is most 
 likely to be confounded with the venereal ulcer, or with the initial 
 lesion of spyhilis. In the early stages there is commonly no diffi- 
 culty in distinguishing the herpetic eruption from these — the vesicular 
 character of the lesions and their number are features quite character- 
 istic of the former — but when, through irritation of any kind, such 
 as frequent coitus, or, more commonly, the application of irritant 
 or caustic substances, often by the patient himself, the lesions inflame 
 and ulcerate and their bases become swollen and hard, there may be 
 some difficulty in arriving at a definite conclusion. Under such cir- 
 cumstances, owing to the very serious results which may follow an 
 error in diagnosis, sexual intercourse should be forbidden until a 
 positive diagnosis has been made. In doubtful cases examination 
 of the secretion from the ulcerating surface for the spirochaetse, by 
 dark-ground illumination or the Burri India ink method, should not 
 be omitted. Since the inguinal lymphatic glands may be swollen in 
 those" cases in which the herpetic lesions have been irritated, as 
 well as in chancre, too much importance should not be laid upon 
 the presence or absence of such swelling in the differential diagnosis. 
 
 Prognosis and Treatment. — An attack of herpes usually runs its 
 course in about a week to ten days, but, as already noted, recurrences, 
 especially in the genital forms, are common and often the source of 
 much annoyance. 
 
 In the ordinary forms of facial herpes, one of the most effec- 
 
158 DISEASES OF THE SKIN 
 
 tive local applications is undiluted alcohol gently mopped on with a 
 pledget of absorbent cotton, three or four times a day, for a few min- 
 utes at a time, followed by a dusting powder of talc and oxide of zinc 
 or subcarbonate of bismuth. When crusting has occurred, a weak 
 ointment of calomel or ammoniated mercury may be applied once or 
 twice a day until healing is complete. In herpes progenitalis the 
 same alcoholic lotion may be employed, followed by a dusting powder 
 composed of equal parts of talc and boric acid. Ointments should not 
 be used about the genitalia as a rule. When the eruption is on the 
 mucous surfaces, the opposed surfaces should be kept apart after the 
 liberal application of the dusting powder by a thin layer of plain gauze. 
 Astringent lotions containing small quantities of tannic acid, sul- 
 phate of zinc, or acetate of lead may also be used. 
 
 For the prevention of recurrences in genital herpes, strict cleanli- 
 ness should be observed, washing the parts daily, and especially after 
 coitus, with a saturated solution of boric acid. The diet should be 
 regulated and the avoidance of spirits, wines, and malt liquors should 
 be advised. In cases in which the prepuce is long, circumcision should 
 be performed. Moderate doses of arsenic administered over a con- 
 siderable period are sometimes of service. Notwithstanding the best 
 directed efforts, the prevention of recurrences is oftentimes a matter 
 of considerable difficulty. 
 
 HERPES ZOSTER 
 
 Synonyms. — Zoster ; zona ; shingles ; Ger., Giirtelausschlag ; Giir- 
 telrose. 
 
 Definition. — An acute inflammatory disease of the skin character- 
 ized by an eruption of vesicles arranged in groups, seated upon an 
 inflammatory base, distributed over the course of a nerve. 
 
 Symptoms.— It usually begins with some degree of pain in the 
 region about to be the seat of the eruption, the amount varying from 
 slight hypersensitiveness to severe neuralgia. Exceptionally there is 
 elevation of temperature, with headache and malaise. After a period 
 varying from a few hours to a day or two, or, in a considerable pro- 
 portion of cases, without prodromal symptoms, variously sized erythe- 
 matous, ill-defined patches appear, on which are shot-sized papules, 
 which speedily become vesicles with clear contents. With the appear- 
 ance of the eruption the pain often becomes less, but not invariably 
 so. New vesicles continue to appear for several days, while the con- 
 tents of the older ones become turbid, purulent, and occasionally 
 hemorrhagic. Unlike the vesicles of eczema, as well as some other 
 inflammatory affections, those of zoster show no tendency to spon- 
 taneous rupture, but dry up into yellow or blackish crusts, which after 
 a week or ten days fall, leaving a slight transient pigmentation, and 
 in the severe cases more or less permanent scarring. Quite commonly 
 the lymphatic glands in the neighborhood of the eruption are some- 
 what enlarged. 
 
INFLAMMATIONS 159 
 
 The number and size of the patches of eruption vary according to 
 the locality attacked and the severity of the attack. There may be 
 but a single patch in very mild cases, although this is unusual, or 
 there may be a half dozen or more, as when the eruption occurs over 
 the distribution of the brachial plexus. Each patch may contain from 
 five or six small vesicles to large numbers, and in the severe cases 
 blebs of various sizes may form by the coalescence of closely adjacent 
 vesicles. In certain regions the patches may be so large and so 
 close together that they coalesce to form one large area covered by 
 the eruption. The contents of the vesicles are usually clear or slightly 
 turbid serum, but they may be bloody (zoster hemorrhagicus). The 
 inflammation may be so violent that it eventuates in gangrene, and 
 instead of crusts of black eschars of varying size and depth are formed 
 (zoster gangrsenosus). In very mild cases a number of the lesions 
 abort in the papular stage and disappear within a few days. 
 
 In the vast majority of cases the eruption is unilateral ; quite ex- 
 ceptionally it is bilateral, and in very rare instances may be more or 
 less general. 
 
 Tenneson, Leredde, and other French observers have called atten- 
 tion to the frequent occurrence of scattered vesicles some distance 
 from the principal eruption, but usually on the same side. Tenne- 
 son asserts that these may be found in nine out of every ten cases 
 of zoster, and Crocker's observations led him to the same conclusion. 
 
 The amount of pain varies greatly. In children it is very com- 
 monly absent altogether or trivial. In young and middle-aged adults 
 it may or may not be present, and varies from slight uneasiness with 
 burning to intolerable neuralgia. In the elderly and old more or less 
 neuralgic pain is the rule. 
 
 The attack in ordinary cases terminates after a course of ten days 
 to three weeks, but when there has been deep ulceration or gangrene 
 two or three months may elapse before recovery is complete. In a 
 considerable proportion of cases various disturbances of sensation, 
 such as burning, formication, or actual neuralgia, may persist for 
 months, even many months, after the disappearance of the eruption. 
 This is especially apt to be the case in old subjects. 
 
 In the great majority of cases but a single attack occurs during 
 the patient's lifetime. A number of cases, however, have been re- 
 ported in which not one but many recurrences were observed. Ka- 
 posi observed a case in which nine relapses occurred, and some years 
 ago the author had under his own observation an elderly man who had 
 many attacks at intervals, varying from a few weeks to several months, 
 all in the distribution of the sciatic nerve and its branches. As a 
 rule, cases of recurrent zoster are the result of traumatism or are 
 secondary to disease in the immediate vicinity of the nerve affected. 
 In the author's case above referred to the malady followed a fracture 
 of the femur. 
 
 A number of clinical varieties are commonly recognized which are 
 
160 
 
 DISEASES OF THE SKIN 
 
 designated chiefly according to the regions they occupy or the nerves 
 involved. The principal varieties are zoster ophthalmicus, occurring 
 in the region of distribution of the ophthalmic branch of the fifth pair ; 
 zoster capillitii, affecting the scalp ; zoster frontalis, occurring on the 
 forehead over the supraorbital branch of the fifth pair; zoster brachi- 
 alis, occurring over the distribution of the brachial plexus ; zoster 
 pectoralis, occupying the side of the thorax, the " shingles " (Fig. 36), 
 of the laity and one of the commonest forms of the disease ; zoster 
 lumbo-abdominalis, over branches of the lumbar plexus ; and zoster 
 femoralis, in the distribution of the sciatic nerve. These several varie- 
 ties, with one or two exceptions, present no essential differences in 
 their symptoms. 
 
 In zoster occurring over the several branches of the fifth pair, 
 .the inflammatory symptoms are occasionally of unusual severity and 
 
 Fig. 35. — Herpes zoster. Unusual location. 
 
 may be accompanied by great pain. The eruption may occur upon the 
 conjunctiva and cornea, in the latter leading at times to perforation, 
 with serious impairment of vision. The inflammation, in rare cases, 
 may extend to the retina, or to the meninges with a fatal result. Ves- 
 icles may also occur upon the nasal, buccal, lingual, and palatal mucous 
 membranes. 
 
 In frontal zoster several small patches, or, in severe cases, one large 
 patch of vesicles which are often of large size and deep-seated, are dis- 
 tributed over the supraorbital nerve from the brow to the margin of 
 the scalp, and often well within the hair, stopping abruptly at the 
 middle line. This variety is frequently followed by very marked and 
 extensive scarring. 
 
 In facial zoster, an unusual variety, the eruption is at times accom- 
 panied or followed by facial paralysis. 
 
 In zoster over the brachial plexus and its branches (zoster brach- 
 ialis, zoster cervico-brachialis) there are numerous patches of vesicles 
 distributed on the side of the neck in the clavicular and scapular re- 
 
INFLAMMATIONS 
 
 161 
 
 gions, over the anterior surface of the arm, extending to the wrist (Fig. 
 35), but very rarely upon the hand. Patches also occur upon the outer 
 surface of the upper arm. 
 
 Thoracic zoster, zoster pectoralis, " shingles," is by far the most 
 frequent form of the affection. In cases of ordinary severity there 
 are, as a rule, three well-defined patches, one close to the spinal col- 
 umn, a second in the axillary line, and a third in the mammary line. 
 Occasionally one or other of these is abortive, consisting of a small 
 
 Fig. 36. — Thoracic herpes zoster (shingles). 
 
 erythematous patch, in which are a few small papules or two or three 
 vesicles, or it may be absent altogether. On the other hand, the 
 eruption may be so abundant that there are no discrete patches, but 
 a wide band of vesicles and blebs extending from the middle line in 
 front to the spinal column in the back. 
 
 In lumbo-abdominal zoster the eruption is situated in the gluteal 
 region, on the lower part of the abdomen, in the inguinal region, and 
 on the inner and upper part of the thigh. 
 
 In femoral zoster there are patches of eruption on the outer and 
 inner surface of the thigh, occasionally upon the genitalia, and down 
 the posterior surface of the thigh to the knee, but rarely on the leg. 
 11 
 
162 DISEASES OF THE SKIN 
 
 Etiology. — Herpes zoster is most common in the second and third 
 decades of life, and although no age is entirely exempt, it is rare in 
 very young children and in infants. Sex is apparently without influ- 
 
 / 
 
 / 
 
 Fig. 37. — Herpes zoster arsenicalis — lichen planus. Patient had a lichen planus, shown on the 
 flexor surface of the wrist, for which he had been taking Fowler's solution. 
 
 ence upon its incidence. It is much more common in the spring and 
 fall than in other seasons of the year. Certain poisonous substances, 
 such as carbon dioxide or carbon monoxide (coal gas), have been 
 known to cause it, and, as was pointed out by the late Sir Jonathan 
 Hutchinson, it may follow the administration of arsenic (Fig. 37). 
 
INFLAMMATIONS 163 
 
 It occasionally occurs in connection with certain infectious diseases 
 of the nervous system, such as epidemic cerebrospinal meningitis, or 
 tubercular meningitis. Traumatism of various kinds may produce it; 
 cases have been observed to follow a blow, the extraction of a tooth, 
 or a hypodermatic injection. Quite recently a number of instances 
 have been observed in which it was associated with renal colic fol- 
 lowing hydronephrosis or nephrolithiasis (Bittorf, Rosenberg). 
 
 Although the infecting agent has not yet been demonstrated, there 
 is little or no doubt that the idiopathic form of the malady — that is, 
 that form which is not secondary to traumatism or the result of the 
 ingestion of toxic substances, such as arsenic — is the result of an in- 
 fection. The self-limited course, the immunity conferred by an at- 
 tack, its occurrence in epidemics, are features which are best explained 
 by this theory. 
 
 Pathology. — Herpes zoster is essentially an interstitial inflamma- 
 tion of the posterior root ganglia of the spinal nerves, and less fre- 
 quently of the peripheral portion of the nerves. While in most in- 
 stances it is a descending neuritis, there is no doubt that in the cases 
 following traumatism the inflammation is seated in the peripheral 
 portion of the nerve. Head and Campbell found hemorrhage in the 
 posterior root ganglia, or inflammation and degenerative changes in 
 the peripheral branches connected with such ganglia. 
 
 The vesicle of herpes zoster is usually situated in the middle and 
 lower portion of the epidermis, but it may lie between the epidermis 
 and the corium, this being usually the case in the severer forms of the 
 affection, such as attack the regions supplied by the fifth pair of nerves ; 
 and this in part accounts for the scarring which is so frequent a sequel 
 of this variety of the disease. In the beginning there is a marked 
 intercellular oedema, the epithelial cells are widely separated, lose their 
 prickles, are often greatly increased in size, and become globular or 
 balloon-shaped, their protoplasm becoming homogeneous and staining 
 readily with acid dyes. These large, round and pear-shaped cells 
 contain a large, frequently double-walled, cavity in which are from 
 two or three to twenty or more large nuclei, so that they may resemble 
 certain forms of protozoa (Fig. 38), and they were regarded, espe- 
 cially by Pfeiffer, as parasitic bodies, but the studies of Unna, Gil- 
 christ, and the author have proved that they are nothing more than 
 epithelial cells which have undergone a peculiar form of degenera- 
 tion, the "ballooning colliquation" of Unna. A similar form of de- 
 generation is observed in some other vesicular affections, such as vari- 
 ola and varicella. In the papillae and upper part of the corium there 
 is a varying degree of leucocytic infiltration, with dilatation of the 
 vessels, and in hemorrhagic cases a varying number of red blood- 
 cells. In a considerable proportion of cases of the severer type the 
 papillae of the corium undergo necrosis, in consequence of which per- 
 manent scarring results. 
 
164 DISEASES OF THE SKIN 
 
 Diagnosis. — The clinical symptoms of herpes zoster are in most 
 cases so characteristic that it is readily distinguished from other vesicu- 
 lar eruptions. The grouped arrangement of the lesions, their situa- 
 tion over well-defined nerve areas, the absence of oozing, the frequent 
 presence of pain, either preceding or accompanying the appearance of 
 the eruption, serve to distinguish it from vesicular eczema, for which 
 it is sometimes mistaken. 
 
 The affection with which it is most apt to be confounded is simple 
 herpes, especially when there are but one or two groups of lesions. 
 But the neuralgic pain, the situation of the eruption, and a history 
 of repeated attacks in the simple form will serve to distinguish the 
 two affections from each other. Cases occur, however, in which it 
 gig is not easy to say whether we 
 
 have to do with an anomalous 
 zoster or a simple herpes. 
 » Prognosis. — In the great 
 
 ^ majority of cases recovery 
 
 takes place in the course of 
 two or three weeks without 
 
 £3 ■>" ' 1x11 1 
 
 £-> sequelae. In the hemorrhagic 
 
 and gangrenous forms of the 
 
 malady, however, recovery is 
 
 often greatly delayed, and 
 
 marked and permanent scar- 
 
 * ring may result. In ophthal- 
 
 mic zoster impairment of 
 
 * ^ t vision, destruction of the eye, 
 
 and, in rare instances, even 
 death from sepsis or menin- 
 
 Fig. 38.— Herpes zoster. "Ballooned" epithelial cells; : + - „,,,„ result Tn elderlv 
 the large one in the centre filled with nuclei resembling a gltlS, may result. in eiueriy 
 
 protozoan. anc [ Q \£ subjects persistent 
 
 neuralgia and annoying disturbances of sensation may follow and 
 continue for many months. 
 
 Treatment.— Since we possess no remedy, either external or inter- 
 nal, which influences the course of the affection, which is a self- 
 limited one, the treatment of mild cases in which there is but little 
 or no pain may be limited to the protection of the eruption by the 
 liberal application of a dusting powder, such as equal parts of talc and 
 oxide of zinc, or subcarbonate of bismuth, to which have been added fifteen 
 or twenty grains (1.0 or 1.30) of powdered camphor to the ounce (32.0). 
 After the application of such dusting powder the affected part should 
 be covered with two or three layers of gauze or a layer of cotton 
 wadding. In cases in which pain or itching and burning accompany 
 the eruption, alcohol, either alone or containing one or two per cent, 
 of resorcin, menthol, or boric acid, may be freely applied several times 
 a day, followed by a dusting powder such as has been mentioned. 
 Collodion, either alone or containing morphia, is advised by some 
 
INFLAMMATIONS 165 
 
 authors, but it is far less useful and agreeable than the alcoholic 
 lotion just mentioned. Ichthyol in water, twenty to thirty per cent., 
 may be applied tw r ice a day with a camel's-hair brush. This, when 
 dry, forms a thin brown varnish, protecting the eruption. Ointments 
 or other local applications which soften and favor the rupture of the 
 vesicles are to be avoided, unless the vesicles are already broken and 
 ulceration is present. 
 
 When pain is a prominent symptom the internal administration 
 of phenacetin, antipyrin, salicylate of soda, or salicin in appropriate 
 doses is indicated, but in many cases nothing short of morphia by 
 the mouth, or, better, hypodermatically, will afford any relief. Other 
 internal remedies have been advised, such as quinine and the phos- 
 phide of zinc, the latter in doses of 1 / 12 to 1 / G of a grain (0.005 to 0.015) 
 every four hours, but they are of more than doubtful efficacy. Mild gal- 
 vanic currents applied to the nerve branches over which the eruption 
 is situated are occasionally of service in relieving the pain after the 
 acute symptoms have somewhat subsided. 
 
 In the neuralgias and disturbances of sensation, which frequently 
 persist for months after an attack of zoster, the patient's general con- 
 dition should be carefully looked after. Iron, quinine, strychnia, and 
 small doses of some form of arsenic are all more or less useful. Cod- 
 liver oil is frequently of service. Everything should be done to im- 
 prove the patient's general nutrition by an abundance of nutritious, 
 easily digested, and assimilable food and moderate exercise in the open 
 air. The local use of galvinism is frequently followed by improve- 
 ment, and in a few instances the author has seen prompt amelioration 
 of the pain follow the use of the X-ray. 
 
 HYDROA VACCINIFORME 
 
 Synonyms. — Hydroa vacciniforme (Bazin) ; Hydroa aestivalis; Re- 
 curring Summer Eruption (Hutchinson). 
 
 Definition. — An inflammatory disease occurring for the most part 
 in children, distinguished by an eruption of vesicles frequently um- 
 bilicated, occurring in summer, followed by scarring. 
 
 Symptoms. — First described by Bazin as Hydroa vacciniforme, it 
 was again described by Hutchinson some years later as Recurring 
 Summer Eruption. The affection begins with the appearance of small 
 red spots, upon which isolated and discrete or grouped vesicles form, 
 situated upon the uncovered parts of the skin, particularly the face, 
 over the nose and cheeks, upon the ears, the upper part of the neck, 
 less numerously upon the hands and wrists, and exceptionally upon 
 the other portions of the body. In the course of a few days the smaller 
 vesicles dry up, while the larger ones crust over, a certain number of 
 them becoming distinctly umbilicated with dark-bluish or blackish 
 centres. At the end of ten days or two weeks the crusts fall, and 
 slightly depressed scars are left, which in the course of time may 
 
166 DISEASES OF THE SKIN 
 
 become so numerous as to produce marked disfigurement, especially 
 upon the ears, which may be largely transformed into cicatricial tissue. 
 An attack usually comes on after exposure to the sun, and may be 
 preceded by slight malaise, with loss of appetite ; it lasts from two or 
 three weeks to a month or two. The affection occurs for the most 
 part in the summer, but may occur in the early spring and late 
 autumn. 
 
 Etiology and Pathology. — The malady begins, as a rule, in the first, 
 second, or third year of life, but has been noted in a considerable pro- 
 portion of cases in later childhood. Exceptionally it has been seen 
 in adults, as late as twenty-six years of age (Boeck). It was formerly 
 supposed to attack males much more frequently than females, but 
 more extended observation has shown that its incidence in the two 
 sexes is practically the same. The eruption follows direct exposure 
 to the sun and wind, and, as already observed, occurs for the most 
 part in the summer season, although one of Crocker's cases was always 
 worse in cold weather. 
 
 In a considerable proportion of the reported cases haematoporphyrin- 
 uria was present (cases of McCall, Anderson, Linser, Moller, Rausch, 
 and Ehrmann) ; and this fact, together with the results of the experi- 
 mental studies of Hausmann, which demonstrated that hsematoporphy- 
 rin exercises a pronounced photosensitizing effect upon the skin, mak- 
 ing it abnormally sensitive to light, makes it seem extremely prob- 
 able that this substance plays an important, if not the chief, role in 
 the production of the eruption. 
 
 According to Bowen, the disease begins with an inflammation in 
 circumscribed areas of the epidermis and upper part of the corium, 
 which results in the formation of vesicles in the rete. In advanced 
 lesions there is necrosis of the epidermis and of the corium to a con- 
 siderable depth. The dark centre of these lesion is due to the pres- 
 ence of hemorrhagic foci in the necrotic areas. 
 
 Diagnosis. — The early appearance of the malady, in childhood, its 
 limitation to uncovered portions of the body, its occurrence chiefly 
 in the summer season, the vacciniform character of many of the lesions, 
 and the scarring which follows the eruption, are features sufficiently 
 characteristic to differentiate it from other vesicular eruptions. 
 
 Prognosis and Treatment. — The affection shows a tendency to di- 
 minish in severity as puberty is approached, and finally disappears 
 when maturity is reached. As already observed, considerable disfigure- 
 ment may result from scarring when the lesions are numerous. 
 
 As a prophylactic measure the patient should avoid as much as 
 possible exposure to the sun and wind. In the summer season a brown 
 veil and gloves should be worn when outdoors. 
 
 Irritant applications should be avoided. A saturated solution of 
 boric acid containing a small quantity of glycerin may be mopped on 
 several times a day, or calamine lotion applied in the early stages 
 of the eruption. When crusting has taken place a two per cent, oint- 
 
INFLAMMATIONS 167 
 
 ment of carbolic acid may be applied twice daily until the crusts have 
 fallen. 
 
 The affection which Hutchinson described under the name Sum- 
 mer Prurigo, Prurigo TEstivalis, is probably a variant of Hydroa Vac- 
 ciniformis. It is distinguished by an eruption of pale red papules 
 situated on the face and hands which is always much worse in the 
 summer season and disappears in large part or wholly in the winter. 
 Severe itching accompanies the eruption, which is followed at times 
 by scarring. Like hydroa, it tends to disappear in adult life, although 
 it may persist in rare cases, according to Hutchinson, throughout the 
 patient's lifetime. 
 
 Unna's hydroa puerorum is regarded by most authors as identical 
 with hydroa vacciniformis, but Haase and Hirschler maintain that 
 it is an independent affection, and do not accept Unna's view that 
 it is a mild form of dermatitis herpetiformis occurring in children. 
 
 POMPHOLYX 
 
 Synonyms. — Cheiropompholyx (Hutchinson) ; Dysidrosis (Tilbury 
 Fox). 
 
 Definition. — An acute inflammatory disease characterized by an 
 eruption of vesicles and blebs, chiefly on the palms, and, less frequently, 
 the soles. 
 
 Symptoms. — This affection was first described by Tilbury Fox, in 
 1873, under the name dysidrosis, and a little later by Jonathan Hutch- 
 inson as cheiropompholyx. It is distinguished by an eruption of deep- 
 seated vesicles situated upon the palms and sides of the fingers, which, 
 at first discrete and filled with a clear fluid, later becomes turbid. As 
 new vesicles appear, they occasionally form irregular groups and may 
 coalesce to form blebs from a half inch to an inch in diameter. It is, 
 as a rule, symmetrical, but it may be confined to one side, and while 
 often limited to the hands it may occasionally occur upon the soles 
 and toes, in which region it is usually less severe than upon the hands. 
 In a small proportion of cases, through secondary infection, the vesicles 
 are transformed into pustules and the blebs are filled with purulent 
 fluid ; in these cases there is decided redness and marked swelling of 
 the hands and considerable pain. The vesicles, unlike those of eczema, 
 do not readily rupture, and are quite firm to the touch. In the course 
 of ten days to two weeks the contents are absorbed and the elevated 
 epidermis exfoliates, leaving a dry, reddened surface, or, much less 
 frequently, instead of drying up, an eczematous condition follows, which 
 may prolong the affection for some weeks. With the development 
 of the eruption, and sometimes preceding it for a short time, itching 
 and burning of varying intensity appear, and less frequently pain 
 accompanies it. The disease varies much in intensity ; in the mildest 
 cases there many be only a few small vesicles scattered along the sides 
 of the fingers, with a few in the palms, while in the severest the palms 
 and occasionally the back of the hands, the soles, and the toes may 
 
168 DISEASES OF THE SKIN 
 
 be covered with numerous vesicles and variously sized blebs (Fig. 39). 
 In a large proportion of the cases there is a more or less well-marked 
 palmar and plantar hyperidrosis which may precede or accompany 
 the eruption. Recurrences are common, usually at intervals of some 
 months, but occasionally at shorter intervals. In a few instances an 
 eruption resembling miliaria, accompanied by itching, occurs upon 
 the extremities coincidentally with the eruption upon the hands (Til- 
 bury Fox). 
 
 Etiology and Pathology.— The malady is seen chiefly in adults and 
 is uncommon in childhood and old age. It is decidedly more frequent 
 in women than in men. As was pointed out by Tilbury Fox, and 
 since confirmed by later observers, its subjects are for the most part 
 
 Fig. 39. — Pompholyx. 
 
 below the normal standard of health, and are often neurasthenic. Its 
 incidence is decidedly influenced by season. It occurs for the most 
 part, although not exclusively, in summer. 
 
 As the name he gave it indicates, Fox thought it a disease of the 
 sweat-glands or their ducts, an opinion supported by Crocker. The 
 studies cf Robinson, Williams, and Santi, however, failed completely 
 to demonstrate any relationship to the sweat apparatus. Williams, in 
 a study of several hundred serial sections of vesicles, was unable to 
 find any connection with the ducts of the sweat-glands. More recently, 
 however, Nestorowsky, who has studied the histology anew, has an- 
 nounced his belief that it is a disease of the sweat-glands, and that 
 the vesicles are closely connected with their ducts. In the beginning 
 stage of the eruption he was unable to find any inflammatory phe- 
 
INFLAMMATIONS 169 
 
 nomena; these only appeared secondarily. Unna was able to demon- 
 strate in all the vesicles examined by Williams and Santi, who worked 
 in his laboratory, a bacillus about the length of the tubercle bacillus, 
 but somewhat broader, which he believes to be the active cause of 
 the disease, but this finding still lacks confirmation by other investi- 
 gators. From all of the foregoing it is very evident that the last 
 word has not yet been said upon the subject. 
 
 The vesicles are situated in the epidermis just beneath the horny 
 layer. According to Robinson, there is a perivascular cellular exudate 
 in the papillae and upper portion of the corium, with migration of leuco- 
 cytes into the rete. Unna finds no change in the papillae except a 
 mechanical flattening at the site of the blisters. 
 
 Diagnosis. — Pompholyx is to be differentiated chiefly from vesicular 
 eczema and dermatitis venenata, and occasionally from eczematoid 
 ringworm of the fingers and toes. It differs from eczema by the deep 
 seat, the unusual firmness of the vesicles, which, unlike those of eczema, 
 show no tendency to spontaneous rupture, and by the limitation of the 
 eruption in most cases to the palms and soles, often to the former alone. 
 
 Dermatitis venenata is seldom limited to the hands and is usually 
 much more acutely inflammatory than pompholyx. There is likewise 
 a history of exposure to contact with some vegetable or chemical irritant. 
 
 Eczematoid ringworm of the hands and toes is usually a chronic 
 affection, although there may be quite acute exacerbations. No organ- 
 ism is demonstrable in pompholyx, while in this variety of ringworm 
 the epidermophyton inguinale is found without much difficulty. 
 
 It must be said, however, that in mild cases the differentiation from 
 eczema is not always easy ; indeed, Kaposi always maintained that 
 pompholyx was nothing more than a vesicular eczema of the hands. 
 
 Prognosis and Treatment. — In the majority of cases the affection 
 runs a comparatively rapid course, terminating at the end of two or 
 three weeks, or even earlier, under appropriate treatment ; but, as 
 already observed, recurrences are common. 
 
 Since in most cases the patient's general condition is more or less 
 below the normal, general tonic treatment is indicated. Iron, quinine, 
 strychnia, arsenic, and cod-liver oil should be given according to the 
 special indications present in each case, and a nutritious diet adopted. 
 
 The local treatment is practically the same as for acute eczema. 
 In the early stages, especially when the eruption is profuse, the con- 
 tinuous application of a saturated solution of boric acid on lint or 
 gauze will usually afford much relief. The blebs should be evacuated 
 by puncture with a sterile needle, and after the acute symptoms have 
 subsided an ointment composed o( equal parts of lead plaster and 
 petrolatum containing 2 per cent, of salicylic acid should be ap- 
 plied twice a day, spread upon lint. If there is much pain and itching, 
 an ointment or paste containing two or three per cent, each of phenol 
 and camphor will usually allay these symptoms. 
 
170 DISEASES OF THE SKIN 
 
 DERMATITIS HERPETIFORMIS 
 
 Synonyms. — Hydroa herpetiformis (Tilbury Fox) ; Herpes circin- 
 atus bullosus (Wilson) ; Herpes gestationis (Milton) ; Pemphigus cir- 
 cinatus (Rayer) ; Hydroa bulleux (Bazin) ; Dermatite polymorphe 
 douleureuse (Brocq). 
 
 Definition. — Dermatitis herpetiformis is a chronic inflammation of 
 the skin characterized by a polymorphous eruption with a more or 
 
 * * 
 
 1 
 
 \ 
 
 FiG. 40. — Dermatitis herpetiformis. Erythematous and vesicular type. . 
 
 less marked tendency to grouping of the lesions, accompanied by severe 
 itching and burning. 
 
 To Duhring belongs the credit of first clearly recognizing that the 
 varieties of this multiform affection, which had been previously de- 
 scribed by Bazin, Tilbury Fox, and others, under a variety of names 
 as distinct diseases, were, in fact, only variants of one disease for which 
 he proposed the name dermatitis herpetiformis. 
 
 Symptoms. — The attack may begin abruptly or gradually, with or 
 without constitutional symptoms, such as chilliness, fever, and loss 
 of appetite. In severe cases with extensive eruption there is nearly 
 always some elevation of temperature for the first few hours or for 
 
INFLAMMATIONS 171 
 
 several days. In milder cases the disease usually begins with itching 
 and burning, which are soon followed by an eruption, the lesions of 
 which may be all of one type — that is, either erythema, vesicles, 
 pustules, or blebs, or a mixture of any two or of all of these. The 
 eruption usually occupies both sides of the body, and frequently ex- 
 hibits a certain degree of symmetry in its arrangement. 
 
 The erythematous type of the affection frequently presents a de- 
 cided resemblance to erythema multiforme, not only in the character 
 of lesions, but in their predilection for the regions affected by that malady. 
 
 It may begin much like an urticaria, with wheals of the usual type, 
 but it rarely persists in this form, but eventually assumes some one 
 of the other forms, such as the erythematous or vesicular. 
 
 The vesicular variety is the commonest and is characterized by an 
 eruption of vesicles which are small, often irregular in shape, elongate, 
 angular, or stellate, and are usually arranged in small irregular groups 
 containing three to six or more lesions (Fig. 40). Not uncommonly they 
 are arranged in distinct circles (Fig. 41), or are situated upon erythe- 
 matous patches, occupying the centre of the patch. Itching is usually severe 
 in this variety, and, in consequence, the eruption is often accompanied 
 by numerous excoriations made by the patient's nails in the effort to 
 obtain relief from this distressing symptom. As a result of long-con- 
 tinued excoriation of the skin, superficial scarring and pigmentation 
 are frequently present in long-standing cases. 
 
 The eruption may be a purely bullous one, the blisters showing 
 the same tendency to grouping as the other forms of the eruption, or 
 in exceptional cases they are annular in shape (Fig. 42). This bullous 
 variety frequently bears the closest resemblance to pemphigus. 
 
 Pustules are often present in association with other varieties of 
 lesions, or they may exist alone, either in small, irregular groups or 
 with a more or less marked tendency to circinate arrangement, as in 
 impetigo herpetiformis. 
 
 In exceptional cases the eruption begins as a purely papular one 
 and remains so until the end of the attack, but much more commonly 
 the papules are succeeded or accompanied by vesicles or pustules. 
 
 Whatever the type of the eruption, it is apt to exhibit more or 
 less marked multiformity, either during the attack or in subsequent 
 outbreaks. The attack which begins with erythematous and papular 
 lesions is pretty certain to show presently vesicles, pustules, or even 
 blebs, or a vesicular attack may be succeeded in time by one in which 
 the eruption is erythematous or bullous, and occasionally all the varie- 
 ties of eruption are present in one and the same attack. 
 
 While most authors state that the disease may attack the mucous 
 membranes, this is an infrequent event, much less common than in 
 pemphigus. 
 
 The extent of the eruption varies much. In a considerable propor- 
 tion of cases it consists of a few scattered patches, occupying only a 
 limited area ; on the other hand, it is frequently very abundant, occupy- 
 ing the trunk and extremities. 
 
172 
 
 DISEASES OF THE SKIN 
 
 Itching is, in most cases, a very prominent symptom, giving the 
 patient rest neither day nor night. 
 
 The malady is a markedly chronic one. It may last for months 
 and years, even many years, exhibiting great variations in its sever- 
 
 / 
 
 I 
 
 U.r 
 
 € 
 
 / 
 
 FlG. 41. — Dermatitis herpetiformis, annular patches of vesicles. 
 
 ity, with periods of exacerbation and remission, or even complete inter- 
 mission. Even in severe cases the patient's general health is fairly 
 well maintained. 
 
INFLAMMATIONS 
 
 173 
 
 L 
 
 I 
 
 
 \ 
 \ 
 
174 
 
 DISEASES OF THE SKIN 
 
 Etiology,- — The immediate cause of dermatitis herpetiformis is still 
 unknown. The theory that disturbance of the nervous system plays 
 an important, if not the chief, part in its causation is maintained by 
 many writers. It has been attributed to nervous shock, nervous strain, 
 to exposure to cold, to disease of the kidneys, and to sepsis. It is 
 somewhat more frequent in men than in women, is much less com- 
 mon in children than in adults, although it is seen at all periods of life. 
 
 A considerable amount of evidence has accumulated in recent years, 
 evidence in some cases little short of proof, that various toxic sub- 
 stances may produce all the symptoms of the affection. In a certain 
 small number of cases it has apparently followed the administration 
 
 FlG. 43. — Dermatitis herpetiformis (herpes gestationis), consisting of rings of vesicles. Eruption 
 appeared with each pregnancy and disappeared at its termination. 
 
 of drugs, such as iodide of potassium (Danlos), mercury (MacLeod), 
 and salicylate of soda (Tenneson), the eruption continuing for months 
 or years after the taking of the drug. One variety (herpes gestationis) 
 (Fig. 43) is intimately associated with pregnancy, a condition in which 
 toxaemias of every kind and degree are especially prone to occur. 
 
 There is incontrovertible evidence that sepsis may produce it. In 
 a case reported by Bogrow in which it was associated with uterine 
 carcinoma, the eruption began to improve with the employment of 
 vaginal douches and came to an abrupt end with the surgical removal 
 of the necrotic cancerous tissue. 
 
 Pathology and Pathological Anatomy.- — There is little doubt that 
 dermatitis herpetiformis is a toxaemia, although the nature of the toxic 
 substance is as yet unknown. It is more than likely that various sub- 
 
INFLAMMATIONS 175 
 
 stances of a toxic character may produce it, such substances arising 
 within the economy as the result of abnormal metabolism, or reaching 
 the circulation through absorption from the gastro-intestinal canal, or 
 from some septic focus. 
 
 The changes in the skin are those characteristic of inflammation. 
 The epidermis shows comparatively little alteration, and that usually 
 of a secondary kind. The chief changes occur in the upper portion 
 of the corium, where there is an abundant cellular exudation composed 
 of lymphocytes, polymorphonuclear cells, and a considerable number of 
 eosinophiles, situated for the most part in the papillae, which are al- 
 ways more or less oedematous. The vesicles in the vesicular form are 
 situated between the epidermis, which forms the roof, and the papillae 
 of the corium, and contain some fibrin and a number of polymorphonu- 
 clear leucocytes and eosinophiles. The blood likewise, in most cases, but 
 not in all, exhibits a more or less pronounced eosinophilia, a feature upon 
 which Leredde and some other French authors have laid great stress as 
 characteristic of the malady; more recent studies have shown that eosino- 
 philia is by no means confined to, or characteristic of, this affection, and it 
 may be entirely absent, as the author's own observations have shown. 
 
 Diagnosis. — The chief diagnostic features of dermatitis herpeti- 
 formis are: (a) the multiformity of the eruption; (b) the more or 
 less marked tendency, always present, to a grouped arrangement of 
 the eruptive lesions; (c) its extremely chronic course, with remissions 
 or intermissions; and (d) unusually severe itching. 
 
 The affections with which it is most likely to be confounded are 
 erythema multiforme, urticaria, and pemphigus. 
 
 The first runs an acute course of about ten days, is rarely accom- 
 panied by any considerable degree of itching, and shows no tendency 
 to a particular arrangement of the eruptive lesions. It must be borne 
 in mind, however, that occasionally the resemblance between the ery- 
 thematous type of dermatitis herpetiformis and erythema multiforme may 
 be so close that a differential diagnosis can only be safely and cer- 
 tainly made after observing the course of the attack. 
 
 In urticaria the lesions are uniformly wheals, while in dermatitis 
 herpetiformis other varieties of lesions are associated with the wheal 
 sooner or later. The former is usually of short duration, running a 
 brief course of a few days in most instances, while dermatitis herpeti- 
 formis is always a chronic malady, lasting many months or years. 
 
 The distinction between the bullous form of the malady and pem- 
 phigus is at times difficult, but the absence of multiformity in the 
 latter and of any special arrangement of the blebs will usually serve 
 to differentiate them. In dermatitis herpetiformis the mucous mem- 
 branes of the mouth are very rarely attacked ; in pemphigus blebs fre- 
 quently occur in this situation. In the former, itching is a pronounced 
 and often most distressing symptom ; in the latter it is uncommon. 
 
 Prognosis. — The prognosis as to relief of the symptoms is usually 
 favorable, but the permanent cure of the disease is generally attended 
 
176 DISEASES OF THE SKIN 
 
 with much difficulty, relapses occurring with distressing obstinacy 
 for months, and even years, despite the best-directed treatment. The 
 patient's general health, however, rarely suffers to any considerable 
 degree, although in severe cases in the aged and enfeebled a fatal ter- 
 mination may occur, but this is decidedly rare. 
 
 Treatment. — The constitutional treatment should be conducted on 
 general principles, every effort being made to improve the patient's 
 general health. The condition of the gastro-intestinal canal should re- 
 ceive careful attention ; the diet should be carefully regulated, only 
 easily digested and easily assimilated food being allowed. Tea, coffee, and 
 alcohol should be avoided, or taken in very limited quantities. All sources 
 of worry or nervous strain should be removed and avoided. 
 
 The one internal remedy of special value is arsenic given in con- 
 siderable doses ; small doses are of little or no use. When given in 
 appropriate quantities there is generally a steady diminution of the 
 eruption, with lessening of itching and a decided lengthening in the 
 intervals between the attacks. As in pemphigus, Crocker has found 
 salicin of almost equal value, sometimes succeeding when arsenic 
 fails. For the relief of the frequently intolerable itching, phenacetin, 
 acetanilid, or antipyrin may be given with good results, the last being 
 most effective when combined with ten- to fifteen-grain (0.65 to 1.0) 
 doses of sodium bicarbonate. 
 
 Among local remedies those which allay itching are especially indi- 
 cated. The alkaline lotion containing menthol, already referred to 
 (vid. Treatment of eczema), will often prove efficacious, particularly 
 if sprayed upon the skin. Carbolic acid, one or two drachms (4.0-8.0) 
 to the pint (500.0) of water, with the addition of twenty to thirty 
 minims of glycerin to each ounce (32.0), softly mopped on, will often 
 afford relief. Coal-tar as a lotion in the form of the liquor carbonis 
 detergens, in the strength of one part to three of liquor calcis, is fre- 
 quently a valuable remedy for the same symptom. Ichthyol, although 
 a somewhat disagreeable application on account of its color and odor, 
 is occasionally of service when employed as a lotion containing ten 
 to twenty per cent. Other lotions which may be tried with occasional 
 good effects are resorcin, five to ten grains (0.30 to 0.65) to the ounce 
 (32.0) of lime water; a saturated solution of boric acid in water con- 
 taining a small proportion of glycerin ; liquor picis alkalinus, one or two 
 drachms (4.0 or 8.0) to the pint (500.0) of water. In some cases much 
 relief follows a bran or gelatin bath taken before retiring. 
 
 Duhring recommended the application of sulphur ointment, espe- 
 cially in very chronic cases, thoroughly rubbing it in, but this is too 
 irritating a remedy to be generally used. Equal parts of cold cream 
 and lanolin containing 0.5 per cent, of menthol will sometimes be found 
 a very effective remedy for the itching. 
 
 In the bullous variety of the disease the local treatment is much 
 the same as in pemphigus. Blebs should be evacuated and a dusting 
 powder composed of equal parts of talcum powder and powdered 
 boric acid should be liberally applied two or three times a day. 
 
INFLAMMATIONS 177 
 
 IMPETIGO HERPETIFORMIS 
 
 Definition. — An inflammatory affection of the skin characterized by 
 a pustular eruption arranged in groups or patches, accompanied by 
 pronounced constitutional disturbance, terminating, with rare excep- 
 tions, fatally. 
 
 Symptoms. — This very rare disease, of which only a little more 
 than a score of cases have been reported since it was first described by 
 Hebra, in 1872, begins with the appearance of patches of pin-head 
 to split-pea-sized flat pustules situated upon the inner surface of the 
 thighs, in the groins, about the umbilicus, over the breasts, and in the 
 axillae. The pustules, seated upon an inflammatory base, within two 
 or three days dry into brownish crusts beneath which the skin may 
 speedily be covered with new epidermis or may remain red and oozing. 
 About the borders of the crusts new pustules continue to appear, and 
 annular patches are thus formed, which continue to enlarge and fre- 
 quently coalesce with neighboring ones until large areas, or even the 
 greater part of the cutaneous surface, are covered. 
 
 The eruption is attended by more or less elevation of temperature 
 of an intermittent character, a rise sometimes with chills preceding 
 and accompanying each new crop of pustules. The lingual, buccal and 
 pharyngeal mucous membranes are also at times affected. Small 
 superficial pustules, which speedily become shallow erosions by macer- 
 ation, appear upon the tongue, the cheeks, and in the pharynx. More 
 or less itching and burning accompany the eruption and are at times 
 a source of great discomfort. As the malady progresses the patient 
 becomes more and more enfeebled ; severe chills with high tempera- 
 ture, reaching io4°-io5°, occur at irregular intervals with vomiting 
 and a diarrhoea, stupor or coma supervenes, and death occurs after a 
 few or several months' duration. 
 
 Etiology and Pathology. — The great majority of the cases reported 
 have occurred in pregnant or parturient women ; a few have, however, 
 been observed in non-pregnant women (the author's case, with a few 
 others) and a few likewise in men (Kaposi, Dubreuilh, Whitehouse, 
 Chambers). The primary cause of the disease is unknown, but its 
 close and undoubted connection with pregnancy suggests very strongly 
 that it is a toxaemia. Scheuer, who would reject all cases not occurring 
 in pregnant women as not conforming strictly with the Hebra type, 
 has recently put forward the theory that it is due to a toxin formed in 
 the placenta, but this theory is as yet unsupported by reliable evidence. 
 
 The pustules have, for the most part, been found sterile, although 
 staphylococci were present in a few instances. Du Mesnil found a 
 well-circumscribed exudate of leucocytes in the papillae immediately 
 beneath the pustule so dense as to completely obscure the line of 
 demarcation between the papillary body and the epidermis. The ves- 
 sels of the papillae were also dilated. The small pustules were quite 
 superficially situated in the epidermis, their roof being formed by the 
 horny layer alone ; the larger lesions were deeper seated. These find- 
 12 
 
178 DISEASES OF THE SKIN 
 
 ings have been confirmed by Dubreuilh and others who have studied 
 the histopathology of the affection. 
 
 Diagnosis. — The disease with which it is most likely to be con- 
 founded is dermatitis herpetiformis, which it may resemble more or less 
 in a number of its features, but it is usually readily differentiated from 
 that affection by the uniformly pustular character of the eruption, the 
 presence of more or less pronounced constitutional disturbance, and 
 its occurrence almost exclusively in pregnant or parturient women. 
 
 Prognosis and Treatment. — The prognosis is most unfavorable, but 
 two recoveries being recorded. The duration varies from one or two 
 to several months and if the patient survives the first attack she almost 
 invariably succumbs to a second or third. 
 
 The treatment is to be conducted on general principles. Internally, 
 quinine in considerable doses, stimulants and an abundance of easily 
 assimilable nourishment are indicated. The eruption should be kept 
 well covered with a dusting powder of talc and boric acid applied often 
 enough and abundantly enough to keep the parts dry. In a few 
 instances the continuous water-bath has been useful. 
 
 PEMPHIGUS 
 
 Synonyms. — Fr., Pemphigus; Ger., Blasenausschlag. 
 
 Definition. — An acute or chronic inflammatory disease of the skin 
 characterized by an eruption of blebs or blisters appearing in succes- 
 sive crops, frequently, but not invariably, accompanied by constitu- 
 tional symptoms of varying intensity. 
 
 There has been, and is yet, considerable divergence of opinion 
 among authors, especially in recent years, as to just what should be 
 included under the term pemphigus. The older authors included a 
 much greater variety of bullous diseases under this term than the 
 recent ones. With the general acceptance of the disease described by 
 Duhring under the name dermatitis herpetiformis as a distinct clinical 
 entity, it seemed for a time as if the term was about to disappear from 
 dermatological nomenclature, especially among the French. The bul- 
 lous affections formerly described as pemphigus were largely regarded 
 as varieties of dermatitis herpetiformis. In consequence of the vigor- 
 ous discussion carried on during the past quarter of a century, the 
 application of the name has been greatly restricted. 
 
 It is not to be supposed that every disease presenting bullae is of 
 necessity pemphigus. Such lesions occur with great frequency in 
 various inflammations of the skin, such as dermatitis venenata, ery- 
 sipelas, and certain cases of erythema multiforme, but these lack the 
 uniformity of lesion, the chronicity of course, and the frequently grave 
 constitutional symptoms which distinguish true pemphigus. 
 
 As our knowledge of the etiology and pathology of the bullous affec- 
 tions of the skin becomes more extensive and exact, there will doubtless 
 be a still further limitation of the term. There still exists a certain 
 
INFLAMMATIONS 179 
 
 group of eruptions, of which the most striking feature is the formation 
 of bullae, in which the symptoms and course are of so uniform a charac- 
 ter as to justify the retention of this term for them. 
 
 Several varieties of pemphigus are recognized, which, while present- 
 ing certain features in common, yet differ to a greater or less degree in 
 their symptoms, course, and mode of termination. Whether these 
 several varieties simply represent variants of one and the same affec- 
 tion, or are in reality distinct diseases due to different causes, is yet a 
 moot question. 
 
 The commonly recognized varieties are acute pemphigus (pem- 
 phigus acutus) ; chronic pemphigus (pemphigus chronicus) ; pemphigus 
 foliaceus ; pemphigus vegetans ; and pemphigus neonatorum, also 
 known as pemphigus contagiosus, pemphigus epidemicus. The last 
 named is quite certainly not a true pemphigus, but a form of impetigo 
 contagiosa (q. v.) of unusual virulence, or occurring in an unusually 
 susceptible skin, such as that of the newborn infant. 
 
 ACUTE PEMPHIGUS 
 
 Symptoms. — Acute pemphigus, a rare form, usually begins with more 
 or less constitutional disturbance, such as chilliness, headache, malaise, and 
 elevation of temperature, the last sometimes considerable, which is 
 followed within a variable period, usually from a few hours to a day, 
 by an eruption of blebs varying in size from that of a pea to a large 
 nut containing clear, turbid, or bloody serum. Usually the lesions arise 
 from seemingly normal skin, are hemispherical in shape and tensely 
 filled with fluid. Less frequently they are seated upon a more or less 
 hyperaemic skin and are surrounded by a narrow inflammatory halo. 
 The number of blebs present at any one time varies considerably. 
 There may be but eight or ten or even less, or there may be scores. 
 They usually appear in successive crops, although there may be but a 
 single outbreak. In severe cases with many lesions they are apt to 
 become confluent, and large denuded areas result from the breaking 
 of the walls of the blebs in which a secondary infection speedily occurs. 
 These areas discharge an abundant sero-purulent, frequently mal- 
 odorous fluid, which dries into thick blackish or brownish crusts. 
 
 The mucous membranes of the lips, tongue, cheeks, pharynx and 
 larynx are frequently the seat of a similar eruption. In this situation 
 the blebs rupture early and leave superficial excoriated areas which 
 are sensitive, making the taking of food and drink painful. 
 
 The duration of acute pemphigus varies from ten days to several 
 weeks, depending largely upon the severity and extent of the eruption 
 in the individual case. 
 
 In mild cases constitutional symptoms may be entirely absent, or, 
 if present in the beginning of the attack, usually disappear after the full 
 development of the eruption. In severe attacks with many lesions, 
 there is commonly considerable elevation of temperature, and in the 
 cases which go on to a fatal termination there are great prostration, 
 
180 DISEASES OF THE SKIN 
 
 delirium, diarrhoea, and other evidences of profound toxaemia preceding 
 death. 
 
 Etiology. — As a considerable number of the cases reported occurred 
 in those who had suffered from a wound, or who were especially 
 exposed to infection, such as butchers, it seems more than likely that 
 the malady is due to an infection of some sort. Bulloch found a diplo- 
 coccus in the blebs of a case reported by Pernet, and a similar organism 
 was found by Demme. In a series of sixteen cases collected by Pernet 
 one-half occurred in butchers, and in four of them there was a history 
 of a wound preceding the disease. 
 
 CHRONIC PEMPHIGUS 
 
 Synonym. — Pemphigus vulgaris. 
 
 Symptoms. — Chronic pemphigus (Plate XII), like the acute form, 
 is characterized by an eruption of variously sized blisters filled with 
 clear, straw-colored or turbid serum. These are globular or hemi- 
 spherical in shape, usually tensely distended and rise abruptly from 
 apparently normal skin (Fig. 44). 
 
 The eruption usually shows no special predilection for any particu- 
 lar region, but occasionally it is distributed symmetrically in the region 
 of the axillae (Fig. 45), on the arms, and in the groins, this distribution 
 being observed in the pemphigus of young subjects much more fre- 
 quently than in adults. The blebs are usually scattered about irregu- 
 larly, but exceptionally they may exhibit a marked circinate 
 arrangement (pemphigus circinatus). The number of blebs present 
 at any time varies from few to many, in many cases there are never 
 more than eight or ten, and there may be so few as one or two; in 
 severe attacks, on the other hand, they may number hundreds. When 
 they are recent, their contents are usually quite clear, but after a day 
 or two they become cloudy, then purulent, when they are surrounded 
 by a narrow inflammatory halo. The eruptive outbreak is usually 
 preceded or accompanied by more or less pronounced constitutional 
 symptoms, such as chilliness, headache and fever. New lesions may 
 appear daily throughout the entire course of the disease (pemphigus 
 diutinus), or there may be exacerbations and remissions, the former 
 lasting from ten days to two or three weeks, the eruption appearing 
 in successive crops, each crop after a time growing less abundant and 
 less well formed, as if the causative agent underwent a progressive 
 diminution in force, until toward the end of the exacerbation there 
 may be nothing more than erythematous patches on which are a few 
 ill-developed small blebs. In a certain, perhaps the larger, proportion 
 of cases, remissions or intermissions occur during which there may be 
 few or no eruptive lesions and the patient is apparently quite well, 
 but sooner or later a new eruption appears in the regions previously 
 affected or in new regions, preceded or accompanied by chills and 
 fever and other constitutional symptoms which pursue a course similar 
 
PLATE XII 
 
 Chronic pemphigus. 
 
INFLAMMATIONS 181 
 
 to that already described. In this manner the malady may last for 
 months or years, the patient's nutrition being gradually lowered with 
 a corresponding loss of strength until death eventually occurs with 
 symptoms of profound toxaemia, or from some intercurrent affection. 
 When the eruption is extensive, particularly when numerous blebs 
 occur upon the back, and inner surface of the thighs, pressure, or fric- 
 tion of the opposed surfaces, quickly ruptures their walls, leaving exten- 
 sive denuded areas from which there is an abundant, frequently fetid 
 discharge which dries into thick crusts. 
 
 ■■■>, 
 
 I 
 
 !%,... 
 
 Fig. 44. — Chronic pemphigus. 
 
 The buccal, lingual, pharyngeal and laryngeal mucous membranes 
 are frequently attacked, producing in the last-named situation hoarse- 
 ness or complete aphonia. The intestinal mucosa is likewise attacked, 
 as is occasionally evidenced by diarrhoea with bloody stools in which 
 there are shreds of mucous membrane. The conjunctiva may be the 
 seat of small blebs, followed in time by inflammatory adhesions be- 
 tween the ocular and palpebral mucous membranes. 
 
 The subjective symptoms are rarely very marked. At times there 
 is a feeling of soreness and burning with moderate itching; in excep- 
 tional cases the itching is most severe (pemphigus pruriginosus). 
 
182 
 
 DISEASES OF THE SKIN 
 PEMPHIGUS FOLIACEUS 
 
 In this rare form of the malady the amount of fluid exudation is 
 insufficient to form well-distended bullae, but instead there are flat, 
 flaccid blebs which rup-ture and leave a raw exuding surface, or dry up 
 into thin crusts. At times the amount of fluid present is scarcely suffi- 
 
 ■1 
 
 Fig. 45. — Pemphigus vulgaris. 
 
 cent to elevate the epiderms which then exfoliates in large flakes and 
 scales. The eruption slowly spreads until it eventually covers the 
 entire cutaneous surface. The scalp is often attacked as well as the 
 smooth surfaces and the hair is lost in consequence, and the nails are 
 occasionally shed. The palms and soles, as well as the regions about 
 
INFLAMMATIONS 183 
 
 the joints, after a time frequently exhibit more or less Assuring. As in 
 other forms of pemphigus the mucous membranes of the cheeks and 
 tongue are likewise involved at times, and the conjunctivae become 
 inflamed with the subsequent production of a more or less marked 
 ectropion. When the disease has reached extensive proportions, and 
 occasionally in its earlier stages, there is usually elevation of tem- 
 perature, with progressive loss of strength. 
 
 The duration of the affection varies from a few months to some 
 years with remissions and exacerbations. While recovery may take 
 place, a fatal termination occurs in the majority of cases, either as the 
 result of exhaustion or from some intercurrent affection, such as 
 pneumonia. 
 
 The peculiar features which characterize this variety of pemphigus 
 may be present from the beginning, or they may follow a dermatitis, 
 such as dermatitis herpetiformis or form the terminal stage of severe 
 chronic pemphigus of the ordinary type. 
 
 PEMPHIGUS VEGETANS 
 
 In 1886 Neumann first described a rare form of pemphigus under 
 the name of pemphigus vegetans, although examples of the disease had 
 been observed earlier by Kaposi, who believed it to be a vegetating 
 syphiloderm (see Plate 64 of his Atlas). 
 
 The affection usually begins upon the mucous membranes of the 
 lips, cheeks, tongue or pharynx with whitish patches and blebs which 
 are speedily broken, leaving painful excoriated areas. After some 
 weeks, or it may be months, well-defined blebs occur upon the skin, 
 usually upon the hands, feet, anterior border of the axillae, in the 
 groins and, in women, about the vulva, extending backwards over the 
 perineum to the anal region. In its later stages the eruption becomes 
 more or less generalized. 
 
 With the rupture of the blebs, a raw, oozing surface is left which 
 frequently shows but little tendency to heal and about the border of 
 which new blebs frequently appear. In the axillae and groins red or 
 grayish papillomatous elevations appear on the oozing bases of rup- 
 tured blebs resembling flat condylomata from which an exceedingly 
 offensive odor is given off. About the corners of the mouth fissures 
 covered with a grayish exudate form and the mucous membrane of the 
 lips is often raw, crusted and bleeding (Fig. 46). There is usually 
 more or less constitutional disturbance, appearing during the course of 
 the affection or present from the beginning. As the disease advances, 
 the patient becomes increasingly enfeebled and frequently falls into 
 a comatose condition from which he is roused with difficulty. This 
 progressive enfeeblement appears even in those cases in which the 
 eruption is of moderate extent, and in the course of a few months death 
 occurs in the great majority of cases, if not invariably. Herxheimer 
 has called attention to muscular tremor as a frequent symptom in exten- 
 
184 
 
 DISEASES OF THE SKIN 
 
 sive cases. In a case under the author's ODservation a few years ago 
 in the wards of the Philadelphia General Hospital, frequent slight con- 
 vulsive movement of the upper extremities often accompanied by a 
 shrill cry, continued at intervals throughout the course of the disease. 
 There was likewise a painful spastic contraction of the adductors of the 
 thigh, with marked increase of the superficial and deep reflexes, symp- 
 toms to which Neumann has called attention. 
 
 Etiology. — Nothing certain is known about the direct cause of 
 pemphigus, but there is increasing evidence that it is a toxaemia. In 
 the acute form of the affection the evidence in favor of its infectious 
 character is little short of demonstration. The cases of Pernet, Bul- 
 
 FlG. 46. — Pemphigus vegetans, negress. In addition to the vegetations shown in the axillae, there 
 were also large and numerous vegetations in the groins and between the buttocks, all of which had been 
 preceded by blebs. The crusts about the mouth and on the arms and the white scars over the chest were 
 also preceded by blebs. 
 
 lock, Bowen, and others, scarcely admit of any other explanation. In 
 the chronic forms of the malady the bacillus pyocaneus has besn found 
 by a number of investigators, but whether this was only accidentally 
 present or bore some etiological relationship to the affection, has not 
 yet been determined. Bruck found that while the contents of the blebs 
 in two pemphigus patients were sterile they contained a streptococcic 
 toxin (" streptolysin "), which, when inoculated into the skin of pem- 
 phigus patients during an intermission, produced blebs at the site of 
 inoculation, although without effect in those free from the disease. 
 These experiments seem to point decidedly to the presence of a toxaemia 
 of bacterial origin. 
 
 The view that it is in some way dependent upon functional dis- 
 
INFLAMMATIONS 185 
 
 turbance of the central or peripheral nervous system has for a long time 
 occupied a prominent place among the theories of its etiology, but the 
 evidence for this still lacks much. The supporters of this theory 
 depend largely upon the instances in which the disease has followed 
 closely upon nervous shock or other disturbance of nervous func- 
 tion. Even those who regard it as due to a toxaemia are inclined 
 to the belief that the toxin or toxins, whatever they may be, are the 
 result of disturbed metabolism resulting from faulty innervation. 
 Various degenerative changes have been found in the spinal cord and 
 peripheral nerves, but none of these were of such a character as to 
 indicate a causal connection with the affection. Kaposi, who had the 
 opportunity to examine nine cases of pemphigus in which a fatal ter- 
 mination occurred, failed to find any evidence of disease in the spinal 
 cord in eight. While it is quite well established that disease and injury 
 of the central and peripheral nervous systems may be followed by the 
 formation of bullae in the skin, this is far from conclusive proof that the 
 lesions of pemphigus have any such origin. 
 
 Pathology. — The bleb may be formed in the upper portion of the 
 rete, its roof consisting of the horny layer of the epidermis, but more 
 frequently it is situated in the deeper portions of the epidermis and, 
 occasionally the entire epidermal layer is stripped from the papillary 
 layer of the corium (Fig. 47) the floor of the bleb consisting of the 
 naked papillae and its roof of the entire thickness of the epidermis. 
 In all the cases which I have had the opportunity of studying histologi- 
 cally, the bleb was situated between the epidermis and the papillary 
 layer of the corium. The blebs usually contain a limited number of 
 leucocytes entangled in a scanty fibrinous meshwork, a considerable 
 percentage of which are eosinophiles. The papillae of the pars papil- 
 laris are markedly oedematous, and filled with leucocytes, for the most 
 part surrounding the vessels, numbers of which are eosinophiles. 
 
 In pemphigus vegetans the blebs present much the same features 
 as in ordinary pemphigus. In a case which the author had the oppor- 
 tunity of studying a few years ago the leucocytes found in the blebs 
 were chiefly of the eosinophilous variety. The papillae of the corium 
 were usually greatly increased in size, especially in the longitudinal 
 direction, projecting into the cavity of the bullae like fingers (Fig. 48). 
 In the vegetative condyloma-like plaques there was a marked acan- 
 thosis with a great increase in the size of the interpapillary prolon- 
 gations of the rete (Fig. 49). 
 
 As in many other bullous affections, there is frequently, but not 
 invariably, a more or less marked increase of eosinophilous cells in 
 the blood. 
 
 Diagnosis. — The diagnosis in well-developed pemphigus is usually 
 made without difficulty. The unfiormly bullous character of the erup- 
 tion, accompanied in many cases by more or less marked constitutional 
 symptoms, and the frequent invasion of the mucous membrane of the 
 mouth, are symptoms which are quite characteristic of the disease. 
 
186 
 
 DISEASES OF THE SKIN 
 
 The affections with which it is most likely to be confounded are the 
 bullous form of erythema multiforme, dermatitis herpetiformis, impe- 
 tigo contagiosa in infants, epidermolysis bullosa, the bullous syhpilo- 
 derm, certain drug eruptions, such, for example, as occasionally follow 
 the ingestion of antipyrin and iodide of potassium, and lastly certain 
 pemphigoid eruptions which sometimes follow septic wounds or 
 vaccination. 
 
 Erythema multiforme usually runs a rapid course as compared 
 
 Fig. 47. — Bleb of pemphigus. 
 
 with acute pemphigus, the only variety for which it might be mistaken, 
 and shows a decided predilection for the extensor surfaces of the fore- 
 arms and backs of the hands. Moreover, the eruption is rarely a 
 uniformly bullous one, but also exhibits erythematous and vesicular 
 lesions. 
 
 Dermatitis herpetiformis frequently presents bullae, but these are 
 often associated with erythema, vesicles and pustules, and the mucous 
 membranes are rarely involved. Itching, too, is usually a very prom- 
 inent symptom, while it is quite exceptional in pemphigus. 
 
 In very young infants impetigo contagiosa frequently presents 
 
INFLAMMATIONS 
 
 187 
 
 extensive blebs, but these exhibit a marked tendency to peripheral 
 extension and rapidly dry up into thin yellowish crusts. 
 
 The septic bullous affections are not always easily distinguished 
 from pemphigus, but the presence of a septic wound, even a slight one, 
 will usually lead to a correct diagnosis, although it must be admitted 
 that in some cases the eruption is indistinguishable from ordinary pem- 
 phigus. Indeed, it is by no means certain that they should not be 
 regarded as a variety of that malady. 
 
 *>rjj:\$j£s&&* 
 
 mmM 
 
 PlG. 48. — Bleb of pemphigus vegetans. The cells in the bleb are largely eosinophiles. Note the greatly 
 
 elongated papilla at P. 
 
 In epidermolysis bullosa the eruptive lesions are situated most 
 commonly upon the hands and feet, or in regions especially subjected to 
 pressure, or exposed to mechanical injury. Moreover, a history of 
 heredity is usually to be obtained and it is usually congenital. 
 
 The bullous syphiloderm, which is seen only in infants, as a rule, 
 may resemble pemphigus, but the bullae are situated almost invariably 
 ■on the palmar and plantar surfaces, regions seldom attacked by pem- 
 phigus, and other symptoms of syphilis are usually present. 
 
 The bullous drug eruptions are distinguished by their sudden 
 appearance after the ingestion of drugs, such as potassium iodide, anti- 
 pyrin, etc. 
 
188 
 
 DISEASES OF THE SKIN 
 
 Pemphigus vegetans may be mistaken for a vegetating syphiloderm. 
 Indeed, the earliest cases were thought to be syphilis, owing to the 
 resemblance of the vegetative lesions in the groin to condylomata, but, 
 the presence of blebs preceding the vegetative lesions, the fever which 
 usually accompanies the disease, the absence of glandular enlargement 
 and, lastly, a negative Wassermann reaction, will serve to establish the 
 differential diagnosis. In its early stages, however, when the symp- 
 toms are confined to the mouth, the diagnosis may be a matter of 
 considerable difficulty. 
 
 Treatment. — The treatment of pemphigus should be both internal 
 
 Fig. 49. — Pemphigus vegetans. Section of a vegetation from groin. Marked acanthosis, with a mod- 
 erate cellular exudate in upper portion of corium. 
 
 and external. In the acute form quinine in large doses is probably the 
 most useful internal remedy. In chronic pemphigus arsenic has long 
 enjoyed a reputation as a remedy of considerable value, and there 
 is little doubt that when given in full doses for some time it shortens 
 the attacks and lengthens the intervals between them, but it does not 
 cure. It may be given either in the form of Fowler's solution, begin- 
 ning with five drops three or four times a day and gradually increasing 
 the dose to the limit of tolerance ; or as the solution of the arseniate 
 of soda in the same doses. The cacodylate of soda may be given 
 hypodermatically in doses of a half grain (0.03) to a grain (0.065) once 
 
INFLAMMATIONS 189 
 
 a day, but after considerable trial the author has not found this as 
 effective as other forms of arsenic. Recently Grouven has reported 
 unusually good results from injections of salvarsan ; others, however, 
 have been less successful with it. Quinine is likewise a valuable 
 remedy in chronic cases and should be given in considerable doses, five 
 grains (0.26 or 0.32) four or five times a day. It has seemed to me that 
 the salicylate is more effective than the commonly employed sulphate. 
 Crocker found salicin succeed sometimes when arsenic failed, putting 
 a stop to the appearance of blebs completely in a considerable propor- 
 tion of cases. It may be given in doses of fifteen grains (1.0) three 
 or four times a day. Strychnia, iron and codliver oil are at times of 
 use, the first being especially valuable when the patient's strength is 
 beginning to fail. As a matter of course, the patient should have 
 an abundance of easily assimilable nutritious food at regular intervals. 
 
 In those cases in which microorganisms are found in the contents 
 of the bullae an autogenous vaccine might be employed with some hope 
 of relief, but, as has already been pointed out, the blebs are usually 
 sterile. 
 
 The blebs should be evacuated by repeated punctures with a sterile 
 needle to prevent their rupture, and a saturated solution of boric acid 
 should be applied continuously on lint or gauze. Denuded areas should 
 be covered with some mildly stimulating ointment spread upon lint. 
 A two per cent, salicylic acid ointment, made up of equal parts of 
 lead plaster and cosmoline, answers very well for this purpose. In 
 extensive eruptions one of the best forms of local treatment consists 
 in the frequent application of large quantities of talcum powder or 
 oxide of zinc, to which has been added twenty to thirty per cent, of 
 powdered boric acid. Such a powder should be applied often enough 
 and in such quantities as to keep the skin thoroughly dry. Although 
 not so agreeable to the patient, this treatment is frequently more 
 effective than lotions or salves. In cases in which large areas are 
 covered by the eruption warm bran or starch baths often prove most 
 comforting, and in the severest cases the continuous water-bath may be 
 employed with much benefit. 
 
 Prognosis. — The prognosis is always serious. In acute cases with 
 extensive eruption, accompanied by marked constitutional symptoms, 
 a fatal issue is common. In chronic pemphigus of moderate severity 
 the disease may continue for years without affecting the patient's gen- 
 eral health to any considerable degree, but when the attacks are severe 
 and frequently repeated death eventually results as the consequence of 
 gradual enfeeblement, or from sepsis or some intercurrent affection, 
 such as pneumonia or nephritis. Pemphigus foliaceus and pemphigus 
 vegetans are almost invariably fatal, the latter even when the eruption 
 is of limited extent. 
 
 Pemphigus of children is usually a much less serious affair than that 
 of adults. 
 
190 DISEASES OF THE SKIN 
 
 EPIDERMOLYSIS BULLOSA HEREDITARIA 
 
 Synonyms. — Congenital pemphigus ; Dermatitis Bullosa Heredita- 
 ria; Acantholysis Bullosa. 
 
 Definition. — A very rare condition of the skin characterized by an 
 extraordinary tendency to the formation of blebs after friction or slight 
 traumatism. 
 
 Symptoms.- — Goldscheider is credited with the first description of 
 this affection, but Tilbury Fox, some years before, had reported two 
 cases of what was probably the same disease. Payne, Legg, Valen- 
 tin, Kobner, Bonaiuti, Herzfeld, Blumer, Elliot, Beaty, Engman and 
 Mook, together with a few others, have since reported cases. The 
 entire number is very limited. The malady is distinguished by the 
 occurrence of variously sized blebs, usually with clear, occasionally 
 with bloody, contents, situated upon the hands, frequently the palms, 
 the elbows and knees, and other parts especially exposed to slight 
 knocks or friction by the clothing, such as the neck, the waist, the 
 region of the garters, and the feet. Luithlen recognizes two types. In 
 the first the blebs disappear without any subsequent alteration of the 
 skin except a slight transient pigmentation ; in the second type the 
 bullae are occasionally hemorrhagic, and scarring, atrophy, perma- 
 nent pigmentation, milia in the scarred areas as in pemphigus, and 
 varying degrees of dystrophy of the nails, even to complete disap- 
 pearance, occur. In this form the blebs are apt to display a certain 
 symmetry in their distribution, and the mucous membranes of the 
 mouth and pharynx may present bullae after eating food which is of 
 firm consistence. The general health is in most cases unaffected even 
 after long duration of the disease. 
 
 Etiology and Pathology. — In the great majority of the cases ob- 
 served the hereditary character of the malady was most pronounced. 
 In Goldscheider's case the patient's father, grandmother, a maternal 
 aunt, a brother, and a sister were affected in the same manner. Blumer 
 has reported its occurrence in four generations, affecting eleven out 
 of twenty-four males and five out of twelve females. Similar examples 
 of its hereditary character have been reported by a number of other 
 authors. In a few cases it has appeared in adults (epidermolysis bullosa 
 acquisita) without any evidence of inheritance. Kablitz has recorded 
 an instance in which it appeared at the age of fifty-nine, and very re- 
 cently Wise and Lautman have reported one in which it began at 
 thirty-nine. 
 
 Elliot regards the disease as a dermatitis resulting from traumatism, 
 occurring in an individual with a special predisposition to excessive 
 response on the part of the blood-vessels to irritation. He found the 
 bullae situated in the lowest portion of the rete, their roofs formed by 
 the entire thickness of the epidermis. The vessels of the papillae were 
 greatly dilated, but there was no exudation of cells about them. In 
 the subpapillary portion of the corium there was dilatation of the ves- 
 sels, which were surrounded by a cellular infiltration. 
 
INFLAMMATIONS 191 
 
 Engman and Mook found that the elastic tissue was greatly di- 
 minished or absent in the skin, even in regions where the skin was 
 apparently sound, a finding which has since been confirmed by Kanoky 
 and Sutton. 
 
 Diagnosis. — The congenital character of the malady, and the ap- 
 pearance of the blebs after traumatism or friction, are features which 
 distinguish it from pemphigus, the only affection for which it is at 
 all likely to be mistaken. 
 
 Prognosis and Treatment. — The prognosis as to recovery is most 
 unfavorable, the malady usually continuing throughout the patient's 
 lifetime. 
 
 No treatment is known by which the abnormal vulnerability of the 
 skin may be lessened. Every means should be employed to protect 
 the skin against knocks and friction. The blebs should be evacuated 
 and exposed raw surfaces covered with a 2 per cent, ointment of 
 carbolic acid until healing has taken place. 
 
 IMPETIGO CONTAGIOSA 
 
 The term impetigo was employed by the early writers with vary- 
 ing significance, and applied to a variety of affections which resembled 
 very little, or not at all, the diseases to which it was applied later. 
 Willan was the first to use it to designate eruptions of a pustular 
 character, recognizing five varieties, among which were included cer- 
 tain forms of pustular eczema. As employed to-day, its use is very 
 much restricted, being limited to the impetigo contagiosa of Tilbury 
 Fox, to the pustular affection known as Bockhardt's impetigo, and to 
 Hebra's impetigo herpetiformis, which is in no way related to the 
 first two. The simple impetigo as described by Duhring was not 
 recognized by most authors, and the several varieties described by 
 Unna, such as impetigo vulgaris, impetigo circinata, impetigo strepto- 
 genes, impetigo multilocularis, are probably nothing more than clini- 
 cal variants of the impetigos of Tilbury Fox and Bockhardt. 
 
 Synonyms. — Porrigo contagiosa ; impetigo vulgaris ; impetigo strep- 
 togenes ; impetigo circinata ; impetigo figurata. 
 
 Definition. — An acute, contagious, inflammatory disease character- 
 ized by an eruption of vesicles, vesico-pustules, and occasionally blebs, 
 which usually show a marked tendency to peripheral extension, and 
 which dry into thin brown crusts. 
 
 Symptoms. — The eruption begins as small red points, at the site 
 of which pin-head-sized vesicles straightway appear, which enlarge 
 to form thin-walled, flat, flaccid, sometimes tense, hemispherical vesico- 
 pustules and blebs varying in size from that of a pea to a coin. In 
 the course of some days these dry up into rather thin, loosely adherent 
 brown crusts, which soon fall, leaving a red, slightly pigmented patch, 
 which completely disappears in a short time. The contents of the 
 lesions in the earliest stages are clear, but they soon become turbid 
 
192 
 
 DISEASES OF THE SKIN 
 
 and finally seropurulent or frankly purulent. They are usually dis- 
 crete, without any particular arrangement, but may occur in patches, 
 forming irregular crusted areas through the coalescence of a number 
 of adjacent lesions. Occasionally, as they spread at the border, they 
 dry up in the centre, forming rings, and two or more of these may 
 join to form gyrate or crescentic figures (impetigo circinata, impetigo 
 figurata). In exceptional cases blebs of considerable size may form 
 
 I 
 
 4 ' 
 
 Fig. so. — Impetigo contagiosa. 
 
 with flaccid or tense walls, which soon rupture, leaving moist red 
 areas denuded of the horny layer of the epidermis (impetigo bullosa). 
 The disease most commonly attacks the uncovered parts of the 
 skin, such as the face (Fig. 50) (its most frequent site), the ears, the 
 hands, the scalp. Much less frequently it occurs upon the trunk and 
 extremities. Upon the hands it is often seen about the root of the 
 nails as a rapidly spreading, flat vesico-pustule containing a small 
 quantity of turbid fluid, scarcely more than sufficient to lift the horny 
 
INFLAMMATIONS 193 
 
 layer of the epidermis from the rete beneath ; these lesions are popu- 
 larly known as "run-arounds." On the scalp it gives rise to thick 
 adherent crusts, matting the hair, beneath which there is a red moist 
 surface. In men the bearded region is often attacked, when it is 
 usually erroneously called "barber's itch" ; not very infrequently it 
 assumes in this region the ringed or crescentic arrangement already 
 referred to (Fig. 51). Quite exceptionally the mucous membranes 
 adjoining the skin, such as the border of the lips, the margin of the 
 nostrils, the conjunctiva, and the vulvo-vaginal junction are attacked. 
 
 Although many of the individual lesions tend to dry up and dis- 
 appear in from eight to ten days, new ones continue to appear, often 
 through auto-inoculation, so that the disease may be prolonged for 
 weeks, or even a month or two, unless cut short by treatment. 
 
 Tilbury Fox, in his de- 
 scription of the affection, |MH 
 noted the occasional occur- ^ljj£ 
 rence of slight fever in the 
 beginning, and Crocker has 
 made a similar observation, 
 but in the great majority of >\ 
 cases there are no constitu- I 
 tional symptoms. Itching 
 may be present, but is seldom I 
 a prominent symptom, and 
 is often absent altogether. 
 
 In very young infants, ^ 
 from a few days to two or 
 three weeks old, the disease 
 presents some features de- 
 serving of special notice. In 
 these it occurs much more 
 frequently on the trunk and 
 
 extremities than in older Sub- FlG - Si-— Impetigo contagiosa circinata. A somewhat 
 
 unusual form. 
 
 jects, and, owing to the great 
 
 delicacy of the skin, the lesions soon rupture, leaving bright-red, moist, 
 rapidly extending denuded areas, about the borders of which are 
 whitish or grayish shreds and tags of the undermined horny layer of 
 the epidermis. Occasionally extensive areas are thus denuded, and in 
 this event it may prove fatal. Its occurrence in the wards of a 
 maternity hospital is always a matter of considerable importance, since 
 it frequently assumes epidemic proportions, spreading rapidly to other 
 infants. Most authors are agreed that this form is identical with the 
 so-called pemphigus neonatorum, an opinion which the author's own 
 observations tend to confirm. 
 
 The tropical disease described by Manson as pemphigus contagiosus 
 is regarded by that author as a variety of impetigo contagiosa. In 
 children the symptoms are much the same as those seen in temperate 
 13 
 
 h 
 
194 
 
 DISEASES OF THE SKIN 
 
 climates, but in adults it is apt to be confined to the axillae and groins, 
 
 where it produces raw, oozing patches, occasioning much discomfort. 
 
 In Bockhardt's impetigo (impetigo staphylogenes) the eruption is 
 
 w 
 
 ' 
 
 Fig. 52. — Bockhardt's impetigo. 
 
 pustular from the beginning, there being no early vesicular stage, as 
 in impetigo contagiosa. The lesions are pin-head to pea-sized, flat 
 pustules (Fig. 52), usually discrete, which show much less tendency 
 to extend peripherally than those of impetigo contagiosa. The erup- 
 
INFLAMMATIONS 195 
 
 tion is situated in the scalp and on other hairy parts of the body, 
 and is always follicular, each pustule having a hair in its centre. In 
 the scalp it is frequently associated with pediculi ; indeed, its occurrence 
 in the occipital region in children is almost certain evidence of the 
 presence of these parasites. Not very infrequently the lesions of this 
 variety coexist with those of impetigo contagiosa. 
 
 Etiology and Pathology. — Impetigo contagiosa is, as its name indi- 
 cates, contagious, and the lesions are likewise auto-inoculable. It 
 occurs chiefly among children, especially among the poorer classes, 
 but is not at all uncommon among the well-to-do and in adults. It 
 occasionally assumes an epidemic form, especially in schools, where 
 it is transmitted by towels, by bathing-clothes, and by direct contact 
 such as occurs in athletic sports and games. It frequently begins in 
 a superficial abrasion or scratch, and such lesions are often inoculated 
 in those who already have the disease. It has been observed to follow 
 vaccination. 
 
 According to Sabouraud, it is a local infection due to a streptococcus 
 which he identifies with the streptococcus of Fehleisen. The staphylo- 
 cocci which are found in the lesions are a secondary invasion, which 
 soon overwhelms the primary infection. Lewandowsky found a strep- 
 tococcus in one hundred cases. According to the recent studies of 
 Dohi and Dohi, there are two varieties of contagious impetigo, one 
 due to a streptococcus, the other of staphylococcic origin. Although 
 there are still those who regard it as due to the ordinary staphylococci, 
 the weight of evidence is decidedly in favor of its streptococcic origin. 
 
 "While most authors are inclined to accept, on clinical grounds, the 
 identity of impetigo contagiosa and pemphigus neonatorum, the re- 
 sults of recent bacteriological studies are by no means conclusive as 
 to this. Lew^andowsky, in a small series of cases, found both strep- 
 tococci and staphylococci, the latter predominating. In a recent study 
 of seven cases observed in an epidemic of the affection, which they 
 call pemphigoid, Cole and Ruh found pure cultures of the staphylo- 
 coccus. They believe it should be sharply differentiated from impetigo 
 contagiosa. 
 
 Bockhardt's impetigo is due to the invasion of the follicles by 
 the staphylococcus aureus and albus, more frequently the former. It 
 is frequently associated with such itching diseases as pediculosis and 
 scabies, infection taking place through scratching. 
 
 The vesicles of impetigo contagiosa are situated between the horny 
 layer of the epidermis and the rete. They contain numerous polymor- 
 phonuclear leucocytes, some lymphocytes, a few loose epithelial cells, 
 and large numbers of streptococci and staphylococci. There is some 
 oedema of the rete, with consequent enlargement of its cells, and an 
 increase in the size of the intercellular spaces, in which there are 
 considerable numbers of migratory leucocytes. In the superficial por- 
 tions of the corium the vessels are somewhat dilated and there is a 
 moderate exudation of round cells. 
 
196 DISEASES OF THE SKIN 
 
 The impetigo of Bockhardt is essentially a pustular folliculitis. 
 The pustule, its roof formed by the horny layer of the epidermis, is 
 situated about the mouth of the follicle, and contains numerous poly- 
 morphonuclear leucocytes, epithelial debris, and large numbers of 
 staphylococci. In the rete immediately about the follicle there are 
 large numbers of migratory leucocytes, which separate the rete cells, 
 many of which lie detached in the cavity of the pustule. According 
 to Sabouraud, necrosis of the superficial portion of the corium imme- 
 diately beneath the pustule frequently occurs, producing a small scar. 
 
 Diagnosis. — Impetigo is to be distinguished from pustular eczema, 
 ecthyma, varicella, and from acute pemphigus. 
 
 The pustules of impetigo are usually discrete, and those of impetigo 
 contagiosa show a marked tendency to peripheral extension. Eczema 
 occurs in diffuse patches, which are often covered by thick crusts, 
 owing to abundant oozing. In eczema itching is commonly a marked 
 symptom, while in impetigo it is trifling or absent altogether. 
 
 Bockhardt's impetigo may be mistaken for ecthyma, but the pus- 
 tules of the latter are larger, deeper seated, and covered with thick 
 crusts beneath which there is ulceration. 
 
 In varicella the lesions are small, frequently very numerous, scat- 
 tered over the trunk as well as the face, and in a large proportion of 
 cases are found on the buccal and palatal mucous membrane, as well 
 as the skin. Constitutional symptoms usually accompany the onset 
 of the disease. Bullous impetigo may be mistaken in its early stages 
 for pemphigus, but the bullae of the latter are usually larger than 
 those of the former, arise from apparently sound skin, and show no 
 tendency to peripheral extension after they are fully developed. The 
 eventual course of the two affections is quite unlike. 
 
 Prognosis. — When left to itself, or if injudiciously treated, impetigo 
 may last for many weeks, but it yields readily to proper treatment. 
 
 Treatment. — The treatment is altogether local, and consists in the 
 application of mild antiseptic lotions and ointments after removal of 
 the crusts by soap and warm water, or by the liberal application for 
 a few hours of a 2 per cent, carbolated vaseline. One of the most ef- 
 fective remedies is an ointment of ammoniated mercury, ten to twenty 
 grains (0.65 to 1.30) to the ounce (32.0), using as a base cold cream 
 or oxide of zinc ointment. This should be applied twice a day with 
 gentle friction, care being taken to impress the patient or his at- 
 tendant with the necessity for applying it to every lesion, however 
 small. In adults, who may find it inconvenient to go about during 
 the day with an ointment on the face, a 1 15000 solution of mercuric 
 bichloride may be softly mopped on two or three times a day and the 
 ointment applied at night upon retiring. In new-born infants the 
 ointment should be somewhat weaker than in older patients, ten 
 grains (0.65) to the ounce (32.0) being a proper strength, and the 
 skin in the neighborhood of the eruption should be frequently bathed 
 with a saturated solution of boric acid. In maternity hospitals the 
 
INFLAMMATIONS 197 
 
 utmost care should be taken to prevent the spread of the disease. The 
 patient's clothing should be thoroughly sterilized and the dressings 
 burned. 
 
 DERMATITIS REPENS 
 
 Synonyms. — Acrodermatitis perstans ; acrodermatite suppurative 
 continue (Hallopeau). 
 
 Definition. — A spreading inflammation of the skin, situated upon 
 an extremity. 
 
 This affection was first described by Crocker, in 1888, and again 
 in 1892, who gave it the very appropriate name dermatitis repens, 
 which has been very generally accepted by authors. 
 
 Symptoms. — It usually begins as a few small vesicles or a flat 
 bleb, which shortly ruptures, disclosing a moist red surface, which 
 steadily extends and is surrounded by a narrow collar of undermined 
 epidermis. In some cases, as in one under the author's care some 
 years ago, the patch spreads by the constant formation of minute vesi- 
 cles and pustules about its margin, which soon rupture and discharge 
 a seropurulent fluid, which dries into a thin crust. As the disease 
 extends, the part of the skin first attacked becomes dry, smooth, and 
 glazed or desquamates. While in the great majority of cases the dis- 
 ease spreads by continuity, small groups of vesicles may appear in 
 the immediate neighborhood of the patch, which soon coalesce with 
 it and thus extend it. It usually continues to spread slowly until a 
 considerable area may be covered, such as an entire extremity, or, in 
 very exceptional cases, it may spread to the trunk. It usually con- 
 tinues for many weeks or several months, and may last for years (Fig. 53). 
 
 According to Crocker, instead of being moist, the disease may be 
 dry throughout its course, the patch spreading peripherally, sur- 
 rounded by a dry, undermined epidermic collar. 
 
 Under the title acrodermatitis perstans (acrodermatite suppurative 
 continue), Hallopeau has described an affection which presents many 
 of the features of dermatitis repens and is probably a variety of it. 
 It begins with a vesicular and pustular eruption, situated in the be- 
 ginning upon a finger, which slowly spreads until it may involve the 
 entire hand. Secondary eruptions of an erythematous or pustular 
 character may appear upon parts more or less remote from the original 
 focus, and may be more or less general in their distribution. The 
 disease is of long duration and repeated recurrences, usually in the 
 same situation, are common. 
 
 Etiology and Pathology. — In the great majority of the reported 
 cases the disease began at the site of an injury, sometimes of a trivial 
 character. The manner in which it spreads is very suggestive of an 
 infection which takes place at the site of the injury. Crocker believed 
 it to be a peripheral neuritis set up by an injury. Hallopeau was con- 
 vinced of its microbic origin, and thought it probably due to the 
 staphylococcus. 
 
198 
 
 DISEASES OF THE SKIN 
 
 Sutton, who has recently studied several cases of the malady, found 
 the yellow staphylococcus in the serum from the spreading margin 
 of the patch. He concludes from its clinical features and its histology 
 that Hallopeau's acrodermatitis perstans and dermatitis repens are 
 the same disease and that both are probably due to a particular strain 
 of the staphylococcus. 
 
 Diagnosis. — The affection for which it is most likely to be mis- 
 taken is eczema, but its usual limitation to an extremity, its well- 
 defined and steadily spreading borders, and the usual absence of any 
 pronounced subjective symptoms are features by which it may be 
 readily differentiated from that disease. 
 
 Prognosis and Treatment. — The malady is usually very rebellious 
 
 Fig. 53- — Dermatitis repens. 
 
 to treatment and may persist for months. Some of Hallopeau's cases 
 lasted for years. The only effective remedies are antiseptic washes 
 and ointments. Crocker found painting the patch with a ten per 
 cent, solution of permanganate of potash, after trimming away the 
 undermined epidermis, the most effective treatment. In a case under 
 the author's care, painting the borders of the patch, after trimming 
 away the loosened epidermis, with a solution of formalin in glycerin, 
 one drachm to the ounce (4.0 to 32.0), followed by Brooke's paste, 
 was followed by a cure after a number of other methods had been 
 tried. (Brooke's paste is Lassar's paste to which is added thirty 
 per cent, of the five per cent, oleate of mercury.) Sutton obtained ex- 
 cellent results from the use of a solution of salicylic and tannic acids 
 in alcohol, two per cent, of the former with ten per cent, of the latter. 
 
INFLAMMATIONS 
 
 199 
 
 DERMATITIS VEGETANS 
 
 The affection first described by Hallopeau under the title dermatite 
 ptistiileuse chronique en foyers a progression excentrique, but to which 
 he later gave the less cumbersome title pyodermite vegetante, resembles 
 in a number of its clinical features pemphigus vegetans, and this 
 author, who at first believed the malady a new and distinct type of dis- 
 ease, later came to regard it as a variety of that affection. 
 
 The cases observed by Hallopeau, Wickham, and the author were 
 characterized by successive crops of vesicles and vesico-pustules oc- 
 curring in patches, chiefly about the groins, on the inner surface of 
 the thighs, and, less frequently, in other regions, such as the hypo- 
 gastric and lumbar regions, the axillae, and in small numbers in the 
 
 Fig. 54. — Dermatitis vegetans. 
 
 mouth. The eruption was succeeded by markedly elevated plaques 
 with uneven, moist, and crusted surface about the borders of which 
 new pustules appeared. Marked itching and burning were prominent 
 symptoms. In the case which the author reported an inflammation 
 presenting all the features of chronic eczema was present upon the 
 lower extremities. More recently Wende, Pusey, and others have 
 reported cases presenting similar vegetative plaques following a der- 
 matitis in various regions. 
 
 The exact place of the affection represented by the cases of Hallo- 
 peau, Wickham, and the author is still undetermined, but its relation- 
 ship to pemphigus vegetans of Neumann is, it seems to the author, 
 doubtful. In some of its features it seems much more nearly related to 
 dermatitis herpetiformis. 
 
 The occurrence of vegetative plaques following a dermatitis is 
 
200 DISEASES OF THE SKIN 
 
 not to be taken as evidence of a relation of such cases to the pyoder- 
 mite of Hallopeau. The cases of Wende and Pusey, in the author's 
 opinion, represented a quite distinct affection. Such vegetative plaques 
 may follow, in exceptional cases, various inflammatory conditions of 
 the skin, such as eczema. In the case of a middle-aged woman under 
 the author's observation in the skin dispensary of the University 
 Hospital some years ago, large papillomatous plaques occurred upon 
 the backs of both hards, apparently as the sequel of an ordinary der- 
 matitis ; these disappeared in the course of a few weeks under the 
 simple application of a saturated solution of boric acid (Fig. 54). 
 
 The treatment consists in strict attention to cleanliness and the 
 frequent application of weak antiseptic lotions, such as a saturated 
 solution of boric acid, or a 1 15000 solution of bichloride of mercury. 
 
 DERMATITIS GANGRENOSA 
 
 Synonyms. — Sphaceloderma ; Gangrene of the skin. 
 
 Gangrene of the skin presents a considerable number of varieties 
 which differ more or less from one another in their cause and course. 
 It may be due to a number of causes, some of which are local and 
 external to the organism, others internal and general. Among the 
 former are direct violence, exposure to heat or cold, contact with 
 caustic substances, and invasion of the skin by microorganisms; 
 among the latter are such diseases of the blood-vessels as result in 
 narrowing or occlusion of their lumen, shutting off the blood supply to 
 the skin, such diseases of the central or peripheral nervous system as 
 interfere with trophic functions, general infections such as typhoid 
 fever, and the exanthemata and diseases like chronic nephritis and 
 diabetes,, which lead to the formation and retention of injurious sub- 
 stance^-in the organism, which injuriously affect the skin and increase 
 its liability to invasion by microorganisms. 
 
 DERMATITIS GANGRENOSA INFANTUM 
 
 Synonyms. — Varicella gangrenosa; Infantile gangrenous ecthyma; 
 Pemphigus gangrenosus ; Multiple cachectic gangrene of the skin; Fr., 
 Ecthyma terebrant. 
 
 The name varicella gangrenosa was given to this affection by Sir 
 Jonathan Hutchinson, who first called attention to it, because of its 
 occasional association with varicella, but, as has been shown by 
 Crocker, Elliot and others, it may occur quite independently of that 
 disease. 
 
 Symptoms. — When it follows varicella the varicellous lesions, in- 
 stead of drying up and disappearing in the ordinary manner, become 
 covered with brown or blackish crusts surrounded by a bright-red 
 areola beneath which ulceration takes place. This ulceration continues 
 to extend peripherally and in depth, for a time producing grayish or 
 black eschars which, when cast off, leave round or oval sharp-cut ulcers 
 
INFLAMMATIONS 201 
 
 varying in size from that of a pea to a coin. As they enlarge in circum- 
 ference, adjacent lesions occasionally unite to form serpiginous ulcers 
 which are sometimes of considerable extent. 
 
 The gangrenous lesions are found for the most part in those regions 
 in which the varicellous eruption is most abundant, such as the head, 
 face and trunk. Occasionally it follows vaccinia and the eruption is 
 then found in the neighborhood of the vaccination, which, however, is 
 usually not attacked. When it occurs as an independent affection the 
 buttocks and the thighs, more especially the former, are the regions 
 usually affected where it begins as small papulo-pustules which are 
 soon covered with a crust and pursue the same course as the lesions 
 already described. The number and size of the lesions vary consider- 
 ably. Many of the cases are mild, with scanty eruption and superficial 
 ulceration (Crocker), or the lesions are bullous with purulent contents ; 
 in such cases, especially if the eruption is abundant, the constitutional 
 symptoms are most pronounced, often septic in character, and death 
 may follow. 
 
 Etiology.— The disease is essentially one of infancy and early 
 childhood, occurring most commonly in the first year, rarely later than 
 the third. Crocker found it much more frequent in female children 
 than in male children, but the experience of other observers does not 
 coincide with this observation. In a certain proportion of cases, as 
 has already been observed, it occurs as a sequel of varicella and occa- 
 sionally follows vaccination ; it may also follow other eruptive fevers, 
 such as measles. Many of the children are ill-nourished or exhibit 
 symptoms of syphilis or tuberculosis. A variety of microorganisms 
 have been found, such as staphylococci, streptococci, the bacillus pyo- 
 caneus (Ehlers, Hitschmann, Kreibich), and the bacillus ramosus 
 (Veillon and Halle) ; but as none of these are constantly present it is 
 not likely that they are the immediate cause of the malady. 
 
 Pathology. — Although a specific organism has not yet been found, 
 there is but little doubt that the disease is due to the invasion of the 
 skin by some microorganism, perhaps not always the same, which 
 finds ready entrance because of the preceding general infection. 
 
 Diagnosis. — The age of the patient, most commonly an infant ; the 
 association of the affection with varicella or measles ; the presence of 
 vesico-pustules or pustules which are soon transformed into punched- 
 out ulcers, are features so characteristic that the disease is usually 
 readily recognized. 
 
 Prognosis. — In the majority of cases recovery takes place, but when 
 the infant is ill-nourished or enfeebled by previous disease, and more 
 especially when the lesions are numerous and large, with symptoms 
 of sepsis, the prognosis is grave. 
 
 Treatment. — In severe cases every effort should be made to support 
 the patient's strength ; suitable nourishment should be given at short 
 intervals and when necessary, stimulants. Locally the lesions should 
 be covered with some antiseptic dressing, such as a saturated solution 
 
202 
 
 DISEASES OF THE SKIN 
 
 of boric acid or very weak bichloride solution, i : 5000, until the sloughs 
 have come away, when the ulcers may be covered with some stimulat- 
 ing ointment, such as aristol, five to ten per cent., europhen in the 
 same strength, or these may be used as dry powders dusted lightly 
 over the surface. 
 
 DERMATITIS GANGRENOSA ADULTORUM 
 
 Under the above title are included a number of forms of gangrene 
 of the skin which differ more or less widely from one another in their 
 cause and clinical symptoms. The cases which have been reported 
 from time to time under a variety of names, such as acute multiple 
 gangrene of the skin, disseminated gangrene, gangrenous urticaria, 
 
 
 Fig. 55. — Infectious multiple gangrene — forearm. 
 
 hysterical gangrenous zoster, occurring for the most part in girls and 
 women who present the stigmata of hysteria, do not, in the author's 
 opinion, properly belong here, but will be considered under factitious 
 dermatitis. 
 
 Symptoms. — Multiple gangrene of the skin is for the most part a 
 disease of adults, although it may also occur in children. It may 
 begin as scattered vesicles or pustules, usually surrounded by a -well- 
 developed inflammatory halo, which rapidly enlarge and are soon 
 covered with a black crust, beneath which ulceration of varying extent 
 takes place. In a case under the author's observation some years ago 
 the disease was distinguished by small red papules and vesicles which, 
 
INFLAMMATIONS 
 
 203 
 
 as they increased in size, resembled closely a variolous pustule. They 
 vsoon were covered with a thick black crust beneath which an extensive 
 and rapidly spreading ulceration went on (Fig. 55). The gangrene 
 is sometimes preceded by erythematous patches or bullae which speedily 
 become gangrenous sloughs. 
 
 Etiology and Pathology. — This variety of gangrene may follow 
 such general infections as typhoid and scarlet fever, or it is at times 
 associated with a local infection situated at points more or less 
 remote from the skin, as in a case reported by Crocker, in which the 
 cutaneous disease followed a suppurative affection of the vagina. In 
 other cases it is the result of a direct local infective process, as in the 
 author's case referred to above, in which the gangrenous lesions fol- 
 lowed a local infection from a wound made with an old meat-hook, and 
 
 in which large numbers of an un- 
 $ -. ~ identified bacillus were present. 
 
 Rotter and Waelsch have also re- 
 ported cases in which pathogenic 
 bacilli were found in the lesions ; in 
 the case of the latter the infection 
 followed the use of an unclean 
 hypodermic needle (Fig. 56). 
 
 Prognosis. — The prognosis is 
 usually favorable except in the 
 cases in which numerous and exten- 
 sive areas of gangrene are formed. 
 
 Treatment. — The gangrenous 
 patches should be continuously cov- 
 ered with moist antiseptic dress- 
 ings frequently renewed until the 
 necrotic tissue separates. The resulting ulcers should be treated with 
 aristol, iodoform or europhen, either in ointment or dusting powders. 
 
 * - 
 
 Fig. 56. — Bacilli in multiple gangrene of skin. 
 Case snown in Hgure 55. 
 
 DIABETIC GANGRENE (DERMATITIS GANGRENOSA 
 DIABETICORUM) 
 
 Gangrene of the skin is an occasional complication of diabetes fol- 
 lowing directly or indirectly upon some injury, often trivial, or some 
 one of the many forms of inflammation of the skin which are common 
 in diabetic subjects. In exceptional cases it appears spontaneously 
 without any perceptible previous alteration of the skin. When it 
 results from an injury the skin becomes livid or black, its temperature 
 is lowered, vesicles and blebs often appear filled with a thin bloody fluid 
 and a slough soon forms, which is cast off after a time, leaving an 
 ulcerating surface. Instead of appearing at once the necrosis may 
 be preceded for a time by more or less marked inflammatory symptoms. 
 Occasionally it follows the inflammations which are so common about 
 the genitalia of both sexes, being especially apt to attack the prepuce. 
 In those cases in which it appears without any previous alteration of 
 
204 DISEASES OF THE SKIN 
 
 the skin, it occurs as variously sized patches, occasionally symmetri- 
 cally arranged, as in Raynaud's disease. As bullo-serpiginous diabetic 
 gangrene, Kaposi described a peculiar form characterized by the for- 
 mation of blebs spreading in a serpiginous manner beneath which 
 gangrene occurred. The gangrene may be preceded by neuralgic pains 
 which are followed by lividity of the skin, lowering of the temperature, 
 and gradual loss of sensation. It may be of the moist or dry variety, 
 but is most often the former, and is situated usually upon the lower 
 extremities, beginning upon the toes, but the upper extremities and the 
 trunk may also be attacked. There may be but a single lesion or there 
 may be a number situated on one or both sides of the body. 
 
 Etiology.— The presence of sugar in all the tissues of the body espe- 
 cially predisposes them to inflammation and greatly lowers their 
 powers of resistance to microbic invasion, so that slight injuries or in- 
 fections are apt to result in the death of the part affected. The spon- 
 taneous form of gangrene is the result of secondary changes in the 
 vessels or disease of the nervous system interfering with its trophic 
 functions. 
 
 Treatment. — The same general treatment should be employed in 
 diabetic gangrene as in diabetes, paying particular attention to the 
 patient's dietary ; supporting measures, tonics and stimulants should 
 also be employed. Locally the treatment is the same as for the other 
 forms of gangrene already described. 
 
 DERMATITIS GANGRENOSA SYMMETRICA 
 (RAYNAUD'S DISEASE) 
 
 Synonyms. — Raynaud's disease ; Local asphyxia ; Fr., Asphyxie 
 locale et gangrene symmetrique des extremites; Ger., Raynaud'sche 
 Krankheit (Plate XIII). 
 
 Definition. — A disease distinguished by paroxysmal attacks of local 
 syncope alternating with local asphyxia, situated upon the extremities, 
 terminating sooner or later in gangrene of the skin and subcutaneous 
 tissues. 
 
 Symptoms. — This infrequent affection, which was first recognized 
 and described as a clinical entity by Raynaud in 1862, usually presents 
 three quite distinct stages : first, local syncope ; second, local asphyxia, 
 and third, the final stage, gangrene ; the first and last of these stages 
 may be absent or ill-defined. It begins with the more or less com- 
 plete arrest of the circulation in one or several fingers of both hands 
 or of the toes of both feet ; quite commonly both fingers and toes are 
 affected. These quite suddenly become dead-white, cold to the touch, 
 and more or less devoid of tactile sensibility ; not infrequently there is 
 also moderate pain, usually of a burning character (stage of local 
 syncope). After a period varying from some minutes to some hours 
 the pallor disappears and is succeeded by a dusky redness which may 
 become slaty blue or almost black, and with this change in color there 
 
PLATE XIII 
 
 Raynaud's disease. 
 
INFLAMMATIONS 205 
 
 is usually severe burning and lancinating pain (stage of local asphyxia). 
 The asphyxia may disappear within a short time and the parts resume 
 their normal appearance, or it may terminate in gangrene of the skin 
 of either the moist or dry form usually preceded by the appearance of 
 vesicles and blebs filled with bloody fluid. The sequence and severity 
 of the symptoms vary a good deal. In the mildest cases local syncope 
 may be the only symptom, often affecting but a single linger, and dis- 
 appearing in the course of a short time ; to this form the name " dead 
 fingers " is commonly applied. In a certain small proportion of cases 
 the ischsemia persists for a considerable period, terminating finally in 
 ulceration of the finger-tips without the appearance of local asphyxia. 
 On the other hand, the asphyxia may be the first symptom noted. The 
 extent of the gangrene varies from superficial necrosis of the tips of 
 one or more fingers to the death of an entire phalanx, or in rare cases 
 of a whole finger. Instead of gangrene marked trophic disturbances 
 may appear : after repeated attacks the fingers become thin and taper- 
 ing, the skin becomes adherent to the underlying parts, and the joints 
 stiff (sclerodactylia) ; or instead of being thin they may become thick 
 and club-shaped with stubby ends and deformed nails. While sym- 
 metry in the distribution of the gangrene is the rule there are occa- 
 sional exceptions ; Raynaud himself observed asymmetrical cases and 
 more recent observers have also described them. 
 
 The paroxysms are usually more frequent and more pronounced in 
 cold weather and may often be brought on by immersing the hands in 
 cold water. Occasionally the attacks exhibit a marked periodicity, 
 coming on with great regularity at definite intervals. 
 
 As a rule there are no general symptoms, but exceptionally there 
 may be headache, loss of appetite and some elevation of temperature 
 either preceding or accompanying the paroxysm, and hemoglobinuria 
 or intermittent albuminuria may also be present. 
 
 Etiology.— It occurs at all ages, but is most frequent in the second 
 and third decades. Females are much more frequently affected than 
 males, the proportion being, according to Munro, two of the former to 
 one of the latter. Exposure to cold is reckoned among the occasional 
 causes, and as has already been observed, it is much more likely to 
 occur in winter than in summer. It has been observed to follow various 
 diseases of the nervous system, of the cardiovascular system, and infec- 
 tions, such as diphtheria, typhoid and scarlet fever, tuberculosis and 
 syphilis. In recent years there has been a notable increase in the 
 number of cases reported in which syphilis was present ; and the present 
 tendency is to attribute a prominent role to this infection as a causative 
 factor. In a considerable proportion of cases it is associated more or 
 less closely with scleroderma, in no less than 7 per cent, according to 
 Munro ; and the author has recently called attention to the relatively 
 considerable number of cases in which it is associated with lupus ery- 
 thematosus. In all probability it is due to some toxin, perhaps not 
 always the same, which especially affects the vascular walls. 
 
206 DISEASES OF THE SKIN 
 
 Pathology. — The local syncope is the result of vasomotor spasm 
 and the gangrene is due to the shutting of the blood supply. It is 
 still a mooted question whether the vascular disturbance is of central 
 or peripheral origin. The tissue changes are those which are seen in 
 other forms of gangrene of the skin. 
 
 Diagnosis. — It is to be distinguished from other forms of gangrene 
 by its symmetrical distribution and by the pronounced vasomotor 
 symptoms which precede the appearance of the gangrene. 
 
 Prognosis. — While there may be but a single attack, this is unfor- 
 tunately not the usual course of the malady, but the paroxysms con- 
 tinue to recur for an indefinite period, not uncommonly for years, with 
 the loss of the ends of one or more fingers, of an entire phalanx, or in 
 exceptional cases of an entire member. In long-continued cases which 
 do not terminate in gangrene the trophic alterations in the fingers 
 may be so extensive as to interfere very seriously with their use. When 
 considerable areas of gangrene develop death may result from exhaus- 
 tion or sepsis, particularly in the feeble and elderly. 
 
 Treatment. — The patient's general condition should be carefully 
 looked after ; he should have an abundance of nutritious food and should 
 spend considerable time in the open air. If possible the winters should 
 be spent in a warm equable climate, or if this is not possible he should 
 be thoroughly protected against cold. In cases in which syphilis is 
 demonstrable or suspected, and it should always be looked for, thor- 
 ough trial should be made of salvarsan, mercury and the iodides. 
 Nitroglycerin and amyl nitrate have been recommended for the purpose 
 of relaxing vascular spasm, but they have proved of little or no use. 
 Raynaud recommended galvanism, applying one electrode over the 
 spine, the other on the affected extremity. During the paroxysm fric- 
 tions with stimulating liniments may be used for the purpose of improv- 
 ing the circulation and relieving pain ; for the latter purpose cold appli- 
 cations are sometimes useful. The treatment of the gangrene is to be 
 conducted according to the usual surgical methods. 
 
 DIPHTHERIA OF THE SKIN 
 
 Diphtheria of the skin may occur as a primary or a secondary 
 affection, the latter as a concomitant or sequel of pharyngeal and nasal 
 diphtheria. While both forms are infrequent, the secondary is much 
 more common than the primary and has long been known, Chomel 
 having called attention to it as long ago has 1759. The primary form, 
 which has only recently been recognized, has been studied by Neisser, 
 Adler, Marschalko, Schucht, Knowles and Frescoln, and a few others. 
 
 In primary diphtheria of the skin a variety of cutaneous lesions 
 may be present, none of which are characteristic. It may occur as an 
 impetiginous or ecthymatous eruption followed by ulcers, resembling 
 the ecthyma of infants ; in rare cases vesicular and bullous eruptions 
 have been present. In the remarkable case reported by Slater, a wide- 
 spread vesicular eruption resembling varicella somewhat, had existed 
 
INFLAMMATIONS 207 
 
 for three years ; the Klebs-Loeffler bacillus was recovered from the 
 lesions and the eruption disappeared after the use of diphtheria antitoxin. 
 
 Diphtheria of the skin, secondary to pharyngeal and nasal diph- 
 theria, usually begins at the site of a wound or abrasion forming an 
 ulcer of variable extent and depth, the bottom of which is covered by a 
 grayish membrane in which the diphtheria bacillus is present. At 
 times extensive destruction of the skin and subcutaneous tissues occurs, 
 with the formation of grayish or blackish sloughs. More or less con- 
 stitutional disturbance is present and not very infrequently death fol- 
 lows. Occasionally ecthymatous and ulcerative lesions or bullae may 
 occur, just as in the primary form. 
 
 A definite diagnosis can only be made by the aid of the microscope 
 and cultures, since, as already observed, the eruptive lesions are not 
 distinctive. 
 
 As Knowles and Frescoln point out, it is important to distinguish 
 between the Klebs-Loeffier organism and the pseudodiphtheria bacillus 
 in making the diagnosis. 
 
 When the presence of the former organism in the lesions has been 
 demonstrated, diphtheria antitoxin should be administered at once 
 
 DERMATITIS 
 
 Definition. — Inflammation of the skin. 
 
 While inflammation of the skin is a frequent and prominent symp- 
 tom of many cutaneous affections, the term is applied chiefly to those 
 inflammations which are the result of various morbific agencies acting 
 locally upon the skin. It may arise from mechanical violence, derma- 
 titis traumatica, from heat, dermatitis calorica, from cold, dermatitis 
 a frigore, frost-bite, or from contact, direct or indirect, with various 
 plants and chemical substances, dermatitis venenata. 
 
 DERMATITIS TRAUMATICA 
 
 Under this term are to be included all such inflammations as follow 
 breaches of continuity in the skin, made by cutting instruments either 
 accidentally, or purposely as in surgical operations, excoriations, such 
 as frequently are inflicted upon the skin in many itching diseases by 
 the nails or by rubbing, after abrasions or wounds resulting from 
 violence or from bites of animals and insects. The inflammation 
 which may follow such traumata may present all grades of severity and 
 may be accompanied by such subjective symptoms as burning and pain, 
 and in severe and extensive cases by more or less constitutional dis- 
 turbance. Very commonly the severe forms are not the direct result 
 of the traumatism, but are due to the secondary infections which 
 frequently follow injuries. 
 
 In the milder forms of traumatic dermatitis the frequent appli- 
 cation of an evaporating lotion, such as equal parts of alcohol and 
 water, or if there is pain, weak lead-water will usually suffice. In the 
 
208 DISEASES OF THE SKIN 
 
 severe grades the inflamed part should be put at rest and when situated 
 upon an extremity, elevated. The inflamed area should be covered 
 with gauze wet with a saturated solution of boric acid, either hot or 
 cold, according to the relief afforded, frequently renewed, or lead-water 
 and laudanum may be employed in the same manner. 
 
 DERMATITIS CALORICA 
 
 Dermatitis calorica, or burn of the skin, presents all degrees of 
 severity, from mild erythema to complete destruction of the skin 
 and subcutaneous tissues. Three degrees of burn are recognized : 
 In the first the skin is reddened with or without slight swelling, 
 and there is more or less burning pain. In the mildest forms of this 
 degree the symptoms usually subside spontaneously in the course of a 
 few hours. In the second degree the symptoms are much more 
 marked : the skin is reddened, swollen, with a more or less abundant 
 transudation of serum beneath the epidermis, forming vesicles and 
 blebs filled with clear fluid ; the pain is usually severe. In the third 
 degree the skin is completely devitalized and is transformed into a 
 brownish or black eschar. In burns of the second and third degrees, 
 involving any considerable extent of surface, there is usually more or 
 less constitutional disturbance. In extensive burns the patient fre- 
 quently suffers from profound shock from which he may not recover, 
 and complains but little of pain. In burns of the second and third 
 degrees suppuration frequently takes place, and when considerable 
 areas are involved this is usually accompanied by fever and frequently 
 by symptoms of sepsis. Burns involving one-half of the surface or 
 more are usually fatal, death occurring often within the first few 
 days. The cause of death in such cases is not well understood, various 
 explanations being offered, such as overheating of the blood and conse- 
 quent paralysis of the heart, destruction of the red blood-cells by over- 
 heating, or the production of toxic substances in the eschar which are 
 absorbed into the circulation, but none of these is altogether satisfac- 
 tory. In the death which occurs late in burns the fatal termination 
 is the result of sepsis or exhaustion from long-continued suppuration. 
 Gastric and duodenal ulcers, especially the latter, are occasional 
 complications of burn. 
 
 In mild burns of the first degree the application of cold water or 
 lotions of weak lead water, followed by a simple dusting powder, will 
 usually afford relief. A solution of sodium bicarbonate, five to ten 
 grains (0.32 to 0.65) to the ounce (32.0), applied on compresses of 
 gauze, will often afford great relief to the pain ; or a one per cent, 
 solution of picric acid may be painted over the burned area or applied 
 on gauze. When blebs are present these should be carefully evacuated. 
 A popular and useful application is the so-called Carron oil or lini- 
 mentum calcis composed of equal parts of lime-water and linseed oil, 
 which should be applied on lint or gauze. Olive oil may be substituted 
 for the linseed oil with equally good results and is more agreeable. 
 
INFLAMMATIONS 209 
 
 Very recently covering the parts with paraffin of a melting point of 
 about 50 C, to which oil of eucalyptus or other antiseptic has been 
 added in varying proportions, has been employed with remarkably 
 good results. It should be applied in the melted condition with a soft 
 flat brush or sprayed on with a suitable apparatus. In severe and 
 extensive burns continuous immersion in a water-bath, as employed 
 by Hebra, is a useful procedure, affording the patient much relief. In 
 cases in which extensive suppuration occurs fomentations of warm satu- 
 rated boric acid solution are very useful and cleanly, favoring the 
 separation of sloughs and eschars. In case of shock, stimulants should 
 be judiciously employed. When long-continued suppoiration over 
 extensive areas follows, every measure looking to the preservation of 
 the patient's strength is to be employed and especial care taken to 
 prevent sepsis. 
 
 DERMATITIS A FRIGORE 
 
 Synonyms. — Dermatitis congelationis ; Congelatio. 
 
 A dermatitis varying from a mild and transient erythema to gan- 
 grene may be produced by exposure to low temperature. For obvious 
 reasons it is seen by far more frequently upon the hands and feet than 
 upon any other portion of the body. On the hands the fingers are 
 most frequently affected, on the feet the toes and heels. 
 
 In the mildest form affecting the fingers and toes the skin is dusky- 
 red, with burning, itching and pain. After a short time, which varies 
 according to the degree of the inflammation, the redness disappears, 
 and the itching and burning grow less, although these are apt to return 
 upon exposure to cold even of moderate degree (erythema pernio, q. v.). 
 
 When the exposure has been more prolonged and the temperature 
 low, the skin on the exposed parts is swollen and red and vesicles and 
 blebs appear which may be followed by ulceration of varying extent 
 and depth. Although the parts are numb at first, decided pain appears 
 with restoration to the normal temperature. 
 
 After long exposure to very low temperature the skin becomes 
 hard and white at first, later it becomes bluish or blackish and blebs 
 of considerable size are formed, followed by ulceration and gangrene ; 
 or the parts may be so completely devitalized that gangrene occurs at 
 once, a line of demarcation forms after a time, and the frozen parts are 
 cast off by suppuration. 
 
 The treatment of the milder forms of frost-bite has already been 
 referred to (vid. erythema pernio). In the severe forms great care 
 should be taken not to restore the warmth of the parts too quickly, as 
 great pain, severe inflammation and ulceration are likely to follow. The 
 frozen parts should be rubbed with snow for some time or placed in 
 cold water, the temperature of which should be slowly raised until it is 
 the temperature of the room. Blebs should be opened and evacuated 
 and subsequent ulcers and sloughs covered with slightly stimulating 
 and antiseptic ointments, such as a two per cent, ointment of salicylic 
 14 
 
210 DISEASES OF THE SKIN 
 
 acid, or a twenty per cent, ointment of boric acid. The occurrence of 
 extensive gangrene is to be treated according to surgical principles. 
 
 ACRODERMATITIS HIEMALIS 
 
 Synonyms. — Acrodermatitis pustulosa hiemalis (Crocker). 
 
 Some years ago Crocker described an affection characterized by an 
 eruption situated exclusively upon the hands, particularly about the 
 knuckles and sides of the fingers, occurring only in the winter. It 
 began with small, red, firm papules, some of which after enlarging 
 slightly became pustules, crusted over and left scars after the crusts 
 fell ; others remained papules and eventually disappeared without 
 leaving any trace. If punctured soon after their appearance, a watery 
 fluid escaped from them. The number of lesions was usually quite 
 small ; they came out in crops and ran a course of about a fortnight, 
 although when the weather was cold they lasted much longer. The 
 eruption recurred year after year, in one case for as long as ten years, 
 in the winter and disappeared with the return of mild weather. Al- 
 though Crocker was the first to call attention to it in a formal way, 
 cases of it had been described previously by Cavafy and Allen. Cavafy's 
 case was characterized by a winter-recurring vesicular eruption on the 
 hands ; Allen reported his as one of " necrotizing chilblains." The latter 
 was distinguished by an eruption of nodules on the hands which ap- 
 peared in winter only, or after washing the hands in cold water; they 
 underwent central necrosis, leaving a scar, and resembled the nodules 
 of the papulo-necrotic tuberculide. 
 
 In recent years the author has seen a number of cases, which, al- 
 though differing in some minor features from those of Crocker, yet 
 resembled them sufficiently to justify placing them in the same cate- 
 gory. The eruption was confined to the hands and consisted of small 
 erythematous patches, dull-red papules, and a few discrete vesicles, 
 on the fingers chiefly. It appeared in the autumn, continued through- 
 out the winter with exacerbations during cold weather, and disap- 
 peared with spring. Unlike Crocker's cases, there was never any scar- 
 ring. Itching and burning were present in the majority of the cases, 
 sometimes of a severe character. 
 
 The affection is apparently related to chilblain on the one hand, 
 and occasionally, on the other, to the papulonecrotic tuberculide. In 
 all the author's cases the extremities became a dusky bluish hue when 
 exposed to cold, the so-called chilblain circulation. Crocker thought 
 his cases a variant of the folliclis of Barthelemy. 
 
 While there is no doubt about the influence of cold weather upon 
 its occurrence, it has seemed to the author that other seasonal influ- 
 ences besides temperature must be concerned in its production, since 
 an examination of the records of the Weather Bureau has shown that 
 the temperature of the localities in which the author's patients resided 
 was lower in the spring months, when the disease disappeared, than 
 in the autumn months, when it began. 
 
INFLAMMATIONS 
 
 211 
 
 The only treatment which has been at all effective in the author's 
 hands has been the application of a twenty-five per cent, solution of 
 ichthyol in water ; this was painted on with a brush every night before 
 retiring and in the morning. If the staining was objectionable it was 
 washed off in the morning with hot water and the morning application 
 omitted. 
 
 DERMATITIS VENENATA 
 
 Definition. — An inflammation of the skin due to contact with vari- 
 ous plants, chemical substances, or other substances of an irritant 
 character. 
 
 Contact with certain plants, many drugs, and chemicals will excite 
 in the skin an inflammation varying from a mild erythema to gangrene, 
 the result depending upon the susceptibility of the individual, the 
 character of the offending agent, and the duration of the contact. 
 
 Fig. 5' 
 
 ■Dermatitis venenata. 
 
 Symptoms. — Every variety of cutaneous lesion, erythema, papules, 
 vesicles, pustules, blebs, and wheals, may occur in this variety of 
 dermatitis. It usually begins with redness and some swelling of the 
 skin, limited at first to the area which has been in contact with the 
 irritant. On this reddened area innumerable small acuminate vesicles 
 appear (Fig. 57), which by coalescence form larger vesicles, and blebs 
 in the severer form of the disease. Although the inflammation is at 
 first limited to the parts which have been in contact with the irritant 
 substance, it often spreads far beyond this. There is frequently an 
 abundant discharge of serum, and in the severe cases pus, which dries 
 into yellow crusts. The inflammation is always accompanied by more 
 or less burning and pain, which in many cases are quite severe. When 
 parts of the skin are affected in which there is an abundance of loose 
 connective tissue, as the eyelids and male genitalia, there is often 
 great oedema, completely closing the eyes and swelling the penis and 
 scrotum to enormous proportions. 
 
212 DISEASES OF THE SKIN 
 
 This variety of inflammation of the skin is far more frequent, in 
 the author's opinion, than is generally recognized. Those cases due to 
 the so-called poison ivy, or rhus toxicodendron, are usually recognized 
 without difficulty, but there are many forms of the disease which are 
 erroneously regarded as acute recurrent eczema; indeed, the author is 
 quite convinced that many, if not most, of the cases of so-called acute 
 eczema are in fact a dermatitis due to contact with some unsuspected 
 plant, dye, or drug with which the patient comes in contact. The 
 author has seen so many cases of what had been regarded as recurrent 
 eczema prove, on careful investigation, to be due to some dye in a 
 fur, some hair-wash, or some window plant, that he is always suspi- 
 cious of the correctness of the diagnosis of eczema in those cases in 
 which there are frequent acute recurrences. 
 
 Etiology. — The number and variety of the substances which may 
 give rise to dermatitis when brought into contact with the skin are so 
 great that a complete list of them would take up more space than can 
 be devoted to them here, but the following are the more important : 
 
 Among the plants the first place must be given to the several 
 varieties of Rhus, Rhus toxicodendron, or poison ivy, and Rhus venenata, 
 poison sumach, the former being an especially common cause of in- 
 flammation of the skin in the United States. In England the Primrose, 
 Primula obconica, is the most frequent source of plant dermatitis, and 
 is a fairly common cause in the United States, although only compara- 
 tively recently recognized as a source of this form of dermatitis. Other 
 plants which occasionally inflame the skin are the Nettle, Urtica dioica, 
 Smartweed, and Rhus vernix, used in the making of Chinese lacquer. 
 Under the name of "lily rash," Walsh a few years ago described a 
 dermatitis prevalent among flower-pickers in the Scilly Islands due 
 to the lily. 
 
 It must be borne in mind that a certain susceptibility of the indi- 
 vidual is necessary to the production of dermatitis even with such 
 plants as the Rhus, some individuals being quite immune. 
 
 Among the chemical substances which are a more or less frequent 
 cause of dermatitis venenata are certain dyes, particularly many of the 
 aniline dyes, salts of chromic acid and picric acid, photographic de- 
 velopers, such as metol, which are usually seen in those engaged in 
 certain trades, or in those who have worn articles of clothing, such as 
 underwear or stockings, dyed with them. Many medicinal substances 
 are to be included in this list, such as the various salts of mercury, 
 especially corrosive sublimate, iodoform, carbolic acid which may 
 produce gangrene when the contact with the skin is prolonged even 
 in weak solutions, formaldehyde which may be used for a considerable 
 period before it produces any disturbance, but when it has once excited 
 a dermatitis will continue to do so even in very minute quantities, the 
 skin becoming increasingly sensitive to its action. Various domestic 
 remedies, such as arnica, turpentine, mustard and various liniments 
 containing these, will, in certain individuals, cause a more or less severe 
 inflammation of the skin. Tincture of iodine or ointments containing 
 
INFLAMMATIONS 
 
 213 
 
 iodine, hair washes, particularly those which contain quinine or certain 
 coal-tar derivatives which darken the hair, are quite commonly the 
 unsuspected source of inflammation of the face and neck. Among 
 aniline dyes paraphenylendiamine, which is used to dye furs and is 
 the active ingredient in a number of proprietary hair-dyes, is a frequent 
 cause of a most violent dermatitis situated usually upon the neck 
 and face. The degree of susceptibility to these various substances 
 varies enormously in different individuals. In the case of a physician 
 
 
 ** 
 
 Fig. 58. Dermatitis venenata. Vesicles in the rete mucosum with lymphoid cells in upper part of the 
 
 corium. The dark line surrounding the vesicle is pigment, the patient being a negress. 
 
 under the author's observation some years ago, who was extremely 
 susceptible to the action of iodoform, the mere picking up of a piece 
 of iodoform gauze with the thumb and finger was followed in a few- 
 hours by a dermatitis which spread over the entire cutaneous surface. 
 For obvious reasons dermatitis venenata usually attacks the ex- 
 posed surfaces, such as the hands, forearms and face, but it may spread 
 by contiguity to other parts, or be transmitted by the hands. In Rhus 
 poisoning the genitalia in the male are very commonly attacked, the 
 irritant being carried to the region by the patient's hands, and penis 
 and scrotum are frequently swollen to enormous proportions, much to 
 the patient's alarm. 
 
214 DISEASES OF THE SKIN 
 
 Pathology. — In a case of Rhus dermatitis, with an abundant vesicu- 
 lar eruption, in a negress which the author studied histologically some years 
 ago, the rete was slightly broader than normal as the consequence of a 
 moderate intercellular oedema and contained vesicles which were situ- 
 ated in its lowest portion ; these contained a small quantity of coagu- 
 lated fibrin in which were entangled a moderate number of leucocytes. 
 The papillary body and the subpapillary portion of the corium to a 
 considerable depth, were occupied by a very pronounced exudation 
 of lymphoid cells with a few polynuclear leucocytes most marked about 
 the vessels, the follicles and the ducts of the sweat-glands (Fig. 58). 
 
 Diagnosis. — The disease with which dermatitis venenata is most apt to 
 be confounded is acute eczema, and the differential diagnosis is not always 
 easy, but the acuteness of the course of the former, the frequent 
 severity of the inflammation with the formation of blebs, its situation 
 upon exposed parts, and the knowledge that the patient has been in 
 contact with an irritant or is employed in a trade or occupation which 
 brings him into contact with chemical or other substances which are 
 known to excite a dermatitis, will usually serve to differentiate the 
 two affections. In ivy poisoning, or other plant poisoning, the fre- 
 quent occurrence of streaks of erythema or vesicles where the branches 
 of the plant have come in contact with the skin is a significant symptom 
 and the involvement of the penis and scrotum in the male in the 
 inflammation is likewise a useful diagnostic point. 
 
 Prognosis. — While most cases of dermatitis venenata run an acute 
 course, subsiding spontaneously in the course of a week or two, yet in those 
 with an eczematous tendency the dermatitis may terminate in an eczema of 
 indefinite duration, especially if improperly treated. In those forms 
 of dermatitis which arise from the use of irritant substances employed 
 in various trades, frequently nothing but the complete abandonment 
 of the occupation will insure freedom from the dermatitis. Too long 
 persistence in exposure to the offending substance frequently gives 
 rise to a chronic eczema which may continue for months and even years 
 :after the removal of the cause — so-called trade-eczema, 
 
 Treatment. — Local treatment is alone required. A saturated solution 
 of boric acid to which has been added one-half to a drachm (2.0 to 4.0) of 
 subcarbonate of bismuth or oxide of zinc, freely and frequently mopped 
 on the inflamed skin, will often afford decided relief. Black wash 
 (lotio nigra) is another useful application employed alone or followed 
 by an ointment composed of two drachms (8.0) of bismuth to six drachms 
 (24.0) of unguentum aquae rosse, which is far more agreeable and 
 effective than the official zinc ointment commonly employed. Alka- 
 line lotions containing three to five grains (0.20 to 0.32) of sodium 
 bicarbonate or borax are frequently of service ; these may be used in 
 conjunction with a dusting powder of talc and oxide of zinc or bismuth. 
 Later, when the symptoms are less active, mild ointments, such as the 
 cold cream and bismuth, may be used alone. Many specifics have been 
 vaunted in the treatment of Rhus poisoning, but there is no evidence 
 
INFLAMMATIONS 
 
 215 
 
 that any of these have any specific properties. When seen early after 
 exposure, the skin should be carefully washed with soap and warm 
 water and then some one of the lotions already mentioned employed. 
 Other lotions which are useful in this variety of dermatitis are dilute 
 lead water; fluidextract of grindelia robusta, one-half to one drachm 
 (2.0 to 4.0) to the ounce (32.0) of water; sodium hyposulphite, one-half 
 to one drachm (2.0 to 4.0) to the ounce (32.0). When blebs are present 
 these should be carefully evacuated with a sterile needle to prevent their 
 rupture, since when torn large, raw surfaces are left which readily become 
 infected. 
 
 Fig. 59 — Arsenical keratosi 
 
 Patient had taken Fowler's solution in large doses for a number of years 
 for dermatitis herpetiformis. 
 
 DRUG DERMATOSES 
 
 Synonyms. — Drug eruptions; Dermatitis medicamentosa; Fr., 
 ^Eruptions medicamenteuses ; Ger., Arzneiexantheme. 
 
 Definition. — Diseases of the skin, for the most part, but not invari- 
 ably, of an inflammatory character, due to the ingestion or absorption 
 of drugs. 
 
 Symptoms. — Disturbances in the skin as the result of the ingestion 
 or absorption of drugs are of common occurrence, and present a wide 
 diversity of symptoms. They are for the most part of an eruptive 
 character, but also occur as sensory or pigmentary disturbances. Every 
 form of cutaneous lesion may occur — erythema, diffuse or macular, 
 papules, vesicles, pustules, blebs, hemorrhage, ulceration and gan- 
 grene may be produced by one drug or another. The commonest 
 
216 DISEASES OF THE SKIN 
 
 variety of eruption is an erythema which may be more or less localized 
 or general, may be diffuse or macular, or urticarial. Only a small 
 number of drugs produce characteristic eruptions, so that it is often 
 difficult, and at times quite impossible, to determine from the eruption 
 alone what drug has produced it. The same drug frequently varies 
 greatly in its effects in different individuals ; in one it may produce 
 a diffuse erythema, in another, urticarial wheals, in a third a vesicular 
 eruption and in a fourth no eruption whatever. A small number, such 
 as the salts of iodine and bromine, produce in most individuals a fairly 
 uniform eruption, so that it is comparatively easy to recognize the 
 cause. A striking peculiarity shown by many drugs is that the erup- 
 tion is often not a matter of the amount taken ; in susceptible indi- 
 viduals one or two doses, or at times a single small dose, will call it 
 forth. The eruptions are for the most part general in their distribution 
 and usually symmetrically arranged, but occasionally they exhibit a 
 more or less pronounced predilection for certain regions ; while com- 
 monly uniform they are often multiform. Occasionally the mucous 
 membranes of the mouth and pharynx are involved along with the skin. 
 Itching and burning are frequent subjective symptoms. In the major- 
 ity of cases the symptoms are confined to the skin, but in a limited 
 number considerable constitutional disturbance, with more or less 
 elevation of temperature, accompanies the eruption. 
 
 The eruptions usually appear quite suddenly, soon after the drug 
 has been taken, sometimes within a few minutes ; in a considerable 
 number of cases, however, they appear only after prolonged use. They 
 usually disappear promptly after its suspension ; or tolerance may be 
 established and the eruption vanish, although the drug is continued. 
 In a case of iodic purpura, repeatedly under the author's observation,, 
 the hemorrhage which appeared within twenty-four hours after begin- 
 ning the iodide of soda disappeared within a few days, notwithstanding 
 the continued administration of the drug. Exceptionally the eruption 
 may persist for some weeks or longer after the drug has been sus- 
 pended, owing, in most cases, to the slow elimination of the latter; 
 the bromide eruptions usually continue for a considerable period after 
 the administration of the salt has been stopped. 
 
 The following is a brief resume of some of the eruptions produced by 
 the drugs in common use with a few of the rarer ones : * 
 
 Acetanilid (Antifebrin).— Erythematous eruption, infrequent ; when 
 taken in considerable doses or for considerable periods in moderate 
 doses cyanosis, most noticeable on the lips ; common. 
 
 Antimony (Tartar Emetic).— Vesico-pustular eruption -uncommon. 
 Antipyrin.— Urticaria, occasionally after a single dose and within 
 a few minutes, common, less frequently a morbilliform erythema ; pur- 
 pura, r^re^Jr^mr^ns^i^^ 
 
 Tpnr a full consideration of the subject of drug eruptions the reader is re- 
 ferred to the monograph of Morrow as edited by Colcott Fox and published 
 by the New Sydenham Society. 
 
Fig. 60. Arsenical pigmentation. Patient also had a mild arsenical keratosis of the palms. 
 
INFLAMMATIONS 
 
 217 
 
 The French have described a peculiar blackness of the penis following 
 its administration, lasting for some time. 
 
 Antitoxin and Other Sera. — Frequently followed by eruptions most 
 frequently of an urticarial character; less common scarlatiniform and 
 morbilliform erythema, or multiform erythema ; usually appear about 
 six to eight days after administration, but may appear much earlier or 
 later; occasionally show predilection for the region of the large joints 
 which may be painful ; severe itching with some constitutional disturb- 
 ance with fever ; common. 
 
 Atophan. — Scarlatiniform erythema. 
 
 Aspirin.— Vid. salicylic acid and its compounds. 
 
 Arsenic. — Great variety of eruptions — erythematous, papular, 
 
 !■■■■■ , — — — ■ "— " 
 
 Fig. 6 i. — Bromide eruption (bromoderma) leg resembling late pustular syphiloderm. (Followed too 
 prolonged use of a proprietary mixture containing a bromide.) 
 
 vesicular, pustular, hyperkeratosis and pigmentation ; infrequent. A 
 special form of hyperkeratosis affecting the palms and soles (Fig. 59). 
 preceded often by hyperidrosis of these regions is peculiar to arsenic. 
 It is characterized by small shot-sized horny elevations like small corns. 
 A number of cases have been reported in which epithelioma has fol- 
 lowed at the site of these keratoses. Arsenical pigmentation occurs as 
 a diffuse or mottled, brownish or grayish, discoloration occupying the 
 greater part of the trunk (Fig. 60). Keratoses and pigmentation occur 
 only after prolonged use. 
 
 Belladonna (and its alkaloid atropin). — Scarlatiniform erythema, 
 commonest type of eruption ; especially in children ; on face and upper 
 part of chest; usually disappears quickly ; may follow ingestion of drug 
 or its absorption from plaster, or instillation of atropin solution into 
 
218 
 
 DISEASES OF THE SKIN 
 
 conjunctival sac; the last may produce erysipelatous inflammation of 
 lids and region about. 
 
 Benzoic Acid and Sodium Benzoate.— Erythematous and maculo- 
 papular; infrequent. 
 
 Boric Acid and Sodium Biborate. — Erythematous ; occasionally 
 follows use of boric acid solutions to wash out cavities, such as the 
 bladder. Borax, when given internally for a considerable period, may 
 produce a scaly eruption closely resembling psoriasis; unusual. 
 
 Bromides of Potassium, Sodium, Ammonium and Other Salts of 
 Bromine. — Eruptions from bromides are common ; most frequent type 
 
 Fig. 62. .—Bromide eruption (bromoderma) . Mother had taken a bromide in final month of 
 pregnancy. Case referred to in text. 
 
 acneform ; on face, chest and back, less frequently upon the extremities. 
 Occasionally aggregated in elevated plaques studded with pustules. 
 A characteristic lesion occurs in children as pea-sized and larger red- 
 dish nodules with a flat pustule on top which are quite solid. Papillomatous 
 and verrucose patches resembling verrucose tuberculosis cutis or blasto- 
 mycosis, also occur. Exceptionally the eruptions may be erythematous, pap- 
 ular, vesicular and in rare instances, bullous. They may occur in nursing 
 infants whose mothers are taking the drug ; and the author has seen an 
 instance in which a characteristic and pronounced eruption was pro- 
 
INFLAMMATIONS 219 
 
 duced in a new-born infant by a bromide mixture taken by the mother 
 in the last weeks of pregnancy, which was suspended at the birth of 
 the infant (Fig. 62). 
 
 Chloral. — Erythematous, urticarial, less frequently vesicular, rarely 
 bullous ; after prolonged use petechias, ecchymoses, ulceration ; 
 infrequent. 
 
 Copaiba. — Most common type morbilliform erythema, less often 
 scarlatiniform ; occasionally resembling erythema multiforme ; rarely, 
 vesicular or bullous. 
 
 Digitalis. — Erythematous, papular, urticarial ; rare. 
 
 Ergot. — Erythema, petechias, gangrene ; only after long-continued 
 use ; may be caused by eating rye bread containing diseased rye. 
 
 Hyoscyamus. — Erythematous, urticarial, occasionally scarlatini- 
 form, rarely pustular. 
 
 Iodine and the Iodides. — Common ; usually as a papulo-pustular 
 eruption resembling acne ; occasionally furuncular, papillomatous, or 
 vegetating as after the bromides ; rarely vesicular, purpuric or bullous. 
 In a middle-aged woman under the author's observation some years 
 ago the administration of iodide of potassium was invariably followed 
 by an intensely itching vesicular eruption limited to the palms. The 
 bullous eruption is usually accompanied by grave constitutional symp- 
 toms and may terminate fatally ; it, as a rule, occurs in those with 
 cardiac or renal disease. 
 
 While the iodic eruptions are in the great majority of cases due to 
 the ingestion of the alkaline iodides, they have been observed after tak- 
 ing the iodide of iron. In rare instances they have followed the 
 external application of the tincture of iodine (Hodara). Iodoform may, 
 in rare instances, produce an erythematous, vesicular or bullous erup- 
 tion, either when given internally or when absorbed from surgical 
 dressings. 
 
 Mercury and Its Salts. — Erythematous, vesicular, pustular ; rare. 
 
 Opium and Morphine. — Macular or scarlatiniform erythema accom- 
 panied by severe itching; pruritus, often limited to the face, especially 
 the nose, occasionally general ; common. 
 
 Phenacetin. — Erythema, scarlatiniform or urticarial ; infrequent. 
 
 Quinine. — Scarlatiniform erythema, urticaria, in rare cases vesicular 
 or bullous. The scarlatiniform erythema may be accompanied by 
 elevation of temperature and followed by extensive desquamation ; 
 occasionally produced by very small quantities. 
 
 Salicylic Acid, Salicylate of Soda, Salol, Aspirin. — Macular or scarla- 
 tiniform erythema, urticaria ; infrequently vesicular, or bullous ; rarely, 
 purpura, gangrene. 
 
 Salvarsan. — Scarlatiniform or morbilliform erythema ; vesicular or 
 bullous ; fairly common. 
 
 Silver Nitrate. — Slate-colored or bluish discoloration of the skin and 
 visible mucous membranes ; only after taking considerable quantities. 
 
220 DISEASES OF THE SKIN 
 
 Sulphonal. — Erythema, macular or scarlatinoid ; after prolonged use 
 accompanied by hsematoporphyrinuria. 
 
 Thallium Acetate. — More or less general alopecia. 
 
 Tuberculin. — Erythema, scarlatinoid or morbilliform ; infrequent. 
 
 Veronal. — Diffuse or blotchy erythema, often accompanied by in- 
 tense itching and burning, sometimes with elevation of temperature; 
 infrequent, but not rare. 
 
 Etiology and Pathology. — We have but little exact information 
 concerning the causes which predispose to drug eruptions and still less 
 knowledge concerning the manner of their production. In many in- 
 stances idiosyncrasy, in most cases congenital, but occasionally 
 acquired, plays a prominent part. There is but little doubt that in the 
 case of some drugs these act after the manner of foreign proteins and 
 the eruptions which they produce are to be considered anaphylactic 
 phenomena. Cole succeeded in passively transferring the idiosyncrasy 
 to potassium iodide by serum, and Bruck (quoted by Cole) was able 
 to passively transfer hypersusceptibility to iodoform and antipyrin 
 from man to guinea pigs. Cardiac and renal insufficiency are occasion- 
 ally predisposing factors. 
 
 The earliest investigators attributed the eruptions to the irritant 
 effects of the drugs upon the glands of the skin by which they were 
 eliminated, but it has been shown quite conclusively that the eruptive 
 lesions are not confined to the region of the glands but occur on other 
 parts of the skin as well. Behrend supposed that they were not due 
 directly to the drugs themselves, but to toxic substances produced by 
 them. Morrow was inclined to view them as being produced through 
 the intermediation of the nervous system. Engman and Mook, in a 
 study of the iodic and bromic eruptions, found that they were especially 
 apt to occur at points of previous inflammation, and in tissues charged 
 with the drug traumatism, pressure and quick changes in temperature 
 might precipitate an eruption. They believe that a " local disturbance 
 of the normal equilibrium between the iodine combined in the serum 
 and the tissues . . . may be induced by various factors, and when 
 it does occur the resultant product acts as a toxin which in its turn 
 causes tissue irritation and the production of various local inflammatory 
 symptoms . . ." 
 
 The histological changes present nothing special; they are those 
 of a dermatitis of ordinary type. 
 
 Diagnosis. — In the presence of an unusual eruption the possibility 
 of its drug origin should always be kept in mind, and inquiry made 
 as to the drugs, if any, taken. Only a small proportion of drug erup- 
 tions present characteristic features, and consequently the diagnosis 
 frequently offers considerable difficulty. 
 
 The localization of arsenical keratosis upon the palms and soles is 
 so distinctive that its recognition usually presents no difficulty. Ar- 
 senical pigmentation may resemble the pigmentation of Addison's 
 disease, but the absence of the marked asthenia, which distinguishes 
 
PLATE XIV 
 
 Dermatitis factit 
 
INFLAMMATIONS 221 
 
 the latter, and of pigment in the mucous membranes, will serve to 
 differentiate the two. 
 
 The scarlatiniform erythema of belladonna and atropin differs from 
 the eruption of scarlatina by its diffuse instead of punctiform character 
 and by the absence of tongue, and throat symptoms and of fever. 
 
 The acneform eruption produced by the iodides is usually much 
 more general in its distribution than ordinary acne, and the bromide 
 eruption is often accompanied by characteristic plaques and flat pustulo- 
 nodular lesions, especially in children. It should be borne in mind that 
 in nursing infants the source of the bromides may be the mother's milk. 
 
 When the eruption of quinine is scarlatinoid, is accompanied by 
 fever and followed by desquamation, its differentiation from scarlet 
 fever may be very difficult, but there is often a history of previous 
 attacks of a similar character. 
 
 The serum eruptions at times resemble scarlatina, but are more 
 commonly multiform and are frequently accompanied by arthritic 
 symptoms. 
 
 Prognosis and Treatment. — The prognosis of most drug eruptions 
 is very favorable ; they usually disappear promptly after the suspen- 
 sion of the drug producing them. Exceptions are the bullous erup- 
 tions following the iodides in those with renal or cardiac disease, 
 which may be accompanied by grave constitutional symptoms and 
 may result in death. The bromide eruptions frequently last for a 
 considerable period after the drug has been withdrawn. 
 
 As has already been observed, the eruptions usually disappear 
 promptly with the discontinuance of the drug. When itching and 
 burning are prominent symptoms, the same lotions and ointments 
 serviceable in other itching eruptions, such as lotions and ointments of 
 menthol and phenol, may be used. The coincident administration of 
 arsenic, as Fowler's solution, with the iodides and bromides, for the 
 purpose of preventing or diminishing the toxic effects of these upon 
 the skin has been recommended, but the author has not been able to 
 convince himself of its efficacy. 
 
 DERMATITIS FACTITIA 
 
 Synonyms. — Dermatitis artefacta; Feigned eruption (Plate XIV). 
 
 Definition. — An artificial eruption, usually of an inflammatory 
 character, occurring for the most part in young women, produced 
 by the patient herself through a morbid desire to excite interest or 
 sympathy, or for the purpose of escaping some disagreeable duty. 
 
 Symptoms. — Feigned eruptions present great variation in their 
 appearance, which depends in part upon the agent employed to produce 
 them and in part upon the caprice or ingenuity of the patient. The 
 commoner forms are variously sized erythematous patches which may 
 be round or angular in shape, often the latter, superficial abrasions, 
 and linear excoriations. Less commonly the eruption consists of 
 patches of pustules, discrete bullae, and in exceptional instances there 
 
222 
 
 DISEASES OF THE SKIN 
 
 is superficial gangrene of the skin. The lesions are rarely numerous, 
 are often solitary, and the eruption as a whole frequently differs so 
 
 : . 
 
 
 * 
 
 1 # 
 
 * m 
 
 
 Fig. 63. — Dermatitis factitia. 
 
 much from the usual forms of cutaneous disease that the -experienced 
 observer is at once impressed with its artificial character. Although 
 the eruption may be situated upon any portion of the body accessible 
 
INFLAMMATIONS 223 
 
 to the patient's hands, it is most frequently seen upon the extremities; 
 when situated upon the trunk it is almost always upon the anterior 
 surface, but exceptionally it is seen upon the back (Fig. 63). 
 
 A highly significant fact, and one to which but little attention has 
 been paid, is that in a considerable number of instances an accidental 
 injury, such as a burn with a hot iron or with some caustic substance, 
 a prick with a needle or other sharp instrument, has preceded the 
 artificial lesion. In a case recently under the author's observation, 
 in which coin-sized black circular eschars appeared from time to time 
 upon the anterior surface of the thigh of a neurotic girl fifteen years 
 of age, the first lesion was an accidental burn of a finger with " con- 
 centrated lye." When suddenly and unexpectedly accused of pro- 
 ducing the eschars, she admitted that she had done so, using the lye 
 for the purpose. Certain forms of gangrene of the skin which have 
 been described from time to time by various authors (Doutrelepont, 
 Kaposi, Quinquaud, and others) under the names of acute multiple 
 gangrene of the skin, gangrenous urticaria, hysterical gangrenous 
 zoster, are believed by most authors to have been examples of factitious 
 dermatitis, a belief with which the author fully agrees. Very recently 
 Matzenauer and Polland, under the name dermatitis symmetrica dys- 
 menorrhceica, have reported a number of cases, occurring for the 
 most part in young girls, characterized by linear patches of erythema 
 and excoriations, wheal-like lesions, and exceptionally by superficial 
 necrosis of the skin. A study of the histories of these cases, and more 
 especially of the excellent illustrations which accompany the report, 
 leaves but little doubt in the author's mind that the eruptions were 
 factitious. 
 
 Etiology. — The patients are, in the great majority of instances, 
 young women who present, the stigmata of hysteria. In men the 
 eruptions are seen most frequently in the inmates of prisons or in 
 garrisons and are produced to avoid the performance of some dis- 
 agreeable duty or to escape work. In rare instances they occur in 
 males who present symptoms of hysteria. All kinds of irritant sub- 
 stances, liquid and solid, are employed, such as mustard, turpentine, 
 carbolic acid, croton oil which produces a pustular eruption, lye, 
 and the mineral acids. Abrasions and excoriations are usually pro- 
 duced by mechanical means, such as friction with some hard substance, 
 or with the fingers or finger-nails, as in the so-called neurotic excoria- 
 tions described by Wilson and Sangster and Fox. 
 
 Diagnosis. — In many cases the eruption is so obviously artificial 
 that the diagnosis is readily made by anyone familiar with the ordinary 
 diseases of the skin ; on the other hand, it may be extremely difficult. 
 Even when quite convinced of the factitious character of the lesions, 
 positive proof of it is often difficult, if not impossible, to obtain. The 
 patient rarely admits the imposture and it is often most difficult to 
 prove it. Features of diagnostic importance are : The frequent limi- 
 tation of the eruption to the left side of the body (to the right side in 
 
224 DISEASES OF THE SKIN 
 
 left-handed individuals) and to the anterior surface when the trunk is 
 its seat; the angular or linear shape of the erythematous patches and 
 excoriations, due in the first to the running of the liquid employed 
 to produce them, and in the latter to the use of the nails ; discoloration 
 of the skin when mineral acids are used ; and, lastly, the occasional 
 bizarre arrangement of the lesions. The application of a fixed dressing 
 over eruptions suspected to be self-produced is frequently of great 
 service in diagnosis, since under such a dressing an artificial eruption 
 will promptly disappear only to as promptly reappear when it is 
 removed. 
 
 Treatment. — With the establishment of the artificial character of 
 the eruption the treatment becomes obvious and needs no discussion. 
 
 RADIODERMATITIS 
 
 Synonyms. — X-ray dermatitis ; Rontgen ray dermatitis ; X-ray 
 burn. 
 
 Symptoms. — Exposure of the skin to the X-ray, if sufficiently pro- 
 longed, or even short exposures if frequently repeated, will produce 
 a dermatitis, which, according to the amount of the exposure, varies 
 from a mild erythema to necrosis, which may affect the epidermis 
 only or involve the entire thickness of the skin. This dermatitis does 
 not appear immediately after exposure, but only after the lapse of a 
 period varying from five or ten days to several weeks, or in rare in- 
 stances after some months. The mildest form occurs as a reddened 
 area of variable extent resembling sunburn, usually accompanied by 
 slight itching or a feeling of heat. After five days or a week the 
 redness fades and a fine, usually scanty, desquamation follows for a 
 day or two. In severe forms which follow a somewhat prolonged 
 exposure, or a number of exposures at short intervals, the erythema 
 is followed by vesicles and blebs which rupture and leave a super- 
 ficial ulcer of varying extent, which usually heals in the course of some 
 weeks without scarring. In the severest forms, which may follow a 
 single prolonged exposure or many shorter exposures, blebs are pro- 
 duced and necrosis of the skin to a varying depth takes place. The 
 resulting eschar is grayish and tough or dry and brown, and usually 
 requires many weeks for its separation, leaving an ulcer which is 
 extraordinarily slow to heal and is often extremely painful. Not 
 infrequently such ulcers remain months or even years without heal- 
 ing, or even refuse to heal altogether, notwithstanding the best- 
 directed efforts to close them. Occasionally they become carcinom- 
 atous and then pursue the usual course of carcinoma. The scars 
 which follow these ulcers are hard, inelastic, and covered in time by 
 great numbers of telangiectases, which increase very markedly the 
 disfigurement. 
 
 A chronic form of dermatitis occurs with considerable frequency 
 upon the hands of those who make skiagraphs or employ the ray 
 with the fluoroscope for diagnostic purposes. This form is dis- 
 
INFLAMMATIONS 225 
 
 tinguished by a patchy erythema upon the backs of the hands and 
 fingers, which after a time is followed by atrophic symptoms, such 
 as thinning and wrinkling of the skin, which becomes dry and is 
 covered with fine, thin, scanty scales. Pigmentation occurs either 
 as freckle-like patches or as a diffuse brown discoloration, and small 
 keratoses appear on various parts of the hands, beneath which ulcera- 
 tion may occur, occasionally leading to epithelioma. The nutrition 
 of the nails is likewise affected — they become thin and brittle and 
 their free edges are broken and uneven. Considerable, at times ex- 
 treme, burning pain, more or less continuous, frequently accompanies 
 the dermatitis. 
 
 At times the therapeutic employment of the ray is followed by 
 a more or less marked atrophy — the skin is thin and wrinkled and 
 without elasticity — even when no inflammatory reaction has been 
 produced beyond a scarcely perceptible erythema. 
 
 The hair on parts exposed to the X-ray, even for a comparatively 
 short time, falls ; and if the exposure is repeated a number of times, 
 or has been sufficiently prolonged, the loss of hair is permanent. 
 
 A dermatitis resembling that produced by the X-ray, but much 
 less pronounced, may be caused by radium emanations. The mild 
 form occurs as erythema with scanty, fine desquamation. When the 
 exposure has been prolonged or frequently repeated there is atrophy 
 of the skin, occasionally accompanied by blunting of sensation or 
 parsesthesia of the ends of the fingers. Obstinate ulceration of the 
 fingers may also occur as the result of prolonged exposure. 
 
 Pathology. — The manner in which the X-ray produces its now 
 well-known effects upon living tissues is still altogether unknown. 
 Scholtz, who has made an elaborate and painstaking experimental 
 study of the effects of the ray upon the skin of rabbits, guinea-pigs, 
 and young pigs, concludes that it affects chiefly the cell-elements of 
 the skin, especially the epithelial cells, producing various forms and 
 degrees of degeneration. This degeneration, after it has reached a 
 certain degree, is followed by inflammatory reaction, as shown by 
 dilatation of the vessels, and perivascular exudation of cells. He be- 
 lieves the vascular changes are probably responsible for the extension 
 of ulceration and its slow healing. 
 
 As was first demonstrated by Darier and since confirmed by Wol- 
 bach and other investigators, the epidermis shows more or less hyper- 
 trophy occurring as a uniform thickening with local keratoses and 
 downgrowths into the corium. The corium shows more or less pro- 
 nounced degenerative changes, the most marked of which are rare- 
 faction of the subepidermal portion and a condensation of the deeper 
 parts. Wolbarth found a marked increase of the elastic tissue. The 
 hair follicles, the sweat- and sebaceous glands disappear completely. 
 
 Prognosis and Treatment. — The milder forms of X-ray dermatitis 
 usually disappear within a short time under judicious treatment, and 
 •even when superficial ulceration occurs this heals within a few weeks 
 15 
 
226 DISEASES OF THE SKIN 
 
 without scarring. When there is considerable necrosis, the ulcers are 
 often extremely slow to heal and may not heal at all, or only after 
 many months or several years. As already observed, such ulcers 
 are prone to become carcinomatous. The chronic form is usually very 
 rebellious to treatment, and the keratoses, as already noted, may be- 
 come the starting-point for epithelioma. 
 
 In mild X-ray dermatitis, calamine lotion or a saturated solution 
 of boric acid containing oxide of zinc or subcarbonate of bismuth 
 in suspension, one-half to one drachm to the ounce (2.0 to 4.0 to 32.0), 
 followed later by some mild ointment, such as cold cream, will usually 
 be all that is necessary. In superficial ulcers a one per cent, oint- 
 ment of salicylic acid made up with equal parts of lead plaster and 
 vaseline often answers well as a mildly stimulating application. Ul- 
 cers which have resisted other forms of treatment should be excised, 
 and the defect closed by the transplantation of sound skin. 
 
 ECTHYMA 
 
 Synonyms. — Ger., Ekthyma, Eiterblase. 
 
 Definition. — An inflammatory affection of the skin distinguished 
 by an eruption of discrete flat pustules surrounded by an inflamma- 
 tory areola, situated most frequently, but not exclusively, on the 
 lower extremities. 
 
 Symptoms. — Although the lesions are in most instances pustules 
 from the beginning, they may begin as vesico-pustules with cloudy 
 contents, which become purulent after twenty-four to thirty-six hours. 
 They vary in size from that of a pea to a dime, or larger, usually in- 
 crease somewhat in diameter after their appearance, and are surrounded 
 by a well-marked inflammatory halo extending some distance beyond 
 the border. They reach their acme after five to six days, when their 
 contents dry up, forming brown crusts, beneath which is ulceration, 
 usually very superficial, but in exceptional cases extending down to 
 or involving the upper portion of the corium. At the end of ten days 
 to two weeks the crust falls, leaving a slightly pigmented patch for 
 a time, or, when the ulceration has been deeper, a superficial scar. 
 The number of pustules varies from two or three to a dozen or more, 
 situated most frequently, without any definite arrangement, upon the 
 lower extremities and the buttocks, but also occasionally upon the 
 trunk and upper extremities. The course of the individual lesions va- 
 ries from ten to fourteen days, but the affection may last several weeks 
 or two or three months by the continued appearance of new lesions, 
 the longer course occurring, as a rule, only in neglected cases. The 
 lesions are usually quite sensitive, and there is some burning and pain, 
 but the subjective symptoms are seldom severe. 
 
 Etiology. — The disease is much more frequent in adults than in 
 children, and is seen as a rule in uncleanly and debilitated subjects, 
 in the ill-nourished, and in chronic alcoholics. In such subjects it is 
 very frequently an accompaniment of some itching disease, such as 
 
INFLAMMATIONS 227 
 
 pediculosis corporis or scabies, infection taking place in the abrasions 
 produced by scratching, as the lesions are auto-inoculable. 
 
 Pathology. — Ecthyma is a local infection situated frequently about 
 a hair follicle. As already noted, the pustules are auto-inoculable, 
 and contain both staphylococci and streptococci, the latter being re- 
 garded by most authorities as identical with the organism found in 
 impetigo. According to Leloir, the epithelial cells of the epidermis 
 undergo a reticular degeneration, " alteration cavitaire" which leads 
 to the formation of cavities containing fibrin and pus. Beneath the 
 pustules in the papillary layer of the corium there is an abundant in- 
 filtration of leucocytes. According to Unna, the pustule of ecthyma 
 differs from that of impetigo in that a characteristic inflammation of 
 the epidermis, which is entirely fibrinous in the centre of the lesion 
 and markedly ©edematous at the periphery, precedes the suppuration. 
 The pus is situated, not beneath the corneous layer, but beneath the 
 epidermis. 
 
 Diagnosis. — Ecthyma is to be distinguished chiefly from impetigo 
 and from the pustular syphiloderm. From the former it differs by 
 the larger size, deeper seat, and more inflammatory character of the 
 lesions, and by their situation upon the lower extremities rather than 
 upon exposed parts. From the latter it is to be differentiated by the 
 acutely inflammatory course of the pustules and their limited number, 
 by the comparatively slight infiltration of their bases, by the absence 
 of deep ulceration, by their thinner crusts, and by the absence of other 
 symptoms of syphilis. 
 
 Treatment. — Cleanliness, good food, and the application of a two 
 to four per cent, ointment of ammoniated mercury will usually promptly 
 bring about a cure. Before applying any local remedy the crusts should 
 be removed by the liberal application for a few hours of carbolated 
 vaseline, or, when they are adherent, by starch poultices made with 
 a saturated solution of boric acid. When the affection is associated 
 with pediculosis or scabies, these, of course, should have appropriate 
 treatment. 
 
 FURUNCULUS 
 
 Synonyms. — Furuncle; Boil; Fr., Furoncle ; Ger., Furunkel, Blut- 
 schwar. 
 
 Definition. — An acute circumscribed inflammation of the skin ter- 
 minating in suppuration and necrosis of the central portion of the lesion. 
 
 Symptoms. — A furuncle begins either as a small pustule, frequently 
 with a hair in the centre, or as a small, firm, painful intradermic nodule. 
 The skin around the pustule or over the nodule becomes red, swollen, 
 and painful, the pain being of a throbbing, burning character, and 
 in the course of some days, from three to five usually, a pea- to nut- 
 sized rounded tumor-like elevation is formed, in the centre of which 
 a small opening appears, through softening of the skin giving exit 
 to pus and blood and a little later to a soft tenacious mass of necrotic 
 tissue, the so-called "core." The cavity left after the escape of the 
 
228 DISEASES OF THE SKIN 
 
 "core" soon closes by granulation, and a scar varying in size accord- 
 ing to the depth and extent of the necrosis is left which is usually 
 permanent. The inflammation does not, however, always go on to 
 suppuration and necrosis, but may stop short of this, forming a small, 
 painful nodule in the skin, which is absorbed in the course of a little 
 time, leaving no trace, the so-called "blind boil." The number of 
 lesions varies from a single one to three or four, or occasionally scores. 
 When there are many they often appear in irregular crops without any 
 special arrangement, either confined to special regions or with a more 
 or less general distribution, a condition to which the term furunculosis 
 is applied. In the hot months of summer it is not unusual to see in 
 ill-nourished and ill-cared-for infants living in the poor quarters of 
 large cities, scores of furuncles situated upon the scalp, face, and 
 trunk, which continue to appear until the advent of cool weather ; this 
 is the affection described by Colcott Fox as " multiple abscesses of 
 infants." 
 
 The regions most frequently affected are the nape of the neck, 
 the axillae, the gluteal region, and the extremities, although no region 
 is immune. The symptoms and course of furuncles are influenced 
 to some degree by their location. When situated upon the upper 
 lip they are frequently accompanied by an unusual amount of pain 
 and swelling and pronounced constitutional disturbance, and they 
 may be followed by phlebitis, thrombosis, and a fatal meningitis. In 
 the auditory canal they give rise to great pain. About the anus they 
 are often of considerable size and are apt to be followed by fistula. 
 
 Etiology. — A furuncle is the direct result of the invasion of the 
 skin, in most cases at the site of a follicle, by a pyogenic organism, 
 most frequently the Staphylococcus pyogenes aureus. Predisposing 
 causes are debility from previous disease, lack of proper or sufficient 
 food, alcoholic excess, general infections, such as typhoid fever and 
 variola, and diabetes mellitus, which makes the skin a favorable soil 
 for the growth of microorganisms. It occurs frequently in itching 
 diseases, such as pediculosis corporis, scabies, and eczema, the in- 
 fection taking place in scratches. New lesions frequently arise in the 
 neighborhood of old ones by auto-inoculation, an extremely important 
 point to remember in connection with treatment. 
 
 Pathology. — The furuncle is the product of an inflammation which 
 results in a limited necrosis, the inflammation being directly due to 
 toxins produced by the invading organisms. The walls of the in- 
 flamed follicle and the perifollicular tissues are occupied by a dense 
 exudate made up of mono- and polymorphonuclear leucocytes through- 
 out which are great numbers of staphylococci. Necrosis follows, de- 
 stroying the follicle, which is replaced by scar-tissue. There is some 
 difference of opinion as to whether the infection is limited to the folli- 
 cles or whether it may not also invade the sweat-glands ; a consider- 
 able number of authors believe the deep-seated furuncles are situated 
 in the latter. According to Unna, there is in most cases first an 
 
INFLAMMATIONS 229 
 
 impetigo pustule, which is followed by a perifollicular abscess of a 
 lanugo hair, and suppuration of the follicle. 
 
 Diagnosis. — The symptoms of a boil are so well known to every- 
 one that it seems quite unnecessary to enter into a detailed considera- 
 tion of the diagnosis. 
 
 Prognosis. — In most cases recovery is prompt, although in furuncu- 
 losis the affection may continue for months, or even a year or two, 
 before recovery takes place. As has already been observed, furuncles 
 occurring upon the face, and particularly upon the upper lip, are at 
 times accompanied by great pain and pronounced constitutional dis- 
 turbance, and in exceptional cases are followed by death. 
 
 Treatment. — When the patient suffers from debility or is ill-nour- 
 ished, he should be given tonics, such as moderate doses of iron, 
 quinine, strychnia, arsenic, and cod-liver oil, with an abundance of 
 good food, and strict attention should always be paid to cleanliness. 
 A great number of internal remedies have from time to time been 
 recommended for the cure of furunculosis, but it is more than doubt- 
 ful whether any of them have any real utility. Brewer's yeast has 
 long had a reputation for the cure of boils, not only among the laity, 
 but among the profession; Crocker and Brocq both advised its use, 
 but it is probably no better than a host of other so-called remedies ; 
 it may be given in quantities of a tablespoonful to a wineglassful 
 three times a day, using the fresh yeast. Calx sulphurata (calcium 
 sulphide) at one time had considerable vogue, but it is without effect. 
 Within the past few years the so-called vaccine treatment — the hypo- 
 dermatic injection of killed cultures of the staphylococcus, preferably 
 made from the patient's own lesions, have been employed with ex- 
 cellent, at times brilliant, results, although it frequently fails. It 
 should always be tried, particularly in furunculosis, when the ordinary 
 methods of treatment have proved ineffective. 
 
 In most cases local treatment is sufficient to bring about a cure. 
 If seen early, the furuncle may often be aborted by thoroughly rubbing 
 in a thirty per cent, ichthyol ointment for ten minutes and afterwards 
 applying the ointment thickly for from ten to twelve hours. In my 
 hands this has been a most useful treatment. It may also be aborted 
 by injecting it with a five per cent, solution of carbolic acid, or by 
 boring into it with a pointed stick — a wooden toothpick answers — 
 dipped into pure carbolic acid. After the first twenty-four or forty- 
 eight hours it is usually too late for abortive treatment. While a 
 great number of local applications are more or less useful, nothing is 
 more effective in relieving pain and in hastening suppuration than hot 
 fomentations of a saturated solution of boric acid ; these soon bring 
 about softening and discharge of the contents of the boil. Incision, 
 which is so generally recommended, is, in my opinion, quite unneces- 
 sary, unless the furuncle is large or deep-seated ; in the ordinary case 
 it in no way influences the course of the lesion and is very painful. 
 In order to prevent the appearance of new lesions in the neighborhood 
 
230 DISEASES OF THE SKIN 
 
 of the old ones the skin should be thoroughly disinfected for some 
 distance around the furuncle, and in the author's experience nothing 
 is more effective for this purpose than a two per cent, solution of 
 salicylic acid in seventy per cent, alcohol mopped on softly two or 
 three times a day. 
 
 CARBUNCULUS 
 
 Synonyms. — Anthrax ; Anthrax simplex ; Carbuncle ; Fr., Carbon- 
 cle ; Ger., Karbunkel, Brandschwar. 
 
 Definition. — An acute inflammation of the skin and subcutaneous 
 tissue characterized by redness and induration, with a marked tend- 
 ency to peripheral extension, terminating in extensive necrosis. 
 
 Symptoms. — It begins as a small, painful subcutaneous induration 
 over which the skin is red, the early stage resembling somewhat a 
 furuncle, although the induration is more decided and deeper seated. 
 The inflammation rapidly extends in all directions, the skin becomes 
 somewhat elevated and of a deep red or purplish color, and at the 
 end of from ten days to two weeks occupies an area varying from 
 two or three to eight or ten inches in diameter. Over the inflamed 
 surface scattered pustules appear with areas of softening, over which 
 the skin, becoming thin and livid, gives way, and from the openings 
 thus formed a purulent fluid is discharged. As these openings enlarge, 
 a grayish pultaceous mass of necrotic connective tissue is seen be- 
 neath the skin, which gradually softens and escapes from the open- 
 ings, leaving a cavity which is slowly filled up by granulation. Not 
 uncommonly the entire skin over the necrotic mass ulcerates, and 
 when the latter is cast off an extensive ulcer is left, which occupies 
 weeks in healing. Exceptionally gangrene, either moist or dry, of 
 the entire inflamed area takes place and the eschar is cast off en masse 
 after a line of demarcation has formed. More or less constitutional 
 disturbance is present in most cases, even from the beginning, which, 
 when the inflamed area is large, may become quite pronounced, and 
 symptoms of sepsis occasionally appear. Severe pain of a throbbing, 
 burning character usually attends the affection, interfering much with 
 rest and sleep. The smaller lesions run a course of two or three weeks ; 
 the larger ones may last as many months. As a rule to which there 
 are few exceptions, there is but a single lesion, differing markedly in 
 this respect from furuncle. The regions of election are the nape of 
 the neck and the upper portion of the back, but any locality may be 
 attacked. 
 
 Etiology. — Carbuncle occurs in the great majority of cases in mid- 
 dle-aged, elderly, or old individuals. It is decidedly uncommon in 
 young adults and never occurs in children. It is more frequent in 
 men than in women. Debility, alcoholism, and diabetes mellitus are 
 predisposing causes, the last-named especially predisposing to it. The 
 immediate cause is the invasion of the skin, usually, if not always, a 
 follicle, by pyogenic organisms, most commonly the staphylococcus 
 aureus. A number of authorities, however, such as Unna, think it 
 
INFLAMMATIONS 231 
 
 probable that a special organism is concerned in its production, but 
 this still awaits demonstration. 
 
 Pathology. — Winiwarter regards the malady as an embolic affec- 
 tion with necrosis followed by an intense fibrinous inflammation. Ac- 
 cording to Warren, the inflammation begins in the subcutaneous tissue, 
 spreads upwards along the column® adiposes, forming pustules about 
 the hair follicles, and laterally along the lymphatics and the vessels 
 going off from the fat columns ; eventually the entire corium is in- 
 volved in a destructive inflammation. Exact details are still wanting 
 concerning the histopathology of the early stages. 
 
 Diagnosis. — In its earliest stage a carbuncle may be mistaken for 
 a furuncle, but the rapid extension of the induration and inflammation, 
 the appearance of multiple openings over the surface, and the pres- 
 ence of fever soon make apparent the real character of the lesion. 
 
 Prognosis. — Carbuncle is always a serious affection, and the prog- 
 nosis should always be a guarded one, especially in feeble and in old 
 subjects, in whom a fatal termination is not uncommon, death result- 
 ing from sepsis or exhaustion. In diabetic subjects it is often of large 
 size and attended by serious general symptoms which frequently end 
 fatally. 
 
 Treatment. — The most effective and certain method of treatment 
 is the excision of the entire lesion, but this is only practicable in the 
 early stages. Injections of a three per cent, solution of carbolic acid 
 made all around the spreading margin will frequently arrest its fur- 
 ther progress. When necrosis has occurred a saturated solution of 
 phenol should be injected in every direction through the openings 
 into the slough, as advised by Wood, Taylor, Manley, and others. 
 As soon as it is sufficiently separated the slough should be removed. 
 Hot boric acid fomentations are often very useful in relieving pain 
 and tension and in accelerating the separating of necrotic tissue. If 
 pain is severe and prolonged, occasional hypodermatic injections of 
 morphia may be necessary. The patient's general condition frequently 
 demands careful attention. If he is the subject of diabetes, treatment 
 appropriate to this affection should be employed. Failure of strength 
 is to be anticipated and met by an abundance of nourishment and the 
 administration of tonics and stimulants. 
 
 ERYSIPELAS 
 
 Synonyms. — St. Anthony's fire ; Fr., Erysipele, La rose ; Ger., Roth- 
 lauf, Rose, Wundrose. 
 
 Definition. — An acute, contagious, and infectious disease character- 
 ized by a spreading dermatitis occurring as dusky-red, well-defined 
 patches, accompanied by fever. 
 
 Symptoms.— The attack usually begins rather abruptly with chilli- 
 ness or a pronounced chill, fever and headache, and a few hours later 
 a dusky-red patch appears, usually on some portion of the face, most 
 frequently near the nose or on the forehead near the margin of the 
 
232 DISEASES OF THE SKIN 
 
 hair, somewhat less frequently upon the ear or in its neighborhood. 
 This patch is somewhat swollen, shining, its borders usually well 
 circumscribed and slightly elevated; it spreads steadily by continuity 
 to neighboring parts until a considerable area, not infrequently the 
 entire face, or the face and scalp, is covered. The face is then mark- 
 edly swollen, the eyes frequently closed, and the ears greatly thick- 
 ened. Not uncommonly the inflamed surface is covered with vesicles 
 and blebs, and in the severest cases the deep cellular tissue may be 
 invaded with the formation of abscesses. In rare instances gangrene 
 of the skin occurs. The temperature is usually high, reaching 104 , 
 105 , or even 106 F., and in the debilitated or in alcoholics there is 
 frequently delirium with great prostration. Often after four or five 
 days the redness and swelling disappear in the region first attacked, 
 although the disease may still be extending on its borders. Occasion- 
 ally the inflammation extends to the mucous membranes of the mouth 
 and throat, which become dry, red, shining, and swollen, and the larynx 
 may be involved with pronounced oedema threatening suffocation. 
 
 Somewhat exceptionally the disease exhibits a tendency to spread 
 widely, not only covering the face and scalp, but extending to the 
 trunk ; in such cases the malady pursues a prolonged course, lasting 
 for several weeks (erysipelas migrans, erysipelas ambulans). In a 
 case of this kind under the author's care the disease spread over the 
 entire face and scalp and down the back to the lumbar region. 
 
 Etiology and Pathology. — Erysipelas is contagious to a mild de- 
 gree and may be communicated by direct contact, or mediately by 
 clothing, or by a third person. The immediate cause is a streptococcus, 
 the Streptococcus erysipelatis, which was first isolated by Fehleisen. 
 It is regarded by most recent authorities as identical with the strepto- 
 coccus pyogenes. It is found abundantly in the lymph spaces at the 
 spreading margin of the dermatitis and some distance beyond in the 
 lymph-vessels. The presence of wounds or abrasions especially pre- 
 disposes to the infection, and it is common in those who have recently 
 undergone surgical operations and in puerperal women. It is uncer- 
 tain whether infection can take place through the unbroken skin, al- 
 though in facial erysipelas there is, as a rule, no discoverable breach 
 of continuity. Individual susceptibility to the infection varies a good 
 deal. There are some individuals who are especially prone to it. In 
 a patient of the author's there were three attacks in four months, and 
 a history of a number of previous attacks. Debility and alcoholism 
 are likewise predisposing causes. Season apparently influences the 
 incidence of the disease ; Anders found it much more prevalent in the 
 spring months, especially April, than in the other seasons of the year. 
 
 The inflammation is, according to Unna, a simple fibrinous one. 
 The collagen of the corium undergoes softening and the elastic tissue 
 disappears. The vessels and capillaries are dilated, and many of 
 them contain fibrinous thrombi which occasionally completely fill them. 
 The epithelium of the epidermis undergoes degeneration and partial 
 
INFLAMMATIONS 233 
 
 necrosis, and when the exudation of serum has been abundant the 
 entire epidermis is lifted up from the papillary body. 
 
 It is a well-known and extremely interesting fact that an attack 
 of erysipelas occasionally exercises a favorable influence upon other 
 morbid conditions, such as malignant neoplasms like sarcoma, and 
 chronic inflammatory diseases. Hallopeau and Roudet have observed 
 the cure of erythematous lupus on the side of the face attacked by 
 erysipelas. 
 
 Diagnosis. — Erysipelas is to be differentiated from simple derma- 
 titis and from eczema. From both these it differs by the peculiar 
 dusky-red color of the patches, their well-defined and somewhat ele- 
 vated borders, and, above all, by the more or less pronounced consti- 
 tutional disturbance which accompanies the inflammation of the skin. 
 
 Prognosis. — The prognosis is, as a rule, favorable in adults who 
 have previously been in good health. The contrary is true in the 
 aged, the debilitated, and especially in alcoholics. In puerperal women 
 and in those who have undergone serious surgical operations its oc- 
 currence is always of serious import. In very young infants, in whom 
 it may spread widely, a fatal termination is the rule. 
 
 Treatment. — The diet should consist largely of milk and eggs, and 
 these should be given in the old and debilitated at short intervals. 
 When stimulants are indicated, alcohol and strychnia may be given, 
 the former in moderate quantities only. If the temperature is high, 
 tepid baths and cold sponging may be employed to reduce it. 
 
 It is very doubtful whether any known internal remedy is capable 
 of favorably influencing the course of the malady. The tincture of 
 the chloride of iron has long been regarded as having especial value 
 in the treatment of erysipelas ; it should be given in doses of from 
 fifteen to thirty minims (i.o to 2.0) every three or four hours, along 
 with quinine, two to three grains (0.13 to 0.20) at a dose. Injections 
 of antistreptococcic serum and of autogenous vaccines have occasion- 
 ally given good results. Attempts have been made to limit the spread 
 of the disease by injecting solutions of carbolic acid, two per cent., 
 and of bichloride or mercury, 1 -.4000, about the borders of the patches 
 with occasional success. With the same end in view, the borders 
 of the patch and some distance beyond may be painted with tincture 
 of iodine. Ichthyol is one of the most useful local remedies, and may 
 be used as a twenty-five per cent, ointment, which should be applied 
 two or three times a day, or as an aqueous solution, twenty-five per 
 cent., painted on with a camel's-hair brush ; the author much prefers 
 the latter as more agreeable and more effective. 
 
 ERYSIPELOID 
 
 Synonyms.— Erythema serpens (Morrant Baker) ; Erythema 
 migrans. 
 
 Definition. — A spreading, patchy erythema of the hands resembling 
 superficially erysipelas. 
 
234 DISEASES OF THE SKIN 
 
 Symptoms.— This affection was given the name erysipeloid by 
 Rosenbach because of its resemblance to erysipelas, but it was first 
 described by Morrant Baker as erythema serpens. It is distinguished 
 by pinkish or violaceous patches, with well-circumscribed margins, 
 which begin about a slight abrasion or puncture in the skin and spread 
 eccentrically. As they extend at the borders they undergo involution 
 at the point of origin, and in this manner may assume an annular 
 shape, or, when two or more neighboring patches coalesce, present a 
 serpiginous arrangement. There may be but a single patch, or there 
 may be several, and they are situated almost exclusively upon the 
 hands. Elliot, however, observed an instance in which the toes were 
 also affected. Some degree of itching and burning is usually present, 
 which may be quite severe, and in some cases there is considerable 
 
 pain. . - 
 
 Etiology and Pathology.— The disease occurs chiefly in butchers, 
 fish-dealers, cooks, and others who are apt to handle decomposing ani- 
 mal matter. Rosenbach attributed it to a microorganism, a cladothrix, 
 with cultures of which he claimed to have reproduced it. Gilchrist, 
 in a large number of cases resulting from crab-bites or lesions produced 
 by crabs, most carefully studied, was unable to find any organism, 
 and all his culture and inoculation experiments resulted negatively; 
 he thinks it probably due to a special ferment. In sections he found 
 the histological changes characteristic of acute inflammation; there 
 were numerous polynuclear leucocytes and lymphoid cells in all parts 
 of the corium, the latter chiefly about the vessels. 
 
 Diagnosis.— The affection is to be distinguished from erysipelas 
 by its almost exclusive localization upon the hands, and the absence 
 of fever. The spreading patches, when they assume an annular shape, 
 may resemble the annular patches of erythema multiforme, erythema 
 annulare, but the latter are usually accompanied by other lesions, such 
 as papules, and are symmetrically distributed on the backs of both 
 
 hands. . . 
 
 Prognosis and Treatment.— The disease is a self-limited one, dis- 
 appearing spontaneously after two or three weeks. Its course may be 
 shortened materially by appropriate local treatment. A twenty-five 
 per cent, ointment of ichthyol or an aqueous solution of the same 
 strength, applied two or three times a day, is one of the most useful 
 applications. Gilchrist found a twenty-five per cent, plaster of sali- 
 cylic acid the most effective remedy in his large series of cases. 
 
 GRANULOMA PYOGENICUM 
 
 Synonyms.— Botryomycosis ; Granuloma telangiectodes; Granu- 
 loma pediculatum ; Fr., Botryomycose humaine (Poncet and Dor); 
 Pseudobotryomycose. 
 
 Definition.— A benign growth composed of granulation-tissue. 
 
 Symptoms.— This small neoplasm was first described by Poncet 
 and Dor, in 1897, who, believing it to be due to an infection by the 
 
INFLAMMATIONS 235 
 
 botryomyces, an organism described by Bollinger, gave it the name 
 human botryomycosis. Although not a common affection, a consider- 
 able number of cases are already on record, reported by Chambon, 
 Sabrazes and Laubie, Reverdin and Julliard, Brault, and a few others 
 in France, by Faber and Siethoff in Holland, by the author and Wile 
 in America, and by KutnofT and Heuk in Germany. The last-named 
 has published a most exhaustive account of it, with abstracts of all 
 the cases reported to date. It occurs as a pea- to a hazel-nut-sized, 
 smooth, red, round or hemispherical tumor, usually attached by a 
 pedicle, but sometimes sessile, projecting through an opening in the 
 horny layer of the epidermis, which surrounds it like a collar. It is 
 usually situated upon the extremities, oftenest upon the hands (Fig. 
 64), occasionally upon the feet, much less frequently upon the cheeks 
 or the lip. Although rarely the seat of spontaneous pain, it is usually 
 quite sensitive and sometimes extremely so. It is extremely vascular 
 and frequently bleeds profusely upon the slightest injury. When 
 removed it frequently recurs again and again, unless the base has 
 been very thoroughly destroyed. In many in- , 
 
 stances a slight injury, such as a small puncture 
 with a needle or other pointed instrument, or a 
 slight abrasion, has preceded the appearance of the 
 tumor. 
 
 Etiology and Pathology. — In all probability! 
 traumatism always precedes the growth, although! 
 this is not demonstrable. As already observed,'^ 
 Poncet and Dor at first believed it to be the result 
 of an infection with the botryomyces, a fungus dis- 
 covered by Bollinger in tumors of the scrotum and 
 spermatic cord of the horse following castration. 
 The only organism present is the staphylococcus. FlG " ^n^hu^b Py °' 
 
 The growth is composed chiefly of young connective-tissue cells 
 and numerous blood-vessels, frequently greatly dilated and filled with 
 blood, giving the sections the appearance of an angioma in places. 
 About some of the vessels there are small collections of lymphocytes 
 and a few "mastzellen." About the periphery there is a moderate 
 number of polymorphonuclear leucocytes and an abundance of staphy- 
 lococci. Heuk would divide the growth into two varieties : granuloma 
 pediculatum simplex, resembling for the most part granulation tissue, 
 and granuloma pediculatum angiomatosum, distinguished by a tend- 
 ency to the formation of large blood-spaces, and collections of spindle 
 cells (Fig. 65). 
 
 Diagnosis. — Their situation, in most cases somewhere upon the 
 hand, as a rule following a slight injury, their great vascularity and 
 sensitiveness are characteristic features. 
 
 Prognosis and Treatment. — Thorough removal is followed by com- 
 plete cure, but recurrences are frequent unless the destruction of the 
 little tumor has been complete. 
 
236 
 
 DISEASES OF THE SKIN 
 
 *«, per «„,. ci„, m „, „( pyrogaIlo| t0 ,„, :™*»^ 
 
 PIG. 65. -Granuloma pyogenicum. Very vascular granulation tissue 
 large dilated vessels. 
 
 Note ni 
 
 days to insure thorough destruction of the base of the tumor After 
 toying a number of methods the author has found this the most effec 
 tive in preventing recurrences. 
 
 INFECTIOUS GRANULOMATA 
 LUPUS VULGARIS ' 
 
 Synonyms.-Lupus exedens; Lupus vorax; Fr., Lupus vulgaire ■ 
 Lupus tuberculeux; Ger., Fressende Flechte (Plate XV) 
 skin D bv n th 10 K _ n n { ff Ction , s ^nulorna due to the invasion of the 
 £ i, , J t " berc « los «. characterized by discrete brownish- 
 
 red nodules and patches of nodules followed by ulceration and scar- 
 s ■ 
 
 Lupus vulgaris is the commonest and best-known of all the forms 
 of tuberculosis of the skin. While it is an infrequent affection in the 
 United States, comprising less than one-half of one per cent of all 
 
PLATE XV 
 
 Lupus vulgaris (elbow). 
 
INFLAMMATIONS 237 
 
 cutaneous affections, according to the statistics of the American Der- 
 matological Association, embracing several hundred thousand cases, 
 it is common in many countries of Europe, such as Austria, France, 
 Russia, and the Scandinavian peninsula. In Great Britain, although 
 decidedly less frequent than on the Continent, it comprises, according 
 to Crocker, about two per cent, of all skin diseases. 
 
 Symptoms.— It usually begins with one or more discrete, pin-head- 
 sized, brownish-red nodules deeply imbedded in the skin, projecting 
 little,' or not at all, above the surface for some time after their ap- 
 pearance. If the skin is stretched, or if the nodules are examined under 
 glass-pressure, they grow paler, assuming a dull yellowish hue, but do 
 not disappear.' New nodules appear from time to time in the neigh- 
 borhood of the old ones, which slowly enlarge, so that in the course 
 of some months or years patches of variable size and shape are formed 
 (Fig. 66). The course of the lesions is variable. They may remain 
 deeply imbedded in the skin, scarcely appreciable by the touch (lupus 
 planus, or lupus maculosus of older writers), undergoing very little 
 
 l TH 
 
 Fig. 66. -Lupus vulgaris. FlG - 67.— Lupus vulgaris. 
 
 change for a period lasting months and even years. Leloir saw a 
 case of this kind which had undergone little or no change in twelve 
 years. Eventually they are absorbed, leaving a thin, parchment-like 
 scar, which exfoliates moderately (lupus exfoliativa). This form, 
 which represents the mildest type of the disease, is rather infrequent. 
 Much more commonly the nodules grow until they reach the size of 
 a small pea; they are then distinctly elevated and exhibit a peculiar 
 semitranslucency which has been compared to apple-jelly. They may 
 either undergo absorption after a variable period, or ulcerate, pro- 
 ducing irregularly shaped, rather shallow ulcers, with thin edges, 
 which discharge a purulent fluid which dries into yellow or greenish 
 crusts (lupus exedens). Although the ulceration usually progresses 
 slowly, it may eventually involve large areas, producing uneven, con- 
 tractile scars which frequently resemble those which follow burns, 
 and which when situated about the smaller points, as the fingers, 
 or other movable part, such as the lower jaw, may interfere more or 
 less with motion. A somewhat characteristic feature of the scars of 
 
238 
 
 DISEASES OF THE SKIN 
 
 lupus is the reappearance of nodules from time to time in the cicatricial 
 tissue which was apparently free from active disease. Although the 
 patches are often irregular in outline, without any definite arrangement 
 of the nodules, they occasionally assume an annular shape (Fig. 67). 
 
 nodules, ulcers, and crusts sur- 
 rounding a central area of scar- 
 tissue. Through the extension of . 
 such annular patches and the coal- 
 escence of their borders, serpigi- 
 nous figures are sometimes formed, 
 an arrangement which is seen most 
 frequently upon the extremities 
 (Fig. 68), less commonly upon the 
 trunk. In many cases there is but 
 a single patch, situated more fre- 
 quently in the face (Figs. 69 and 70) 
 than elsewhere, but there may be 
 several, and exceptionally there 
 may be many scattered over the 
 face, extremities, and trunk (lupus 
 disseminatus). Some portion of the 
 face, usually the cheek, is the part 
 most frequently attacked ; the nose 
 is also a common site. In the last- 
 named region the disease usually 
 begins upon one or both alse, ex- 
 tending thence to other portions of 
 the organ, or it may begin at the 
 edge of the nostril, invading the 
 mucous membrane as well as the 
 skin. In the course of months or a 
 year or two all the soft parts are 
 invaded as well as the cartilage, and 
 eventually destroyed, the nose be- 
 ing transformed into a pointed, 
 beak-like prominence covered with 
 thin scar-tissue, the nostrils more or less narrowed, or, in exceptional 
 cases, completely occluded. 
 
 Lupus frequently occurs upon the external ear, beginning as a 
 rule upon the lobe, which is more or less thickened, brownish-red or 
 violaceous in color, translucent and gelatinous in appearance, and 
 often slightly scaly. The disease slowly spreads to other parts of the 
 ear, absorption or ulceration takes place in time, and finally nothing 
 is left but the cartilage covered with thin, shrunken scar-tissue. 
 
 Although the above-mentioned regions are those in which the 
 malady is most frequently met with, no portion of the cutaneous sur- 
 
 ■■■. '"■■ '■ ■■■■■ 
 
 Fig. 68. — Lupus vulgaris, thigh. 
 
INFLAMMATIONS 
 
 239 
 
 face is exempt. Next to the face in order of frequency are the ex- 
 tremities (Fig. 71), which are attacked oftener than the trunk, which 
 is invaded, as a rule, only in those cases in which the disease is wide- 
 spread. The scalp and genitalia are rarely attacked. 
 
 More or less marked departures from the usual type and course 
 occur with considerable frequency. In certain cases there is solid 
 oedema, with hyperplasia of the fibrous tissue of the corium as the 
 result of blocking up of the lymph-channels by infiltration of lupus 
 tissue, or from repeated attacks of lymphangitis (lupus hypertrophi- 
 cus) (Fig. 72). When this occurs upon the lower extremities it is 
 frequently accompanied by extensive papillary hypertrophy, producing 
 a condition resembling elephantiasis. 
 
 Some years ago Leloir called attention to a peculiar and unusual 
 variety in which, instead of tubercles, there is a uniform, dusky-red 
 
 Fig. 69. — Lupus vulgaris. Much crusting. 
 
 Fig. 70. — Lupus vulgaris. 
 
 infiltration of the skin, forming patches with slightly elevated borders, 
 and after a time a slightly depressed centre, the surface often desqua- 
 mating moderately. On account of its resemblance to lupus erythema- 
 tosus, especially when it occurs in the face, where it may show a sym- 
 metrical bilateral arrangement, he gave this variety the name lupus 
 vulgaris erythematodes (lupus vulgaire erythematoide). Although 
 no decided nodules are present, if the skin is examined when stretched 
 or under glass-pressure miliary nodules may be seen at the borders 
 of the patch. The progress of this form is extremely slow. Ulceration 
 never occurs, but the patches may be absorbed, leaving depressed 
 cicatrices. 
 
 The lupus sclerosus of this author is, as he stated, only a form of 
 the tuberculosis verrucosa cutis of Riehl and Paltauf. 
 
 Whatever form it may assume, the course of the disease is slow 
 and irregular, marked by periods of inactivity followed by exacerba- 
 tions. New lesions are added to the borders of the patches, which 
 
240 
 
 DISEASES OF THE SKIN 
 
 are thus slowly enlarged, and new foci spring up occasionally at 
 points more or less remote from the original one, which serve as the 
 nuclei for new patches. As the disease slowly extends, variously-sized 
 
 Fig. 7i. — Lupus vulgaris, forearm. (This patient developed tuberculosis of larynx and lungs.) 
 
 ^BBB 
 
 #% 
 
 
 Fig. 72. — Lupus hypertrophicus. 
 
 areas of scar-tissue are formed, either through the absorption of the 
 lupus infiltrate or the ulceration of the nodules, the scars which fol- 
 low absorption being, as a rule, smooth and parchment-like, while those 
 
INFLAMMATIONS 241 
 
 which result from ulceration are irregular and uneven, like those Re- 
 sulting from a burn. Upon the face the amount of disfigurement which 
 follows in long-standing and extensive cases is extreme. Lips, eye- 
 lids, nose, ears may all be replaced by cicatrices, changing the face 
 into a hideous mask. Pain is rarely a prominent symptom. 
 
 Lupus does not limit its ravages to the skin, but attacks the mu- 
 cous membranes of the nose, lips, pharnyx and larnyx. The nasal 
 mucous membrane is attacked very frequently, in from twenty to 
 thirty per cent, of all cases, the disease usually extending to this 
 region from the skin, although it may begin here. In the mouth it 
 is found on the inner surface of the lips and on the gums, where it 
 produces infiltration and ulceration with papillomatous growths. On 
 the hard and soft palate it produces ulceration and often considerable 
 distortion of the soft parts by the contraction of the resulting cica- 
 trices. The mucous membrane of the larnyx is much less frequently 
 invaded than the other mucous membranes ; in this region it produces 
 ulceration with hoarseness or even complete loss of voice, and occa- 
 sionally more or less dyspnoea. The conjunctival mucous membrane 
 may be attacked, although infrequently, the disease usually extending 
 to this region from the lachrymal duct, from the lids or from the 
 cheek ; in rare instances it is primary. 
 
 Complications and Sequelae. — Pulmonary tuberculosis is a frequent 
 complication of lupus. According to Leloir, it occurs in thirty per 
 cent, of all cases, and other observers give an even higher percentage. 
 Tubercular meningitis and miliary tuberculosis also occur, although in- 
 frequently. Inflammation of the lymphatics and of the lymphatic 
 glands frequently occurs, the latter not uncommonly suppurating. A 
 serious, although happily an infrequent, sequel is epithelioma, which 
 usually develops in a scar and occurs more frequently in the face 
 than elsewhere. 
 
 Etiology. — Lupus vulgaris begins in the 'great majority of cases in 
 childhood and early youth, but is rare before three years of age and 
 appears infrequently after puberty. Exceptions occur, however; 
 Colcott Fox saw five cases in which it began in the first year of life, 
 and the author has seen it as early as the second year. Very excep- 
 tionally it begins quite late ; the author has under his observation at 
 present a woman with an extensive lupus of the face in whom it began 
 at 62 years of age. It is decidedly more frequent in women than in 
 men, according to Crocker's experience in the proportion of four of 
 the former to one of the latter. Although its subjects often appear 
 in good general health, a very considerable proportion show signs of 
 active or past tuberculosis, especially of the glands and bones; Fox 
 found more than 30 per cent, of 96 cases suffered from glandular dis- 
 ease. In a very large proportion of instances there is a history of 
 tuberculosis in other members of the patient's family (Fox, Crocker, 
 Bender and others). 
 
242 
 
 DISEASES OF THE SKIN 
 
 It is an occasional sequel of the eruptive fevers, more especially of 
 measles, a considerable number of instances being recorded in which a 
 more or less widely disseminated lupus followed shortly after an attack 
 of that disease. 
 
 The direct cause is the bacillus tuberculosis. It may arise from 
 direct inoculation of this organism into the skin, or it may follow 
 tuberculosis of the deeper tissues as a secondary affection. Examples 
 of direct inoculation have been reported by numerous observers ; it has 
 been noted to follow piercing of the ears, vaccination, contact of an 
 abrasion with tuberculous sputum, tattooing, the needle having been 
 
 
 Fig. 73- — Lupus vulgaris, abundant exudation of lymphoid cells with here and there a giant-cell, g. 
 
 moistened with the saliva of the operator, who was the subject of 
 pulmonary tuberculosis (Jadassohn). As a secondary affection, it 
 frequently begins at the external opening of a sinus connected with 
 a tuberculous gland or carious bone ; the case of the elderly woman 
 above referred to was an example of this mode of origin, the disease 
 having begun about a sinus connected with a suppurating tuberculous 
 gland at the angle of the jaw. Much less frequently the bacillus 
 
INFLAMMATIONS 243 
 
 reaches the skin by way of the lymphatic and blood channels from some 
 primary visceral focus ; and in such cases the patches are usually much 
 more numerous and more widely disseminated than in the cases which 
 arise by direct inoculation. 
 
 Pathology. — Lupus is an infectious granuloma of tuberculous na- 
 ture, and may be taken as the type of cutaneous tuberculosis. While 
 its histopathology corresponds in its principal features with the histo- 
 pathology of tuberculosis of other tissues, it varies considerably in 
 its details. In recent nodules the subpapillary portions of the corium, 
 much less frequently the papillae, are occupied by round, oval, or 
 irregularly-shaped, usually quite well-circumscribed, collections of 
 cells, situated about or in the neighborhood of a vessel, and imbedded 
 in a delicate fibrous mesh-work. The cells are usually of three 
 kinds — epithelioid cells, small, round, or lymphoid cells, and in much 
 smaller numbers large multinucleated giant-cells of the Langhans 
 type (Fig. 73). Not uncommonly there are few or no epithelioid cells, 
 all being of the lymphoid variety with scattered giant-cells, the so-called 
 lymphoid tubercle (Fig. 73). According to Unna, the epithelioid cells 
 are plasma cells, and the small round cells are derivatives of these, 
 "daughter" plasma cells. He finds that in the very earliest stage of 
 the lupus tubercle it is composed entirely of plasma cells. In a con- 
 siderable proportion of cases, instead of being collected in circum- 
 scribed areas, the cells are more or less uniformly distributed through- 
 out the corium, or they are arranged in irregular branching and anasto- 
 mosing tracts, following the blood-vessels and the lymphatic spaces. 
 In many cases the cellular infiltrate is composed of numerous quite 
 round areas of cells, surrounded by an ill-defined, narrow, fibrous 
 capsule, giving it a figured appearance. In the older nodules the centre 
 of the tubercle is occupied by a faintly-staining granular area in which 
 formed elements are no longer visible, the cells, together with the col- 
 lagenous and elastic fibres, having more or less completely disappeared. 
 The vessels are entirely obliterated, either as the result of pressure or 
 from blocking up of their lumen by swollen endothelium. Caseation, 
 such as occurs so commonly in other forms of tuberculosis, does not 
 occur in lupus, and the three-zone arrangement of a caseating centre 
 surrounded by epithelioid cells and an outer zone of small round 
 cells is practically never seen. The further course pursued by the 
 lupus infiltrate varies considerably. The degenerated areas may be 
 slowly absorbed and replaced by fibrous connective tissue with the 
 formation of a cicatrix, or the epidermis, thinned by pressure from 
 below by the growing tubercle, eventually gives way and ulceration 
 follows. In certain cases there is a marked hyperplasia of the con- 
 nective-tissue cells, and the cellular lupus tissue is largely replaced 
 by fibrous tissue, producing, on the lower extremities particularly, 
 an elephantiasic condition, as in lupus hypertrophicus. While tuber- 
 cle bacilli are always present, they are often demonstrated with dif- 
 ficulty, owing to their scanty numbers, it frequently being necessary 
 
244 DISEASES OF THE SKIN 
 
 to examine many sections before finding a single example. They are 
 usually found in the giant-cells, but may be found lying free outside 
 of these. 
 
 Various secondary changes, often of a marked character, occur in 
 the epidermis. It is commonly increased in width, the increase being 
 due chiefly to a hyperplasia of the rete, and in a considerable pro- 
 portion of cases, particularly in those in which the lupus infiltrate 
 occupies the papillae, there is a marked increase in the length of the 
 interpapillary processes of the rete, which may extend down into the 
 corium as branching and anastomosing tracts resembling those seen 
 in epithelioma. There is usually more or less parakeratosis result- 
 ing in desquamation, which at times is quite abundant, as in lupus 
 exfoliativus. 
 
 Diagnosis. — The disease with which lupus is most likely to be 
 confounded is syphilis, particularly the tubercular or nodular lesions 
 of the tertiary period. While as a rule these two affections are readily 
 distinguished from each other, there are cases in which the distinction 
 is made with considerable difficulty. The nodules of lupus are usually 
 less elevated and more deeply imbedded in the skin than those of syphi- 
 lis, particularly in the early stages, and more yellowish and translucent. 
 There is usually but a single patch of lupus, while there are frequently 
 two or more of syphilis ; the former are, as a rule, without any definite 
 arrangement, while the patches of syphilis are frequently annular or 
 crescentic in shape. The progress of a patch of lupus is ordinarily 
 quite slow, months or even years elapsing before it reaches any con- 
 siderable size, while the syphilitic patch grows comparatively rapidly 
 and ulcerates early, the ulcers being much deeper than those of lupus 
 and often exhibiting a punched-out appearance and a circular or cres- 
 centic shape. The scars produced by the two affections are usually 
 quite characteristic ; the scar of lupus is often rough, uneven, and irreg- 
 ular in outline, and frequently shows nodules in the centre, while the 
 scars of syphilis are smooth, round, soft, and pliable, and never contain 
 nodules except at the border, a feature of decided value in diagnosis. 
 The age incidence of the two diseases is also markedly different. Lupus 
 begins almost invariably in childhood, while syphilis is in most in- 
 stances an affection of adult life. In doubtful cases injections of small 
 doses of tuberculin may be tried, always keeping in mind that not only 
 severe local, but general, symptoms may follow in tuberculous 
 subjects. 
 
 Lupus is sometimes mistaken for epithelioma, but the yellowish- 
 red nodules of the former are quite unlike the pinkish nodules of the 
 latter; lupus occurs in patches, while epithelioma is usually found as 
 a single lesion. The ulcers of lupus are shallow, with thin edges, 
 and extend very slowly ; those of epithelioma are frequently quite deep, 
 grow rapidly, and have an infiltrated, bead-like border. Lupus is a 
 disease of early life, epithelioma is seldom seen before middle age, 
 usually after fifty years. 
 
INFLAMMATIONS 245 
 
 The lupus vulgaris erythematodes of Leloir, when situated upon 
 the face and bilaterally distributed, may resemble lupus erythematosus 
 quite closely, but when examined carefully, especially with the aid of 
 glass-pressure, miliary nodules will be found about the borders of the 
 patch, which are never present in the latter affection. 
 
 Quite exceptionally in extensive lupus of the face there may be 
 so much infiltration as to produce a condition resembling the leonine 
 facies of lepra, and the serpiginous patches occasionally seen upon the 
 extremities may be mistaken for that malady, but the presence of the 
 soft, yellowish-red, semitranslucent nodules, and especially the ab- 
 sence of anaesthesia, are features which readily differentiate it from 
 leprosy. 
 
 Occasionally, when there is considerable scaling of the lupus 
 patches (lupus exfoliativus), they may be mistaken for psoriasis, but 
 the scaling never presents the mica-like appearance nor the laminated 
 arrangement so characteristic of the latter disease. 
 
 A thickened patch of inveterate scaly eczema may at times bear 
 some resemblance to a patch of lupus, but the much greater scaling, 
 the itching often severe, the absence of characteristic nodules, and a 
 history of occasional oozing are symptoms so characteristic of eczema 
 that the two diseases are not likely to be mistaken for each other. 
 
 Treatment. — Individuals suffering from lupus, like all other tuber- 
 culous subjects, should live as much as possible in the open air. Fresh 
 air and sunlight are most valuable aids to any method of treatment, 
 and much more useful and effective than drugs. They should have 
 an abundance of easily digested, readily assimilable food, plenty of 
 milk, cream, fresh eggs, with butter and other foods of a similar chan 
 acter. Everything should be done to increase their nutrition, so that 
 their powers of resistance to infection may be brought to the highest 
 possible point. Although not directly influencing the disease, cod- 
 liver oil, iron, arsenic, and quinine are of use in helping to improve the 
 general condition. 
 
 Thyroid gland given internally, as first proposed by Bramwell, 
 was thought by Crocker to directly act upon the lupus tissue, and 
 was regarded by him as a most important aid to the local treatment ; 
 Pringle found it remarkably effective in cases of the so-called florid 
 type. 
 
 Beginning with five grains (0.30) a day, the quantity should be 
 slowly increased until fifteen grains (1.0) a day are being taken, the 
 patient being carefully watched for symptoms of thyroidism ; should 
 these appear, the drug should be suspended or the dose diminished. 
 It should be continued for some time, several months to a year. 
 
 After the complete failure to realize the extravagant hopes which 
 were at first entertained concerning the curative powers of tuberculin, 
 it was completely abandoned for a time as a useless and frequently 
 dangerous agent, but in late years it has been taken up again, and 
 evidence is accumulating that while not a specific, as at first thought, 
 
246 DISEASES OF THE SKIN 
 
 it has a certain measure of usefulness when used with care and dis- 
 crimination. In beginning treatment with this very powerful agent, 
 the dose should be small, the aim being to produce effective local 
 reaction with the minimum amount of constitutional disturbance. The 
 initial dose should rarely be larger than 0.02 mg. of the new tuberculin 
 (tuberculin TR), and an even smaller quantity, 0.002 mg., may be 
 advisable in many cases; a second injection should not be given until 
 the reaction produced by the first one has entirely subsided. Ordinarily 
 the interval between the doses should be from eight to ten days, and 
 the size of the dose should be slowly and cautiously increased. The 
 treatment may be controlled by the opsonic index, as advised by 
 Wright, but if due care is exercised this is not necessary. 
 
 Local Treatment. — However useful general treatment may be, it 
 must be regarded only as an adjuvant, an important adjuvant, it is 
 true, to the local treatment. Since we possess no remedy which, when 
 applied to the lupus tissue, will destroy the tubercle bacillus without 
 at the same time injuring the skin in which it is imbedded, the aim 
 of all local treatment is to remove the disease or to destroy it in situ. 
 
 The various forms of local treatment may be considered under 
 three divisions : First, the mechanical removal or destruction of the 
 disease by surgical procedures, such as excision, erasion, or scarifi- 
 cation ; second, its destruction in situ by various chemical caustics, and 
 the thermo-cautery or the galvano-cautery ; third, its exposure to 
 various forms of radiant energy, such as light, the X-ray, and radium, 
 or phototherapy and radiotherapy. 
 
 When the patches are of moderate size and favorably situated, 
 they may be excised — a method elaborated and largely employed by 
 Lang. In practicing excision, a liberal margin of sound skin down 
 to the subcutaneous fat should be included in order to insure the re- 
 moval of all infected tissue, and the utmost care should be taken to 
 avoid infection of the operation wound by the instruments or sutures 
 employed. When the operation wound is small, it may be closed by 
 sutures in the ordinary way, but if considerable tissue has been re- 
 moved Thiersch grafts should be applied or a plastic operation done, 
 replacing the diseased tissue by a flap of sound skin. Notwithstand- 
 ing every precaution, recurrences occasionally take place in the opera- 
 tion scar. 
 
 The disease may be removed by the curette, but curettement alone 
 is not sufficient to remove all of the lupus tissue ; it should always 
 be followed by the application of some caustic, such as caustic potash, 
 either as a fifty per cent, solution or the solid stick, or pyrogallol 
 applied as a plaster. 
 
 Thorough and repeated scarifications with a fine knife, such as a 
 tenotome, or the many-bladed knife devised for the purpose, first 
 introduced by Balmano Squire and afterwards advocated by Vidal, is 
 capable of producing excellent results, especially from a cosmetic 
 point of view. The patch should be thoroughly cross-hatched, and 
 
INFLAMMATIONS 247 
 
 when the bleeding has been checked it should be dressed with a I :iooo 
 bichloride of mercury solution, or painted with tincture of iodine. 
 
 Formerly the actual cautery was employed a good deal, but at 
 the present time its use is limited to the galvanocautery in the treat- 
 ment of lesions of the mucous membranes. 
 
 Many and various chemical caustics have at one time or another 
 been employed in the treatment of lupus. Arsenic, caustic potash, 
 nitrate of silver, chloride of zinc, pyrogallol, chromic acid, lactic acid, 
 trichloracetic acid, and many others have been used at one time or 
 another for the destruction of the lupus tissue. Of all these, arsenic 
 and pyrogallol, which exercise a more or less selective action upon 
 the diseased tissue, are the most useful. 
 
 Arsenic may be used in the form of Cosme's paste, as modified 
 by Hebra, the formula for which is as follows : 
 
 Acid, arseniosi gr. xx (1.30) 
 
 Cinnabaris 3i (4.0) 
 
 Ungt. aq. rosae Si (32.0) 
 
 M. 
 This should be thickly spread upon lint, applied to the diseased 
 area, covered with a layer of absorbent cotton, and fixed in place by 
 a roller bandage. The dressing should be renewed once every twenty- 
 four hours, cleansing the surface with a saturated boric acid solution 
 or other mild antiseptic solution at each dressing. After three or 
 four days the arsenic paste is discontinued and a wet dressing of boric 
 acid solution is applied continuously until all necrotic tissue has come 
 away and a clean granulating surface is left ; a two per cent, salicylic 
 acid ointment may then be applied until healing is complete. To avoid 
 possible poisoning from absorption, this paste should not be applied 
 to a surface more than three inches (75 mm.) square. The chief 
 objection to arsenic as a caustic is the severe pain which it produces. 
 Pyrogallol, which the author much prefers to any other caustic, 
 may be used as a stiff twenty-five to thirty per cent, ointment or 
 plaster. A formula which the author has employed w T ith much satis- 
 faction is as follows : 
 
 Pyrogallol 3iiss (10. 0) 
 
 Cerat. resinse Bss (16.0) 
 
 Bals. Peruvian q.s. 
 
 M. 
 
 This should be spread thickly upon lint, or, better, upon kid, laid upon 
 the patch to be destroyed, covered with a layer of absorbent cotton, 
 and kept in place by a bandage. The plaster should be renewed twice 
 a day and continued for five to six days. It acts much more rapidly 
 if before applying it the surface to which it is to be applied is first 
 lightly rubbed over with a stick of caustic potash or painted with a 
 50 per cent, solution, and after a few minutes neutralized with dilute 
 acetic acid. The pain which accompanies the use of pyrogallol is sel- 
 dom severe and often trifling. 
 
248 DISEASES OF THE SKIN 
 
 The solid carbon dioxide introduced by Pusey into dermatological 
 therapeutics has not proved a satisfactory remedy in the author's 
 hands ; its effects do not extend deeply enough, and it is therefore only 
 applicable, if applicable at all, to the most superficial cases. 
 
 Cauterization by means of a stream of hot air directed against the 
 patch, as advocated by Hollander, possesses no advantages and some 
 disadvantages over chemical caustics. 
 
 The introduction of the light treatment, phototherapy, by Finsen 
 marked a great advance in the treatment of lupus, and this and the 
 X-ray have pushed all other methods of treatment very much into the 
 background. 
 
 The Finsen treatment consists essentially in the exposure of the 
 diseased area to the concentrated rays of light. In the original ap- 
 paratus sunlight was employed, but in the more recent apparatus the 
 electric arc lamp is used as the source of light, the rays from which 
 are concentrated by a suitable arrangement of quartz lenses, quartz 
 being employed since glass prevents the passage of the actinic rays. 
 Many modifications of the original apparatus of Finsen have been made 
 by Reyn, Lortet, and Genoud, which have increased the practicability 
 of the treatment. 
 
 The part to be treated is made as anaemic as possible and kept 
 so during the exposure by pressure with a quartz compressor, since the 
 blood shuts off the chemical rays of light. Each exposure lasts from 
 one-half hour to two hours, the length of time depending upon the 
 amount of infiltration present. Some hours, usually from twenty to 
 thirty-six, after the exposure the skin becomes reddened and a crop 
 of vesicles and blebs appears, which disappear in the course of from 
 eight to ten days. A second exposure is not given until the reaction 
 caused by the previous one has completely subsided. The treatment 
 is continued in this manner until the nodules have completely disap- 
 peared. Patients should return at intervals of a month or two for 
 examination, so that recurrences may be attacked at once. When ul- 
 cers are present these must be healed by suitable treatment before 
 employing the light, since it is not applicable to ulcerated surfaces. 
 
 The X-ray, which was first employed by Schiff in the treatment of 
 lupus, frequently gives results little, if at all inferior, to those obtained 
 by phototherapy, and usually requires much less time than the latter 
 to produce the same effect, since the sittings are from ten to fifteen, 
 minutes and a much larger surface can be treated at a sitting. There 
 are two methods of conducting X-ray treatment. In the first, moderate 
 doses (three or four H.) are given, each exposure lasting ten to fifteen 
 minutes, with the anode at a distance of five or six inches (125 or 150' 
 mm.), allowing an interval of five days between the exposures. In 
 this manner the nodules may be made to disappear with the minimum 
 amount of reaction, usually nothing more than a moderate erythema. 
 In the so-called "massive dose" method, doses of six to eight H. are 
 given at intervals of three or four weeks, producing a decided derma- 
 titis, sometimes with superficial necrosis. This latter method of 
 
INFLAMMATIONS 249 
 
 treatment is more effective than the moderate dose method in cases 
 in which there is marked infiltration with thick rugous cicatrices; 
 but the danger of producing ulceration, which may require months for 
 healing and which is apt to be followed by scars disfigured by numer- 
 ous telangiectases, is considerable. In many cases a combination of 
 phototherapy and the X-ray produces much better results than either 
 alone. The treatment should be begun as a rule by the X-ray, espe- 
 cially if ulceration is present, and when the ulcers have healed and 
 improvement seems to be at a standstill phototherapy may be begun. 
 In the treatment of lupus of mucous membranes phototherapy can- 
 not be employed owing to the inaccessibility of the lesions, although 
 the use of the X-ray is at times quite practicable. In lupus of the 
 nasal and palatal mucous membranes, cauterization with the galvano- 
 cautery is an effective method of treatment, repeating the cauteriza- 
 tions at intervals until the disease is destroyed. The curette may like- 
 wise be employed under local anaesthesia, followed by cauterization 
 with trichloracetic acid. In lupus of the nasal mucous membrane the 
 method of Pfannenstiel is frequently effective. This method consists 
 in the internal administration of iodide of sodium and the application 
 of tampons of gauze within the nose, which are kept wet with hydrogen 
 peroxide,, which sets free nascent iodine. 
 
 TUBERCULOSIS VERRUCOSA CUTIS 
 Synonyms. — Lupus verrucosus ; Lupus sclerosus ; Verruca necro- 
 genica; Anatomical wart; Postmortem wart. 
 
 Although this form of cutaneous tuberculosis had been previously 
 described by Leloir and others as a variety of lupus under the names 
 lupus verrucosus, lupus sclerosus, it was Riehl and Paltauf who, in 
 
 Fig. 74. — Tuberculosis verrucosa cutis, back of hand. Patient developed pulmonary tuberculosis later. 
 
 1886, first definitely demonstrated its tubercular nature, and gave it 
 the name of tuberculosis verrucosa cutis. 
 
 Symptoms. — It usually begins as a flat, dusky-red or violaceous 
 nodule, situated in most cases upon the back of the hand or fingers, 
 
250 DISEASES OF THE SKIN 
 
 which slowly and painlessly enlarges peripherally, and soon becomes 
 covered with small horny scales or papillary elevations, which give 
 it a wart-like appearance. When fully developed it presents the ap- 
 pearance of a flat, usually rounded, slightly elevated plaque surrounded 
 by a narrow, purplish-red border and a more or less well-marked 
 papillomatous surface covered with grayish, hard, adherent crusts. Oc- 
 casionally miliary pustules are scattered over the surface, according 
 to Riehl and Paltauf, especially in the border, and thick cheesy pus 
 may be expressed from the sulci between the papillae which cover its 
 surface. The patches, usually the size of a coin and rounded in shape, 
 may reach a much more considerable size and be quite irregular in 
 outline. In a certain proportion of cases the papillomatous feature is 
 only moderately developed ; the surface of the plaque is rough and 
 grater-like, covered with small, adherent, horny scales instead of 
 
 Fig. 75- — Tuberculosis verrucosa cutis. (Negro.) 
 
 the usual papillae and crusts. As a rule there is but one lesion, but 
 it is not at all uncommon for two or more to be present; quite rarely 
 there may be many patches scattered over a considerable area. The 
 favorite location for the lesions is the back of the hand (Fig. 74), 
 but they may occur upon the forearm or upon the lower extremities 
 (Fig. 75), but are rarely seen upon the trunk. 
 
 The progress of the affection is commonly slow, the patches chang- 
 ing little from month to month when once they have reached some 
 size. Occasionally symptoms of acute inflammation, such as redness 
 with swelling and some pain, appear, but these usually soon subside. 
 After a variable time, usually many months, or it may be a year or 
 two, the older portion of the patch may become less elevated and 
 smoother and may eventually disappear leaving a thin scar, while the 
 more recent part slowly advances. Sometimes spontaneous involution 
 of the central portion of the plaque takes place, so that an irregular 
 
INFLAMMATIONS 251 
 
 papillomatous ring is formed, which surrounds a smooth scar. Ul- 
 ceration may occur, but this is a decidedly unusual termination. Sub- 
 jective symptoms of any sort are, as a rule, absent, although pain is 
 occasionally present, particularly when the lesion becomes acutely 
 inflamed. 
 
 Verruca Necrogenica. — The verruca necrogenica of Wilks, or an- 
 atomic wart, is a variety of the foregoing and has many features in 
 •common with it, both clinically and histologically. It begins as a 
 small, rather firm, deep-seated red nodule, upon which a pustule de- 
 velops sooner or later, which is soon followed by a crust which falls 
 off after a time, leaving an uneven papillomatous surface. As it 
 slowly enlarges the papillomatous character of the lesion usually 
 becomes more pronounced, and it then resembles the verrucose lesions 
 described by Riehl and Paltauf. There is rarely more than a single 
 lesion, situated in most cases upon the back of the hands, over the 
 knuckles, varying in size from that of a small pea to a bean. Occasion- 
 ally the infection extends to the lymphatic vessels, producing a tuber- 
 culosis lymphangitis, which may be followed by general infection, a 
 sequel which, according to Knickenberg and others, is more apt to 
 occur after this lesion than after the tuberculosis verrucosa of Riehl 
 and Paltauf. The course of the affection is practically the same as 
 that of other forms of wart-like tuberculosis of the skin ; its progress 
 is usually very slow, and spontaneous involution occasionally takes 
 place. 
 
 Etiology. — Verrucose tuberculosis is due to the direct inoculation 
 of the bacillus tuberculosis into the skin. As already noted, it is situ- 
 ated upon exposed parts, particularly the hands, where inoculation 
 readily takes place through some one of the abrasions which are 
 so frequently present upon these members. It is found more frequently 
 upon the hands of those who come into direct or indirect contact with 
 animals, particularly such as butchers, than of those of other occupa- 
 tions. There is no doubt that it is occasionally the result of auto- 
 inoculation, a striking example of this mode of origin having been 
 under the author's observation some years ago. A gentleman who 
 was the victim of pulmonary tuberculosis developed a typical verru- 
 cose tuberculosis upon his right thumb, which he was in the habit of 
 biting, in fits of abstraction, and there is little doubt that inoculation 
 of the skin occurred as the result of this habit. Fabry has called atten- 
 tion to the unusual frequency with which German miners suffer from 
 the affection, a frequency which he believes is the result of inoculating 
 abrasions upon the hands by wiping the mouth with the back of the 
 hand, many of the miners suffering from pulmonary tuberculosis. 
 Verruca necrogenica occurs upon the hands of those who are brought 
 into contact with dead bodies, and is a disease especially of anatomists, 
 dissecting-room attendants, pathologists, etc. 
 
 Pathology. — Very pronounced histological changes are present in 
 both the epidermis and the corium. There is a more or less marked 
 hyperkeratosis; the rete mucosum is greatly increased in breadth, 
 
252 
 
 DISEASES OF THE SKIN 
 
 sending long irregular branching and anastomosing processes welt 
 down into the corium, and contains a considerable number of miliary 
 abscesses. The papillary body is filled with lymphoid, epithelioid and 
 scattered giant-cells, and numerous foci of similar cells are scattered 
 throughout the upper portion of the corium. Tubercle bacilli are 
 usually more numerous than in lupus and are usually found in the 
 giant-cells (Fig. 76). 
 
 Diagnosis. — It is only when the lesions are small and in the early 
 stage that they are at all likely to be mistaken for warts or simple 
 
 
 Fig. 76. — Tuberculosis verrucosa cutis. Enormous increase in length of the interpapillary down- 
 growths of the rete mucosum; miliary abscess at a; exudate composed of lymphoid and epithelioid cells, 
 in corium, with occasional giant-cell, g. 
 
 papilloma. The infiltrated base on which they are seated and more 
 particularly the narrow violaceous border which surrounds them will 
 serve to distinguish them from such lesions. The resemblance be- 
 tween verrucose tuberculosis and blastomycosis of the skin is often- 
 times very close and a differential diagnosis impossible without the aid 
 of the microscope. There is no doubt that formerly these two affec- 
 tions were frequently confounded, and for that matter are yet. 
 
 Treatment. — The lesions may be very readily removed by the 
 
INFLAMMATIONS 253 
 
 curette followed by a thirty per cent, pyrogallol plaster, or they may 
 be excised. When they are flat and not too extensive the pyrogallol 
 plaster alone, without previous curettement, often does well, particu- 
 larly if the surface is first lightly rubbed with a stick of caustic potash, 
 which should be neutralized by dilute acetic acid before applying the 
 plaster. 
 
 TUBERCULOSIS FUNGOSA 
 
 In rare instances tuberculosis of the skin may give rise to tumor- 
 like infiltrations and fungoid ulceration resembling more or less sar- 
 coma or granuloma fungoides, such cases having been described by 
 Riehl and Pick under the name tuberculosis fungosa. Morrow, some 
 years ago, reported a remarkable case in which the face was covered 
 by large, bright-red papillomatous formations ; and Wickham observed 
 one in which along with other lesions of a frankly tuberculous aspect 
 there were frambcesiform papillomatous masses on the foot. 
 
 In the absence of other characteristic tuberculous lesions the diag- 
 nosis in such atypical cases is attended with much difficulty and uncer- 
 tainty. Reliance must be placed upon the finding of tubercle bacilli 
 in the tissues, or the demonstration of their presence by experimental 
 inoculations. 
 
 TUBERCULIDES 
 
 In 1896, Darier proposed the term " tuberculide " to designate the 
 members of a group of eruptions, most of them of acneform type, which, 
 while constantly associated with evidences of tuberculous infection, 
 were not themselves demonstrably tuberculous — the tubercle bacillus, 
 with one or two doubtful exceptions, was not found in them, nor was 
 their histopathology such as is usually found in tuberculous diseases. 
 He included under this term acne cachecticorum, acne scrofulosorum, 
 disseminate erythematous lupus (Boeck), and a small group of very 
 closely related, if not identical, diseases, disseminate folliculitis, 
 acnitis, folliclis, hydradenitis destruens suppurativa, and " unnamed 
 granuloma." To these, later investigators have added a number of 
 other affections, such as erythema induratum, sarcoid, particularly the 
 sarcoid of Boeck, and pityriasis rubra (Hebra). Hallopeau proposed 
 to apply the term to all tuberculous affections of the skin which he 
 divided into two classes, viz., those in which the bacillus tuberculosis 
 is constantly present, bacillary tuberculides, and those in which this 
 organism cannot be found, toxituberculides, these last being due to 
 tuberculous toxins. As the toxic character of the latter class is as yet 
 largely hypothetical, Hallopeau's suggestion has not been generally 
 accepted. Indeed, the recent improvements in the technic of tissue 
 examination, such as the use of antiformin, and the discovery by Much 
 of forms of the tubercle bacillus which are not acid-fast and which differ 
 in their morphology from the ordinary rod-like forms, have resulted in 
 the demonstration of the presence of the bacillus in some of these 
 supposedly toxic varieties of eruption, and it seems likely that the 
 bacillary character of all or most of them will eventually be 
 demonstrated. 
 
254 DISEASES OF THE SKIN 
 
 As most of these diseases have already been described elsewhere, 
 we shall consider here only a small group of acne-like eruptions which 
 have been variously named, and which are regarded by a considerable 
 number of authors as clinical variations of a single affection. 
 
 PAPULO-NECROTIC TUBERCULIDE 
 Synonyms. — Lupus erythemateux dissemine (Boeck) ; small pustu- 
 lar scrofuloderm (Duhring) ; folliclis (Barthelemy) ; tuberculide (Dar- 
 ier) ; folliculitis exulcerans (Lucasiewicz) ; acrodermatitis pustulosa 
 hiemalis (Crocker). 
 
 Definition. — An eruption of tuberculous origin characterized by dis- 
 crete red and violaceous papules with necrotic centres, followed by pit- 
 like scars. 
 
 Symptoms. — The eruption begins as small red points which mark 
 the site of shot-like nodules deeply imbedded in the skin. These 
 
 i 
 
 Fig. 77. — Papulonecrotic tuberculide. 
 
 nodules, as they approach the surface, form distinct, rather harcT 
 papules of a dusky-red or violaceous color upon the summits of which 
 small pustules or less frequently vesicles form, which dry into blackish 
 crusts beneath which are small, deep excavations. After a somewhat 
 variable period, usually several weeks, these crusts fall, leaving pit-like 
 scars which are more or less pigmented for a time, but which eventually 
 become white. The lesions are discrete and without any definite 
 arrangement ; they are usually found upon the backs of the hands 
 (Fig. yy), particularly the backs of the fingers, on the forearms, around 
 the elbows, and much less frequently upon the lower extremities, 
 usually about the knees and ankles. The face is usually but not always 
 free. The ears are occasionally attacked, and in long-standing cases 
 in which there are many scars, the helix may present considerable 
 
INFLAMMATIONS 255 
 
 deformity, looking as if it had been gnawed. In most cases little or no 
 pain accompanies the eruption, but exceptionally some of the lesions 
 may be quite sensitive. It may come out in successive crops or appear 
 quite irregularly, the number of lesions present at any time varying 
 from a dozen to forty or fifty. The course of the affection is usually 
 slow and irregular, each lesion consuming from four to six weeks in its 
 evolution, and the disease as a whole lasting from one year to several 
 years, with occasional periods of quiescence. 
 
 In a large proportion of the cases there is more or less noticeable 
 cyanosis of the extremities — the hands, feet and ears are dusky red 
 or bluish, as if cold, and the blood returns with unusual slowness 
 when pressed out of the skin. In practically all cases there is evidence 
 of tuberculous infection, such as swelling or suppuration of the lym- 
 phatic glands, caries, or less frequently pulmonary tuberculosis. In 
 a young girl under the author's care some years ago, the cutaneous 
 lesions were associated with tuberculous arthritis of the hip-joint and 
 a well-marked erythema induratum. 
 
 Etiology. — It occurs most frequently in children and adolescents, 
 but is occasionally seen in older subjects. According to the obser- 
 vations of Nobl, it is a fairly frequent affection in children, since he 
 found thirteen cases among 450 children ill with various diseases. 
 
 While all authorities are practically of one mind as to its tuberculous 
 origin, there is some difference of opinion as to whether it is to be 
 regarded as a bacillary or a toxituberculide. Until recently the major- 
 ity have inclined to the latter view, owing to the almost invariable 
 failure to find the bacillus or to produce tuberculosis by experimental 
 animal inoculation. Recent improvements in the technic of tissue 
 examination and the introduction of new methods of staining have in- 
 creased the number of cases in which the bacillus has been found. 
 Quite recently Hidaka has found it with Much's granules in the lesions ; 
 and it would seem as if the bacillary character of the eruption had been 
 demonstrated. 
 
 Pathology. — Barthelemy thought it a special type of folliculitis, but 
 this was soon shown to be erroneous. It begins with changes of an 
 inflammatory character in and about the blood-vessels in the deepest 
 part of the corium, which extend thence to the more superficial por- 
 tions. There is an abundant exudation of leucocytes about the vessels 
 and in their walls, leading to great thickening of the latter, which 
 together with swelling of the endothelium produces narrowing or even 
 complete occlusion of their lumina. In advanced stages of the lesions 
 there are considerable areas of necrosis, usually in the deeper parts 
 of the corium surrounding vessels with greatly thickened walls. 
 
 Diagnosis. — The localization of the eruption, commonly upon the 
 back of the hands, and about the elbows and knees, with occasional 
 involvement of the rims of the ears ; the central necrosis of the papules 
 resulting in the formation of small black crusts covering pit-like excava- 
 tions with consequent pit-like scarring; its association with symptoms 
 
256 DISEASES OF THE SKIN 
 
 of tuberculosis, such as chronic adenitis, caries or pulmonary tubercu- 
 losis, are features so characteristic that the disease is usually recog- 
 nized without difficulty. 
 
 Treatment. — The patient should have an abundance of nutritious 
 food and should live in the open air as much as possible. In a young 
 man under the author's care for a considerable time, with a typical erup- 
 tion, decided improvement promptly followed the giving up of work 
 in an office for a life outdoors. Iron alone, or with moderate doses of 
 arsenic, may be given in anaemic subjects, and codliver oil is especially 
 useful in children. Locally mercurial ointments, such as ammoniated 
 mercury, twenty grains (1.30) to the ounce (32.0), a lotion of bichloride 
 of mercury, 1:2000, or one containing fifteen grains (1.0) "each of 
 sulphate of zinc and sulphuret of potash to the ounce (32.0) of water, 
 may be employed with more or less benefit. 
 
 Prognosis. — The prognosis as to the eventual disappearance of the 
 eruption is favorable, particularly in those cases in which there is no 
 extensive tuberculous infection involving important organs. The 
 course of the disease, however, is in most instances a prolonged one, 
 extending over many months or years. 
 
 TUBERCULOSIS MILIARIS CUTIS 
 
 Synonyms. — Tuberculosis propria cutis ; Tuberculosis cutis ori- 
 ficialis ; Miliary tuberculosis of the skin. 
 
 Symptoms. — This, the first definitely recognized form of tubercu- 
 losis of the skin and for a time thought to be the only true cutaneous 
 tuberculosis, was first described clinically and histologically by Jarisch 
 and Chiari. The earliest stage of the affection is a small pin-head-sized 
 yellowish-red nodule which speedily softens, breaks down and forms 
 an ulcer, and it is usually in the ulcerative stage that it first comes 
 under observation. The ulcers are usually shallow, of irregular or 
 roundish shape with thin, occasionally slightly undermined, unevenly 
 indented borders and a pale red or grayish-yellow floor, secreting a 
 scanty seropurulent fluid. Small reddish nodules appear at the edges 
 of the ulcers from time to time, soon break down and increase the area 
 of the ulcer, giving to its borders a polycyclic contour. Abortive 
 attempts at cicatrization may occur, but spontaneous healing rarely 
 takes place. At times the ulcers are accompanied by severe pain. 
 The sites of predilection are the mucocutaneous orifices. The ulcers 
 may be situated on the lips, about the edges of the nostrils, around 
 the anus, or on the labia, sometimes extending into the vagina, but 
 they may also occur upon other portions of the cutaneous surface. 
 They may be single or multiple, and in the latter event two or more 
 may coalesce to form quite extensive serpiginous lesions. The affec- 
 tion is seen exclusively in those suffering from pulmonary or laryngeal 
 tuberculosis and usually pursues a rather acute course, lasting but a 
 few months as a rule. A number of cases affecting the genitalia of 
 male infants have been reported as the result of ritual circumcision, 
 the operator having been the subject of pulmonary tuberculosis. 
 
INFLAMMATIONS 257 
 
 Diagnosis. — The tuberculous character of these ulcers is usually 
 readily recognized ; their situation about the mucous orifices and their 
 association with pulmonary or laryngeal tuberculosis are always sug- 
 gestive of their tuberculous character. Tubercle bacilli are usually 
 quite abundant and are easily found in the discharge or in scrapings 
 from the bottom of the ulcers. 
 
 Treatment. — Probably the best local application is iodoform lightly 
 dusted over the ulcer. If the odor is objectionable, europhen or aristol 
 may be used instead, but is less effective. 
 
 Acute disseminated miliary tuberculosis of the skin was first described 
 by Heller, and other cases have since been reported by Leichenstern, 
 Pelagatti, and a number of others. It is characterized by an eruption 
 of quite small papulopustules and red nodules scattered about on the 
 face and extremities in variable numbers. The eruption usually ap- 
 pears quite suddenly and shows a decided tendency to come out in 
 successive crops. After a time many of the lesions undergo spon- 
 taneous evolution and may disappear without leaving any trace, or 
 they may ulcerate, forming small, round, punched-out ulcers. Prac- 
 tically all the cases thus far observed have occurred in children, and 
 have been part of a general miliary tuberculosis, or have been asso- 
 ciated with tuberculous meningitis ; a considerable proportion of them 
 have followed measles or scarlet fever. 
 
 The treatment is altogether secondary to that of the general tuber- 
 culosis, which it accompanies, and needs no special consideration. 
 
 ERYTHEMA INDURATUM 
 
 Synonyms. — Erytheme indure des scrofuleux; Bazin's disease. 
 
 Definition. — A chronic disease situated for the most part upon the 
 legs, characterized by deep-seated nodules with redness of the over- 
 lying skin, and ulceration. 
 
 Symptoms. — This affection, which was first described by Bazin, 
 begins with one or more pea- to nut-sized, firm, painless nodules deeply 
 situated in the hypoderm. These slowly enlarge, and as they near the 
 surface the skin over them assumes a dull-red or violaceous hue and 
 becomes adherent. When there are several nodules, as is not infre- 
 quently the case, a violaceous plaque of considerable size may be 
 formed having an uneven nodular surface. Having reached this stage, 
 it may remain without much change for some months and then slowly 
 disappear by absorption, leaving a depressed atrophic area with some 
 pigmentation. More often, however, one or more openings form in the 
 skin, discharging a seropurulent fluid, which enlarge to form ulcers 
 of variable shape and extent. As a rule little or no pain attends the 
 affection, although there are occasional exceptions. In the great 
 majority of cases it is confined to the legs, most frequently the lower 
 part of the calf (Fig. 78), although it may also occur upon the anterior 
 17 
 
258 
 
 DISEASES OF THE SKIN 
 
 surface, and exceptionally upon the thighs. In a few instances it has 
 been observed upon the arms. Its course is commonly slow and irregu- 
 lar. Partial or even complete healing of the ulcers may take place, 
 followed shortly by relapse. New nodules may appear from time to 
 time which form new ulcers, and in this manner the disease may con- 
 tinue for two or three years before definite recovery takes place. 
 
 Etiology and Pathology. — Its subjects are, for the most part, girls 
 and young women under twenty years of age, although .it is sometimes 
 
 seen in middle-aged women. It is 
 decidedly rare in males, but not un- 
 known ; quite recently the author has 
 seen an example of it in a young 
 man twenty years old. As a rule to 
 which there are few exceptions, 
 evidences of present or past tubercu- 
 lar infection, the latter often in the 
 shape of scars in the neck the result 
 of an adenitis, are present. In many 
 cases the patient suffers from a slug- 
 gish venous circulation, as shown 
 by a more or less marked dusky hue 
 of the extremities commonly much 
 more noticeable in cold weather, the 
 so-called chilblain circulation. 
 
 The histopathology is in the main 
 that of tuberculosis, although not all 
 observers are agreed as to details, 
 some finding only inflammatory 
 changes. Special features are a 
 marked leucocytic infiltration of the 
 walls of .the vessels, particularly of 
 the veins, causing at times an enor- 
 mous increase in their thickness with 
 narrowing or obliteration of their 
 lumen, and an atrophy of the fat 
 tissues. The studies of Harttung 
 and Alexander, the successful inocu- 
 lation experiments of Thibierge and 
 Ravaut and others, the reaction of the lesions to tuberculin, as observed 
 by Mantegazza and Jadassohn, leave but little room for doubt con- 
 cerning the tuberculous character of the disease. Whitfield is of the 
 opinion that there are two varieties of the malady, which, while re- 
 sembling each other closely in their clinical symptoms, are etiologi- 
 cally different. One is a tubercular affection, seen in young subjects; 
 the other is an inflammatory disease, a nodular phlebitis, and occurs 
 in middle-aged individuals. He would explain in this way the dis- 
 crepancies in the histological findings of various observers. 
 
 FiG. 78. ■ — Erythema induratum with papulo- 
 necrotic tuberculide Irregular ulcer on calf 
 surrounded by palm-sized violaceous area. 
 Small scars on upper portion of leg followed the 
 tuberculide. 
 
INFLAMMATIONS 259 
 
 Diagnosis. — The two affections for which it is most apt to be mis- 
 taken are erythema nodosum and the syphilitic gumma. 
 
 The first is an acute disease which appears quite suddenly, is 
 accompanied by pain and tenderness, the latter often marked, and is 
 usually situated on the anterior surface of the leg over the tibia, while 
 erythema induratum is a chronic affection, unaccompanied by pain as a 
 rule, and is situated on the posterior surface of the leg, on the calf 
 in most cases. The syphilitic gumma usually occurs in adults, ulcer- 
 ates much earlier than erythema induratum, and produces round, sharp- 
 cut ulcers unlike the ulcers with ragged edges in the latter. 
 
 Treatment. — The patient should be regarded as a tuberculous sub- 
 ject and treated accordingly. Codliver oil, iron, particularly the syrup 
 of the iodide of iron, and small doses of arsenic, are all more or less 
 useful, the first-named being more serviceable than the others. 
 
 Whitfield and more recently McKee have reported decidedly bene- 
 ficial results from injections of tuberculin. 
 
 Rest in the recumbent position, with elevation of "ihe limb, is to be 
 advised ; when this is not possible, as frequently happens, the patient 
 should wear constantly, when not in bed, a properly applied roller 
 bandage, or, what is much better, an elastic bandage. 
 
 Iodoform, aristol, or europhen dusted on the ulcers once or twice 
 a day, are useful local applications, the first being the best, but objec- 
 tionable on account of its odor. A stiff ointment of ammoniated mer- 
 cury, 30 grains (2.0) to the ounce (32.0), is likewise useful. At each 
 dressing the ulcers should be carefully cleansed with a saturated solu- 
 tion of boric acid or some other mild antiseptic wash. 
 
 SCROFULODERMA 
 
 Synonyms. — Tuberculosa gummosa; Tuberculosis colliquativa cu- 
 tanea; Fr., Gomme scrofulo-tuberculeuse ; Cold abscess of the skin. 
 
 Under the name scrofuloderma were formerly included a consider- 
 able number of chronic inflammations of the skin attended by suppura- 
 tion and ulceration, occurring in individuals of the so-called strumous 
 diathesis. At the present time the use of the term is restricted to 
 certain chronic affections of the skin, chiefly of an ulcerative type, 
 secondary to tuberculous adenitis and to circumscribed nodular 
 gumma-like infiltrations of the subcutaneous tissue. 
 
 Symptoms. — The most frequent and characteristic form is that 
 which occurs in connection with chronic tubercular adenitis of the 
 cervical glands in children and young adults. It begins with swelling 
 of a gland, often at the angle of the jaw, which slowly and painlessly 
 enlarges until it reaches the size of a nut or a pigeon's egg. After 
 a considerable period, usually some months, the overlying skin becomes 
 red and adherent to the gland beneath, softening of the gland occurs, 
 the skin becomes bluish, thin, and eventually gives way, and an ulcer 
 with thin ragged, undermined edges is formed which discharges a thin 
 seropurulent fluid. Not uncommonly several glands are affected 
 
260 DISEASES OF THE SKIN 
 
 simultaneously or in succession and a considerable tumor with irregular 
 nodular surface is formed over which the skin opens in several places, 
 giving rise to a number of ulcers which may eventually unite. Sinuses 
 which burrow immediately beneath the skin, producing long cord-like 
 ridges or extend deeply down to the periglandular tissue, are frequently 
 associated with the ulcers. Occasionally typical lupus nodules form 
 about the external opening of such sinuses and may serve as the start- 
 ing point for a spreading patch of this disease. 
 
 The course of the affection is extremely chronic ; when ulceration 
 has occurred it may continue for one, two or three years. So long as 
 any remnant of glandular tissue remains, the sinuses continue to dis- 
 charge and the ulcers remain open. When recovery takes place more 
 or less scarring, often of an unsightly character, follows. 
 
 Instead of following an adenitis, the ulceration may be preceded by 
 one or more deep-seated nodules in the hypoderm which slowly enlarge 
 and over which the skin becomes red and finally ulcerates. This is the 
 so-called scrofulous gumma which frequently bears a considerable 
 resemblance to the syphilitic gumma. 
 
 Occasionally such ulcers, as well as those which are associated with 
 adenitis, become the seat of considerable fungoid masses of granula- 
 tion tissue. 
 
 Ulcers of a similar kind may occur in connection with tuberculous 
 lymphangitis through the breaking down of the small nodules which 
 are distributed along the course of the lymphatic vessels. 
 
 A much less frequent form of scrofuloderma begins as small intra- 
 dermic nodules which after a time soften and produce small punched- 
 out ulcers. In rare instances variously-sized firm nodules appear in 
 the hypoderm, which after a variable period slowly disappear without 
 involving the skin, as in the case reported by Wende. 
 
 Etiology and Pathology. — In the largest proportion of cases the sub- 
 jects of the scrofulodermata are children or quite young adults, because 
 the tuberculous affections to which they are secondary, such as adenitis, 
 are far more common in these than in older individuals. The tuber- 
 culous character of the affection has been well established, the tubercle 
 bacillus having been repeatedly found by a number of observers, 
 although it is not always easily demonstrated. The histology of the 
 lesions is in all essentials that of other forms of tuberculosis, but there 
 is more extensive necrosis than in some other forms, such as lupus, 
 for example, and there is frequently much more inflammatory reaction, 
 as indicated by an abundant exudation of leucocytes about the necrotic 
 areas. According to Unna the extensive necrosis is due to the toxic 
 effect of considerable collections of bacilli. 
 
 Diagnosis. — Scrofulous ulcers and sinuses of the neck, secondary 
 to adenitis, are usually so characteristic in appearance that mistakes 
 in diagnosis are not likely to occur, but they may be confounded with 
 syphilis and actinomycosis. From the former they are to be distin- 
 guished by the youth of the patient, the absence of other symptoms 
 
INFLAMMATIONS 261 
 
 of syphilis, and their frequently evident association with a chronic 
 adenitis ; from the latter by the absence of the peculiar sulphur-yellow 
 granules composed of actinomycetes from the discharge. The scrofu- 
 lous gumma often bears considerable resemblance to the gumma of 
 syphilis, but the latter usually runs a much more rapid course and 
 forms round sharp-cut ulcers, while the ulcers resulting from the 
 former are usually quite irregular in shape, with ragged, livid, under- 
 mined edges. 
 
 Treatment. — The local treatment is essentially surgical. Suppurat- 
 ing glands should be removed, sinuses divided and curetted, and 
 dressings of iodoform, aristol, or bichloride of mercury applied. Pusey 
 and others have obtained good results from the use of the X-ray. 
 
 LICHEN SCROFULOSORUM 
 
 Synonym. — Lichen scrofulosus. 
 
 Definition. — A chronic inflammatory disease of the skin occurring 
 in tuberculous subjects, characterized by an eruption of small red or 
 yellowish-red scaly, follicular papules, arranged in round and circinate 
 patches. 
 
 Symptoms. — It begins with the appearance of pin-head- to millet- 
 seed-sized discrete papules which are soon covered with a small, thin, 
 only slightly adherent scale, and which are usually arranged in round, 
 circinate, and crescentic patches, but which may also occur in irregular 
 areas, sometimes of considerable extent, without any particular arrange- 
 ment. The papules are at first red or brown-red in color, but grad- 
 ually fade to a pale yellow, and may even become the color of the 
 normal skin. After a variable duration, usually many months, they 
 begin to undergo slow involution and eventually completely disappear, 
 leaving nothing more than a slight and transient pigmentation. In 
 addition to the papular lesions there are quite commonly a few scat- 
 tered miliary vesicles, pustules and patches of follicles the mouths of 
 which contain small, slightly projecting horny spines (lichen pilaris). 
 The eruption is usually confined to the trunk (Fig. 79), particularly 
 the sides of the thorax, the abdomen, and to a less degree, the back; 
 the extremities are only infrequently affected, and when these are in- 
 vaded it is the legs rather than the arms. On the latter the lesions 
 may present a decidedly livid appearance owing to slight hemorrhage 
 into the follicles (lichen lividus). Beyond occasional slight itching 
 the eruption is accompanied by no subjective symptoms. Occasionally 
 a variable number of acne-like papules and pustules are scattered over 
 the lower extremities and the face which pursue the usual course of 
 ordinary acne lesions (acne scrofulosorum). In the more marked 
 cases eczema of the pubic region, the groins and scrotum may be 
 present, which in the pubic region is apt to be of the pustular type, 
 and which is usually accompanied by abundant oozing and crusting 
 and an extremely offensive odor. 
 
262 
 
 DISEASES OF THE SKIN 
 
 As an atypical form of lichen scrofulosorum mention may be made 
 here of a lichenoid eruption observed recently by Bosellini and Vignolo- 
 Lutati in tuberculous individuals. In the cases reported by these 
 authors there was an eruption of flat, red papules, some of them umbili- 
 cated, situated upon the backs of the hands and the forearms, which 
 
 Fig. 79- — Lichen scrofulosorum. 
 
 resembled closely the papules of lichen planus. Both patients were 
 adult females and suffered from pulmonary tuberculosis. 
 
 Etiology and Pathology. — Lichen scrofulosorum is confined to 
 children and adolescents and is most frequent in the second decade of 
 life ; it is rare after twenty. 
 
 In the great majority of cases, in ninety per cent, according to the 
 observations of Hebra, it occurs in those who suffer from swollen or 
 suppurating glands, from periostitis, caries of bone, chronic ulcers, 
 
INFLAMMATIONS 263 
 
 or other evidences of tuberculous infection. Jadassohn found symp- 
 toms of tuberculosis in fourteen out of nineteen typical cases. 
 
 Histologically it is a folliculitis of special type. As was pointed out 
 by Kaposi, who was the first to study its histopathology, the histologi- 
 cal changes are confined to the follicles with their glands, and the 
 papillae immediately adjacent to the follicles. In and around these is 
 a circumscribed cellular exudate consisting of epithelioid cells, a lesser 
 number of giant-cells surrounded by a border of variable width made 
 up of leucocytes. The tissue changes, in a word, are such as are usually 
 found in tuberculosis. 
 
 In the epidermis the alterations are usually trifling, and consist for 
 the most part of a slight hyperkeratosis and a moderate invasion of the 
 rete by leucocytes which lie in the interepithelial spaces. 
 
 The search for tubercle bacilli in the lesions has for the most part 
 been a vain one, but Jacobi and Wolff have reported the rinding of a 
 few bacilli ; their cases, however, were not typical ones. In both the 
 atypical cases with lesions like those of lichen planus reported by 
 Bosellini and Yignolo-Lutati, tubercle bacilli were found in the papules. 
 Haushalter and Pellizzari both succeeded in producing tuberculosis 
 in the guinea-pig by inoculations with lesions taken from cases under 
 their observation, but in Pelizzari's case the first attempt was unsuc- 
 cessful, and it was only after the papular eruption had been replaced 
 by an atypical pustular one that inoculation succeeded. In a number 
 of instances a more or less characteristic reaction has been noted after 
 injections of tuberculin. Jadassohn observed a reaction in fourteen 
 out of sixteen cases treated with this agent. A few instances have 
 been reported in which an eruption resembling lichen scrofulosorum 
 has followed such injections, but none of them is free from criticism. 
 Quite recently Nobl has reported five cases in which a typical eruption 
 followed inunctions of tuberculin ointment. 
 
 Upon the whole, the weight of evidence seems to be in favor of the 
 view that the eruption is not a bacillary one, but one due to tuberculous 
 toxins. 
 
 Diagnosis. — Lichen scrofulosorum is to be distinguished from the 
 small papular syphiloderm and from papular eczema. 
 
 The papules of syphilis are somewhat larger and firmer than those 
 of lichen, are a deep-red or brownish-red color and are found on the 
 face and extremities, situations usually avoided by lichen. Other 
 characteristic symptoms of syphilis are also likely to be present. 
 
 In papular eczema the lesions are of a bright-red color, show no ten- 
 dency to arrangement in round an4 circinate patches, and are accom- 
 panied by severe itching. 
 
 Treatment. — The internal and external use of codliver oil, as advised 
 by Hebra, is usually followed by the disappearance of the eruption in 
 a short time. Instead of codliver oil inunctions, which are extremely 
 disagreeable, other less unpleasant fats may be used, and with equally 
 good results. Crocker found plain vaseline, or vaseline with five grains 
 
264 DISEASES OF THE SKIN 
 
 of thymol or five minims of oil of cade to the ounce (32.0), quite as useful 
 as codliver oil. Equal parts of lanolin and vaseline with one per cent, of 
 salicylic acid may also be used with good effect. 
 
 SARCOID 
 
 The term sarcoid was first employed by Kaposi to designate a 
 group of new growths of the skin, such as mycosis fungoides, lympho- 
 derma perniciosa, and a few others which, while resembling sarcoma 
 in their histopathology, differed from that malady in their clinical 
 course and termination. More recently it has been applied by Boeck, 
 Darier, and others, to a small group of diseases which, with the excep- 
 tion presently to be noted, are either closely related to tuberculosis 
 or are actually tuberculous. According to Darier there are four varie- 
 ties of sarcoid : (a) The affection first described by Boeck under the 
 name multiple benign sarcoid for which he later substituted the name 
 miliary lupoid; (b) the subcutaneous sarcoid of Darier-Roussy ; (c) 
 a variety which resembles the erythema induratum of Bazin; (d) the 
 round-celled neoplasm described by Spiegler, Fendt and others under 
 the name sarcoid, which, while clinically resembling the preceding 
 forms, is probably related to them only by a superficial resemblance. 
 
 MULTIPLE BENIGN SARCOID (BOECK) 
 
 Synonym. — Benign miliary lupoid. 
 
 Definition. — A chronic disease of the skin characterized by large and 
 small red and brownish-red nodules and variously-sized bluish-red 
 plaques, probably of tuberculous origin. 
 
 This affection was described for the first time by Boeck, in 1899, 
 although the cases described by Hutchinson in his Archives of Surgery 
 a year before, under the name of Mortimer's malady, were probably 
 examples of the same disease, as was suggested by Boeck himself. 
 
 Symptoms. — Acording to Boeck the eruptive lesions are of three 
 kinds — small nodules or papules ; large nodules ; and ill-defined infil- 
 trations or plaques. The nodules vary in size from that of a pin-head 
 to a small nut, are bright red when they first appear, but as they grow 
 older, become bluish-red, brownish-red, and finally brown. By the 
 slow peripheral growth of some of the nodules, ill-defined bluish-red 
 plaques are gradually formed with narrow, yellowish, slightly elevated 
 and occasionally finely scaly borders and depressed atrophic centres 
 in w T hich are numerous fine vessels. The eruption usually appears 
 rather suddenly and in the beginning may be accompanied by redness 
 and swelling of the skin with itching which subsides in the course of 
 ten days or two weeks. Or it may begin slowly and almost imper- 
 ceptibly, the nodules being deep-seated at first, producing distinct ele- 
 vations only after some little time as they approach the surface. The 
 lesions are found most frequently in the face, on the upper portion of 
 the trunk, the extensor surface of the upper extremities, and exception- 
 
INFLAMMATIONS 265 
 
 ally in the scalp. As a rule they are distributed more or less symmetri- 
 cally and show decided tendency to occur in the scars of old lesions. 
 Examined under glass-pressure (diascopy), all varieties of lesion, both 
 the nodules and plaques, show fine yellowish or grayish puncta, a 
 feature which Boeck greatly emphasized, and which led him to sub- 
 stitute the name miliary lupoid for sarcoid. In a considerable propor- 
 tion of cases the eruption is accompanied by swelling of the lymphatic 
 glands. The course of the disease is usually extremely slow and it 
 may continue for years. After remaining for months without much 
 change the lesions become depressed in the centre, flatten out, and 
 eventually completely disappear, leaving a slight brownish pigmen- 
 tation or an atrophic telangiectatic scar. 
 
 In the sarcoid of Darier-Roussy the lesions are situated in the hypo- 
 derm and are small to large nut-sized, round or oval painless nodules 
 over which the skin, at first movable, becomes adherent and red or 
 violaceous. They may be discrete, may form nodular cords following 
 the course of the vessels, or they may unite to form variously-sized, 
 ill-defined bluish plaques with uneven surface. They appear very 
 gradually and show no tendency to softening or ulceration. They are 
 usually, according to Darier, exclusively situated upon the trunk, and 
 are seen only in adults. 
 
 In the sarcoid resembling erythema induratum, cases of which have 
 been reported by Pelagatti, Thibierge and Bord, Darier and others, 
 there are nut-sized and larger livid swellings which occasionally ulcer- 
 ate, and which are situated upon the extremities, chiefly of women. 
 
 In the affection described as sarcoid by Spiegler, Fendt and others, 
 there are multiple variously-sized tumors and infiltrated plaques of a 
 red or bluish-red color situated deeply in the skin. They are found 
 usually upon the trunk and pursue a variable course, sometimes rapid, 
 at others slow, and although ulceration is not the rule it may occur. 
 Partial or complete involution may follow the administration of arsenic. 
 
 Etiology and Pathology. — The affection occurs as a rule in adults, 
 but few cases having been observed before puberty, and is decidedly 
 more frequent in women than in men. 
 
 In about one-third of the reported cases evidences of tuberculosis 
 were present, usually referable to the lymphatic glands, and in about the 
 same proportion of cases a positive tuberculin reaction was noted. 
 In one of Boeck's cases an acid-fast bacillus was found in an infiltrate 
 situated on the mucous membrane of the nose and a positive result 
 followed experimental inoculation in the guinea-pig. 
 
 Although the evidence is far from conclusive, it seems likely that 
 the disease is a tuberculosis of feeble virulence, as has been suggested 
 by Darier. 
 
 The histological picture presented by the Boeck type is a very 
 characteristic one. In the corium are rounded or irregularly-shaped 
 sharply circumscribed collections of epithelioid cells, with an occasional 
 rather small giant-cell, a few plasma cells and lymphocytes, the last 
 
266 
 
 DISEASES OF THE SKIN 
 
 about the borders (Fig. 80). The central portion of the older areas 
 show some evidence of degeneration ; the cells are less well-defined, 
 and do not stain sharply, and the elastic tissue has disappeared. 
 
 In the Darier-Roussy type the tissue changes are situated in the 
 hypoderm and resemble more or less closely those found in tubercu- 
 losis. There are collections of epithelioid cells with numerous giant- 
 cells of the Langhans type, with lymphocytes and a few plasma cells 
 and " mastzellen." These cell areas are much less well-circumscribed 
 and more extensive than in the Boeck variety. In the third variety of 
 sarcoid the histological changes are practically the same as those pres- 
 ent in erythema induratum. 
 
 ^ : '^w:-: 
 
 Fig. 80. — Multiple benign sarcoid. Rounded and oval areas of cells, chiefly of connective-tissue type, 
 with a few epithelioid cells. Low power. 
 
 In the Spiegler-Fendt sarcoid the tumors present the histological 
 features of a lymphogranuloma. They are made up of well-circum- 
 scribed, sometimes encapsulated collections of large and small round 
 cells situated in the corium and subcutaneous tissue. 
 
 The first two members of this group without much doubt represent 
 varieties of the same disease, but it is very doubtful whether the third 
 member is anything more than a somewhat atypical form of erythema 
 induratum. As to the Spiegler-Fendt disease, it is quite distinct both 
 in its histopathology and almost certainly in its etiology from the 
 other three and probably ought not be included with them. 
 
INFLAMMATIONS 267 
 
 Diagnosis. — The diseases from which it is to be distinguished are 
 lepra, syphilis, the nodular form of erythematous lupus, leukaemia 
 cutis and erythema induratum. From all of these it differs in a number 
 of particulars, such as the absence of ulceration and the presence of fine 
 yellowish points in the lesions which are best seen under glass-pres- 
 sure, this last feature being regarded by Boeck as almost pathog- 
 nomonic. While its clinical features are often sufficient to distinguish 
 it from the diseases which resemble it, a biopsy is frequently necessary 
 to establish the diagnosis. 
 
 Treatment. — In all of Boeck's cases the eruption disappeared under 
 vigorous arsenical treatment. In order to obtain the best results with 
 arsenic it is necessary to give the drug in considerable doses, unin- 
 terruptedly, for a considerable period. Darier found that the lesion 
 of the subcutaneous variety quickly retrogressed after injections of 
 calomel, of tuberculin and the X-ray, but the effect of these was not 
 permanent. Ichthyol applied to the lesions seems to exert a favorable 
 influence. 
 
 Prognosis. — -Left to itself, the malady may last almost indefinitely, 
 but under appropriate treatment the eruption usually slowly disappears. 
 More or less scarring usually remains after the disease has disappeared. 
 
 SYPHILIS 
 
 Definition. — Syphilis is a chronic infectious and contagious disease, 
 acquired or inherited, due to the spirochczta pallida or treponema palli- 
 dum, beginnng in the acquired form with a local lesion known as the 
 chancre or initial sclerosis, and characterized by a great variety of 
 cutaneous eruptions. 
 
 It presents three usually well-defined stages, viz., a primary stage 
 beginning with the appearance of the chancre ; a secondary stage 
 characterized by generalized eruptions and affections of the adjoining 
 mucous membranes, beginning about four or six weeks after the 
 appearance of the chancre and lasting about a year ; and a tertiary stage, 
 which begins at the end of the second or in the third year, characterized 
 by asymmetrical and localized cutaneous lesions usually of an ulcerative 
 character, affecting the deeper portions of the skin and subcutaneous 
 tissues as well as the bones and viscera. 
 
 The initial lesion is the port of entry of the infecting organism, and 
 appears about twenty-one days after infection, but the period of incu- 
 bation may be considerably shorter or much longer in exceptional cases. 
 As a rule it is single, but there may be two or more lesions. In the 
 vast majority of cases it is situated somewhere upon the genitalia. 
 In men it is seen in most instances upon the prepuce or upon the glans 
 penis, in the sulcus behind the corona. Less frequently it is situated 
 upon the shaft of the penis or at the urinary meatus or exceptionally 
 within it. In women the most frequent situations are the labia and the 
 introitus vaginae ; a less common situation is the fourchette. 
 
268 
 
 DISEASES OF THE SKIN 
 
 It presents a variety of forms. It may occur as an oval superficial 
 erosion with a smooth red surface which after a time becomes covered 
 with a grayish pseudomembrane ; as a circumscribed superficial or deep 
 ulcer with sharp-cut edges and indurated base, the " Hunterian 
 chancre " ; or as a dark-red slightly scaly indurated papule or nodule. 
 
 I ■ ■ w 
 
 Fig. 8i. — Initial lesion of syphilis. 
 
 Although, as just stated, the initial lesion is found as a rule upon the 
 genital organs, it may occur anywhere upon the skin or the adjoining 
 mucous membranes. The most frequent sites of the extragenital 
 
 - 
 
 ■'if 
 
 - 
 
 2 
 
 Fig. 82. — Initial lesion of syphilis. 
 
 chancre are the lips, the tongue, the fingers, and the nipple in women 
 (Plate XVI). 
 
 Upon the lips it may occur as a superficial erosion, or an ulcer (Fig. 81 ) 
 covered with a grayish membrane, accompanied by induration, or it 
 may begin as a fissure which becomes indurated and refuses to heal. 
 
PLATE XVI 
 
 Initial lesion of syphilis. (Patient was a physician with a large obstetric practice 
 and was infected in the practice of his profession.) 
 
 Maculopapular syphilocU 
 
INFLAMMATIONS 269 
 
 These are always followed by painless swelling of the submaxillary 
 glands which is often marked. Chancre of the finger, a variety seen 
 most frequently in obstetricians and midwives, is situated in most 
 cases upon the terminal phalanx of the index, occurring as an ulcer 
 often about the root or lateral borders of the nail, sometimes presenting 
 a fungoid appearance owing to the presence of exuberant granulations. 
 Sometimes the whole phalanx is swollen and painful and the nail is 
 eventually lost; the epitrochlear gland is usually decidedly swollen. 
 These lesions are often very sluggish in their course, lasting for 
 months. Chancre of the face usually presents the appearance of a 
 sluggish ulcer with firm infiltrated borders, accompanied by swelling 
 of the parotid or submaxillary glands. Occasionally such lesions may 
 resemble epithelioma to a considerable degree (Fig. 82). 
 
 Diagnosis. — The recognition of an initial lesion when situated upon 
 the genitalia is usually easy, but the diagnosis of the extragenital 
 chancre at times is attended with considerable difficulty. An indolent, 
 painless ulcer, of some weeks' duration, with indurated base, accom- 
 panied by swelling of the neighboring lymphatic glands, situated 
 upon the lips, fingers, or upon the nipple is most likely to be the initial 
 lesion of syphilis.- In case of doubt the treponema should be sought 
 for in the secretion of the lesion by dark-ground illumination or by the 
 India ink method. 
 
 SYPHILODERMATA 
 
 The first cutaneous symptoms of syphilis usually appear from six to 
 eight weeks after the chancre or initial lesion, but they may occur as 
 early as the third or fourth week and may be delayed considerably 
 beyond the eighth week. The early eruptions, or those of the second- 
 ary period, differ considerably from the late eruptions, not only as 
 to the character of the lesions composing them, but also as to their 
 distribution and course. They are, as a rule, more or less general 
 and are often preceded or accompanied by some elevation of tempera- 
 ture, sometimes considerable. In color they vary from a bright-red 
 to a dark-red or " copper-color," and frequently exhibit a more or less 
 decided tendency to an annular or crescentic arrangement. The erup- 
 tions of this period usually exhibit more or less marked polymorphism, 
 an important characteristic from a diagnostic point of view. Many 
 of them show a tendency to spontaneous disappearance after a time, 
 leaving pigmentation but seldom scarring. Subjective symptoms are, 
 as a rule to which there are few exceptions, absent or insignificant. 
 
 The late lesions, or those of the tertiary period, are usually localized 
 and asymmetrical. They are, as a rule, much deeper seated than the 
 secondary eruptions, frequently extending to the subcutaneous tissues. 
 They are prone to ulceration, producing ulcers with a characteristic 
 reniform or crescentic shape, leaving permanent scars, which, owing to 
 their special characters, such as their shape, smoothness and softness 
 and frequent pigmentation, are often of considerable diagnostic value. 
 
270 DISEASES OF THE SKIN 
 
 They show little or no tendency to spontaneous disappearance, but may 
 last for years when left untreated. The eruptions of the secondary 
 period exhibit many varieties which differ from one another in the 
 character of the lesions, their number and size, in their distribution and 
 arrangement, and in the course which they pursue. The principal varie- 
 ties are : the erythematous or macular ; the papular ; the vesicular, a rare 
 form; and the pustular. With the exception of the first, all of these 
 present a number of subvarieties. The tertiary lesions are : the nodular 
 or tubercular ; the gummatous ; and a papulo-squamous resembling the 
 papulo-squamous lesion of the secondary stage, but confined to the 
 palms and soles and almost always unilateral. 
 
 Erythematous Syphiloderm. — Synonyms. — Syphilid ; roseola syphil- 
 itica; Ger., Fleckensyphilid (Plate XVI and Fig. 83). 
 
 This, the earliest of the syphilitic eruptions, probably never fails 
 to appear, although it is frequently so faint as to escape the patient's 
 observation altogether. It appears from six to eight weeks after the 
 initial lesion as round or oval, pinkish to brownish-red, occasionally 
 somewhat violaceous spots varying in size from that of a small pea to 
 the little finger-nail, scattered over the anterior and lateral portions of 
 the trunk, particularly the lower two-thirds, the flexor surfaces of the 
 arms, the inner surface of the thighs, and the back. It is quite com- 
 monly seen on the palms and soles, where it is frequently maculo- 
 papular rather than strictly macular and slightly scaly. It is prac- 
 tically never seen on the backs of the hands. When the eruption is faint 
 and violaceous, the skin presents a mottled appearance which becomes 
 much more pronounced after it has been exposed to the air for a few 
 minutes. Moist papules may occur coincidently with this eruption 
 about the corners of the mouth, about the anus, and on the opposed 
 surfaces of the thighs and scrotum. Not infrequently a considerable 
 • number of the macules show a tendency to infiltration after a time, 
 becoming maculo-papular, or distinctly papular. While in many cases 
 the patient is apparently in his usual health, the eruption is frequently 
 preceded or accompanied by headache and pains in the limbs, usually 
 much worse at night, sore throat, and a generalized adenopathy. 
 Occasionally there is a continuous fever for a week or two prior to the 
 appearance of the eruption, resembling typhoid fever, for which it is 
 sometimes mistaken. 
 
 Fournier has described a variety of erythematous eruption with a 
 marked tendency to recurrences, which occurs in the late secondary 
 or in the tertiary stages. Quite frequently this eruption exhibits an 
 annular arrangement, being made up of red or pink rings and gyrate 
 figures produced by the coalescence of two or more patches. 
 
 The eruption usually develops slowly, macules continuing to appear 
 for a week or ten days, but it may come out rapidly, reaching its full 
 development within two or three days. After a period varying from 
 some weeks to a month or two, it slowly fades, leaving a faint transient 
 brownish or yellowish stain. Relapses may occur. 
 
PLATE XVII 
 
 Late squamous syphiloderm of the palm. 
 
INFLAMMATIONS 
 
 271 
 
 Diagnosis. — This is usually readily made, but it may at times be 
 mistaken for measles or rotheln. Both of these occur in epidemics and 
 are usually seen in children, while the syphilitic eruption is, for the 
 most part, seen in adults. The catarrhal symptoms which invariably 
 accompany measles are absent in syphilis. In rotheln the macules are 
 smaller and more uniform in size than those of syphilis and more 
 abundant. In both measles and rotheln the face is abundantly covered ; 
 
 FlG. 83. — Erythematous syphiloderm. 
 
 in syphilis it usually escapes. In the syphilitic eruption the initial 
 sclerosis is usually still present, and there are apt to be mucous mem- 
 brane lesions, such as mucous patches and moist papules about the 
 anus and on the scrotum. 
 
 Papular Syphiloderm. — The papular syphiloderm, although less fre- 
 quent than the macular eruption, is very common. It presents a num- 
 ber of varieties which differ from one another principally in the size 
 
272 
 
 DISEASES OF THE SKIN 
 
 and shape of the lesions and in their anatomical seat. They may be 
 large or small, flat or acuminate; they may be seated in the follicles, 
 or they may occur independently of these. 
 
 The small flat papular syphiloderm occurs as small red and 
 brownish-red flat papules from an eighth to a quarter of an inch in 
 diameter. At first they are smooth and some of them remain so, 
 but most of them become slightly scaly after a time and many of them 
 are surrounded by a narrow ring of loosened epidermis, the " epidermic 
 collarette " which is a feature of considerable diagnostic significance. 
 
 Fig.: 
 
 -Papular syphiloderm. 
 
 Exceptionally the scaling may be quite abundant, in rare cases so much 
 so as to resemble psoriasis. The eruption is usually widely distributed, 
 the papules numerous. It is situated upon the forehead, particularly 
 at the margin of the hair, where it forms the so-called corona veneris, 
 in the face (Fig. 84), about the nose and mouth, upon the trunk an- 
 teriorly and posteriorly, avoiding, however, the clavicular region, upon 
 the flexor surface of the arms and in most cases the palms and soles, 
 where the papules are nearly always scaly and sometimes corn-like 
 (corneous papules). Even when very abundant they remain discrete, 
 but occasionally when very numerous they coalesce in certain localities, 
 such as the chin and around the mouth and nose, to form reddish 
 plaques with nodular or uneven surface. Occasionally the eruption 
 
INFLAMMATIONS 
 
 273 
 
 assumes an annular form, the papules being arranged in distinct rings 
 or semicircles. Such annular patches are made up of a number of small 
 confluent papules, or arise through involution of the central portion 
 of papules which continue to extend at the periphery. The favorite 
 site for such patches is the face, where they are situated about the 
 mouth, on the chin, cheeks and forehead. Although this annular form 
 is rare in individuals of the white race, it is not very uncommon in 
 the negro (Fig. 85). 
 
 Fig. 85- — Circinate papular syphiloderm. 
 
 The papular syphiloderm occurs early in the course of the infection, 
 usually from the third to the sixth month. It may be the first observed, 
 or more commonly it follows the macular syphiloderm with which it 
 may be associated. When it appears early it may be accompanied by 
 sore throat, headache and malaise and elevation of temperature. 
 
 Its course is usually sluggish ; if left to itself it may persist for 
 months, new lesions appearing to take the place of the older ones 
 which slowly retrogress. When it disappears a faint brownish or 
 yellowish-brown pigmentation is left at the site of the papules which 
 gradually fades. 
 18 
 
274 
 
 DISEASES OF THE SKIN 
 
 'The large flat papular syphiloderm begins as small red spots which 
 enlarge in circumference and become distinctly elevated, forming round 
 or oval papules varying in diameter from a one-quarter to one-half inch. 
 They are brownish-red in color when fully developed, smooth or very 
 slightly scaly, less so, however, than the small papular syphiloderm. 
 The eruption is usually a rather sparse one, although there are many 
 exceptions to this rule, and the lesions remain discrete. It may occur 
 on any part of the skin, but is most common on the forehead, the lower 
 
 Fig. 86. — Annulo-papular syphiloderm. (Secondary.) 
 
 part of the face, upon the back of the neck and the upper part of the 
 back (Fig. 86), on the flexor surface of the limbs, the inner surface of 
 the thighs, upon the palms and soles, and about the genitalia and anus. 
 In regions where there are opposed skin surfaces, such as the scrotum 
 and thighs, or between the buttocks, the surface of the papules becomes 
 grayish-white or superficially excoriated, forming condylomata lata. 
 Along with the larger papules smaller ones may coexist and here 
 and there a macule or a pustule may be found, although this eruption 
 is usually quite uniform. In rare instances the papules may undergo 
 
INFLAMMATIONS 
 
 275 
 
 a considerable increase in size ; their surface becomes papillomatous 
 or wart-like, and secretes a seropurulent fluid which dries into yellowish 
 crusts. This is the " vegetating " or " framboesioid " syphiloderm of 
 authors. Such lesions are most apt to occur upon the face, in the 
 scalp and about the genitalia. In the bearded region they may resem- 
 ble the lesions of deep trichophytosis (Fig. 87). The course of the 
 eruption is a chronic one and it may show but Tittle change for months. 
 When it disappears it leaves a slowly fading brownish pigmentation. 
 
 Although it may occur quite early, even before the macular eruption 
 has entirely disappeared, it is seen more frequently from four to six 
 months after the initial lesion and occasionally considerably later. 
 Relapses are not uncommon. 
 
 Diagnosis. — The recognition of the flat papular syphiloderm is 
 usually easy. The character of the lesions, their distribution, the 
 
 Fig. 87. — Sycosiform syphiloderm (frambcesiform syphiloderm). 
 
 absence of subjective symptoms, their association with moist papules 
 about the anus and genitalia are features of the eruption which usually 
 leave but little room for doubt as to its character. The circinate 
 patches are sometimes mistaken by the inexperienced for ringworm, 
 but the decided infiltration present and the absence of the fungus of the 
 latter make the differential diagnosis easy. Occasionally the papulo- 
 squamous lesions, as already noted, may resemble those of psoriasis, 
 indeed in rare instances the resemblance to this disease may be very 
 close, but a careful examination of the whole eruption will be almost 
 certain to disclose an occasional smooth papule, or perhaps a pustule ; 
 moreover the syphilitic eruption shows no special predilection for the 
 extensor surfaces of the extremities as does psoriasis, but is more 
 abundant on the flexor surfaces. The frambcesiform papules of the 
 bearded region are to be distinguished from parasitic sycosis by the 
 retention of the hair in the follicles, and the absence of the trichophyton 
 fungus. 
 
276 
 
 DISEASES OF THE SKIN 
 
 Follicular Syphiloderm — Synonyms. — Miliary papular syphiloderm ; 
 Syphilitic lichen ; Lichen syphiliticus ; Acuminate papular syphiloderm. 
 
 Like the flat papular syphiloderm, the follicular variety occurs in 
 two forms, a large and a small, but both forms of lesions are not un- 
 commonly seen together. While less frequent than the flat variety 
 
 : 
 
 Fig. 88. — Miliary papular and pustular syphiloderm. 
 
 of papular eruption, it is by no means rare. The papules, which are 
 situated about the mouths of the hair follicles, are acuminate or conical 
 in shape and vary in size from that of a pin-head to a millet seed and 
 somewhat larger. At first a bright red in color, they soon become 
 brownish-red and usually have a small scale on their summit. The 
 eruption may come out quite rapidly, reaching its full development 
 
INFLAMMATIONS 277 
 
 in two or three days, or, as is more frequently the case, it may require 
 from ten to fourteen days to reach its acme. It is situated upon the 
 face, the trunk, especially the back over the scapulae, on the outer side 
 of the upper arm and upon the thighs (Fig. 88). Often without any 
 special arrangement, it frequently shows a decided tendency to occur 
 in groups or patches which may be distinctly annular at times, or 
 corymbiform. In most cases a few small pustules are scattered about 
 with the papules. This eruption usually occurs within the first three 
 or four months of the disease and pursues a chronic course. 
 
 An unusual variety, characterized by very small papules, occurs 
 as a late eruption, in the great majority of cases in cachectic women. 
 The papules occur in closely aggregated patches resembling those 
 of lichen scrofulosorum. Although red at first, they rapidly fade until 
 they may differ but little in color from the normal skin. This is usually 
 a very chronic form, yielding but slowly to treatment. 
 
 Diagnosis. — While the arrangement, distribution and color of the 
 eruption and its association with other evidences of syphilis usually 
 make the diagnosis an easy one, it may be at times confounded with 
 papular eczema, punctate psoriasis, keratosis pilaris, lichen planus 
 and lichen scrofulosorum. Papular eczema is almost invariably accom- 
 panied by intense itching, a symptom rarely present to any noticeable 
 degree in syphilis ; the papules of psoriasis are uniformly scaly, while 
 those of syphilis are commonly mixed with a few pustules ; keratosis 
 pilaris is found as a rule upon the extremities and is a very chronic 
 affection ; in lichen planus the papules are flat-topped and more or less 
 pruritic and never associated with pustules ; lichen scrofulosorum is 
 rare after puberty and is, as a rule, confined to the trunk, while the 
 small follicular papular syphiloderm is seen for the most part in adults, 
 and occurs upon the face and extremities as well as the trunk. 
 
 Vesicular Syphiloderm. — Synonyms. — Syphiloderma vesiculosum ; 
 Syphilide eczemateuse ; Syphilide herpetiforme. 
 
 The existence of this variety of syphilitic eruption has been regarded 
 with considerable scepticism or denied, but the observations of Basse- 
 reau, Hardy, Hutchinson, and other equally experienced observers, 
 leave no doubt of its existence, although it is very rare, probably the 
 rarest of all the cutaneous symptoms of syphilis. 
 
 A few years ago the author had the opportunity to study a well- 
 marked example of this eruption in the wards of the Philadelphia 
 Hospital. It consisted of numerous small vesicles seated upon a 
 slightly reddened base scattered over the face and extremities and to a 
 less extent upon the trunk without any definite arrangement; within 
 a day or two the contents of the lesions, which at first were trans- 
 parent, became turbid, and in some instances purulent, and dried into 
 small crusts. 
 
 According to the size and arrangement of the lesions, a number of 
 varieties have been described. The vesicles may be quite small and 
 
278 DISEASES OF THE SKIN 
 
 closely aggregated in patches like those of eczema, or they may occur 
 in well-defined groups like those of herpes, or in ring-shaped patches, 
 the Syphilide herpetiformc of Fournier. Occasionally they are quite 
 large and resemble those of varicella. Hutchinson and Crocker have 
 described a variety in which the eruption resembled that of herpes 
 zoster, but differed from that affection in being symmetrical instead of 
 unilateral. 
 
 This eruption is, as a rule, an early one, usually occurring within 
 the first six months of the disease, but exceptionally it may be seen 
 much later. It occurs upon the trunk and extremities, and in rare 
 instances in the face. It is a much less persistent form of eruption 
 than the papular, commonly drying up and disappearing in the course 
 of five or six weeks. 
 
 Diagnosis. — It may be mistaken for eczema, for herpes and for 
 varicella. From the first-named it is to be distinguished by the absence 
 of oozing and itching, by the presence of other syphilitic symptoms, 
 and the pigmentation which follows it. The herpetiform variety differs 
 from herpes by the papulovesicular character of the lesions, by the 
 symmetrical arrangement of the patches, and by the comparatively 
 slow course of the eruption. The varicelliform variety differs from 
 varicella in being confined to adults, in its much slower development 
 and much longer course. 
 
 Pustular Syphiloderm. — Synonyms. — Syphiloderma pustulosum ; 
 Acneform syphilid ; Ecthymaform syphilid ; Syphilid pustulo-crustacee. 
 
 While less frequent than the macular and papular varieties of 
 syphilitic eruption, the pustular forms are not at all uncommon. 
 Although not often a very early manifestation of syphilis, they may 
 occur at any period of the secondary stage and occasionally in the ter- 
 tiary stage. In size and arrangement of the lesions they resemble 
 the papular eruptions and like these are divided into large or small, 
 flat or acuminate varieties, without any special arrangement, or 
 arranged in groups or annular patches (Fig. 89). The lesions may be 
 pustular from the beginning, or they may begin as papules or vesico- 
 papules which shortly become distinct pustules. The subjects of the 
 pustular eruptions are, as a rule, ill-nourished or debilitated, either as 
 the result of the infection or from other causes such as insufficient 
 food, alcoholism, etc. 
 
 The acuminate or miliary pustular syphiloderm (Figs. 90 and 91) 
 resembles in the size, shape and distribution of the lesions the miliary 
 papular syphiloderm. It consists of pin-head- to millet-seed-sized 
 conical or acuminate pustules situated about the hair-follicles. These 
 begin as small red papules upon the summit of which a pustule or 
 vesicopustule rapidly develops, the contents of which soon dry up into 
 small brownish crusts which when they fall leave a pigmented spot 
 or exceptionally a small scar. The eruption is rarely purely pustular, 
 
INFLAMMATIONS 
 
 279 
 
 Fig. 89- — Pustular syphiloderm. (Late secondary eruption.) 
 
280 DISEASES OF THE SKIN 
 
 but along with the pustules are a variable number of scaly acuminate 
 papules. It may appear quite acutely, covering a considerable portion 
 of the skin within a day or two, or it may come out in crops extending 
 over a period of ten days to two weeks. When it comes out rapidly 
 and early in the second stage it is commonly accompanied by some 
 elevation of temperature. It is situated chiefly on the face, particularly 
 the forehead, scalp, back of the neck, over the shoulders, and on the 
 arms and legs. Not uncommonly, especially in the relapsing forms, 
 
 t 
 
 if. 
 
 Fig. 90. — Miliary pustular syphiloderm. 
 
 there is a more or less marked tendency to arrangement in well-defined 
 patches or in rings and segments of circles. 
 
 It usually occurs within the first six months of the disease, but is 
 infrequent as a very early eruption ; it may be seen quite late. Its 
 course is usually somewhat sluggish, lasting for some months. In- 
 stead of small pin-head-sized pustules the lesions may be as large 
 as split peas, resembling those of acne, the large acuminate pustular 
 or acneform syphiloderm. Occasionally this variety may exhibit a 
 more or less close resemblance to variola, many of the pustules show- 
 ing umbilication ; indeed the resemblance at times is so close as to 
 necessitate great care in the differential diagnosis (Fig. 92). 
 
 The small flat pustular syphiloderm, the impetiginous syphilid, 
 syphilitic impetigo or pustulo-crustaceous syphilid occurs as pea-sized 
 
INFLAMMATIONS 
 
 281 
 
 flat pustules usually arranged in ill-defined patches or less frequently 
 scattered about without any definite arrangement. The contents soon 
 dry into rather thick brown crusts which may be discrete or, when the 
 pustules are numerous and closely aggregated, may cover considerable 
 areas through the coalescence of the lesions (Fig. 93). Beneath these 
 crusts there is usually superficial ulceration. The eruption affects particu- 
 larly the hairy regions, such as the scalp, the beard, and the pubes, but 
 
 i 
 
 Fig. 91. — Miliary pustular syphiloderm. 
 
 also occurs about the angles of the mouth, the alse of the nose, upon the 
 chin, less frequently on the extremities. The number of lesions varies 
 considerably ; when the eruption occurs early they are usually discrete 
 and general, but when it occurs late or in debilitated subjects they 
 are more numerous and form confluent patches. It is rarely an early 
 eruption, but occurs in the late secondary or early tertiary period. 
 
 The large flat pustular syphiloderm or ecthymatous syphiloderm 
 occurs in two forms, a superficial and a deep form. The former is the 
 earlier eruption of the two and may appear at any time within the first 
 
282 
 
 DISEASES OF THE SKIN 
 
 year, although it usually occurs six to eight months after the initial 
 lesion. The pustules differ from those of the small flat variety chiefly 
 in their larger size (Fig. 94). They are covered with thick crusts 
 beneath which are superficial ulcerations or erosions, and are scattered 
 over the scalp, the trunk and extremities, particularly the lower ones. 
 Not infrequently they are associated with lesions of another type, such 
 as papules or smaller pustules. The eruption may come out in a short 
 time, or it may come out in successive crops over a period of some 
 weeks ; and the earlier it appears the more abundant the eruption is 
 
 Fig. 92.— Varioliform syphiloderm. 
 
 likely to be. The greater number of pustules disappears without leav- 
 ing any trace beyond a transient pigmentation, but a few scattered 
 scars occasionally follow. 
 
 In the deep-seated variety the lesions may be pustules from the 
 beginning, but more frequently they begin as flat papules or tubercles 
 which are speedily transformed into large pea- to finger-nail-sized 
 pustules whose contents soon dry into thick brown or greenish crusts 
 beneath which are ulcers of variable depth. In a certain proportion 
 of cases these crusts increase in thickness and circumference by the 
 
INFLAMMATIONS 
 
 283 
 
 addition of successive layers from beneath, each new layer being 
 larger than the preceding one, owing to the peripheral extension of 
 the underlying ulcer ; and in this manner laminated oyster-shell-like 
 crusts are produced covering sharp-cut, at times quite deep, ulcers. 
 This variety of eruption is known as rupia. When the crusts fall the 
 ulcers slowly heal by granulation, leaving a round or oval smooth scar 
 which is more or less pigmented, especially about its borders, and this 
 pigmentation may last for many months or even years. 
 
 The eruption is situated upon the shoulders, the back, and extremi- 
 
 f 
 
 'f 
 
 Fig. 93. — Pustular syphiloderm. 
 
 ties, being most abundant in the last-named region on the legs. Its 
 course is slow, continuing for many months or more than a year, new 
 small crops of pustules appearing 'at intervals of a week or two for 
 many months. It is a comparatively late manifestation, appearing 
 about the end of the secondary stage or the beginning of the tertiary, 
 although it may occur as early as the sixth month of the infection as 
 a precocious symptom, when it is commonly much more destructive 
 than when it appears at a later period. The patient usually shows 
 symptoms of debility or is decidedly cachectic. 
 
284 
 
 DISEASES OF THE SKIN 
 
 Diagnosis. — The several varieties of the pustular syphiloderm may 
 at times be mistaken for acne, variola, impetigo, pustular eczema, and 
 ecthyma. 
 
 The follicular pustules of syphilis are to be distinguished from 
 those of acne by their much wider distribution and association with 
 enlarged lymphatic glands and other evidences of general infection ; 
 the pustules of acne are in the vast majority of cases confined to the 
 face and upper portion of the chest and back and are accompanied 
 
 
 
 Fig. 94. — Large papulo-pustular syphiloderm. 
 
 by comedones ; the course of the syphilitic eruption is comparatively 
 acute, while that of acne is decidedly chronic. 
 
 When the pustular syphiloderm is situated in the scalp or beard 
 it may be mistaken for pustular eczema, but the latter is much more 
 superficial, never produces ulceration, and is accompanied by itching 
 and burning. The distinction between the varioliform syphiloderm 
 and variola is at times made with difficulty. The eruption of the latter 
 is preceded by a prodromal period with high temperature and severe 
 
INFLAMMATIONS 285 
 
 pain in the lumbar region, it begins as shot-like papules which become 
 umbilicated vesicles and later pustules, and is remarkably uniform in 
 character. The lesions of syphilis have no vesicular stage, are not 
 uniformly umbilicated, and there are usually a variable number of 
 small scaly papules mixed with the pustules. When the eruption 
 occurs early the initial sclerosis is usually still present. It should be 
 remembered that the syphilitic eruption may at times be accompanied 
 by fever. 
 
 The impetiginous syphiloderm differs from impetigo in the greater 
 number and wider distribution of the pustules, the absence of inflam- 
 matory symptoms, itching and burning, and its chronic course. The 
 large pustular syphiloderm at times resembles ecthyma, but differs 
 from that affection in the deeper ulceration which accompanies it and 
 the pigmented round scars which frequently follow it. Ecthyma is 
 seen usually in broken-down subjects, alcoholics, and almost always 
 in those who are the subjects of some itching affection, often pedicu- 
 losis corporis ; it is for the most part limited to the lower extremities. 
 
 Pigmentary Syphilide. — Synonyms. — Syphiloderma pigmentosum ; 
 Syphilitic leukoderma. 
 
 Synonyms. — Syphiloderma pigmentosum ; Syphilitic leukoderma. 
 
 In 1853 Hardy called attention to a peculiar pigmentation of the 
 skin as a symptom of syphilis, occurring in the great majority of 
 cases upon the sides and back of the neck. It appears under several 
 forms, first as ill-defined yellowish-brown or cafe-au-lait round or 
 oval spots varying in size from an eighth of an inch to an inch in 
 diameter; as a well-defined band of diffuse pigmentation surrounding 
 the neck, " the collar of Venus " ; or as oval or round whitish patches 
 surrounded by a reteform pigmentation, the last-named sometimes 
 following the second form. As already remarked, its usual situation 
 is the neck, although it may extend to the trunk, and in exceptional 
 cases may cover the greater part of it. It is seen almost exclusively in 
 women before the age of thirty ; according to Maireau, it is rare after 
 the twenty-fifth year. Most authors describe it as a very uncommon 
 symptom, but Shillito found it in about seventy-five per cent, of fifty 
 consecutive cases, and Maireau describes it as extremely common in 
 young women. There is a good deal of uncertainty as to whether the 
 pigmentation appears as a primary symptom or as the sequel of a 
 preceding roseola. Shillito is quite convinced that in the majority of 
 cases, if not invariably, the latter is the case. It is usually an early 
 symptom occurring in the early months of the secondary stage, 
 although it may appear late. It may disappear after two or three 
 months, or it may last for several years, or even indefinitely, and is 
 but little if at all influenced by antisyphilitic treatment. 
 
 Diagnosis. — It is to be distinguished from chloasma, vitiligo or 
 leukoderma and from tinea versicolor. 
 
 Chloasma is situated, in most cases, upon the face, and is commonly 
 associated with pregnancy or uterine disease ; the white patches of 
 
286 DISEASES OF THE SKIN 
 
 vitiligo are usually much better defined than those of syphilitic leuko- 
 derma and are seldom confined to the neck ; in tinea versicolor, which 
 rarely extends to the uncovered parts of the neck, the discoloration 
 is on, not in, the skin, and the microsporon furfur is readily found in 
 scrapings from the discolored patch. 
 
 Bullous Syphiloderm. — Synonyms. — Syphiloderma bullosum ; Pem- 
 phigus syphiliticus. 
 
 Synonyms. — Syphiloderma bullosum ; Pemphigus syphiliticus. 
 
 Although the bullous syphiloderm is not uncommon in congenital 
 syphilis, it is among the very rare forms of eruption in the acquired 
 disease. It occurs as pea- to nut-sized blebs usually surrounded by a 
 narrow dull-red halo, with transparent contents which soon become 
 cloudy or purulent. These, in a few days, dry into brown or greenish 
 crusts, which at times assume a rupial character, beneath which there 
 is usually superficial ulceration. The blebs are discrete, rarely numer- 
 ous, and are scattered over the extremities, often, like the congenital 
 variety, upon the palms and soles, and less frequently upon the face 
 and trunk. Other types of eruptive lesion are usually associated with 
 the blebs as well as other symptoms of syphilis. In rare instances 
 bullae have been observed upon the buccal mucous membrane, as in the 
 cases reported by Fox and by Vomer. The eruption usually occurs 
 in the latter part of the secondary or in the early tertiary stage, and 
 pursues a somewhat indefinite course, lasting from some months to a 
 year or two in exceptional cases. It is commonly regarded as indica- 
 tive of a severe infection. 
 
 Diagnosis. — The only affection for which it is at all likely to be 
 mistaken is pemphigus, to which it at times bears considerable resem- 
 blance ; indeed, the blebs frequently do not differ in any particular 
 from those of pemphigus. The presence of other lesions and symp- 
 toms of syphilis and the occurrence of ulceration, with the occasional 
 formation of rupial crusts, are features of the syphilitic eruption which 
 usually serve to make the differential diagnosis one of no great 
 difficulty. 
 
 Moist Papules. — Synonyms. — Flat condyloma (Fig. 95); Mucous 
 patches; Fr., Plaques muqueuses ; Ger., Schleimhaut papeln. 
 
 When syphilitic papules are situated in regions where the skin is 
 constantly warm and moist and subjected to friction, or upon mucous 
 membranes, they are more or less modified in their appearance, differ- 
 ing from the lesions found in other regions. In regions where there 
 are opposed skin surfaces, such as the inner surface of the upper thigh, 
 the scrotum, the vulva, between the buttocks around the anus, less 
 commonly beneath the pendent breasts of women, and occasionally 
 between the toes and fingers, the papules soon become grayish or 
 yellowish-white through maceration of the epidermis and secrete a 
 mucopurulent foul-smelling discharge. Not infrequently, especially 
 in those who are not cleanly, they undergo hypertrophy, become de- 
 
INFLAMMATIONS 
 
 287 
 
 cidedly elevated with a papillomatous surface, forming the lesion 
 known as the flat condyloma. Sometimes this hypertrophy is exces- 
 sive, giving rise to large cauliflower-like masses of vegetations covered 
 with an extremely offensive secretion (vegetating or papillomatous 
 syphiloderm). 
 
 The mucous patch, which is a form of moist papule, occurs upon 
 the mucous membranes of the lips, tongue, cheeks, the hard and soft 
 palate, the tonsils, inner surface of the labia, and the anus, as roundish, 
 
 Fig. 95. — Flat condylomata. 
 
 oval or irregular, quite flat, very slightly elevated grayish patches from 
 the size of a pea to the little finger-nail, which look as if lightly painted 
 with silver nitrate. At times they are eroded or superficially ulcerated, 
 when they may be quite sensitive, making the taking of hot drinks, or 
 highly seasoned food painful when situated in the mouth. 
 
 Both moist papules and mucous patches are very common lesions in 
 the secondary stage of syphilis, and may be found in the majority of 
 cases, the former particularly around the anus and vulva, the latter 
 on the mucous membrane of the lower lip and tongue. Owing to their 
 
288 
 
 DISEASES OF THE SKIN 
 
 peculiar and usually well-defined features, they are of considerable 
 value in diagnosis. While usually quite amenable to treatment, the 
 mucous patch may recur with great persistency in the mouths of 
 smokers. 
 
 At the corners of the mouth, fissured moist papules are common : 
 these are highly characteristic lesions not to be mistaken for any other 
 affection. 
 
 Mucous patches when ulcerated may. be mistaken for aphthous 
 ulcers, but the latter are distinctly vesicular when they first appear, 
 are very painful, and run a very acute course, while the former are 
 persistent lesions, often lasting for months. 
 
 LATE OR TERTIARY SYPHILODERMATA 
 
 The late cutaneous lesions of syphilis or the tertiary syphilo- 
 dermata, as already observed, are distinguished from the early or sec- 
 
 • . 
 
 \ 
 
 
 Wi 
 
 
 Fig. 96. — Nodular syphiloderm 
 
INFLAMMATIONS 
 
 289 
 
 ondary eruptions by the comparatively small number of the lesions, 
 their asymmetrical distribution, their tendency to ulceration and their 
 extremely chronic course. There are several distinct varieties of 
 lesion present in the tertiary stage, although fewer than those of the 
 early period. The late syphilodermata are : the nodular or tubercular 
 syphiloderm ; the gumma ; and the papulosquamous syphiloderm, 
 limited to the palms and soles. 
 
 Nodular Syphiloderm. — Synonyms. — Tubercular syphiloderm ; Sy- 
 philoderma tuberculosum. 
 
 HMMSUW 
 
 ,,-, 
 
 • 
 
 ^\ 
 
 w* 
 
 Fig. 97. — Ulcerating nodular syphiloderm. Distribution resembling a thoracic zoster. 
 
 The nodular syphiloderm is characterized by patches of dull-red or 
 brownish-red elevations varying in size from that of a small to a large 
 pea, with a smooth or slightly scaly surface usually aggregated in 
 variously sized patches or groups either without definite arrangement 
 or, what is common, arranged in circles or segments of circles. Al- 
 though such patches may be annular from the beginning, they also 
 frequently arise through the absorption of the centrally situated lesions, 
 while new nodules are added to the circumference. The nodules 
 may undergo absorption after a month or two, leaving pigmented 
 19 
 
290 
 
 DISEASES OF THE SKIN 
 
 atrophy of the skin, or they may ulcerate, forming patches made up of 
 a number of small round punched-out ulcers covered with crusts. 
 These ulcerating patches are often crescentic or reniform in shape, 
 advancing on the convex border and healing on the concave side, or 
 they may form extensive serpiginous figures which ulcerate and crust 
 over, and frequently involve large areas (Fig. 96) in the course of 
 months or years, producing extreme destruction of the skin followed by 
 scarring of a characteristic kind. The number of patches is usually 
 a very limited one ; often there is but a single one, although there may 
 be several. The nodular syphiloderm is usually seen two or three years 
 after infection, although quite exceptionally it occurs in the late second- 
 ary period, when the lesions are likely to be much more numerous 
 than the later eruption, although never generalized and symmetrical. 
 
 It very commonly occurs ten years or 
 more after the initial lesion (Figs. 97, 
 98, and 99). 
 
 Although it may occur on any por- 
 tion of the skin, it is most frequently 
 seen in the face, especially on the fore- 
 head, the nose, on the trunk, usually 
 the posterior surface, and on the ex- 
 tensor surface of the extremities. 
 
 The course is a chronic one, the 
 patches slowly extending and lasting 
 for years unless removed by treatment. 
 Usually there are no very marked 
 subjective symptoms. Even when ex- 
 tensive ulceration occurs, there is little 
 or no pain, but exceptionally there 
 may be severe pain when the ulcers are 
 situated about the joints, such as the 
 ankle, where they are subjected to frequent movement. 
 
 Diagnosis. — The nodular syphiloderm is usually recognized with- 
 out difficulty, the only affection for which it is at all likely to be mis- 
 taken being lupus vulgaris. The former is almost always a disease 
 of adults, the latter begins as a rule in childhood ; the former fre- 
 quently shows an annular or crescentic arrangement, the latter very 
 infrequently does so ; the syphilitic affection pursues a much more 
 rapid course than lupus, producing as much ulceration in a few 
 months as the latter does in as many years ; and, lastly, when recurrence 
 takes place in old areas, in lupus new nodules frequently appear in 
 the midst of the cicatrices, whereas the nodules of syphilis are never 
 or seldom found in, but at, the margin of the scars. 
 
 Squamous Palmar and Plantar Syphiloderm (Plate XVII). — Refer- 
 ence has already been made to the scaly papular eruption of the palms 
 and soles which forms part of a general eruption in the secondary 
 
 Fig. 98. — Nodular syphiloderm. 
 
INFLAMMATIONS 
 
 291 
 
 ■.^; 'i!S 
 
 j 
 
 Fig. 99. — Nodular syphiloderm date). The case had been mistaken for lupus, which it resembled very 
 much. Recovered promptly under specific treatment. 
 
 Fig. 100. — Circinate squamous syphiloderm (late). 
 
292 
 
 DISEASES OF THE SKIN 
 
 period. There is also a scaly syphiloderm of the palm and soles which 
 is a common and characteristic eruption of the late or tertiary stage. 
 It differs from the papulo-squamous eruption of the secondary period by 
 its asymmetrical distribution — it affects a single palm or sole, occasion- 
 ally both a palm and sole, but rarely, if ever, both palms and soles. 
 It occurs under two forms. The first is distinguished by sharply 
 denned, scaly patches with slightly elevated borders made up of pinkish, 
 red, or yellowish hemp-seed-sized, flat, confluent nodules covered with 
 thin adherent scales. Quite often the patches are perfectly annular 
 (Fig. ioo), varying in diameter from that of a large pea to a dime, and 
 may be present in considerable numbers, or by the junction of two or 
 more, they may form a patch of considerable size with polycyclic or 
 
 Fig. ioi. — Squamous syphiloderm (.late). 
 
 serpiginous borders. For a time after their appearance they slowly 
 extend, but when fully developed they are apt to remain stationary 
 for months. In a certain proportion of cases there is more or less 
 pronounced hyperkeratosis with Assuring in the normal furrows. Upon 
 the soles this hyperkeratosis may be extreme, forming a thick horny 
 plate with fissures extending deeply into the corium which make walk- 
 ing very painful. 
 
 A second form occurs as pea- to finger-nail-sized or larger map-like 
 round or oval pinkish or red, slightly desquamating patches sur- 
 rounded by a narrow collar of horny epidermis, with its turned up 
 edge toward the centre of the patch (Fig. ioi). 
 
 The course of this form of syphiloderm is usually extremely chronic ; 
 when once established it may last for many months, and not uncom- 
 
PLATE XVIII 
 
 Ulcerating syphilitic gummata. 
 
INFLAMMATIONS 293 
 
 monly for years, without undergoing any very marked change in its 
 appearance. It is one of the most rebellious of all the forms of 
 cutaneous syphilis, demanding for its successful treatment vigorous 
 internal and external measures, and is extremely prone to recur. 
 
 Diagnosis. — The squamous palmar syphiloderm is to be distin- 
 guished from squamous eczema and psoriasis. It differs from the first 
 by the absence of itching, the sharp circumscription of the patches and 
 their often annular or circinate shape. 
 
 Psoriasis is quite uncommon on the palms and soles and is never 
 confined to them, but is always accompanied by characteristic patches 
 elsewhere, particularly the scalp, elbows and knees. The scale is char- 
 acteristically laminated, quite unlike the scale of the syphiloderm. 
 
 The gummatous syphiloderm or gumma (Plate XVIII) is usually 
 a manifestation of the late or tertiary stage of syphilis, but may occur 
 in the late secondary stage or even, very exceptionally, in the early 
 secondary stage, when it is usually to be regarded as a symptom of 
 so-called precocious syphilis. 
 
 It begins as a small, firm subcutaneous nodule which, as it enlarges, 
 becomes adherent to the overlying skin which, at first of normal color, 
 becomes red and slightly elevated. It grows rather rapidly and in the 
 course of a month or six weeks may reach the size of an English 
 walnut or a small egg. The skin becomes stretched, bluish in color, 
 and finally gives way, a viscid bloody fluid escaping through the open- 
 ing. Within a short time a sharp-cut " punched-out " ulcer is formed 
 which is usually of considerable depth, sometimes extending down to 
 the subcutaneous tissue ; this ulcer may continue for months or a year 
 or two, unless healed by appropriate treatment, slowly extending in 
 depth and circumference. 
 
 Instead of a circumscribed nodule there may be a diffuse infiltration 
 of the subcutaneous tissue and skin, forming a firm, rather ill-defined 
 dusky-red or bluish plaque of variable size in which after some weeks 
 or a month or two several round openings appear (Fig. 102) from which 
 a viscid fluid is discharged. These openings may remain as discrete 
 ulcers, or several of them may unite to form a serpiginous ulceration 
 of considerable extent, or the whole plaque may eventually break down 
 to form one large ulcer with irregular or polycyclic margins. While 
 the usual course of the gumma is to soften and ulcerate, it may, after 
 a time, disappear by absorption without ulceration. When extensive 
 gummatous infiltration and ulceration occur upon the legs or the 
 female genitalia, the lymphatic circulation may be greatly interfered 
 with and a condition of fibrous thickening with papillomatous growth 
 may arise resembling elephantiasis. 
 
 The most frequent site of the gumma is the legs, particularly the 
 outer side of the calf, but it may occur on any portion of the body. 
 Upon the buttocks and thighs, regions in which there is an abundance 
 of subcutaneous tissue, it is often extensive and deep. Over flat bony 
 surfaces, such as the sternum, the forehead and scalp, where there is 
 
294 
 
 DISEASES OF THE SKIN 
 
 little subcutaneous tissue, it frequently involves tin 4 periosteum and 
 is followed by necrosis of the bono. 
 
 When it occurs in the late or tertiary stage it is usually a solitary 
 lesion, although several are not at all uncommon. Gumma ol" the 
 earlier stages is much more apt to be multiple and when there are a 
 number they are usually smaller than when there is but a single lesion. 
 
 It is usually without pain in its earlier stages, or it pain is present 
 it is rarely pronounced, but when ulceration has occurred there may 
 
 PlC. 10a. Multiple ulcerating syphilit: 
 
 mata. Rapid 
 
 under specific treatment. 
 
 be decided pain, especially when it is situated in the neighborhood o\ 
 a joint where it is subjected to Frequent movement, 
 
 Diagnosis. — In the ulcerative stage the recognition o\ the syphilitic 
 gumma usually presents but little difficulty ; its circular shape and 
 " punched-OUt " appearance, its situation on the calf in many cases. 
 or over flat bony surfaces, the absence (^i pain or its comparatively mild 
 character when present, and the scars <^i old syphilitic ulceration 
 often to be found i* looked tor. are quite distinctive. The case is 
 otherwise, however, before ulceration has taken place, and the diag- 
 nosis may then present considerable difficulty, It may be mistaken 
 
INFLAMMATIONS 295 
 
 for various forms of new-growth, benign or malignant, such as fibroma, 
 lipoma, sarcoma, or the tuberculous gumma. From the new-growths it 
 differs by its comparatively rapid growth, by the early appearance of 
 ulceration, by its situation on the legs, a region seldom attacked by 
 new-growths ; from the tuberculous gumma, which occurs upon the 
 calf, in young women most frequently, the erythema induratum of 
 Bazin ; it differs also by the much earlier appearance of ulceration and 
 by the circular shape of the ulcers, quite unlike the irregularly-shaped 
 ulcers with undermined borders which occur in the tuberculous 
 affection. 
 
 When there is the slightest uncertainty in the differential diag- 
 nosis between an ulcerating gumma and the ulcer which results from 
 malignant disease, it is wise to give the patient the benefit of a short 
 course of specific treatment before subjecting him to a serious and muti- 
 lating operation. The author has known this precaution to serve a 
 most useful purpose in more than one instance. The Wassermann 
 reaction may be absent in late syphilis, and its presence only proves that 
 the patient is a syphilitic subject and not that the ulcer is of necessity 
 syphilitic. 
 
 Congenital Syphilis (Syphilis Cutanea Congenita). — The eruptions 
 of infantile, congenital or inherited syphilis present much the same 
 features as those of the acquired or adult form, but they also pre- 
 sent certain peculiarities in symptoms and course which distin- 
 guish them somewhat from the latter. They are not preceded by 
 an initial lesion and their development is not marked by the more or 
 less orderly stages which characterize the development of acquired 
 syphilis. The type of eruption is more or less influenced by a number 
 of factors, important among which is the period at which infection has 
 taken place, i.e., whether it has occurred at the moment of conception 
 or at an early or late period of the pregnancy. The later in the preg- 
 nancy the infection takes place, the more nearly the eruptions approach 
 in type those of acquired syphilis. The character of the eruptions is 
 also influenced to a considerable degree by certain anatomical and 
 physiological peculiarities of the infant skin. They are usually de- 
 cidedly more hypersemic and less infiltrated than those of the adult. 
 The profound prejudicial influence which the infection exerts upon the 
 development of the entire infant organism and the frequent concomitant 
 occurrence of grave visceral disease, due also to the infection, must 
 exercise a considerable effect upon the cutaneous symptoms. 
 
 The most frequent type of eruption is the erythematous or macular 
 which appears about the third week' after birth, but may appear in the 
 first week or as late as the sixth or eighth week. It is distinguished 
 by red patches, varying in size from that of a pea to a finger-nail, which 
 soon assume a brownish-red hue and do not wholly disappear under 
 pressure, owing to the presence of slight pigmentation. Occasionally 
 there is a slight degree of infiltration producing some elevation, maculo- 
 
296 DISEASES OF THE SKIN 
 
 papules, and the papules may at times show a slight scale upon ex- 
 posed parts. The eruption shows a certain predilection for the 
 abdomen, buttocks, genitalia, and inner surface of the thighs, but 
 may occur on the trunk, forearms, especially upon the palms and soles, 
 and in the face about the alse of the nose and around the mouth. A 
 frequent and characteristic symptom is a coryza which interferes with 
 breathing through the nose and consequently with nursing, producing 
 the well-known " snuffles." There is commonly more or less hoarse- 
 ness, or complete aphonia. Occasionally the eruption is so slight and 
 disappears so rapidly that it attracts but little attention, or may escape 
 notice altogether, but in most cases it is quite abundant, lasts for a num- 
 ber of weeks, and may continue for a longer period by the appearance 
 of new lesions from time to time. 
 
 A papular eruption also occurs in infantile syphilis which resembles 
 the papular syphiloderm of acquired syphilis, but the papules are 
 usually much less infiltrated than in the adult and less inclined to 
 scale. It is situated upon the cheeks, the forehead, and the nates 
 principally. About the anus, on the scrotum and thighs, and about the 
 mouth, it occurs as moist papules or flat condylomata, which frequently 
 ulcerate, sometimes quite deeply, and when numerous, extensive de- 
 struction may result. About the angles of the mouth they are fre- 
 quently accompanied by fissures. 
 
 Many years ago Taylor described a characteristic symptom of con- 
 genital syphilis to which attention has been more recently called by 
 Meyer and Hochsinger. This is a diffuse infiltration occurring upon 
 the palms and soles and buttocks, which Taylor attributed to the fusion 
 of numerous papules. The palms and soles are a dull red color, thick- 
 ened and somewhat scaly. It appears most frequently in the fourth 
 week after birth, reaches its acme in the second or third month, and 
 then slowly disappears. Mracek does not regard it as related to 
 papules in any way but as following an erythema. 
 
 A vesicular eruption also occurs, but is extremely rare, and is almost 
 always asociated with pustular and bullous lesions. 
 
 The pustular eruption does not differ in any essential particular, 
 neither as to the character of the pustules nor their distribution from 
 the pustular syphiloderm of acquired syphilis ; it is less frequent than 
 the macular and papular eruptions and usually occurs in infants whose 
 nutrition is profoundly affected by the infection. While it usually 
 disappears without leaving any permanent alteration, it may be fol- 
 lowed by considerable scarring. 
 
 The nodular or tubercular syphiloderm and the gumma are rarely 
 seen in infants, but may occur at a later period as symptoms of inherited 
 syphilis ; they do not differ from the lesions of the acquired form. 
 
 In a certain proportion of cases the syphilitic infant is born with 
 an eruption which consists of pea- to nut-sized blebs situated in most 
 instances upon the palms and soles, the so-called syphilitic pemphigus. 
 According to Mracek's statistics, fully one-half of all prematurely born 
 
INFLAMMATIONS 297 
 
 syphilitic infants are thus affected. The contents of the blebs, at first 
 turbid serum, soon become purulent, the blebs rupture, leaving an 
 excoriated surface which frequently becomes the seat of an ulcer. The 
 nails are frequently affected; the matrix inflames and ulcerates, the 
 nails become brown, loose, and drop off. Although occurring most 
 frequently upon the palmar and plantar surfaces, the eruption may 
 also occur upon the trunk and limbs. The infants are profoundly 
 marasmic ; the skin is pale, yellowish, flabby and wrinkled, the face is 
 that of an old man or woman, the nose is blocked up with crusts and 
 the cry is hoarse or there is complete aphonia. In the great majority 
 of cases death occurs in the course of a week or two, or earlier. 
 
 Symptoms. — The features of the several eruptions which have 
 already been described ; the early age at which they appear, usually 
 within the first six weeks, seldom later than the third month ; the 
 marasmic appearance of the infant — the yellow, withered, flabby skin 
 and weazened features, like that of old age ; the nasal obstruction ; the 
 hoarse cry or aphonia, the presence of moist papules about the anus 
 and rhagades at the corners of the mouth all combine to present a 
 picture which is readily recognized and once seen is not soon forgotten. 
 In older children the cutaneous symptoms are frequently accom- 
 panied by symptoms referable to other tissues, such as dactylitis, a 
 gummatous inflammation of one or more of the phalanges producing a 
 spindle-shaped swelling of one or more fingers, keratitis, and the pecu- 
 liar notched condition of the permanent central incisors — Hutchinson's 
 teeth ; these are frequently valuable corroborative symptoms. 
 
 Etiology. — In the vast majority of cases syphilis is acquired in sexual 
 intercourse, but infection frequently occurs in other ways. Owing to 
 the frequent occurrence of lesions in the mouth, which are highly con- 
 tagious, it may be transmitted by kissing, by bites, e.g, the nursling 
 frequently infects the wet-nurse. It may be transmitted indirectly by 
 a great number of objects in daily use which have been used by infected 
 individuals. Drinking-glasses, and other table utensils, toilet articles, 
 tobacco-pipes, the mouth-pieces of musical wind-instruments, surgical 
 and dental instruments, may all be the media of infection (syphilis of 
 the innocent, syphilis insontium) . The obstetrician and the midwife 
 occasionally acquire it in the performance of their duties, the initial 
 lesion being situated in most instances upon the finger, but occasionally 
 upon other parts of the hand. Both sexes are alike susceptible, and no 
 age is exempt. It is highly contagious in the primary and secondary 
 stages, but only slightly so in the tertiary stage. 
 
 It is frequently congenital, infection taking place through the pla- 
 centa from the mother and only indirectly through the father ; opinions 
 vary, however, on this point. 
 
 The direct cause is a motile spiral microorganism shaped like a cork- 
 screw, the spirochceta pallida or treponema pallidum, discovered by 
 Schaudinn and Hoffmann in 1905. It is from five to fifteen microns 
 long and has from three to ten or more spirals. It is present in the 
 
298 DISEASES OF THE SKIN 
 
 initial lesion, in the eruptive lesions of the secondary stage usually in 
 great numbers, and in small numbers in the lesions of the tertiary stage, 
 in the lymphatic glands and in great numbers in the viscera in congeni- 
 tal syphilis, being especially abundant in the liver. Its causal relation- 
 ship to the malady has been demonstrated by the production of charac- 
 teristic lesions in the monkey and chimpanzee by the inoculation of 
 pure cultures, and it has been successfully cultivated by Noguchi. 
 It may be demonstrated in smears or scrapings from the initial lesion 
 or from mucous patches, moist papules and papules upon the skin, by 
 dark-ground illumination, or very readily by the India ink method of 
 Burri. The author has found that the India ink may be very satis- 
 factorily replaced by nigrosine, as suggested by Goosman. 
 
 Pathology. — Syphilis is an infection, a spirillosis, due to the spiro- 
 chseta pallida (treponema pallidum), and the lesions which distinguish 
 it belong to the infectious granulomata. The histological changes 
 which characterize it are, with the exception of a number of compara- 
 tively unimportant details, practically the same in all forms of eruption. 
 
 In the erythematous (macular) syphiloderm the changes are slight ; 
 there is some dilatation of the vessels of the superficial plexus, chiefly 
 in the papillary body, beginning endothelial proliferation and a slight 
 increase of cells about the vessels, the follicles and the sweat-glands. 
 
 In the papule, which may be taken as the histological type of the 
 syphilitic lesion, there is at first a very abundant perivascular leucocytic 
 exudation which is soon replaced by a dense infiltration of plasma cells 
 (Fig. 103) in the papillary body and the subpapillary portion of the 
 corium. Occasional giant-cells are also present, in many of which 
 the peripheral ring of nuclei is incomplete, a feature which distinguishes 
 them from the giant-cells of the tuberculous granuloma (Unna). 
 Occasionally there are also a varying quantity of red blood-cells scat- 
 tered throughout the mass of plasma cells. In the region occupied 
 by the exudate the elastic tissue has in large part or completely disap- 
 peared. The epidermis is at first but little altered, but later there is 
 inter- and intracellular oedema of the rete, with numerous migratory 
 leucocytes in the intercellular spaces, and in places small collections 
 of polynuclear leucocytes, especially beneath the horny layer, which at 
 times unite to form small pustules (papulo-pustular syphiloderm). 
 
 The miliary papular syphiloderm differs from the larger papular 
 syphiloderm chiefly by its situation about the follicles, the greater 
 number of giant-cells in the exudate and a more pronounced tendency 
 to superficial destruction (Ehrmann) ; it is, in fact, a syphilitic follicu- 
 litis and perifolliculitis. 
 
 In the syphilitic condyloma (flat condyloma), in addition to the 
 plasma-cell exudate in the papillary and subpapillary portion of the 
 corium, there is an enormous increase in the length and breadth, espe- 
 cially the former, of the papillae and a corresponding increase in the 
 size of the interpapillary prolongations of the rete. In the latter there 
 is an abundant immigration of leucocytes which may at times lead to 
 
INFLAMMATIONS 
 
 299 
 
 the destruction of the rete, which is then cast off as a crust, leaving 
 a raw, easily bleeding surface. 
 
 According to Unna, the lesions of the tertiary stage are nothing 
 more than " the rejuvenated remains of old syphilitic products of the 
 secondary, or even primary period," a view which was also held by 
 Hutchinson. 
 
 The nodular (tubercular) syphiloderm is histologically much like 
 the syphilitic papule. It is made up of plasma cells and young connec- 
 tive-tissue cells with dilated blood-vessels and lymph-spaces. 
 
 Vli 
 
 mm 
 
 mmm* 
 
 f^vft 'S 
 
 
 
 Pig. 103. — Vegetating syphilitic papule. Greatly elongated interpapillary rete processes; plasma -cell 
 exudate in papillary and subpapillary portion of corium. 
 
 The gumma differs considerably in its structure from the other 
 syphilodermata. It is surrounded by a capsule of connective tissue, 
 next to which is an inflammatory exudate composed of leucocytes and 
 plasma-cells while the centre is granulation tissue in which are large 
 connective-tissue cells and a few giant-cells, much fewer in number 
 than in the lesions of the secondary stage. The centre may undergo 
 caseation, or be transformed into cicatricial connective tissue. When 
 it involves the epidermis, the latter is invaded by leucocytes and even- 
 tually gives way, permitting the discharge of the softened contents of 
 the centre of the gumma. 
 
300 DISEASES OF THE SKIN 
 
 Diagnosis. — -As the diagnosis of the various syphilodermata has 
 already been discussed in the sections devoted to their consideration, 
 we shall confine ourselves here to an account of those symptoms which, 
 common to the whole group of syphilitic eruptions, are to be con- 
 sidered in the diagnosis of cutaneous syphilis considered as a whole. 
 
 The eruptions of the secondary stage are almost without exception 
 more or less general in their distribution and symmetrical in their 
 arrangement. While they may occur on any part of the skin, they 
 manifest a partiality for certain regions, such as the border of the 
 scalp on the forehead (the so-called corona veneris), about the alse 
 of the nose, around the mouth, the flexor surfaces of the forearms and 
 the palms of the hands. Their color is somewhat distinctive — although 
 often a bright red when they first appear, they soon assume a brownish- 
 red hue, the so-called " coppercolor " or " ham-color," but too much 
 stress should not be laid upon this symptom, since it is frequently absent 
 or so little marked as to be of no account. A much more valuable 
 diagnostic feature is polymorphism, which is rarely absent, and is often 
 quite marked. With every macular eruption there is pretty sure to 
 be a certain number of papules, and in every papular eruption scattered 
 pustules are present. This polymorphism is due to the fact that the 
 eruptions usually come out in crops and the lesions undergo further 
 development after their appearance, so that various stages are present 
 simultaneously. A negative symptom of some value is the complete 
 absence in many cases of subjective symptoms, or their trivial character 
 when present ; syphilitic eruptions rarely itch, but there are exceptions 
 to this rule. In negroes itching is often present to a considerable 
 degree, so much so that they often refer to their disease as an " itch." 
 
 Symptoms on the part of the mucous membranes, of the eye, and of 
 the lymphatic glands are frequently associated with the eruptions and 
 are of very great value in corroborating the diagnosis. Lesions of the 
 mucous membranes of the mouth and pharynx are often present. Sore 
 throat, at times accompanied by hoarseness, is very often complained 
 of in the early eruptive stage, and mucous patches are frequent at the 
 corners of the mouth, on the inner surface of the lips, the cheeks, the 
 tongue, tonsils, and the mucous surface of the labia. Moist papules, 
 flat condylomata, are common about the anus, on the scrotum, the 
 vulva and inner surface of the thighs. 
 
 Iritis is a frequent occurrence in the early secondary stage. 
 
 In the great majority of cases a more or less general adenopathy 
 is present during the secondary eruptions, most readily perceived in 
 the post-cervical, epitrochlear and inguinal glands. Too much impor- 
 tance should not be attached to this symptom, however, since it is by 
 no means confined to syphilis, but is present in some of the acute 
 exanthemata. 
 
 It should be kept in mind that in a considerable proportion, if not in 
 the majority, of cases the early eruptions are preceded and accom- 
 panied by fever, the elevation of temperature being at times consider- 
 
INFLAMMATIONS 301 
 
 able. The author has known cases of this kind to be mistaken for 
 typhoid fever. 
 
 In 1901 Bordet found that when the blood of one animal was in- 
 jected into another of a different species, as the blood of a rabbit 
 into a guinea-pig, the serum of the second animal acquired the power 
 to dissolve the blood-corpuscles of the first, and that this hemolytic 
 property was due to the presence of two substances, " amboceptor " 
 and " complement," in the serum of the injected animal. It was also 
 found that certain substances known as "antibodies" are present in the 
 blood of those suffering from various infections, which under certain 
 conditions (addition of an " antigen ") may fix the complement and pre- 
 vent hemolysis. Wassermann, Neisser and Bruck, utilizing these dis- 
 coveries, devised a method of serum diagnosis since known as the Was- 
 sermann reaction, complement-fixation test, which has proven to be of 
 the greatest value, not only as a diagnostic method, but as a method of 
 controlling the results of treatment. Although it has been variously 
 modified by a number of serologists, notably by Noguchi, making it 
 more delicate and accurate and less complicated, it nevertheless re- 
 quires considerable technical training and skill for its proper perform- 
 ance, and should, therefore, always be entrusted to the laboratory- 
 worker. Unless skilfully done, it is not only wholly unreliable, but 
 what it worse it is likely to be misleading. The reader who desires 
 details as to its performance is referred to the manuals of pathology. 
 
 It is to be employed in all cases in which the diagnosis is the least 
 in doubt, but it should also be borne in mind that it has its limitations. 
 It does not appear until the end of the first week after the appearance 
 of the initial lesion, and usually appears later, as late as the end of the 
 fourth week; it is not invariably present even in the secondary stage, 
 being absent in about ten per cent, and is absent in a still larger per 
 cent, of cases in the tertiary stage. It may be absent in alcoholics and 
 after the inhalation of ether. It is present in other diseases besides 
 syphilis, such as leprosy, yaws, malaria, and scarlet fever. It should 
 always be kept in mind that a positive reaction means nothing more 
 than that the individual is syphilitic ; it is by no means definite proof, 
 but only presumptive evidence, that his cutaneous affection is syphilis. 
 
 Another procedure of considerable diagnostic value, particularly in 
 the teritary stage, is the intradermic injection of " luetin " the name 
 given by Noguchi to a suspension or extract of killed pure cultures of 
 the spirochsetse. A positive result is indicated by the appearance of 
 a red papule at the site of the injection at the end of from twenty- 
 four to thirty-six hours. Occasionally after two or three days a pustule 
 takes the place of the papule and in rare cases the reaction may be 
 delayed for a week or more. As the reaction is frequently negative in 
 the secondary stage, it is much less valuable than the Wassermann re- 
 action, but i> is usually present in the tertiary stage. Sherrick has very 
 recently announced that a positive reaction may be obtained in ninety- 
 nine per cent, of all cases, syphilitic or otherwise, in which iodide of 
 
302 DISEASES OF THE SKIN 
 
 potassium or other preparations of iodine are being administered. If 
 subsequent observations should prove the correctness of this statement 
 it should be remembered as a possible source of error. 
 
 Prognosis. — The prognosis of the early syphilodermata is, upon the 
 whole, very favorable, most of them disappearing after some weeks or 
 a month or two spontaneously, and their disappearance is greatly ac- 
 celerated by judicious treatment. The early erythematous or macular 
 eruption is often an insignificant one, at times so slight as to give the 
 patient but little concern or even escaping his notice altogether. Ex- 
 ceptionally the disease may apparently come to an end with this erup- 
 tion ; cases occur in which it is the first and only symptom of infection. 
 
 The pustular eruptions, especially those of the later secondary 
 period, are apt to be more persistent, and the larger lesions are fre- 
 quently followed by permanent scarring. 
 
 Mucous patches in the mouth are frequently most annoying lesions, 
 resisting treatment and recurring with extraordinary persistency, par- 
 ticularly in smokers. Moist papules about the anus and genitalia of 
 both sexes are often persistent, especially in the uncleanly, and in 
 alcoholics or those debilitated by unhygienic living. Ulceration may 
 occur causing considerable pain and destruction of tissue. 
 
 In rare cases the symptoms are unusually severe from the begin- 
 ning, or shortly after the appearance of the early eruption (malignant 
 syphilis, syphilis prsecox). Pustular and ulcerative lesions appear in 
 the early secondary stage, unusually rebellious to treatment, the pa- 
 tient becoming profoundly cachectic, and death may follow in the 
 severest cases. 
 
 The tertiary lesions, such as the nodular (tubercular) and gum- 
 matous syphilodermata, are chronic affections and, unlike the second- 
 ary eruptions, show little or no tendency to spontaneous healing, but 
 may last for many months or years when untreated; they usually re- 
 spond readily, however, to judicious treatment. The scaly palmar 
 syphiloderm of the late stage is an exception ; it is one of the most re- 
 bellious of all the syphilodermata, often yielding only to intensive in- 
 ternal and external treatment. 
 
 The prognosis in congenital syphilis is far more serious than in the 
 acquired form. In infants born with bullous lesions, the so-called 
 syphilitic pemphigus, and in those with pronounced malnutrition, death 
 within the first month or two after birth is common, although recovery 
 may last for many months or years when untreated ; they usually re- 
 One of the most important factors influencing the prognosis is the 
 character of the treatment employed in the early stages of the infection. 
 If it has been begun early and has been carried out vigorously and 
 methodically, a permanent cure may be confidently anticipated, but if, 
 on the contrary, it has been begun late and has been conducted ir- 
 regularly, relapses and the occurrence of tertiary lesions may be looked 
 for in a very large proportion of cases. 
 
 Treatment. — The treatment of cutaneous syphilis is practically the 
 
INFLAMMATIONS 303 
 
 treatment of syphilis in general ; the symptoms of the early stages, of 
 the first or second years, are largely and often entirely confined to the 
 skin. 
 
 The subject of active syphilis should pay the strictest attention to 
 personal hygiene, and when ulcerative lesions are present, the utmost 
 cleanliness should be observed ; and this is especially necessary in the 
 case of infantile syphilis in which the eruptions are apt to be on the 
 buttocks, around the genitalia and anus and about the mouth. The 
 diet should be a generous one and in the case of infants especial atten- 
 tion should be given to the patient's nutrition, which is usually much 
 impaired. In adults the use of alcohol should be forbidden, or if the 
 patient has been accustomed to its daily use the quantity should be 
 greatly restricted. When mucous patches are present in the mouth the 
 use of tobacco in every form should be strictly forbidden, especially 
 smoking, which always exerts a most injurious effect upon such lesions. 
 In anaemic subjects, especially those with extensive ulcerative lesions, 
 some easily assimilable form of iron, such as the potassio-tartrate, 
 should be given. Codliver oil, if easily digested, may also be given 
 with advantage when there are evidences of defective nutrition. 
 
 The patient, if an adult, should always be informed of the infec- 
 tious nature of his disease and the possibility of infecting those about 
 him and should be urged to take every precaution in the use of toilet 
 articles and table utensils to avoid such an unfortunate occurrence. 
 The attendants of syphilitic infants should be similarly instructed. 
 
 The medicinal treatment consists in the internal administration of 
 mercury and its salts, certain synthetic compounds or arsenic, the most 
 important of which is salvarsan, arsenobenzol, or dioxydiaminoarseno- 
 benzol, and the iodides of potassium and sodium. These exercise a 
 specific effect upon the infection, causing the disappearance of the 
 spirochsetse, or inhibiting their activity, and bringing about the disap- 
 pearance of the lesions characteristic of the malady. 
 
 Mercury is the oldest of these remedies, and until the introduction 
 of salvarsan was undoubtedly the most efficacious of all the drugs used 
 in the treatment of syphilis. It is used in many forms : as metallic mer- 
 cury in mercurial ointment (unguentum hydrargyrum), in gray oil 
 (oleum cinereum), in mercury-with-chalk (hydrargyrum cum creta) ; 
 as salts of the metal, such as the mild chloride (calomel), the bichloride, 
 the protiodide, the biniodide, the salicylate, and many others. As the 
 therapeutic effect of these does not differ materially, if at all, the 
 choice of the particular form will depend upon convenience of admin- 
 istration, certainty of effect, individual susceptibility, age and other 
 factors of a similar kind. 
 
 For oral administration the protiodide is a favorite salt with many ; 
 it should be given in doses of one-quarter to one-half grain (0.016 to 
 0.03) three times a day. It is apt to produce more or less abdominal 
 pain and diarrhoea in many individuals, even when given in moderate 
 doses ; this may be obviated to some degree by the simultaneous ad- 
 
304 DISEASES OF THE SKIN 
 
 ministration of small doses of opium, but this is often inadvisable. The 
 author much prefers the mercury-with-chalk (hydrargyrum cum creta) 
 or gray powder, which should be given in doses of one to two grains 
 (0.065 to 0.13) three times a day. It is much less apt to produce intes- 
 tinal disturbances than the protiodide and is just as effective. It is 
 especially to be preferred in the oral treatment of infantile syphilis. 
 
 One of the most efficient ways of using mercury is by inunction. 
 The method is objectionable because it is dirty, time-consuming, fre- 
 quently produces a severe dermatitis necessitating the suspension of 
 the treatment and cannot be used as a rule without betraying its use. 
 
 After a warm bath and thorough drying of the skin one dram (4.0) 
 of mercurial ointment is rubbed into the region selected for twenty min- 
 utes by the clock, no less, and occasionally longer when the ointment 
 is not readily taken up. The parts selected for the inunctions are com- 
 monly the inner surface of the thighs, the calves, the abdomen, the 
 sides of the thorax, and the flexor surface of the arms and forearms. 
 Each of these is used in regular succession in such a manner that no 
 one region is rubbed oftener than once a week ; in this manner the 
 production of a dermatitis may usually be avoided. The morning fol- 
 lowing the inunction, a warm bath may be taken to remove the oint- 
 ment which still remains upon the skin. The inunctions should be 
 made daily until from thirty to forty have been taken, when they should 
 be suspended for a time. At Aix la Chapelle (Aachen), where the 
 inunction treatment has been very thoroughly elaborated, the first 
 course lasts six weeks ; a second is given at the end of a year, lasting 
 one month. 
 
 In infantile syphilis treatment by inunction is much to be preferred 
 to all other methods. One dram (4.0) of equal parts of mercurial oint- 
 ment and lanolin should be gently rubbed into the abdomen or, what 
 is quite effective, spread upon the abdominal binder, daily. 
 
 One of the most efficient, if not the most efficient method of admin- 
 istering mercurial treatment, is the intramuscular injection of metallic 
 mercury as gray oil (oleum cinereum), or the salicylate, or some one 
 of the soluble salts. Of the soluble salts the bichloride is the most fre- 
 quently used ; it is dissolved in sterile normal saline solution and given 
 in doses of one-quarter to one-half grain (0.016 to 0.05) three times 
 a week, the injections being most conveniently made in the gluteal 
 region. 
 
 The insoluble preparations, however, are to be preferred to the 
 soluble salts; their effect is a more continuous one and the injections 
 need not be given so frequently. Those most frequently used are 
 calomel, metallic mercury and the salicylate of mercury ; these are sus- 
 pensions in some sterile bland oil, such as oil of sesame, oil of sweet al- 
 mond or fluid petrolatum. Calomel is seldom used at the present time 
 owing to the pain which follows its injection ; metallic mercury, as gray 
 oil (oleum cinereum), and the salicylate are the preparations most fre- 
 quently employed. These may be conveniently obtained already pre- 
 
INFLAMMATIONS 305 
 
 pared in sterile ampoules, each of which contains one dose. The equiva- 
 lent of one grain (0.065) of mercury or from one-half to one grain 
 (0.03 to 0.065) of the salicylate should be given at each injection and 
 the injections should be made once a week. The best site for the in- 
 jections is the gluteal muscles, although any region in which there is a 
 thick mass of muscles may be used ; they should be made directly and 
 deeply into the muscles, with the strict observance of asepsis. A glass 
 syringe, so constructed that all parts of it may be thoroughly sterilized, 
 should be used. 
 
 Mercurial fumigation is seldom used at the present time, although 
 there is no doubt about its value in the treatment of syphilis, especially 
 in the ulcerative forms. The patient is placed in a bath cabinet with 
 the head outside, seated upon a cane-seated chair beneath which is a 
 small stand with a receptacle in which is placed twenty to thirty grains 
 (1.30 to 2.0) of calomel, which is vaporized by a small alcohol lamp. 
 
 During the carrying out of every form of mercurial treatment spe- 
 cial attention should be paid to the condition of the mouth ; the tooth- 
 brush should be used frequently in conjunction with some mild anti- 
 septic mouth-wash, or a saturated solution of potassium chlorate. If 
 signs of ptyalism appear (and ptyalism sometimes appears very sud- 
 denly during inunctions or intramuscular injections), the treatment 
 should be suspended until they have disappeared. 
 
 The presence of nephritis is a contra-indication to every form of 
 mercurial treatment, and particularly to the more intensive forms, such 
 as inunction and intramuscular injection. 
 
 In 1910 Ehrlich announced the discovery of a new arsenical com- 
 pound, arsenobenzol, salvarsan (dioxydiaminoarsenobenzol) possess- 
 ing remarkable spirillicide properties with which he hoped to be able 
 to destroy all the spirochsetae at one stroke and thus bring the infection 
 to an abrupt end. The hope that it might be possible to cure syphilis 
 with one dose was not realized, unhappily, but the drug has been 
 proved to have extraordinary value in the treatment of that malady. It 
 occurs as a yellow powder containing a large proportion (thirty-four 
 per cent.) of arsenic which readily oxidizes on exposure to the air; its 
 solutions should therefore be prepared just before using. Somewhat 
 later Ehrlich prepared a modification of arsenobenzol or salvarsan, 
 neosalvarsan, which is readily soluble in water and therefore much 
 more convenient to use than the former, although it is pretty generally 
 agreed among those whose experience best fits them to judge that it 
 is less efficient therapeutically. 
 
 Both salvarsan and neosalvarsan may be used by intramuscular and 
 intravenous injection; the latter is much to be preferred in adults, but 
 in children in whom the veins are small the intramuscular method may 
 be employed. 
 
 The intravenous injection of salvarsan is performed in the following 
 manner : The dose, 0.6 for an adult man, somewhat less for a woman, 
 is dissolved in 30 c.c. of sterile, freshly distilled hot water in a suit- 
 
306 DISEASES OF THE SKIN 
 
 able glass jar, also thoroughly sterilized, with frequent shaking. When 
 it is dissolved, a sterile fifteen per cent, solution of sodium hydroxide is 
 added, drop by drop, until a fine precipitate appears and is redissolved; 
 sufficient sterile, freshly distilled water is then added to bring the 
 whole to 200 c.c. The whole is then filtered through a sterile filter into 
 the injection apparatus. Any large vein conveniently situated may be 
 used for the injection, but one of those in the bend of the elbow is com- 
 monly chosen. The skin over and around the vein selected is thor- 
 oughly cleansed with alcohol and with ether, a tourniquet is firmly but 
 not too tightly placed around the upper arm and the needle carefully 
 inserted into the vein. When the flow of blood from the needle in- 
 dicates that it has entered the vein the tube of the injection apparatus 
 is attached to the needle and the injection of the salvarsan solution 
 begun. The patient should be in the recumbent position and about 
 ten minutes should be consumed in the injection. 
 
 The injection of neosalvarsan is a much simpler matter. The dose 
 (0.9 for an adult) is dissolved in 20 to 40 c.c. of freshly distilled water 
 at room temperature ( it must not be heated) and injected into a vein 
 either with the apparatus used for salvarsan or with a glass syringe of 
 sufficient capacity. Ravaut and others have shown that much more 
 concentrated solutions may be safely employed — as little as 10 c.c. of 
 water may be used to dissolve the dose. 
 
 If for any reason the intramuscular injections are preferred to the 
 intravenous ones, the oily suspensions should be used rather than the 
 aqueous solutions ; the latter are painful, often extremely so, may give 
 rise to marked inflammatory reaction and at times to extensive necrosis. 
 The oily suspensions may be obtained in sterile ampoules ready for 
 use. Intramuscular injections of neosalvarsan are especially indicated 
 in children in whom the small size of the veins frequently make intra- 
 venous injections impracticable. They are to be made into the glu- 
 teal region in the same manner as mercurial injections, with the 
 strictest asepsis, and the dose should be proportioned to the age. 
 
 From three to four intravenous injections of salvarsan should be 
 given at intervals of a week, and these should be followed by a course 
 of intramuscular injections of gray oil or the salicylate of mercury, 
 eight to ten injections. 
 
 The presence of cardiac or renal disease or advanced disease of the 
 brain and cord contra-indicates the use of salvarsan ; if used at all under 
 such circumstances, it should be with the utmost caution and a full ap- 
 preciation of the dangers attending its use. 
 
 Occasionally nausea, vomiting, chills and fever follow within a 
 few hours after an injection, and rashes, usually morbilliform or scar- 
 latinoid, may appear, but all these symptoms, which were quite com- 
 mon when the drug was first employed, are comparatively infrequent 
 since only freshly distilled water has been used for making the solu- 
 tions. 
 
 The iodides of potassium and sodium are especially indicated in the 
 
INFLAMMATIONS 307 
 
 lesions of late syphilis, such as the nodular and gummatous forms. 
 They are of little value in the secondary stages. They may be given in 
 doses of five to ten grains (0.32 to 0.65) three times a day; in excep- 
 tional cases much larger doses may be necessary. As Hutchinson 
 pointed out many years ago, and as the author has had the opportunity 
 to demonstrate many times, they are quite often as effective in much 
 smaller doses, two or three grains, than in those commonly given, es- 
 pecially if the patient has not taken them before. The cure produced 
 by the iodides is a symptomatic one only, and they should be given 
 either with mercury or should be followed by it or salvarsan. 
 
 In most secondary eruptions local treatment is not necessary and 
 may therefore be dispensed with. In the case of the nodular syphilo- 
 derm or of ulcerating gummata, however, local treatment will acceler- 
 ate the disappearance very materially. An ointment of calomel or ara- 
 moniated mercury, thirty to sixty grains (2.0 to 4.0 to the ounce (32.0) 
 will often answer well ; or a piece of spread mercurial plaster, changed 
 daily or every other day, makes a convenient, cleanly and effective 
 application. 
 
 Whatever the remedy chosen or the method of treatment employed, 
 it should be begun at the earliest possible moment after the diagnosis 
 has been established, and should be continued not only for some time 
 after all symptoms have disappeared, but until a permanently negative 
 Wassermann reaction has been obtained. Two months after the sus- 
 pension of the treatment, a Wassermann test should be made, and if 
 negative another should be made at the end of two or three months 
 again, and so on for at least a year. Should the reaction become posit- 
 ive again after having been negative for a time the treatment should be 
 resumed as before. 
 
 LEPRA 
 
 Synonyms. — Leprosy ; Elephantiasis grsecorum ; Fr., la lepre ; Aus- 
 satz ; Spedalskhed. 
 
 Definition. — An extremely chronic infectious and contagious dis- 
 ease, due to the bacillus leprae, affecting principally the tegumentary 
 and nervous systems and ending almost invariably in death. 
 
 Known since the earliest historic times, leprosy is one of the oldest, 
 if not the oldest, of the great plagues which afflict mankind. Originat- 
 ing in the Orient, probably in Egypt or in India, it slowly spread to 
 Europe by way of Greece and Italy. During and immediately follow- 
 ing the Crusades there was an enormous increase of the malady- in 
 Europe. In the beginning of the thirteenth century there were no less 
 than 2000 leproseries in France alone, while in the whole of Christian 
 Europe there were 19,000. It continued to spread until the beginning- 
 of the fifteenth century, when it began to decline in consequence of the 
 restrictive measures adopted, chiefly isolation of the diseased. 
 
 Although no part of the world is entirely free from it, it is found 
 chiefly in India, China, Japan, the coastal regions of Africa and in 
 Egypt, in Sweden and Norway, Iceland, Russia, the islands of the 
 
308 DISEASES OF THE SKIN 
 
 South Pacific, in the West Indies, Mexico and in Central America and 
 the northern countries of South America. In the United States it is 
 found to a very limited extent in the Northwest, almost exclusively 
 among immigrants from the Scandinavian peninsula, in Louisiana, on 
 the Pacific Coast among Chinese immigrants. Isolated examples of 
 it are almost always present in the large cities of the East, such as 
 Boston, New York and Philadelphia. 
 
 The time which elapses between the entrance of the infecting 
 organism and the appearance of the first manifestations of the dis- 
 ease, the period of incubation, varies within wide limits ; it may be 
 but a few months or it may be several or even many years. Bidenkap 
 observed a case in which the period of incubation was only a few weeks ; 
 Arning, one of three months ; Morrow, one of ten months, the dis- 
 ease appearing within that period after a sojourn of two weeks in 
 the Sandwich Islands; Leloir has reported one of 14 years, while 
 Danielssen and Boeck have observed still longer periods. In all prob- 
 ability the duration of the incubation period depends upon a number of 
 factors, such as individual susceptibility, the varying virulence of the 
 lepra bacillus, hygienic surroundings, etc. The appearance of definite 
 and characteristic evidences of infection is, as a rule, preceded by a 
 period during which symptoms of an indefinite character appear. At- 
 tacks of slight fever with chilliness and malaise or well-marked chills 
 with considerable elevation of temperature lasting for some days appear 
 at irregular intervals ; headache, vertigo, epistaxis, profuse sweating 
 and muscular pains, likewise occur without apparent cause. In cases 
 in which the nervous system is chiefly involved, in addition to the 
 febrile attacks, there are hypersesthesia, neuralgia, pruritus, formication 
 and various forms of parsesthesia. None of these prodromal symp- 
 toms exhibit anything characteristic, and are in consequence commonly 
 attributed to " catching cold," malaria, rheumatism, etc. Exceptionally 
 such symptoms are completely absent, or so mild and infrequent as to 
 escape the patient's attention altogether. The duration of this pro- 
 dromal period varies from some months to a year or more. 
 
 The symptoms of leprosy are numerous and of a varied character, 
 and are referable chiefly to the tegumentary and nervous systems, al- 
 though in the more advanced stages symptoms indicative of visceral 
 involvement likewise occur. According as the bacilli invade the skin 
 or the nerve trunks and branches, the disease presents two principal 
 varieties, viz., tubercular leprosy, lepra tuberosa, and anaesthetic or 
 nerve leprosy, lepra ansesthetica, lepra nervorum. In a certain propor- 
 tion of cases mixed forms occur in which the symptoms are those of 
 both varieties — mixed leprosy. 
 
 Lepra Tuberosa. — Symptoms. — The earliest cutaneous symptoms 
 of this variety are usually macules and erythematous patches (erythema 
 leprosum) varying in color from pink to a brown-red, according to the 
 complexion of the patient and the duration of the eruption; they are 
 pink or red in those with fair skins and in the early stages, brown-red or 
 
INFLAMMATIONS 309 
 
 sepia in those with dark complexions, or when they have lasted for some 
 time. These patches vary in size from that of a coin to the palm, are round 
 or oval in shape, the centre usually deeper in color than the periphery, with 
 an oily shining surface ; or they may be annular or band-like and marginate 
 like those of erythema multiforme, a form, according to Leloir, rare in 
 the face, but common upon the trunk. They may remain stationary 
 or may slowly increase in size for a time after their appearance, and 
 then gradually fade. The earlier eruptions, after a variable duration, 
 usually disappear, leaving no trace. They are seen usually upon the 
 dorsal surface of the hands and feet, rarely upon the palms and soles, 
 in the face and less frequently upon the trunk. Their appearance 
 is frequently preceded by chills and more or less elevation of tem- 
 perature which subsides with the appearance of the eruption. Sub- 
 jective symptoms may be entirely absent, or there may be hyperesthe- 
 sia, itching, pricking formication, or incomplete anaesthesia. From 
 time to time new eruptive outbreaks occur, preceded or attended by 
 constitutional symptoms and the patches instead of disappearing as in 
 the earlier stages, remain, becoming deeper in color, usually brown or 
 occasionally black, and presenting some infiltration, which marks the 
 beginning of the nodular stage. At times the centre of some of these 
 later patches may be entirely depigmented and completely anaesthetic, 
 resembling the white patches of vitiligo in appearance. This is, how T - 
 ever, much less frequent in the nodular than in the anaesthetic variety. 
 
 The hair suffers in its nutrition ; it becomes thinned, brittle and falls 
 out. This leprous alopecia is usually most noticeable in the eyebrows, 
 where it begins, but it likewise affects the hair of the trunk, occurring 
 chiefly, if not exclusively, at the site of the eruptive patches. The hair 
 of the scalp, however, usually shows little or no alteration and may 
 be quite normal, this immunity being due to the fact that this region 
 is seldom the seat of eruption. 
 
 Although most authors deny the occurrence of tubercular lesions 
 without a precedent stage of erythematous or macular eruptions, Le- 
 loir asserts that in rare cases the first lesions may be tuberculous or 
 nodular. 
 
 After a period varying from some months to several years, during 
 which the symptoms consist of the erythematous and pigmented erup- 
 tions already described, thickened patches and tubercles appear, com- 
 monly at the site of such patches, but also in places where the skin has 
 previously shown no sign of disease. The infiltration may occur as 
 flat, thickened plaques or as distinct nodules and tubercles varying in 
 size from that of a pea to a hazel-nut, and larger ; the latter may be 
 discrete or when numerous, may form bosselated plaques of variable 
 extent. In color they vary from a pink to violaceous, from yellow to 
 mahogany-red or sepia, the darker lesions occurring in the dark-skinned 
 individuals. Although they may appear on almost any portion of the 
 body except the scalp, which almost invariably escapes, they exhibit 
 a decided predilection for the face, especially the forehead in the 
 
310 
 
 DISEASES OF THE SKIN 
 
 supraorbital region, where the first infiltrations appear, upon the nose, 
 cars, particularly the lobules, upon the dorsal surface of the hands and 
 feet, upon the thighs and buttocks (Fig. 104). In the earlier stages the 
 tubercles are usually small, varying in size from that of a shot to a pea, 
 resembling the papules of acne, or the nodules of syphilis or lupus, but as 
 the malady progresses they increase in size and number, some of them 
 
 ^''Wr$%&. 
 
 
 *K 
 
 x 
 
 / ,r 
 
 Fig. 104. — Lepra tuberosa. (Dr. John A. Johnston.) 
 
 reaching the size of a nut and larger, often producing when numerous 
 and closely aggregated, thickened areas with irregular nodular sur- 
 faces, the individual lesions often separated by well-marked furrows. 
 Upon the face this thickening is especially noticeable in the supraor- 
 bital region producing a marked and characteristic leonine appearance 
 (leontiasis). The lobes of the ears are frequently transformed into 
 brownish-red or violaceous pendulous masses. At times the flat infil- 
 
INFLAMMATIONS 311 
 
 trated patches present a markedly stippled appearance, owing to ex- 
 aggeration of the mouths of the follicles, a feature which was especially 
 well marked in a case under the author's observation some years ago. 
 
 Alterations of sensation, such as hyperaesthesia, or all degrees of 
 diminished tactile sensibility, the latter being more frequent than the 
 former, are often, but not invariably present. 
 
 The alterations of the pilo-sebaceous apparatus become still more 
 marked ; in consequence of the suppression or diminution of the se- 
 baceous secretion, the skin is harsh and dry and complete loss of hair 
 takes place at the site of the lesions. 
 
 The nails occasionally exhibit signs of disease ; they are distorted 
 in consequence of interference with their growth, or they are lost either 
 as the result of leprous infiltration and subsequent ulceration of the 
 nail-bed, or may fall without any special alteration. 
 
 The progress of the disease may be slow and continuous, new 
 nodules appearing, while the older ones increase in size or undergo 
 resorption ; or new lesions may appear in successive crops at irregular 
 intervals, the eruptive outbreaks occurring acutely and preceded or ac- 
 companied by constitutional disturbance which subsides with the ap- 
 pearance of the eruption. These acute outbreaks, as Danielssen and 
 Boeck have shown, are coincident with the softening and absorption 
 of some of the nodules, and as Leloir believes, are due to absorption of 
 leprous Virus by the lymphatics. At times the accompanying erup- 
 tion resembles erysipelas, at others it presents the appearance of ery- 
 thema nodosum. 
 
 The lymphatic glands, particularly those of the groin, more or 
 less swollen from the beginning of the tubercular eruption, may at 
 times reach a considerable size, and, in infrequent cases, undergo 
 suppuration. 
 
 After reaching a certain stage of development, the tubercles may 
 show but little change for an indefinite period, but eventually they 
 either undergo gradual absorption, or ulceration. Occasionally they 
 undergo a kind of fibrous degeneration resembling keloid ; diminish- 
 ing in size, they increase in firmness, the skin covering them becoming 
 atrophied and whitish. Interstitial absorption may take place ; the 
 nodules become less prominent and eventually disappear, leaving a 
 slightly depressed, more or less pigmented scar. In certain cases owing 
 to softening and absorption of the central portion of a nodule it may 
 present an umbilicated appearance. In the later stages of the malady 
 ulceration of many of the lesions takes place, especially upon the hands 
 and feet and in the face, either spontaneously or as the consequence 
 of traumatism often of a trivial character. The ulcers are round or ir- 
 regular in shape, with well-defined edges or undermined borders, and 
 of variable extent and depth. At times the ulceration is extensive and 
 deep, penetrating joints, laying bare tendons and bones, followed by 
 
312 DISEASES OF THE SKIN 
 
 necrosis of the latter and the loss of members, such as fingers and 
 toes. Although these ulcers are usually sluggish and of indefinite dura- 
 tion, they frequently heal with rest and cleanliness. 
 
 In addition to those upon the skin, tubercles occur frequently upon 
 the mucous membranes of the nose, mouth, pharynx, larynx and upon 
 the conjunctiva; and these like those upon the skin undergo softening 
 and ulceration. The mucous membrane of the nose is especially apt 
 to be invaded; Morrow was of the opinion that the earliest manifesta- 
 tions of the disease frequently occurred in this region, an opinion like- 
 wise held by Sticker. When the larynx is invaded, its functions are 
 sooner or later impaired ; the patient becomes hoarse or aphonic, and, 
 as a consequence of cicatricial contraction following ulceration, dysp- 
 noea, sometimes of a marked character, and even strangulation, may 
 result. As the result of invasion of the conjunctiva, blindness fre- 
 quently occurs, the leprous nodules which begin in the conjunctiva 
 spreading to the cornea and invading the deeper parts of the eye. 
 
 In the great majority of cases the disease pursues a very chronic 
 course, lasting from eight to ten years, and longer, the patient eventu- 
 ally dying from exhaustion resulting from extensive and long-continued 
 ulceration or from some intercurrent affection, such as pulmonary 
 tuberculosis or nephritis. When the larynx is invaded death may 
 occur from suffocation. Arning and others regard the pulmonary 
 and nephritic complications as the result of leprous invasion of the 
 lungs and kidneys, and not as independent diseases. 
 
 In a small proportion of cases new nodules cease to appear after a 
 time, the ulcers heal and actual or symptomatic recovery takes place. 
 
 In rare cases the malady pursues an acute course. It begins with 
 high fever accompanied by intense headache, delirium, diarrhoea and 
 other symptoms of a typhoid character, followed shortly by an erup- 
 tion of leprous nodules in the skin and mucous membranes which rap- 
 idly ulcerate. These acute symptoms may then subside and the disease 
 pursue the usual chronic course ; or death may occur from pneumonia, 
 exhausting and uncontrollable diarrhoea, etc. 
 
 Lepra — Anaesthetica : Lepra Nervorum. — Symptoms. — The pro- 
 dromal symptoms of anaesthetic leprosy do not differ essentially from 
 those which precede the tubercular form, but the febrile attacks which 
 occur in the former are less frequent than in the latter, and symptoms 
 referable to the nervous system are apt to predominate. Prodromal 
 symptoms, while present in the great majority of cases, are occasion- 
 ally so trivial as to escape the patient's notice altogether, and in 
 exceptional cases may be entirely absent. 
 
 As in lepra tuberosa, slowly spreading erythematous and pig- 
 mented patches appear upon the face, trunk, and extremities, in the 
 last-named region affecting the extensor rather than the flexor surfaces, 
 and more frequently arranged symmetrically than in the tuberous 
 form. They may be round, oval or irregular in shape without well- 
 defined borders, or like the eruption of erythema multiforme, they may 
 
INFLAMMATIONS 
 
 313 
 
 be marginate, annular or polycyclic in contour (Figs. 105, 106, and 107). 
 The color of the patches varies considerably ; it may be pink, yellowish- 
 red, dark-red, violaceous, slate-colored, varying shades of brown, from 
 sepia to almost black. It usually becomes duller and deeper with time, 
 but may completely disappear in the centre of the patches, leaving 
 them dull white and completely anaesthetic. 
 
 The hair in the patches loses its color, becomes thin and dry and 
 
 
 FlG. 105. — Lepra, maculo-anaesthetic. (Dr. John A. Johnston.) 
 
 eventually falls out. The secretion of the sweat and sebaceous glands 
 is at first scanty, later completely suppressed, and the skin in conse- 
 quence becomes dry, harsh and desquamating. 
 
 In the beginning the affected areas are the seat of hyperaesthesia, 
 pruritus, formication, or other abnormal sensations, but after a time 
 these are replaced by diminished sensibility and eventually by com- 
 plete abolition of sensation. 
 
 Instead of an erythematous eruption, the first cutaneous symptom 
 may be an eruption of blebs and bullae resembling those of pemphigus, 
 
314 
 
 DISEASES OF THE SKIN 
 
 although such lesions are more commonly seen in the later stages 
 when they are not uncommon. Their appearance may or may not be 
 preceded by general symptoms, such as fever, headache, and malaise. 
 They are rarely numerous, vary in size from that of a pea to a hazel- 
 nut, occasionally larger, and are situated upon the back of the hands, 
 tops of the feet and the extensor surface of the elbows and knees. 
 They may continue to appear for an indefinite time, or during the whole 
 duration of the malady, associated with other forms of eruption, or as 
 the only symptom for a number of years (leprc lazarine). They may 
 
 Pig. 106. — Macular leprosy. (Dr. John A. Johnston.) 
 
 be followed by destructive ulceration, or they may crust over and eventually 
 heal, leaving permanent anaesthetic cicatrices. 
 
 Along with the cutaneous symptoms, or a variable period after their 
 first appearance, or even when these are wholly absent, symptoms on 
 the part of the nervous system appear, sometimes preceded by eleva- 
 tion of temperature. These are the result of the invasion of the nerve 
 trunks and their branches by the lepra bacillus. At first there is more 
 or less marked hyperesthesia, at times extreme, making the slightest 
 touch upon the affected parts painful. This increased sensitiveness 
 occurs not only in the areas occupied by eruption, but often in the parts 
 
INFLAMMATIONS 315 
 
 adjoining. It may be limited to certain regions or it may be wide- 
 spread. Paresthesia of various kinds, such as pricking, formication, 
 sensations of heat or cold, frequently occur. Neuralgic pains follow- 
 ing the course of the nerve trunks are frequent, coming on paroxysmally 
 and usually worse at night. The trunks of the nerves, particularly the 
 ulnar, tibial and peroneal, present fusiform or, much less frequently, 
 
 Fig. 107. — Lepra, maculo-anaesthetic. Pinkish and violaceous rings. 
 
 nodular swellings. The thickened ulnar nerve is usually readily palpa- 
 ble where it passes over the internal condyle of the humerus, and like 
 the other thickened nerve trunks, is more or less painful on pressure. 
 
 After a period varying from some months to several years these 
 symptoms are succeeded by others indicative of degeneration of the 
 peripheral nerve trunks and their branches. Tactile sensibility is 
 diminished or notably retarded, the patient experiencing difficulty in 
 
316 
 
 DISEASES OF THE SKIN 
 
 picking up small objects because of this loss of sensation. There is 
 occasionally dissociation of sensation, the temperature sense diminish- 
 ing or disappearing before tactile sensibility. Eventually areas of 
 anaesthesia, usually symmetrically distributed, appear, beginning upon 
 the extremities, particularly the hands and feet, and later involving the 
 face, and, occasionally, the trunk. Along with these sensory disturb- 
 ances, trophic changes occur; the muscles of the extremities atrophy, 
 this atrophy beginning commonly in the upper extremities, usually in 
 the hand and forearm, the muscles of the thenar eminence and the in- 
 terossei being first affected. The flexors and extensors of the forearm 
 soon become involved and contractures of the tendons follow, produc- 
 
 V 
 
 \ 
 
 FlG. 108. — Anaesthetic leprosy; contraction of fingers, so-called leper claw. (Dr. John A.Johnston.) 
 
 ing the peculiar contraction of the fingers upon the palms, the so-called 
 "leper claw" (Fig. 108). Similar changes occur in the lower ex- 
 tremities. 
 
 In consequence of inflammatory and degenerative changes in the 
 fifth and seventh pairs of cranial nerves, atrophy and paralysis of the 
 facial muscles occur. The mouth may be drawn to one side ; there may 
 be inability to completely close the eye as a result of paralysis of the 
 orbicularis palpebrarum, or because of ocular motor paralysis the pa- 
 tient may have a peculiar, fixed stare. From paralysis of the bucci- 
 nators and of the orbicularis oris the cheeks may be flaccid and the 
 lower lip pendulous, permitting the saliva to flow from the mouth. 
 
INFLAMMATIONS 317 
 
 The mucous membranes of the nose, mouth and pharynx also ex- 
 hibit sensory and trophic disturbances'. The palatal and pharyngeal 
 mucous membrane may be completely insensitive. The muscles of 
 deglutition may be paralyzed, so that swallowing is performed with 
 difficulty, food and drink regurgitating through the nose. 
 
 The skin in the anaesthetic areas undergoes atrophy ; it becomes 
 thin and wrinkled, or, when it covers bony prominences, tense and 
 smooth, and is abnormally dry from suppression of the sebaceous secre- 
 tion and the sweat. This dryness and loss of elasticity leads to As- 
 suring about the joints and the lingers and frequent ulceration (Fig. 
 109). The nails become dystrophic, are more or less deformed and 
 occasionally lost. 
 
 As a result of defective innervation, slight injuries are frequently 
 
 Fig. 109. — Lepra ansesthetica. (Dr. John A. Johnston.) 
 
 followed by indolent and painless ulcers, which, on the extremities, 
 especially the fingers and toes, may result in the loss of phalanges or 
 even of the hand or foot. Perforating ulcers occur, especially upon 
 the sole, which, extending to the deeper tissues, lay bare the bony 
 structures, and as the result of such ulceration extensive mutilation is 
 produced. Or absorption of the bony structures may lead to similar 
 mutilation and deformity. 
 
 The duration of the anaesthetic variety is usually notably longer 
 than that of the tubercular form. The febrile attacks so common in the 
 latter are much less frequent and less pronounced. Anaesthesia event- 
 ually involves all the extremities, the face, and, in advanced stages, 
 the entire body. Deformity and mutilation of the hands and feet may 
 reach an extreme degree, and paralysis of the facial muscles may ban- 
 
318 DISEASES OF THE SKIN 
 
 ish all expression from the face, which then resembles a mask. Death 
 eventually occurs from exhaustion or amyloid degeneration of the liver 
 and kidneys. Pulmonary tuberculosis is a much less frequent compli- 
 cation than in the nodular variety. 
 
 Mixed Leprosy: Complete Leprosy. — As already remarked, in a 
 certain proportion of cases, about fifteen per cent., symptoms of both 
 the tubercular and anaesthetic types occur either simultaneously, which 
 is infrequent, or in succession. In a small number of cases the symp- 
 toms are of the mixed type from the beginning. According to Leloir 
 the tubercular form may be completely replaced by the anaesthetic 
 type, the tubercles completely disappearing, to be succeeded by symp- 
 toms referable to the nerve trunks and their branches. 
 
 Etiology. — Leprosy is very uncommon before the fifth year, al- 
 though it has been observed as early as the second year. In the major- 
 ity of cases it begins in the second or third decade of life. Sex has ap- 
 parently but little influence upon its occurrence, although it is much 
 more frequent in women than in men, probably owing to the greater 
 exposure to infection of the latter through their occupations. Dark 
 races are much more susceptible than Europeans. Unfavorable hy- 
 gienic surroundings and bad or insufficient food, by lowering the in- 
 dividual's powers of resistance, may and probably do make him more 
 susceptible to the infection. Certain articles, of -food, particularly fish, 
 imperfectly cured, have long been regarded as <; ,a contributing cause. 
 Among modern authors, Sir Jonathan Hutchinson vigorously upheld 
 the view that the consumption of fish, particularly spoiled fish, was a 
 potent cause of the malady. This view, however, is not accepted by the 
 majority of investigators. 
 
 Although most prevalent in tropical regions, and hence regarded 
 as a tropical disease, it also occurs in cold climates — indeed no region 
 of the world is entirely exempt, and climate, therefore,, cannot be re- 
 garded as an etiological factor, although the type of the disease seems 
 to be influenced by it. The nodular type is more prevalent in cold 
 latitudes, while the anaesthetic variety is seen more frequently in the 
 tropics. When introduced into virgin soil, like other infections, it 
 shows unusual virulence, spreading with great rapidity, as is illustrated 
 in the Sandwich Islands and in New Caledonia. In the latter place it 
 was introduced in 1865 and in 1888 there were some 4000 cases. In 
 the early ages it was regarded as highly contagious, but later this 
 was denied. At present, contagiousness of the malady is generally ad- 
 mitted, although intimate and prolonged contact is necessary for its 
 transmission. The possibility of its hereditary transmission was long 
 regarded as established, but at present few experienced observers be- 
 lieve this a common occurrence. 
 
 The direct exciting cause is a bacillus resembling in its morphology 
 and tinctorial properties the bacillus tuberculosis, discovered, in 1874, 
 by Hansen. The manner in which this organism enters the human 
 economy is as yet quite unknown. Although many attempts at in- 
 
INFLAMMATIONS 319 
 
 oculation have been made, these have for the most part resulted in 
 complete failure. Within the past few years a number of successful 
 experimental inoculations in animals have been reported, but none of 
 these are conclusive in their results. Although the possibility of its 
 transmission by the bites of insects, such as fleas, mosquitoes and bed- 
 bugs, has been suggested, there is as yet no positive proof that it may 
 be so transmitted. 
 
 Morrow, Sticker, and others believe that the nasal mucous mem- 
 brane is the port of entrance for the bacillus in a large proportion of 
 cases. Sticker found the organism in the nasal secretion in 128 out of 
 153 cases examined and believes that the malady begins with an initial 
 lesion, an ulcer, on the septum. 
 
 Pathology. — The bacillus lepra, the direct cause of leprosy, is an 
 acid- fast organism resembling 
 closely in its size, shape and stain- 
 ing properties the bacillus tubercu- 
 losis. It is about five microns long, 
 one micron broad, straight or 
 slightly curved, somewhat thinner 
 at the ends than in the central part, 
 and frequently exhibits a bead-like 
 arrangement resembling a chain 
 of spores (Fig. no). It differs 
 from the tubercle bacillus in stain- 
 ing somewhat more readily with 
 the weak carbol-fuchsin stain and 
 in being somewhat less resistant to 
 acids. It is very abundant in the 
 
 11 1 • „ r .1 «1,;„ U-,-,4- ,'0 FxG II0 - — Bacillus lepras. Smear from a nodule 
 
 nodular leSlOnS OI the SKin, bUt IS of Hawaiian leprosy (prepared by Dr. Joseph V 
 
 present only in small numbers in Klauder )- 
 
 the macular and erythematous patches and in the nerve trunks in the 
 earlier stages of the anaesthetic variety. It is found in the viscera, 
 such as the lungs, liver and the spleen, producing in the first-named, 
 lesions resembling those of tuberculosis. It is likewise found in the 
 testes and lymphatic glands. It occurs in large numbers in the purulent 
 discharge from the nose and in the pus of ulcerated nodules. In the 
 tissues it is found both within and between the cells. 
 
 Until quite a recent period, all attempts at the cultivation of the or- 
 ganism failed, but within the past few years a considerable number 
 of successes have been reported. The results obtained, however, by 
 numerous experimenters by no means agree, the organism grown dif- 
 fering considerably from the organism as seen in the tissues. The most 
 recent view is that the organism is pleomorphic to a marked degree, its 
 character varying according to the age of the culture and the media 
 upon which it is grown. By some bacteriologists it is believed to be a 
 streptothrix which breaks up into acid-fast rods. In a recent summing 
 up of the result obtained from the attempts to grow the organism 
 
320 DISEASES OF THE SKIN 
 
 Fraser and Fletcher conclude that the bacillus has not yet been cul- 
 tivated. Experimental inoculation invariably fails, if we except the 
 doubtful case of Arning. Until a recent period, Rost, Bayon, Duval, 
 Reenstierna, and others claim to have succeeded in producing lepra- 
 like lesions in dancing mice, rats and monkeys by employing cultures 
 of an organism obtained from leprous lesions. 
 
 According to Unna the bacillus is always extra-cellular and is 
 situated in the lymph-spaces of the corium. According to him, the 
 lepra cells, or " globi," are not cellular structures, but masses of bacilli 
 embedded in a mucous envelope. Leloir asserted that the organism 
 was found both in and between the cells, while Hansen found them 
 only in the cells. 
 
 The histological changes are those characteristic of the infectious 
 granulomata. The epidermis is usually but little altered, and such 
 alterations as are present are secondary to the changes in the corium. 
 Immediately beneath the lower border of the rete is a narrow zone in 
 which there are neither bacilli nor tissue changes. In the central por- 
 tions of the corium are more or less circumscribed foci composed of 
 plasma cells, leucocytes, a few giant-cells and the so-called lepra cells, 
 or " globi," containing numerous bacilli. Hansen and Looft asserted 
 that in many thousand examinations of leprous tissue which they had 
 made they had never found giant-cells of the Langhans type. When 
 these were present they regarded them as indicative of a mixed infec- 
 tion, tuberculosis and leprosy. But typical cells of this type have been 
 observed by Jadassohn, Darier, Klingmuller, and a number of others, 
 both in the tubercular and anaesthetic forms of the malady. 
 
 Diagnosis.— The symptoms of the prodromal stage, such as irregu- 
 lar attacks of chilliness and fever followed by profuse sweats, head- 
 ache, nose bleed, etc., present nothing characteristic, although when 
 they occur without obvious cause in individuals living in regions where 
 leprosy is endemic they should excite suspicion. The early cutaneous 
 symptoms, such as erythematous patches, may be mistaken for ordinary 
 erythema, which they may resemble more or less closely, but from 
 which they differ by their greater extent, longer duration, and the 
 usual presence of more or less anaesthesia, especially marked in the 
 centre of the patches, sometimes accompanied by hyperesthesia of the 
 borders. Leloir attaches great importance to the absence of desqua- 
 mation as a diagnostic symptom. The nodules may be mistaken for 
 the lesions of syphilis, especially when they are small and widely dis- 
 tributed, but they lack the circinate or crescentic arrangement so fre- 
 quent in the latter, and the amount of infiltration is usually greater, 
 the course is much more sluggish and they usually show a decided 
 predilection for the face, especially the supraorbital region, producing, 
 when abundant, the characteristic leonine appearance. Owing to the 
 fact that leprosy gives a positive Wassermann reaction, that reaction 
 is not available as a diagnostic procedure in the differential diagnosis 
 of the two affections. 
 
INFLAMMATIONS 321 
 
 Lupus vulgaris, when extensive, may at times be confounded with 
 leprosy, but the lesions of the former are usually much more super- 
 ficial, are never accompanied by anaesthesia and are rarely so extensive 
 in their distribution. 
 
 Granuloma fungoides has certain features in common with leprosy, 
 but the erythema of the prefungoid stage of this affection is usually 
 decidedly eczematous, not only in its appearance, but in the intense 
 pruritus which accompanies it. The ulcerations which occur in the 
 fungoid stage are usually quite unlike the ulcers of leprosy. 
 
 The achromatic patches of the anaesthetic variety present certain 
 resemblances to vitiligo and morphcea, but may readily be distinguished 
 from these by their less well-defined borders and more particularly 
 by the presence of anaesthesia, especially in the centre of the patches 
 where it is often complete. The muscular atrophies and contraction, 
 which are such prominent symptoms in anaesthetic leprosy, resemble 
 in many ways those which follow other forms of neuritis, but are to be 
 distinguished from these by the presence of cutaneous eruptions and 
 the previous history. The affection with which anaesthetic leprosy is 
 most likely to be confounded is syringomelia, but in the latter so-called 
 dissociated anaesthesia, that is, alterations of the pain and temperature 
 sense, without abolition of tactile sensibility, is a characteristic symp- 
 tom, while in leprosy it is infrequent. Painless whitlow or felon, asso- 
 ciated with trophic disturbances, a variety of syringomyelia known as 
 Morvan's disease, is another characteristic symptom not found in 
 leprosy. Cutaneous eruptions preceding the sensory and trophic dis- 
 turbances occur in leprosy but are absent in syringomyelia. 
 
 In doubtful cases search should be made for the bacillus in the nasal 
 secretion and in the discharge from ulcerating lesions, or a biopsy may 
 be performed and search made for the lepra bacillus and the so-called 
 " lepra cells " in sections of the lesions. It must not be forgotten, 
 however, that the organism is sometimes absent from the erythem- 
 atous and pigmented patches, or present only in very small numbers 
 so that it can be found only by examining a large number of sections. 
 
 Prognosis. — The vast majority of cases of leprosy terminate fatally, 
 but the duration of the malady varies within wide limits, the nodular 
 variety running a much more rapid course than the anaesthetic form. 
 In the former the average duration is about ten years, although quite 
 exceptionally death may occur within a year or two. The average 
 duration of the anaesthetic form varies from fifteen to thirty years 
 and may be even considerably longer. The progress of the disease is 
 usually retarded by the patient's removal to a temperate climate, by 
 an abundance of good food and by careful antiseptic treatment of 
 ulcerating lesions. In exceptional cases a spontaneous cure or an arrest 
 of the malady takes place, this being more frequently observed in the 
 anaesthetic than in the nodular variety. In a considerable proportion 
 of cases death occurs as the result of some intercurrent disease, one 
 of the commonest being pulmonary tuberculosis. 
 21 
 
322 DISEASES OF THE SKIN 
 
 Treatment. — There is as yet no known specific for leprosy, although 
 the course of the disease may at times apparently be favorably modi- 
 fied, or at least prolonged, by the use of certain remedies. 
 
 When possible the patient should be removed to a temperate or 
 cool climate. He should be placed in the best hygienic surroundings, 
 should have an abundance of wholesome food and should pay the most 
 careful attention to cleanliness of person and clothing. 
 
 Among internal remedies chaulmoogra oil, an oil expressed from 
 the seeds of an East Indian plant, the gynocardia odorata, is apparently 
 the most efficacious. It is given in doses of from five to ten drops, 
 either in capsule or in emulsion, gradually increasing the dose to the 
 limit of tolerance. Quite recently it has been employed hypoder- 
 matically with decided benefit. Heiser employs the following oily 
 mixture : Chaulmoogra oil and camphorated oil, each 60 ex., resorcin, 
 4 grammes. Mix, dissolve with the aid of heat, and filter. Injections 
 of this mixture are made once a week in increasing doses, the initial 
 dose being 1 c.c. Heiser has obtained better results from this treat- 
 ment than from any other. Sandwich and Manson likewise employ the 
 oil hypodermatically. In connection with its internal administration, 
 inunctions may also be used on the affected areas, mixing it with equal 
 parts of olive oil or lard. The treatment should be long-continued. 
 Instead of the oil, gynocardic acid or its sodium or magnesium salt 
 may be given in doses of one-half to three grains (0.03 to 0.20) three 
 
 times a day. 
 
 Quite recently Rogers has employed the gynocardate of sodium 
 hypodermatically, beginning with a dose of one-tenth of a grain 
 (0.006) and gradually increasing it to four-fifths of a grain (0.052). 
 He observed a local reaction in the leper tissue after injections of two- 
 fifths of a grain (0.026). _ . 
 
 Gurjun balsam, wood oil obtained from the dipterocarpus lavis, is 
 employed in the same doses and in the same manner as the chaulmoogra 
 oil, but seems less useful and has somewhat fallen into disrepute. 
 
 'Strychnia, or nux vomica, likewise exerts a beneficial effect and 
 may be given in conjunction with chaulmoogra oil. 
 
 Crocker obtained decided benefit from the hypodermatic injection 
 of bichloride of mercury, giving one-quarter grain (0.016) in aqueous 
 solution once or twice a week and continuing the treatment for a long 
 
 Per Danielssen regarded salicylate of soda as the best internal remedy, 
 beginning with a dose of fifteen grains (1.0) four times a day and 
 gradually increasing it. Unna claims to have obtained favorable 
 results even a cure in several cases, from the internal administration 
 of ichthyol combined with the local application of reducing agents, as 
 pyrogallol or chrysarobin in ten per cent, ointment. In a case of nerve 
 leprosy Manson saw all the symptoms disappear after the administra- 
 tion of thyroidin. Salvarsan has been employed recently with varying 
 results • upon the whole, the reports have not been favorable to its use. 
 
PLATE XIX 
 
 Granuloma fungoides. Beginning tumor formation and ulceration. 
 
INFLAMMATIONS 323 
 
 Repeated attempts have been made to produce curative sera and 
 vaccines, but they have, for the most part, been failures. Rost, by 
 employing a substance obtained from leprous nodules which produces 
 a reaction resembling that following tuberculin, obtained favorable 
 results, but others have failed with it. 
 
 Deycke obtained from cultures of the streptothrix leproides an organ- 
 ism which he found in leprous nodules and cultivated upon milk, a 
 fatty substance to which he gave the name " nastin." Combined with 
 benzoyl chloride and dissolved in sterile olive oil, this forms his 
 " nastin B," which is employed hypodermatically. Although favorable 
 results have been reported by a number of authors, its use upon the 
 whole has been disappointing. Wise, experimenting with it in British 
 Guiana, obtained better results from benzoyl chloride alone. 
 
 Systematic exposure of the diseased parts to the X-ray produces 
 temporary improvement, sometimes of a marked character, causing the 
 nodules to undergo involution. Heiser has reported an apparent cure 
 from X-ray treatment. 
 
 The ulcerating lesions should be kept as clean as possible by the 
 frequent employment of mild antiseptic solutions, such as mercuric 
 bichloride, i : 2000 ; a saturated solution of boric acid, hydrogen dioxide 
 or weak solutions of formalin. Ointments of aristol, iodoform, euro- 
 phen, balsam of Peru, and salicylic acid are likewise useful. 
 
 There can be no doubt that the most effective, if not the only 
 effective measure for the prevention of the spread of the disease is 
 isolation of the diseased individual. Wherever and whenever this 
 measure has been adopted there has been a steady diminution in the 
 number of cases. While the efficacy of segregation cannot be denied, 
 it should be employed with judgment and modified according to the 
 circumstances of the individual case. The subject of anaesthetic leprosy 
 is little, if at all, dangerous to those with whom he may come in contact 
 and may accordingly be allowed considerable liberty, but the individual 
 with nodular leprosy, with ulcerating lesions, should be rigidly isolated. 
 
 GRANULOMA FUNGOIDES 
 
 Synonyms. — Mycosis fungoides ; Lymphadenie cutanee ; Inflamma- 
 tory fungoid neoplasm ; Sarcomatosis cutis ; Lymphomatose cutanee 
 generalised (Plate XIX). 
 
 This fatal and fortunately rare disorder was first described by 
 Alibert, who regarded it as closely related to yaws, and gave it the name 
 plan fungo'ide, which later he abandoned for mycosis fungoides. Other 
 authors who have since greatly contributed to our knowledge of its 
 clinical features and histopathology are Bazin, Ranvier, Vidal and 
 Brocq, Besnier and Hallopeau, Kobner and Duhring. 
 
 Definition. — A chronic and almost invariably fatal disease charac- 
 terized by dermatitis, frequently eczematoid in type, followed by 
 tumors which terminate in ulceration. 
 
 The malady presents three usually well-marked stages, although 
 
324 
 
 DISEASES OF THE SKIN 
 
 the boundaries which separate them are often ill-defined. In a con- 
 siderable number of cases the disease begins, with more or less marked 
 pruritus unaccompanied by any eruptive symptoms. This is followed, 
 after a variable period, by a dermatitis, most frequently of an eczema- 
 toid character consisting of scattered and ill-defined more or less scaly 
 
 Pig. hi. — Granuloma fungoides. Early, so-called premycosic stage with red eczematoid patchy erup- 
 tion accompanied by severe itching. 
 
 patches distributed over the trunk (Fig. in). At other times these 
 patches, instead of being diffuse and Avithout special configuration, 
 are round and well defined, somewhat annular, with slightly elevated 
 borders. In the early stages the malady is at times scarcely or quite 
 indistinguishable from eczema and is frequently mistaken for that 
 
PLATE XX 
 
 Granuloma fungoides. Scaly erythrodermia preceding tumor stage. 
 
PLATE XXI 
 
 Erythematous lupus. 
 
INFLAMMATIONS 
 
 325 
 
 affection. In other cases this dermatitis is markedly psoriosiform, 
 so much so that it at times is mistaken for psoriasis. Whatever the 
 type of inflammation, it is usually accompanied by itching often of a 
 very severe character. In a considerable proportion of cases, instead 
 of being patchy, it is universal in its distribution, occupying the entire 
 cutaneous surface. In such cases it may present the features of a 
 universal dermatitis exfoliativa (Plate XX). This stage, the premy- 
 cosis erythrodermia of French authors, is of variable duration, but 
 usually lasts for months and not infrequently for years before the more 
 characteristic symptoms of the malady appear. As variations from the 
 
 Fig. i 1 2. — Same patient as Plate XXI, two years later. Tumor formation with ulceration ; total loss of 
 
 hair of scalp, brows and beard. 
 
 ordinary type, it may begin with an urticarial eruption, or vesicles 
 and bullae may be present. Upon the scalp and elsewhere the hair 
 becomes thin and dry and may eventually fall out, leaving the parts 
 completely bald. 
 
 The second stage, or stage of infiltration, is characterized by 
 variously sized, flat, usually well-defined, slightly elevated plaques, 
 which are red or bluish-red in color. These occur' on various parts of 
 the skin and resemble in shape large flat buttons imbedded in the skin. 
 They vary considerably in number and at first certain of them, after 
 a duration of a month or two, spontaneously disappear, while new 
 
326 DISEASES OF THE SKIN 
 
 ones arise. This stage, as compared with the preceding one, is of 
 rather short duration and is followed after some months by the third, 
 or tumor stage. 
 
 In the third stage tumors, varying in size from that of a hazelnut to 
 an egg, appear, most commonly on those parts of the skin which are 
 already inflamed, or in the infiltrated areas, but they also occur on 
 portions of the skin which previously had shown no signs of disease. 
 Smaller tumors occasionally disappear spontaneously after a time, but 
 more commonly they undergo ulceration, forming mushroom-like ulcers 
 with everted vegetating borders. Even when ulceration has occurred, 
 spontaneous healing followed by absorption of the tumor may take 
 place. New tumors continue to appear which sooner or later undergo 
 ulceration. The patient's general health, which up to the appearance 
 of ulceration, had been unaffected, now begins to suffer and death even- 
 tually occurs either from exhaustion, from some intercurrent disease, 
 or secondary septic complications (Fig. 112, Plate XXI). 
 
 Exceptionally the third or tumor stage is the first manifestation of 
 the disease, the mycosis d 'emblee of the French. In such cases a 
 dermatitis, resembling that of the first stage, either follows or accom- 
 panies the tumors. These cases pursue the usual course but are com- 
 monly much shorter in duration than the other forms of the disease. 
 
 When the malady has reached its acme it consists of numerous 
 diffuse red and scaly patches, frequently eczematoid in appearance, or 
 rounded, sometimes annular patches with slightly elevated borders, 
 flat, infiltrated, red or bluish-red plaques of variable size, well-defined 
 tumors and fungoid ulcers occupying practically every region of the 
 cutaneous surface. 
 
 The duration of the disease varies from a few months to several 
 years. The premycosic stage not uncommonly lasts for a considerable 
 period. In a case recently under the author's observation it had ex- 
 isted for many years as the only symptom of the disease. The stage 
 of ulceration is usually a short one, death occurring in a few months 
 after its appearance. 
 
 Etiology. — While it was formerly thought that men were much 
 more frequently affected than women, more recent observations have 
 shown that the sexes are equally subject to it. It is infrequent in 
 young subjects. The earliest age at which it has been observed is 
 fifteen years ; its maximum frequency occurs between the ages of forty 
 and sixty. Very little is known about the causes which predispose to 
 it and nothing whatever about its direct causation. A variety of micro- 
 organisms has been found in the lesions by a number of investigators, 
 but none of these has been proved to have any causal relationship to 
 the malady. 
 
 Pathology. — There is a marked divergence of views, among those 
 who have studied the affection, as to its pathology. The earlier authors 
 regarded it as closely related to sarcoma, if not a variety of that neo- 
 plasm ; but very few of the more recent investigators entertain this 
 
INFLAMMATIONS 327 
 
 opinion. A considerable number regard it as closely related to 
 leukaemia of the skin, while others, as Unna, consider it a disease 
 sui generis. While satisfactory proof is as yet altogether lacking, it 
 seems most probable that it is an infection. The histological changes 
 found in the malady are practically the same in all stages, differing 
 only in degree. In the stage of dermatitis, the so-called premycosic 
 stage, there is some thickening of the epidermis, with an increase in 
 the length of the interpapillary prolongations of the rete. In the 
 papillary and subpapillary portions of the corium there is a diffuse 
 •cellular exudate made up chiefly of small round cells of lymphoid type, 
 with a few imperfectly developed plasma cells and connective-tissue 
 cells. In the tumors the epidermis is markedly thinned as the result 
 of pressure from below, and the corium is filled with a dense mass of 
 small round cells with a few plasma-cells and an occasional giant-cell. 
 As Unna and others have pointed out, a characteristic feature is the 
 remarkable variety of form exhibited by the cells, in large part the 
 result of degenerative changes, and numerous granules, the result of 
 fragmentation of the cells, are scattered throughout the growth. As a 
 rule " mastzellen " are present only in normal numbers, but in a case 
 studied by the author these were found to be increased in numbers and 
 were larger than usual. 
 
 Diagnosis. — In its early stages it is frequently confounded with 
 eczema and, indeed, may be clinically indistinguishable from that 
 affection before the appearance of infiltration and flat plaques ; with the 
 appearance of these, however, the diagnosis at once becomes clear. 
 Even in the early stages the microscopic examination of sections of 
 skin taken from the inflamed areas will reveal characteristic histologic 
 features, and may be advantageously resorted to in doubtful cases. 
 
 The tumors may be mistaken for sarcoma, but the eczematoid der- 
 matitis, which so frequently precedes and accompanies them, is a very 
 •characteristic differentiating feature. 
 
 Occurring in regions in which leprosy is endemic, it may be mis- 
 taken for that affection, but the characteristic eczematoid dermatitis 
 which precedes the tumor stage almost invariably, and the absence of 
 the bacillus lepra, are features which readily distinguish it from that 
 malady. 
 
 Prognosis. — The malady is almost invariably fatal. While a few 
 cases of recovery have been recorded, the diagnosis, in some of these 
 at least, was open to doubt. The duration varies within considerable 
 limits. While in the majority of cases it lasts for two or three years, 
 exceptionally it may terminate in the course of a few months, or, on the 
 other hand, may last for many years, as in a case under the author's 
 observation. 
 
 Treatment. — There is no specific treatment. In a limited number 
 of cases the internal administration of arsenic in considerable doses 
 seems to exert an inhibiting influence upon the progress of the malady, 
 but in most cases it is without effect. In recent years the X-ray has 
 
328 
 
 DISEASES OF THE SKIN 
 
 proved of great value ; it frequently brings about rapid absorption 
 of the tumors and for a time at least, holds the disease in check. In 
 a few instances it has seemed to have been curative, but it is as yet too 
 early to determine whether the favorable results in such cases are 
 permanent. 
 
 BLASTOMYCOSIS CUTIS 
 
 Synonyms. — Blastomycetic dermatitis; Dermatitis blastomycotica; 
 Saccharomycosis hominis ; Fr., Blastomycose cutanee ; Ger., Hefen- 
 mykose ; Hautblastomykose. 
 
 Definition. — A chronic infectious disease of the skin due to a yeast 
 fungus, the Blastomyces, characterized by one or more variously-sized 
 patches with a verrucous or papillomatous surface, and a well-defined 
 elevated violaceous border in which are numerous miliary abscesses. 
 
 Fig. 113.- -Blastomycosis cutis. Seen by the author with Dr. Duhring. 
 
 In 1894, at the annual meeting of the American Dermatological 
 Association, Gilchrist demonstrated the presence of blastomycetes in 
 sections taken from a large papillomatous patch on the back of the 
 hand of a middle-aged man under the care of Dr. Duhring, who had 
 made a clinical diagnosis of scrofuloderma. A few months later Busse 
 reported a fatal case of systemic infection by the same organism, in 
 which there had been cutaneous lesions resembling abscesses. Since 
 these first cases, a considerable number of others have been reported 
 by various observers, most of them in the United States, and the 
 disease has been most thoroughly studied clinically and bacteriologi- 
 cally, especially by Hyde, Hektoen, Montgomery and Ricketts, in 
 America, and by Buschke in Germany. 
 
 Symptoms. — It usually begins with one or more inflammatory 
 papules or papulopustules which slowly enlarge and crust over. As 
 the disease progresses, variously-sized, irregularly-shaped, elevated 
 
INFLAMMATIONS 
 
 329 
 
 patches are gradually formed by the enlargement of the primary lesions 
 and frequently by the addition of new ones about their periphery. 
 These patches are covered with crusts beneath which is a moist papillo- 
 matous surface, and are sur- 
 rounded by a characteristic 
 border, violaceous in color 
 and studded with miliary ab- 
 scesses which appear as yel- 
 low points, and in the pus 
 from which blastomycetes 
 may be demonstrated, often 
 in pure culture (Figs. 113 
 and 114). Occasionally the 
 patches are dry, with a wart- 
 like surface, resembling 
 closely the patches of ver- 
 rucose tuberculosis of the 
 skin. Ulceration of a rather 
 superficial character com- 
 monly occurs in the patches, 
 which may slowly extend, or 
 after a time may undergo 
 spontaneous healing, leaving 
 uneven scars. 
 
 When the cutaneous dis- 
 ease is the sequel of a sys- 
 temic infection, irregular 
 ulcers appear in the skin 
 which begin as subcutaneous 
 abscesses. The extent of the 
 disease varies considerably. 
 Although there may be but 
 a single patch, there are usu- 
 ally several, and exception- 
 ally there may be many scat- 
 tered about over the face and 
 extremities, some of them 
 occupying a large surface. 
 In secondary blastomycosis 
 there may be many ulcers 
 and abscesses scattered over 
 the greater portion of the 
 body. 
 
 The patient's general 
 health, as a rule, remains unimpaired, except in the infrequent cases in 
 which systemic infection accompanies or follows the cutaneous disease. 
 
 The course of the malady is slow and irregular. As a rule the 
 
 Fig. 114. — Blastomycosis cutis. 
 
330 
 
 DISEASES OF THE SKIN 
 
 patches grow very slowly, months elapsing before they reach any 
 considerable size. 
 
 Etiology and Pathology. — Blastomycosis occurs far more frequently 
 in males than in females, quite three-fourths of the reported cases hav- 
 ing been in men. One-half of all the cases have been in individuals 
 over forty years of age, but it is by no means confined to this period; 
 Kessler has reported a case in an infant eight months old, the youngest 
 yet observed. 
 
 The direct cause is a fungus belonging to the yeasts, the Blasto- 
 myces. In a certain small proportion of cases a traumatism of some 
 kind seems to have preceded the infection, and it is altogether likely 
 that a solution of continuity in the skin, either the result of injury or 
 perhaps some precedent inflammatory affection, is necessary as a port 
 of entry for the fungus, except in those cases in which infection of the 
 skin follows systemic infection. 
 
 Fig. us 
 
 Fig. 116 
 
 Fig. 115. — Blastomycosis cutis. Blastomyces. 
 FlG. 116. — Blastomycosis cutis. B, blastomycetes in G, giant-cell. 
 
 The blastomyces is a round or oval cell (Fig. 115) varying from 
 ten to twenty microns in diameter, with a double-contoured wall, 
 within which is a granular protoplasm separated from the inner wall 
 by a narrow space, and frequently containing a vacuole. It is found 
 between the cells of the epidermis, in miliary abscesses, and in giant- 
 cells (Fig. 116) singly, in pairs usually of unequal size, or less fre- 
 quently in aggregations containing ten to twenty without any special 
 arrangement. Budding forms are frequently observed, but mycelia 
 have not been found in the tissues, although produced in cultures. 
 It grows readily upon a variety of media, and on glycerin-agar produces 
 white cultures with aerial hyphse. In the tissues reproduction takes 
 place by budding, but in cultures, under certain conditions, reproduc- 
 tion by sporulation may also occur. The number of organisms present 
 varies greatly ; at times they are very abundant and are readily found, 
 at others a long search may be necessary to discover them. Owing to 
 their comparatively large size, they are usually readily demonstrated 
 
INFLAMMATIONS 
 
 331 
 
 either in stained sections, or in the pus obtained from the minute 
 abscesses about the borders of the patch in which they are apt to be 
 found in pure culture. In unstained sections and in pus they are easily 
 demonstrated by placing these in a strong solution of potassium 
 hydroxide, or in equal parts of glycerin and liquor potassae underneath 
 a cover. The histological changes are marked and resemble closely 
 those which occur in tuberculosis verrucosa cutis (Fig. 117). The 
 horny layer of the epidermis is in places completely lost, in others 
 
 Pig. 117. 
 
 •Blastomycosis cutis. Enormous elongation of the interpapillary prolongations of the rete 
 mucosum. m. Miliary abscess. Low power. 
 
 greatly thickened, especially between the papillary elevations. The 
 most striking alterations are found in the rete mucosum, which is 
 enormously overgrown, sending irregularly-shaped, branching proc- 
 esses of epithelial cells downward into the corium, and scattered 
 throughout the hyperplastic rete are miliary abscesses containing 
 numerous polymorphonuclear leucocytes, loose epithelium in all stages 
 of degeneration, and a varying number of blastomycetes. The cells 
 of the rete are decidedly increased in size, and their prickles are un- 
 usually prominent, probably owing chiefly to the increased width of 
 
332 DISEASES OF THE SKIN 
 
 the intercellular spaces. Within and between the cells are numerous 
 polymorphonuclear leucocytes, and scattered here and there in the 
 intercellular spaces are blastomycetes. In the corium are marked signs 
 of inflammation, especially noticeable in the upper portion. There is 
 an abundant cellular exudate composed of polymorphonuclear leuco- 
 cytes, small lymphocytes, plasma cells, a variable number of " mast- 
 zellen," and giant-cells. Here and there are likewise miliary abscesses 
 similar to those in the epidermis, containing a variable number of 
 blastomycetes. 
 
 Diagnosis. — The affection for which blastomycosis is most likely 
 to be mistaken is verrucose tuberculosis of the skin, the resemblance 
 between these two being frequently so close that a differential diag- 
 nosis from the clinical symptoms alone is often well-nigh, if not alto- 
 gether, impossible. The differentiation of the two must in many cases 
 depend upon demonstrating the presence or absence of the blastomy- 
 cetes in the pus and tissues. At times it may be confounded with 
 lupus vulgaris, but the characteristic violaceous border containing 
 miliary abscesses in the pus from which the organism is usually found, 
 will serve to differentiate these without much difficulty. 
 
 It may be mistaken for syphilis, particularly for the late ulcerative 
 forms, but its comparatively slow course, the usual absence of any 
 tendency to a circular or crescentic arrangement of the patches, which 
 is so common in syphilis, the presence of the blastomycetes in the dis- 
 charge, and the Wassermann reaction, usually render the differential 
 diagnosis a comparatively easy and certain one. 
 
 Since the blastomyces is a comparatively large organism and one 
 very easily recognized, failure to find it in any given case must always 
 throw doubt upon the diagnosis. 
 
 Treatment. — When there are but one or two small patches favorably 
 situated, they may be excised; if this is carefully done, going some- 
 what wide of the visible disease, recurrences are not likely. When, 
 however, the patches are of considerable size and multiple, making 
 excision impracticable, thorough curettement followed by the appli- 
 cation of tincture of iodine should be employed, together with the 
 internal administration of large doses of iodide of potassium. Large 
 doses of the iodides usually produce a marked improvement in the 
 disease, especially at first, but a complete cure is rarely if ever obtained 
 by the use of the drug alone; improvement ceases after a time, rem- 
 nants of the patches remain indefinitely and a recrudescence begins 
 immediately upon its suspension. The X-ray has proved of benefit, 
 especially when used in conjunction with intensive iodide treatment. 
 
 Prognosis. The prognosis as to an ultimate cure in cases of moder- 
 ate extent and duration is favorable, judicious treatment being usually 
 followed by cure. In systemic blastomycosis the prognosis is exceed- 
 ingly grave, a fatal termination being the rule. 
 
INFLAMMATIONS 333 
 
 SPOROTRICHOSIS 
 
 Definition. — A chronic infectious disease due to several varieties of 
 a vegetable organism, the sporotrichum, characterized by cutaneous 
 and subcutaneous nodules, abscesses, ulcers and sinuses. 
 
 The mycotic character of certain forms of chronic subcutaneous 
 abscess was first pointed out by Schenk, in 1898, who found in the 
 contents of such abscesses a fungus belonging to the sporotricha. A 
 little later Hektoen and Perkins, in America, and De Beurmann, in 
 France, confirmed Schenk's finding. The last-named has been espe- 
 cially active in the study of the malady, and much of our present 
 knowledge of its etiology and pathology is due to his work. 
 
 Symptoms. — The disease usually begins with the appearance of 
 small, hard, painless subcutaneous nodules, which are at first deeply 
 seated so that they are perceptible to touch only, producing no visible 
 elevation of the skin, but as they slowly enlarge visible tumors of 
 variable size are produced. After a period varying from four to six or 
 eight weeks, these soften and may then remain for an indeterminate 
 period as soft fluctuating tumors, or what is less frequent, they may 
 open and discharge a viscous purulent fluid, leaving fistulous openings. 
 The number of such lesions varies from a single one to as many as 
 thirty or forty scattered about without any definite arrangement over 
 the trunk and extremities. Occasionally large abscesses may form, 
 as in a case observed by Dor, in which as much as 500 c.c. of pus were 
 evacuated from a single lesion. 
 
 Less frequently the disease begins at the site of an injury, often 
 trivial, on the finger or other portion of the hand, with the appearance 
 of a sluggish ulcer or small, rather firm nodule which after a time is 
 followed by an indolent lymphangitis extending up the forearm, small 
 firm nodules appearing along the course of the lymphatics which are 
 swollen and feel like knotted cords beneath the skin, which is usually 
 somewhat reddened, or exceptionally, unchanged in appearance. After 
 a variable period, usually some weeks, the nodules soften. They may 
 then remain as soft tumors varying in size from that of a hazel-nut to a 
 walnut or even much larger, or they may ulcerate, leaving fistulse or 
 open ulcers discharging a seropurulent fluid. Occasionally after a 
 period of some months the unopened tumors undergo involution, leav- 
 ing permanent scars. 
 
 When the lesions open spontaneously, or are opened by incision, 
 leaving fistulae or ulcers, papillomatous masses of granulation tissue 
 may form about the fistulous openings or on the bottom of the ulcers. 
 In rare instances the nodules are situated within the derma, and occa- 
 sionally, as the result of a secondary infection with the sporothrix, 
 vesicles and papulo-vesicles develop in the epidermis about the fistulous 
 openings. 
 
 The buccal and pharyngeal mucous membranes, as well as the 
 viscera, may be attacked, although these are only rarely invaded. 
 
 Constitutional symptoms are absent, the patient's general health 
 
334 DISEASES OF THE SKIN 
 
 not being affected even in cases in which the malady has lasted for a 
 considerable time. 
 
 The course of the affection is a very chronic one ; new lesion appear 
 from time to time, while the old ones show but very little change from 
 month to month, although occasionally, as has already been noted, 
 spontaneous healing may occur in certain of them. 
 
 Etiology and Pathology. — Sporotrichosis is a mycosis due to a 
 fungus, the sporotrichum, of which three varieties have been identified, 
 viz., S. Schenki, S. Beurmanni, and S. indicum. It is apparently much 
 more frequent in France and the United States than elsewhere, but has 
 been found in various other parts of the world, such as South America, 
 Ceylon, etc. The fungus is rarely discoverable in the tissues, but 
 may be readily demonstrated in the pus obtained from the lesions by 
 cultivation on various media. Cultures succeed best on Sabouraud's 
 peptone-glucose agar upon which the organism forms round white 
 colonies with a somewhat elevated surface covered with fine irregular 
 convolutions, which after a time (twenty days) become brown. In 
 a small percentage of cases a wound has served as the starting-point 
 of the infection, but as a rule, the mode and place of entrance of the 
 fungus are not discoverable. The disease has been observed in the 
 horse and the dog, and probably these domestic animals, occasionally at 
 least, serve as the carriers of the contagion to man. 
 
 The fungus consists of mycelial threads and spores. The former 
 are long, straight, or slightly curved, occasionally branched, and about 
 two microns in diameter ; the latter are oval or round, five to six microns 
 in diameter, brown in color, and are arranged around the mycelium 
 as a sheath, or in small groups. 
 
 The changes in the tissues which result from the invasion of the 
 fungus are confined largely to the deeper portions of the corium. The 
 centre of the lesion is occupied by a necrotic area in which all cell- 
 elements and the collagen and elastic tissues have wholly or in part, 
 disappeared. This necrotic area is surrounded by a narrow zone of 
 proliferating connective-tissue cells and polymorphonuclear leucocytes, 
 while the periphery is composed of numerous lymphocytes, plasma 
 cells, proliferating connective-tissue cells, and a variable number of 
 giant-cells. The papillary layer of the corium shows a moderate 
 round-cell exudate principally about the vessels. In the epidermis 
 there is moderate proliferation of the cells of the rete with intercellular 
 oedema. 
 
 Diagnosis. — The lesions of sporotrichosis frequently bear a great 
 resemblance to the gummata of syphilitic and tuberculous origin. 
 From syphilis they are to be distinguished by their usually greater num- 
 ber, by their more rapid evolution, and by the usual absence of any 
 tendency to spontaneous ulceration. When ulceration does occur the 
 ulcers lack the circular or serpiginous outline so often present in the 
 syphilitic lesions. Tuberculous gummata are usually much slower 
 in their evolution, and ulceration occurs sooner or later, the ulcers 
 
INFLAMMATIONS 335 
 
 having irregular, undermined livid borders. In doubtful cases cultures 
 and animal inoculations should be resorted to. An indolent lymphan- 
 gitis of the forearms should always arouse the suspicion of a possible 
 sporotrichosic infection, especially when there is a history of a prece- 
 dent injury of the hand. 
 
 Treatment. — The softened lesions should not be incised unless they 
 contain large quantities of fluid, since, according to De Beurmann, 
 ulceration, in most cases, follows incision. Iodide of potassium, given 
 in considerable doses, usually produces speedy improvement, and 
 eventually a cure ; the administration of this drug should be continued 
 some time after all the lesions have disappeared to prevent relapses. 
 Open lesions, fistulse and ulcers, should be treated locally with solu- 
 tions of iodide of potassium and iodine, Lugol's solution, diluted, 
 answering well. 
 
 ACTINOMYCOSIS 
 
 Synonyms. — Lumpy jaw; Fr., Actinomycose ; Ger., Aktinomykose. 
 
 Definition. — An infectious disease of the skin and viscera due to the 
 Actinomyces, or ray fungus. 
 
 The first published account of this affection was by Lebert, in 1848, 
 although von Langenbeck had found the yellow granules peculiar to 
 it in the pus from a case of vertebral caries in 1845. ^ ts infectious char- 
 acter was first established by Bollinger, in 1876, and the name actino- 
 myces was given the fungus by Harz, to whom Bollinger had submitted 
 it for examination. Human actinomycosis was first described by 
 Israel, and its identity with the bovine form was established by 
 Ponfick shortly after. 
 
 Symptoms. — Actinomycosis, as a primary affection of the skin, is 
 decidedly infrequent. In the great majority of cases the cutaneous 
 affection is secondary to infection of the deeper parts and the viscera. 
 The most frequent site of cutaneous actinomycosis is the face and neck, 
 especially in the region of the lower jaw, where infection takes place 
 most frequently through the buccal cavity, or often by way of a carious 
 tooth. 
 
 The primary form begins with the appearance of one or more 
 firm nodules deeply imbedded in the skin, which at first are a bright 
 red, but later become a dusky-red or slate-color. After a variable 
 period, these nodules, which vary in size from that of a pea to a nut, 
 soften, open and discharge a purulent or sero-purulent fluid containing 
 numbers of yellow or grayish-yellow granules, small masses of the ray 
 fungus. The number of lesions present varies considerably : there may 
 be but a single one, usually there are several, and there may be a con- 
 siderable number forming a bluish-red infiltrated plaque with bosse- 
 lated or rugous surface over which are scattered variously sized open- 
 ings, many of which are connected with sinuses traversing the plaque 
 and extending into the subcutaneous tissues. Raingeard has described 
 peculiar macular plaques of a deep-red color with circumscribed borders 
 
336 DISEASES OF THE SKIN 
 
 which when present usually coexist with the nodular and ulcerative 
 lesions, but which may he present a considerable time as the only 
 symptom of the infection. As a rule, little or no pain attends the 
 evolution of the disease so long as it is confined to the skin; when, 
 however, the deeper parts are invaded with the formation of abscesses 
 as the result of secondary infection severe pain may be present. Not 
 infrequently with the opening of the nodules ulceration takes place, 
 and ulcers of varying extent and depth may be formed, resembling those 
 which occur in tuberculous and syphilitic gummata, or they may pre- 
 sent a fungating appearance, their surfaces being covered with papillo- 
 matous masses. When the cutaneous affection is secondary to a vis- 
 ceral or other deep-seated infection, as is most frequently the case, 
 there is at first an ill-defined, rather deep infiltration of the subcu- 
 taneous tissues and the skin with oedema ; the skin becomes red or 
 bluish-red, softening takes place in one or more circumscribed areas 
 over which the skin becomes thin and eventually gives way, forming 
 ulcers or fistulous openings which communicate by sinuses with the 
 primary focus. 
 
 As a rule the neighboring lymphatic glands show no alteration ; 
 but swelling of these and inflammation may occur, usually as the result 
 of secondary infection with some one of the pyogenic microorganisms. 
 
 The course of the disease is usually slow, continuing for months 
 or not infrequently for several years, new foci of infection appearing 
 in adjacent parts, so that eventually considerable areas are involved. 
 Exceptionally it runs an acute course, beginning somewhat suddenly 
 with redness and swelling and other symptoms of an acute phleg- 
 monous inflammation, the skin softens and openings form from which 
 escapes pus containing the usual small granules of the ray fungus, 
 and after a comparatively short course, lasting from some weeks to 
 two or three months, recovery takes place with more or less scarring. 
 
 Etiology and Pathology. — Actinomycosis is most common between 
 the ages of twenty and forty, although cases have been observed in 
 children. It is considerably more than twice as frequent in men as 
 in women, without doubt because of the much greater exposure to 
 infection of the former through their occupations. It is much more 
 common, indeed is found almost exclusively, in dwellers in the rural 
 districts. 
 
 Its direct cause is the actinomyces or ray fungus, infection taking 
 place through abrasions of the skin, by direct contact, or, what is 
 much more frequent, through the buccal mucous membranes, the 
 mucous membranes of the air passages, or of the gastro-intestinal canal. 
 
 The yellow granules found in the discharge which escapes jrom the 
 openings in the skin are small spheroidal masses of the fungus, and 
 consist of a central close network of fine threads from which radiate 
 numbers of mycelia dividing dichotomously and terminating in thick, 
 club-like ends, the whole forming mulberry- or rosette-like masses 
 (Fig. 118). Quite frequently the clubs are divided transversely into 
 
INFLAMMATIONS 
 
 337 
 
 several segments ; they exhibit great variety in shape and arrange- 
 ment. Round and oval spores are also present. The Gram method 
 of staining, followed by a weak solution of eosine, is one of the most 
 convenient and satisfactory methods of staining the organism. 
 
 Cultivation of the fungus on various media succeeds readily. On 
 glycerin-agar it produces colonies which at first are white and shining, 
 but later, usually in a week or ten days, become a bright yellow. The 
 actinomyces exists as a saprophyte upon grains, hay, straw, and other 
 vegetable substances, whence it is transmitted to horses and cattle, and 
 from these to man. There is some evidence that it may be transmitted 
 from one individual to another, as from husband to wife. 
 
 The histological changes produced by the infection are character- 
 istic of the infectious granulomata. The fungus lies in the midst of an 
 amorphous granular mass which represents an area of complete cellular 
 
 
 
 
 
 c£s "4* *£.* - 
 
 Fig. i i 8. — Actinomycosis. (Section from collection of Professor Allen J. Smith.) 
 
 degeneration, and about this is a zone of plasma cells the inner layers 
 of which show more or less degenerative changes, and outside this 
 zone is a more or less abundant exudate of lymphoid cells. A few 
 giant-cells, together with " mastzellen," are likewise present. Accord- 
 ing to Unna the suppuration, which is one of the results of the infection, 
 is not due to a secondary infection with the ordinary pus-forming organ- 
 isms, but is the direct effect of the ray fungus which he regards as a 
 pyogenic organism. 
 
 Diagnosis. — Actinomycosis is m6st likely to be mistaken for tuber- 
 culosis or syphilis, especially for tuberculous and syphilitic gummata. 
 From tuberculous gummata it is to be distinguished by the age of the 
 patient, usually an adult, and the absence of glandular enlargement. 
 The slow progress of the disease, the presence of variously sized 
 nodules which soften and discharge a thin pus in which are present 
 22 
 
338 DISEASES OF THE SKIN 
 
 small yellow granules, and the existence of sinuses distinguish it 
 from syphilis. Much stress is laid by some French authors, particu- 
 larly Monestie, upon the peculiar slate-color which the lesions assume, 
 as a diagnostic symptom, but in the last analysis the definite differential 
 diagnosis must depend upon the demonstration of the ray fungus in 
 the discharge, or in the tissues. 
 
 Prognosis. — The prognosis of primary actinomycosis of the skin is 
 always favorable, if the true nature of the affection is recognized suffi- 
 ciently early. In neglected cases, or in those in which a correct diag- 
 nosis has not been made and proper treatment in consequence has not 
 been pursued, the duration may be long, and the deeper parts may 
 eventually be involved, with serious results. The prognosis of second- 
 ary actinomycosis is essentially that of the primary lesions ; when 
 these involve important organs the outlook is grave. 
 
 Treatment. — The treatment should be both local and constitutional. 
 The former is strictly surgical : sinuses should be laid open and curetted, 
 abscess evacuated, their walls curetted, and afterwards painted with, 
 tincture of iodine, or covered with lint wet with bichloride solution, 
 i : 2000. When the diseased parts are favorably situated for such 
 procedure, they may be completely removed. Rydygier reports two 
 cases successfully treated by parenchymatous injections of a one per 
 cent, solution of one of the iodides, the iodide of sodium being 
 preferable. 
 
 Iodide of potassium should be given internally in considerable doses, 
 since it has been demonstrated that this drug has an almost specific 
 effect upon the disease in some cases. While in most cases it exerts a 
 decidedly favorable effect, especially in recent cases and in those in 
 which secondary infection has not yet taken place, it sometimes fails, 
 and reliance must then be placed upon the surgical treatment. 
 
 ANTHRAX 
 
 Synonyms. — Pustula maligna ; Splenic fever ; Wool-sorter's dis- 
 ease ; Fr., Charbon ; Ger., Milzbrand. 
 
 Definition. — An acute infectious disease derived from animals suf- 
 fering from splenic fever, due to a specific organism, the bacillus 
 anthracis, distinguished by carbuncle-like inflammation of the skin. 
 
 Symptoms. — After an incubation period varying from two or three 
 days to a week, a small red spot appears at the site of infection accom- 
 panied by itching and burning, which speedily becomes a red papule 
 on the summit of which a vesicle or vesico-pustule develops in the 
 course of some hours. This vesicle, usually broken by scratching or 
 ruptured spontaneously, dries into a blackish crust which is somewhat 
 depressed and surrounded by a ring of small vesicles. Swelling is 
 usually marked and the neighboring lymphatics and glands are in- 
 flamed, red lines extending from the crust marking the course of the 
 former. For the first two or three days the affection remains a local 
 one, but with the increase in the local symptoms constitutional symp- 
 
INFLAMMATIONS 339 
 
 toms of general infection appear; there is some elevation of tempera- 
 ture, sometimes considerable, headache, nausea, delirium and diarrhoea, 
 and after from six to eight days, or earlier in severe cases, the patient 
 dies, frequently with symptoms of collapse. In the cases which pursue 
 a favorable course the constitutional symptoms are usually mild, the 
 eschar is cast off by suppuration and recovery takes place at the end 
 of from ten days to two weeks. 
 
 There is usually but a single lesion, but exceptionally there may be 
 two or more, and it is almost invariably situated upon some uncovered 
 part of the body, in the great majority of cases somewhere upon the 
 head or face. When it is situated upon an extremity the swelling 
 may occupy the entire limb and there is frequently an extensive 
 lymphangitis. 
 
 Instead of beginning with a vesicopustular lesion, such as has just 
 been described, the first symptom may be a marked local cedema 
 (malignant oedema) situated in most cases in the face, particularly 
 on the lids. The swelling is extensive and firm, the skin red or livid, 
 and vesicles and blebs, frequently filled with bloody serum, appear on 
 the oedematous area. In these cases symptoms of general infection 
 usually appear early, are commonly of a grave character and are usually 
 followed by a fatal termination. 
 
 Etiology and Pathology. — The malady is seen almost exclusively in 
 those who come into contact with herbivorous animals or products 
 derived from them — in butchers, veterinarians, farmers, tanners, and 
 wool-sorters, and it is therefore practically confined to men. The im- 
 mediate cause is the bacillus anthracis, discovered about the same 
 time by Pollender and Davaine, the latter demonstrating its causal 
 relationship to the affection. This organism is a rod-shaped bacillus, 
 one to one and a half microns in diameter and from five to twenty 
 microns long, which grows readily on a variety of media, forming long 
 filaments frequently containing spores. It is present in enormous 
 numbers in the pustule and surrounding skin and in the blood 
 
 The anthrax pustule is the product of a serofibrinous inflammation 
 which rapidly leads to necrosis of the skin. In a fresh nodule situated 
 upon the lip Unna found great numbers of bacilli at the level of the 
 subpapillary vascular network extending upward into the papillae and 
 the epidermis. A distinctive feature was a fibrinous network following 
 the collagenous fibres of the corium and filling the lymphatics and 
 veins ; and there was likewise a peculiar oedema of the papillary body 
 with consequent formation of vesicles. 
 
 Diagnosis. — The pustule of anthrax is to be distinguished from car- 
 buncle, the initial lesion of syphilis and from poisoned wounds. The 
 patient's occupation, in most cases one which brings him into contact 
 with cattle or horses or with hides, hair, or wool ; the black eschar sur- 
 rounded by a ring of vesicles ; the extensive oedema and the constitu- 
 tional symptoms, are features which, when occurring conjointly, usually 
 suffice to establish the diagnosis. Owing to their comparatively large 
 
340 DISEASES OF THE SKIN 
 
 size and great numbers, the bacilli are usually readily demonstrated 
 microscopically in the fluid of the lesion. 
 
 Prognosis. — The prognosis is always serious, death occurring in 
 from ten to twenty per cent, of the cases. It varies considerably accord- 
 ing to the seat of the lesion, being most unfavorable when the head 
 or face is attacked and least so when it is situated upon the lower 
 extremity (Nasorow, quoted by Frank, Mracek's Handbook). In the 
 cases which begin with a local oedema, or in those with marked con- 
 stitutional symptoms, death usually follows. 
 
 Treatment. — Early excision of the pustule should be practised, 
 going wide of the lesion, and dressing the resulting wound with some 
 antiseptic, such as bichloride of mercury ; or it may be destroyed with 
 the thermocautery. Free incision, with the subsequent application of 
 pure carbolic acid, has also been employed for the destruction of the 
 pustule. Injection of tincture of iodine, or of five per cent, solution of 
 carbolic acid, made into the pustule and the surrounding tissues has 
 been followed by favorable results. Such local measures, however, 
 are chiefly of use in the early stages before a general infection has taken 
 place. The serum prepared by Sclavo has been successfully employed 
 in a considerable number of cases, especially in Italy and England. 
 Quite recently Fortineau, having demonstrated a marked antagonism 
 between the bacillus pyocyaneus and the bacillus anthracis, has em- 
 ployed injections of the former with favorable results. Internally, 
 sulphite of soda, which has been successfully employed in the treatment 
 of splenic fever in cattle, should be given in liberal doses along with 
 quinine. Stimulants should be given when symptoms of cardiac failure 
 or collapse appear. 
 
 EQUINIA 
 
 Synonyms. — Glanders ; Farcy ; Fr., Morve ; Ger., Rotz. 
 
 Definition. — A contagious and inoculable disease derived from the 
 horse or ass, running an acute or chronic course, characterized by pro- 
 nounced constitutional symptoms and inflammatory and ulcerative 
 lesions situated in the skin and nasal mucous membranes, due to a 
 specific organism, the bacillus mallei. 
 
 Symptoms. — A period of incubation, usually of about five days' 
 duration, but in exceptional cases lasting from two to three weeks, 
 precedes the appearance of the affection. The early symptoms present 
 nothing characteristic: these are headache, malaise, pains in the joints 
 and muscles and occasionally nausea. When infection has taken place 
 through some wound or abrasion the site of the inoculation becomes 
 red and swollen, the wound enlarges, becoming a spreading ulcer dis- 
 charging a purulent offensive fluid, and the neighboring lymphatics and 
 glands become inflamed and swollen. Sometimes within a few days, 
 at other times only after two or three weeks, dark-red spots appear 
 upon the skin which become papules, then pustules, and finally ulcers. 
 Through the coalescence of adjacent lesions, serpiginous ulcers covered 
 with necrotic sloughs are formed which when situated upon the face 
 
INFLAMMATIONS 341 
 
 may lead to extensive mutilation. Abscesses involving the deeper tis- 
 sues form which, when opened surgically or spontaneously, give rise 
 to deep ulcers, laying bare tendon and bone. The lymphatic vessels, 
 not only in the neighborhood of the ulcerating lesions, but elsewhere 
 present nodular swellings the so-called " farcy buds," which ulcerate 
 and discharge. 
 
 The nasal mucous membrane becomes inflamed and a thin viscid 
 mucus escapes from the nostrils. Later ulceration occurs, especially 
 over the vomer and the discharge becomes thick, purulent, bloody and 
 offensive ; the nose is red and swollen and painful, the redness extend- 
 ing to the adjacent parts of the forehead and cheeks. The nasal symp- 
 toms usually occur early, especially in the acute variety, but they may 
 be considerably delayed and in the chronic form are altogether absent 
 in about one-half the cases. 
 
 With the progress of the malady the constitutional symptoms be- 
 come more pronounced and frequently grave ; the temperature is high, 
 severe chills occur followed by profuse sweats, diarrhoea appears, the 
 patient falls into a comatose state and death follows at the end of two 
 or three weeks, or earlier. 
 
 In the chronic form the constitutional symptoms are less marked 
 and remissions occur from time to time in which the disease is com- 
 paratively quiescent. The skin lesions are usually less numerous, but 
 do not differ from those present in the acute form, and, as already 
 observed, symptoms referable to the nasal mucous membrane are 
 absent in a considerable proportion of cases (about fifty per cent.). Re- 
 covery may take place after a period varying from some months to 
 several years, or the patient may eventually succumb. Not infre- 
 quently acute symptoms suddenly appear ; the temperature becomes 
 high, abscesses form, the patient becomes comatose or delirious, and 
 death quickly follows. 
 
 Etiology and Pathology. — The malady is in most cases contracted 
 by direct contact with a diseased horse, ass or mule, but the infection 
 may arise indirectly through clothing soiled with discharge from the 
 nose or from ulcerating lesions. The direct agent is an organism, 
 the bacillus mallei, discovered, in 1882, by Loffier and Schutz, which 
 is present in the nasal discharge and in the pus of ulcerating lesions on 
 the skin. From cultures of this organism an extract may be obtained, 
 mallein, which, when injected hypodermatically in animals with 
 glanders, produces a reaction resembling that which follows the injec- 
 tion of tuberculin in tuberculous subjects, and which may be employed 
 for diagnostic purposes. 
 
 In the early stages of the glanders lesion there is a more or less 
 abundant cellular exudate composed of mono- and poly-nuclear leuco- 
 cytes with thrombosis of the capillaries which are more or less com- 
 pletely occluded by greatly swollen endothelium and fibrin. A charac- 
 teristic feature is the early and extensive fragmentation of nuclei which, 
 although not peculiar to glanders, is much more extensive than in other 
 
342 DISEASES OF THE SKIN 
 
 maladies. In the perivascular areas of necrosis there are great num- 
 bers of bacilli without any definite arrangement. In the epidermis 
 there is marked dilatation of the intercellular spaces and reticular 
 degeneration of the epithelial cells ; according to Unna, bacilli are not 
 present in this region. 
 
 Diagnosis. — The diagnosis of glanders in the human subject is beset 
 with difficulties. The most satisfactory method is the demonstration 
 of the presence of the bacillus mallei in the nasal discharge or in the 
 pus from ulcers, either by the microscope or by culture. The method 
 of Strauss is also of much value. This consists in the intraperitoneal 
 injection of cultures or pus from a lesion into a male guinea-pig; should 
 the bacillus mallei be present in the suspected material, swelling and 
 inflammation of the testicle will occur in two to four days. Hypoder- 
 matic injections of mallein may likewise be cautiously employed, as 
 in cattle. 
 
 Prognosis. — The prognosis is always grave. In acute cases death 
 almost invariably occurs in the course of from three to six weeks and 
 not infrequently earlier, even before the cutaneous symptoms have 
 appeared. In the chronic form recovery takes place in about one-half 
 the cases. 
 
 Treatment. — There is no specific remedy. Mercurial inunctions 
 have been employed with asserted curative effect by Gold, but the 
 experience of others has failed to confirm the usefulness of this treat- 
 ment. Monneret and Andral recommend the iodide of potassium 
 (Bodin). When possible the initial lesion should be destroyed by the 
 actual cautery, especially if seen early, and the same agent may be 
 used to prevent the spread of ulcers. In chronic cases ulcerating 
 lesions should be treated with antiseptics, and quinine, iron, strychnia 
 and other remedies of a like kind be given along with abundant nourish- 
 ment. Careful trial may also be made of hypodermatic injections of 
 mallein, favorable results have been reported from its use. 
 
 MYCETOMA 
 
 Synonyms. — Madura foot; Fungus foot of India; Podelcoma; Fr., 
 Mycetome, Pied de Madure ; Ger., Madurafuss. 
 
 Definition. — A mycotic disease endemic in certain parts of India, 
 and occurring sporadically in various other parts of the world, attack- 
 ing chiefly the feet, occasionally the hands, and in rare instances other 
 parts of the body. 
 
 Although the affection was mentioned as early as 1712 by Kaempfer, 
 it was first accurately described by Godfrey of Madras in 1843. Balin- 
 gall suggested its parasitic nature in 1855, but Vandyke Carter was the 
 first to call attention, in i860, to the presence of fungus in the discharge 
 which comes from the diseased parts ; and it is to this author that we 
 owe much of our knowledge of the malady. Among recent authors 
 especial mention must be made of Brumpt, who has made detailed 
 studies of the various fungi found in it. 
 
INFLAMMATIONS 343 
 
 Symptoms. — In most cases, but not invariably, the disease begins 
 upon the sole, with the appearance of one or more firm, painless nodular 
 swellings, which after a time soften and discharge a peculiar oily puru- 
 lent fluid in which are contained yellowish or grayish granules which 
 have been likened to fish-roe, or black grains resembling " coarse gun- 
 powder " ; quite exceptionally these granules are pink or red. When 
 once the nodules have softened and opened they do not close but con- 
 tinue to discharge ; and new swellings appear from time to time, so that 
 eventually the number of these fistulous openings is considerable. As 
 the disease progresses the foot enlarges, the sole becomes swollen, so 
 that it is no longer concave but convex, the toes are spread apart ; and 
 the whole member in time becomes a lumpy, shapeless mass, while the 
 muscles of the leg are markedly atrophied from disuse. Occasionally 
 in long-standing cases the tibia may be invaded, or when the hand is 
 the seat of the disease, the bones of the forearm. 
 
 The lymphatic glands as a rule are not affected, but inflammation of 
 these may occur as the result of secondary infection with pyogenic 
 organisms. Pain, as a rule, is not a prominent symptom. 
 
 The course of the disease is usually slow, reaching its full develop- 
 ment only after a period of two or three years, and lasting from ten 
 to twenty or more years, when the patient succumbs to exhaustion 
 resulting from the long-continued drain upon his vitality, or dies with 
 symptoms of sepsis. 
 
 Etiology and Pathology. — Although occurring sporadically in the 
 Temperate Zone, mycetoma is essentially a disease of warm climates, 
 and is seen far more frequently in certain parts of India, especially in 
 Madura, hence one of the names by which it is known, Madura foot, 
 than in any other part of the world. It is a disease of the rural districts, 
 the inhabitants of the town escaping. It occurs much more frequently 
 in men than in women, and is uncommon in children. 
 
 As was shown so long ago as i860, by Vandyke Carter, it is a mycosis. 
 Recent studies of the affection, especially those of Brumpt, have shown 
 that it is not due to a single species of organism, but that a number of 
 species of fungi are concerned in its production. According to Brumpt 
 there are no less than eight varieties of the malady etiologically con- 
 sidered. Two of them are due to varieties of the Discomyces, two of 
 them certainly to the Aspergillus, while the remaining four are likewise 
 probably due to varieties of this latter fungus. According as one or 
 the other of these fungi is present, the character of the granules in 
 the discharge varies. In the so-called white varieties of the affection, 
 the Discomyces is usually present, while in the black forms some 
 variety of the Aspergillus is found. These fungi probably exist as 
 saprophytes upon various plants and obtain entrance into the tissues 
 of the foot through the abrasions or slight wounds which are so apt to 
 "be present in those who go barefoot. The early histological changes 
 are those usually found in the infectious granulomata — areas of granu- 
 lar cell-degeneration surrounded by plasma cells and leucocytes with a 
 
344 DISEASES OF THE SKIN 
 
 varying number of giant-cells and " mastzellen." In the advanced 
 stages all the tissues of the foot are fused together into a grayish or 
 yellowish mass in which the various parts are no longer distinguish- 
 able ; even the bones and finally the tendons and fascia disappear. The 
 entire foot is riddled with variously sized cysts and sinuses lined with 
 a smooth membrane and filled with a yellowish roe-like substance, or 
 with black or brownish granular friable masses in which the microscope 
 shows elements of the fungus. 
 
 Diagnosis. — The situation of the disease, in most cases upon the 
 foot, the extensive swelling and deformity, the numerous sinuses from 
 which are discharged the peculiar yellowish granules or black, gun- 
 powder-like grains in which the fungus may be demonstrated micro- 
 scopically, are features which make the diagnosis a comparatively 
 easy one. 
 
 Prognosis. — The prognosis is unfavorable, as the malady when once 
 established steadily progresses until all the tissues of the foot have 
 been completely disorganized and the member rendered not only useless 
 but a burden. After some years the patient succumbs to the continued 
 drain upon his strength. 
 
 Treatments — In its very earliest stages, when the disease is confined 
 to a limited area, excision or its complete removal with the curette may 
 check it, but when well-developed amputation of the foot or hand, 
 at a point well removed from the disease, offers the only hope of cure. 
 
 ORIENTAL SORE 
 
 Synonyms. — Aleppo boil; Oriental boil; Delhi boil; Pendje sore; 
 Biskra button; Fr., Bouton d'Alep ; Clou de Biskra; Clou de Gafsa; 
 Ger., Orientbeule. 
 
 Definition. — A chronic ulcerative disease, endemic in certain tropi- 
 cal and subtropical regions, particularly of the Orient, due to a specific 
 organism, the Leishmania tropica. 
 
 This affection, first described about the middle of the eighteenth 
 century by Russell as observed in Aleppo, was at one time regarded 
 as confined to Syria and particularly to Aleppo, hence one of the names 
 by which it is known, Aleppo boil. Later, however, it was found in 
 other countries, in India, in Northern Africa, and in the Western 
 Hemisphere in Brazil, Panama and Central America. 
 
 Symptoms. — The appearance of the disease is preceded by a period 
 of incubation varying from a few days to several months. Nicolle 
 found that in the experimentally produced disease in monkeys the incu- 
 bation period varied from 16 to 166 days. 
 
 It begins at the site of inoculation as a small firm red itching 
 papule. This papule enlarges, becomes scaly after some days, and later 
 the scales are replaced by an adherent crust beneath which is an ulcer 
 surrounded by an inflammatory areola. The ulcer slowly enlarges 
 until in the course of some months it reaches a diameter of one to two 
 inches. New ulcers occasionally arise in the immediate neighborhood 
 
INFLAMMATIONS 345 
 
 of the primary sore and by extension and coalescence with it may form 
 an ulcer several inches in diameter. After a period varying from three 
 months to a year or longer, healing begins, not uncommonly in the 
 centre of the ulcer which still continues to extend at the periphery for 
 a time. When healing is complete a depressed whitish cicatrix is left 
 which when large may cause pronounced disfigurement by irregular 
 contraction. On the other hand, the scarring which follows the ulcer 
 may be insignificant. 
 
 Occasionally the primary papule persists for some months as a 
 scaly nodule which, instead of undergoing ulceration, is graduallv 
 absorbed. 
 
 Usually there is but a single lesion, although two, three, or more 
 are not uncommon, and exceptionally there may be many. They are 
 
 mhfc 
 
 lP*3 as 
 
 
 Fig. 119. — Oriental sore (Central America). 
 
 in most instances situated upon exposed parts, such as the hand, arm, 
 feet and legs, and upon the face, this last being a favorite site in chil- 
 dren. The palms, soles and scalp remain free and the trunk is only in- 
 frequently invaded. In cases observed in South America and in Pan- 
 ama, the ear is a common site (Darling). In a case recently under the 
 author's observation, in which the malady was acquired in Central 
 America, the lesion was situated in this region (Fig. 119). 
 
 While as a rule constitutional symptoms do not occur, Manson is 
 of the opinion that there are exceptions to this rule and that fever may 
 precede or accompany the appearance of the initial papule. 
 
 As a rule, to which, however, there are numerous exceptions, one 
 attack confers immunity 
 
 Etiology. — It occurs in both sexes and at all ages, but is most com- 
 mon in the early years of life. Race is apparently without influence 
 
346 DISEASES OF THE SKIN 
 
 upon' its occurrence. It is contagious and inoculable, but the exact 
 mode of infection is yet unknown. It may be communicated by direct 
 contact with infected individuals or with soiled clothing, etc. It is 
 quite probable that in a certain proportion of cases it is transmitted by 
 the bites of insects. 
 
 The direct agent in its production is the organism discovered 
 by Wright, in 1903, for which he proposed the name Helcosoma tropi- 
 cum, but which was later called Leishmania tropica. This organism, 
 found in the tissues of the ulcer, resembles very closely the Leishman 
 bodies found in kala-azar, a chronic febrile disease endemic in parts 
 of India. The presence of this organism in the tissues of the disease 
 has been confirmed by a number of observers, and Nicolle has culti- 
 vated it and has reproduced the malady in monkeys by inoculation 
 of pure cultures, thus definitely establishing its causal relationship 
 to the affection. 
 
 Manson thinks it likely that infection occurs in two ways : Either 
 the infecting organism is inoculated directly into the skin, or infection 
 takes place indirectly through some insect which serves as an inter- 
 mediate host in which the organism undergoes further development. 
 
 Pathology. — The chief histological alterations are found in the 
 corium which is occupied by a cellular exudate, most abundant in the 
 neighborhood of the blood-vessels. This exudate is made up of lym- 
 phoid, plasma and a few giant-cells, together with large mononuclear 
 cells which Wright regards as endothelial, in the cytoplasm of which 
 are numerous microorganisms. The changes in the epidermis are 
 secondary to those in the corium and vary according to the age of the 
 lesion. At times there is atrophy of the rete, at others it is much 
 thicker than normal, sending branching processes down into the 
 corium. 
 
 Diagnosis. — In countries where the malady is endemic the diag- 
 nosis is usually made without difficulty, but it is not always easy. 
 In doubtful cases the organism should be looked for in smears or scrap- 
 ings taken from the ulcer, since this is the most certain method of 
 diagnosis and sometimes the only satisfactory one. 
 
 Treatment. — Cauterization or excision of the lesion has been ad- 
 vised, and if done early may cut short the disease. Quite recently the 
 tartrate of antimony in one per cent, solution has been successfully 
 employed intravenously, by Ferra in Brazil ; five c.c. were given once 
 a day for five successive days. DaSilva, likewise, reports success with 
 this method of treatment. 
 
 ESPUNDIA 
 
 Under the name, Espundia, an unusually virulent form of Leish- 
 maniasis has been described as occurring in Brazil, Peru and Paraguay. 
 It begins with an initial ulcer resembling in some respects a chancre, 
 on some exposed part of the body, which pursues an indolent course, 
 
INFLAMMATIONS 347 
 
 healing after a duration of some months. This lesion, after a variable 
 period, is followed by destructive ulceration of the tongue and mucous 
 membranes of the mouth and nose. The malady lasts for years and 
 may produce extensive destruction of tissue followed by marked de- 
 formity, and in certain cases produces death. The Leishman bodies are 
 found in small numbers in the ulcers. 
 
 FRAMBCESIA 
 
 Synonyms. — Yaws ; Fr., Pian ; Ger., Beerschwam ; Boubas (Brazil) ; 
 Paranghi (Ceylon). 
 
 Definition. — An infectious and contagious disease endemic in the 
 tropics, due to the spirochcuta pertenuis (treponema pertenue) char- 
 acterized by an eruption of papules and papillomatous nodules. 
 
 This affection was first described by Oviedo, in 1535, and was given 
 the name framboesia by Sauvages, in the latter part of the eighteenth 
 century (1761). It is essentially a tropical disease, prevailing exten- 
 sively on the west coast of Africa, in the Islands of the South Pacific, 
 in Ceylon, in the West Indies and in the tropical countries of South 
 America. Although at the present time found only in ihe tropics, it 
 is altogether likely that the malady which prevailed in Ireland in the 
 latter part of the eighteenth and early part of the nineteenth centuries 
 known as " button scurvy " was yaws. 
 
 Symptoms. — An incubation period varying from two to four weeks 
 precedes the appearance of the characteristic eruption in the disease 
 when acquired in the ordinary way. In cases, however, in which it 
 has followed experimental inoculation the incubation period has been 
 much shorter, varying from ten to twenty days (Paulet and Charlouis). 
 During this period constitutional symptoms occur, such as fever, mus- 
 cular and arthritic pains, gastric disturbances and diarrhoea. These 
 may be so slight as to scarcely attract attention, or they may be well 
 pronounced. The skin becomes dry, small, ill-defined, oval and ir- 
 regular patches covered with fine branny scales appear, which may 
 persist throughout the disease. These symptoms are followed by the 
 primary or initial lesion at the site of inoculation. 
 
 The initial lesion, the existence of which is denied by some authors, 
 begins as a papule which slowly enlarges and at the end of a week 
 is covered with yellow cheesy material resembling sebum, which, after 
 some days, dries into a yellow adherent crust beneath which is an 
 ulcer with well-defined edges. This ulcer may heal in the course of 
 two or three weeks, leaving a whitish cicatrix, or it may increase in 
 size and persist as a papillomatous growth, the so-called " mother 
 yaw," around which smaller lesions occasionally form. Instead of ul- 
 cerating, it may persist as a nodule, which after a time undergoes ab- 
 sorption, the skin over it scaling slightly. It may occur on any part 
 of the body, but is most frequently seen upon exposed portions, such 
 as the arms and hands, the lower extremities, the face in children, and 
 in infants about the mouth. In women the breast is a frequent site, 
 
348 DISEASES OF THE SKIN 
 
 particularly in the region of the nipple and areola. The genital region 
 is less frequently affected. 
 
 From one to three months after the appearance of the primary 
 lesion, a more or less generalized eruption of small conical papules 
 occurs, usually preceded or accompanied by some elevation of tempera- 
 ture, with headache and pains in the muscles and joints. At first these 
 papules are quite small, but they rapidly increase in size and at the end 
 of a week their tops are covered with a yellow wax-like secretion which 
 dries into yellow firmly adherent crusts beneath which is a red papil- 
 lomatous surface covered with a viscid acid secretion, compared by 
 Numa Rat to the cauliflower. Not all of the papules, however, undergo 
 this development, many of them, without any increase in size after a 
 number of weeks, disappear. The papules usually reach their complete 
 development in about two weeks and then remain for some weeks 
 longer without material change. The crusts then fall off, the nodules 
 shrivel up and finally disappear, leaving more or less pigmented patches. 
 The number and size of the lesion vary greatly. The nodules when 
 fully developed vary in size from that of a pea to a nut. There may 
 be hundreds occupying all the regions of the body or there may be less 
 than a dozen, sometimes not more than two or three, limited to one or 
 two localities. When the lesions are numerous and closely aggregated 
 they may form patches of considerable size, and about the mouth and 
 anus they form ring-shaped papillomatous masses {ringworm yaws). 
 Occasionally ulceration occurs, usually limited to the lesion itself, but 
 sometimes extending to the surrounding skin, continuing under such 
 circumstances for long periods. Lesions occur upon the sole of the 
 foot and palm of the hand, and in the former region are usually quite 
 painful, being compressed by the thick horny layer of the epidermis. 
 Walking is painful and the patient adopts a peculiar crab-like gait 
 (crab yaws). Occasionally the plantar lesions ulcerate, producing 
 deep ulcers situated most frequently at the base of the great toe. Al- 
 though more or less itching accompanies the eruption, the lesions 
 themselves are as a rule painless, although Charlouis states that they 
 are frequently painful when they first appear. The mucous membranes 
 of the lips and nose may be invaded, but these are not commonly 
 attacked. The matrix of the nails is occasionally inflamed and papil- 
 lomatous lesions may develop about their roots. The hair is not affected, 
 except in regions where ulceration occurs, in which event permanent 
 alopecia may result, owing to destruction of the hair follicles. 
 
 In cases of, ordinary severity the general health is but little affected, 
 but when the malady occurs in broken-down subjects or in those im- 
 properly housed and fed or injudiciously treated, the general health 
 may suffer to a marked degree. 
 
 The duration of yaws varies within wide limits. In healthy in- 
 dividuals an attack of moderate severity runs its course in about six 
 weeks to two months, but in debilitated subjects or when the disease 
 is severe it may continue for six to eight months or even one year, 
 successive crops of eruption appearing from time to time. 
 
INFLAMMATIONS 349 
 
 As a sequel of the foregoing symptoms, ulcerative lesions follow- 
 ing gumma-like infiltrations, serpiginous ulcers, periostitis, destructive 
 ulceration of the mucous membranes of the nose and pharynx occur 
 in a certain proportion of cases, constituting the tertiary stage of Numa 
 Rat, Castellani and others. There is considerable difference of opinion, 
 however, among equally experienced observers as to the nature of 
 these lesions. While the above-mentioned authors regard them as a 
 part of the yaws infection, others consider them the result of a con- 
 current syphilis or tuberculosis. 
 
 Etiology. — Yaws is a highly contagious affection. It may be trans- 
 mitted by direct contact, provided there is a break in the continuity of 
 the skin. Any abrasion, such as a scratch, may serve as the point of 
 entry for the infection, which also frequently takes place through the 
 medium of pre-existing ulcers, whatever their origin. There is also 
 some evidence that it may be transmitted by the bites of insects, such 
 as mosquitoes, etc. Heredity plays no part in its production. It occurs 
 in both sexes, more frequently in men than in women, and is common 
 in children, although infrequent before one year of age. In 1905, 
 Castellani demonstrated the presence of an organism in yaws tissue 
 resembling closely the spirochseta pallida of syphilis to which he gave 
 the name spirocheeta pertenuis, and this finding has since been con- 
 firmed by a number of other observers. There is little doubt that this 
 organism is the direct cause of the malady. 
 
 Pathology.— The spirochcuta pertenuis is decidedly more slender 
 than the spirochaeta pallida and varies in length from a few microns 
 to eighteen or twenty (Castellani). It stains with difficulty but may 
 be stained by the Leishman and Giemsa methods. Inoculation of this 
 organism into monkeys produces lesions similar to those observed in 
 man. Noguchi has succeeded in cultivating it, employing ascitic fluid 
 as a culture-medium. 
 
 The histopathology of yaws is that of an infectious granuloma. The 
 epidermis shows marked acanthosis with hyperkeratosis and pro- 
 nounced down-growth of the interpapillary processes of the rete. The 
 papillae of the corium are increased in length in proportion to the in- 
 creased length of the interpapillary prolongations. The corium is 
 occupied by a diffuse cellular infiltration composed chiefly of plasma 
 cells, with a few polymorphonuclear leucocytes. Unlike other varieties 
 of granuloma, there are no large multinuclear cells nor giant-cells of 
 the Langhans type. There is rarefaction of the collagen and of the 
 elastic tissue in the region occupied by the exudate. Unlike the syph- 
 ilitic granuloma there are no proliferative changes in the walls of the 
 vessels and in the endothelium, histological features so characteristic 
 of syphilis. 
 
 Diagnosis. — The disease for which it is most likely to be mistaken 
 is syphilis. Indeed, it was formerly regarded by a number of authors, 
 prominent among whom was Sir Jonathan Hutchinson, as nothing 
 more than a modified form of that disease. The initial lesion, which is 
 
350 DISEASES OF THE SKIN 
 
 usually extra-genital, never exhibits the induration characteristic of the 
 initial lesion of syphilis. The eruption is quite uniform in character, 
 whereas syphilitic eruptions are remarkably polymorphous. The yel- 
 low waxy crusts which cover the nodules are altogether unlike the 
 crusting which occurs in pustular syphilitic lesions. Many of the 
 lesions, if not most, in yaws are papillomatous in character, a form of 
 lesion quite uncommon in syphilis. The mucous membranes so com- 
 monly the seat of syphilitic lesions are infrequently attacked in yaws 
 and in the latter there is neither alopecia nor iritis. Itching is a 
 common and frequently a well-marked symptom in yaws, but is rare in 
 syphilis. 
 
 Prognosis. — Recovery usually takes place within from three to six 
 months in cases of moderate severity occurring in those in good gen- 
 eral health, but when severe and occurring in debilitated subjects the 
 prognosis as to early recovery is unfavorable. The disease may last 
 one or more years. Death is infrequent, and when it occurs is usually 
 the result of septic complications. 
 
 Treatment. — Proper hygienic surroundings and abundance of good 
 food and strict cleanliness of person and clothing are of great impor- 
 tance in the management of the malady. Mercury and the iodides 
 exert a decidedly beneficial effect when judiciously employed. The 
 most effective remedy, howver, is salvarsan or neosalvarsan, given in 
 the usual dose either intravenously or intramuscularly, preferably the 
 former. This remedy causes the rapid disappearance of the erup- 
 tion in every stage of the disease. Ulcers should be cleansed fre- 
 quently with antiseptic washes, such as the saturated solution of boric 
 acid or an aqueous solution of mercuric bichloride, 1 to 2000. 
 
 In order to prevent the spread of the disease, contact with diseased 
 individuals should be carefully avoided, soiled clothing and the dwell- 
 ing of the patient should be thoroughly disinfected or burned. 
 
 VERRUGA PERUANA 
 
 Synonyms. — Peruvian wart ; Carrion's disease ; Oroya fever. 
 
 Definition. — An endemic disease confined to certain elevated valleys 
 on the western slopes of the Andes in Peru, characterized by fever, 
 marked anaemia and an eruption of nodules and papillomatous tumors 
 situated upon the skin and mucous membranes. 
 
 This malady was first mentioned in European literature, in 1543, by 
 Zarrate in his History of Pent, and was first medically described, in 
 1845, by Tschudi. Since then it has been extensively studied by 
 Ordriozola, Escomel, and Yzquierdo and very recently by Strong. 
 
 Symptoms. — After an incubation period lasting from one to six 
 weeks, the disease begins with constitutional symptoms of a more or 
 less pronounced character. There is fever, frequently intermittent in 
 character, the temperature ranging from ioo° F. to 103 or 104 F. 
 with severe muscular and arthritic pain. These symptoms are fol- 
 lowed after some weeks or months by an eruption of small red papules 
 
INFLAMMATIONS 351 
 
 or vesicles which slowly increase in size and become papillomatous 
 nodules and tumors varying in size from that of a small pea to a large 
 nut or pigeon's egg. Subcutaneous nodules likewise occur over which 
 the skin is freely movable. With the appearance of the eruption, 
 which may appear in a single crop or in successive outbreaks, there is 
 an abatement of the constitutional symptoms. The eruptive lesions, 
 after reaching a certain size, are red, shining and elastic, and very 
 vascular, bleeding readily, often spontaneously, or from scratching, so 
 that many of them are covered with a red or blackish crust of dry 
 blood. They are markedly affected by temperature, becoming turgid 
 under the influence of heat and shrinking up when subjected to cold. 
 The number of lesions present varies greatly. They may be quite 
 limited in number or there may be scores and hundreds of them. The 
 face and extremities are the sites of election, but the trunk may also be 
 affected. The eruption is not confined to the skin, but occurs upon the 
 conjunctiva, upon the mucous membranes of the lips, cheeks, pharynx, 
 upon the gastro-intestinal mucosa and in the vagina. 
 
 The eruptive period varies from four to six months. The smaller 
 lesions gradually shrivel up and disappear, leaving for a time a small 
 pigmented spot. The large lesion and the subcutaneous nodules 
 usually disappear by ulceration. 
 
 Etiology. — The malady is confined within comparatively limited 
 geographical boundaries and within these boundaries is restricted to 
 certain localities. 
 
 Neither age nor sex exerts any influence upon the occurrence of 
 the affection. The weak and ill-nourished more readily fall victims to 
 it than the strong and well-fed. 
 
 It is inoculable, as was conclusively demonstrated by the fatal 
 experiment of Carrion, who lost his life after an experimental inocula- 
 tion performed upon himself. The fact that it has been known to 
 occur in individuals who have spent but a very short time, even so 
 little as an hour or two, in regions in which it is endemic, suggests 
 the possibility, if not the probability, that it is conveyed by the bite of 
 some insect. Townsend would incubate a species of phlebotomus 
 as the carrier of the infection. A number of organisms have been 
 found in the blood and in the tissues of those affected, but the relation- 
 ship of these to the disease has not yet been definitely determined. 
 
 Until quite recently Carrion's experiment was considered to have 
 definitely determined the identity of verruga and Oroya fever, a grave 
 febrile disorder prevailing in the regions in which the former is en- 
 demic, but quite recent studies have thrown considerable doubt upon 
 the accuracy of this view. Strong, as the result of his studies in Peru, 
 concludes that the two affections are distinct from one another, and 
 due to different causes. 
 
 Pathology. — The microscopic changes in the lesions are such as are 
 found in the infectious granulomata in general: The corinm is occu- 
 
352 DISEASES OF THE SKIN 
 
 pied by a diffuse cellular exudate composed of lymphoid, polymorpho- 
 nuclear, and plasma cells. The lesions are markedly vascular, some- 
 times resembling in appearance angioma. 
 
 During the febrile stage preceding the eruption, rods resembling 
 bacilli are present in the red blood-cells which disappear with the 
 appearance of the cutaneous lesions. 
 
 Diagnosis. — The recognition of the disease during the febrile stage 
 may be very difficult, and the diagnosis must frequently wait upon the 
 appearance of the cutaneous symptoms. 
 
 Prognosis. — The disease is a serious one, the mortality varying 
 from ten to forty per cent. The gravity of an attack is in direct pro- 
 portion to the severity of the constitutional symptoms. With the 
 appearance of the eruption the prognosis is materially improved. 
 
 Treatment. — When possible those stricken should be removed from 
 the region in which the malady prevails, preferably to the seashore. 
 The medicinal treatment consists in the administration of quinine and 
 iron and stimulants when indicated. Very recently favorable results 
 from the use of salvarsan have been reported. 
 
 GANGOSA 
 
 Synonym. — Rhinopharyngitis mutilans (Leys.) 
 
 Definition. — A disease endemic in certain tropical regions char- 
 acterized by progressive destructive ulceration of the nasopharynx and 
 adjacent parts. 
 
 This malady is found chiefly in the Philippine Islands, Fiji, the 
 Caroline Islands, Guam, and to some extent in some of the islands 
 of the West Ind ; es, British Guiana and Panama. In Guam it is es- 
 pecially prevalent, it being estimated that from one to five per cent, 
 of the entire population are affected. 
 
 Symptoms. — It begins with ulceration of the soft palate or pillars 
 of the fauces, spreading thence to the hard palate and to the naso- 
 pharynx, producing extensive destruction of the soft parts, cartilage 
 and bone. Extending through the nose to the nares, it sometimes 
 completely destroys the cartilaginous septum and the bony structures, 
 permitting the nose to sink in, or it may completely destroy it, usually 
 sparing the adjacent part of the upper lip. It may extend upward 
 through the lachrymal duct to the orbit, where it may destroy the eye- 
 ball. Less frequently it extends downward to the larynx, interfering 
 more or less markedly with the functions of this organ. 
 
 While the progress of the affection is commonly slow, it may at 
 times be quite rapid. A fulminating type occurs in children, which 
 begins suddenly and is accompanied by extreme prostration, with 
 marked swelling of the cervical lymphatic glands (Mink and McLean). 
 These cases run a very rapid course, death occurring usually within 
 forty-eight hours with symptoms of profound toxaemia. If the patient 
 
INFLAMMATIONS 353 
 
 survives, characteristic mutilation occurs and the disease pursues the 
 ordinary course. 
 
 Constitutional symptoms as a rule are absent. Pain is not com- 
 monly a prominent symptom and the patient's general health is but 
 little affected. 
 
 The course of the malady is a chronic one and is apt to be intermit- 
 tent, periods of activity being followed by periods of quiescence. It 
 usually lasts for years and produces at times extreme destruction 
 with great deformity. Occasionally the ulceration terminates spon- 
 taneously before much mutilation has been produced. 
 
 Etiology and Pathology. — It is most frequent in the second and 
 third decades of life. Sex is without influence upon its occurrence. 
 It is confined to the natives of the regions in which it occurs, the only 
 case in a European thus far observed being reported by Stitt. This 
 case occurred in a man who had lived in Guam in intimate association 
 with families in which the disease prevailed. The affection is probably 
 contagious, although definite proof of this is still lacking. 
 
 There is but little doubt that it is a specific infection of some sort, 
 but the infecting agent is still unknown. By some it is regarded as a 
 form of syphilis, while others look upon it as a sequel of yaws or 
 framboesia. 
 
 Histologically it is a granuloma, resembling somewhat tubercu- 
 losis (Fordyce). 
 
 Diagnosis. — The diseases for which it may be mistaken are leprosy, 
 lupus vulgaris, syphilis and yaws. From the two former it may be 
 distinguished by its comparatively rapid course and the absence of the 
 specific organism of these affections. It is much more likely to be 
 mistaken for syphilis than any other disease, but the absence of other 
 symptoms of this infection and the negative Wassermann reaction 
 readily differentiate it. 
 
 Cases of the fulminating type resemble more or less diphtheria and 
 Vincent's angina, but the absence of the Klebs-Loeffier bacillus of the 
 former and of the bacillus of Vincent, present in the latter would exclude 
 these affections. 
 
 Prognosis. — Except in the infrequent fulminating form, the malady 
 involves no danger to life, but it may continue for years, producing 
 extensive destruction of tissue in the nasopharynx and the face with 
 extreme disfigurement. 
 
 Treatment. — There is no specific treatment for this disease. Caus- 
 tics, such as nitrate of silver, phenol, chromic acid, are useful in limit- 
 ing the spread of the ulceration. Mink and McLean regard tincture 
 of iodine applied freely as the best local remedy. Antiseptic washes, 
 such as the saturated solution of boric acid, or a I : 2000 solution of 
 bichloride of mercury, should be freely applied. For the correction 
 of the fetor which often accompanies the disease a one per cent, 
 solution of permanganate of potash may be used. In the fulminating 
 type of the affection supporting treatment is indicated. 
 23 
 
354 DISEASES OF THE SKIN 
 
 GRANULOMA INGUINALE TROPICUM 
 
 Synonyms. — Groin ulceration ; Ulcerating granuloma of the puden- 
 da (Galloway). 
 
 Definition. — A chronic ulceration of the groin and pudenda occur- 
 ring in tropical regions. 
 
 The first account of this affection was given by Conyers and Dan- 
 iels, in 1896, who observed it in British Guiana in West Indian negroes. 
 A similar disease has been observed in some parts of India, in Fiji and 
 in South China (Manson). Quite recently its occurrence in negroes 
 in the United States has been reported by Grindon. 
 
 Symptoms. — According to Conyers and Daniels, it begins as a small 
 papule which enlarges until it becomes a nodule a half inch or more in 
 diameter, with a smooth, pink, shining surface ; this is soon excoriated 
 or abraded and ulcerates. In men it begins on the penis, pubes or in 
 the groin, in women usually upon the labia. The ulceration extends 
 slowly along the groin where it forms an ulcerating furrow, spreads 
 over the pubes, back over the perineum and around the anus. In 
 women it spreads over the labia, the perineum and into the vagina, 
 sometimes destroying the recto-vaginal septum. The borders of the 
 ulcers are covered with vegetations, and there is usually a profuse 
 watery discharge from the surface with a peculiarly offensive odor. 
 As the ulceration extends, the parts first invaded cicatrize, so that 
 after some time there is a large area of uneven pigmented scar-tissue 
 with a serpiginous ulcerating border. The disease spreads slowly and 
 lasts for a number of years. While it usually spreads by continuity, 
 it may invade new regions by inoculation of opposed surfaces, as when 
 it spreads from the scrotum or the vulva to the inner surface of the thigh. 
 
 Etiology and Pathology. — It occurs in both sexes but is somewhat 
 more frequent in women than in men. It is most common between 
 puberty and forty years of age. It especially affects negroes in the 
 regions in which it prevails, but also occurs in other dark races and 
 has been noted in a few instances in individuals of the white race. 
 Manson thinks there is reason for believing it a venereal disease and 
 Maitland believes it may be sometimes inoculated on a preexisting 
 venereal ulcer, such as an ulcerating bubo. Donovan (quoted by Man- 
 son) found in scrapings from the bottom of the ulcer, in cases seen 
 in Madras, a short bacillus with rounded ends, measuring two microns 
 by one micron, situated in large mononuclear cells, either scattered 
 throughout their protoplasm or oftener, in clusters of eight or ten ; the 
 relationship of this organism to the disease has not yet been deter- 
 mined. Wise has reported the finding of spirochsetse resembling the 
 Spirochseta refringens and the Spirochseta pallida in the ulcers. His- 
 tologically, the affection is a granuloma without special characteristics. 
 
 Diagnosis. — It is to be distinguished from tuberculosis and syphi- 
 litic ulceration. It differs from both tuberculosis and syphilis by its 
 very slow progress, its limitation to the groin and pudenda, its extreme 
 
 
INFLAMMATIONS 355 
 
 chronicity and the absence of glandular involvement and of general 
 symptoms even when it has lasted for years. 
 
 Prognosis and Treatment. — It is usually very rebellious to treat- 
 ment, and as already noted, lasts for several years. The general health 
 suffers but very little, even in long-standing cases. 
 
 Conyers and Daniels found phenol-camphor one of the best local 
 applications, but it does not cure the ulcer. Mercury and the iodides 
 have been tried without effect, and quite recently Choyce and Mac- 
 Cormac have used salvarsan without benefit. Very recently the X- 
 ray has been found to give better results than any other form of treat- 
 ment. 
 
 RHINOSCLEROMA 
 
 Definition. — A malignant new-growth characterized by nodules 
 and plaques of cartilaginous hardness occupying the nose and adjacent 
 parts. 
 
 This affection was first described by Hebra and Kaposi in 1870, 
 their description of it being based upon 15 cases almost all of which 
 were observed in the Vienna Clinic. It is found chiefly in Austria, 
 Hungary and Southeastern Russia; next to these countries it is seen 
 most frequent in Brazil. Scattered and infrequent cases have been ob- 
 served in Italy, Switzerland, Belgium, Spain and the United States. 
 In the last-named country all the cases with but two exceptions have 
 occurred in foreign-born individuals. 
 
 Symptoms. — The disease begins with the appearance of discrete 
 and confluent nodules and slightly elevated circumscribed plaques of 
 cartilaginous hardness situated in the great majority of cases upon 
 some portion of the nose. According to Wolkowitsch, 95 per cent, of 
 the eighty-five cases collected by him began in the nasal fossae. These 
 nodules and plaques may be the color of the normal skin or brownish- 
 red, are hard, glossy and smooth, with dilated capillaries coursing over 
 their surface. They slowly enlarge, increasing the size and changing 
 the shape of the nose, wmich is broadened and flattened. With the 
 growth of the neoplasm the nasal openings are gradually encroached 
 upon until in time they are so completely occluded that the patient 
 can no longer breathe through them and is compelled to breathe 
 through the mouth. In time the upper lip is involved ; it becomes 
 thick and misshapen. The naso-pharynx and even the larynx are in 
 time implicated in the process. After a time Assuring occurs in trie- 
 natural furrows about the nose and from these fissures a viscid fluid 
 escapes which dries into yellowish crusts. Sometimes the growth is 
 confined, for a time, at least, to the nasal mucosa and produces but little 
 change in the external appearance of the nose. Although spontaneous 
 pain is not present in the growth, pressure may produce severe pain 
 persisting for some time. While the nose and adjacent parts are the 
 most frequent site of the disease, it occurs also in other regions in ex- 
 ceptional cases ; the soft palate, the pharynx and the larynx are oc- 
 
356 
 
 DISEASES OF THE SKIN 
 
 casionally affected, and two cases have been reported in which the dis- 
 ease was situated in the auditory canal (Pick, Kaposi). 
 
 The course of the malady is extremely chronic, the growths slowly 
 extending to the neighboring parts, and interfering seriously with res- 
 piration through closure of the nasal passages and occasional narrow- 
 ing of the glottis. But little change occurs in the growth, when once 
 established, although at times oozing followed by crusting takes place. 
 Occasionally superficial excoriation is observed on the surface of the 
 lesions, and in rare instances softening (Zeissl). 
 
 Etiology. — The disease affects both sexes alike ; out of eighty-five 
 cases collected by Wolkowitsch, forty-eight were men and thirty-seven 
 women. The same author found the maximum frequency of the dis- 
 
 
 Fig. 120. — Rhinoscleroma. Large epithelioid cells, e, with a Mickulicz cell, m. In the latter, in properly 
 stained sections, numerous bacilli are usually found. 
 
 ease to be between fourteen and thirty years of age. Nearly all the 
 cases thus far observed have occurred in the very poor, but in those who 
 apparently have been in good general health. 
 
 In 1882 Frisch discovered a bacillus in the tissues of the neoplasm 
 which he believed to be the cause of the disease. This bacillus is a 
 short rod from 1.5 to three microns long; it is surrounded by a capsule 
 .and resembles the pneumococcus of Friedlander. This organism is 
 •constantly present in the tissues of the neoplasm and has been success- 
 fully cultivated. Efforts at reproducing the disease, however, by in- 
 oculation of such cultures have thus far failed. 
 
 Pathology. — While the growth presents in a general way the feat- 
 ures of a granuloma, it differs considerably from the ordinary granu- 
 loma in some of its details. In the earty stages the corium is occupied 
 
INFLAMMATIONS 357 
 
 by numerous foci of cells which are for the most part plasma cells. 
 Later peculiar large cells are present, some of which have undergone 
 colloid degeneration, others contain vacuoles in which are numbers 
 of bacilli enclosed in a gloea; these are the cells of Mikulicz and give 
 to sections of the neoplasm a quite characteristic appearance (Fig. 
 120). Numerous bands of fibrous connective tissue are also present 
 which give to the growth its peculiar hardness. 
 
 Diagnosis. — The peculiar cartilaginous firmness of the neoplasm 
 and its situation upon the nose and adjacent parts is characteristic 
 of the malady, making it readily recognizable in most cases. It may 
 be mistaken for keloid, but this usually follows traumatism, and is 
 found only in rare instances upon the nose. In the enlargement which 
 occurs in rhinophyma the tissues are soft and' vascular and frequently 
 pitted with small scars, altogether unlike the hard smooth surface of 
 rhinoscleroma. 
 
 Prognosis. — The affection is without influence upon the general 
 health, but continues for years. Owing to the interference with respira- 
 tion through narrowing of the nasal passages and the larynx, sleep is 
 frequently greatly interfered with and the taking of food troublesome. 
 In advanced cases, through closure of the glottis, death may occur 
 from suffocation. 
 
 Treatment. — No method of treatment has yet been found which 
 definitely checks the course of the disease, although the employment 
 of the X-ray has recently been found to exercise a favorable influence 
 upon it. Temporary relief to the embarrassed respiration may be ob- 
 tained by the surgical removal of a part of the neoplasm, but it in- 
 variably recurs. The galvano-cautery may be employed for this pur- 
 pose, or the curette. Lang observed improvement after injection of 
 a solution of salicylic acid, one per cent., into the tumor, and Wolko- 
 witsch after injections of carbolic acid, but other observers have not 
 been so fortunate. 
 
 LUPUS ERYTHEMATOSUS 
 
 Synonyms. — firytheme centrifuge (Biett) ; Seborrhcea congestiva 
 (Hebra) ; Lupus erythematodes ; Ulerythema centrifugum (Unna) ; 
 Fr., Lupus erythemateux (Plate XXI). 
 
 Definition. — A chronic, in rare instances acute, inflammatory dis- 
 ease characterized by circumscribed red or violaceous, variously sized 
 patches situated in the face, much more frequently than elsewhere, 
 followed by cicatricial atrophy. 
 
 This affection, first described by Biett under the name erytheme 
 centrifuge, later by Hebra as seborrhoea congestiva, was given the 
 name by which it is generally known at present by Cazenave in 185 1. 
 
 Symptoms. — The affection presents considerable variation in its 
 symptoms and course. Kaposi, who has been followed by most 
 authors, recognized two clinical varieties — a discoid, lupus erythema- 
 tosus discoides, and a disseminate, lupus erythematosus disseminatus. 
 
358 DISEASES OF THE SKIN 
 
 To these Croker added two others, a telangiectic and a nodular form. 
 The several varieties are usually very much alike in the beginning, 
 and are differentiated from one another chiefly by the course which 
 they pursue later. 
 
 The most frequent variety is the discoid, which is situated in the 
 .great majority of cases upon the face and ears, considerably less fre- 
 quently upon the scalp, and occasionally upon the hands and feet. It 
 begins as pin-head to pea-sized, red, slightly elevated spots covered 
 with a scanty thin scale which slowly, or at times quite rapidly, en- 
 large until they reach the size of a coin. When there are several ad- 
 jacent patches they may coalesce to form patches half the size of the 
 palm, and larger, often with crescentic or gyrate margins. After a 
 variable period the central portion becomes somewhat depressed, 
 atrophic, and whitish or bluish-white, while the margin remains more 
 or less elevated, and red or violaceous in color. The surface of the 
 
 Fig. 121. — Lupus erythematosus. Mild type. 
 
 patches is covered with scanty grayish or yellowish adherent scales 
 from the lower side of which small spine-like projections dip into the 
 mouths of the follicles, which are noticeably dilated and many of which 
 contain comedo-like plugs of horny epithelium. 
 
 When fully developed the disease presents a very characteristic ap- 
 pearance. The borders of the patches are marginate, more or less dis- 
 tinctly elevated and of a dusky-red or violaceous color, while the 
 central portion is depressed and occupied by smooth or slightly scaly, 
 bluish-white parchment-like scar-tissue. In a large proportion of cases 
 of the discoid form the disease begins over the malar eminences and 
 spreads thence to the cheeks and over the bridge of the nose, forming 
 symmetrical patches which have been likened to a bat with outspread 
 wings or to a butterfly ; and on account of this fancied resemblance the 
 disease is sometimes popularly known as the bat's-wing disease (French, 
 Vespertillio), or the butterfly disease (German, Schmetterling, Figs. 
 
INFLAMMATIONS 
 
 359 
 
 121 and 12.2). A variable amount of infiltration is present. At times 
 it is very slight, there being apparently little more than a marked 
 erythema, either with or without scaling, as in the telangiectic variety 
 described by Crocker, which occurs as smooth, bright to dusky-red cir- 
 cumscribed patches most frequently on the cheeks. On the other hand 
 the infiltration may be considerable, the patches being quite thick with 
 uneven nodular surface, resembling lupus vulgaris. 
 
 Decided subjective symptoms are rarely present; exceptionally, 
 considerable itching and burning are complained of. The ears are fre- 
 quently involved along with the face, where it occurs as ill-defined 
 patches in the concha in which the follicles are markedly dilated and 
 filled with comedo-like plugs. In long-standing cases the entire ear 
 may eventually be involved, and the organ be reduced to its cartilagi- 
 nous framework over which is stretched thin scaling scar-tissue in which 
 
 Fig. 122. — Lupus erythematosus. 
 
 ulceration occasionally occurs. On the scalp it produces round or ir- 
 regularly shaped areas of baldness, the borders of which are somewhat 
 elevated and scaling. Usually it is associated with patches upon non- 
 hairy parts, such as the face, but occasionally it exists in this region 
 alone. The loss of hair which results is permanent, the follicles being 
 completely destroyed (Fig. 123). 
 
 Upon the hands and feet it occurs as small round and oval patches 
 Avhich present much the same features as those in the face, with which 
 it is nearly always associated. It sometimes occurs as dull-red or 
 bluish-red, smooth or slightly scaly, circumscribed patches, usually 
 situated over the joints of the fingers, which resemble chilblains and 
 which like these, are usually w^orse in winter and better in summer. 
 This form, which is known as lupus pernio, or on account of its re- 
 semblance to chilblain, chilblain lupus, may also attack the ears and 
 nose. In a certain small proportion of cases, vascular and trophic 
 
360 DISEASES OF THE SKIN 
 
 symptoms resembling those of Raynaud's disease precede or accom- 
 pany erythematous lupus of the hands and other regions. There are 
 paroxysmal attacks of local asphyxia and local syncope affecting the 
 terminal phalanges of the fingers and toes accompanied by pain and 
 followed by necrosis of the tips of the fingers and of the toes ; and in cases 
 in which these symptoms have continued for some time, marked atrophy 
 of the fingers with impairment of motion, sclerodactylia, may result. 
 
 The nutrition of the nails may be very much disturbed when the 
 phalanges are attacked. They lose their lustre, their free edges are 
 brittle and broken, and in exceptional cases the entire nail-plate is 
 greatly distorted or almost completely destroyed. 
 
 The mucous membranes are occasionally attacked, usually coin- 
 cidently with the skin, in rare instances, alone. It is not rare upon the 
 
 FlG. 123. — Lupus erythematosus, scalp. (Same patient as Fig. 121.) 
 
 mucous surface of the lower lip, where it gives rise to small, ill-defined, 
 slightly scaly depressed patches, to shallow erosions and bluish-white 
 depressed atrophic areas. On the inside of the cheeks and on the hard 
 palate the recent patches are bright-red and somewhat infiltrated, while 
 the older ones are bluish-white and depressed. On the tongue, where 
 it is quite rare, it occurs as smooth red patches devoid of papillae. 
 
 The course of the discoid variety is an exceedingly chronic one. 
 After reaching an indeterminate size the patches often show but very 
 little change for months, or after an indefinite duration they may 
 slowly disappear completely or in part, leaving an area of smooth, 
 whitish scar-tissue. Exceptionally, in cases with little infiltration, the 
 disease may disappear spontaneously, leaving scarcely any trace, but 
 the recovery is seldom permanent, recurrence being the rule. 
 
 As a rare complication epithelioma occurs in the scar, but this is 
 much less frequent than in lupus vulgaris. 
 
INFLAMMATIONS 361 
 
 The disseminate variety, lupus erythematosus disseminatus, may follow 
 the ordinary discoid form. Beginning upon the face, spreading thence 
 gradually to the trunk and extremities, it may eventually involve large 
 areas, and in exceptional cases may be almost universal. The eruption 
 consists of numerous very slightly scaly, hypergemic pin-head to large 
 pea-sized spots and patches, some of which disappear spontaneously, but 
 most of which persist for months, pursuing much the same course 
 and undergoing the same evolution as the lesions of the discoid 
 type. 
 
 It may begin acutely with elevation of temperature, often con- 
 siderable, with headache, pain and swelling of the joints and glandular 
 swellings, the eruption coming out rapidly and in successive crops. As 
 an occasional serious complication Kaposi has described, under the 
 name erysipelas perstans faciei, a persistent, erysipelas-like swelling of 
 the face accompanied by high temperature, terminating in a large 
 proportion of cases in coma and death. In rare instances vesicular and 
 bullous eruptions, at times hemorrhagic, occur, as observed by Besnier, 
 Kaposi, Hallopeau and others. Albuminuria, with or without ursemic 
 symptoms, has been noted by Crocker, Sequiera, Danlos, and other 
 observers. A_ large proportion of the acute cases terminate fatally, 
 fifty per cent, of the deaths being due to pneumonia 
 
 Etiology. — According to the statistics compiled by the American 
 Dermatological Association, it comprises considerably less than one- 
 half of one per cent, of all diseases of the skin ; and according to the 
 same statistics is only a little more frequent than lupus vulgaris. In 
 the author's experience, however, it is decidedly more common than 
 the latter. It is unknown in infancy and quite infrequent in childhood 
 and old age ; it occurs most commonly between the ages of twenty and 
 forty. Women are much more frequently affected than men, the 
 proportion of cases in the former as compared with the latter being 
 as two to one. In a considerable proportion of cases the peripheral 
 circulation is sluggish, as evidenced by lividity of the hands, feet and 
 ears, particularly noticeable in cold weather, the so-called chilblain 
 circulation. It has been observed to follow other diseases of the skin 
 usually of an inflammatory character, such as seborrhceic dermatitis, 
 erysipelas and variola. In some instances prolonged exposure to the 
 rays of the sun seems to have been the exciting cause ; a very 
 marked example of this has very recently been under the author's 
 observation. 
 
 Since Besnier first called attention to the fact that in a large pro- 
 portion of cases more or less decided evidences of tuberculosis are 
 present, its etiological relationship to that malady has been, and still 
 is, the subject of much discussion. That symptoms of tuberculosis 
 are present in a very large proportion of the cases of lupus erythe- 
 matosus is abundantly proved by the statistics of Boeck, Roth and 
 others. Of 250 cases collected by Roth 185, or seventy-four per cent., 
 exhibited tuberculous disease of glands, bones, the lungs or other 
 
362 DISEASES OF THE SKIN 
 
 viscera. Its association with other cutaneous diseases commonly re- 
 garded as tuberculous, such as the papulonecrotic tuberculide, has been 
 repeatedly observed. On the other hand, Jadassohn, Kern, and others 
 have reported cases of erythematous lupus, dead from a variety of 
 diseases in which the autopsy failed to disclose the slightest evidence 
 of tuberculosis. The absence of the histological features usually pres- 
 ent in tuberculous tissues ; the failure to find the tubercle bacillus in 
 the lesions ; the almost invariably negative results of animal experi- 
 mental inoculation lead those who believe it a tuberculous disease to 
 adopt the view that it is not a bacillary affection, but one due to the 
 toxins produced by tubercle bacilli in foci more or less remote from 
 the eruption. 
 
 Very recently a number of investigators, among them Arndt, 
 Hidaka and Friedlander, by employing antiformin and special stains, 
 have succeeded in finding bacilli which morphologically and tinc- 
 torially resemble the bacillus tuberculosis; but neither Arndt nor 
 Hidaka regards this finding as conclusive proof of the tuberculous 
 character of the disease. In the past few years a number of successful 
 experimental inoculations have been recorded ; and quite recently 
 Bloch and Fuchs have reported the production of tuberculosis in 
 guinea-pigs by inoculation with pieces of tissue taken from four typical 
 cases. 
 
 The suggestion of Galloway and MacLeod that it may be due to 
 various toxins of unknown nature has as yet little of ascertained fact 
 to support it. 
 
 Although the results of the most recent bacteriological studies lend 
 much support to the view that it is a tuberculous disease, its etiology 
 must still be regarded as sub judice. 
 
 Pathology. — The most generally accepted view concerning the 
 pathology of lupus erythematosus is that it is a chronic inflammatory 
 process produced by toxic substances of tuberculous origin. As the 
 author has previously pointed out elsewhere, its occasional associa- 
 tion with vasomotor phenomina characteristic of Raynaud's disease is 
 very suggestive of the presence of a toxin which affects primarily the 
 blood-vessels. 
 
 The histological picture varies considerably according to the stage 
 of the disease, and this probably accounts in large part for the differ- 
 ences in the findings of those who have studied its histopathology. 
 The primary and principal changes are situated in the papillary and 
 subpapillary portions of the corium. The vessels and capillaries are 
 markedly dilated, filled with blood and surrounded by dense, usually 
 well-circumscribed, areas of round cells, chiefly lymphocytes, which in 
 the acme of the disease may extend to the deepest part of the corium. 
 The sebaceous and sweat-glands are often surrounded by a similar 
 exudate, a feature, which along with the comedo-like plugs filling the 
 mouths of the follicles, led the earlier observers to attribute a special 
 share in the malady to the sebaceous glands. A few instances have 
 
INFLAMMATIONS 363 
 
 been reported in which giant-cells were noted, but this is altogether 
 exceptional. Unna asserts that the cells which compose the exudate 
 are, in the earliest stages of the lesions, plasma cells ; he likewise 
 describes as " central canalization," a system of irregular tubes winding 
 through the cell areas to which he attributes special significance. 
 
 There is oedema of the corium, with swelling of the collagen fibres, 
 and dilatation of the lymph-spaces. 
 
 Most authors speak of enlargement of the sebaceous glands with 
 increased secretion, but others regard this as an error of observation, 
 the glands of the nose and cheeks, the regions most frequently attacked, 
 being normally very large and active. 
 
 In the atrophic stages various degenerative processes appear. The 
 cells of the exudate undergo a degeneration which has been variously 
 interpreted as fatty, colloid, hyaline, etc. According to Holder this 
 degeneration is peculiar in that it does not affect the cells en masse, 
 but individual cells scattered here and there. 
 
 Among the most characteristic changes are those which affect the 
 elastic tissue. In the papillary and subpapillary portions of the corium 
 the elastin fibres become somewhat swollen, less sharply defined than 
 normal, and later are transformed into acidophile granular masses 
 (collastin), or basophile fibres (elacin), the former sometimes almost 
 completely replacing the collagen fibres of the papillae. In the areas 
 occupied by the cell infiltrate the elastic tissue has completely disap- 
 peared. Both the sebaceous and sweat-glands undergo atrophy, with 
 diminished or entirely suppressed excretion (Fig. 124). 
 
 The changes in the epidermis are secondary to those in the corium, 
 and vary somewhat according to the age of the lesion. There is a more 
 or less marked hyperkeratosis, and numerous horny plugs fill the 
 dilated mouths of many of the follicles and depressions in the rete, 
 unconnected with the follicular openings. At the acme of the malady 
 there is usually a moderate acanthosis, but later the rete is thinned 
 and the cells of the lowest layers show more or less degeneration. 
 
 Diagnosis. — The appearance of a well-developed patch of lupus 
 erythematosus of the ordinary discoid type is so characteristic that it 
 is not readily mistaken for any other affection. It may at times be 
 confounded with seborrhceic dermatitis, but it differs from that dis- 
 ease by its bluish-red or dusky-red color, by the dry adherent scales 
 which cover its surface, unlike the loose fatty scales characteristic of 
 the seborrhceic affection, and above all by the peculiar cicatricial 
 atrophy of the central portion of the patches. It may resemble lupus 
 vulgaris of the type described by Leloir as lupus vulgaris erythema- 
 todes ; but there are no milium-like yellowish puncta in the border 
 of the patches such as are to be found in that disease. 
 
 Occasionally there may be considerable resemblance between a 
 patch of erythematous lupus of the infiltrating type and a patch of the 
 superficial, non-ulcerating nodular syphiloderm ; but the latter is more 
 distinctly nodular, is often crescentic in shape, spreads more rapidly, and 
 
364 
 
 DISEASES OF THE SKIN 
 
 never presents the parchment-like atrophy characteristic of the former. 
 Quite exceptionally there may be an unusual amount of scaling, 
 so much so that it may bear a superficial resemblance to psoriasis, but 
 the latter disease is never followed by scarring, almost invariably 
 a sequel of erythematous lupus. The telangiectic form described by 
 Crocker may be mistaken for rosacea, but there are no papules and 
 pustules such as accompany that affection. Lupus erythematosus 
 affecting the scalp is to be distinguished from alopecia areata by the 
 
 " ; «i 1 ***** **^* 
 
 R 
 
 Fig. 124. —Lupus erythematosus. R, round-cell exudate; c, collastin (degenerated elastin) ; 
 
 h. horny plug in mouth of follicle. 
 
 presence of the red and infiltrated border which surrounds the bald 
 patches, and by the scarring which always follows it. 
 
 Prognosis. — Lupus erythematosus is usually a very chronic affec- 
 tion and extremely rebellious to treatment. In superficial cases of 
 recent origin much may be accomplished by judicious persevering 
 treatment. In rare cases it may disappear spontaneously, leaving 
 very little trace of its existence, but as already mentioned relapses in 
 such cases are common. When the patches are at all infiltrated a 
 cure is always a matter of prolonged treatment, and even under the 
 most favorable conditions a certain amount of scarring is certain to 
 
INFLAMMATIONS 365 
 
 follow. Even with the cure of existing patches there is no certainty 
 that new ones will not appear either in the immediate neighborhood 
 of the old ones or in new regions. In the acute disseminated form, 
 fortunately rare, the prognosis is always serious, since a fatal termina- 
 tion is a frequent occurrence. 
 
 Treatment. — The patient's general health should, on general prin- 
 ciples, be carefully looked after, endeavoring to correct whatever is 
 found amiss. Tea, coffee, alcoholic beverages of every kind, condi- 
 ments, hot soups, or other articles of food which tend to increase facial 
 hyperemia should be forbidden or greatly restricted. Exposure to 
 the direct rays of the sun should be carefully avoided. The author is 
 quite convinced that this is decidedly injurious. 
 
 As is always the case in intractable diseases, a host of remedies, 
 both internal and external, have been advised in this affection ; and it 
 must be admitted that most of them are of more than doubtful efficacy. 
 Among the internal remedies, arsenic, iodide of starch, iodide of potas- 
 sium and phosphorus have been employed with asserted curative effect, 
 but ample experience has proved their uselessness to control the malady 
 in any appreciable degree. There are a few drugs, however, which 
 seem to exert a favorable influence in certain types of the disease and 
 these are quinine, salicin and the salicylates. Quinine should be 
 given in considerable doses, not less than twenty to twenty-five grains 
 (1.30 to 1.60) per diem; the salicylates and salicin in quantities of not 
 less than one drachm (4.0) a day. 
 
 In the author's experience these remedies are useful chiefly in the 
 superficial or recent cases, and in these they often produce a decided 
 diminution of the hyperemia. Crocker thought he obtained a similar 
 result from the internal administration of ichthyol, in five-grain (0.32) 
 doses, three times a day. In the acute form trial should be made of 
 quinine in large doses. The choice of the local remedies to be em- 
 ployed must depend a good deal upon the type of the disease. In 
 superficial patches with decided hyperemia and little infiltration, mild 
 lotions, such as the calamine lotion, or the lotion of sulphate of zinc and 
 sulphuret of potash, five to fifteen grains (1.0 to 0.32) of each to the 
 ounce (32.0) of water, as advised by Duhring, will often be found more 
 effective than stronger applications. Ninety-five per cent, alcohol, 
 freely and frequently mopped on, as recommended by the younger 
 Hebra, is likewise a useful lotion, lessening the hypersemia decidedly. 
 When the patches are irritable, as happens occasionally, a saturated 
 solution of boric acid in water may be used with good effect for a time. 
 In the author's hands no application has proved quite so effective in 
 superficial and recent cases as a solution of ichthyol in water, thirty 
 per cent, to fifty per cent., painted on with a camel's-hair brush twice 
 a day. This solution dries into a smooth brown varnish which is 
 readily removed with warm water. If its color makes it impracticable 
 to have it on during the daytime, it may be applied at bedtime and 
 removed in the morning with a sponge and hot water. Unna recom- 
 
366 DISEASES OF THE SKIN 
 
 mends a ten-per-cent. mixture of ichthyol in collodion, but this is no 
 more effective than the aqueous solution and is decidedly less agreeable 
 to use. 
 
 In the more sluggish cases, with some infiltration, more stimulating 
 applications may be used. Daily frictions with green soap or the 
 tincture of green soap are useful ; if these produce any considerable 
 inflammatory reaction they should be suspended for a few days and the 
 calamine lotion or a lotion of boric acid applied. Salicylic acid in collo- 
 dion, two per cent, to three per cent., or resorcin in the same propor- 
 tions, may be painted on the patches every day or every second day. 
 The resorcin collodion should be used with some care, since it occasion- 
 ally produces an unexpected amount of inflammation. The author 
 has recently employed with much benefit in cases with considerable 
 infiltration a three per cent, solution of salicylic acid in seventy per 
 cent, alcohol, mopping it on freely twice a day until decided desqua- 
 mation is produced ; it should then be intermitted for a few days and 
 resumed later. Hollaender recommends the daily painting of the patches 
 with tincture of iodine in conjunction with the internal administration 
 of quinine, 7y 2 grains (0.5) three times a day. The iodine is continued 
 for five or six days, when it is suspended until the crust which it has 
 produced peels off; the application is then resumed. Hollaender 
 claims a specific effect for this treatment ; it sometimes answers very 
 well, but it also frequently fails. When the disease is stationary, show- 
 ing little tendency to extend, and when it has failed to respond to milder 
 methods of treatment, the superficially acting caustics may be cau- 
 tiously used. One of the best of these in the author's experience 
 is trichloracetic acid, which should be lightly brushed over the surface 
 of the patches once a week or every ten days, the frequency of the 
 application depending upon the effect produced. Pure carbolic acid 
 may be applied every ten days, as suggested by George Henry Fox, 
 or a mixture of equal parts of carbolic acid and camphor, as recom- 
 mended by Crocker. 
 
 Freezing with carbon dioxide " snow " (solid carbon dioxide) is 
 a very satisfactory method of treating " fixed " patches of moderate 
 size. The duration of the application of the snow varies from twenty 
 to forty seconds, being governed by the amount of infiltration present. 
 The cosmetic results of such treatment are usually much superior to 
 those obtained by other caustic applications. Destructive caustics, 
 such as arsenic paste and pyrogallol, are advised at times, but these, in 
 the author's opinion, should rarely if ever be used, since they are likely 
 to produce as much disfigurement as the disease itself, if not more. 
 
 The X-ray, the Finsen light and radium have been employed with 
 beneficial results, but their effect is somewhat uncertain; at times 
 they not only fail to produce improvement, but actually aggravate the 
 disease. In employing these agents it is always well, in view of the 
 uncertainty of the results, to expose a small area at first, until some 
 definite idea of their effect is obtained, before applying them to the 
 whole patch. 
 
INFLAMMATIONS 
 
 367 
 
 Quite recently the high-frequency current has been used with 
 asserted excellent effect in a considerable number of cases. 
 
 PELLAGRA 
 
 Synonyms. — Mai de la rosa ; Mai del sole; Lombardy leprosy; Fr., 
 Pellagre ; Erytheme endemique. 
 
 Definition. — A chronic endemic disease characterized by an ery- 
 thema chiefly of exposed parts with gastro-intestinal and nervous 
 symptoms. 
 
 First observed and described in Spain by Casal in the early part 
 of the eighteenth century, it spread to Italy, where it assumed enor- 
 mous proportions in the course of years ; to the south of France ; to 
 Roumania, where it became very prevalent ; and to other countries of 
 southeastern Europe. In recent years it has acquired a special inter- 
 est for the medical profession and health authorities of the United 
 States, where it has been found to be widely distributed, being espe- 
 cially prevalent in the Southern States. 
 
 FlG. 125.— Pellagra. 
 
 Symptoms. — The early stage is usually marked by languor, head- 
 ache, vertigo, loss of appetite with gastro-intestinal symptoms, such 
 as pain or uneasiness in the epigastrium and abdomen and diarrhoea, 
 or diarrhoea alternating with constipation. Following these symptoms 
 or coincidently with them an erythema resembling sunburn rather 
 suddenly appears upon exposed parts, such as the back of the hands 
 (Figs. 125 and 126), stopping abruptly at the wrist, upon the tops 
 of the feet, and upon the legs in those who go barefoot, and less 
 frequently about the neck, where it may occur as a band two or three 
 inches wide, the so-called pellagrous collar. The backs of the hands 
 are dusky-red, more or less swollen, and in the severe cases covered 
 with vesicles and blebs ; in the latter case there is often quite severe 
 burning pain. This dermatitis is usually made much worse by ex- 
 posure to the sun. These symptoms usually appear in the early spring, 
 and after lasting for a period varying from two or three weeks to 
 
368 
 
 DISEASES OF THE SKIN 
 
 as many months gradually disappear ; the erythema fades, the skin 
 desquamates and after a time regains its normal appearance except 
 for a slight pigmentation, and the patient is apparently quite well. 
 
 The following spring these symptoms recur and are usually more 
 pronounced than in the first attack, and recovery is slower and less 
 complete. After two or three such seasonal recurrences the symp- 
 toms become continuous and more pronounced ; the skin on the back 
 of the hands is a reddish brown, thick, dry, rough, and scaly, and 
 the entire cutaneous surface is more or less discolored, harsh, dry, 
 and finely desquamating ; diarrhoea becomes more profuse and less 
 controllable ; there is a marked burning of the mouth and tongue, 
 
 Fig. 126. — Pellagra. Same patient as Fig. 125. 
 
 the latter dry and smooth and sometimes superficially ulcerated. The 
 nervous symptoms likewise become more pronounced ; exaggerated 
 tendon reflexes, muscular tremors, convulsive movements of the ex- 
 tremities, occasionally epileptiform convulsions, paralyses, and ocular 
 symptoms such as ptosis, amblyopia, diplopia are some of the symp- 
 toms referable to the nervous system. Usually the patient is more 
 or less melancholic and frequently exhibits a decided tendency to 
 suicide, especially by drowning; at other times he becomes maniacal. 
 
INFLAMMATIONS 369 
 
 With the progress of the malady the skin on the back of the hands, 
 instead of being thickened, becomes atrophied — it is thin and shriv- 
 elled ; there is profuse diarrhoea, and the patient is no longer able 
 to control the bladder and bowels ; he becomes greatly emaciated 
 and stuporous and finally dies after a period varying from two to 
 ten or more years. 
 
 Exceptionally the disease runs an acute course with high tempera- 
 ture, extreme prostration, delirium, with stiffness of the muscles of 
 the neck and occasionally opisthotonos. Such cases are observed 
 much more frequently in regions in which the malady has been re- 
 cently introduced than in those in which it has prevailed for some 
 time. Acute cases of this type have been observed with especial 
 frequency in the southern United States. 
 
 Etiology. — It is considerably more frequent in women than in men, 
 and occurs at all ages, although it is most common in adults between 
 the ages of twenty and fifty. It is far more frequent among the in- 
 habitants of the rural districts than among the dwellers in towns, 
 among the very poor and ill-nourished than among the well-to-do, 
 although, as observed in the United States, it also occurs among 
 the latter to a limited extent. Alcoholism and exposure to the sun 
 are predisposing causes. 
 
 The direct cause is as yet undetermined. For many years the 
 maize theory — the theory that it was in some way due to the use of 
 a diet the chief article of which was corn — numbered many sup- 
 porters. Corn was supposed to be deficient in some substance neces- 
 sary to proper nutrition, or to contain some toxic substance, either 
 normally or as the result of decomposition, which acted injuriously 
 upon the human economy (Lombroso). None of these suppositions, 
 however, has been satisfactorily proved, and it has been definitely 
 shown that the malady may occur in those who have not used a corn 
 diet. Recently the theory that it is an infection probably conveyed 
 by some insect has had supporters, and Sambon incriminates the 
 sand-fly or buffalo gnat, a species of simulium, as the carrier of the 
 infecting agent, but the correctness of this theory has not yet been 
 demonstrated. Quite recently Alessandrini and Scala have expressed 
 the opinion that silica in colloidal solution in drinking water may be 
 instrumental in its production. Experiments recently conducted by 
 Goldberger and others of the United States Public Health Service 
 would seem to have demonstrated the dietary origin of the affec- 
 tion. Goldberger and his associates believe it to be the result of the 
 use of an unbalanced diet, one largely composed of carbohydrates, 
 and have apparently proved the correctness of this view by produc- 
 ing symptoms resembling those of pellagra by the experimental em- 
 ployment of such a diet in a number of individuals. 
 
 Pathology. — The pathological changes in the skin present nothing 
 characteristic and are chiefly indicative of inflammation. The epi- 
 dermis is at times thinner than normal, at others thickened with con- 
 siderable hyperkeratosis, and there is a pronounced increase in the 
 24 
 
370 
 
 DISEASES OF THE SKIN 
 
 pigment in the lower cells of the rete. In the corium there are peri- 
 vascular collections of round cells with some oedema of the collagen 
 fibres. Raymond, who specially looked for alterations of the nerves 
 in the skin, was unable to find any trace of such change, but recently 
 Corlett and Schultz have described inflammatory and degenerative 
 changes in the nerves of the corium which they believed to be primary. 
 In sections from a case of chronic pellagrous dermatitis, which 
 the author had the opportunity to study through the courtesy of 
 Professor Allen J. Smith, there was moderate hyperkeratosis with 
 
 4*S3Lf*l< -* 
 
 Fig. 127. — Pellagrous dermatitis. Extremely marked acanthosis; inflammatory exudate in corium. 
 
 parakeratosis and an enormous acanthosis, the rete extending in long, 
 branched and anastomosing processes some distance down into the 
 corium. The papillary body and the subpapillary portion of the corium 
 were occupied by an abundant exudation of lymphoid cells with a 
 limited number of plasma cells (Fig. 127). 
 
 The intestinal mucosa is hypersemic, and ulceration is not uncom- 
 mon. Chronic degenerative changes, particularly fatty degeneration, 
 with marked pigmentation, are present in the viscera. Inflammatory 
 and degenerative changes are likewise present in varying degree in 
 
INFLAMMATIONS 371 
 
 the central and peripheral nervous systems of such a character as 
 to suggest their toxic origin. 
 
 Diagnosis. — The cardinal symptoms of pellagra are : first, a der- 
 matitis situated on the exposed parts of the skin ; second, gastro- 
 intestinal symptoms, usually with diarrhoea ; and, third, mental symp- 
 toms, more especially melancholia. These, together with their mark- 
 edly seasonal recurrence, usually make the disease readily recogniz- 
 able, particularly in regions where it is known to be endemic. Not 
 all these symptoms are invariably present, however, and when mild 
 or ill-defined, the real character of the affection may be easily over- 
 looked. When the mental symptoms are pronounced and the cutane- 
 ous and gastro-intestinal symptoms inconspicuous, it may readily be 
 mistaken for ordinary insanity. 
 
 Prognosis. — In mild cases under favorable circumstances recovery 
 frequently takes place ; in severe and advanced cases death is the 
 rule, the average duration of the malady being about five years, al- 
 though it may last much longer. In acute cases with extreme pros- 
 tration and high temperature, death almost invariably takes place 
 within a short time. 
 
 Treatment. — The only treatment found thus far to be of service 
 is dietetic and hygienic. The patient should be given an abundance 
 of nutritious, easily digested food of a varied character; he should 
 take fresh meat, milk, eggs, and fresh vegetables, particularly fresh 
 (or dried) peas and beans, which Goldberger in the studies already 
 referred to found especially useful. It is very doubtful whether any 
 drug exerts any appreciable effect upon the course of the disease, 
 although arsenic is regarded by a number of authorities as having 
 some value. 
 
 For the dermatitis, which when acute may be accompanied by 
 considerable pain of a burning character, soothing washes and oint- 
 ments, such as are useful in other forms of dermatitis, may be em- 
 ployed. Exposure to the rays of the sun should be avoided in the 
 acute attacks, since the injurious effects of these upon the skin have 
 been abundantly demonstrated. 
 
 ACRODYNIA 
 
 Synonyms. — Mai des pieds et des mains ; Erytheme epidemique. 
 
 Definition. — An acute epidemic disease characterized by erythema 
 of the extremities accompanied by gastro-intestinal and nervous symp- 
 toms. 
 
 This affection, which bears a considerable resemblance to pellagra, 
 was first observed in Paris in 1828, where it occurred as a widespread 
 epidemic which extended to other parts of France. Epidemics and 
 sporadic cases have likewise occurred in Belgium, the Crimea, Con- 
 stantinople, and Mexico, principally in garrisons, hospitals, and 
 prisons. 
 
 Symptoms. — It usually begins with nausea and vomiting, fre- 
 
372 DISEASES OF THE SKIN 
 
 quently accompanied by diarrhoea, the last often continuing to the 
 end of the attack. After five to ten days, pricking and burning of the 
 hands and feet, particularly of the palms and soles, appear, followed 
 by an erythema with some cedema, or, less frequently, vesicles and 
 blebs, which extends to other parts of the extremities and exception- 
 ally to portions of the trunk; there is likewise a conjunctivitis with 
 transient swelling of the face. Hyperesthesia and burning appear 
 upon various parts of the skin, which may at times be so severe as 
 to be almost insupportable; later anaesthesia may replace the hyper- 
 esthesia, and in severe cases there may be painful muscular contrac- 
 tions and paralysis. The skin becomes thick and scaly and brown 
 or blackish, especially in those regions, such as the folds of the axillae, 
 the nipples, and the groins, where pigment is normally present. The 
 duration of the affection is usually from three to four weeks, but 
 relapses, which are not infrequent, may prolong it to two or three 
 months. Recovery, although slow, is the rule, except in the old and 
 feeble, in whom it may terminate fatally. 
 
 Etiology. — Owing to the resemblance of its symptoms to those of 
 pellagra, it is commonly believed to be due to some toxic substance 
 of unknown character in some article of food, but this is yet nothing 
 more than conjecture. 
 
 Treatment.— The treatment is altogether symptomatic and is to 
 be conducted on general principles. 
 
 TRYPANOSOMIASIS CUTIS 
 
 Synonym. — Sleeping sickness. 
 
 Definition. A chronic systemic disease of Central and Southern 
 
 Africa, due to infection by the Trypanosoma gambiense and other 
 varieties of trypanosoma, characterized by irregular fever, cutaneous 
 eruptions, extreme prostration, and stupor, ending in death. 
 
 Symptoms.— Infection takes place through the bite of the tsetse 
 fly, of which two varieties, Glossina palpalis and Glossina morsitans, 
 are known to serve as intermediate host for the trypanosome. In 
 a certain proportion of cases a more or less marked local reaction 
 follows in a few hours after the bite of the fly; redness and swelling, 
 accompanied by itching, burning, and a feeling of tension, appear at 
 the site of the bite, and after twenty-four hours an elevation about 
 the size of a dime, resembling to some extent a furuncle, forms, ac- 
 companied by swelling of the neighboring lymphatic glands. These 
 lesions, which are found usually upon the legs, neck, in the axillae, 
 and on the flanks, disappear after a few days, leaving a transient pig- 
 mentation. Exceptionally the inflammation is very severe, and is 
 accompanied by lymphangitis and high temperature. In the earlier 
 stages of the infection pustular and papular eruptions are common, 
 the latter itching intensely, especially in the negro. Transient ery- 
 thematous patches resembling erythema multiforme occur upon the 
 trunk and face; these frequently assume a circinate arrangement, 
 
INFLAMMATIONS 373 
 
 the rings often being several inches in diameter. According to Man- 
 son, erythema nodosum likewise occurs. Local oedemas, most notice- 
 able in the face and in the erythematous patches, are also of frequent 
 occurrence. These eruptions are of considerable diagnostic impor- 
 tance. r 
 
 Treatment.— Apart from local applications, such as lotions of 
 phenol, menthol, etc., for the relief of the pruritus, which is frequently 
 severe, the treatment is that of the general infection. Arsenic par- 
 ticularly atoxyl, and antimony are the most effective remedies. ' 
 
 EXANTHEMATA 
 
 Under the term exanthemata, or eruptive fevers, is included a 
 small but highly important group of diseases, all of which are dis- 
 tinguished by a well-marked and characteristic cutaneous eruption- 
 all are infectious, extremely contagious, and some of them rank among 
 the most dangerous disorders which attack mankind. All have the 
 remarkable property of conferring partial or complete immunity upon 
 the individual attacked, so that second attacks are infrequent or even 
 rare. In this group are included smallpox, chickenpox, scarlet fever 
 measles, and rubella, or rotheln. 
 
 SMALLPOX 
 
 Synonyms.-^-Variola ; Fr., Petite verole, Variole ; Ger., Rlattern 
 Pocken ; Ital., Vaiuolo ; Span., Viruela. 
 
 Definition.— An acute, infectious, and highly contagious febrile 
 disease characterized by an eruption which is successively papular 
 vesicular, and pustular (Plate XXII). 
 
 Symptoms.— A period of about twelve days elapses between in- 
 fection and the appearance of definite symptoms, but this period of 
 incubation may be considerably shorter or longer in exceptional cases. 
 During this time the patient is apparently in his usual health, but 
 in the final days there may be malaise, headache, and loss of appetite. 
 
 The stage of invasion, or initial stage, usually begins suddenly 
 and often violently, with a severe rigor or chilliness, violent head'- 
 ache, nausea, and vomiting, epigastric pain, and in about one-half the 
 cases severe lumbar and sacral pain ; the temperature rises rapidly to 
 103 or 104 , and may go to 105° or 106 in the following twenty- 
 four hours, when delirium, occasionally of a violent type, fre- 
 quently appears. In children drowsiness, stupor, or coma and con- 
 vulsions are not infrequent during this period. In the invasive stage 
 eruptions, prodromal rashes, frequently appear, usually about the sec- 
 ond day, which may be erythematous or petechial in type. The most 
 frequent is an erythematous eruption bearing considerable resemblance 
 to measles, from which it differs, however, in being less elevated, more 
 strictly macular; it may be more or less general in its distribution 
 or may be limited to certain regions, and is more frequently observed 
 in mild than in severe cases ; occasionally instead of resembling measles it 
 
374 DISEASES OF THE SKIN 
 
 may be decidedly scarlatinoid. Less frequently a petechial eruption ap- 
 pears during the initial stage, which is of much more serious import ; 
 while it may appear in cases which pursue a mild course, it much 
 more frequently occurs in the severe forms of the malady and may 
 be the precursor of a hemorrhagic eruption. It exhibits a special 
 predilection for the axillae, sides of the thorax and pectoral regions, 
 for the lower part of the abdomen, the groins, and inner surface of 
 the thighs, the axillary and crural triangles of Simon. The duration 
 of these prodromal eruptions, especially of the erythematous variety, 
 is usually quite short, and the frequency with which they appear 
 varies much ; in certain epidemics they are quite common, while in 
 others they are altogether exceptional. 
 
 The initial or invasive stage lasts three days, but it may be as 
 short as two days or as long as four. On the third day the variolous 
 
 K k 
 
 Fig. 128. — Smallpox. 
 
 eruption appears, first upon the face, especially upon the forehead at 
 the border of the hairy scalp, around the mouth, and upon the wrists, 
 whence it spreads in the course of from thirty-six to forty-eight hours 
 to the trunk and lower extremities. The earliest stage of the eruption 
 is a small red spot which increases in size and elevation until at the 
 end of twenty-four hours it has become a hard "shotty" papule. New 
 lesions continue to make their appearance for one or two days, or 
 exceptionally for three. With the appearance of the eruption the tem- 
 perature begins to decline, and in mild cases may go to the normal 
 or slightly below, and there is a decided amelioration of all the symp- 
 toms. According to Welch, this fall in the temperature, with improve- 
 ment in the general condition, does not take place in unmodified small- 
 pox until the second, third, or fourth day of the eruption. About the 
 third day of the eruption, the sixth day of the disease, small acuminate 
 vesicles (Fig. 128) with clear contents appear upon the summit of 
 
INFLAMMATIONS 375 
 
 the papules, which continue to enlarge for two or three days, until 
 they reach the size of a pea. When fully developed these present 
 a well-marked central depression, umbilication, which is characteristic 
 of the variolous eruption. Unlike the vesicle of an ordinary dermatitis, 
 the vesicle of smallpox is multilocular, so that a single puncture does 
 not evacuate the entire lesion. About the sixth day of the eruption, 
 the ninth or tenth of the disease, the contents of the vesicles become 
 turbid and shortly purulent ; the pustules are surrounded by an in- 
 flammatory halo and the skin is more or less swollen. When the erup- 
 tion is abundant the face may be so swollen that the patient is no 
 longer recognizable. W T ith the appearance of suppuration the umbili- 
 cation which characterized the vesicles disappears. Owing to the 
 somewhat later appearance of the eruption upon the trunk and lower 
 extremities, these changes in the lesions are correspondingly delayed 
 in these regions, so that the pustular stage may be fully established 
 upon the face while the trunk, thighs, and legs are still covered with 
 ■vesicles. Upon the palms and soles the eruption presents a special 
 aspect ; owing to the thickness of the horny layer of the epidermis, 
 the lesions are flat and deeply imbedded in the skin, are usually very 
 abundant, often confluent, and accompanied by severe pain. They do 
 not rupture, but dry into flat, dark-brown, adherent crusts, which 
 may remain imbedded in the horny layer for weeks unless forcibly 
 removed. 
 
 Coincidentally with the cutaneous eruption an eruption appears 
 upon the mucous membranes of the mouth, pharynx, nasopharynx, and 
 nose, larynx, and trachea, with difficulty in swallowing and hoarseness 
 or aphonia. The tongue may be covered with pustules and greatly 
 swollen (glossitis variolosa) ; the nose may be blocked with crusts 
 so that the patient can no longer breathe through it, and oedema of 
 the glottis may occur, threatening death from suffocation. Much less 
 frequently the eruption appears upon the vaginal and rectal mucous 
 membranes. Owing to the moisture of the parts, the eruption upon 
 the mucous membranes is whitish or grayish, and the vesicles through 
 maceration soon become superficial ulcers. 
 
 With the appearance of the pustular stage the fever rises again, 
 the rise sometimes preceded by a chill and headache, restlessness, and 
 delirium, often of a violent type, following. 
 
 With pustulation the eruption reaches its final stage, and about 
 three days later, the eleventh or twelfth day of the eruption, the period 
 of desiccation appears ; the pustules begin to dry up into yellowish 
 or brownish crusts, the inflammation and swelling of the skin rapidly 
 subside, the fever begins to decline, the restlessness and delirium dis- 
 appear, and the patient becomes more and more comfortable. After 
 the fall of the crusts, depressed red scars are left, which become quite 
 livid on exposure of the skin to cold ; later pigmentation appears in 
 many of them, which may persist for months. During the period 
 of desiccation the hair of the scalp, beard, and brows may be lost 
 
376 DISEASES OF THE SKIN 
 
 wholly or in part, but this alopecia is in most cases a transient one 
 except in those regions in which the pustules have been so deep-seated 
 as to destroy the hair follicles. The nails may likewise be lost, but 
 this is rare. 
 
 Numerous departures from the usual type as just described are 
 observed. The number of eruptive lesions may be very small, or 
 the eruption in rare cases may be absent altogether (variola sine 
 exanthemata). On the other hand, they may be so numerous as to 
 form a continuous sheet covering the face and extremities (variola 
 confluens). 
 
 In the confluent type the symptoms of the initial stage are com- 
 monly of a severe character ; the temperature quickly reaches a height 
 of 104 , 105 , or 106 , there is violent headache with nausea and vomit- 
 ing and severe lumbar and sacral pain. According to most authors, 
 the eruption appears earlier than in the ordinary type, eighteen to 
 twenty-four hours earlier (Curschmann), but Welch finds it develops 
 less rapidly. Instead of consuming two or three days to extend over 
 the body, it reaches its full development in twenty-four to thirty- 
 six hours, and is especially abundant upon the face and hands, where 
 it is accompanied by great swelling, and numerous lesions coalesce 
 to form large blebs filled with seropurulent fluid. Although confluent 
 upon the face, hands, and feet, the eruption usually remains discrete 
 upon the trunk even in the severest cases. 
 
 The eruption is likewise unusually severe upon the mucous mem- 
 branes ; the mouth, tongue, and pharynx are covered with a grayish 
 mass which extends upwards into the nasopharynx and nose and 
 downwards to the larynx and trachea ; there is parenchymatous inflam- 
 mation of the tongue, with extreme swelling ; necrosis of the carti- 
 lages of the larynx and oedema glottidis frequently occur. Inflamma- 
 tion of the parotid gland is common, and marked salivation may be 
 a prominent and annoying symptom. Conjunctivitis and corneal ulcer 
 are also among the complications which may be present, especially in 
 the pustular stage. 
 
 While the usual fall in the temperature occurs upon the appear- 
 ance of the eruption, it is much less marked than in the cases of the 
 ordinary type, it falls very slowly and begins to rise with the appear- 
 ance of pustulation. Coma or violent delirium is common, and un- 
 controllable vomiting and diarrhoea may persist throughout the 
 attack. 
 
 The usual termination of the confluent form is death, or if recov- 
 ery takes place convalescence is slow and often interrupted by numer- 
 ous sequelae, such as multiple abscesses, erysipelas, and occasionally 
 gangrene. Extreme scarring usually results, and permanent alopecia 
 may follow, owing to the depth of the pustules on the scalp. 
 
 Hemorrhagic smallpox occurs under two forms, viz., purpura vario- 
 losa and variola pustulosa hemorrhagica. 
 
 In purpura variolosa, in the latter part of the initial stage, which 
 
INFLAMMATIONS 377 
 
 does not differ in any essential particular from the initial stage of the 
 ordinary form, a scarlatiniform eruption appears upon the trunk and 
 extremities, leaving the face free, and upon this eruption petechias 
 and ecchymoses presently appear, which rapidly increase in numbers 
 and extent. The face becomes red and swollen, the lids discolored 
 by hemorrhage, the conjunctivae filled with effused blood, at times 
 sufficient to produce a marked chemosis. Severe retching and vomit- 
 ing occur, frequently with the voiding of bloody material ; cough with 
 serous and bloody expectoration is also common. The temperature 
 seldom reaches the height observed in the non-hemorrhagic forms and 
 the patient usually, but not always, preserves his consciousness and 
 intelligence until the end. This form is usually rapidly fatal, death 
 occurring in from three to five days, commonly before the appearance 
 of the variolous eruption. 
 
 In the second form, variola pustulosa hemorrhagica, the hemorrhage 
 takes place into the variolous lesions, appearing most frequently dur- 
 ing the vesicular stage, although it may occur at any stage of the 
 eruption. The hemorrhagic lesions usually appear first upon the lower 
 extremities, the vesicles being filled with a bloody fluid instead of 
 the usual clear serum ; in addition to the hemorrhagic vesicles and 
 pustules there may also be petechias and ecchymoses between them. 
 In this, as in the preceding form, purpura variolosa, bleeding may 
 take place from the mouth, nose, bowels, and bladder. While it usually 
 runs a somewhat longer course than the purpuric form, it is no less 
 fatal, and in the rare cases in which the patient survives, a protracted 
 convalescence follows. 
 
 VARIOLOID 
 
 As the consequence of a partial immunity, either natural or acquired 
 through a previous attack or vaccination, smallpox at times presents 
 great variations from the usual type ; to this modified form the term 
 varioloid is applied, although it is limited by some authorities to the 
 modified form occurring in vaccinated subjects. 
 
 The initial stage, or stage of invasion, may be decidedly longer 
 or shorter in varioloid than in the unmodified form ; it may last but 
 two days, or even exceptionally but one (Curschmann), or it may be 
 protracted to four or five. The symptoms of this stage, while usually 
 milder than in the ordinary form, may be quite as severe, but with the 
 appearance of the eruption the temperature undergoes a decided and 
 sudden fall to the normal, or even slightly below, and seldom goes 
 above this point again in mild cases, although there may be a slight 
 rise when the eruption becomes pustular if it is abundant. Erythema- 
 tous eruptions, such as have already been described, are much more 
 frequent in the initial stage of varioloid than in that of variola ; and 
 Curschmann was of the opinion that the more extensive such erup- 
 tions are, the less the development of the pocks which follow them. In 
 varioloid the eruption, contrary to what occurs in variola, does not 
 always begin upon the face, but may appear first upon the trunk ; it 
 
378 DISEASES OF THE SKIN 
 
 is often scanty, but may be quite abundant, even semiconfluent at 
 times. It may appear as a single crop, and usually reaches its full 
 development in a shorter time than the unmodified form ; it frequently 
 aborts in the vesicular stage, drying up before suppuration appears, 
 although up to this point it has undergone the usual development. 
 Occasionally after reaching the papulo-vesicular stage the vesicle dries 
 up and the papule remains as a small wart-like elevation (variolois 
 verrucosa) which may remain for a considerable time ; this form of 
 lesion is seen most frequently in the face. The period of desiccation 
 is usually short, and scarring is either altogether absent, the usual 
 rule, or very slight, although exceptions are observed. 
 
 Numerous complications and sequelae are observed in all forms of 
 smallpox except in the modified form, varioloid. Furunculosis, crops 
 of abscesses, phlegmonous dermatitis, erysipelas, and, in rare instances, 
 gangrene, are among those which may appear in the skin, the first two 
 being very common. An impetiginous eruption characterized by 
 scanty blebs filled with a dirty yellow fluid is common during the stage 
 of desiccation (Welch and Schamberg). Gangrene, when it occurs, 
 usually attacks the scrotum, and is a very grave complication, terminat- 
 ing fatally as a rule. Ulceration of the cornea with subsequent blind- 
 ness, chronic suppurative otitis media, with more or less impairment 
 of hearing, are likewise occasional sequelae. Pregnant women almost 
 invariably abort. 
 
 Etiology and Pathology. — Neither age nor sex exerts any appreci- 
 able influence upon the incidence of smallpox. It is decidedly more 
 frequent in the winter season than in the warm months. It is highly 
 contagious, and is acquired in the great majority of cases by direct 
 contact with a diseased individual or indirectly through contact with 
 infected clothing or other articles used by him. While direct or indi- 
 rect contact is the most frequent manner of its transmission, there is 
 apparently but little doubt that it may also be transmitted for some 
 distance through the air. It is most contagious during the period of 
 suppuration and desiccation, but is probably contagious at all periods 
 except the stage of invasion. 
 
 Numerous bacteria of various kinds are present in the pustules, 
 and in severe cases may also be found in the blood, but none of these 
 are to be regarded as other than secondary infections, having no etio- 
 logical significance. In 1892 Guarnieri described a protozoon found in 
 the lesions of vaccinia and smallpox, which he regarded as the direct 
 cause of the malady, and to which he gave the name cytoryctes vaccina ; 
 these findings were subsequently confirmed by Wasielewski, and more 
 recently, in large part, by Councilman, Magrath, BrinckerhofT, and 
 Tyzzer. Although it seems probable that this organism is the pri- 
 mary cause of the disease, further study and observation are still 
 necessary to definitely determine its significance. 
 
 The vesicle of smallpox is situated in the epidermis, beginning in 
 the upper layers of the rete. The epithelial cells become oedematous, 
 
INFLAMMATIONS 379 
 
 their protoplasm is transformed into a large-meshed reticulum (the 
 reticulating colliquation of Unna, the alteration cavitaire of Leloir), 
 and several such cells unite to form a multilocular vesicle filled with 
 a fluid which at first is clear, but later becomes purulent. Many of 
 the epithelial cells in the lower layers of the rete, which form the 
 bottom of the vesicle, are transformed into large round, oval, or pyri- 
 form bodies, two or three times the size of normal epithelial cells, 
 containing a large cavity in which are from two to a dozen or twenty 
 large round nuclei, the "ballooned" epithelium of Unna ; these changes 
 are followed by fibrinoid metamorphosis. The umbilication, which is 
 a characteristic feature of the smallpox vesicle, was formerly believed 
 to be due to its situation about a hair follicle or the mouth of a sweat- 
 duct which held down the centre, but the vesicles are not confined 
 to these localities. Auspitz and Basch thought the periphery swelled 
 more rapidly than the centre of the vesicle, so that the latter remained 
 below the level of the former; Unna's explanation of the umbilication 
 is in effect the same. 
 
 Marked dilatation of the vessels of the corium occurs and numerous 
 plasma-cells are present in the adventitia. After the fifth day all the 
 vessels of the cutis are dilated and there is an abundant exudation 
 of leucocytes, especially dense in the papillae, and extending upwards 
 between the cedematous and ballooned epithelial cells of the epidermis. 
 Important changes are found in all the viscera. 
 
 Diagnosis. — The disease with which smallpox is most frequently 
 and most readily confounded is chickenpox, and the differential diag- 
 nosis is not always easy, especially when it concerns the mild forms 
 of the former. In smallpox the eruption is preceded by high tempera- 
 ture, headache, backache, nausea, and vomiting lasting for three days ; 
 in chickenpox the eruption is frequently the first symptom of illness, 
 and the constitutional symptoms are as a rule mild, and may be so 
 slight as to escape notice altogether. In the former the eruption be- 
 gins as hard papules, which in the course of two or three days become 
 vesicles and later pustules ; in the latter the eruption is vesicular from 
 the beginning and the vesicles are comparatively thin-walled and 
 readily ruptured. The eruption of smallpox comes out in the course 
 of thirty-six to forty-eight hours, in one crop, while the eruption of 
 chickenpox comes out in successive crops for some days, so that suc- 
 cessive stages of the lesions may be present at the same time. The 
 lesions of smallpox require ten to twelve days for their complete evolu- 
 tion, while those of chickenpox run a comparatively rapid course, 
 drying up in the course of three or four days. Umbilication of the 
 lesions is the rule in smallpox, the exception in chickenpox, and when 
 it does occur in the latter it is usually ill-defined. 
 
 The lesions of the pustular syphiloderm are at times mistaken for 
 the pustules of smallpox, and vice versa, but the syphilitic eruption 
 is not preceded by a short and definite stage of invasion, practically 
 never exhibits a vesicular stage, and as a rule is not accompanied by 
 
380 DISEASES OF THE SKIN 
 
 marked elevation of temperature, although it must not be forgotten 
 that there are exceptions to this last; other characteristic symptoms 
 usually coexist with the eruption, such as mucous patches, condylo- 
 mata, and general adenopathy. The Wassermann reaction is also 
 a valuable aid in the differential diagnosis, but it should be remem- 
 bered that smallpox is just as likely to occur in a syphilitic as in a 
 non-syphilitic subject. 
 
 Smallpox may be at times mistaken for measles, either in the 
 period of invasion, when a morbilliform rash is sometimes present, 
 or in the early eruptive stage, when the papules are very numerous and still 
 small ; but the absence of coryza, conjunctivitis, and bronchitis, and the 
 more or less decided fall in temperature which occurs with or shortly 
 after the appearance of the eruption will serve to distinguish it from 
 the latter affection. 
 
 Impetigo contagiosa is occasionally mistaken for smallpox when 
 the latter is epidemic, but the absence of constitutional symptoms, the 
 usual limitation of the eruption to the uncovered parts of the skin, 
 in most instances the face, the very superficial character of the lesions, 
 which show a decided tendency to extend peripherally, are character- 
 istics which make the differential diagnosis easy. 
 
 Prognosis. — The prognosis is unfavorable at both extremes of life. 
 In infancy and childhood the mortality is very high ; in the epidemics 
 observed by Curschmann the mortality in children under ten years 
 of age was as high as fifty-eight per cent. Alcoholic subjects bear 
 the disease badly, and delirium tremens, a not uncommon complica- 
 tion in such, is usually fatal. Confluent smallpox is very dangerous, 
 and all the hemorrhagic forms are almost invariably fatal. In vario- 
 loid the prognosis is very favorable ; death is infrequent. 
 
 Treatment. — There is no specific for smallpox, and the treatment 
 must be conducted on general principles. The patient should occupy 
 a large, thoroughly ventilated room, and will usually be more com- 
 fortable if it is somewhat darkened. He should have an abundance 
 of easily digested and assimilable nourishment, and should be sponged 
 or bathed at intervals, especially when the temperature is high. In 
 confluent cases, especially during the stages of suppuration and desic- 
 cation, the continuous warm bath has been found of use, adding much 
 to the patient's comfort. A great many local remedies have been 
 recommended at various times for the prevention of scarring, but few 
 or none of these have any demonstrable effect. Moore recommended 
 the application to the face of a mask of lint soaked in iced water 
 and glycerin, an application which Schamberg finds greatly relieves 
 the itching and burning. Painting the face with tincture of iodine 
 has been advised; this measure seems to be of service occasionally 
 and should therefore be tried. The red-light treatment, which has 
 for its aim to completely exclude the actinic rays of light from the 
 room occupied by the patient, has been recently revived by Finsen, 
 who stated that suppuration was prevented when treatment was begun 
 
INFLAMMATIONS 381 
 
 before the fourth or fifth day ; other observers, however, have found 
 it without influence. 
 
 VACCINAL ERUPTIONS 
 
 Generalized Vaccinia, Vaccinia Generalisata. — Occasionally it hap- 
 pens that some days after vaccination, most frequently some time 
 between the fifth and tenth day, an eruption appears, most commonly 
 in successive crops, composed of lesions resembling the vaccine lesion, 
 and which pass through the same evolution — they are successively 
 papules, vesicles, and pustules. The number and distribution of the 
 lesions vary greatly ; there may be but a half dozen or less, limited to 
 the vaccinated arm and the neighborhood of the vaccine lesions, or they 
 may be very numerous, with a more or less general distribution, in 
 which event there may be some accompanying constitutional dis- 
 turbance for a short time. There is but little doubt that the great 
 majority of the cases of generalized vaccinia are due to auto-inocula- 
 tion, the vaccine virus being conveyed from the vaccine vesicle to 
 various parts of the skin by the patient's fingers or those of his 
 attendants. In the rare cases in which there are many lesions with 
 a general distribution, it is believed to be the result of systemic in- 
 fection with the vaccine virus. This form may resemble variola, but, 
 unlike that affection, is not preceded by an invasive stage and occurs 
 coincidently with vaccination. 
 
 In a certain proportion of cases vaccination is attended by a mor- 
 billiform erythema, which, beginning about the point of inoculation, 
 spreads over the arm and to the trunk and may become more or less 
 general ; instead of being coarsely macular like measles, it may be 
 diffuse, resembling scarlatina. It is usually of short duration, dis- 
 appearing in the course of a few hours, or at most after a day or two. 
 
 Occasionally erythema multiforme and urticaria are observed after 
 vaccination, usually appearing some time before the tenth day ; these 
 eruptions do not differ in any respect from the ordinary type. 
 
 Far more important, because more serious, are certain bullous 
 eruptions which occasionally follow vaccination after a variable pe- 
 riod, usually several weeks, sometimes a month or two. These in 
 most instances resemble in the character of the lesions and the course 
 of the eruption pemphigus ; less frequently they are multiform and 
 are made up of erythematous and vesicular patches together with 
 bullae. Bowen has reported a small series of six cases, all in children, 
 in which the symptoms resembled dermatitis herpetiformis, which 
 pursued a chronic course lasting from five or six months to two or 
 three years. More recently Howe has reported a series of ten cases, 
 all in adults, characterized by an extensive eruption of bullae appear- 
 ing a few weeks after vaccination ; all these ran an acute course of 
 some weeks, and more than half of them terminated in death. 
 
 The exact relationship of these bullous eruptions to vaccination 
 has not yet been definitely determined ; it is not known whether they 
 
382 DISEASES OF THE SKIN 
 
 are directly due to the vaccine virus or to some accidental con- 
 tamination with some organism not yet identified. The cases re- 
 ported by Howe present analogies with the cases of acute pemphigus 
 reported by Pernet and Bulloch which occurred in those exposed to 
 infection by decaying animal matter (vid. pemphigus). 
 
 In eczematous children it occasionally happens that vaccination 
 is followed by an exacerbation of a present eczema or by a recur- 
 rence of an old one, a fact which should be kept in mind when asked 
 to vaccinate a child with eczema or an eczematous history. There 
 is no evidence, however, that vaccination is ever the primary cause of 
 eczema. 
 
 In a few instances psoriasis has been observed to follow vacci- 
 nation, the eruption beginning in the vaccination scar, so-called vac- 
 cinal psoriasis (vid. psoriasis). 
 
 In rare instances syphilis and tuberculosis have been conveyed 
 by vaccination when humanized virus has been used, but such un- 
 fortunate accidents are no longer to be feared since the general em- 
 ployment of bovine lymph. 
 
 As a sequel of vaccination, particularly of imperfect vaccination, 
 a small to large pea-sized bright-red, very vascular tumor occasion- 
 ally appears at the site of the vaccination, which may last for months. 
 This growth is analogous to, if not identical with, the small neoplasm 
 known as granuloma pyogenicum (q. v.) 
 
 The recognition of these post-vaccinal eruptions presents no espe- 
 cial difficulties, and their treatment is precisely the same as that of 
 similar eruptions occurring independently of vaccination. Generalized 
 vaccinia is self-limited affection and requires no treatment beyond the 
 protection of the lesion from the patient's fingers. 
 
 SCARLATINA 
 
 Synonyms. — Scarlet fever ; Fr., Scarlatine ; Ger., Scharlach, Schar- 
 lachfieber. 
 
 Definition.- — An acute infectious and very contagious disease char- 
 acterized by fever, usually high, sore throat, and a bright-red puncti- 
 form eruption followed by abundant desquamation (Plate XXIII). 
 
 Symptoms. — The period of incubation of scarlet fever is shorter 
 and varies more than that of the other exanthemata. Its average 
 duration is from four to seven days, but Murchison's observations 
 led him to the conclusion that it might be only a few hours, and 
 in a considerable proportion of cases was not longer than forty-eight 
 hours. 
 
 The attack usually begins suddenly with chills, or in children with 
 convulsions, vomiting, sore throat, and fever. The temperature rises 
 rapidly, so that on the evening of the first day it frequently reaches 
 103 , 104 , or even higher, and the pulse is accelerated, frequently 
 out of proportion to the temperature, in children at times reaching 
 a rate of 140 to 160 beats per minute, a symptom of some diagnostic 
 
INFLAMMATIONS 383 
 
 value. The tongue is covered with a thick yellowish-white fur through 
 which swollen papillae project here and there as red dots; the uvula, 
 soft palate, and half-arches are bright red, the redness often punctate, 
 and the tonsils more or less swollen. 
 
 In the great majority of cases the eruption appears within the 
 first twenty-four hours ; much less frequently it is delayed until the 
 second day, and only rarely appears as late as the third. It appears 
 first upon the neck and chest and spreads rapidly to other parts of 
 the trunk face, and extremities. In the face it is frequently confined 
 to the forehead and cheeks, while the lower part of the nose, the 
 lips and chin appear pale by contrast; in mild cases the face may 
 escape altogether. It is, as a rule, a bright scarlet, but varies con- 
 siderably in intensity, and on close inspection is seen to be made 
 up of innumerable fine red dots which in well-marked eruptions may 
 after a time give way to a diffuse redness. The skin is hot and dry 
 and often somewhat swollen, particularly in the face about the lids 
 In well-developed eruptions it is quite common to see small red 
 papules situated about the hair follicles of the extremities, particularly 
 of the forearms and legs, and it is equally common to see numerous 
 minute vesicles filled with a turbid fluid on the abdomen, in the pubic 
 regions less frequently upon other parts of the trunk and upon the 
 extremities If the skin is rapidly stroked with the finger-nail or 
 with a pencil, a white line shortly appears which remains for a minute 
 or more (tache scarlatinale) , a symptom which is regarded by some 
 authorities as of some diagnostic value. 
 
 With the complete development of the eruption, the tongue first 
 becomes red at the tip and sides and then loses its coating, pre- 
 senting a bright-red surface covered with swollen papillae which has 
 been aptly compared with a ripe strawberry, the so-called " straw- 
 berry tongue," a very characteristic symptom and one rarely entirely 
 
 absent. . , - 
 
 Shortly after reaching its acme, the eruption begins to fade, hrst 
 upon the face and upper part of the trunk, then upon the extremities, 
 and in the course of three to four days it has completely disappeared, 
 its entire duration being in cases of average severity five to seven 
 days; in mild cases it may be very much shorter lasting only one 
 two, or three days, or even only a few hours. With the fading of 
 the eruption the temperature declines, the sore throat disappears, 
 and the patient's general condition gradually improves unless com- 
 
 plications appear. . . 
 
 With the fading of the eruption another very characteristic symp- 
 tom makes its appearance, viz., desquamation. This usually appears 
 first upon the neck and upper part of the chest and spreads thence 
 to other parts of the surface. It varies much in character and quan- 
 tity the former depending somewhat upon the region in which it 
 occurs, the latter upon the intensity of the eruption. As a rule it is 
 quite abundant and lamellar ir. character, the horny epidermis coming 
 
384 DISEASES OF THE SKIN 
 
 off in large flakes and even in sheets in certain regions. When the 
 eruption has been intense the horny epidermis of the hands and feet 
 may be cast off entire like a glove or sock, and in rare instances the 
 nails are lost. A very characteristic form of desquamation is that 
 which occurs upon the finger-tips, beginning beneath the free border 
 of the nails. In this situation very characteristic denuded patches 
 are often produced by constant picking at the loosened epidermis. In 
 the face and after mild eruptions the desquamation is apt to be rather 
 fine and bran-like and is often scanty. In rare cases of unusual mild- 
 ness desquamation may not appear at all. 
 
 The duration of the period of desquamation is indefinite and de- 
 pends a good deal upon the severity of the attack. In mild cases it 
 is often completed at the end of two weeks, but in severe cases it 
 may continue for five or six weeks ; occasionally it occurs a second 
 time or even oftener. 
 
 A more or less general adenopathy is the rule in scarlet fever,- the 
 greatest swelling usually occurring in the glands beneath the angle 
 of the jaw; suppuration of these glands is not at all uncommon in 
 severe cases. Schamberg found those in the inguinal region always 
 enlarged. 
 
 More or less marked departures from the usual symptoms and 
 course are common. In many instances the symptoms are of so 
 mild a character as to justify Sydenham's opinion of the malady, 
 viz., that it was only " the name of a disease." In such cases there is 
 only a moderate fever, with slight sore throat and an eruption so 
 little marked and so evanescent that it attracts little or no attention 
 from those about the patient, disappearing in the course of a single 
 day or even after a few hours. Many cases of this sort are only recog- 
 nized when a nephritis develops some weeks later, or when other 
 members of the family develop a well-marked attack. The desquama- 
 tion which follows is often slight and limited to certain regions, so 
 that it, too, may be overlooked unless searched for. 
 
 In marked contrast to these extremely mild cases are those in 
 which the eruption is intense, covering every portion of the surface, 
 often a dark or dusky red, or coarsely macular or blotchy, like measles, 
 accompanied by severe throat symptoms (scarlatina anginosa). The 
 tonsils and soft palate are intensely red and the former markedly 
 swollen, are soon covered with a grayish membranous exudate which 
 extends to the pharynx and upwards to the nose, from which escapes 
 a thin purulent discharge. The glands at the angle of the jaw are 
 enormously swollen and eventually suppurate or at times become 
 gangrenous, leading to extensive destruction of the deep tissues of 
 the neck. Symptoms of sepsis appear, and the patient frequently 
 perishes. 
 
 In cases fortunately rare, the infection is overwhelming from the 
 beginning (scarlatina maligna). The temperature rapidly mounts 
 to an unusual height, 107 , 108 , no°, and in rare instances even 
 
INFLAMMATIONS 385 
 
 higher; the patient soon becomes delirious or falls into coma; the 
 throat symptoms are of an unusually severe type, and the eruption 
 exhibits more or less irregularity, being frequently dark red and 
 patchy or hemorrhagic, and in some instances death takes place be- 
 fore the eruption appears. 
 
 In rare instances the eruption is of a dusky hue and shortly nu- 
 merous petechiae and ecchymoses appear with bleeding from the 
 gums, nose, kidneys, bowels, and bladder (scarlatina hemorrhagica). 
 The general symptoms are also of unusual severity ; the temperature 
 is high, there is great prostration and severe inflammation of the 
 throat. Such cases almost invariably terminate fatally. 
 
 Complications and sequelae of various kinds are common and fre- 
 quently add materially to the gravity of the disease. One of the 
 commonest complications, so common indeed that it might very well 
 be regarded as a symptom rather than a complication, is acute nephri- 
 tis. While this may appear at any time during the attack, it is seen 
 most commonly about the third week. The first symptom noted is 
 a peculiar pallor of the face with oedema of the lids, which is soon 
 followed by anasarca. The urine is at first increased in quantity, 
 but later is usually less than normal and contains varying, sometimes 
 large, amounts of albumen with red blood-cells and casts. Occasion- 
 ally symptoms of uraemia appear, such as vomiting, diarrhoea, stupor, 
 and convulsions. 
 
 Myocarditis, pericarditis, arthritis (scarlatinal rheumatism) are 
 also occasional complications. 
 
 One of the commonest sequels of scarlatina is a chronic suppura- 
 tive inflammation of the middle ear, which frequently persists for 
 many months. 
 
 Furuncles, abscesses, gangrenous dermatitis, and occasionally 
 eczema are some of the complications and sequelae which at times 
 affect the skin. 
 
 Etiology and Pathology. — Among the factors which predispose to 
 scarlatina, age occupies a prominent place. It is largely a disease 
 of childhood, although it is infrequent before the first year of life. 
 According to Murchison's statistics, which were based on a very large 
 number of cases, almost 150,000, almost ninety per cent, of the deaths 
 from scarlet fever occur in those under ten years of age ; the sus- 
 ceptibility rapidly decreases after puberty, and only 1. 57 per cent. 
 of the deaths occur in those over twenty-five. Race is likewise a 
 factor of some importance, the negro being much less susceptible 
 than the European. Surgical operations are occasionally followed 
 by an attack, the wound presumably serving as the port of entry 
 for the infection ; there is little doubt, however, that a certain propor- 
 tion of the cases of so-called surgical scarlatina are scarlatinoid erup- 
 tions of septic origin. 
 
 The malady is undoubtedly due to a living contagium, but the 
 causative organism has not yet been identified. It is contagious at 
 25 
 
386 DISEASES OF THE SKIN 
 
 all stages, although probably least so in the earliest, and is trans- 
 mitted by direct contact, by infected clothing or other articles which 
 have been in contact with the patient. The notion long entertained 
 by many, and not yet abandoned, that it is most contagious during the 
 period of desquamation, the contagion being carried by the scales, 
 has been shown to be without foundation. There is quite convincing 
 evidence that it is occasionally transmitted by milk, a number of epi- 
 demics having been traced to this source. 
 
 A large number of organisms of various kinds have been found 
 in the skin, discharges from the throat and ears, and in the blood, 
 but none of these has been shown to have a causal relationship to 
 the disease. Streptococci are present in a large proportion of cases 
 and have been believed by a number of investigators to be the pri- 
 mary etiological factor, but this opinion has been shown to be incor- 
 rect by more recent investigations. There is little doubt, however, 
 that this organism is responsible for many of the inflammatory and 
 suppurative complications which are so common. Mallory has re- 
 cently described a protozoon found in the skin of scarlet fever patients 
 to which he has given the name eye taster scarlatinalis, which he thinks 
 may have a causal relationship to the malady, but this still remains 
 
 to be proved. 
 
 As a rule there is a more or less marked leucocytosis, the degree 
 depending upon the severity of the attack; in severe and fatal cases 
 there may be 30,000 to 40,000 white cells (Kotschetkoff). An eosino- 
 philia is usually present after the first two or three days, which con- 
 tinues to increase until the disease reaches its acme ; exceptions, how- 
 ever, have been noted. 
 
 The eruption is almost entirely due to a tremendous hyperemia 
 of the skin, the histological changes being comparatively slight. Ac- 
 cording to Unna, there is an enormous dilatation of all the vessels of 
 the cutis, with a very slight cellular exudate. In the epidermis there 
 is a parakeratosis which leads to scaling, but the rete shows neither 
 oedema of its cells nor intercellular emigration of leucocytes. 
 
 Numerous pathological changes are present in the viscera which 
 are in part the result of high temperature and in part due to the 
 toxaemia. The kidneys show the changes characteristic of acute inter- 
 stitial nephritis. 
 
 Diagnosis.— Typical cases of scarlet fever usually present such 
 well-marked and characteristic symptoms that the diagnosis is made 
 without difficultv, but quite the reverse is true of the atypical cases 
 so frequently met with. The sudden onset with high temperature and 
 a disproportionately rapid pulse, vomiting, sore throat, and a red 
 punctate rash, form a collection of symptoms readily recognized, but 
 any one or several of these may be absent or so little developed as 
 to make a positive diagnosis most difficult at times. 
 
 The diseases with which it is most likely to be confounded are 
 
INFLAMMATIONS 387 
 
 recurrent scarlatiniform erythema, measles, rotheln, drug and anti- 
 toxin rashes, smallpox, tonsilitis, and diphtheria. 
 
 Recurrent scarlatiniform erythema, as its name indicates, resem- 
 bles scarlatina at times very closely, but the eruption is as a rule 
 diffuse and only very exceptionally punctiform ; constitutional symp- 
 toms are frequently absent, or if present are much less pronounced 
 than in the latter disease ; sore throat is rarely a symptom, and straw- 
 berry tongue is never present ; desquamation is usually abundant 
 and begins earlier than in scarlet fever. In most cases there is a dis- 
 tinct history of recurrences. 
 
 At times the eruption of scarlatina is blotchy and resembles measles, 
 but it appears much earlier than in that affection and the catarrhal 
 symptoms so characteristic of the latter are wanting. 
 
 While scarlatina and rotheln are usually very readily differentiated, 
 the distinction between the two may at times be attended by con- 
 siderable difficulty when the eruption of the latter is so abundant that 
 its macular character is lost ; but the high fever, the vomiting, and 
 sore throat which characterize the onset of the former are absent in 
 the latter. The eruption of scarlet fever begins upon the neck and 
 chest and is usually quite scanty in the face, while that of rotheln 
 begins and is most abundant in the latter region. Desquamation in 
 the latter is frequently altogether absent, and when it occurs is scanty 
 and bran-like. 
 
 The erythema, which is at times seen in the invasive stage of small- 
 pox, may be decidedly scarlatinoid, but its usually evanescent char- 
 acter and the appearance of the variolous eruption will serve to dis- 
 tinguish it from scarlatina. 
 
 Quinine, belladonna, and its alkaloid atropin, salicylic acid, and 
 its salts, antipyrin and sera employed therapeutically occasionally 
 give rise to a scarlatinoid erythema, but it lacks the punctiform char- 
 acter of the rash of scarlet fever and is, as a rule, but not invariably, 
 unattended by elevation of temperature and sore throat. 
 
 Anginose scarlatina is at times mistaken for diphtheria, but the 
 presence of the eruption and the absence of the Klebs-Loeffler bacillus 
 would exclude the latter. In the cases in which diphtheria is accom- 
 panied by an erythematous eruption the differential diagnosis may 
 be very difficult and can only be made after a most painstaking con- 
 sideration of all the symptoms. 
 
 Prognosis. — A guarded prognosis should be given in every case 
 of scarlatina, since even the mildest cases occasionally terminate un- 
 favorably. Unfavorable symptoms are high temperature with a very 
 rapid pulse, lividity and irregular development of the eruption, se- 
 vere inflammation of the throat with great enlargement of the cervical 
 glands, and nephritis in the early stages of the attack. In children 
 under five years of age the mortality is two or three times greater 
 than in older children. Hemorrhagic scarlatina is almost invariably 
 fatal. 
 
388 DISEASES OF THE SKIN 
 
 Treatment. — The patient should be isolated and kept in bed even 
 in the mildest cases, and should be put upon a milk diet, which should 
 be continued as long as the fever lasts. High temperature is best 
 and most safely controlled by repeated cold sponging or the tepid 
 bath ; in the treatment of hyperpyrexia the cold bath is the most effi- 
 cient measure. Antiseptic sprays and gargles, when the patient is 
 old enough to use the latter, are to be employed for the throat. Fre- 
 quent inunctions with cold cream, or lanolin and oil of sweet almond 
 or other bland ointment, are useful in allaying the heat and itching 
 which are at times most annoying. The various complications are to 
 be treated as they arise according to the principles of general medi- 
 cine. 
 
 The only efficient prophylactic measure is complete isolation. 
 
 MEASLES 
 
 Synonyms.— Rubeola ; Rougeole ; Ger., Masern; Ital., Morbilli. 
 
 Definition. — An acute contagious and infectious febrile disease, 
 occurring chiefly in children, characterized by lacrymation and photo- 
 phobia, coryza and cough, and a dull-red macular eruption (Plate 
 
 XXIV). 
 
 Symptoms. — After an incubation period of about ten days the 
 attack begins rather suddenly, as a rule, in very mild cases gradually, 
 with fever, sneezing, cough, lacrymation, and photophobia, and in 
 children sometimes with convulsions. The temperature rises rapidly, 
 reaching 102 to 104 in the evening of the day of the attack; on the 
 second day it commonly declines and may approach or reach the nor- 
 mal on the morning of the third day, but soon begins to rise again. 
 On the fourth day of the illness, exceptionally late on the third or 
 early on the fifth, the eruption appears, first on the sides of the neck 
 behind the angles of the jaw, and then on the face, where it is usually 
 most abundant and often confluent, with considerable swelling. It 
 begins as small red, slightly elevated macules, which may be dis- 
 tinctly felt upon passing the hand over the skin, and which as they 
 enlarge and increase in numbers frequently form crescentic patches. 
 This crescentic arrangement, which is, in the author's opinion, unduly 
 emphasized as a symptom in many text-books, is frequently absent. 
 With the increase in size and number of the macules the eruption 
 presents a coarsely macular or blotchy appearance which is quite 
 characteristic. With the appearance of the eruption the fever con- 
 tinues to rise, the catarrhal symptoms increase in severity, there is 
 increased cough with symptoms of bronchitis, and in a considerable 
 proportion of cases diarrhoea. The eruption spreads rapidly over the 
 trunk and extremities, reaching its full development in about thirty- 
 six hours after its first appearance, and at the same time the fever 
 reaches its acme, not infrequently io4°-io5°. Shortly after reaching 
 its acme the eruption begins to fade, first upon the face and then in 
 quick succession upon the trunk and extremities; the skin becomes 
 
INFLAMMATIONS 389 
 
 yellowish or brownish and usually remains so for some days, and 
 a branny desquamation appears, which lasts for five days to a week, 
 but in severe cases it may last for ten days, while in mild ones it 
 may be absent altogether. More or less itching usually accompanies 
 the eruption. 
 
 An eruption also occurs upon the mucous membranes of the mouth, 
 where it appears decidedly earlier than upon the skin, as early as 
 the second day. It consists of small, bright-red, irregularly shaped 
 spots situated upon the mucous membranes of the cheeks and lips, 
 which contain in the centre a minute bluish-white point. Although 
 these spots were first described by Flindt some years ago, they are 
 known as Koplik's spots since Koplik has more recently called at- 
 tention to them; they are regarded as pathognomonic of measles by 
 most authorities. 
 
 Like the other exanthemata, measles occasionally exhibits various 
 anomalies in its symptoms and course. At times the catarrhal symp- 
 toms are extremely mild or absent altogether, an anomaly seen, ac- 
 cording to Thomas, in young children especially. The eruption may 
 be absent, while the catarrhal symptoms present the usual features; 
 it is probably true, however, as Thomas has observed, that the "diag- 
 nosis of measles without exanthem is more often made than justified." 
 Anomalies are occasionally observed in the character, distribution, 
 and extent of the eruption. At times the eruption is purely macular, 
 the spots being quite smooth and imperceptible to the touch, morbilli 
 Iceves of the older writers, or, on the other hand, it may be quite un- 
 mistakably papular. Occasionally the eruption is associated with 
 miliary vesicles, and in rare cases bullae are present, pemphigoid 
 measles (Henoch, DuCastel, Baginsky, Zuhr, and others). Not very 
 infrequently the spots are bluish and do not disappear on pressure, 
 owing to a slight extravasation of blood. Variations in the size of 
 the macules are likewise observed ; at times they are unusually large 
 or very small, and in exceptional cases instead of being general the 
 eruption is limited to certain regions. In rare instances it may return 
 after it has begun to fade, the reappearance being accompanied by a 
 rise in temperature. 
 
 Exceptionally the infection exhibits unusual severity, all the symp- 
 toms being of an exaggerated character; the temperature reaches an 
 unusual height, io6°-io7°, the patient is extremely restless or may 
 be stuporous, and death may occur before the eruptive stage has 
 been reached. 
 
 The most malignant variety is the hemorrhagic or "black measles," 
 a form fortunately rare, most common in those who have been weak- 
 ened by previous disease or other causes. The attack presents un- 
 usually severe symptoms from the beginning ; the temperature is 
 high, the eruption is of a dusky hue or violaceous, petechiae and ecchy- 
 moses appear with hemorrhage from the nose, bowels, kidneys, and 
 bladder. 
 
390 DISEASES OF THE SKIN 
 
 Various complications may arise during the course of the disease, 
 the most frequent being those referable to the respiratory apparatus. 
 Bronchopneumonia is a very frequent and dangerous complication, 
 being the cause of death in a very large proportion of the fatal cases. 
 Diarrhoea, sometimes accompanied by tenesmus and bloody stools, is 
 an occasional complication. 
 
 Measles apparently at times predisposes to tuberculosis, since in 
 a considerable number of instances some form of the latter has been 
 observed to follow an attack of the former; acute miliary tubercu- 
 losis, disseminated lupus vulgaris (Du Castel, Adamson, Abraham, 
 and a number of others), lichen scrofulosorum (Haushalter), although 
 by no means of frequent occurrence, have been noted as sequelae. 
 
 Furuncles, cutaneous abscesses, and gangrene of the skin are occa- 
 sional sequellae affecting the skin. The last-named in rare instances 
 occurs about the mouth as noma or cancrum oris, an extremely fatal 
 affection ; much less frequently it attacks the prepuce or vulva. Otitis 
 media, although much less frequent than after scarlatina, is not very 
 uncommon after measles. 
 
 Etiology and Pathology. — Measles is highly contagious, the most 
 contagious of all the exanthemata. It is usually contracted by direct 
 contact with an infected individual, and very infrequently through 
 the intermediation of clothing, etc. ; indeed, the possibility of the 
 latter mode of transmission is denied by a number of authorities. It 
 occurs most frequently in childhood between one and ten years of age, 
 but is decidedly infrequent before the sixth month. Although with- 
 out doubt due to a living contagium, this has not yet been discov- 
 ered. A number of microorganisms have been found in the buccal 
 and nasal secretion by a considerable number of investigators, but 
 none of these has yet been satisfactorily shown to have a causal rela- 
 tionship to the malady. Goldberger and Anderson have recently suc- 
 ceeded in reproducing the disease in monkeys by inoculating them 
 with blood of human beings obtained in the late pre-eruptive stage, 
 or within twenty-four hours after the first appearance of the eruption ; 
 they have also determined the infectious character of the buccal and 
 nasal secretion. 
 
 Notwithstanding the striking appearance of the eruption, the path- 
 ological alterations in the skin are slight. According to Unna, there 
 is, in addition to the hyperaemia, a spastic oedema of the cutis, most 
 marked about the coil-glands, the follicles, and the muscles which lie 
 in widely dilated spaces. Neumann found a moderate perivascular 
 and perifollicular exudate of round cells in the papillae. In the macules, 
 however, Unna found no cellular exudate. In the epidermis the 
 granular layer disappears- in part, and the middle and upper portion 
 of the horny layer separates from the basal portion, producing des- 
 quamation. Catrin (quoted by Unna) has described certain colloid 
 changes in some of the deep epithelial cells. 
 
INFLAMMATIONS 391 
 
 Diagnosis. — The affection which resembles measles most closely 
 is rubella or rotheln, German measles. In the former the eruption 
 is preceded by a prodromal period of four days, marked by decided 
 fever and catarrhal symptoms, and is dark-red and coarsely macular ; 
 in the latter the prodromal period is often less than twenty-four hours 
 and the eruption may be the first sign of illness; the color of the 
 eruption is lighter than that of measles, and the macules are much 
 more uniform in size and more e\ T enly distributed. Koplik spots are 
 present in the former, absent in the latter. 
 
 Anomalous forms of scarlatina occasionally exhibit a coarse and 
 blotchy instead of the usual punctiform eruption, which may resemble 
 the eruption of measles, but the coryza, photophobia, and cough char- 
 acteristic of measles are absent. 
 
 Measles is occasionally mistaken for smallpox when the latter is 
 prevalent, but the associated coryza and cough, the soft "velvety" 
 feel of the maculopapules, quite unlike the hard, shotty feel of the 
 papules of the latter, are the distinguishing features. 
 
 Occasionally measles is mistaken for the macular syphiloderm, 
 and vice versa, but the latter is not preceded by a distinct prodromal 
 period and never presents catarrhal symptoms ; other characteristic 
 symptoms of syphilis are also likely to be present. 
 
 Certain drugs, such as copaiba, cubebs, antipyrin, and quinine, 
 and sera at times, produce morbilliform eruptions, but these are never 
 accompanied by coryza and cough. 
 
 Treatment. — The patient should be carefully isolated in a well- 
 ventilated and slightly darkened room, which should be kept at an 
 even temperature of 68° to 70 , and should be put to bed and kept 
 there until the temperature has been normal for some days ; in severe 
 cases, with well-marked bronchial or pulmonary symptoms, he should 
 be kept in bed at least a week after the disappearance of fever. Tepid 
 sponging and inunctions with cold cream, if there is much itching, 
 may be used with advantage. High temperature is best combatted 
 by the tepid bath. The diet should consist largely, if not exclusively, 
 of milk, especially in children. The various complications, such as 
 pneumonia and diarrhoea, are to be treated in the usual manner. 
 
 Prognosis. — -The prognosis in uncomplicated cases is very favor- 
 able, but owing to the frequency with which complications occur, espe- 
 cially pneumonia, the mortality is considerable ; it varies greatly, how- 
 ever, in different epidemics. In debilitated children and pregnant 
 women it is a dangerous malady. In institutions for children, such 
 as foundling asylums, hospitals, etc., the mortality is frequently very 
 high. Hemorrhagic measles is usually fatal. 
 
 RUBELLA 
 
 Synonyms. — Rubeola; German measles; Bastard measles; Fr., 
 Rougeole fausse ; Ger., Rotheln. 
 
 Definition. — An acute contagious, mildly febrile, epidemic disease 
 
392 DISEASES OF THE SKIN 
 
 occurring chiefly in children, characterized by a macular eruption. 
 
 Symptoms. — The period of incubation of rubella is much less defi- 
 nite than that of the other exanthemata. According to most authori- 
 ties, it is about twelve to fourteen days or longer, but it is not very 
 infrequently decidedly shorter. Thomas puts it at two and a half to 
 three weeks ; Griffith, in an epidemic in an institution, noted an in- 
 cubation of five days in one case, but in the greater number it was 
 about eleven days ; Michaelis was able to fix it with precision at nine- 
 teen days in two of his own children. 
 
 After a few hours of malaise, with mild catarrhal symptoms, such 
 as sneezing with cough and mild suffusion of the conjunctivae, or with- 
 out any premonitory symptoms, the eruption appears, usually upon 
 the face first, but occasionally upon the trunk and extremities, and 
 spreads rapidly to other regions. It consists of pin-head to pea-sized 
 pink or rosy round or oval spots, sometimes very slightly elevated, 
 but for the most part smooth and non-elevated, scattered about with- 
 out any definite arrangement, and usually discrete except upon cer- 
 tain regions, such as the face or upon parts subjected to pressure, 
 where it may become confluent, forming diffuse erythematous patches. 
 As Thomas has noted, it reaches its maximum upon different parts 
 of the body at different times, so that it may have already faded 
 upon the face while it is at its acme upon the trunk or extremities. 
 While some degree of fever is present in the majority of cases, the 
 temperature reaching ioi°-io2° in the evening, or exceptionally going 
 higher, it is absent in a large number of cases, this symptom varying 
 considerably in different epidemics. It commonly falls to normal 
 on the second day, but in rare cases may continue for some days. 
 The eruption reaches its maximum development upon the second day, 
 after which it rapidly fades, and by the third, or at most the fourth, 
 day has entirely disappeared, often leaving for a very short time a 
 faint brownish stain, and sometimes followed by a scanty branny 
 desquamation which lasts for a day or two. Itching is an occasional 
 symptom. There is usually sore throat of a mild character from the 
 beginning, with diffuse, exceptionally punctate (Griffith and others), 
 redness of the soft palate, half-arches, and inner surface of the cheeks. 
 The posterior cervical lymphatic glands are almost invariably en- 
 larged, forming a readily palpable and sometimes visible chain on 
 each side of the neck. 
 
 Not very infrequently the eruption presents anomalous forms. 
 Griffith recognizes two types of variation from the usual form, viz., 
 a morbilliform type which may resemble measles very closely, and 
 a scarlatiniform type which simulates the eruption of scarlet fever. 
 Complications are rarely observed. 
 
 Etiology and Pathology.— Rubella is chiefly a disease of children, 
 but is seldom seen before six months of age ; although infrequent in 
 adults, it is by no means rare. Thomas believes that the suscepti- 
 bility to it steadily diminishes after puberty, and at forty is almost 
 
INFLAMMATIONS 393 
 
 lost. It is probably contagious at all periods, but there is some dif- 
 ference among authorities as to the degree of contagiousness and the 
 period of its greatest infectiousness. The infecting organism is still 
 unknown. 
 
 The eruption is due to a capillary hyperemia of the papillae and 
 upper portion of the corium, which is occasionally followed by a 
 slight inflammatory exudate in some places and in some of the 
 macules (Thomas). 
 
 Diagnosis. — Rubella is to be distinguished from measles and scar- 
 latina, both of which it may resemble very closely. 
 
 It differs from measles by the absence or very short duration of 
 prodromal symptoms, the eruption often being the first sign of the 
 disease ; by the lighter color and much more uniform distribution of 
 the eruption; by the very much less pronounced character of the ca- 
 tarrhal symptoms, and by the absence of fever or its very trifling de- 
 gree when present, and its early disappearance. 
 
 Although the eruption of rubella in most instances is readily dis- 
 tinguished from that of scarlatina, it occasionally resembles the latter 
 to a marked degree, but the mild character of the early symptoms — 
 the absence of high fever, vomiting, severe sore throat with swelling 
 of the tonsils and enlargement of the glands at the angle of the jaw — 
 symptoms which characterize the latter, are usually sufficient to make 
 a positive differential diagnosis, although it occasionally happens that 
 the differentiation is extremely difficult. Desquamation in the former 
 is often absent and very slight and of short duration when present, 
 while it is often profuse in scarlet fever and almost never absent. 
 
 Prognosis and Treatment. — The prognosis is, in the vast majority 
 of cases, very favorable, although occasionally death occurs in feeble 
 or poorly nourished children. 
 
 The patient should be confined to a well-ventilated and uniformly 
 heated room and put upon a light diet for a few days, but may be 
 allowed to remain out of bed unless there is decided fever. Drugs are 
 seldom required. 
 
 VARICELLA 
 
 Synonyms. — Chickenpox ; Fr., Varicelle, Verolette ; Ger., Varicel- 
 len, Wasserpocken, Spitzblattern. 
 
 Definition. — An acute, contagious, mildly febrile disease occurring 
 chiefly, but not exclusively, in children, distinguished by a vesicular 
 eruption coming out in successive crops (see Plate XXII). 
 
 Symptoms. — The period of incubation exhibits considerable varia- 
 tion, but is in most cases about fourteen days, although Welch and 
 Schamberg observed an incubation of twenty-one days in one case 
 and Trousseau one of twenty-seven days. 
 
 Prodromal symptoms are in most cases absent, although the erup- 
 tion may be preceded by a period of malaise and mild fever lasting 
 a few hours or a day. In adults a prodromal stage of one day, much 
 
394 DISEASES OF THE SKIN 
 
 less frequently of two or even three days, is occasionally observed, 
 a fact often of much importance in differential diagnosis. In the 
 great majority of cases the eruption is the first symptom of illness 
 and makes its appearance upon the trunk first, as a rule, and shortly 
 afterwards upon the face, scalp, and extremities. It is usually most 
 abundant upon the trunk (Fig. 129) and least so upon the wrists, 
 hands, ankles, and feet. It is often sparse upon the face even when 
 abundant upon the trunk. Although it has been stated by some 
 authors that the palms and soles escape, differing thus from small- 
 pox, this is not strictly correct, since it does occur occasionally in 
 these regions, although much less frequently and much less abun- 
 dantly than in the latter affection. The lesions begin as small red 
 spots which quickly become vesicles filled with a fluid which is at 
 first clear, but later becomes turbid and in a limited number purulent. 
 The vesicles are surrounded by an inflammatory halo, are discrete 
 even when present in large numbers, and vary in number from a 
 dozen or two to many hundreds or thousands. More or less itching 
 is a common symptom and may be at times quite severe, so that 
 many of the vesicles are broken by scratching and covered with small 
 blood-crusts. The eruption appears in successive crops at intervals 
 of a day or two and continues to come out for four or five days, 
 or exceptionally for a week, and as a consequence all stages of the 
 lesions, vesicles, pustules, and crusts are present simultaneously. The 
 duration of the individual lesions is short ; after two or three days 
 they dry up into small brownish crusts which fall after a few days, 
 leaving small transient hypersemic spots, or when the lesions have 
 become well-developed pustules, as happens in a limited number, a 
 small permanent scar. A certain small number of the lesions are 
 abortive, appearing as small papules which soon vanish. 
 
 As a rule a few vesicles are seen upon the mucous membrane of 
 the hard and soft palate, the posterior wall of the pharynx, and ex- 
 ceptionally upon the tongue ; Hennoch observed them in one case 
 upon the conjunctiva and gums. 
 
 Along with the eruption some elevation of the temperature occurs, 
 from 99 to 101 , but occasionally it reaches a considerable height, 
 as much as io4°-io5°. The fever is usually of short duration, in 
 mild cases disappearing in twenty-four hours or less, and seldom last- 
 ing longer than two or three days in any case. 
 
 Chickenpox is rarely attended by complications or followed by 
 sequelae. As a fairly frequent occurrence, some of the vesicles spread 
 peripherally after the manner of those of impetigo, and may reach 
 the size of a coin (impetigo varicellosa, Welch and Schamberg). 
 
 Under the name varicella gangrenosa, Hutchinson some years ago 
 described a rare and at times grave complication. Instead of the 
 crust being cast off in the usual manner, ulceration occurs beneath 
 it, a blackish slough is formed, which after a time is cast off, leaving 
 a sharp-cut ulcer of -variable depth from a quarter of an inch to an 
 
INFLAMMATIONS 
 
 395 
 
 PlG. 129. — Varicella. 
 
396 DISEASES OF THE SKIN 
 
 inch in diameter. Or the vesicle, instead of crusting over, is trans- 
 formed into a bleb, sometimes with bloody contents, which after a 
 time becomes a slough. The number of lesions which undergo this 
 transformation varies greatly; when any considerable number are 
 thus affected there is pronounced constitutional disturbance, with a 
 decided rise in temperature, and death may follow with symptoms of 
 
 sepsis. . j. . u 
 
 Porter has reported a case in which the eruption, widely distrib- 
 uted was confluent, partly bullous, and hemorrhagic; Knowles has 
 reported one terminating fatally in which the eruption was hemor- 
 rhagic and gangrenous. Cases such as these are, however, extremely 
 rare. In exceptional cases nephritis may occur as a sequel (Hennoch, 
 
 Beardsley). . . 
 
 Etiology and Pathology.— Although the great majority of cases 
 of chickenpox occur in childhood, between the first and tenth years, 
 it is by no means so rare in adults as is asserted by a number of writers. 
 Thomas, for example, has stated that he never saw a case in an 
 adult but Welch and Schamberg saw two score and more m a few 
 years' and the author has seen at least a score in those past twenty. 
 
 The affection is very contagious, and is usually contracted by 
 direct contact. The infecting organism has not yet been identified, 
 and the manner in which it obtains entrance into the economy is as 
 yet unknown A number of attempts have been made at various times 
 to inoculate it, but in most instances with negative results. Sterner 
 however, succeeded in eight out of ten children inoculated, and fixed 
 the period of incubation in the inoculated cases at eight days. Quite 
 recently Kling has reported no less than fifty-eight successful inocu- 
 lations According to his observations, the incubation period is, as 
 Steiner found, eight days, and successful inoculation confers immunity 
 upon the inoculated subject. Out of ninety-five children in the Gen- 
 eral Hospital for Children in Stockholm during an epidemic of vari- 
 cella thirty-one were successfully inoculated and all of these but 
 one escaped, while out of sixty-four not inoculated, twenty-four were 
 
 attacked 
 
 ' According to Unna, the varicellous vesicle begins at the hyper- 
 semic spot with a reticulating liquefaction of a few of the cells in the 
 central and upper part of the rete, and confluent cavities are thus 
 formed, divided by septa composed of compressed cells which have 
 not been liquefied. The younger cells at the bottom of the vesicle 
 undergo "ballooning colliquation" by which they are transformed into 
 lar^e round, oval, or pear-shaped cells containing from two to twenty 
 or more nuclei. The contents of the vesicles consist of finely granular 
 coagulated fibrin and a few ballooned cells. In the cutis there is 
 marked dilatation of the vessels with enlargement and multiplication 
 of the cells around them. . 
 
 Diagnosis — The disease with which chickenpox is most likely to 
 be confused is smallpox, and while in most cases the two are readily 
 
INFLAMMATIONS 397 
 
 differentiated, the distinction between severe chickenpox and mild 
 smallpox of the type which has been prevalent in the United States 
 for some years past may present considerable difficulty ; indeed, 
 may at times be impossible without twenty-four to thirty-six hours' 
 observation. 
 
 The eruption of chickenpox is not preceded by prodromal symp- 
 toms ; that of smallpox appears after a prodromal period of three 
 days during which there is pronounced constitutional disturbance, 
 such as vomiting, headache, severe lumbar pain, and high fever. The 
 eruption of chickenpox is vesicular from the beginning; that of small- 
 pox begins as papules which become umbilicated vesicles and finally 
 pustules with thick crusts. The eruption of chickenpox appears first 
 upon the trunk where it is most abundant, and is scanty upon the 
 face, sometimes altogether absent, while that of smallpox appears 
 first upon the face, where it is usually very abundant. The eruption 
 of chickenpox appears in successive crops, usually for four or five 
 days ; that of smallpox comes out continuously until it is completed, 
 usually in twenty-four to forty-eight hours. 
 
 Chickenpox and impetigo contagiosa are occasionally mistaken for 
 one another, but the vesicles of the latter are as a rule quite limited 
 in number, are often confined to the face, show a marked tendency 
 to peripheral extension, frequently reaching the size of a coin, and are 
 auto-inoculable. 
 
 Prognosis and Treatment. — The prognosis of uncomplicated chick- 
 enpox is invariably favorable. 
 
 Treatment is altogether expectant. The patient should be con- 
 fined to the house until the crusts have fallen, and if itching is a 
 troublesome symptom a lotion containing from one to one and a half 
 per cent, of phenol with a small quantity of glycerin will usually afford 
 prompt relief. 
 
CHAPTER IX 
 INFLAMMATIONS DUE TO VEGETABLE PARASITES 
 
 A very considerable and important group of cutaneous affections 
 is the result of invasion of the skin by various fungi belonging botan- 
 ically to the moulds and yeasts. Some of these are limited in their 
 ravages to the skin and its appendages, such as the hair and the nails, 
 while others not only attack the skin, but may, and frequently do, 
 invade the subcutaneous tissues and even the viscera, giving rise 
 to general infection. The majority of them are contagious, while 
 others occur only as the result of indirect inoculation. The amount 
 of disturbance produced in the skin by these organisms varies greatly ; 
 in some there is but little, oftentimes no, change beyond discolora- 
 tion and desquamation; in the majority, however, there is more or less 
 inflammation and in some deep-seated changes and destruction of 
 tissue. 
 
 The diseases belonging to this group are : Favus ; the trichophy- 
 toses, or several varieties of so-called ringworm; tinea versicolor; 
 erythrasma ; pinta ; actinomycosis ; blastomycosis, and sporotrichosis. 
 
 Owing to the character of the tissue-changes which distinguish them 
 actinomycosis, blastomycosis and spirotrichosis have been placed 
 among the Infectious Granulomata. Since inflammatory changes are 
 as a rule, to which there are very few exceptions, wholly absent in 
 tinea versicolor, it is considered among the pigmentary disorders. 
 
 FAVUS 
 
 Synonyms. — Tinea favosa ; honeycomb ringworm ; Fr., Teigne fa- 
 veuse ; Ger., Erbgrind. 
 
 Definition. — A parasitic disease of the skin due to a vegetable para- 
 site, the Achorion Schonleinii, characterized by cup-shaped crusts, 
 sulphur-yellow when recent, a dirty yellowish gray when old. 
 
 Symptoms. — While no part of the surface of the skin is exempt 
 from the disease, its most frequent site is the scalp (Plate XXV). In 
 this region it begins with the appearance of small slightly reddened 
 spots about the hairs, which presently show a thin scale and then a 
 small bright-yellow crust pierced by a hair. This yellow crust slowly 
 enlarges in circumference and thickness, and even when quite small 
 presents a central depression ; as it grows it becomes distinctly cup- 
 shaped. So long as the crusts remain discrete they preserve this cup- 
 shaped character, but when they are at all numerous and close to- 
 gether this is soon lost by their coalescence, and the affected area 
 is in time covered with a grayish-yellow friable mass in which the 
 cups are no longer apparent. The favus cup, or scutulum, as it is 
 called, is composed almost entirely of fungus elements mixed with 
 some epidermic scales. In its earliest stages the under surface is 
 398 
 
PLATE XXV 
 
 Favus of the scalp. 
 
VEGETABLE PARASITES 399 
 
 soft and putty-like, but it soon becomes dry and friable. Under- 
 neath the crusts the scalp is red, smooth, often moist, and not infre- 
 quently suppurating. In time, owing to atrophy from pressure and 
 superficial ulceration when suppuration occurs, it becomes thin and 
 cicatricial. The hairs are early affected ; they become dry, lustreless, 
 split up and broken off ; they may be readily extracted, and frequently 
 fall out spontaneously, so that areas of baldness, which are often per- 
 manent, owing to complete atrophy or destruction of the follicles, 
 are produced. The extent of surface involved varies ; often there are 
 onlv a few small finger-nail-size patches scattered over the scalp, but 
 the entire scalp may be affected, which in time is transformed into 
 an extensive cicatricial surface from which the hair has completely 
 vanished except a narrow fringe in the occipital region or a few small 
 tufts here and there. In cases in which there are extensive crusts, 
 a peculiar mouse-like odor is quite perceptible. In the majority of 
 cases there is more or less severe itching, and the scratching to which 
 this leads adds to the amount of inflammation and is often followed by 
 secondary pus infection. The scalp is excoriated and bleeds, and 
 the crusts in consequence become brown or blackish owing to ad- 
 mixture of pus and blood. In those cases accompanied by a consider- 
 able degree of inflammation with suppuration, the cervical glands 
 are frequently markedly enlarged. 
 
 More or less variation from the ordinary type of the disease may 
 occur upon the scalp. Dubreuilh divides these atypical forms into 
 three varieties: First, a pityriasic form, which may readily be con- 
 founded with psoriasis of the scalp; second, an impetiginous form 
 in which pustules resembling impetigo are present; and, third, an 
 alopecic form in which there are areas of baldness surrounded by a 
 border of inflamed follicles, resembling erythematous lupus of the 
 scalp or a folliculitis decalvans. 
 
 Favus of the scalp is a chronic affection, its duration frequently 
 running into years, even fifteen or twenty. It commonly begins in 
 childhood or less frequently in youth. 
 
 Favus of the bodv or of the non-hairy skin differs usually in no 
 essential particular from the disease as seen upon the scalp; there 
 are the same cup-shaped yellow crusts which, at first discrete, event- 
 ually coalesce, when numerous, to form thick, uneven, often bark- 
 like' masses which in neglected cases (Fig. 130) may be a half inch 
 or more in thickness and may cover the greater part of an extremity, 
 or even a considerable portion of the whole cutaneous surface. In 
 a certain proportion of cases it may begin like the ordinary ringworm 
 of smooth surfaces with a round, scaly, red patch, about the periphery 
 of which there are numerous small vesicles ; in the course of eight to 
 ten days the small, yellow, characteristic cups appear, usually around 
 a lanugo hair, which undergo the usual evolution. While commonly 
 associated with favus of the scalp, it may exist upon the body and 
 extremities alone. On the other hand, it frequently exists for years 
 
400 
 
 DISEASES OF THE SKIN 
 
 ^■:P 
 
VEGETABLE PARASITES 401 
 
 on the scalp without involvement of the trunk or extremities. The 
 spread of the disease is commonly decidedly more rapid on non-hairy 
 parts than on the scalp. Considerable inflammation of the skin be- 
 neath the crusts, with suppuration and ulceration, may occur here, 
 as on the scalp, but as a rule scarring is much less marked after 
 recovery than in the latter region. 
 
 The mucous membranes may quite exceptionally be the seat of 
 scutula. These have been observed on the glans penis, and Kaposi 
 and Kundrat have reported a remarkable case of extensive favus in 
 which the patient died with symptoms of gastro-intestinal inflamma- 
 tion ; at the autopsy ulcers and swellings were found in the gastro- 
 intestinal mucosa which were shown to contain the fungus of favus. 
 
 In rare instances it invades the nails. When these are attacked 
 the infection commonly begins beneath the free border, where small 
 irregularly shaped yellowish spots appear, due to the presence of small 
 collections of the achorion which show through the translucent nail- 
 substance. As the infection slowly extends backward, the nail itself 
 is infected; it becomes thick, uneven, dry, lustreless, and brittle, and 
 the nail-plate is lifted up from the nail-bed by an accumulation of 
 elements of the fungus and horny epithelial cells. In long-standing 
 cases when the disease has invaded the entire nail, involving the 
 matrix, marked deformity may result, or the nail may be practically 
 destroyed. It may be limited to the nail of a single finger or all 
 may be attacked ; the nails of the toes may likewise be implicated, 
 but these are much less frequently invaded than the finger-nails. In 
 the great majority of cases infection occurs through scratching other 
 infected regions, such as the scalp, and it is somewhat remarkable that 
 it does not occur oftener ; quite exceptionally it exists alone, and may 
 continue without infection of other regions for years. 
 
 Etiology. — Favus is the result of the invasion of the skin, more 
 particularly of the hair follicles, by a vegetable parasite named after 
 its discoverer, Schonlein, Achorion Schonleinii. It is always the re- 
 sult of direct transference from one individual to another, or, in rare 
 instances, from some one of the lower animals, such as the cat. the 
 dog, mice, rabbits, and from fowls. The cat is without doubt the 
 commonest animal source, acquiring the diseases from mice, animals 
 which are especially liable to it. The author has seen one instance 
 in which a child certainly acquired it from a kitten with which she 
 played, which was found to have an exquisite scutulum upon the 
 belly ; and another in which there was considerable evidence to show 
 that it had been acquired from a dog. In the great majority of cases 
 it begins in childhood, but may occur in adults, even in middle age. 
 The affection, although common in certain parts of Europe, such as 
 Italy, France, Austria, Poland, and Russia, these last two particularly, 
 is quite rare in natives of the United States, practically all the cases 
 seen here being immigrants from some one of the above-mentioned 
 countries of Europe. Favus of the smooth parts of the skin and of 
 26 
 
402 
 
 DISEASES OF THE SKIN 
 
 the nails is in the great majority of cases secondary to favus of the 
 scalp ; favus of animal origin, however, is practically limited to the 
 non-hairy parts of the skin. 
 
 There is apparently but little doubt that children whose powers 
 of resistance have been lowered by insufficient or improper food and 
 unwholesome surroundings, such as prevail among the poorer classes, 
 are much more commonly affected than the healthy and robust. Chil- 
 dren the subjects of favus are almost without exception thin and pale. 
 
 All the pathological changes characteristic of favus are the result 
 of the invasion of the skin and its appendages by the achorion. The 
 elements of this fungus, spores and mycelia (Fig. 131), are to be 
 found in the hairs, nails, and epidermis, and may be quickly and 
 easily demonstrated microscopically by placing a minute portion of 
 a crust, a hair, or scrapings from beneath the nail upon a slide with 
 a drop of liquor potassse, covering it with a cover-glass rather firmly 
 pressed down, and examining it after a few minutes with a power 
 of 250 to 300 diameters. As the crusts are made up almost entirely 
 
 Fig. 131. — Favus. Achorion Schonleinii. 
 
 of spores and mycelia, which also exist in great abundance in affected 
 hairs and nails, there is no difficulty in finding the fungus. 
 
 The spores are round, oval, elongate, or irregularly quadrilateral, 
 shining, very pale, greenish-yellow, structureless bodies having a 
 diameter of about 5 microns. The mycelia are long, flat, curved 
 and dichotomously branching tubes with occasional transverse septa 
 having a diameter varying from three to four microns. 
 
 The part usually first invaded is the follicular infundibulum, where 
 the scutulum or favus cup has its beginning (Fig. 132). As the fungus 
 multiplies it extends not only toward the surface, but downwards into 
 the follicle, invading the hair, disrupting its shaft, and frequently 
 destroying the papilla with resultant permanent loss of hair. The 
 
VEGETABLE PARASITES 
 
 403 
 
 hair-shaft contains numerous mycelial threads and long rows of quad- 
 rilateral or oval spores running parallel with its long axis. The scutu- 
 lum consists of spores, mycelia, and epithelial debris, and is situated 
 between the horny layer of the epidermis and the rete mucosum. The 
 marginal portion is made up of mycelial threads running at right 
 angles to the surface, while the central portion is composed of spores 
 and mycelia running in all directions. A vertical section of a scutulum 
 shows it embedded in the epidermis much as the stone is set in a 
 ring. The epidermis about its margin is increased in width, its inter- 
 
 Fig. 132. — Favus. F, C, favus cup, scutulum, imbedded in the rete mucosum; F, follicle. Note that the 
 favus cup is largely composed of fine threads, mycelia. 
 
 papillary projections greatly elongated, but beneath it it is markedly 
 thinned, the result of pressure. In the papillary and subpapillary 
 portions of the corium there is a considerable cellular exudate of 
 round cells, and, according to Unna, some plasma cells, Exception- 
 ally, owing to the penetration of the corium by the fungus, a granu- 
 loma resembling that sometimes found in trichophytosis is produced. 
 Darier and Halle have described such a case in which the corium 
 contained a cellular infiltration made up of polymorphonuclears, giant- 
 cells and lymphoid cells. 
 
 A number of authors, such as Frank, Unna, and Neebe, maintain 
 
404 DISEASES OF THE SKIN 
 
 the plurality of the species of the achorion, the latter having described 
 no less than nine varieties. In all probability, however, what have 
 been regarded as separate varieties are in fact only variations due 
 to differences in mode of cultivation and the conditions of growth, 
 such as temperature and soil. In two hundred cases of favus of the 
 scalp, Sabouraud never found but one variety, the Achorion Schonleinii. 
 There are, however, at least four fairly well-distinguished varieties of 
 achorion, producing favus in the lower animals: the Achorion Quinck- 
 eanum, found in mice and transmissible to man, attacking when so 
 transmitted smooth or non-hairy surfaces, but never found on the 
 scalp; Achorion gallinarum, producing favus in fowls; Oospora camna, 
 the organism causing favus in the dog and probably, although quite 
 rarely, inoculable in man; and the Achorion gypseum, producing an 
 affection resembling deep trichophytosis. 
 
 Diagnosis. — The diagnosis of favus is usually made without much 
 difficulty, but occasionally it may be confounded with other diseases, 
 such as eczema, psoriasis, seborrhoea, erythematous lupus, and ring- 
 worm or trichophytosis. 
 
 In the first three named affections the crusts or scales never pre- 
 sent the bright sulphur-yellow color of the recent crusts of favus, nor 
 the cup shape of the discrete crusts. There are never scarring and 
 atrophy, and never patchy baldness ; when loss of hair occurs it occurs 
 as. a diffuse thinning. No organism is to be found in the crusts and 
 scales of these diseases, while the crusts of favus, as has already been 
 mentioned, are composed almost entirely of the spores and mycelia 
 of the achorion. 
 
 While in erythematous lupus of the scalp scarring and atrophy 
 with areas of baldness frequently occur, resembling at times that which 
 occurs in favus, there are never at any time the characteristic cup- 
 shaped yellow crusts. 
 
 When the crusts have been completely removed, as is often done 
 by arriving immigrants just before coming into port, and nothing 
 but scarring and atrophy are perceptible, an immediate positive diag- 
 nosis may be difficult or impossible. Under such circumstances a 
 period of two or three weeks without washing or applications of any 
 sort will usually be sufficient to produce a new growth of character- 
 istic cups. 
 
 The differential diagnosis between favus and ringworm of the 
 scalp sometimes presents considerable difficulty and cannot always 
 at once be made even with the aid of the microscope, since the acho- 
 rion and the trichophyton may at times be differentiated microscopi- 
 cally with difficulty. The employment of cultures with suitable media 
 or inoculation in mice w r ill solve the difficulty. 
 
 As a rule, however, the achorion may be distinguished from the 
 trichophyton by the larger size of its spores and mycelia and the 
 greater variation in their shape and size. 
 
 The only affection with which favus of non-hairy parts is at all 
 
VEGETABLE PARASITES 405 
 
 likely to be confounded is ringworm of smooth parts or trichophytosis 
 corporis (tinea circinata), and then only in the early stages, when it 
 occasionally appears as a scaly disc which undergoes involution in 
 the centre. Very soon, however, the characteristic yellow cups ap- 
 pear, which at once determines diagnosis. 
 
 Treatment. — The most effective method of treatment is complete 
 and thorough depilation by the X-ray.. This may be accomplished at 
 a single sitting, according to the method advocated by MacKee, or 
 by repeated exposures of comparatively short duration. The treat- 
 ment should always be controlled by the use of some reliable meter 
 with a proper recognition of the possibility of untoward results if 
 due care is not employed. (For details of X-ray treatment vid. Ring- 
 worm of the scalp.) 
 
 When for any reason X-ray treatment is not or can not be em- 
 ployed, dependence must be placed upon the application of parasiticide 
 lotions and ointments, preferably the latter, since they can be made 
 to penetrate the diseased follicles more readily than the former. Be- 
 fore beginnng the use of these, the diseased parts should be freed of 
 crusts ; this may be best accomplished by thorough soaking with olive 
 oil, or, better, by vaseline containing two per cent, carbolic acid, which 
 should be liberally applied and kept on constantly for a day or 
 two until the crusts have become so soft that they can be readily 
 removed. When the disease is situated upon non-hairy parts, such 
 as the trunk or extremities, frequent and prolonged warm alkaline 
 baths will expedite their removal materially. After this preliminary 
 cleansing, depilation should be begun when the scalp is the part 
 affected, and continued until all the diseased hairs have been ex- 
 tracted. This may be performed by broad-bladed forceps or by 
 drawing the hairs between the thumb and the back of a knife-blade. 
 
 Among useful lotions are solutions of bichloride of mercury, either 
 in alcohol or in water, 0.5 to 1.0 per cent.; of hyposulphite of soda, 
 2 drachms (8.0) to the ounce (32.0) of water; of salicylic acid, 2 to 3 
 per cent, in alcohol. These should be mopped on thoroughly twice 
 a day. Among the most effective ointments are sulphur, 20 to 25 
 per cent.; ammoniated mercury, 10 to 15 per cent.; chrysarobin, 5 to 
 10 per cent. ; resorcin, 10 to 12 per cent. (Crocker) ; naphthol, 10 per 
 cent. In using chrysarobin especial care must be taken that it does 
 not get into the eyes. The ointments should be thoroughly rubbed 
 in once or twice a day, and during their use the scalp should be washed 
 every second or third day with tincture of green soap and hot water. 
 The treatment should be continued without intermission for three or 
 four months, when it should be suspended for two weeks in order to 
 learn what progress toward cure has been made. If new crusts 
 appear, as is likely, the treatment should be resumed and continued 
 as before. When no new signs of disease appear for a period of six 
 to eight weeks after the suspension of treatment, and more especially 
 if the microscope shows no fungus in the hair, the disease may be 
 regarded as cured. 
 
406 DISEASES OF THE SKIN 
 
 On non-hairy parts the treatment is usually much less trouble- 
 some and much more rapidly effective. After removal of the crusts, 
 the same ointments and lotions employed in favus of the scalp may 
 be used In addition to applications already mentioned, tincture ot 
 iodine either full strength or diluted with an equal quantity of alcohol, 
 painted on once a day, will often prove most useful. 
 
 When the nails are affected, these should be trimmed closely and 
 scraped as thin as possible, after which they should be immersed ma 
 solution of mercuric bichloride, 1 : 5 oo, for ten minutes at a time, twice 
 a dav a hot saturated solution of hyposulphite of soda may be used 
 fn a'smilar manner. Sabouraud recommends a solution containing 
 £ grain (0.05) iodine, 15 grains (1.0) iodide of potassium, in 3 ounces 
 (icfoo of water, which is to be applied every night on lint covered with 
 p otect ve such as oiled silk or a rubber finger-cot. In cases which do 
 not yiem'to the usual treatment avulsion of the nail may be resorted 
 to followed by the usual local remedies. 
 
 pYognosis.-Although prolonged treatment is usually necessary 
 especially in favus of the scalp and nails, a cure may always be obtained 
 bv the use of proper remedies used with perseverance. In long- 
 standing cases affecting the scalp, permanent loss of hair commonly 
 occurs often wtth mofe or less scarring, but on non-hairy parts the 
 dLease is cured with comparative ease and ^sually *£*£?£*£ 
 
 ^T^^^^^y^ - time to properly directed 
 
 treatment. . 
 
 TRICHOPHYTOSIS 
 
 Svnonvms -Tinea trichophytina ; Ringworm; Fr., Trichophytie. 
 STJ disease of the' skin and its appendages due to a vege- 
 «££££ belonging to ^^^^^g^ 
 
 ."^tSZtJ^^^^^. -cognized clinical 
 phytosis presents tour w -. ons trichophytosis capitis, or ring- 
 
 varieties two J^JJjfJ^. ri ngworm of the 
 r m A one situated upon the smooth or non-hairy surfaces-tr.cho- 
 Jhyto7s° TorpoHs *t ringworm of the body-and one attacking the 
 nails-trichophytosis unguium, affection 
 
 Until a ^P-7'^ e t^«rf he organism, but the 
 were thought to be due to as ingle sp ec.es g conc l U sively 
 
 epoch-making researches of Saboma«d and £ and that 
 
 Phvtlet stceTey are n'ot due to a trichophyton, but to closely 
 ^l^^S^- Ccalpif^^onest of all the 
 
PLATE XXVI 
 
 Ringworm of the sea In i"rv;„u i_ 
 
 me scalp. (Inchophytosis capitis.) 
 
VEGETABLE PARASITES 407 
 
 forms of trichophytic infection. Indeed, there are few schools or 
 other institutions for children in which cannot always be found one 
 or more examples of this aifection (Plate XXVI). 
 
 It usually begins as a small round, hyperaemic, scaly spot in which 
 at first the hairs show no evidence of disease. This spot steadily 
 enlarges, often with considerable rapidity, until it becomes a round or 
 oval, usually well-circumscribed patch (Fig. 133); the hyperemia 
 disappears, the hairs in the patch become dry, lustreless, and brittle, 
 and break off, leaving short stumps projecting a line or more above the 
 surface, which readily yield to traction. Usually more or less itching 
 is present, although this is rarely severe. The number and size of 
 the patches vary considerably. There may be but a single one, but 
 
 Fig. 133. — Ringworm of the scalp. 
 
 usually there are several, and in long-standing cases which have been 
 neglected there may be many patches which as they enlarge coalesce 
 (Fig. 134), eventually involving the greater portion of the scalp. 
 Not infrequently the disease begins with more decided symptoms of 
 inflammation : the small early patch may be decidedly reddened, the 
 border surrounded by small vesicles and pustules with slight crusting, 
 but these disappear early and the subsequent course does not differ 
 from that already described. Or there may be numerous pin-head- 
 sized discrete pustules situated at the mouths of the follicles, scattered 
 about irregularly over the affected region. While this pustular erup- 
 tion is often the result of the invasion of the follicles by the tricho- 
 
408 
 
 DISEASES OF THE SKIN 
 
 numi 
 
 phyton, it may also result from the application of too irritant parasiti- 
 cide ointments or washes. 
 
 While in most cases the baldness is incomplete and the patches 
 covered with grayish scales, occasionally there are perfectly smooth 
 completely bald areas, the so-called bald ringworm first described by 
 Liveing. This form, however, begins in the usual fashion with scali- 
 ness and brittleness of the hair, and only shows the smooth patches 
 which closely resemble alopecia areata, after it has existed for a time. 
 In young children with very fair, fine hair, the hair loss may be 
 insignificant, the disease consisting of ill-defined, very slightly scaly 
 areas in which the hair is thinned and dry. 
 
 In another variety, known as disseminated ringworm, there are 
 lerous small scaly spots scattered about over the greater portion 
 
 of the scalp, each spot involving only 
 a few follicles in which are broken 
 hairs or stumps of hairs, which, un- 
 less the scalp is carefully gone over 
 with a hand lens, are readily over- 
 looked. 
 
 In microsporic ringworm, or that 
 due to the Microsporon Audouini, the 
 patches are round or oval, are usually 
 limited in number, sometimes but a 
 single one being present, and are cov- 
 ered with grayish scales. According 
 to Sabouraud this variety of ring- 
 worm may be readily distinguished 
 clinically from trichophytic ringworm 
 by the grayish appearance of the 
 plaques in which all the hairs are 
 broken off a few millimetres above 
 the surface. Each stump is sur- 
 rounded by a sheath of epithelial 
 debris, which, projecting from the mouths of the follicles, gives to the 
 surface of the patch the peculiar grayish granular appearance which has 
 been aptly likened to the skin of a plucked fowl or to cutis anserina. 
 
 Exceptionally, deep and severe inflammation of the hair follicles 
 occurs over a circumscribed area producing a bright red, boggy, tumor- 
 like swelling, varying in size from a small nut to an egg. The hairs 
 speedily become loose and fall out, leaving a completely bald surface, 
 and from the swollen mouths of the empty follicles a viscid, puriform 
 fluid exudes. Usually more or less pain accompanies the inflamma- 
 tion, and in the severer forms subcutaneous abscesses may occur. This 
 unusually inflammatory form of ringworm, which is known as kerion, 
 may follow the usual type, or it may occur independently of any other 
 manifestation. 
 
 Fig. 134. — Ringworm, scalp, 
 tosis capitis. 
 
VEGETABLE PARASITES 409 
 
 Under the name lichenoid trichophytosis Guth and Herxheimer 
 and Koster have reported a number of cases of a papular eruption 
 associated with deep trichophytosis, in most cases of the scalp in 
 children (kerion). The papules were for the most part follicular; 
 the eruption bore considerable resemblance to lichen scrofulosorum 
 and was situated on the trunk and extremities. In some cases it was 
 of short duration, in others it lasted for several weeks. There were 
 no subjective symptoms. 
 
 The course of ringworm of the scalp is an eminently chronic one, 
 all the various forms lasting for months or even years. Kerion, how- 
 ever, occasionally terminates spontaneously, the severity of the inflam- 
 mation and the complete depilation bringing about the destruction of 
 the fungus, 
 
 Diagnosis. — Fully developed ringworm of the scalp is not readily 
 mistaken for other affections of the same region. The rounded, 
 more or less circumscribed, partly bald, gray, scaly patches in which 
 are many broken hairs and stumps of hairs, the peculiar granular sur- 
 face resembling the so-called " goose skin," the age of the patient, 
 who is almost without exception a child, are features which character- 
 ize the affection sufficiently in most cases to prevent mistake. It is, 
 however, occasionally confounded with other affections of the scalp, 
 such as eczema, psoriasis, seborrhoea, alopecia areata, and favus. In 
 the first two of these the symptoms of inflammation are well marked 
 while in ringworm these are usually slight or absent altogether, except 
 in the earliest stages. In psoriasis the scaling is thick and laminated, 
 mica-like, totally unlike the branlike scaling of ringworm. In ecze- 
 ma, instead of scales, there are much more likely to be oozing 
 and crusting at one time or another, and there is nearly always a 
 good deal of itching. In seborrhoea the scales are fatty, usually quite 
 abundant, and scattered over the vertex and parietal region in ill- 
 defined instead of well-circumscribed areas; the hair is thinned, not 
 broken off in rounded patches. In alopecia areata the baldness is 
 complete and the scalp smooth instead of scaly; but in certain cases it 
 is not always easy to distinguish the so-called " bald ringworm " from 
 this affection. A careful examination of the scalp, however, will often 
 reveal slightly scaly patches or a few stumps of hairs about the borders 
 of the bald areas in which the microscope shows the trichophyton, 
 which is, of course, never present in alopecia areata. Favus and ring- 
 worm of the scalp can only be mistaken for one another when the 
 characteristic yellow crusts of the former are absent ; the scarred and 
 atrophic areas completely devoid of hair so common in favus are never 
 seen in ringworm. The microscope is invaluable as an aid to diagnosis 
 in this, as in all other forms of ringworm, and should never be neglected. 
 A few stumps of hairs from the affected area are placed upon a slide 
 with a drop of a 5 per cent, solution of potassium hydrate and covered 
 
410 
 
 DISEASES OF THE SKIN 
 
 with a cover firmly pressed down. In a few minutes the hairs become 
 translucent so that spores and mycelia, if present, may be readily seen 
 with a power of 250 to 300 diameters. 
 
 Ringworm of the Beard (Trichophytosis Barbae).— Synonyms.— 
 Tinea sycosis; Sycosis parasitica; Barber's itch; Fr., Trichophytie 
 sycosique; Ger., Parasitare Bartfinne. 
 
 Symptoms.— Ringworm of the beard is much less frequent than 
 ringworm of the scalp and non-hairy skin, but is not a very rare affec- 
 tion (Plate XXVII). It may begin much like ringworm of non-hairy 
 
 FlG. 135. — Ringworm of the beard. 
 
 parts, with small, red, scaly spots which speedily enlarge to form 
 rounded patches or rings, about the margins of which there are occa- 
 sionally minute vesicles and pustules which dry into small crusts the 
 hairs show but little sign of disease, but soon become loose and fall out, 
 leaving bald areas. While it may remain of this superficial character, 
 
PLATE XXVII 
 
 Ringworm of the beard. (Trichophytosis barbae.) 
 
VEGETABLE PARASITES 411 
 
 much more commonly the fungus invades the deeper portions of the 
 skin, producing a pustular folliculitis accompanied by more or less 
 marked swelling resembling that seen in kerion of the scalp. Pustules, 
 nodules, and tubercles appear, varying in size from a pea to a hazel- 
 nut, with bright red, smooth surface from which the hair has fallen, or, 
 if the hairs still remain, they may be painlessly and easily withdrawn 
 from the follicles (Fig. 135). In the more marked cases there may 
 be considerable crusting owing to the drying of the puriform fluid 
 which escapes from the inflamed follicles. Occasionally the inflam- 
 mation is severe, producing marked nodular or lumpy fluctuating 
 swellings as large as a nut, resembling abscesses. Pain, which is at 
 times quite severe, usually accompanies these swellings. The extent 
 of the affection varies much ; there may be only a few pustules and 
 nodules situated upon the chin or about the angle of the jaw or in the 
 submaxillary region of one side, or the entire bearded region, with the 
 exception of the upper lip, which usually escapes, may be invaded by 
 the fungus. Exceptionally the disease extends to the side, and back 
 of the hairy region of the neck, as in a case under the author's care 
 some little time ago. When left to itself, it usually runs a course 
 lasting for months, although it seldom exhibits the extreme chronicity 
 shown by ringworm of the scalp. 
 
 Diagnosis. — The symptoms of ringworm of the beard are usually 
 so characteristic that it is not readily mistaken for other diseases of 
 this region. The malady with which it is most likely to be con- 
 founded is sycosis vulgaris, likewise a folliculitis of the bearded region. 
 In ringworm the inflammatory symptoms are as a rule much more 
 severe and acute than in nonparasitic sycosis ; the swelling is more 
 marked and the hairs are loose and often fall out spontaneously or 
 may be extracted painlessly and with ease. In sycosis the hairs are 
 firm in the follicle and efforts at extraction cause acute pain. In 
 ringworm the upper lip is very rarely invaded, in sycosis this region 
 is often affected. Lastly, the trichophyton may be demonstrated in 
 the hairs in ringworm ; in sycosis this organism is absent. 
 
 Ringworm of the beard may at times resemble somewhat pustular 
 eczema of that region, but the latter is much more likely to affect the 
 bearded region and spread beyond it, is accompanied by decided 
 oozing and crusting with severe itching, and never presents the 
 peculiar lumpy swellings seen in the former. The trichophyton is 
 always present in the former, never in the latter. Ringworm is 
 invariably accompanied by loosening of the hair, while eczema is not. 
 
 Ringworm of the beard may be mistaken for the nodular syphilo- 
 derm, but it is much more acute in its course, is inflammatory and does 
 not produce ulceration, a symptom common in the latter. The micro- 
 scope is a valuable aid in the differential diagnosis. 
 
 Ringworm of the Body (Trichophytosis Corporis).— Synonyms.— 
 Tinea circinata ; Herpes circinatus ; Fr., Trichophytie. 
 
412 DISEASES OF THE SKIN 
 
 Symptoms. — Ringworm of the smooth or non-hairy parts of the 
 skin is a very common affection, occurring only a little less frequently 
 than ringworm of the scalp. The symptoms which it exhibits vary 
 considerably, according to the region affected and according to the 
 variety of the fungus producing the infection. 
 
 The commonest clinical type ordinarily begins as one or more 
 small, slightly red and scaly spots which enlarge peripherally, often 
 with considerable rapidity, and as they enlarge the central portion 
 
 becomes less scaly and may even 
 become quite smooth, so that the 
 scaly spots are soon transformed 
 into rings varying in diameter from 
 a dime to three or four inches and 
 even more (Fig. 136). Less fre- 
 quently this central involution does 
 not take place, but the patches be- 
 come round scaly discs varying in 
 size from a dime to a silver half- 
 dollar. The hypersemia present in 
 the beginning of the disease is 
 usually slight and soon disappears, 
 leaving the skin without signs of 
 inflammation. Less frequently the 
 redness may be quite decided and, 
 as in ringworm of the scalp, may 
 be accompanied by minute vesi- 
 cles and pustules situated about 
 the margins of the rings and 
 patches ; there may be even a cer- 
 tain amount of infiltration with 
 
 Fig. I3 6.-Ringworm. Trichophytosis corporis. ^^ The parts att acked are 
 
 usually the uncovered portions of the skin, such as the face, neck, 
 hands, and lower part of the forearms, but the trunk is by no means 
 immune, although less frequently invaded. The number of patches 
 present is ordinarily small, often but a single one, but there may be 
 several, exceptionally very many (Fig. 137), in rare cases distributed 
 over the greater portion of the trunk. Occasionally as the rings en- 
 large new ones form within the old ones, so that there may be two or 
 more concentric rings (Fig. 138). Moderate itching is usually present 
 in the early stages, but is rarely a prominent symptom. 
 
 In addition to the foregoing ordinary type there are a number of 
 others which are characterized by a considerable degree of inflam- 
 mation (Plate XXVIII). 
 
 In ringworm of the thighs, tinea cruris, formerly known as eczema 
 marginatum, semicircular, bright-red, sharply marginate patches occur 
 on the inner surface of one or both thighs and the scrotum, which spread 
 
PLATE XXVIII 
 
 Eczematoid ringworm of the toe 
 
VEGETABLE PARASITES 413 
 
 peripherally, sometimes undergoing central involution, but often re- 
 maining as solid patches, with scaly borders. These patches are often 
 decidedly inflamed, presenting eczematoid symptoms, such as oozing 
 and crusting, accompanied by severe itching; indeed, it was formerly 
 supposed to be a special form of eczema, hence the name eczema 
 marginatum given to it by Hebra, who first described it. In ordinary 
 cases the eruption is limited to the thighs, the patches rarely exceeding 
 the size of the palm, but in long-standing or neglected cases it may 
 extend downwards to the knees, backwards over the perineum, and up 
 between the buttocks, and anteriorly up over the pubis and abdomen 
 as far as the umbilicus and even higher, as in a case very recently 
 
 Fig. 
 
 -Ringworm. Infection from cat. All the members of the family (five) affected. 
 
 under the author's observation (Fig. 139). The axillae are almost 
 as frequently attacked in the same manner; here the disease assumes 
 the shape of variously sized, round or oval, bright-red patches with 
 sharply circumscribed borders attended by decided itching and burning 
 (Fig. 140). Unlike the other forms of ringworm, this variety, when 
 occurring in hairy regions such as the pubis, does not attack the hairs. 
 This form of ringworm is known in the Orient as Dhobie itch, a name 
 given to it because of its supposed transmission through the laundry. 
 In another variety, occurring upon the hands and feet, in the latter 
 region between and on the under surface of the toes, the resemblance 
 
414 DISEASES OF THE SKIN 
 
 to eczema is still more marked, justifying the name eczematoid ring- 
 worm recently applied to it. Upon the hands it may resemble a mild 
 erythemato-squamous eczema of the palm with a moderate amount of 
 redness and some scaling, which often extends to the sides of the 
 fingers, and occasionally over the dorsal surface. Or less frequently 
 it begins very acutely with redness, swelling, and an abundant erup- 
 tion of vesicles and pustules, the clinical symptoms resembling those 
 
 Fig. 138. — Ringworm of the body. Trichophytosis corporis. Concentric rings. 
 
 of acute eczema to such a degree that it may be quite indistinguishable 
 from that affection without the aid of the microscope. In this form of 
 the disease the usual marginate character of the diseased area is absent. 
 Upon the toes it resembles an intertriginous eczema, for which it 
 is usually mistaken (Plate XXVIII). The skin between the toes is red 
 and desquamating; less frequently it is moist, and there is more or 
 less itching. The disease often spreads backwards upon the sole, 
 the advancing border being rounded, or serpiginous and quite sharp. 
 The course of this eczematoid eczema of the hands and feet is usually 
 very chronic, many cases lasting for months and even years. This 
 variety of ringworm, the knowledge of which we owe chiefly to Sabou- 
 
PLATE XXIX 
 
 Deep ringworm (Trichophytosis profunda) (animal origin). 
 
 Deep ringworm (Trichophytosis profunda) of the neck with ringworm of the beard (Trichophytosis 
 barbae). Probably animal origin. 
 
VEGETABLE PARASITES 
 
 415 
 
 raud and Whitfield, is in all probability much more frequent than has 
 hitherto been supposed; indeed, Sabouraud asserts that eight out of 
 every ten cases of so-called intertrigo of the toes are in fact examples 
 
 of ringworm. u 
 
 In still another form, confined to the palms and soles, usually more 
 commonly the latter, first described by Djelaleddin Mouktar, in 1892, 
 there is at first an eruption of deep-seated vesicles and pustules present- 
 ing a more or less circular arrangement, which after a time is followed 
 by desquamation, and later by marked hyperkeratosis. 
 
 In a certain small proportion of cases the fungus penetrates deeply 
 
 Fig. 139. — Tinea cruris (ringworm of the thigh). 
 
 into the follicles, giving rise to severe folliculitis (Plate XXIX). In 
 this deep variety of trichophytosis (trichophytosis profunda) there 
 are rounded or irregular patches of follicular pustules seated upon 
 a swollen and inflamed base, varying in size from a silver com to the 
 palm of the hand ; exceptionally quite extensive areas may be involved, 
 as in a case under the author's observation years ago m which the 
 lower two-thirds of the outer side of one leg was occupied by an 
 extensive plaque of inflamed and swollen follicles. After reaching 
 a certain size the patches are apt to remain stationary ; they rarely 
 show the rapid peripheral extension which often occurs m the more 
 superficial forms. In the severest form abscesses and even ulceration 
 may occur (Fig. 141). This trichophytic folliculitis was first de- 
 scribed by Leloir, under the title perifolliculitis suppurativa conglom- 
 
416 
 
 DISEASES OF THE SKIN 
 
 erata, but he was entirely unaware of its parasitic nature. It is espe- 
 cially apt to occur in dairymen, liverymen, hostlers, and others whose 
 occupation brings them into frequent and more or less close contact 
 with horses and cows, and is most frequently situated upon the un- 
 covered parts, as the backs of the hands" and the wrists. In rare 
 instances the mucous membranes adjoining the skin, such as the 
 tongue, the buccal mucous membrane, the conjunctiva, may be invaded 
 
 Fig. 140. — Ringworm of the axilla. 
 
 by the trichophyton, Rille, Stern, and EichhofT having reported exam- 
 ples of such invasion. 
 
 Etiology. — All the forms of ringworm are caused by the invasion 
 of the skin and its appendages by a vegetable parasite, either some one 
 of the varieties of the trichophyton, or by a closely related organism, 
 the Microsporon Audouini, which was until recently also regarded as 
 a trichophyton. All the varieties of the malady are more or less 
 contagious, infection occurring through immediate contact or, what 
 
VEGETABLE PARASITES 
 
 417 
 
 is much more frequent, through the intervention of various articles 
 of clothing, such as hats, underwear, or articles of the toilet, such as 
 towels, combs, brushes, etc., which serve as carriers of the infecting 
 organism. The disease is quite frequently contracted from some one 
 of the lower animals, such as the horse, the cow, cats, and dogs, this 
 origin being especially common in those varieties exhibiting unusually 
 inflammatory symptoms, or accompanied by suppuration with in- 
 vasion of the deeper tissues, as in kerion and other forms of deep tricho- 
 phytosis. Although there can be no ringworm without the fungus, 
 infection is favored by certain favoring elements. Ringworm of the 
 scalp is practically never seen in adults, its occurrence in those past 
 the age of fifteen is so infrequent as to be a clinical curiosity. Ring- 
 worm of the smooth or non-hairy surfaces may occur at any age, but 
 
 Pig. 141. — Deep ringworm.— Trichophytosis profunda. Infection traced to kitten. 
 
 is much less common in adults than in children ; the so-called eczema 
 marginatum or ringworm of the thighs, however, is a disease of adult 
 life. Sex as sex has apparently but little influence ; the more violent 
 inflammatory forms are, however, seen more frequently in males than 
 in females, because the former are much more likely to come in contact 
 with the lower animals from which these forms are contracted. Occu- 
 pation, as affording special opportunity for infection, exerts some 
 influence in its production; dairymen, hostlers, and all others whose 
 employment brings them into contact with the lower animals are 
 particularly liable to the deep forms, in whom, indeed, they are seen 
 chiefly. School children and the inmates of orphan asylums or other 
 institutions in which large numbers of children are collected are espe- 
 cially the subjects of it. Sabouraud has found that inoculation with 
 the parasite succeeds much more readily in those with alkaline sweat, 
 acidity of this fluid apparently diminishing susceptibility. 
 27 
 
418 DISEASES OF THE SKIN 
 
 In ringworm of the scalp about 90 per cent, of the cases are due to a 
 small spored fungus, the Microsporon Audouini (Figs. 142 and 143), 
 the remaining 10 per cent, are trichophytic, i.e., due to some one of the 
 varieties of the trichophyton, the trichophyton endothrix, or, in the 
 case of the inflammatory varieties, the endo ectothrix. 
 
 In ringworm of the non-hairy surfaces the Microsporon Audouini 
 or some one of its varieties derived from the lower animals, the dog- 
 or the horse, is present, or more frequently a large spored fungus, 
 usually the ectothrix, or less frequently an endothrix. In deep-seated 
 trichophytosis such as kerion of the scalp, ringworm of the beard, 
 and the agminate folliculitis, a large spored trichophyton of the 
 
 ; :' ,:■■:'■- 
 
 ; 
 
 Fig. 142. — Ringworm of the scalp. Hair containing spores and mycelia of the Microsporon Audouini 
 
 Stained. 
 
 ectothrix variety, is present. In ringworm of the thighs and axillae the 
 active cause is the Epidermophyton inguinale, a sub variety of the 
 trichophyton which, unlike the other varieties, does not invade the hair. 
 
 The statement made by some authors that fair-haired subjects are 
 more susceptible than dark-haired ones is not confirmed by the author's 
 experience, he being quite sure that he has seen just as many if not 
 more cases in those with dark complexions ; nor has he found that 
 the patient's general condition influences in any way his susceptibility 
 to the malady, nor its course when once contracted. 
 
 Pathology and Pathological Histology. — Ringworm in all its forms 
 is a dermatomycosis, i.e., a disease resulting from the invasion of the 
 
VEGETABLE PARASITES 
 
 419 
 
 skin and its appendages by a fungus. Gruby, between 1841 and 1845, 
 made to the French Academy of Sciences three communications in 
 which he announced the discovery of a cryptogam first, in the hairs of 
 ringworm of the beard, later in the hairs of ringworm of the scalp, which 
 he regarded as the cause of these diseases. Although Gruby's dis- 
 coveries were eventually confirmed by other observers and the parasitic 
 nature of ringworm fully established, his division of the parasites into 
 three distinct varieties was entirely overlooked, and for a half century 
 
 •;Vi s k 
 
 Fig. 143. — Ringworm of the scalp. Spores and mycelia in hair. Unstained. 
 
 there was supposed to be but a single organism concerned in the pro- 
 duction of ringworm, the trichophyton. But the epoch-making re- 
 searches of Sabauraud, begun in 1892, fully confirmed the statements 
 of Gruby as to the plurality of the fungi. 
 
 Two species of parasitic cryptogam are found in ringworm, the 
 microsporon, an organism with small spores, and a large-spored organ- 
 ism, the trichophyton. Of the former there are several varieties, 1 the 
 most important of which is the Microsporon Audouini, found, as has 
 already been mentioned, in about 90 per cent, of all cases of ringworm 
 of the scalp, to which region it is practically limited. In addition there 
 
 1 It is still a matter for debate as to whether all these variations repre- 
 sent real varieties or are only variations due to differences in conditions of 
 growth. 
 
420 DISEASES OF THE SKIN 
 
 are two forms of animal origin which are likewise pathogenic in man, 
 the M. lanosum, found in the dog, and the M. equinum, found in the 
 horse ; the former gives rise to a ringworm of the scalp and of the 
 smooth surfaces ; the latter has been observed on the non-hairy parts 
 only in a few instances. 
 
 In the scales taken from a patch of ringworm of the scalp due to 
 the M. Audouini, the fungus exists as a network of slender curved 
 and undulatory mycelial tubes varying in size from I to 3 microns 
 in diameter, with lateral projections and transverse septa at intervals 
 which are best seen in stained specimens. Hairs from such a patch 
 are surrounded by a sheath of small spores 2 to 3 microns in diameter, 
 which extends a short distance above the intrafollicular portion of the 
 shaft and downwards to the neck of the bulb, the spores showing no 
 definite arrangement. No spores are found in the substance of the 
 hair itself, but delicate mycelia, which run in a longitudinal direction, 
 are present within the hair shaft, which extend as a delicate fringe 
 below the lower end of the sheath of spores about the neck of the bulb, 
 the fringe of Adamson. Cultures of the organism upon proof medium 
 {milieu d'epreuve) begin as a small white downy disk with a small 
 elevation at the point of inoculation ; later as the disk grows larger 
 it becomes grayish-white and is divided into sectors by 3 or 4 
 furrows radiating from the centre. The appearance of the cultures 
 varies somewhat according to the medium upon which they are grown. 
 Cultures of M. lanosum are more rapid in their growth and more downy 
 than those of M. Audouini, but later exhibit a central smooth area around 
 which a characteristic elevated white woolly ring forms which serves 
 to identify it. 
 
 Two species of the large spored fungus or trichophyton are con- 
 cerned in the production of ringworm, viz., T. endothrix, in which 
 the spores are found within the structure of the hair shaft ; and the 
 T. ectothrix, in which they are outside of it, although recent investi- 
 gations would seem to show that under certain circumstances this 
 variety may also penetrate the shaft, and for this reason it is also 
 designated T. ecto endothrix. Both these varieties are again divided 
 into a number of subvarieties, the division being based chiefly upon 
 cultural peculiarities. Of the Trichophyton endothrix there are three 
 principal subvarieties, which are named after certain cultural character- 
 istics — T. acuminatum, T. crateriforme, and T. violaceum. The endo- 
 thrix varieties of the trichophyton are found in ringworm of the scalp 
 and of the smooth surfaces, and are rarely attended by any considerable 
 degree of inflammation. In the epidermic scales the fungus exists as 
 mycelial filaments composed of numerous short rectangular joints or 
 spores. In the hair the T. crateriforme occurs as long ribbons or 
 chains made up of square elements within the hair shaft parallel with 
 its long axis, while the T. acuminatum shows mycelia or long chains 
 of round spores resembling a string of beads, also within the hair. 
 The T. violaceum gives rise to lesions upon the smooth skin, in the 
 
VEGETABLE PARASITES 421 
 
 beard and the scalp which are occasionally more or less inflammatory 
 and may attack the nails. In the epidermis it occurs as slender mycelia 
 with few divisions ; in the hair the spores do not occur as chains or 
 ribbons, but without any definite arrangement. This variety is in the 
 beginning both an ecto- and an endo-thrix, but when fully established 
 it is strictly limited to the interior of the hair, a pure endothrix. 
 
 Two varieties of trichophyton, the T. cerebriforme and T. plicatile, 
 neither of them of frequent occurrence, and the latter rare, have been 
 placed in a group by themselves under the name T. neo-endothrix, 
 since they present the features of both an endothrix and an ectothrix, 
 some of the hairs showing the fungus within their shafts, while in 
 others it remains outside. The T. cerebriforme attacks the scalp, 
 the smooth surfaces, and more especially the beard. The cultures of 
 this organism upon proof media are characterized by a wrinkled sur- 
 face, which becomes more and more marked as they grow. 
 
 The T. ectothrix, of which there are two principal varieties and a 
 number of subvarieties, remains outside the hair, about which it forms 
 a sheath. All the varieties of this parasite are of animal origin and are 
 found in the inflammatory and suppurative forms of ringworm. There 
 are two principal groups of this trichophyton, viz., one which has 
 small spores 3 to 4 microns in diameter, approaching in size those of 
 the microsporon, and a second in which the spores are large, 8 to 9 
 microns in diameter. The most important of the small-spored ecto- 
 thrix trichophytons, although none of them are of frequent occurrence, 
 is the T. asteroides, which is found in some ringworms of the scalp pre- 
 senting the symptoms of kerion and certain pustular forms upon the 
 smooth surfaces. The cultures of this variety are of rapid grow r th, 
 have in the beginning a central eminence, which later becomes umbili- 
 cated, surrounded by a star-like border, the surface covered with a 
 white powder. 
 
 The most important of the large-spored trichophytons are the 
 T. rosaceum, with rose-colored cultures, which produces an eruption 
 in the beard resembling somewhat keratosis pilaris ; the T. equinum, 
 which occurs on the smooth surfaces and in the beard, producing 
 suppurative lesions in the latter region ; and the T. ochraceum, with 
 favus-like cultures, found in those who come in contact with cattle, 
 producing pustular lesions. 
 
 The manner in which the fungus penetrates the hair has been the 
 subject of considerable discussion; needlessly so, as it seems to the 
 author. The older investigators thought the fungus reached the hair 
 shaft by growing downwards until it reached the softer cells of the 
 bulb, where it entered. Others, like Leslie Roberts and MacFayden, 
 found that the fungus produced a keratolytic substance which, eroding 
 the outer surface of the shaft, permitted it to enter the substance of 
 the hair. But it hardly seems necessary to invoke any process beyond 
 a purely mechanical one, by which the elements of the parasite insinuat- 
 
422 DISEASES OF THE SKIN 
 
 ing themselves beneath the free border of the cells of the cuticle are 
 enabled to penetrate the hair. 
 
 In all the varieties of ringworm the horny cells of the epidermis 
 are first invaded, the hairs being attacked later when the mouths of 
 the follicles are reached. 
 
 The Epidermophyton inguinale, the parasite present in ringworm 
 of the thighs and axillae (Fig. 144), the so-called eczema marginatum, 
 and in certain inflammatory ringworms of the hands and feet, although 
 morphologically and culturally closely akin to the trichophytons, 
 presents some characteristic features which separate it from these 
 fungi. It is confined to the epidermis, where it occurs as mycelial 
 threads (Fig. 145) with rectangular double-contoured joints having a 
 transverse diameter of 4 to 5 microns and somewhat variable length. 
 Even in hairy regions, such as the pubis and the axilla, the hairs remain 
 free, a fact noted by Hebra. Cultures are of slow growth, have a 
 downy surface, with a slightly eccentric, hood-like elevation, are 
 
 divided by a number of radiating 
 furrows, and are of a characteristic 
 greenish-yellow color. 
 
 Pathological Anatomy. — In the 
 scalp and beard, as the result of their 
 invasion by the fungus, the nutrition 
 of the hairs is soon interfered with ; 
 they become bent and twisted, are 
 split longitudinally by the growth of 
 the mycelium and spores between 
 their fibres, and in consequence, break 
 off readily, leaving stumps with 
 brush-like ends projecting a short dis- 
 Fig. 144.— Epidermophyton inguinale. tance above the surface of the scalp ; 
 
 From tinea cruris, ringworm of the thighs. n 1 1 t r i 
 
 eventually they are loosened from the 
 hair papilla and fall out spontaneously while those remaining may 
 be readily extracted (Fig. 146). 
 
 In the superficial forms of ringworm such as occur upon the scalp 
 and smooth surfaces, the tissue changes are usually trivial ; there is 
 a moderate hyperemia with a very slight exudation of cells in the 
 papillae of the corium and between the cells of the epidermis, and a 
 moderate degree of parakeratosis producing more or less desquamation. 
 Not uncommonly there is a moderate intercellular oedema in the rete 
 with the formation of vesicles and crusts ; these changes are present 
 only in the early stages, and as a rule soon disappear. 
 
 In the deep form of ringworm, trichophytosis profunda, the changes 
 are much more decided and extensive. In kerion and agminate fol- 
 liculitis there are all the features of a folliculitis and perifolliculitis 
 with suppuration of the follicles and the formation of miliary abscesses 
 in the epidermis ; occasionally the follicle is completely destroyed. 
 Spores and mycelia, the latter principally, are present within the fol- 
 
VEGETABLE PARASITES 
 
 423 
 
 licule, and within and around its walls are numerous polymorpho- 
 nuclear leucocytes and lymphocytes. Majocchi has described intra- 
 dermic lesions presenting the histological features of a granuloma, due 
 
 Pig. 145. 
 
 -Tinea cruris, ringworm of the thighs. Fungus, Epidermophyton inguinale, in the horny layer 
 of the epidermis. 
 
 to the invasion of the corium by the trichophyton. Sabouraud be- 
 lieves the granuloma of Majocchi occurs about fragments of hair which 
 have accidentally penetrated the derma; he does not believe that the 
 
 Fig. 146. — Trichophytosis. Ring of spores around hair. 
 
 trichophyton ever actively invades the corium. The author is quite 
 convinced, however, from his own observations, that, quite exception- 
 ally it is true, the fungus may break through the walls of the follicle 
 
424 
 
 DISEASES OF THE SKIN 
 
 and invade the derma ; he has seen one undoubted instance of this 
 (Figs. 147 and 148). 
 
 Plato found that by employing a nitrate of cultures made from the 
 organism present in the deep form of trichophytosis (which he calls 
 " trichophytin ") he could produce a general and local reaction in those 
 suffering from deep trichophytosis, and that an unmistakable therapeu- 
 tic effect followed the reaction ; these results were confirmed later by 
 Trufn. Bruhns and Alexander, following the observation of Jadas- 
 sohn that peasants who once had bovine trichophytosis seemed to have 
 acquired immunity for that affection, found that a partial immunity 
 followed inoculation with cultures of certain of the trichophytons. 
 
 ;#■ 
 
 Pig. 147. — Deep trichophytosis. (Trichophytosis profunda.) Hair follicle filled with cellular debris 
 and mycelia, M, the latter breaking through the bottom of the follicle. 
 
 It would seem, therefore, that this organism, like other pathogenic 
 organisms, produces immunizing substances. 
 
 Treatment. — Ringworm of the Scalp. — The utilization of the 
 extraordinary depilatory properties of the Rontgen rays by Sabouraud 
 in the treatment of ringworm of the scalp marked a very great advance 
 in the therapeutics of this usually obstinate and troublesome malady. 
 The comparative rapidity, ease, and certainty with which a cure may 
 be obtained by the proper use of this agent make it the remedy of 
 choice, especially in institutions where large numbers of children are to 
 be treated ; but it must be said at once that it is not a remedy to be used 
 by the inexperienced nor the careless, since in such hands it is capable 
 of producing disastrous results. The essential feature of X-ray treat- 
 ment is the exposure of the diseased area, at a single sitting, to the 
 
VEGETABLE PARASITES 425 
 
 action of the ray for a length of time just sufficient to produce com- 
 plete temporary loss of hair without the production of a dermatitis, the 
 average duration of a sitting being about fifteen minutes. The dura- 
 tion of the sittings should be controlled by a suitable measuring device, 
 such as the radiometer of Holzknecht or the pastiles of platino-barium 
 cyanide devised by Sabouraud and Noire. The hair should be cut 
 short and the sound portions of the scalp protected by diaphragms 
 of sheet-lead with openings for the areas to be rayed, or, what is much 
 more convenient, the X-ray tube is enclosed in a hood composed of 
 some material impervious to the rays, provided with an opening 
 through which the rays are directed, the size of which may be varied 
 
 M 
 
 M 
 Fig. 148. — Trichophytosis profunda. (Deep trichophytosis.") M, mycelia in the bottom of the hair 
 
 follicle. Same section as Fig. 147. 
 
 according to the size of the patch to be treated. In the method used 
 by Sabouraud the scalp is placed 15 cm. from the anode of the tube 
 (or centred and kept at this distance during the seance, and a pastile 
 of platino-barium cyanide contained in a special holder is placed 
 midway between the scalp and the anode. When the pastile has lost 
 its greenish-yellow color and has become a color corresponding to 
 the standard tint " B " of Sabouraud or to 4 or 5 " H " of the scale of the 
 Holzknecht meter, the sitting should be ended. When there are a 
 number of patches, care must be taken that the irradiated areas do not 
 overlap, which is best prevented by covering the patches already treated 
 with disks of sheet-lead which may be conveniently held in place by 
 rubber bands. 
 
426 DISEASES OF THE SKIN 
 
 Fifteen to twenty days after a properly made exposure the hair 
 begins to fall, and depilation is complete in about ten days. When 
 the hair begins to fall the scalp should be washed daily with tar, 
 salicylic acid or sulphur soap and warm water, and afterwards anointed 
 with an ointment containing one-half drachm (2.0) of ammoniated 
 mercury to the ounce (32.0), or one-half drachm (2.0) precipitated 
 sulphur to the ounce (32.0). The hair begins to grow again after 
 about two months, and is completely restored at the end of four. When 
 there are small patches scattered over the greater part of the scalp it 
 may be best to depilate the entire scalp ; when this is to be done, the 
 method devised by Kienboeck as modified by Adamson, may be em- 
 ployed by which this may be accomplished in five sittings. Five points 
 are selected — one anteriorly, 3 to 4 cm. within the border of the hair 
 over the centre of the forehead ; a second posteriorly, 3 to 4 cm. above 
 the centre of the lower border of the occipital region ; a third midway 
 between these two on the vertex, and one on each side of the head 
 3 to 4 cm. above the ears. By directing the rays upon each one of these 
 points in succession, giving each one a depilatory dose, all portions 
 of the scalp will be equally exposed. As the rays fall obliquely and 
 therefore with diminished intensity upon the overlapping parts, owing 
 to the curved surface, the actual amount of rays received by these is 
 no more than equal to that received by the portions of the scalp 
 upon which the rays fall directly. 
 
 If for any reason the X-ray treatment cannot be employed, recourse 
 must be had to the older method of treatment which consists essen- 
 tially in the application of parasiticides in the shape of ointments or 
 lotions, preferably the former, to the diseased areas, for the purpose 
 of destroying the fungus or inhibiting its growth. 
 
 The hair should be cut short before beginning the treatment, 
 since this greatly facilitates the application of the lotions or ointments 
 selected, and, what is of great importance, it enables the physician 
 to see small patches which would escape notice if the hair were long. 
 While it is desirable for the reasons given to have the hair short, it 
 should not be shaved, since if this is done the diseased and healthy 
 areas can no longer be readily distinguished from one another. De- 
 pilation is without doubt a valuable auxiliary in the treatment, since it 
 not only gets rid of a considerable quantity of fungus, but by emptying 
 the follicles it enables the local applications to penetrate more readily 
 and more deeply into them. This is most conveniently performed with 
 a broad-bladed pair of forceps; and each seance should be followed 
 by the application of the parasiticide lotion or unguent selected. The 
 scalp should be washed every three or four days, employing a sulphur- 
 salicylic acid soap, or a tar soap of good quality, and hot water. Daily 
 washings as advocated by some authors are not necessary, and more- 
 over remove the parasiticide ointment or lotion, which in order to pro- 
 duce the best effect should be continuously in contact with the diseased 
 areas. 
 
VEGETABLE PARASITES 427 
 
 To prevent the spread of contagion, especially in schools and other 
 institutions for children, the patient should wear constantly a close- 
 fitting cap made of some material such as oiled silk, and, when pos- 
 sible to prevent it, should not come in contact with other children. 
 
 Ointments are usually more effective than washes for the reason 
 that they can be more effectively applied and can be made to more 
 readily penetrate the hair-follicles where the fungus is seated. Solu- 
 tions of parasiticides in alcohol, ether, or chloroform penetrate the 
 follicles much more readily than watery ones and should always be 
 preferred to the latter. 
 
 The number of parasiticide substances which may be employed is 
 considerable. Sulphur, the various salts of mercury, such as the 
 bichloride, the biniodide, nitrate, ammoniated mercury, oleate, iodine, 
 betanaphthol formalin, picric acid, chrysarobin, oleate of copper, are 
 some of the drugs which may be employed with more or less good 
 effect. Success depends not so much upon the selection of any one 
 of these, as upon the intelligence and perseverance with which the 
 treatment is carried out. 
 
 Iodine is usually employed in alcoholic solution. Either the 
 ordinary tincture of full strength or somewhat diluted is painted upon 
 the patches once or twice daily. Dissolved in oil of tar or oil of 
 cade (two drachms to the ounce, 8.0 to 32.0) it forms an application long 
 in use in England known as Coster's paste ; this is thoroughly rubbed in 
 with a stiff brush daily, removing the blackish crust which forms after a 
 few days, before making further applications. Jackson recommends 
 an ointment containing one drachm in an ounce (4.0 to 32.0) of goose 
 grease which penetrates more readily than other fats, applying it 
 twice a day. In the author's experience this remedy has proven more 
 effective than any other. 
 
 Sulphur is an old and effective remedy and is best applied as an 
 ointment, 10 to 20 per cent., thoroughly rubbed in twice a day. 
 
 Betanaphthol in an ointment containing 10 to 12 per cent, is a most 
 useful remedy and one which rarely produces any undue amount of 
 inflammatory reaction, even after prolonged use ; it should be thor- 
 oughly rubbed in once a day. 
 
 Of the mercurial preparations the bichloride of mercury is the 
 most efficient. This is best employed in alcoholic solution, 2 : 1000 to 
 5 : 1000, painted on with a brush. Considerable irritation usually fol- 
 lows the applications of the stronger solutions after a time ; if this 
 occurs, they should be suspended, and some mild ointment applied 
 until the inflammation subsides. It should be kept in mind that the 
 use of such solutions is not entirely devoid of danger from absorption. 
 Ammoniated mercury as a 5 to 10 per cent, ointment is likewise a use- 
 ful application, especially in the cases attended by pustular lesions. 
 The oleate of mercury in full strength (20 per cent.) or diluted is 
 another useful mercurial preparation, but is apt to produce considerable 
 irritation after a time ; it should be well rubbed in, as other ointments. 
 
428 DISEASES OF THE SKIN 
 
 Chrysarobin is an efficient parasiticide and may be used either as an 
 ointment containing 3 to 10 per cent., or it may be applied in saturated 
 solution in chloroform repeatedly painted on until a film of chrysarobin 
 powder covers the patch, which is then to be painted over with collo- 
 dion, as recommended by Stelwagon. In using this remedy care must 
 be taken that a severe dermatitis is not produced, and especially that it 
 does not get into the patient's eyes. 
 
 Picric acid in a 50 per cent, solution of camphor in alcohol, as 
 recommended by Williams, painted on the patches with a brush twice 
 a day, is an effective remedy ; the formula advised by Williams is as 
 follows : 
 
 Camphor, 
 
 Spt. vin. rect aa Siv (120.0) 
 
 Acid picric gr. vij (0.50) 
 
 The chief, indeed the only, objection I have found to this application is 
 the intense yellow stain which it imparts to everything it touches. 
 Formaline, a 40 per cent, solution of formaldehyde, is another effective 
 parasiticide which has been recommended in the treatment of ring- 
 worm of the scalp. This should not be employed in full strength, 
 but should be diluted with water, 1 : 10, or, better, glycerin, 1:5, as 
 less irritating, and thoroughly brushed with a stiff brush. The great 
 irritation which usually follows this remedy limits its usefulness very 
 much, and it should not be used over large areas, but on small circum- 
 scribed patches. Not uncommonly a combination of two or more parasiti- 
 cides seems to be more effective than either one alone ; thus, the addition 
 of salicylic acid to ointments of sulphur, of betanaphthol, or chrys- 
 arobin materially enhances their effects ; combinations of mercury and 
 iodine, or tar and sulphur, at times do better than either one alone. 
 Stelwagon finds a solution of mercuric biniodide, one to three grains 
 (0.65-0.20) to the ounce (32.0) of tincture of iodine, one of the best 
 applications in young children or in recent cases, painting it on two 
 or three times daily. One or two drachms (4.0 or 8.0) of sulphur in 
 the ounce (32.0) of the officinal tar ointment is often a most useful, 
 although dirty, application. In obstinate cases applications of croton 
 oil which produce a folliculitis resembling that which occurs at times 
 spontaneously may be applied, either pure or diluted every day or two 
 until a pustular folliculitis is produced. When this appears, the oil 
 must be suspended and a poultice applied. Hairs loosened by the 
 folliculitis should be extracted. This method is painful and should not 
 be employed in the case of young children ; the oil should be applied 
 by the physician himself in order to avoid accidents. There is danger 
 that areas of scarring with consequent permanent baldness may result 
 if the inflammation becomes too severe. 
 
 In the treatment of the more inflammatory forms, and in the deep- 
 seated variety with swelling known as kerion, the milder parasiticide 
 applications, such as a solution of sodium hyposulphite one drachm 
 (4.0) to the ounce (32.0) of water, or comparatively weak ointments 
 
VEGETABLE PARASITES 429 
 
 of sulphur or ammoniated mercury should be employed at first ; and 
 as the inflammation subsides the stronger ointments or lotions may 
 be resorted to as in the ordinary types. In very inflammatory cases 
 the continuous application of a saturated solution of boric acid applied 
 on lint covered with oiled silk may be used for a few days before trying 
 more active remedies. 
 
 Ringworm of The Beard. — In the treatment of ringworm of the 
 beard the same local remedies are to be employed as in ringworm of 
 the scalp, but somewhat weaker. If crusts are present, these should 
 be removed by the application of olive oil or vaseline containing 2 to 
 3 per cent, carbolic acid, followed by washing with soap and hot 
 water; or if there is much swelling and tenderness, a starch poultice 
 made up with a saturated solution of boric acid instead of plain water 
 may be applied for twelve to twenty-four hours. In this variety of 
 the malady depilation is even more useful than in ringworm of the 
 scalp, and, owing to the thickness and stiffness of the hairs and their 
 looseness, is more readily performed than in the latter region. In ad- 
 dition to the extraction of all loose hairs, the beard should be shaved 
 daily or every other day, or at least kept as short as possible by clipping 
 with scissors. Parasiticide lotions or ointments may be used. A solu- 
 tion of sodium hyposulphite, one drachm (4.0) to the ounce (32.0) of 
 water may be mopped on three or four times a day ; or a solution of 
 mercuric bichloride, I :iooo or 1 12000, the strength depending upon the 
 sensitiveness of the skin and the severity of the inflammation, may be 
 applied in the same manner. Sulphur ointment, one drachm (4.0) to 
 the ounce (32.0) of cold cream or of equal parts of lanoline and vase- 
 line, is a very effective application ; this should be gently rubbed in once 
 or twice a day. An ointment of ammoniated mercury, 45 to 60 grains 
 (3.0 to 4.0) to the ounce (32.0) of ointment base, is another useful 
 remedy. An effective method of treatment is to use both a lotion and an 
 ointment, the former to be applied during the day two or three times, 
 the latter at night upon retiring ; thus, a lotion of hyposulphite of soda 
 may be softly mopped on several times a day, and an ointment of 
 sulphur such as has been mentioned above, thoroughly rubbed in at 
 bedtime. Or a lotion of bichloride of mercury, 1 12000, may be applied 
 to the entire region, except the upper lip, two or three times a day with 
 a mop of absorbent cotton, and an ointment of ammoniated mercury, 
 one drachm (4.0) to the ounce (32.0), applied at night with gentle 
 friction. 
 
 Ringworm of Non-Hairy Parts. — The treatment of ringworm of non- 
 hairy parts, the so-called smooth surfaces, is a much less complicated mat- 
 ter than that of the scalp and beard. , With the exceptions already noticed, 
 the disease is much more superficial than in the latter regions and the 
 amount of inflammation often trivial, the application of the parasiticides 
 much easier, and their effect upon the fungus much more prompt. The 
 hyposulphite of soda solution with a few minims of glycerin to the ounce 
 (32.0) already mentioned, or tincture of iodine, painted upon the patch 
 once a day, will usually suffice to bring about the disappearance of the 
 
430 DISEASES OF THE SKIN 
 
 disease within a comparatively short time. The bichloride of mercury 
 solution, i : iooo, in water is a cleanly and effective application. Among 
 ointments, one containing a drachm (4.0) of precipitated sulphur to the 
 ounce (32.0), well rubbed in twice a day, is usually effective; an am- 
 moniated mercury ointment, 45 to 60 grains (3.0 to 4.0) to the ounce 
 (32.0), is equally efficacious. 
 
 In ringworm of the thighs and axilla, the so-called eczema mar- 
 ginatum, the solutions or ointments must frequently be considerably 
 diluted owing to the amount of inflammation present and the conse- 
 quent irritability of the skin. In this form of the malady the solution 
 of hyposulphite of soda is especially useful, but it should not be used 
 stronger than one drachm (4.0) to the fluid ounce (32.0), and even in 
 this strength it will sometimes irritate so that its use must be sus- 
 pended for a day or two. As a rule, washes do better than ointments 
 in this variety of ringworm since the latter, unless made up with min- 
 eral fats, speedily become rancid and add to the irritation. If the in- 
 flammation is not too great, the patches may be lightly painted with 
 diluted tincture of iodine once a day. The author has recently employed 
 a 2-per-cent. solution of salicylic acid in 70 per cent, alcohol with 
 great satisfaction ; it cures promptly, is cleanly and without odor, and 
 seldom irritates. 
 
 In the deep forms of ringworm occurring upon the hands and 
 arms, arising from the lower animals, the same precautions as to the 
 strength of the applications should be observed as in the other un- 
 usually inflammatory forms. 
 
 In the eczematoid ringworm of the hands and feet, one of the most 
 efficacious applications is the ointment of salicylic acid (3 per cent.) 
 and benzoic acid (5 per cent.) recommended by Whitfield, but it 
 must be used with some degree of care, since it frequently produces 
 so much dermatitis that it must be suspended for a time. 
 
 In ringworm of the nails, as much of the diseased nails should be 
 trimmed away as possible and the remainder scraped quite thin. 
 They should then be immersed daily in a hot solution of bichloride 
 of mercury, 1 : 2000, for twenty minutes, and afterwards wrapped up 
 in an ointment of ammoniated mercury, one drachm to the ounce (4.0 
 to 32.0). Prolonged immersion in a saturated solution of sodium hypo- 
 sulphite, followed by the application of a sulphur ointment, one drachm 
 to the ounce (4.0 to 32.0), spread upon lint, may also be employed. In 
 cases which resist less heroic measures, avulsion of the nails may be 
 performed under an anaesthetic, followed by daily applications of tinc- 
 ture of iodine (10 per cent.). Sabouraud recommends dressing the dis- 
 eased nails with the following solution : Iodine, .05 ; iodide of potassium, 
 I.o; distilled water, 100.0, every night, covering it with protective. 
 
 TINEA IMBRICATA 
 
 Synonyms. — Tokelau ringworm ; Bowditch Island ringworm ; 
 Gune; Herpes desquamans ; Cascadoe. 
 
 Definition. — Tinea imbricata is a parasitic disease of the tropics 
 
VEGETABLE PARASITES 431 
 
 characterized by patches of imbricated, papery scales arranged in 
 concentric rings. 
 
 Symptoms. — The disease begins as small slightly elevated round or 
 oval brown patches, in the centre of which the epidermis splits and 
 loosens as the patches enlarge, forming rings of tissue-paper-like 
 scales. When these rings have reached about one-half inch in di- 
 ameter, a new small brown patch appears in the centre, which under- 
 goes the same evolution as the first one, and this is repeated a number 
 of times until the patches contain as many as seven or eight concentric 
 rings. According to Koniger and Tribondeau, the eruption begins as 
 rings of papules or papules and vesicles, accompanied by severe itching, 
 followed by desquamation. The disease extends with considerable rapid- 
 ity, the patches growing in diameter from one-quarter to one-half inch a 
 week; and as they enlarge adjacent patches frequently intersect, forming 
 gyrate and serpiginous patches of considerable extent, covering, in long- 
 standing cases, the greater part of the trunk and extremities. The 
 scales are quite large and thin, with the free edge toward the centre 
 of the patch slightly curled up, while adherent on the outer edge, 
 producing an appearance somewhat like the arrangement of tiles on 
 a roof (Fig. 149). Occasionally the ringed arrangement disappears 
 after a time, or may be absent from the beginning, the disease then 
 appearing as a diffuse, widespread, abundant desquamation. In old 
 cases the scales, instead of being thin and paperlike, are thick and 
 horny, causing the skin to appear as if coated with clay, hence one of 
 the native names for the malady meaning clay-covered. When the 
 scales are removed the skin beneath is seen to be covered with num- 
 erous dark concentric rings and serpiginous lines which remain for 
 a long period and may be permanent. 
 
 While every part of the cutaneous surface may be attacked, the 
 face and scalp commonly escape. According to most authors, the 
 hair follicles and the hairs are not affected, although Koniger asserts 
 that the hair of the body is practically destroyed on those parts where 
 the disease exists. Castellani has observed that the nails, too, may 
 be involved, becoming greatly thickened, contrary to the statement 
 of Tribondeau that these as well as the hair are always exempt. In- 
 tense itching accompanies the disease, which is greatly increased by 
 high temperature and by certain articles of food, such as fish. Accord- 
 ing to Castellani, a moderate eosinophilia is present, most marked in 
 old and extensive cases, and occasionally signs of anaemia. The pa- 
 tient's general health seems to be little, if at all, affected. The malady 
 occurs only in tropical regions, where the humidity and temperature 
 are high and the latter is subject to but little variation. It prevails 
 in the Malay Peninsula and Malay Archipelago, in Burma, southern 
 China, and the islands of the South Pacific. As has been pointed out 
 by Manson, its distribution corresponds closely with that of the co- 
 coanut tree. 
 
 Etiology. — The cause of the affection is a parasitic fungus resem- 
 bling in many of its characters the trichophyton ; indeed, Sabouraud 
 
432 
 
 DISEASES OF THE SKIN 
 
 considers it a large-spored variety of this organism but little different 
 from the large-spored European trichophyton of animal origin. Its 
 etiological relationship to T. imbricata was first demonstrated by 
 Manson in a series of inoculation, experiments in which he succeeded 
 
 Fig. 149. — Tinea imbricata (R. Koch). 
 
 in reproducing the malady. The fungus is present in great abundance 
 and is found only in the epidermic scales where it forms an interlacing 
 network of mycelia, with comparatively few spores. Castellani, who 
 has recently studied the organism as it is found in Ceylon, would 
 create a new genus for which he proposes the name Endodermophyton, 
 
VEGETABLE PARASITES 433 
 
 of which two species are found, viz., E. concentricum and E. indicum 
 (Fig. 150). ^ 
 
 Diagnosis. — The disease with which Tinea imbricata is most likely 
 to be confounded is ringworm of the body, or tinea circinata. In 
 ringworm the number of patches is usually small, often there is but 
 a single one, and the centre of the patches is usually clear, although 
 exceptionally there may be two or three concentric rings ; scaling is 
 slight, and itching, if present at all, is trivial. In tinea imbricata, on 
 the other hand, the disease is usually widely disseminated, the greater 
 part of the trunk and extremities often being covered; the patches 
 are made up of many concentric rings, and beneath the scales are 
 numerous pigmented concentric and sinuous lines ; the scales, which 
 are large and very abundant, show an imbricated arrangement, and 
 the itching is usually very severe. 
 
 It is sometimes mistaken for ichthyosis, but the large papery 
 
 scales are unlike those seen in this 
 affection ; and the readily demon- 
 strated fungus, which exists in 
 great abundance in the scales, 
 makes the differential diagnosis be- 
 tween these two affections an easy 
 one. 
 
 Treatment. — The clothing 
 should be thoroughly sterilized by 
 appropriate means, or, if these are 
 lacking, burned, which is perhaps 
 better than to attempt to sterilize 
 them. Manson found strong lini- 
 ment of iodine, about double the 
 strength of the formula of the 
 British Pharmacopoeia, an effective 
 remedy, a part of the trunk or a limb being covered at each applica- 
 tion. An ointment of chrysarobin containing from 5 to 10 per cent., 
 well rubbed in once a day, is likewise a very efficient parasiticide 
 application. Castellani recommends resorcin dissolved in compound 
 tincture of benzoin, one to two drachms (4.0 to 8.0), to the fluid ounce 
 (32.0), painted over the affected regions freely once a day. During 
 the treatment the patient is given a hot bath once or twice a week 
 and scrubbed with sand-soap. The same author finds formalin effec- 
 tive on small patches, but as it causes pain and severe inflammation 
 it must be used with care ; sulphur, recommended by some, has in his 
 experience been useless. 
 
 Prognosis. — While there are a number of remedies which are more 
 or less effective in killing the fungus, its great abundance and wide 
 distribution make treatment difficult and prolonged, and relapses are 
 common. In the early stages, however, when the patches are small 
 and limited in number, it may usually be readily checked by the use 
 01 any of the above-mentioned parasiticide applications. 
 28 
 
 Fig. 150. — Mycelia in tinea imbricata. 
 
434 DISEASES OF THE SKIN 
 
 ERYTHRASMA 
 
 This affection was first described by Burckhardt, in 1859, an d 
 again in 1862 by Barensprung, and has been studied more recently by 
 Balzer and Dubreuilh, Koebner, de Michele, Ducrey and Reale, and 
 others. 
 
 Definition. — Erythrasma is a disease due to a vegetable parasite, 
 affecting particularly regions in which skin surfaces are in contact, 
 such as the genito-crural and axillary regions. 
 
 Symptoms. — It occurs as rounded, rosette-like, or irregularly 
 shaped, non-elevated, slightly furfuraceous plaques with well-defined 
 borders which in the beginning are a bright-red color, but later be- 
 come a darker brownish-red. The disease is situated in the great 
 majority of cases in the inguinal regions and on the inner surface of 
 the upper thighs where they are in contact with the scrotum, in the 
 cleft between the buttocks, and in the axillae. Less frequently it is 
 observed in the bend of the elbows, beneath the breasts in women, 
 and in the folds of skin of the abdomen in the obese. Exceptionally 
 it spreads from these regions to the free surfaces of the skin on the 
 trunk and extremities, covering in rare cases considerable areas as 
 in the case seen by Besnier in which the eruption covered the thighs 
 and the upper arms. 
 
 Subjective symptoms are trivial, or may be wholly wanting, the 
 patient discovering the disease by chance ; occasionally there is slight 
 itching. 
 
 The course of the disease is slow, and its duration indefinite. Usu- 
 ally the patches after reaching moderate dimensions cease to enlarge, 
 or increase almost imperceptibly. 
 
 Etiology and Pathology. — Erythrasma, while apparently quite 
 common in certain parts of Europe, as in France, is decidedly infre- 
 quent in the United States. It is uncommon before puberty, and is 
 much less frequent in women than in men. 
 
 It is due directly to a parasitic fungus discovered by Burckhardt 
 in 1859, to which Barensprung later gave the name Microsporon min- 
 utissimum. This fungus, which is found only in the horny layer of the 
 epidermis, belongs to the order of hyphomycetes, and consists of 
 slender, irregularly jointed, non-branching threads with cylindrical 
 swellings which form an abundant interlacing network, in the meshes 
 of which are scattered small numbers of minute spores. The mycelia 
 or threads are unusually slender, measuring according to Sabouraud 
 from .8 to 1.3 microns in diameter. 
 
 De Michele succeeded in transmitting the disease to healthy in- 
 dividuals by inoculating cultures of an organism obtained from the 
 scales, but Ducrey and Reale failed in similar attempts. The latter 
 authors found an organism presenting characteristics like those of 
 the Microsporon minutissimum in the skin of sound individuals, and 
 think, consequently, that special conditions of soil, etc., are necessary 
 to produce the disease. 
 
 Diagnosis. — The affection may at times bear considerable resem- 
 
VEGETABLE PARASITES 435 
 
 blance to tinea versicolor ; indeed, it was at first thought by a number 
 of authors to be a form of this disease, but its red color, its usual lim- 
 itation to the genitocrural region and the axillae ; the slight tendency 
 which it shows to spread to other regions, and the microscopic ex- 
 amination serve to distinguish it from that malady. In tinea cruris 
 the oftentimes considerable inflammation accompanied by more or 
 less marked itching, and the easily demonstrated presence of the 
 epidermophyton, an organism which is quite unlike the Microsporon 
 minutissimum, will serve to prevent mistake. 
 
 Treatment. — Erythrasma does not readily yield to treatment ; and 
 relapses after apparent cure are frequent. Parasiticide lotions 
 such as a solution of hyposulphite of soda, one drachm (4.0) to the 
 fluid ounce (32.0), or a solution of mercuric bichloride, 1 15000, may 
 be used with good effect ; or the patches may be painted daily with 
 tincture of iodine. Behrend found a 10-per-cent. chrysarobin oint- 
 ment act as a specific, producing a cure in a few days; of course, such 
 an ointment should be used with caution in regions like the groin, 
 where its use is likely to cause more or less severe dermatitis. 
 
 PINTA 
 
 Synonyms. — Mai de los pintos ; Mai del pinto; Caraate ; Quirica; 
 Spotted sickness ; Fr., Carate. 
 
 Definition. — A contagious disease endemic in certain parts of tropi- 
 cal America, particularly in Mexico, Central America, and the north- 
 ern portion of South America, characterized by scaly, variously col- 
 ored patches. 
 
 Symptoms. — The disease usually begins upon the uncovered parts, 
 such as the hands and face, but may occupy any part of the skin ex- 
 cept the palms and soles. According to some authors, in exceptional 
 cases general symptoms, such as fever, headache, and gastric dis- 
 turbance, precede the eruption, which appear some weeks later ; the 
 correctness of this observation is, however, somewhat doubtful. The 
 eruption consists of scaly patches of various colors; some are red, 
 others a grayish-blue or violet, black, or a dull white. All the patches 
 may be of one color, or all these colors may be present at one time, 
 giving a very striking piebald appearance to the skin. The color of 
 the individual patches, however, does not change, but remains the 
 same throughout the disease. The extent of the eruption varies; it 
 may be limited to a few small patches or there may be many which, 
 eventually coalescing, cover the entire cutaneous surface. The 
 patches vary much in shape and arrangement; they may be round or 
 irregularly shaped, well circumscribed or ill-defined. In old cases 
 the skin is dry, rough, and desquamating; and in the red form there 
 may be thickening, with hyperkeratosis, fissuring, and ulceration, 
 particularly in the flexures of the joints ; the mucous membranes 
 adjoining the skin may eventually be involved. When hairy parts 
 are attacked, the hair becomes thin and loses its color, as in patches 
 of vitiligo. Itching, which at times precedes the appearance of the 
 
436 DISEASES OF THE SKIN 
 
 discoloration, is at first moderate, but as the disease progresses be- 
 comes severe. A disagreeable odor accompanies the malady, which 
 has been compared to that given off by mildewed linen, or to the urine 
 of the cat. 
 
 The course pursued by the disease is a chronic one, but the several 
 varieties present some differences in this respect. In the red form 
 the patches spread very slowly, or may even remain without much 
 change for a considerable time, while the blue and black forms spread 
 rapidly and may cover large areas in a short period. 
 
 Etiology and Pathology. — Pinta is found only in hot and moist 
 climates. Neither age nor sex seems to exert any influence upon its 
 occurrence ; it occurs at all ages and in equal numbers in the two sexes. 
 According to Montoya Florez, the blue and black varieties are found 
 chiefly in negroes, while the red form attacks principally whites. It 
 is seen chiefly among the dirty and ill-cared-for and in those who work 
 outdoors. Gastambide has described a fungus consisting of pigmented 
 spores and mycelium found in the epidermis which he believed to be 
 the cause of the malady. Montoya y Florez, who has made careful 
 and extensive studies of it as it occurs in Colombia, was not able to 
 confirm Gastambide's findings. He regards the several varieties of 
 the affection as aspergilloses of the skin due to an aspergilloid fungus 
 which is found in the epidermic scales as long, slender, smooth, dicho- 
 tomous threads which in place form a close network. This fungus 
 is probably a saprophyte, since Montoya has found in mine-water and 
 in certain varieties of the mosquito and other insects a fungus identical 
 with that present in the violet patches. In the blue and black forms, 
 only the more superficial portions of the epidermis are affected ; but 
 in the red and white patches, the deeper portion of the epidermis and, 
 according to Iryz, the corium are involved. In all probability the 
 white patches do not represent active disease, but are a secondary 
 leucoderma resulting from the destruction of the normal pigment by 
 the fungus. 
 
 Diagnosis. — The diagnosis presents few or no difficulties. The 
 peculiar colors of the individual patches and the frequent parti-colored 
 effect of the eruption as a whole, together with the presence of the 
 fungus in the scales, are features by which it is easily distinguished 
 from other affections. 
 
 Treatment. — The treatment, which is practically that of other 
 mycotic diseases of the skin, consists in the application of parasiticide 
 ointments and lotions to the diseased areas. Montoya finds that in 
 the superficial blue and black forms and in cases not over six months 
 old, tincture of iodine painted on the patches once a day is promptly 
 curative. In older cases he paints a 10 per cent, solution of chrysarobin 
 in chloroform over the patches, at first every four, later every eight 
 days, painting traumaticine over the chrysarobin after the chloroform 
 has evaporated. According to Barbe, citrine ointment is the remedy 
 most employed in Colombia, two applications to each patch being suffi- 
 cient for a cure ; of course, mercurial ointments must be used cau- 
 tiously over large surfaces or mercurialism may follow. 
 
CHAPTER X 
 INFLAMMATIONS DUE TO ANIMAL PARASITES 
 
 PEDICULOSIS 
 
 Synonyms. — Phthiriasis ; Morbus pedicularis ; Lousiness ; Fr., 
 Phthiriase ; Ger., Lausesucht. 
 
 Definition. — A disease of the skin due to an animal parasite, the 
 pediculus, characterized by a multiform eruption chiefly of secondary 
 character the result of scratching. 
 
 The pediculus is an apterous insect belonging to the family of 
 Pediculidse, of which there are three varieties parasitic in man : Pedicu- 
 lus capitis, Pediculus corporis, or, more accurately, Pediculus vesti- 
 mentorum, and Pediculus Pubis, found respectively as their names indicate 
 in the scalp, the clothing, and the pubic region. As a rule to which there 
 are only occasional exceptions, each variety is confined to its own particular 
 region, seldom invading any other. 
 
 Pediculosis Capitis. — In the beginning of the disease when the parasites 
 are few in number the only symptoms are itching of the scalp, and ova or 
 " nits " on the hairs. In a short time, however, scratching produces a 
 variety of secondary lesions, such as 
 excoriations, pustules, oozing, and 
 crusted patches, in the average case 
 most abundant in the occipital region, 
 although every portion of the scalp 
 may be affected. In women and girls 
 the back of the neck below the mar- 
 gin of the hair is often the seat of • * 
 a somewhat characteristic erythema- * 
 
 tous and finely papular eruption with 
 numerous scattered, minute blood 
 crusts. In long-standing, neglected 
 cases, such as are seen in the careless 
 and dirty poor, the entire scalp is 
 
 Covered with pustules and CrUStS COm- Fig. is i.— Pediculus capitis. 
 
 posed of dried pus, serum, and blood, beneath which it is raw and oozing 
 and in which are myriads of pediculi. The hairs, which are inextrica- 
 bly matted together, contain great numbers of ova which at a little dis- 
 tance make them look as if covered with dust. Not infrequently the 
 posterior cervical glands are swollen, especially in children, and some- 
 times suppurate. 
 
 Etiology. — Pediculosis capitis is much more frequent in children 
 than in adults, and in the poor and badly-cared-for than in the well- 
 to-do and the cleanly (Fig. 151). Women are oftener affected than men, 
 
 437 
 
438 
 
 DISEASES OF THE SKIN 
 
 owing probably to their long hair. There is apparently but little doubt that 
 
 for unknown reasons, acquire pediculi more readily 
 
 certain individuals, 
 than others. 
 
 The pediculus is grayish in color, an elongated oval in shape, 
 pp-" m ^ 1 and varies in length from 1.5 mm. to 3 mm., the 
 
 J| female being decidedly larger than the male. The 
 
 head is triangular in shape and is provided with two 
 jointed antennae; the abdomen, which is the largest 
 part of the parasite, has dark margins, and is divided 
 into seven segments by deep marginal notches. The 
 legs, which are six in number, are attached to the 
 thorax and are provided with hairs and terminal 
 claws. In the male the penis, which is wedge- 
 shaped, is on the dorsal surface of the last abdom- 
 inal segment. The ova or " nits " are grayish, some- 
 what lustrous, slightly translucent, pear-shaped 
 bodies attached to the shaft of the hair, with the 
 small end directed towards its root (Fig. 152). The 
 female lays from 50 to 60 ova, which are hatched 
 in six and are fully developed in twelve to fourteen 
 days. 
 
 Diagnosis. — Although the diagnosis of pedicu- 
 losis capitis can always be made without the slightest 
 difficulty if even ordinary care is exercised, it is 
 often mistaken for eczema of the scalp. Itching 
 of the scalp, accompanied by a pustular eruption in 
 the occipital region, should always lead to a search 
 for pediculi and ova or " nits " ; indeed, an eruption 
 of this character in children is almost certain to be 
 due to pediculi. 
 
 Treatment. — A popular and at the same time 
 ^very effective method of killing the pediculi and ova is to apply refined 
 petroleum (kerosene) to the scalp, a single thorough application usually 
 being sufficient. Care should be taken that it does not run down over 
 the forehead and neck, since it often causes considerable irritation when 
 applied to the non-hairy skin. Instead of using the petroleum alone it 
 may be mixed with balsam of Peru, one part of balsam to two of petro- 
 leum. A solution of bichloride of mercury, 1 : 500, in water or dilute 
 alcohol, is a cleanly and effective remedy ; it should be well sponged into 
 the scalp and hair once a day for several days in succession. Tincture of 
 coculus indicus, one part to three of alcohol, may be used effectively 
 in the same manner. For the pustular eruption which is so often 
 present on the scalp, nothing is better than an ointment of ammoniated 
 mercury, thirty grains (2.0) to the ounce (32.0), applied twice a day; 
 this ointment also exerts a decided parasiticide effect. The nits may be 
 loosened by washing the hair with solutions of bicarbonate of soda or 
 borax in warm water. Dilute acetic acid, ten to twenty minims to the 
 ounce (32.0) of water, may be used for the same purpose; or it may 
 
 Fig. 152. — Ovum pedic- 
 -ulus capitis containing em- 
 "ibryo. (Magnified) 
 
ANIMAL PARASITES 439 
 
 be added to the solution of bichloride of mercury mentioned above. 
 
 The hair in women and girls should not be cut off unless there is so 
 much matting that it is impossible to properly apply the necessary 
 remedies ; in men and boys it should be cut short. 
 
 Pediculosis Corporis. — Pediculosis corporis begins with itching of the 
 trunk and lower extremities, worse at night, and usually quite severe (Fig. 
 153). Within a little while secondary lesions, the chief of which are linear 
 excoriations (Fig. 154), covered with blood-crusts, make their appearance 
 over the shoulders, the sacrum, but- 
 tocks, thighs, and legs ; and scattered 
 pustules appear sooner or later as the 
 result of a secondary infection with 
 pus organisms. In alcoholics ecthe- 
 matous pustules are common on the 
 legs. The characteristic lesion, how- 
 ever, is a minute hemorrhage in the 
 skin appearing at the point where the 
 parasite has inserted his proboscis in 
 feeding. This punctate hemorrhage 
 must not be confounded with the 
 minute blood-crusts which result 
 from scratching the tops of small 
 papules ; the former, being in the 
 
 skin, cannot be felt, while the latter FlG ^.-Pediculus corporis. 
 
 make a slight elevation which is readily felt when the finger is passed 
 over it. In a considerable proportion of cases more or less marked 
 dermographism, with factitious urticarial wheals, is present ; indeed, one 
 of the most extraordinary examples of the former condition the author 
 has seen occurred in a man with body lice. The distribution of the eruption 
 is quite characteristic ; it is markedly more abundant over the shoulders, 
 around the waist, over the sacrum, and on the thighs than elsewhere, 
 while parts not readily reached by the patient's fingers, as between 
 the scapulae, often show little or nothing; uncovered parts, such as the 
 face and hands, are entirely exempt. In long-standing cases, especially 
 in the old, the skin is dry, in places decidedly eczematous and thick- 
 ened, and deeply pigmented, the so-called vagabond's disease When 
 the pediculi are very numerous there may be more or less elevation 
 of temperature, a symptom to which Jameson, and later Payne, have 
 called attention. 
 
 Etiology. — Pediculosis corporis is seen most commonly in the 
 middle-aged and old, the most aggravated examples being seen in the 
 aged poor; it is decidedly uncommon in children. 
 
 The pediculus corporis resembles very much the Pediculus capitis, 
 but has an oval head, and is decidedly larger. It dwells in the seams 
 and meshes of the clothing, where it lays its ova, and is found on the 
 skin only when it is feeding. 
 
 Diagnosis. — The numerous excoriations, most of which are linear, 
 the distribution of the eruption over the shoulders, the sacrum, and 
 
440 
 
 DISEASES OF THE SKIN 
 
 thighs, the presence of punctate hemorrhages in the skin presents a 
 characteristic picture readily recognized; indeed, if the patient is 
 stripped, the diagnosis can usually be made at a glance. While the 
 
 Fig. 154. — Pediculosis corporis. 
 
 parasites and the ova are usually readily found in the seams of the 
 clothing, the search is not always successful, especially when the 
 patient has recently changed his underwear. Since, according to. 
 
INFLAMMATIONS DUE TO PARASITES 441 
 
 Jamison, the ova are sometimes deposited upon the lanugo hairs, 
 these should be examined as well as the clothing in doubtful cases. 
 
 Treatment.— The most important procedure in the treatment of 
 pediculosis corporis is the thorough disinfection of the clothing and 
 the bedclothes, since the pediculi live in these and not upon the skin ; 
 indeed, in many cases this, with a bath, is quite sufficient to rid the 
 patient of his disease. After the disinfection of the clothing and a 
 bath with soap and hot water, a lotion containing two drachms (8.0) 
 of carbolic acid and an ounce (32.0) of glycerin to the pint (500.0) of 
 water may be applied twice a da}^ for three or four days. Or in order 
 to insure the destruction of stray pediculi and ova which may be on the 
 lanugo hairs, an ointment of staphisagria, two drachms (8.0) to the 
 ounce (32.0), or one of beta naphthol, 30 grains (2.0) to the ounce 
 (32.0), may be rubbed over the trunk and extremities for four or five 
 nights. 
 
 Pediculosis Pubis. — Pediculosis pubis, commonly known as crab 
 lice, is characterized by itching in the pubic region, accompanied by an 
 eruption of inflammatory papules, excoriations, and in the severer cases 
 by more or less eczematous inflammation of the pubes, the scrotum, and 
 inner surface of the upper thighs. The skin of the pubic region is sprinkled 
 with a considerable number of minute reddish granules, the excrement of 
 the parasite, particularly near the roots of the hair. Very special lesions 
 sometimes present, known as maculcc cccrulccc, the taches blcuatres 
 of the French, are bluish-gray macules or stains varying in size from 
 a pea to a finger nail, scattered about on the skin of the abdomen, 
 thighs, and sides of the thorax. These macules, which when present 
 are usually limited in number, are accumulations of pigment deposited 
 in the epidermis by the parasite, as has been proven by the experiments 
 of Duguet. Both Jamison and Payne have noted that cases in which 
 these stains are present usually suffer but little from itching. The 
 pediculus is usually found clinging to the hairs near the root with its 
 head partly buried in the mouth of the follicle ; the ova, which are 
 smaller than those of the other varieties of pediculi, are, like those of 
 the Pediculus capitis, attached to the hair-shaft. Occasionally the 
 parasites are found in the hair over the sternum, particularly in hairy 
 individuals, in the hair of the axillae, and exceptionally in the eyelashes 
 and eyebrows (Fig. 155). 
 
 Etiology. — Pediculosis pubis is, as a rule, for obvious reasons, seen 
 only in the adult, and is commonly contracted in sexual intercourse, 
 although it may be acquired in other ways. Quite exceptionally it is 
 seen in the eyelashes of children. 
 
 The parasite is smaller than the other varieties of pediculus, the 
 female being from 1 to 2 mm. long ; the male is only about half as 
 large. The head is an oblong oval seated directly upon the thorax, 
 which merges with the abdomen, the last being quite broad in compari- 
 son with its length. With the exception of the anterior pair, which 
 are slight, the legs are stout and provided with strong claws by which 
 
442 DISEASES OF THE SKIN 
 
 the parasite clings to the hair. The female lays from ten to fifteen ova, 
 which are hatched in a week, and the young are capable of procreation 
 in two weeks. 
 
 Diagnosis. — Itching in the pubic region should always suggest the 
 probability of pediculi as its cause and lead to a search for the parasite 
 and its ova, which are usually detected, when present, without much 
 difficulty. Maculae caeruleae are pathognomonic of pediculosis pubis, 
 as they are found in no other disease. 
 
 Treatment. — A very effective and at the same time a very dirty 
 method of treatment is the thorough application of mercurial ointment 
 to the regions affected, once a day for several days. Not uncommonly 
 this ointment excites a severe dermatitis which may extend far beyond 
 
 Fig. 155. — Pediculus pubis. 
 
 the region to which it has been applied, giving the patient much distress. 
 A solution of bichloride of mercury, 1 : 500, sponged on twice a day, is 
 much more cleanly and just as effective ; this also should be used with 
 some caution in order to avoid a mercurial dermatitis. If ten to 
 twenty minims of acetic acid are added to each ounce (32.0) of this 
 solution, it also serves to loosen the attachment of the ova to the hair 
 so that they may be removed by washing. Solutions of bicarbonate 
 of soda or of borax in warm water also serve the same purpose. The 
 pediculi may be destroyed at once by the vapor of chloroform applied 
 on a folded napkin, but if applied too long considerable inflammation 
 of the skin is apt to follow. When the pediculi are found in the eye- 
 lashes they should be picked off with fine forceps, and a rather weak 
 
ANIMAL PARASITES 443 
 
 ammoniated mercury ointment should be gently applied to the edges 
 of the lids for a few days. 
 
 CIMEX LECTULARIUS 
 
 Synonyms. — Bed-bug; Acanthia lectularia; Fr., Punaise des lits ; 
 Ger., Bettwanze. 
 
 This insect, belonging to the order of Hemiptera, is found in all 
 parts of the world, and its appearance is too well known to require 
 any detailed description. It lives in beds and bed-clothing, in the 
 crevices of walls and floors, in furniture, particularly in upholstered 
 furniture, and only goes upon the skin in search of food. Like other 
 members of this order its jaws are specially adapted for piercing and 
 sucking rather than actual biting. When the skin is pierced by the 
 proboscis of the bug, a wheal is produced in the centre of which is a 
 minute hemorrhagic point and surrounding which is an area of hyper- 
 emia ; more or less itching and burning follow the puncture. The 
 amount of inflammation varies a good deal according to the individual ; 
 in some there is little more than a hemorrhagic point, while in others 
 there is marked swelling accompanied by severe itching and burning. 
 In young children the punctures are frequently surrounded by exten- 
 sive areas of hypersemia so that bright-red patches half as large as the 
 palm may be produced when there are several " bites " close together. 
 The bites of the bedbug are sometimes mistaken for urticaria, but the 
 central hemorrhagic point, the usually comparatively limited number 
 of the lesions, and their duration will serve to distinguish them from 
 that affection. 
 
 Treatment. — The itching which follows the bites may be relieved 
 by the application of alkaline lotions, such as dilute ammonia, or solu- 
 tions of bicarbonate of soda or borax, 5 to 10 grains (0.32 to 0.65) to the 
 ounce (32.o) of water; phenol, 5 to 8 grains (0.32 to 0.52) to the ounce 
 (32.0) of water, is also effective. 
 
 PULEX IRRITANS 
 
 Synonyms. — Flea ; Fr., Puce commune ; Ger., Gemeiner Floh. 
 
 The flea is widely distributed, and is especially troublesome in warm 
 climates, where it may be the source of much annoyance. Its bite 
 produces a minute hemorrhage surrounded by an erythematous halo, 
 or less frequently a small wheal with a central hemorrhagic point. 
 When the bites are very numerous, particularly on the lower extremi- 
 ties, a purpuric eruption may be produced, which differs, however, 
 from the true purpuric eruption in showing minute dark hemorrhagic 
 points. More or less itching acco'mpanies the bites, but individual 
 susceptibility varies much ; in some the bite produces nothing more 
 than a trifling, very evanescent itching, while in others the pruritus 
 is extreme and lasts for some time. 
 
 The ordinary alkaline and phenol lotions usually employed for the 
 relief of pruritus may be used to allay the itching. 
 
444 DISEASES OF THE SKIN 
 
 Protection from the attacks of the insect may be afforded to some 
 extent by wearing small bags of camphor or sulphur under the clothing. 
 
 SCABIES 
 
 Synonyms. — Itch; Fr., Gale; Ger., Kratze. 
 
 Definition. — A contagious disease of the skin due to an animal para- 
 site, the Acarus scabei, characterized by a special lesion, the cuniculus 
 or burrow, and a multiform eruption accompanied by itching of a 
 severe grade. 
 
 Symptoms. — The disease begins with itching, usually worse at 
 night, speedily followed or accompanied from the beginning by an 
 eruption of papules, vesicles, and pustules which exhibit a decided 
 predilection for certain regions, these being, in order of frequency, 
 the sides and webs of the fingers (Plate XXX), the flexures of the 
 wrists, the anterior axillary folds, the abdomen, the inner surface of the 
 thighs, the penis in the male and the areola of the nipple in the female. 
 When it has existed for some time, this characteristic regional distribu- 
 tion is usually much less noticeable, since the eruption may then 
 occupy the greater portion of the cutaneous surface. However long 
 the disease may last, the face is always spared except in very young 
 infants, in whom this region may be, although infrequently, affected. 
 In cases of average severity in addition to the papules and vesicles 
 resulting from the burrowing of the female mite in the skin, there soon 
 appear numerous secondary lesions the result of scratching, and sec- 
 ondary pus infection, such as excoriations, crusting, eczematous 
 patches of variable extent, and pustules. 
 
 The distinctive lesion is the burrow or cuniculus, which is found 
 chiefly in regions where the skin is soft and delicate, as the sides and 
 webs of the fingers, the palms of the hands in children and in young 
 adults whose palms have not been hardened by manual labor, the 
 flexor surface of the wrist where it joins the palm ; less commonly the 
 areola of the nipple in women and the prepuce and glans penis in men. 
 They also occur, but much less frequently and abundantly, in other 
 regions, such as the anterior axillary folds, the umbilicus, and the 
 buttocks (Plate XXXI), in the last-named region especially in those 
 whose occupation compels them to sit several hours a day. This lesion, 
 which occurs as a sinuous or zigzag, rarely straight, usually dotted, 
 linear elevation of the epidermis, is, as its name indicates, a tunnel 
 from 2 mm. to 2 cm. long or even longer, made in the epidermis by 
 the female mite in which she deposits her ova as she travels along. 
 With the aid of a loup, or even with the naked eye, the mite may be seen 
 at one end of the burrow as a whitish or grayish dot which may be 
 extracted with a little care and good vision, with the point of a needle. 
 While burrows are present as a rule and may usually be readily found 
 in the localities named, there are exceptions, and one occasionally 
 looks for them in vain, commonly because they have been destroyed 
 by rubbing and scratching; in the very early stage of the malady they 
 may not have had time to be formed. 
 
PLATE XXX 
 
 Scabies. 
 
PLATE XXXI 
 
 Scabies. 
 
ANIMAL PARASITES 445 
 
 The extent, amount, and severity of the eruption vary greatly. 
 In the very early stages of the attack and in cleanly individuals there 
 may be but a limited number of papules and vesicles about the fingers, 
 in the axillae, and on the abdomen ; in long-standing cases and in the 
 uncleanly, even after a few weeks, there may be all the symptoms of 
 an extensive dermatitis, the entire trunk and extremities being covered 
 with papules, vesicles, pustules, scratch-marks, and crusts. In infants 
 and young children the hands and especially the palms frequently 
 present numerous rather large flat pustules which may quite excep- 
 tionally bear some slight resemblance to the pustules of variola, and 
 we have seen them mistaken for such (Fig. 156). While the face 
 remains free in adults, even in long-standing cases with widespread 
 
 r 
 
 
 ■ 
 
 Fig. 156. — Scabies. 
 
 and abundant eruption, it may be attacked in very young infants whose 
 faces are buried in the pillow or the mother's breast for a good part of 
 the time. Although the hands are as a rule the earliest and commonest 
 region to be attacked, they may be quite free from eruption in those 
 who wash them often or in those whose hands are covered with lime 
 and plaster, such as masons and bricklayers, or in machinists, whose 
 hands are covered with oil and grime. In dark-skinned individuals 
 in infrequent cases, a few scattered brownish-red, solid papules may be 
 found on the anterior axillary fold, on the belly, and the shaft of the 
 penis, which bear a considerable resemblance to syphilitic papules, but 
 differ from these in being the seat of severe itching. 
 
 Itching, which is usually worse at night, is a prominent symptom, 
 and is often so severe as to make sleep impossible. It is not always 
 in proportion to the amount and extent of the eruption ; patients with 
 
446 DISEASES OF THE SKIN 
 
 but a few lesions often suffer quite as much as, or even more than, 
 those with an abundant and widespread eruption. 
 
 Although scabies is a local disease without constitutional symptoms, 
 it is occasionally accompanied by a slight transient albuminuria. 
 According to Nicolas and Jambon, who have recently studied the sub- 
 ject, this albuminuria is fairly frequent ; and in certain cases there 
 may be actual nephritis. It is quite probable that in certain of these 
 cases the renal symptoms are the result of the absorption of the local 
 remedies employed, such as betanaphthol and balsam of Peru ; but not 
 all of them can be explained in this manner. 
 
 In an unusually severe form of scabies first observed in leprous 
 subjects in Norway, hence known as Norway itch or Scabies norwegica, 
 numerous crusts composed of epithelial scales and dried pus are scat- 
 tered over various parts of the body, including the scalp, face, palms 
 and soles, in which are great numbers of acari. Although first observed 
 
 m 
 
 " « *<? ; . * "~\ 
 Fig. 157. — Acarus scabiei. A, male; B, female; latter contains ripe ovum. 
 
 in lepers, it is not confined to the leprous, but occurs in other subjects 
 as the result of uncleanliness and neglect. 
 
 Quite exceptionally certain species of acari found in the domestic 
 animals, such as the horse, the cat, and the dog, are transferred to the 
 human subject, producing a dermatitis resembling that arising from 
 the Acarus scabies, except that burrows are not present and the face 
 is sometimes attacked. Spontaneous recovery usually takes place in 
 the course of six to eight weeks, as these mites do not find the human 
 skin a suitable habitat. 
 
 Etiology and Pathology. — Scabies is highly contagious disease and 
 is readily transmitted by direct or indirect contact with an affected 
 individual. It occurs at all ages and both sexes are equally liable to it. 
 It is much more frequent among the poor and uncleanly than among the 
 well-to-do, although the latter are by no means exempt. It is very 
 commonly contracted by sleeping with an affected individual, or by 
 
ANIMAL PARASITES 
 
 447 
 
 occupying his bed without a previous change of bed linen. It may be 
 acquired through towels and other articles of the toilet, and possibly 
 by shaking hands, although this mode of transmission is not common. 
 The active agents in its production is an animal parasite belonging 
 to the class Arachnidcc, order Acari, the Acarus scabiei, also known 
 as the Sarcoptes scabiei (Fig. 157). The female mite, which alone 
 burrows in the skin and produces the symptoms of the disease, is 
 oval in shape, about one-third of a millimetre long, and one-fourth 
 of a millimetre broad. The dorsal surface is slightly convex and 
 studded with a number of minute spines, and both dorsal and ventral 
 surfaces are marked with numerous fine transverse striations. It is 
 
 *BP 
 
 Fig. 158. — Burrow of scabies C, horny layer of epidermis; B, burrow R, rete mucosum. 
 
 provided with four pairs of legs, two pairs anteriorly which terminate 
 in suckers, and two pairs posteriorly which terminate in long fine 
 bristles or hairs. The male acarus is much smaller than the female, 
 and produces no symptoms, not burrowing in the skin like the female ; 
 its sole role is to impregnate the female, after which it soon dies. It 
 differs from the female in being provided with suckers on the fourth 
 pair of legs instead of hairs, which serve as prehensile organs in the 
 act of copulation. In the larval stage the acarus has but six legs, and 
 does not reach its complete development until it has undergone a series 
 of moultings. 
 
 When placed upon the skin, the female immediately begins to 
 burrow and in a very short time forms a tunnel in which she deposits 
 
448 DISEASES OF THE SKIN 
 
 ova as she. travels along. The burrow (Fig. 158) containing the 
 female mite, ova in various stages of development, and brown or black 
 granular masses of faeces, is situated almost without exception in the 
 horny layer alone, although according to Schisca the mite may enter 
 the upper portion of the rete in regions where the horny layer is thin. 
 Beneath the burrow, the rete and papillary layer of the corium show 
 varying degrees of inflammatory reaction. In the former there may be 
 slight intercellular oedema with a few leucocytes between the epithelial 
 cells, while in the papillae there is a moderate cellular exudate around 
 the vessels. Not infrequently there is sufficient exudation in the rete 
 to form vesicles which are situated either between the epithelial cells 
 or between the upper layers of the rete and the horny layer, the latter 
 forming the roof of the vesicle in which it is not unusual to see the 
 burrow. 
 
 In a series of eighteen cases in which he studied the blood condition, 
 Kolmer always found a slight but definite eosinophilia, the degree of 
 which appeared to be in proportion to the extent and severity of the 
 eruption. 
 
 Diagnosis. — Although the affection is usually recognized, errors in 
 diagnosis are of frequent occurrence. An eruption accompanied by 
 severe itching worse at night, situated on the hands, the anterior folds 
 of the axillae, the abdomen, and inner surface of the thighs, with lesions 
 on the penis in men, is almost certain to be scabies. The burrow is 
 the most characteristic symptom, indeed it is pathognomonic, and the 
 finding of a single lesion is absolutely diagnostic of scabies ; it should 
 therefore always be carefully searched for in the regions already indi- 
 cated. The diseases with which scabies is most likely to be confounded 
 are eczema and pediculosis of the body. From both it is to be dis- 
 tinguished by the characteristic regional distribution and the presence 
 of burrows. In eczema there is no history of contagion, while this is 
 common in scabies ; in the former the face is often involved, in the 
 latter practically never. In pediculosis corporis the eruption is con- 
 fined to the covered parts, while in scabies the hands are usually 
 affected ; in the former excoriations, particularly over the shoulders, 
 are usually much more abundant and extensive than in the latter. 
 
 It must not be forgotten that the hands, which so frequently are 
 the seat of a well-defined eruption, may be entirely unaffected in certain 
 cases, even when trunk and thighs present unmistakable signs of the 
 disease. 
 
 Treatment. — The treatment of scabies, which is wholly external, 
 consists in the application of parasiticides to the skin, most frequently 
 in the shape of salves or ointments, for the purpose of destroying the 
 acarus; with the death of the mite the symptoms usually speedily 
 subside. Among the oldest and most efficient of the parasiticides which 
 may be successfully employed for this purpose is sulphur. An ointment 
 containing from ten to twenty per cent, of precipitated sulphur is a 
 most effective remedy. Sherwell finds that a drachm or two (4.0-8.0) of 
 
ANIMAL PARASITES 449 
 
 dry powder of sulphur (sulphur lotum), gently rubbed into the skin at 
 night, and sprinkled between the sheets, acts quite as efficiently as the 
 ointment, and is much less disagreeable : a week of such treatment is 
 usually sufficient for a cure. 
 
 Another equally efficacious remedy is betanaphthol applied as an 
 ointment containing ten per cent. This is in some respects a more 
 cleanly and therefore more agreeable application than the sulphur 
 ointment, but occasionally its application is followed by severe burning 
 lasting for a half hour or more, which some patients find intolerable. 
 Balsam of Peru is a very active parasiticide, killing the acarus more 
 promptly than sulphur, and is highly commended as a remedy in 
 scabies, especially by the French ; it is applied pure with a brush to 
 the entire surface and allowed to remain on over night. Although 
 effective, it is not an agreeable application, owing to its stickiness. 
 Liquid stryax is an effective and non-irritating remedy, especially use- 
 ful in infants and young children. It is to be mixed with one or two 
 parts of olive oil or oil of sweet almond and to be well rubbed into 
 the skin. 
 
 Whatever remedy be selected, detailed directions should be given 
 the patient as to the manner in which it is to be used ; without this, 
 satisfactory results are seldom obtained, even with the best remedy. 
 The application of the ointment selected should be preceded by a bath 
 with hot water and green soap, well rubbed in ; if, however, the skin is 
 much inflamed, this preliminary bath should be omitted. From four to 
 six ounces (120 to 180) should be given the patient with directions to 
 thoroughly rub it in over the entire body, and with especial thoroughness 
 into the hands, the axillae, the abdomen, and the thighs, for four nights 
 in succession, omitting the bath during this period. After the fourth 
 rubbing, a bath with soap and hot water should be taken, clean under- 
 wear put on, and the bed supplied with clean linen. A period of three 
 or four days may now be permitted to elapse without any treatment ; 
 if at the end of this period there is a return of itching and eruption, 
 another course of rubbings with the ointment should be taken. As 
 a rule to which there are few exceptions, the second course completes 
 the cure. The patient should be advised that too long use of the oint- 
 ment is quite sure to excite a dermatitis which is often quite as annoy- 
 ing as the original disease. Not uncommonly such a dermatitis is 
 mistaken by the patient and his physician for a symptom of scabies, 
 and the irritating ointment continued more vigorously than before 
 with most annoying consequences ; indeed, I have known such a derma- 
 titis kept up in this way for many months, long after all the itch-mites 
 were destroyed. 
 
 In children the strength of the ointments employed, particularly 
 those which contain sulphur, should be less than those used in adults, 
 otherwise the skin is likely to be greatly irritated. 
 
 Prognosis. — The prognosis is always favorable, a cure promptly 
 following properly directed treatment. In a considerable proportion 
 29 
 
450 DISEASES OF THE SKIN 
 
 of cases, however, itching persists for some time after all other symp- 
 toms have disappeared ; but this usually yields to a carbolic acid wash 
 applied twice a day, one or two drachms (4.0 or 8.0) to the pint (500.0) 
 of water with fifteen to twenty minims of glycerin to the ounce (32.0), 
 or an ointment containing two or three grains (0.15 or 0.20) of menthol 
 to the ounce (32.0). 
 
 GRAIN ITCH 
 
 Synonyms. — Straw itch; Straw dermatitis; Barley itch; Mattress 
 itch; Acrodermatitis urticarioides (Schamberg). 
 
 Definition. — A disease of the skin caused by a mite, the Pedicu- 
 loides ventricosus, characterized by an eruption of wheals and vesicles 
 accompanied by severe itching. 
 
 Although cases of this disease were reported from time to time by 
 various observers, in France, Germany, and other countries of Europe 
 during the latter half of the last century, and its relationship to grain 
 and straw noted, it was not observed in the United States until about 
 1889-90, when cases of it began to be seen in Philadelphia and other 
 parts of eastern United States. It was first described, in 1901, by 
 Schamberg, and the etiological relationship of the pediculoides to it 
 established by Goldberger and this author jointly in 1909. 
 
 Symptoms. — It begins with an eruption of small wheal-like papules, 
 on the summits of which are minute vesicles with transparent contents 
 which later become turbid or purulent. These lesions are scattered 
 about over the trunk and extremities in variable numbers without 
 any definite arrangement; occasionally they are found in the face in 
 small numbers, but the hands and feet as a rule escape. After a few 
 days the urticarial character of the eruption usually becomes less 
 marked, and it then frequently resembles varicella. Owing to the 
 intense itching which accompanies the eruption, many of the papules 
 and vesicles have their tops torn off and are covered with small blood- 
 crusts. When the disease has lasted some time, there are usually 
 also linear excoriations, crusted eczematoid patches, and pustules re- 
 sulting from infected scratches. The extent of the eruption varies 
 much ; there may be but a score or two of lesions or there may be 
 hundreds of them covering the trunk and extremities. Itching of a 
 most aggravated character accompanies the affection, which is always 
 much worse at night and interferes greatly with the patient's rest. 
 
 As a rule the symptoms are entirely local, but occasionally the dis- 
 ease begins with chilliness, some elevation of temperature, headache, 
 and nausea. In cases with extensive eruption there may be slight 
 albuminuria. The disease runs a course lasting one or two weeks; but 
 in cases in which the nature of it is not recognized and the patient in 
 consequence continues to be exposed to the cause, it may last much 
 longer, six or eight weeks. 
 
 Etiology and Pathology. — It occurs at all ages and in both sexes, 
 and is seen only in the warm months between May and October. It is 
 most frequently acquired by sleeping on a new straw mattress, or by 
 
ANIMAL PARASITES 451 
 
 handling grain and straw. In the cases seen in Philadelphia some 
 years ago the disease could be traced to straw mattresses in nearly 
 every instance. Its cause is a mite, the Pediculoides ventricosus, be- 
 longing to the class Arachnidcc, order A carina, found in straw and 
 grain, where it preys upon certain grain-destroying insects. The mite, 
 ^unlike the Acarus scabiei, does not burrow in the skin, but punctures it 
 and at the same time injects an irritating substance which gives rise 
 to wheal-like lesions. According to Schamberg, the tissue-changes in 
 the lesions resemble those found in urticaria; and there is usually a 
 slight increase in the number of leucocytes and eosinophiles. 
 
 Diagnosis. — The diseases for which grain itch is most likely to be 
 mistaken are urticaria, scabies, varicella, and pediculosis corporis. In 
 urticaria the lesions are very evanescent, often linear, and rarely 
 vesicular; and the attack is usually of short duration. In scabies the 
 distribution of the eruption is quite unlike that seen in grain itch, and 
 burrows are usually readily found when looked for in the proper locali- 
 ties. In varicella the lesions are strictly vesicular, are commonly 
 found on the face and scalp and on the mucous membranes of the 
 mouth ; in grain itch the last-named region is never attacked. In most 
 cases a history of having recently occupied a bed with a new straw 
 mattress or of having handled grain or straw is obtainable. 
 
 Treatment. — The most important measure is to ascertain the source 
 of the disease ; if this is a straw mattress, as is commonly the case, 
 it should be abandoned at once and thoroughly fumigated with sulphur 
 dioxide or formaldehyde before being used again, and the clothing 
 should be dealt with in the same manner. With the recognition 
 and avoidance of the cause it is usually soon cured. 
 
 One of the most effective local applications is an ointment contain- 
 ing thirty to forty grains (2.0 to 3.60) of precipitated sulphur and 
 two to three grains (0.13 to 0.20) of menthol to the ounce (32.0) ; 
 applied with gentle friction twice a day, this usually gives prompt relief 
 from the intolerable itching. 
 
 COPRA ITCH 
 
 Quite recently Castellani has described an affection occurring 
 among the workers in copra (dried cocoanut) in Ceylon, distinguished 
 by an eruption of itching papules, papulo-pustules, and pustules, the 
 first frequently covered by blood-crusts, situated on the hands, arms, 
 legs, and sometimes the entire body, with the exception of the face. 
 It begins on the hands and spreads thence to other parts, but the face 
 is never affected. 
 
 It was found by Castellani to be due to a small mite which Hirst, 
 to whom it was given for identification, regards as a variety of the 
 Tyroglyphus longior. It does not burrow in the skin, but produces 
 a dermatitis much in the same manner as the Pediculoides ventricosus, 
 the cause of " straw itch." Castellani succeeded in producing the 
 affection experimentally by placing the mite upon the skin beneath 
 a piece of lint kept in place by a bandage. 
 
452 DISEASES OF THE SKIN 
 
 The eruption resembles scabies somewhat, but differs from that 
 affection by the absence of burrows and its spontaneous disappearance 
 when the patient gives up his work so that he no longer comes in 
 contact with the copra. 
 
 An ointment of betanaphthol, 5 to 10 per cent., was found useful 
 by Castellani. 
 
 BROWN-TAIL MOTH DERMATITIS 
 
 In 1901 Dr. James C. White called attention to a dermatitis which 
 he had recently observed in New England, resulting from contact with 
 the caterpillar of the brown-tail moth (Euproctis chrysorrhea) which 
 had been recently accidentally introduced into Massachusetts. 
 
 This dermatitis is characterized by erythematous patches and urti- 
 carial wheals which appear within a short time, twenty minutes to a 
 half hour after contact, accompanied by more or less severe itching. 
 In the mild cases the inflammation usually disappears in the course of 
 three or four days, but in the severer ones, which may follow crushing 
 of the caterpillar upon the skin, in which there are decided redness and 
 swelling with patches of confluent wheals, it continues for several 
 weeks. The exposed parts, such as the arms, face, and neck, are the 
 regions usually attacked, but the covered parts may also be affected 
 through the wearing of clothing with which the moth or the caterpillar 
 has been in contact. The disease is seen most frequently in June, when 
 the caterpillar is fully grown, but may occur at other seasons, when it 
 arises from contaminated clothing. 
 
 As Tyzzer has shown, the dermatitis is the consequence of the 
 penetration of the skin by the " nettling " hairs found on the caterpillar 
 and moth and in the structure of the cocoon. These hairs are from 
 0.07 to 0.02 mm. in length, and are provided with three rows of barbs 
 which prevent their withdrawal from the skin when they have once 
 penetrated it. The irritation produced by these hairs is not merely me- 
 chanical, but the result of some irritating chemical substance which 
 produces a peculiar reaction with the blood, and necrosis of the 
 epidermal cells with which the hairs are in contact. 
 
 Treatment. — Calamine lotion, or a lotion of carbolic acid, one per 
 cent., will usually afford relief; in the severer cases, however, the affec- 
 tion is often rebellious. 
 
 LEPTUS 
 
 Synonyms. — Harvest bug; Fr., Rouget ; Ger., Erntemilbe. 
 
 The Leptus, of wdiich there are several varieties, Leptus Ameri- 
 canus, Leptus autumnalis, and Leptus irritans,, is not uncommonly a 
 temporary parasite on the skin of man. It is a minute reddish insect, 
 the larval form of the genus Trombidium, just barely visible with the 
 naked eye. It varies in length from y 3 to J / 2 mm., is oval in shape and 
 is provided with six legs. It is found on various grasses and shrubs, 
 particularly in low and moist places, and commonly attacks the ankles 
 
ANIMAL PARASITES 453 
 
 and legs of workers in the fields, although it may occur on other parts 
 of the body. According to Duhring the American variety is found on 
 the scalp and in the axillse as well as in other regions, and more 
 frequently attacks children than adults. It is common on the bushes 
 of the whortleberry or blueberry, and the pickers of this berry fre- 
 quently suffer from its attacks. The mite buries its head in the skin, 
 producing an eruption of papules, wheals, and vesicles accompanied by 
 severe itching and burning; in severe cases more or less dermatitis of 
 an eczematous character may result. The leptus is not a permanent 
 parasite on the skin of man, but after a time voluntarily abandons its 
 human host. 
 
 The application, once or twice a day, of an ointment of sulphur, 
 thirty grains (2.0) to the ounce (32.0), or of betanaphthol of the same 
 strength, or of balsam of Peru, one drachm (4.0) to the ounce (32.0), 
 usually affords prompt relief. A lotion of phenol, one or two drachms 
 (4.0 or 8.0) to the pint (500.0) of water, mopped on several times a day, 
 is also efficient. 
 
 PULEX PENETRANS 
 
 Synonyms. — Dermatophilus penetrans; Rhynochoprion penetrans; 
 Chigoe; Jigger; Sand-flea; Fr., Puce de sable; Ger., Sandfloh. 
 
 The sand-flea resembles in its general appearance the common flea, 
 but is distinguished from the latter by its smaller size and the much 
 greater length of its proboscis, which is as long as its body. Originally 
 confined to tropical America, it has spread to Africa and parts of India, 
 where it is of considerable importance because of the frequency with 
 which it attacks the natives, causing painful and sometimes serious 
 disease. 
 
 The impregnated female pierces the skin into which she burrows, 
 and in which she remains until the completion of pregnancy and the 
 discharge of the ova. The entrance of the insect into the skin produces 
 painful swelling with inflammation, suppuration, and ulceration. As 
 the consequence of secondary infection the resulting ulceration may 
 extend considerably and gangrene may occur. The regions most fre- 
 quently attacked are the feet, particularly between the toes and under- 
 neath the nails ; but other regions are not infrequently attacked. While 
 there are usually but one or two parasites in the skin, there may be, 
 according to the observations of Manson, hundreds. 
 
 Treatment. — The insect should be removed, after enlarging the 
 opening by which she has entered, with a clean needle, care being 
 taken not to rupture the abdomen greatly distended by ova; the 
 resultant small wound should be dressed antiseptically. The parasite 
 may be killed by the application of chloroform or turpentine. 
 
 In regions in which the parasite is prevalent shoes should always 
 be worn to protect the feet, and accumulations of dust and dirt in which 
 the insect lives should be removed. The floors and walls of dwellings 
 should be well sprinkled with pyrethrum powder at short intervals. 
 
454 DISEASES OF THE SKIN 
 
 IXODES 
 
 Synonyms. — Wood-tick; Fr., Pou de bois; Ger., Holzbock. 
 
 Several varieties of ioxides or wood-tick, Ixodes ricinus, Ixodes re- 
 duvius, Ixodes unipunctatus, are occasional temporary parasites on 
 the skin of man. The tick, which belongs to the order of A carina, 
 dwells on trees and shrubs from which it drops on passing individuals, 
 and inserting its proboscis in the skin, continues to suck blood until it 
 is distended to the size of a pea. When fully distended with blood it 
 resembles a small pedunculated tumor attached to the skin ; after a day 
 or two it loosens its hold and drops off. A small wheal is produced 
 at the site of the puncture which itches and pains more or less for some 
 time. If the attempt is made to forcibly remove the tick while it is 
 feeding the buried proboscis is apt to be torn off and 'left in the skin 
 where it may give rise to severe pain and inflammation. If a drop of 
 oil of turpentine, benzine, or tobacco juice is placed upon it, it at 
 once withdraws its proboscis and dies. 
 
 A lotion of carbolic acid, five to eight minims to the ounce (32.0) of 
 water, is useful to relieve the itching and burning which occur at the site 
 of the puncture. 
 
 CYSTICERCUS CELLULOSiE CUTIS 
 
 The occurrence of the cysticercus cellulosse, the scolex of T<znia 
 solium, in the subcutaneous tissue of man has been recognized since 
 the middle of the seventeenth century, when it was first described 
 by Bonatus. In parts of Europe, particularly in countries where the 
 eating of raw or imperfectly cooked pork is common, such as in North 
 Germany, the disease is not at all infrequent. Kiichenmeister and 
 Ziirn have stated that in 5 per cent, of all cases of Tccnia solium the 
 skin, or more exactly the subcutaneous tissue, is affected. The cysti- 
 cercus forms small elastic tumors varying in size from a pea to a 
 cherry, occasionally as large as a walnut, over which the skin is mov- 
 able and unaltered in appearance. They give the patient but little 
 annoyance unless they are subjected to pressure or grow to an unusual 
 size, when they may become inflamed and painful. As a rule several 
 tumors are present and they may be very numerous ; Lancereaux has 
 reported the case of a woman in whom there were 1000, and Bonhomme 
 found in a cadaver, in addition to 900 in the muscles, 2000 in the subcu- 
 taneous tissues. They are situated most frequently on the trunk, but 
 are also found on other parts of the body. After a duration varying 
 from three to seven years the parasite dies, the tumor shrinks, becomes 
 hard and occasionally undergoes calcification, or is destroyed by inflam- 
 mation and abscess. 
 
 Diagnosis. — Cysticercus is likely to be mistaken for syphilitic 
 gumma, for lipoma, sebaceous cyst, and fibroma. From all of these 
 it may be readily distinguished by exploratory puncture and exam- 
 ination of the fluid which escapes, in which hooklets are easily 
 discovered. 
 
ANIMAL PARASITES 455 
 
 CESTRUS 
 
 Synonyms. — Gad-fly ; Bot-fly. 
 
 Certain dipterous insects belonging to the family CEstridce not 
 infrequently attack the skin of man, especially in tropical countries, 
 such as Africa, and Central and South America, for the purpose of 
 depositing their ova. In Shetland such invasion of the skin is said to 
 be common, and confined to women. The ova are deposited beneath 
 the skin through an opening made by the ovipositor of the fly, and the 
 larvae produce inflammatory swellings resembling furuncles with a cen- 
 tral opening from which a seropurulent fluid escapes and through 
 which the larvae may be expressed. At times the larvae burrow beneath 
 the skin some distance, producing red or purplish sinuous lines, at the end 
 of which suppuration eventually occurs, with the formation of abscess 
 through which they escape fom the skin. 
 
 Treatment. — The larvae should be removed through a free incision, 
 and the cavity thoroughly washed out with antiseptic solutions, such as 
 bichloride of mercury I : iooo, or carbolic acid, i : 40. 
 
 ANKYLOSTOMIASIS CUTIS 
 
 Synonyms. — Ankylostomum dermatitis ; Uncinarial dermatitis ; 
 Ground itch ; Water itch ; Water pox ; Water sores. 
 
 Definition. — An inflammation of the skin confined to the feet, due 
 to the larvae of an intestinal parasite, the Ankylostomum. 
 
 The Ankylostomum is a widely distributed nematode intestinal 
 parasite met with practically in all tropical and subtropical regions. 
 When it invades the intestinal canal it produces a progressive and 
 eventually profound anaemia by abstraction of blood, the so-called 
 tropical anaemia, miner's anaemia, hookworm disease, an affection very 
 prevalent in the Southern States of the United States, in Porto Rico, 
 and in many other countries in the tropics. In 1902 Stiles discovered 
 that the affection as seen in the United States and Porto Rico is due 
 not to the Ankylostomum duodenale, but to a closely allied species, 
 the Necator Americanus. Through contact with soil contaminated by 
 fecal matter containing the larvae of the ankylostomum or the necator, 
 a dermatitis of the feet is produced characterized by erythema, and an 
 eruption of pustules, vesicles, pustules, and not infrequently, in the 
 severer cases, by ulceration. The sides of the feet and the toes are 
 the parts most frequently affected ; severe itching usually accompanies 
 the eruption. Apart from the annoyance which it occasions, in the 
 severe cases interfering decidedly with walking, the affection is one of 
 considerable importance, since the experiments of Looss, Schaudinn, 
 Sandwith, and others have shown that the parasite may reach the intes- 
 tinal canal through the skin as well as through the mouth. 
 
 Treatment. — The disease usually yields readily to cleanliness and 
 the use of mild antiseptic lotions, such as a saturated solution of boric 
 acid or a i-per-cent. solution of phenol applied several times a day. An 
 
456 DISEASES OF THE SKIN 
 
 ointment of ammoniated mercury or of calomel fifteen to twenty grains 
 i.o to 1.30) to the ounce (32.0) may also be used. To prevent infec- 
 tion, shoes should be worn, especially during the rainy season. 
 
 DERMANYSSUS AVIUM ET GALLING. 
 
 Synonyms. — -Chicken louse ; Bird mite ; Fr., Dermanysse des 
 oiseaux; Ger., Vogelmilbe. 
 
 The chicken louse or bird mite is occasionally a very transient 
 parasite upon the human skin, where it produces at times considerable 
 irritation with an erythematous eruption. As the mite seldom remains 
 long upon the human subject, the occasional application of a carbolic- 
 acid lotion, 1 : 40, for the relief of the irritation, is usually all that is 
 necessary in the way of treatment. 
 
 DRACONTIASIS 
 
 Synonyms. — Dracunculus ; Dracunculus medinesis ; Filaria meddi- 
 nensis ; Guinea-worm ; Fr., Ver de Guinee ; Ger., Peitschenwurm. 
 
 Definition. — An endemic disease of the tropics due to the invasion 
 of the body by a nematode worm, characterized by subcutaneous 
 abscess. It is endemic in certain parts of Africa, particularly the West 
 Coast, Abyssinia, and Upper Egypt, in Arabia, Persia, certain parts 
 of India, such as the Deccan, and in tropical South America, to which 
 it was brought by negroes from Africa. 
 
 Symptoms. — Introduced into the body by way of the gastrointes- 
 tinal canal, from which it soon enters the connective tissues, the worm 
 produces no symptoms until, fully developed, it can be seen or felt 
 beneath the skin. It frequently migrates to a considerable distance 
 from the place at which it was first observed, travelling as a rule down- 
 wards. At the point where it is about to pierce the skin, which, accord- 
 ing to Manson, is somewhere on the lower extremities in 85 per cent, 
 of all cases, a small vesicle forms, which after a time ruptures, leaving 
 a superficial ulcer or erosion from a half to three-quarters of an inch 
 in diameter, in the centre of which is a small opening at which the 
 head of the worm usually, but not always, presents. From this open- 
 ing the head is gradually extruded, and in the course of some time 
 the entire worm is expelled. It sometimes happens that the head is 
 withdrawn, the opening closes, and the worm migrates to another 
 locality where a new opening is formed. If, as Manson has shown, 
 the skin in the region of the opening is douched with cold water, a small 
 quantity of fluid escapes from the opening which is at first clear, but 
 later milky, in which great numbers of larvae can be seen with the 
 microscope. If in attempts to extract the worm the head is torn off, 
 as not infrequently happens, leaving the body in the skin, severe 
 inflammation with lymphangitis and septic symptoms may occur. 
 Usually there is but one worm, but there may be two or more. Ex- 
 ceptionally the worm dies prematurely without having pierced the 
 
 
ANIMAL PARASITES 457 
 
 skin ; abscess may then result or the worm may undergo calcification. 
 According to some observers (Sutherland and Bartet), fever and urti- 
 caria may precede the appearance of the worm beneath the skin in a 
 certain proportion of the cases. 
 
 Etiology and Pathology. — The female worm alone penetrates the 
 tissues. It has an average length of about 90 cm., although much 
 longer specimens have been reported, and is about 1.5 mm. in diameter. 
 It is smooth, cylindrical in shape, with a rounded head containing a 
 triangular mouth surrounded by two large and four small papillae, 
 and has a pointed, somewhat hook-like tail. The uterus occupies the 
 greater portion of the body and contains enormous numbers of 
 embryos. 
 
 Infection takes place from drinking-water containing a minute 
 crustacean, the cyclops, which serves as the intermediate host for the 
 worm. As was demonstrated by Fedschenko, the embryos upon reach- 
 ing water enter the cyclops in which they undergo complete larval 
 development, requiring for this development a period varying from 
 five to nine weeks, according to the temperature of the water. In the 
 gastro-intestinal canal the larvae escape from the cyclops and undergo 
 further sexual development ; and the impregnated female migrates into 
 the connective tissues, where she reaches maturity. Very little is 
 definitely known about the male ; but it probably dies in the intestinal 
 canal and is discharged with the faeces. 
 
 Treatment. — The method of treatment employed by the natives 
 in regions in which the Guinea-worm occurs is to seize the head, 
 fasten it to a stick, and slowly, day by day, with very gentle traction, 
 wind the worm around it. Not infrequently, however, the worm is 
 torn, the embryos escape into the tissues, and serious inflammation 
 with abscess and sloughing follows, with prolonged convalescence. 
 Manson's method is to repeatedly douche the skin of the region occu- 
 pied by the worm with cold water, which causes contraction of the 
 uterus and expulsion of the embryos through the opening in the skin ; 
 after fifteen or twenty days the uterus is completely emptied and the 
 worm emerges spontaneously or is absorbed without expulsion. The 
 method of treatment devised by Emily is probably the best. A solu- 
 tion of bichloride of mercury, 1 : 1000, is injected into the body of the 
 worm ; this kills it, and it may then be readily extracted. Even if 
 allowed to remain in the tissues, it is gradually absorbed without any 
 serious results. 
 
 ECHINOCOCCUS CUTIS 
 
 Echinococcus cysts are occasionally found in the subcutaneous 
 tissue where they form soft, fluctuating, slightly translucent tumors of 
 variable size, the skin over them showing no alteration. Beyond a 
 feeling of tension they are accompanied by no subjective sensations. 
 In the course of a year or two the parasite dies, and the tumor occa- 
 sionally undergoes calcification. The diagnosis is to be made by ex- 
 
458 DISEASES OF THE SKIN 
 
 ploratory puncture and microscopic examination of the fluid contained 
 in the tumor in which the hooklets of the parasite are present. 
 
 DEMODEX FOLLICULORUM 
 
 Synonyms.— Acarus folliculorum ; Steatozoon folliculorum ; Ento- 
 zoon folliculorum ; Fr., Acare des follicules ; Ger., Haarbalgmilbe. 
 
 This parasite, which was discovered by Henle in 1841 in the ceru- 
 minous glands, and a year later by Simon in the sebaceous glands, 
 is found in the skin, particularly of the face, ears, and upper third of the 
 trunk. It is especially abundant in those with greasy skins, and from 
 one to ten or twelve may be found in a gland. According to Gmeiner, 
 who examined a large number of cadavers, it is found in practically 
 all individuals in the sebaceous glands of the face ; and although not 
 present in the glands of the newborn, this observer has found it in 
 infants a few weeks old. While in some of the lower animals, such 
 as the dog, nearly related species of acarus may give rise to severe 
 inflammation of the follicles, it is rarely pathogenic in man. However, 
 De Amicis Majocchi, and Dubreuilh have reported cases of a yellow- 
 ish-brown pigmentation of the skin resembling somewhat that of tinea 
 versicolor, which seems to have been due to the demodex. 
 
 The parasite varies in length from yi to Yz mm., and is made up 
 of three segments, the head, the thorax, and abdomen. It is provided 
 with four pairs of short jointed legs which are attached to the thorax; 
 in the larval stage there are but three pairs of legs. The abdominal 
 segment is two or three times the length of the thorax, and is cylin- 
 drical in shape with a tapering extremity. 
 
 In the case of pigmentation reported by De Amicis, washings with 
 soft soap were curative, but in Dubreuilh's case treatment was 
 unavailing. 
 
 LARVA MIGRANS 
 
 Synonyms. — Creeping eruption; Hyponomoderma ; Dermamyiasis 
 linearis migrans cestrosa. 
 
 Definition. — A disease of the skin due to the larva of Gastrophilus 
 characterized by a sinuous burrow in the epidermis of variable length. 
 
 This affection was first described by Lee, in 1875, under the name of 
 " creeping eruption " ; and since that time additional cases have been 
 reported by Crocker, Neumann and Rille, Stelwagon, Simon-Him- 
 melstjerna, and others. 
 
 Symptoms. — The characteristic feature of the disease is a burrow in 
 the skin represented by a slightly elevated serpiginous red line from 
 an eighth to a sixth of an inch wide. The old part of the burrow is 
 much paler than the recent portion and frequently shows a number 
 of small vesicles and scales over it. It usually extends quite rapidly, 
 advancing from a fraction of an inch to an inch or even several 
 inches in the course of twenty-four hours ; and in some cases appears 
 
ANIMAL PARASITES 
 
 459 
 
 to advance much more rapidly by night than by day. It seldom 
 moves in a direct line, but usually pursues a sinuous or irregular 
 course, not uncommonly turning on itself ; and in the course of some 
 months it may have extended over a considerable portion of the sur- 
 face. At the advancing end of the burrow, where the larva can some- 
 times be seen under glass-pressure with a loup as a black dot, there 
 is frequently more or less itching and burning. The disease is most 
 common on exposed parts, such as the hands, the face, and the feet, 
 but it has been seen on the buttocks and extremities. As a rule there 
 is but a single parasite, but cases have been observed in which there 
 were two or more. The duration of the affection is variable ; com- 
 monly it lasts for some months, but it may exist much longer, as in 
 a case reported by Crocker in which it had lasted for more than two 
 years. Although a rare disease elsewhere, it is quite common in 
 certain parts of Russia, along the Volga. Attempts at recovering 
 
 A B 
 
 Fig. 159. — Larva migrans. A, old burrow; B, recent burrow. 
 
 the larva from the burrow, while usually fruitless, are occasionally 
 successful. 
 
 Etiology and Pathology. — The malady is due to a larva identified 
 by Himmelstjerna and Sokoloff as the larva of a fly belonging to 
 the order of CEstridcc, genus Gastrophilus. It is about 1 mm. long, 
 contains ten segments, has a mouth surrounded by hooklets and 
 provided with two suckers. Sokoloff claims to have seen black nits 
 upon the hair about the entrance of the burrow. 
 
 According to Lenglet and Delaunay, and Rille, who have studied 
 the histopathology of the affection, the burrow is situated in the 
 upper portion of the epidermis between the corneous layer and the rete. 
 There is some intercellular oedema of the rete and a few leucocytes in 
 the intercellular spaces. In the papillae and around the vessels of the 
 upper part of the corium there is a varying amount, usually moderate, 
 
460 DISEASES OF THE SKIN 
 
 of cellular exudate in which Lenglet and Delaunay found eosinophiles. 
 The cavity of the burrow is usually filled with cellular debris. 
 
 Treatment. — Excision of the advancing end of the burrow and of 
 the parts immediately surrounding it is probably the most certain way 
 of getting rid of the parasite. Stelwagon cured his cases by introduc- 
 ing into the skin a solution of bichloride of mercury, two grains (0.13) 
 to the ounce (32.0), by cataphoresis over the advancing end of the 
 burrow and applying nitric acid. The hypodermatic injection of a few 
 drops of a 1 : 1000 solution of bichloride of mercury would probably 
 be effective. In an extensive case very recently under the author's 
 care (Fig. 159) the parasite was destroyed by the application of chloro- 
 form over the advancing end of the burrow for ten minutes at a time 
 several times a day. The chloroform was applied by inverting a test-tube 
 containing several drachms over the end of the burrow. 
 
 CRAW-CRAW 
 
 A good deal of uncertainty exists as to the nature of the disease 
 described under this name, since, as Brault has pointed out, the natives 
 of the West Coast of Africa, where it prevails, apply the term kra-kra 
 to most itching vesico-papular eruptions; and in all probability several 
 affections which are more or less etiologically distinct are included 
 under it. O'Neill has described a contagious affection bearing some 
 resemblance to scabies, but without burrows, characterized by an 
 eruption of papules, vesicles, and pustules, accompanied by severe 
 itching, situated on the trunk and extremities. He believes it to be 
 due to a species of filaria which he found in sections of papules teased 
 out and examined in water. 
 
 The disease described by Emily under this name begins with an 
 eruption of red or brown-red spots situated on the backs of the hands 
 and on the lower extremities, which itch intensely ; pustules and multi- 
 ple ulcers appear later. Manson has seen a similar affection in India 
 and South China. The author believes the so-called veld sore of 
 South Africa to be identical with it, or closely related to it. 
 
 Treatment. — Emily has found the liberal application of powdered 
 boric acid, after thorough scrubbing with a 1 : 1000 solution of bichlo- 
 ride of mercury, very efficient in the treatment of the malady. Manson 
 advises the application of warm lotions of carbolic acid, 1 : 20, fol- 
 lowed by a dry dressing of boric acid. Infected shoes and stockings 
 should be destroyed. 
 
PLATE XXXII 
 
 Purpura simplex. 
 
CHAPTER XI 
 
 HEMORRHAGES— HEMORRHAGIC 
 
 PURPURA 
 
 Synonyms. — Hsemorrhcea petechialis ; Ger., Blutfleckenkrankheit. 
 
 Definition. — A disease characterized by cutaneous hemorrhage 
 which appears as bright crimson or violaceous spots, lines, streaks, or 
 patches which undergo the changes in color characteristic of eflused 
 blood. 
 
 Symptoms. — Hemorrhage into the skin may appear as pin-head 
 to pea-sized, round or oval, non-elevated, crimson spots (petechias) ; 
 as lines or streaks of varying length, usually short (vibices) ; as patches 
 varying in size from a large coin to the palm of the hand or even much 
 larger (ecchymoses), or it may be so extensive as to produce slightly 
 elevated flat tumor-like swellings (ecchymomata, hsematomata). 
 
 A number of varieties of purpura are recognized, viz., purpura 
 simplex; purpura hemorrhagica; purpura rheumatica or peliosis rheu- 
 matica. While usually more or less distinct from one another in their 
 clinical symptoms and more especially in their course, they may merge 
 more or less with one another, the difference between them being 
 often one only of degree. 
 
 Purpura Simplex. — (Plate XXXII). — As a rule, without any prece- 
 dent or accompanying constitutional disturbance, but occasionally with 
 slight malaise and fever, crimson pin-head to pea-sized spots appear in 
 variable numbers upon the legs, and in the more pronounced cases 
 upon the thighs ; somewhat exceptionally a similar eruption occurs 
 upon the upper extremities, usually the forearms. These do not disap- 
 pear under pressure, and in the course of twenty-four to forty-eight 
 hours become darker and purplish ; later they become greenish, yellow- 
 ish, then brown, and finally disappear, the changes in color being 
 those which occur in the ordinary contusion. While the first eruption 
 is passing through these changes, it is quite common for a new crop 
 to appear which goes through similar changes, so that there are present 
 all stages of the process at the same time. In the mildest cases there 
 may be but a single crop and the disease comes to an end in ten days 
 to two weeks, but much more frequently new crops appear at longer 
 or shorter intervals, prolonging the disease to weeks or months, or, 
 with intermissions of variable length, one or more years. 
 
 As uncommon variations from the usual type the hemorrhages may 
 assume a circinate arrangement (Duhring, Stelwagon), or may appear 
 as wheals (purpura urticans). It is somewhat uncertain, however, 
 whether such ca^es properly belong to purpura ; the former might very 
 well be classified as hemorrhagic erythema multiforme, the latter as 
 hemorrhagic urticaria. 
 
 461 
 
462 DISEASES OF THE SKIN 
 
 Purpura Hemorrhagica. — Morbus maculosus Werlhoffii ; Land 
 scurvy. — This form differs from the foregoing chiefly in the greater 
 severity of the symptoms, in the greater extent of the hemorrhages, 
 which are not limited to the skin, but occur in the mucous membranes 
 also. It may begin as a simple purpura with symptoms such as have 
 just been described, or it may begin with considerable constitutional 
 disturbance, such as headache and decided elevation of temperature, 
 accompanied or soon followed by extensive ecchymoses upon the 
 extremities and trunk and bleeding from the nose, gums, and, some- 
 what less frequently, from the bladder and bowels. Occasionally 
 hemorrhages take place into the meninges or into the brain with 
 apoplectic symptoms. In severe cases the amount of blood lost may 
 be sufficient to put the patient's life in imminent danger or to cause 
 death. The attack usually lasts from four to six weeks, but it may 
 considerably exceed this and is apt, like other forms of the affection, 
 to recur at irregular intervals. In a case under the author's care 
 there were a number of attacks at intervals of about a year for ten 
 years, the patient's life being in danger on several occasions from the 
 extensive loss of blood from the nose and mouth. In rare instances 
 the affection runs a very rapid course with symptoms of profound 
 depression, terminating in death in the course of some hours or a 
 day or two (purpura fulminans). 
 
 Purpura Rheumatica. — Peliosis rheumatica ; Schonlein's disease. — 
 As its name indicates, this variety is associated with rheumatic 
 symptoms, such as swelling and pain of the joints, which may precede 
 the appearance of the cutaneous symptoms, but usually appears coinci- 
 dently with them. Some constitutional disturbance, such as malaise, 
 loss of appetite, headache, and elevation of temperature which at times 
 may be considerable, are present in varying degree in a large propor- 
 tion of the cases. The eruption usually appears upon the lower ex- 
 tremities, which are more or less swollen and painful, especially in the 
 region of the ankles and knees, and in the mild cases may remain 
 limited to these, but in the severer ones the upper extremities are also 
 affected. The eruption, which consists of pin-head to coin-sized smooth 
 patches, which, when they first appear, are crimson, but soon become 
 purplish, is apt to appear in successive crops, gradually spreading to 
 new regions. Occasionally ecchymoses occur in the mucous mem- 
 branes of the mouth and pharynx which in exceptional cases may be 
 followed by sloughing (Osier). In a considerable proportion of cases 
 an exudative erythema is present along with the purpuric eruption ; 
 occasionally urticarial wheals also appear. In a patient under the 
 author's care for some time both forms of eruption were at times pres- 
 ent, at others one or the other alone appeared, always accompanied 
 by pain and swelling of the knees and ankles. Pericarditis, endocar- 
 ditis, and nephritis are occasional complications. 
 
 In the variety known as Hennoch's purpura, although it was de- 
 scribed by Willan long before Hennoch called attention to it, the 
 
HEMORRHAGES 463 
 
 arthritic and cutaneous symptoms are accompanied by severe gastric 
 and enteric disturbance, such as vomiting occasionally of blood, 
 paroxysms of abdominal pain, and hemorrhage from the bowels. In 
 addition to the cutaneous hemorrhages or alternating with them there 
 may be eruptive lesions characteristic of erythema multiforme or of 
 urticaria. A marked feature of this form is the tendency to repeated 
 attacks which may occur at short intervals or after intervals of a month 
 or longer. Although most frequently seen in children, it also occurs 
 in adults as well. 
 
 Etiology and Pathology.- — The causes of hemorrhage into the skin 
 are numerous and of varied kind. They may follow mechanical in- 
 juries or the bite of insects such as the flea (purpura pulicosa) ; they 
 may follow sudden obstruction to the circulation such as may occur 
 in the paroxysms of whooping-cough or in the convulsions of epilepsy ; 
 they may follow a sudden change in the direction of the blood stream, 
 such as occurs at birth (purpura neonatorum, Kaposi) ; and, lastly, 
 they may follow long-standing inflammations, especially of the lower 
 extremities, or slight unnoticed traumata in the old in whom the walls 
 of the vessels have undergone senile changes (purpura senilis). All these, 
 however, while presenting the superficial symptoms of purpura and 
 occasionally so designated, are in fact only accidental hemorrhages. 
 
 Purpuric eruptions are in some instances an occasional, in others 
 a constant, accompaniment of certain general infections, such as small- 
 pox, scarlet fever, typhus fever, measles, varicella, epidemic cerebro- 
 spinal meningitis, and endocarditis. Rheumatism has long been re- 
 garded as a cause of purpura because of the frequent association of 
 arthritis with the eruption, but it is doubtful whether the affection of 
 the joints is actually rheumatic. 
 
 Although a number of microorganisms have been found in the blood 
 by numerous observers (Martin de Goimard, Tizzoni and Giovannini, 
 Letzerich, Kolb, Carriere, and a number of others), the relationship 
 of these to the disease is still undetermined. 
 
 Torok believes that all true purpuras are due to some infective 
 or toxic agent in the blood of varying kind which acts directly upon the 
 vessel-walls. This view finds much support in the fact that purpura 
 at times follows the ingestion of certain drugs, such, for example, as 
 iodide of potassium and salicylate of soda. In a young woman under 
 the author's observation some years ago the administration of iodide 
 of potassium was invariably followed by a purpuric eruption, but toler- 
 ance was soon established and the eruption usually disappeared in a 
 few days, notwithstanding the continuance of the drug. If, however, 
 it was suspended for an interval of some weeks or a month and then 
 resumed, the purpura again appeared as before. Hemorrhagic pur- 
 pura has been observed to follow the long-continued inhalation of the 
 vapor of benzol used for manufacturing purposes (Selling). Purpuric 
 eruptions are occasionally noted after injections of antitoxin, and snake- 
 venom produces most extensive hemorrhages in the skin, as seen after 
 the bites of venomous serpents. 
 
464 DISEASES OF THE SKIN 
 
 Duke, in a study of the blood in purpura hemorrhagica, found a 
 great diminution in the number of blood-platelets and he believes this 
 to be the cause of the cutaneous hemorrhages. Graham Little has re- 
 ported a small series of cases associated with hemorrhage into the supra- 
 renal capsules, and he thinks it probable that the purpura is due to the 
 absence of the suprarenal secretion from the blood consequent upon the 
 destruction of the secreting structure of these bodies. 
 
 The blood findings have varied so much that no definite conclusions 
 can be drawn from them. In some cases, as might have been ex- 
 pected, the number of erythrocytes has been greatly diminished, in 
 others there has been a more or less marked leucocytosis. 
 
 The mechanism of the production of the hemorrhage is still a mat- 
 ter of some discussion. The blood may escape through rupture of the 
 walls of the vessels, or through the unruptured walls by diapedesis. 
 According to Sack, rupture of the vessels is present in the large major- 
 ity of cases, escape of the blood by diapedesis being the exception. 
 In a few instances the flow of blood in the small vessels and capillaries 
 has been found obstructed by thrombi composed of masses of micro- 
 organisms. Exceptionally an endarteritis is present. The hemor- 
 rhage is situated in the papillary and subpapillary portions of the 
 corium, between the collagen fibres, but may extend down to the 
 subcutaneous tissue when extensive. In old hemorrhages brown 
 granular pigment derived from the coloring matter of the blood is also 
 present in considerable quantity. 
 
 Diagnosis. — The diagnosis is usually easy. The bright crimson 
 color of the early eruption, which cannot be made to disappear by 
 pressure, and the changes in color which it undergoes are quite charac- 
 teristic features. 
 
 The symptomatic purpuric eruptions which occur in certain of the 
 infectious diseases which have been already referred to are to be distin- 
 guished from the primary purpuras by the severity of the general symp- 
 toms, particularly the high temperature, and the associated eruptions 
 characteristic of the several affections. 
 
 Rheumatic purpura may at first be mistaken for acute rheumatism 
 when the arthritis precedes the eruption, but the appearance of cuta- 
 neous hemorrhages soon reveals the true nature of the attack. Errors 
 may arise also when the lesions of erythema multiforme are associated 
 with the affection, but petechias and ecchymoses appear sooner or later. 
 In Hennoch's purpura the youth of the patient and the associated 
 severe gastric and enteric symptoms are characteristic when taken in 
 connection with the purpuric eruption. 
 
 Purpura may be confounded with scurvy or scorbutus, but the for- 
 mer never presents the peculiar swollen, spongy condition of the gums 
 nor the brawny, discolored swellings in the muscles and subcutaneous 
 tissues characteristic of the latter. 
 
 Prognosis. — The prognosis as to recovery is in most instances fa- 
 vorable, recovery taking place in cases of ordinary severity in a few 
 
HEMORRHAGES 465 
 
 weeks, although the disease may be considerably prolonged by re- 
 peated recurrences. In hemorrhagic purpura the prognosis should 
 be guarded, since the loss of blood may be so large as to imperil the 
 patient's life or cause his death. Even when recovery takes place, 
 severe anaemia and debility frequently follow for a considerable period. 
 As has already been mentioned, cardiac and nephritic complications 
 occasionally occur. 
 
 Treatment. — In all cases except the very mildest, the patient should 
 be put to bed when possible, since nothing can take the place of rest 
 in the recumbent position. On the other hand, the duration of the 
 attack is frequently much prolonged if the patient continues to go 
 about or is on his feet for hours at a time. Crocker found turpentine 
 given in doses of fifteen to twenty minims three times a day, or by 
 inhalation, one of the most reliable internal remedies. In the severe 
 cases ergotin hypodermatically may be given for the purpose of con- 
 tracting the vessels. Recently Wright has recommended the adminis- 
 tration of calcium chloride for the purpose of increasing the coagula- 
 bility of the blood ; it may be given in doses of fifteen to twenty grains 
 (i.o to 1.30) three times a day. The author has employed it in a 
 limited number of cases, but he is not satisfied that it is a remedy 
 of much value. The tincture of the chloride of iron in doses of fifteen 
 to thirty minims three or four times a day may also be given, w T ith 
 the view of combating the anaemia which results from the loss of 
 blood and for its astringent effect. In hemorrhagic purpura the hypo- 
 dermatic injection of ten to twenty minims of the 1 : 1000 solution 
 of adrenalin chloride may be tried as recommended by MacGowan. 
 In cases accompanied by arthritis the salicylates may be given in ap- 
 propriate doses. Quite recently injections of blood-serum, human and 
 foreign, have been employed, but with such varying results that noth- 
 ing very definite can be said as yet about their usefulness. 
 
 PURPURA ANNULARIS TELANGIECTODES 
 
 Synonyms. — Telangiectasia follicularis annulata. 
 
 This affection, of which only a small number of cases has as yet 
 been recorded, was described for the first time in 1896 by Majocchi. 
 Additional cases have since been observed by Arndt, Vignolo-Lutati, 
 Lindenheim, MacKee, and a few others. Very recently MacKee has 
 published a new case, the first to be recorded in America, together 
 with an exhaustive account of its clinical features, histopathology, 
 and an analysis of the literature to date. 
 
 Symptoms. — The disease begins as well-defined red and viola- 
 ceous spots situated upon the legs, which upon close inspection are 
 seen to be composed of minute telangiectases. In these spots and at 
 their margins dark-red points, minute hemorrrhages, appear, usually 
 situated about the mouths of the follicles. The spots slowly enlarge 
 peripherally until they reach the size of a coin, and as they enlarge they 
 assume an annular appearance, the centre being more or less pig- 
 30 
 
466 DISEASES OF THE SKIN 
 
 mented. The eruption is usually confined to the legs, but it may ex- 
 tend to the thighs, and occasionally occurs upon various parts of the 
 trunk and upper extremities. The evolution of the lesions is very slow, 
 many weeks being required to reach their full development, and the 
 disease usually lasts for months or a year or two. After a variable 
 period the patches become less well defined, change color, becoming 
 a yellowish-brown, and finally disappear, usually, but not invariably, 
 leaving a slight atrophy, occasionally accompanied by alopecia and 
 pigmentation of the affected areas. As the early lesions disappear, 
 new ones may appear, so that all the stages of their evolution and 
 involution may be present at the same time. 
 
 Etiology and Pathology. — Nothing is known about the direct causes 
 of the affection. Age and sex are apparently to be reckoned among 
 the predisposing causes, since the great majority of the cases thus 
 far observed have occurred in young male adults ; only a few have 
 been seen in children and still fewer in women. 
 
 The essential feature of its histopathology is an obliterating endar- 
 teritis and endophlebitis, which, according to MacKee, begin in the 
 hypoderm and extend to the capillaries of the entire derma. In the 
 early stages the vessels of the papillae and subpapillary portion of the 
 corium are tortuous and dilated and there is a moderate diapedesis 
 of red cells. In the more advanced stages there is a moderate peri- 
 vascular and perifollicular cellular exudate composed of lymphoid and 
 connective-tissue cells, and scattered accumulations of granular pig- 
 ment. In the final stages the epidermis is somewhat thinned, the 
 papillae are flattened out or have disappeared, and the hair follicles 
 are more or less atrophied. 
 
 Diagnosis. — It is to be distinguished from the ordinary forms of 
 purpura by the annular shape of the patches, the presence of pigmen- 
 tation, and its slow chronic course. It may be mistaken for syphilis, 
 but the telangiectases of the early stages and the atrophy of the final 
 stage will serve to distinguish it from that affection. 
 
 Prognosis. — The tendency of the disease is toward recovery, al- 
 though it may last for some months or even a year or two. 
 
 Treatment. — The treatment is not very satisfactory. Rest, espe- 
 cially in the recumbent position, and the use of a properly applied 
 elastic bandage are the only measures likely to be of use. MacKee 
 thought the local use of resorcin produced some improvement in his 
 case. 
 
 SCORBUTUS 
 
 Synonyms. — Purpura scorbutica; Scurvy. 
 
 Definition. — A systemic disease usually occurring in epidemics, but 
 also sporadically, characterized by mental depression, extreme debil- 
 ity with a tendency to syncope, swollen and spongy gums, and hemor- 
 rhages into the skin and from the mucous membranes. 
 
 Symptoms. — After a period of apathy and physical weakness last- 
 ing from one to several weeks, small hemorrhages appear as crimson 
 
HEMORRHAGES 467 
 
 or purple spots on the legs, usually in the neighborhood of the ankles 
 at first, and the gums become purplish, swollen, painful, and bleed 
 readily. This condition of the gums is one of the most characteristic 
 symptoms of the affection and usually appears early, but it may not 
 appear until late, and exceptionally may be entirely absent. With 
 the progress of the disease the purpuric eruption becomes more abun- 
 dant and more extensive, and spreads to the thighs, trunk, and upper 
 extremities. Extensive ecchymoses appear on the lower extremities, 
 firm, discolored swellings appear in the muscles and subcutaneous tis- 
 sues, due to extravasations of blood, the gums become still more 
 swollen and ulcerate, the teeth become loose and occasionally drop 
 out, and hemorrhages take place from the mouth, nose, and from the 
 bowels. Hemorrhagic effusions take place in the joints and into the 
 larger serous cavities of the body, attended at times by a rise in tem- 
 perature. Ulceration of the skin frequently occurs, either at the 
 site of the hemorrhages, in old scars, or after slight traumatism. In 
 the advanced stages there is great emaciation with extreme prostration 
 and oedema of the feet and ankles. 
 
 In infants and children the cutaneous symptoms are usually much 
 less prominent, although petechiae and ecchymoses occur as in adults, 
 but usually fewer in number. Symptoms of rickets are frequently 
 present, such as swelling of the epiphyses and the so-called beading 
 at the junctions of the costal cartilages and the ribs. The most promi- 
 nent and characteristic symptom is an extreme tenderness of the legs 
 with periosteal swellings. Sponginess and swelling of the gums, char- 
 acteristic symptoms in adults, are only present as a rule when the 
 eruption of the teeth is partly or entirely completed. Occasionally 
 there is a proptosis of one eye from subperiosteal hemorrhage in the 
 orbit. Hematuria is also occasionally present and may be an early 
 symptom. 
 
 Etiology and Pathology. — Scorbutus occurs as a rule in epidemics 
 among sailors, prisoners, and others who have had an unbalanced diet, 
 one in which fresh fruits, vegetables, and meats have been largely or 
 entirely wanting. In infants, in whom it occurs chiefly between the 
 ages of six and eighteen months, it is observed in those who have 
 been fed upon proprietary foods from which fresh milk is absent, 
 or in those who have been fed on condensed or sterilized milk. 
 
 A more or less marked diminution of erythrocytes is present, but 
 no characteristic changes are discoverable in the blood and blood- 
 vessels. Numerous hemorrhages are present in the skin, subcutaneous 
 tissues, muscles, and in the serous cavities. Fatty degeneration of the 
 heart, liver, and kidneys is not uncommon. 
 
 Diagnosis. — The epidemic occurrence of the disease in those who 
 have been deprived of fresh fruit, vegetables, and fresh meat, the pur- 
 puric eruption, and especially the swollen and spongy condition of 
 the gums, are so characteristic that the diagnosis is usually made with- 
 out any difficulty. In children and infants it may be mistaken for 
 
468 DISEASES OF THE SKIN 
 
 rickets, but the extreme tenderness of the lower extremities, the pe- 
 riosteal swellings, and the condition of the gums in those who have 
 cut some or all of the teeth are characteristic symptoms, especially in 
 artificially fed children. 
 
 Prognosis and Treatment. — Although always a serious affection, 
 the prognosis is usually favorable unless proper treatment is too long 
 delayed. As a rule, the free administration of an abundance of fresh 
 fruit, lemon or lime juice, fresh vegetables, and raw meat juice is 
 promptly followed by an amelioration of all the symptoms and event- 
 ually their complete disappearance. The medicinal treatment is to be 
 conducted on general principles, and in many instances may be entirely 
 dispensed with. For the inflamed and ulcerated gums, mild antiseptic 
 mouth-washes should be employed. 
 
CHAPTER XII 
 
 HYPERTROPHIES— HYPERTROPHIC 
 
 CLAVUS 
 
 Synonyms. — Corn; Fr., Cor; CEil de perdrix; Ger., Leichdorn ; 
 Hiihnerauge. 
 
 Definition. — A circumscribed overgrowth of the horny layer of the 
 epidermis situated, in most instances, upon the toes. 
 
 Symptoms. — Two varieties of corns are recognized, viz., hard and 
 soft corns, the differences between the two being largely the result of 
 differences in situation. 
 
 The hard corn, which is much the more frequent of the two varie- 
 ties, is a small flat or slightly conical horny elevation about the size 
 of a pea, with a smooth surface, in the centre of which is a small 
 whitish spot, sometimes slightly elevated — the eye or core — which 
 may be picked out with the point of a knife-blade and extends deeply 
 downward in the epidermis. It is found upon the dorsal surface of 
 the toes, over the bony prominences, on the outer side of the little 
 toe, and less frequently upon the sole. It is usually quite sensitive 
 to pressure and often spontaneously painful, frequently becoming more 
 so with changes in the weather. 
 
 The soft corn is situated on the sides of the toes, and, owing to 
 maceration, it is soft and grayish instead of hard and yellowish-white. 
 It is usually much more painful than the hard corn, and often the 
 source of much discomfort. 
 
 Both varieties frequently become inflamed, sometimes suppurate, 
 and occasionally undergo ulceration. 
 
 Etiology and Pathology. — Corns are almost invariably the result of 
 pressure or friction, and are commonly caused by the wearing of tight 
 or ill-fitting shoes. 
 
 They are circumscribed hyperkeratoses, the result of pressure, 
 and consist of an accumulation of horny epidermic cells which, in the 
 central portion or core, which is conical, with the small end downward, 
 are so compressed that separate layers can no longer be distinguished. 
 Beneath the core the rete is markedly atrophied, but about the border 
 of the lesion it is increased in thickness. The papillae in the central 
 portion are flattened out or obliterated, but at the margins are more 
 or less elongated. 
 
 Treatment. — Pressure should be removed and friction avoided by 
 the wearing of properly fitting shoes. After thoroughly soaking in 
 hot water the top should be carefully pared with a sharp knife or 
 scraped off with a- dull knife-blade, or, what is better, a small curette, 
 removing as thoroughly as possible the central portion or core ; after- 
 
 469 
 
470 DISEASES OF THE SKIN 
 
 ward a perforated felt plaster, the so-called corn-plaster, should be 
 applied and worn for some time to ward off pressure. Salicylic acid 
 as a ten to fifteen per cent, plaster or dissolved in the same quantity 
 in collodion, or, better, liquor guttas-perchse, may likewise be success- 
 fully employed for the removal of corns. 
 
 CALLOSITAS 
 
 Synonyms. — Tylosis ; Tyloma ; Keratoma ; Callus ; Callosity ; Fr., 
 Callosite ; Ger., Schwiele. 
 
 Definition. — An acquired circumscribed increase in the thickness of 
 the horny layer of the epidermis, situated most frequently upon the 
 palms and soles, but not confined exclusively to these localities. 
 
 Symptoms. — Callosities occur as variously sized, yellowish or gray- 
 ish, smooth horny thickenings of the skin, with ill-defined borders, 
 situated as a rule upon the palms, palmar surface of the fingers, 
 and upon the soles, in the last-named region particularly upon those 
 parts especially exposed to pressure, such as the base of the great 
 toe and the heel. Although the just-mentioned localities are those in 
 which they are most frequently observed, they may occur upon other 
 parts when subjected to long-continued or often-repeated pressure, 
 as happens in certain occupations. Although usually unattended by 
 any noteworthy subjective symptoms, they occasionally become sensi- 
 tive and painful, and exceptionally the underlying skin may inflame 
 or even suppurate, the callosity being cast off as a result. Upon the 
 sole of the foot, especially upon the borders of the heel, fissures may 
 occur which are more or less painful. 
 
 Etiology and Pathology. — Callosities belong to the large group of 
 occupational dermatoses and are very common upon the hands of 
 laborers, of those who work at various trades, and of those who play 
 much upon stringed musical instruments. 
 
 In uncomplicated cases they are pure hyperkeratoses ; there is a 
 greater or less increase in the thickness of the horny layer of the epi- 
 dermis, usually with little or no change in other parts of the skin, al- 
 though there may be atrophy of the rete as the consequence of pres- 
 sure from the overlying thickened horny layer. 
 
 Treatment. — When the pressure which has caused them is removed, 
 moderately developed callosities usually disappear. When large and 
 thick they may be soaked thoroughly in a warm solution of bicarbonate 
 of soda or borax and afterward pared down with a sharp knife or 
 scraped off. The continuous application of a ten to twenty per cent, 
 plaster of salicylic acid for a week or two is likewise an effective 
 method of removing them; a fresh piece of the plaster should be ap- 
 plied every two or three days, scraping or rubbing off the softened 
 surface before applying the fresh plaster. 
 
HYPERTROPHIES 471 
 
 CORNU CUTANEUM 
 
 Synonyms. — Cornu humanum ; Cutaneous horn ; Fr., Corne de la 
 peau ; Ger., Hauthorn. 
 
 Definition. — A circumscribed elongate horny growth resembling 
 the horns of animals. 
 
 Symptoms. — Cutaneous horns vary much in size, shape, and gen- 
 eral appearance. They may be cylindrical, flat, or conical ; straight, 
 curved, twisted, and in rare cases branched ; yellowish, grayish, brown, 
 or blackish, and vary in diameter from 0.5 to 3 or 4 cm., and in length 
 from 3 or 4 m. to 25 or 30 cm. in rare cases ; Sutton refers to a case 
 in which a horn seated in the centre of the forehead, curving down- 
 ward in front of the face, extended below the chin. Their surface is 
 quite hard, but they may be less firm in their interior. While, as a 
 rule, they are solitary, there may be several, and in rare cases they 
 may be very numerous, as in one recorded by MansurofI (quoted by 
 Janovsky), in which there were 133. They usually grow quite slowly, 
 but in exceptional cases they may reach a considerable size in the 
 course of a few months or even in a few weeks (Dubreuilh). When 
 accidentally knocked off or pulled off, they are usually reproduced. 
 As an infrequent occurrence they may fall off spontaneously. While 
 they have been observed on practically all parts of the body, they are 
 much more frequently seen in the face and on the scalp than else- 
 where ; in more than one-half of the 109 cases collected by Lebert, 
 they were situated in these regions. 
 
 Etiology. — Cutaneous horns may occur at any age, but are infre- 
 quent before forty, and are somewhat more common in women than 
 in men. They have their origin in sebaceous cysts and warts, may 
 follow injuries, and exceptionally may be due to syphilis (Lewin and 
 Heller). 
 
 According to Unna, there are two stages in the formation of a 
 horn ; in the first there are both acanthosis and hyperkeratosis, and 
 in the second the former diminishes while the latter increases. The 
 horny layer is enormously increased in thickness, out of all propor- 
 tion to the changes in other portions of the epidermis, and the rete 
 is likewise at first increased in breadth, but later is somewhat thinned 
 by the pressure of the thickened horny layer. The papillae are usually 
 much elongated, but there are usually no other changes in the derma ; 
 occasionally, however, there are a slight increase in the number of 
 connective-tissue cells and a moderate perivascular exudate of leu- 
 cocytes. 
 
 Dubreuilh would make a separate variety of the multiple horns 
 observed in young subjects, such as the cases of Mansuroff and Batge, 
 and would class them with the systematized nsevi. 
 
 Prognosis and Treatment. — In most cases horns continue to grow 
 slowly but steadily, but, as already observed, in exceptional cases they 
 fall off spontaneously. In a certain proportion of cases, twelve per 
 cent., according to Lebert, epithelioma follows. 
 
472 
 
 DISEASES OF THE SKIN 
 
 The only effective treatment is surgical ; the larger ones should be 
 excised with the knife, together with a portion of the surrounding 
 skin, to insure against recurrence ; the small ones may be clipped off 
 with curved scissors. 
 
 KERATOSIS SENILIS 
 
 Synonyms. — Keratoma senile ; Fr., Acne sebacee ; Acne concrete. 
 
 Definition. — A hyperkeratosis peculiar to middle and old age, char- 
 acterized by yellowish, brownish, or blackish patches which show a 
 decided tendency to epitheliomatous change. 
 
 
 •-. 
 
 
 #" 
 
 Fig. 160. — Keratosis senilis — epithelioma. 
 
 Symptoms. — It occurs as pea- to dime-sized, seldom larger, often 
 ill-defined, yellowish, brownish, or blackish, more or less elevated 
 crusts, sometimes friable and rather greasy, seated on slightly erythem- 
 atous areas, at others dry and horny without any other visible altera- 
 tion of the skin. They are usually quite firmly adherent, and when 
 forcibly removed present a number of small spines on their under 
 
HYPERTROPHIES 
 
 473 
 
 surface which have filled the dilated mouths of the follicles ; the skin 
 beneath is red, moist, or not uncommonly superficially ulcerated. 
 Many of the crusts exhibit little or no change for months or years, 
 but sooner or later some of them become thick and wart- or horn- 
 like, and beneath them an epitheliomatous ulcer forms which pursues 
 the usual course (Fig. 160). Upon the backs of the hands the crusts 
 are frequently quite black and more or less depressed, and so firmly at- 
 tached to the skin that they cannot be removed without considerable 
 force. Along with the horny patches, the skin frequently presents 
 evidences of senile change ; here and there are patches of brownish pig- 
 mentation, whitish atrophic or scar-like areas, and telangiectases. 
 
 ^K#^» 
 
 *' 
 
 Fig. 161. — Keratosis senilis. K, Greatly thickened horny layer; F, follicle containing large horny plug; 
 R. C, round-cell exudate in papilla. 
 
 The malady shows a marked predilection for the uncovered re- 
 gions, such as the face, particularly the cheeks and nose, somewhat 
 less frequently the forehead, the rims of the ears, the back and sides 
 of the neck, and the backs of the hands. 
 
 Etiology. — In the great majority of cases it occurs in those past 
 fifty years of age, although it may occur as early as thirty-five or 
 forty in exceptional cases. Its subjects are for the most part those 
 whose occupation exposes them to the sun and air, and for that reason, 
 probably, is much more common in men than in women, although the 
 
474 DISEASES OF THE SKIN 
 
 most marked example the author has ever seen occurred in an Italian 
 peasant woman who worked in the fields. 
 
 Pathology. — In a study of the histopathology of the affection made 
 a few years ago, the author found an enormous increase in the thick- 
 ness of the horny layer of the epidermis, in which many nuclei were 
 still preserved, the greatest increase being about the mouths of the 
 hair follicles and of the sweat-ducts, the former being greatly dilated 
 and filled with horny plugs. The granular layer had completely 
 disappeared everywhere except about the mouths of the follicles 
 and the sweat-gland ducts. In the more recent lesions there was 
 a moderate hyperplasia of the rete, with evidences of increased cell 
 activity in the basal cell layer ; in the older ones this hyperplasia was 
 still greater and in places the rete was beginning to invade the corium 
 in which there was a dense cellular exudate composed of mononuclear 
 leucocytes plasma cells, and "mastzellen." In those with markedly 
 depressed and tightly adherent crusts, such as are seen upon the backs 
 of the hands, instead of a hyperplasia there was a more or less decided 
 pressure atrophy of the rete. The sebaceous glands showed nothing 
 abnormal, but the sweat-gland apparatus was invariably the seat of 
 pathological changes. There was an abundant exudation of cells 
 about the duct where it entered the epidermis ; in places the lining 
 epithelium of the coils showed marked proliferation, sometimes com- 
 pletely blocking the lumen, and in other places there was cystic dila- 
 tation of the coils (Fig. 161). 
 
 Diagnosis. — The appearance of these lesions is so characteristic 
 that they are readily recognized. They are sometimes mistaken for 
 senile warts, but the latter are only exceptionally found upon the 
 face, are often limited to the back, and are usually quite elevated. 
 
 Prognosis and Treatment. — Every senile keratosis is a potential 
 epithelioma; many, if not most, of the flat superficial epitheliomata so 
 common in the face begin in this manner. While they may show 
 but little alteration for several years, sooner or later ulceration takes 
 place beneath them. In the earliest stages, when the crust is thin, 
 an ointment of salicylic acid, two to three per cent., either alone or 
 combined with three to four per cent, of sulphur, may be of service. 
 Painting the patches with trichloracetic acid as recommended by Davis 
 is likewise an effective treatment. Older and larger lesions may be 
 destroyed by freezing with carbon dioxide "snow." They often dis- 
 appear under X-ray treatment in a very satisfactory manner. When 
 ulceration has once taken place, they should be treated as epithelioma. 
 
 KERATOSIS PILARIS 
 
 Synonyms. — Lichen pilaris; Pityriasis pilaris; Keratosis supra- 
 follicularis. 
 
 Definition. — A follicular hyperkeratosis characterized by small 
 horny papules situated at the mouths of the hair-follicles. 
 
 Symptoms. — The eruption which distinguishes this affection con- 
 
HYPERTROPHIES 
 
 475 
 
 sists of discrete, pin-head-sized, horny elevations occupying the mouths 
 of the hair-follicles. These may be readily picked out by the finger-nail, 
 leaving a small depression which often contains a coiled or broken 
 hair; or the papule may be pierced by the hair, which is at times 
 broken off and then appears as a small black dot in the centre of the 
 papule. It is situated most frequently upon the outer surface of the 
 upper arms and thighs, somewhat less frequently upon the arms and 
 legs, and in extensive cases upon the trunk. The skin between the 
 papules is, as a rule, normal in appearance, but is usuallv dry. Sub- 
 
 FlG. 162. — Keratosis pilaris. 
 
 jective symptoms are frequently absent altogether, but there may be 
 a moderate amount of itching. It varies much in the degree of its 
 development; often the lesions are scanty and limited to the arms 
 and thighs (Fig. 162), or they may be present in great numbers, 
 giving the skin a coarsely granular aspect and a grater-like feel. 
 
 Etiology. — The malady is most frequent in children and young 
 adults, and is seen in its greatest development in those who do not 
 bathe frequently, but is by no means limited to them. It is often 
 present to a marked degree in those with ichthyosis, although a num- 
 ber of authors regard this form as a part of the ichthyosis and a dis- 
 
476 DISEASES OF THE SKIN 
 
 tinct affection. It is commonly much more noticeable in winter than 
 in summer. 
 
 Pathology. — The disease is a hyperkeratosis limited to the mouths 
 of the hair-follicles, which are more or less completely blocked by an 
 accumulation of cornified epithelial cells. Unna regards it as an 
 inflammation ; he always finds a greater or less increase of connective- 
 tissue cells, both around and within the follicles, and a permanent 
 dilatation of the vessels in about one-third the cases. 
 
 Diagnosis. — The characteristic features of the eruption are the 
 horny character of the papules ; their follicular situation ; their dis- 
 tribution on the extensor surfaces of the arms and thighs ; and the 
 absence of symptoms of inflammation. It may bear some resemblance 
 to cutis anserina ("goose-skin"), but this is a transient affection due 
 to cold or fear, which disappears with the exciting cause. It may be 
 mistaken by the inexperienced for the miliary papular syphiloderm, 
 but it never presents the red-brown color and tendency to occur in 
 small groups characteristic of that eruption. It may resemble to some 
 degree lichen scrofulosorum, but differs from that affection in at- 
 tacking the extremities rather than the trunk, to which the latter is, 
 as a rule, confined. 
 
 Treatment. — The treatment is much the same as that of mild ichthy- 
 osis. Frequent baths, preferably made alkaline by the addition of 
 sodium bicarbonate or sodium biborate, four ounces to thirty gal- 
 lons (128 to 100 L.), followed by inunctions of a 2-per-cent. oint- 
 ment of salicylic acid in lanolin, seven parts, oil of sweet almond, 
 or lard oil, one part, will usually soon bring about the disappearance 
 of the eruption. The treatment must be continued for some time 
 after the eruption disappears to prevent relapses. 
 
 LICHEN PILARIS SEU SPINULOSUS 
 
 Under this title Crocker has described an affection of the hair- 
 follicles closely resembling keratosis follicularis, and of which it is 
 probably a variant. It is characterized by an eruption of quite small, 
 red, conical papules situated about the mouths of the hair-follicles, 
 which contain a small spine in the centre. After a time the redness 
 disappears, the papules become the color of the skin, and may then 
 remain unaltered for an indefinite period. The eruption is arranged 
 in symmetrically disposed patches of various sizes and is situated most 
 commonly upon the back of the neck, the extensor surface of the 
 arms, the abdomen, the buttocks, in the region of the trochanters, on 
 the posterior surface of the thighs, and in the popliteal spaces. Crocker 
 never saw it attack the face, upper part of the chest, nor the hands 
 and feet. It may be scanty or abundant, and is apt to appear rather 
 suddenly in crops, patches coming out overnight. 
 
 Etiology and Pathology.— It occurs, as a rule, in children, is more 
 frequent in boys than in girls, and occasionally is seen in adults. Ac- 
 cording to Crocker, there is first a hypersemia, which is followed by a 
 
HYPERTROPHIES 477 
 
 perifollicular effusion and a hyperplasia of the epidermic cells lining 
 the follicle. No study of its histopathology has been made, however. 
 
 Diagnosis. — It is to be distinguished from keratosis follicularis, 
 the only affection for which it is likely to be mistaken, by the red 
 color of the papules in their early stage and by their arrangement in 
 patches. 
 
 Treatment. — The treatment is practically the same as for keratosis 
 follicularis. Crocker obtained benefit from a liniment of soft soap 
 and alcohol containing one drachm (3.40) of oil of cade to the ounce 
 (30), rubbed in with a piece of flannel. 
 
 KERATOSIS FOLLICULARIS 
 
 Synonyms. — Keratosis vegetans (Crocker); Fr., Darier's disease; 
 Fr., Psorospermose folliculaire vegetante ; Acne sebacee cornee. 
 
 Definition. — A chronic affection characterized by an eruption of 
 brownish crusted papules, frequently follicular, symmetrically dis- 
 tributed, and showing a decided predilection for certain localities, 
 such as the face and scalp, the axillae and groins, but not limited to 
 these regions. 
 
 Symptoms. — This infrequent and remarkable malady was first ac- 
 curately described independently, in 1889, by James C. White and 
 Darier, the former giving it the name keratosis follicularis, the latter 
 calling it " psorospermose folliculaire vegetante." 
 
 Exhibiting a decided predilection for those regions in which the 
 sebaceous and sweat-glands are most active, such as the face and 
 scalp, the sternum, the axillae, and genito-crural regions, it is character- 
 ized in its early stages by pin-head to hemp-sized solid elevations 
 which at first differ but little in color from the normal skin (Fig. 163). 
 Schweninger and Buzzi, who had exceptional opportunity for watch- 
 ing the development of the lesions, assert that in their earliest stages 
 they are red spots or very small red papules, a statement confirmed 
 by Janovsky. As the lesions enlarge they become reddish or brown- 
 ish and are covered with a grayish, brownish, or blackish adherent 
 scale or crust, which upon removal is seen to be embedded in the 
 dilated mouth of a hair-follicle or in a funnel-shaped depression in 
 the epidermis, the imbedded portion being much softer than the top. 
 As the disease progresses, these enlarge and increase in number, form- 
 ing confluent patches about the temples (Fig. 164), on the sternum, 
 in the groins and axillae, covered with yellowish-gray or brownish 
 fatty crusts. In regions where there are opposed skin surfaces, where 
 there is more or less moisture, such as the axillae and inguinal and 
 genital region, the lesions reach their greatest development; here in the 
 most advanced cases they form nodules and papillomatous masses 
 covered with thick macerated crusts, underneath which superficial 
 ulceration sometimes occurs and from which is given off a most 
 offensive odor. Similar vegetating masses may form in the furrows 
 behind the ears. 
 
478 
 
 DISEASES OF THE SKIN 
 
 Upon the scalp the appearance is somewhat like that of a sebor- 
 rhceic dermatitis; it is covered with scales or yellowish crusts, be- 
 neath which is a moist, red, frequently slightly papillomatous, surface. 
 The hair is usually unaffected. 
 
 Upon the backs of the hands and tops of the feet are numerous 
 horny, corn-like elevations which at times are so numerous as to 
 form a continuous horny plate, grayish or blackish in color, as in 
 
 Fig. 163. — Keratosis follicularis (Darier's disease). 
 
 the case reported by White. Less frequently a punctiform keratosis 
 appears upon the palms and soles, in Darier's case as yellowish trans- 
 lucent points ; or these regions may be the seat of a diffuse kera- 
 tosis, presenting a uniform thickening of the horny epidermis. 
 
 The nails are usually more or less affected ; they are thickened, 
 furrowed longitudinally, brittle, with broken, ragged, free borders. 
 
 The progress of the malady is continuous and at first quite rapid, 
 but later is apt to be slow. Occasionally acute outbreaks occur in 
 
HYPERTROPHIES 479 
 
 which new territory is invaded. In the course of many months or 
 years the greater part of the surface may be more or less involved, 
 and even in regions in which there are no crusts the skin is apt 
 to be thickened and discolored. At times, however, it remains lim- 
 ited to certain restricted regions, as in the case reported by Bowen, 
 in which the head and hands alone were affected. In a case under 
 the author's observation a few years ago the eruption was limited to 
 scattered lesions on the sides of the thorax and abdomen. 
 
 The subjective symptoms are often insignificant, but there may 
 be at times quite severe itching. In the cases in which ulceration 
 of the vegetations in the groin occurs, there may be severe pain. There 
 are no general symptoms. 
 
 Etiology. — The early view that the affection was due to the in- 
 vasion of the follicles by psorosperms was soon shown to be errone- 
 
 Fig. 164. — Keratosis follicularis (Darier's disease). Yellow crusts above and behind ears. 
 
 ous, the supposed parasites being nothing more than peculiarly al- 
 tered epithelial cells. The direct cause still remains unknown. It 
 is considerably more frequent in men than in women, and in the 
 majority of cases begins in childhood or youth. In a considerable 
 proportion of the reported cases the disease presented a markedly 
 familiar character. White, Boeck, and Ehrmann observed two or 
 more cases in the same family, and Pohlmann and Trimble have each 
 reported five cases occurring in three generations. This is regarded 
 by most authors as evidence that heredity, in some cases, at least, 
 plays an important role in its causation ; but it might equally well be 
 explained by contagion, although it is generally believed to be non- 
 contagious. 
 
 Pathology. — The malady is an anomaly of cornification. As al- 
 ready remarked, Darier at first was of the opinion that the peculiar 
 
480 
 
 DISEASES OF THE SKIN 
 
 round bodies present in the rete were psorosperms, hence the name 
 which he gave it; but the later studies of Bowen, Boeck, Buzzi, and 
 Miethke, and of Darier himself, have proved definitely that the so- 
 called psorosperms are degenerated epithelial cells. Nor are the 
 lesions confined to the pilo-sebaceous follicles, as at first supposed, 
 but they also occur at the mouths of the sweat-gland ducts and in 
 parts of the epidermis in no way connected with the glandular ap- 
 paratus. 
 
 The histological changes are quite characteristic, and are found 
 chiefly in the epidermis. There is a marked hyperkeratosis, and in 
 
 FlG. 165. — Darier 's disease (keratosis follicularis) . A, degenerated epithelial cells in a horny plug filling 
 the follicle, formerly thought to be psorosperms. F, fissure in the rete mucosum. 
 
 follicular lesions the dilated funnel-shaped mouth of the follicle is 
 filled with cornified epithelial cells. The most characteristic features 
 are found in the rete. About the borders of the papule it is consider- 
 ably broader than normal ; the interpapillary prolongations are much 
 increased in length, and the cells of the basal layer and those imme- 
 diately adjacent contain numerous mitoses and a considerable amount 
 of granular pigment. In the central portion it is thinner than normal, 
 owing probably to the pressure of the thick overlying horny layer. 
 In its upper and middle portions are a variable number, rarely nu- 
 merous, of round, refractile bodies somewhat larger than the normal 
 
HYPERTROPHIES 481 
 
 epithelial cells, with granular protoplasm, with or without a nucleus, 
 and frequently provided with a double-contoured wall ; in the upper 
 part of the rete, and especially in the lower portion of the horny layer, 
 these lose their granular protoplasm and are quite transparent, with 
 very sharply defined outlines (Fig. 165). These are the " corps ronds" 
 of Darier, which were at first regarded as parasitic organisms. In 
 the lower part of the rete, fissures of considerable size are occasionally 
 seen, the exact significance of which is still a matter of conjecture. 
 
 The changes in the corium are comparatively insignificant. The 
 papillae at the borders of the lesion are greatly elongated and contain 
 a moderate exudate of leucocytes, principally in the neighborhood of 
 the vessels, with some granules of pigment, and those at the borders 
 of the papule are greatly elongated. 
 
 Diagnosis. — In well-developed cases the affection is usually recog- 
 nized without any difficulty. In its early stages or in mild cases it 
 may bear some resemblance to keratosis pilaris, but differs from 
 that affection in its regional distribution. In well-marked cases it 
 may resemble acanthosis nigricans, affecting for the most part the 
 same localities, but it does not, like that malady, affect the mouth, 
 and never presents such marked pigmentation. The histological feat- 
 ures are so characteristic that a biopsy is always of great value in the 
 differential diagnosis. 
 
 Prognosis.— The prognosis as to recovery is very unfavorable, but 
 the general condition is not impaired. The malady usually steadily 
 progresses and does not yield readily to treatment, although much 
 may be done, particularly in mild cases, to improve the condition of 
 the skin. In a case reported by Wende, multiple epithelioma developed 
 in some of the lesions. 
 
 Treatment. — Frequent warm alkaline baths are of great service, 
 and, when there is much crusting, may be supplemented by the use 
 of green soap or soaps containing sulphur or resorcin. When the 
 skin has been freed from crusts, ointments and pastes of salicylic 
 acid, resorcin, or sulphur, varying in strength from two to five per 
 cent., may be used with benefit. Pyrogallol has also been recom- 
 mended, but this is an extremely dirty remedy, possesses no advan- 
 tage over those already mentioned, and its use is not devoid of danger. 
 Mook, Lieberthal, and Stelwagon have observed favorable results from 
 the use of the X-ray, and Ritter has reported a case of cure. In a 
 mild case under the author's care a few years ago, decided improve- 
 ment followed the use of this agent. Herxheimer reports the cure 
 of two cases by the thermocautery, cauterizing superficially the af- 
 fected areas. 
 
 KERATOSIS FOLLICULARIS CONTAGIOSA 
 
 Some years ago (T892) Brooke described a very rare form of follic- 
 ular keratosis, apparently contagious, resembling in many of its clini- 
 cal features the keratosis follicularis of White and Darier, which 
 he regarded as identical wth the acne sebacee cornee of Cazenave, 
 31 
 
482 DISEASES OF THE SKIN 
 
 the acne cornee of Leloir and Vidal, the ichthyosis sebacea cornea of 
 Erasmus Wilson, and the keratosis follicularis of Morrow. Other 
 cases have since been reported by Little, Elliot, and others. 
 
 It begins with a slight thickening of the horny layer of the epi- 
 dermis, accentuating the normal lines of the skin, and in the polygonal 
 areas thus outlined two or three small black points appear, of which 
 one or more develop into small papules, from the summit of which 
 firmly attached horny spines project, some of which are long and 
 slender, others short and thick-like comedones. Some of the larger 
 lesions become inflamed like those of acne, while others resemble 
 warts. The eruption is symmetrically distributed and is found upon 
 the nape of the neck, the extremities, and to a less degree the trunk 
 and face. In Brooke's cases it reached its greatest development on 
 the outer surface of the posterior axillary folds, where it formed thick 
 wart-like patches from which long spines projected. 
 
 Etiology and Pathology.— While the contagiousness of the malady 
 has not yet been definitely proven, the clinical evidence in favor of 
 it is very strong. Out of seven children in a family under Brooke's 
 observation, six were affected in the course of some months, and 
 three children in a second family were attacked in the course of a 
 few weeks. Graham Little also saw three cases in the children of 
 one family. 
 
 The histopathology has been studied by Leloir and Vidal, by Rob- 
 inson, who examined Morrow's case, by Brooke and Unna, all of 
 whom are practically agreed as to its histological features. It is a 
 hyperkeratosis resembling in many of its features keratosis pilaris, 
 but, unlike that affection, the process is not limited to the hair-folli- 
 cles, but also affects the interfollicular regions. While clinically it 
 presents many of the features of a mild keratosis follicularis of the 
 Darier type, neither Brooke nor Unna was able to find the large round 
 bodies in the rete characteristic of that disease. 
 
 Diagnosis. — While it resembles the keratosis follicularis of Darier, 
 the papillomatous lesions and greasiness of the skin which are present 
 to a greater or less degree in that affection are absent; instead, the 
 skin is usually abnormally dry. 
 
 Treatment. — Brooke found the eruption disappeared rapidly after 
 inunctions with " mollin " (lard saponified by caustic potash, to which 
 has been added fresh lard and a small quantity of glycerin). Sapo 
 mollis would probably be just as effective. 
 
 KERATOSIS PALM^ ET PLANTS 
 
 Synonyms. — Tylosis palmse et plantse ; Ichthyosis palmaris et plan- 
 taris ; Fr., Keratodermie palmaire et plantaire ; Keratodermie symme- 
 trique hereditaire. 
 
 Definition. — A diffuse thickening of the horny layer of the palms 
 and soles, which may be hereditary or acquired. 
 
 Symptoms.— The hereditary form of this affection (Fig. 166), which 
 
HYPERTROPHIES 
 
 483 
 
 is decidedly uncommon, usually begins in infancy, sometimes within 
 the first few weeks, but more commonly some months after birth, 
 with some roughness and desquamation of the palms and soles, about 
 the margins of which and along the lateral borders of the fingers is 
 a narrow red or violaceous zone separating the diseased area from 
 the sound area. After a variable time thickening of the palms and soles 
 takes place, which, when the malady is fully developed, are covered with a 
 horny layer which varies from a few millimetres to as much as a centi- 
 metre in thickness, is yellowish or grayish, slightly translucent or opaque,, 
 and smooth or more or less pitted. Fissuring, especially noticeable upon 
 the palms, sometimes occurs, either in the normal furrows or inde- 
 pendently of these, producing a mosaic-like effect ; less frequently,, 
 instead of diffuse thickening, there are numerous wart-like, horny 
 
 Fig. 166.— Hereditary keratosis of the palms and soles. A younger brother and maternal uncles. 
 
 similarly affected. 
 
 elevations. Upon the soles the thickening may be confined to those 
 parts especially exposed to pressure, such as the heels and the ball 
 of the foot, while the part beneath the arch is relatively normal. 
 While in the majority of cases the thickening is limited to the 
 palms and soles, it occasionally extends to the dorsal surface of the 
 fingers, over the knuckles, and the elbows and knees may be affected 
 (Neumann). Occasionally the nails are altered; they become thick, 
 opaque, and uneven. In many cases there is a more or less marked 
 hyperidrosis of the palms and soles, which in the latter region pro- 
 duces maceration of the horny layer, which may be cast off in conse- 
 quence. As a rule, the condition is a persistent one, but there may 
 
484 
 
 DISEASES OF THE SKIN 
 
 be intermittent desquamation and at times a shedding of the horny- 
 epidermis. 
 
 Under the name keratodermia symmetrica erythematosa, Besnier de- 
 scribed an acquired form of palmar and plantar keratosis, which pre- 
 sents a number of points of resemblance to the hereditary affection. 
 It is distinguished by thick hyperkeratosic patches surrounded by an 
 erythematous zone situated upon the palmar and plantar surfaces. Its 
 
 Fig. 167. — Keratosis of the soles (following eczema). 
 
 course is characterized by exacerbations, and it is worse in the winter 
 season. 
 
 Brooke has also described as erythema keratodes an acquired form 
 which resembles in some respects still more the hereditary variety. 
 It begins with marked redness and swelling of the palms and soles, 
 which are followed by horny thickening, and is more or less painful. 
 It has thus far been observed only in adults, and disappears under 
 treatment, although apt to relapse. 
 
HYPERTROPHIES 485 
 
 Diffuse hyperkeratosis of the palms and soles, sometimes very 
 marked and extensive, is occasionally observed as a sequel of chronic 
 eczema in these regions (Fig. 167). 
 
 An especially interesting and important variety of palmar and 
 plantar keratosis may follow the prolonged use of arsenic internally. 
 It usually begins with a more or less marked hyperidrosis of the 
 palms and soles, which is followed sooner or later by hemp-seed- 
 sized and larger horny corn-like elevations, which may be few and 
 scattered or very numerous ; in the latter case they may coalesce to 
 form a thick, horny plate covering the entire palmar and plantar regions 
 (in Fig. 120). As was first pointed out by Sir Jonathan Hutchinson, 
 whose observations were later confirmed by those of the author and others, 
 this form of keratosis may be followed by epithelioma, the number of 
 such cases now on record being considerable. 
 
 Etiology and Pathology. — The hereditary character of the variety 
 beginning in early life is usually well marked and has been amply 
 confirmed by the observations of Thost, Dubreuilh, Crocker, and nu- 
 merous other authors. Although usually affecting both sexes alike, 
 it occasionally descends only in the male or female line. It has been 
 observed in three, four, or five successive generations; Vomer has 
 recently recorded a striking example of its hereditary character in 
 which, out of a family consisting of forty members in four generations, 
 forty per cent, inherited the affection. 
 
 Under the name mal de Meleda, Hovorka some years ago described 
 a hereditary palmar and plantar keratosis, previously described in 
 1826 by Stulli, which occurs in the island of Meleda, off the coast of 
 Dalmatia. He at first regarded it as a manifestation of lepra, but 
 later study of the affection in conjunction with Ehlers convinced him 
 that it was not related to that malady. 
 
 The etiological relationship of chronic eczema and of arsenic to 
 certain of the acquired forms has already been referred to. 
 
 Pathology. — The earlier observations of Thost concerning its his- 
 topathology have been confirmed by the later ones of Unna and 
 Vomer. The horny layer of the epidermis is greatly thickened, as 
 well as the rete, the increase in the latter being due to a hyper- 
 plasia of the prickle-cell layer. The papillae are greatly elongated, 
 and the coils of the sweat-glands are hypertrophied. Unna regards 
 these changes as indicating "a nsevoid hypertrophy of the palms and 
 soles." 
 
 Diagnosis. — Its early beginning, in infancy or childhood ; the his- 
 tory of its occurrence in other members of the family or near rela- 
 tives ; the absence of symptoms of inflammation, and its limitation 
 to the palms and soles will serve to distinguish the hereditary form 
 from other forms of keratosis. The acquired form may be mistaken 
 for chronic eczema and for late syphilis, but the former is markedly 
 inflammatory and the latter is rarely so symmetrically distributed. 
 Arsenical keratosis is seldom diffuse, but occurs as more or less dis- 
 crete corn-like elevations. 
 
486 DISEASES OF THE SKIN 
 
 Prognosis and Treatment. — The inherited variety usually persists 
 throughout the patient's life, and, although unaccompanied by pain, 
 itching, or other disagreeable subjective symptoms, it interferes very 
 •decidedly with the use of the hands, particularly in occupations requir- 
 ing nicety of touch. The acquired forms are usually much more 
 amenable to treatment, but the possibility of epithelioma occurring 
 as a sequel, especially in the arsenical variety, should, not be for- 
 gotten. 
 
 While some authors advise internal treatment, particularly the 
 administration of arsenic (Brocq), this may very well be dispensed 
 with as of more than doubtful value ; the only effective treatment is 
 local treatment. Prolonged and frequent soaking of the hands and 
 feet in warm solutions of sodium bicarbonate or biborate, with fric- 
 tions with green soap, are useful auxiliaries to other applications. The 
 most useful local remedy is salicylic acid in ointment, or, what is 
 much more effective, in a plaster varying in strength from 10 to 20 
 per cent. ; this should be worn continuously for some time, renewing 
 it every two or three days. Under such a plaster the horny epi- 
 dermis is softened so that it can be rubbed or scraped off, which 
 should be done each time before applying fresh plaster. Ormsby 
 and others have reported more or less marked improvement after the 
 use of the X-ray. 
 
 KERATOSIS BLENNORRHAGICA 
 
 Synonyms. — Keratodermia blennorrhagica ; Fr., Keratodermie 
 blennorrhagique ; Keratose blennorrhagique. 
 
 Definition. — A keratosis, general or local, usually the latter, asso- 
 ciated with gonorrhoea. 
 
 Symptoms. — This rare affection was first recognized by Vidal, 
 in 1893, and a limited number of cases have since been recorded by 
 other French observers, by Sequiera and Graham Little in England, 
 by Baermann and Arning and Meyer-Delius in Germany, and by 
 Simpson in the United States. 
 
 It is distinguished by elevated horny lesions, usually discrete, some- 
 times aggregated, varying in size from hemp-seed to a small coin, 
 which may be disseminated over the general surface, most numerous 
 upon the extremities, rarely upon the face and scalp, or, what is much 
 more frequently the case, limited to the hands and feet, particularly 
 the palms and soles. They are yellowish or brownish in color, some- 
 times slightly translucent, laminated, and more or less adherent to 
 the underlying surface, which is red and somewhat moist. They ap- 
 pear coincidently with a gonorrhoeal arthritis and may be preceded 
 by vesicles and pustules, although this is quite exceptional. When 
 limited to the hands and feet the palms and soles are diffusely thick- 
 ened, and upon them are scattered discrete and confluent conical horny 
 elevations, which are apt to be most abundant upon the heels, outer 
 border of the soles, and the ball of the foot ; they may also appear upon 
 
HYPERTROPHIES 487 
 
 the sides of the feet, the tops of the toes, and upon the sides and 
 backs of the fingers. The nails are usually more or less affected ; the 
 nail-fold proliferates and the nails become opaque, thick, and elevated 
 by an accumulation of horny material beneath them, and may be lost. 
 There are no subjective symptoms referable to the cutaneous lesions. 
 The duration varies with that of the gonorrhceal symptoms ; when 
 these disappear, the horny crusts fall spontaneously, leaving a slightly 
 pink surface. 
 
 Etiology. — Although it is invariably associated with a general 
 gonorrhceal infection, the gonococcus has not yet been demonstrated 
 in the lesions. Chauffard and Fiessinger succeeded in producing 
 lesions by auto-inoculation, but their attempts to reproduce them in 
 animals failed. One attack seems to predispose to others, since when 
 an individual has once had it, although he may have had previous at- 
 tacks of gonorrhoea without the keratosis, it almost invariably recurs 
 with subsequent infections. The patient in whom Vidal first observed 
 the disease had two attacks coincident with two gonorrhceal infections, 
 separated by an interval of thirty-two months. 
 
 Pathology. — The malady belongs among the hyperkeratoses. Ac- 
 cording to Arning and Meyer-Delius, Baermann, and Chauffard and 
 Fiessinger, it begins as an inflammation characterized by a marked 
 exudation of leucocytes, chiefly polymorphonuclears, with some "mast- 
 zellen," which surrounds the dilated vessels of the papillae and extends 
 into the epidermis ; this is followed by a parakeratosis of the upper 
 layers of the epidermis. 
 
 Diagnosis. — It may at times resemble to some extent syphilis or 
 psoriasis, but its association with unmistakable symptoms of a gen- 
 eral gonorrhceal infection, and its frequent limitation to the hands 
 and feet, are features sufficiently characteristic to prevent mistake. 
 
 Prognosis and Treatment. — With the disappearance of the arthritis 
 and other symptoms of gonorrhceal infection, the skin lesions likewise 
 disappear. The treatment is that of the underlying gonorrhceal infec- 
 tion. Chauffard and Fiessinger recommend frequent washings with 
 soap and water and the application of moist dressings ; Simpson found 
 ointments of sulphur and resorcin useful. 
 
 POROKERATOSIS 
 
 Synonyms. — Hyperkeratosis excentrica (Respighi) ; Hyperkera- 
 tose figuree centrifuge atrophiante (Ducrey and Respighi). 
 
 Definition. — A hyperkeratosis characterized by centrifugally 
 spreading patches surrounded by a narrow horny ridge with a fine 
 furrow on the summit. 
 
 Symptoms. — First recognized by Majocchi, this affection was de- 
 scribed simultaneously by Mibelli and Respighi in 1893, the former 
 calling it porokeratosis, the latter hyperkeratosis excentrica. It begins 
 as one or more dirty-brown horny papules, which slowly enlarge 
 peripherally to form round, oval, or irregularly shaped, sharply cir- 
 
488 DISEASES OF THE SKIN 
 
 cumscribed patches surrounded by a narrow horny ridge, the sum- 
 mit of which is divided longitudinally by a linear furrow, along the 
 bottom of which usually extends a fine thread-like corneous elevation. 
 The central portion of the patches may be atrophic and rather smooth 
 or slightly desquamating and somewhat depressed; or it may be thick- 
 ened and contain a number of small horny papules similar to the 
 primary ones. In hairy regions the patches usually, but not invariably, 
 become more or less bald. They vary in size from a small pea to 
 a coin, but exceptionally may cover a considerable area, as in the 
 case described by Mibelli, in which the outer side of the forearm and 
 back of the hand to the knuckles were covered by a single patch with 
 serpiginous borders. They are round, oval, or polycyclic in shape, 
 may be solitary or multiple, and occasionally exist in considerable 
 numbers. The regions affected by preference are the dorsal surfaces 
 of the hands and feet, but the face, arms, legs, and genitalia may 
 likewise be affected. 
 
 The horny ridge which forms the margin of the patches, with the 
 furrow running along its summit, is one of the most characteristic feat- 
 ures of the malady and is peculiar to it. It usually rises quite abruptly 
 on the side towards the sound skin and frequently contains numerous 
 minute horny elevations. It is, as a rule, continuous, but is at times 
 broken, especially in the cases in which the patches are irregular or 
 polycyclic in shape ; and in a few instances two or more concentric 
 ridges or crescents have been observed. Occasionally it happens, 
 more frequently in the face than elsewhere, that instead of a con- 
 tinuous ridge the patches are surrounded by numerous brownish, mil- 
 iary conical or hemispherical horny elevations arranged linearly instead 
 of a continuous ridge. 
 
 When the disease is seated upon the hands, the nails may also be 
 involved ; they become thick, uneven, and opaque. 
 
 According to Ducrey and Respighi, lesions similar to those upon 
 the skin are fairly common upon the mucous membranes of the mouth. 
 In this situation they occur as whitish or opalescent patches, round or 
 oval, with a white elevated border. 
 
 The progress of the affection is usually very slow ; new patches 
 may appear from time to time, while the old ones enlarge very grad- 
 ually and may remain for months without perceptible change. 
 
 Etiology and Pathology. — That heredity is an important factor in 
 its production may be inferred from the relatively considerable num- 
 ber of instances in which two or more cases have been observed in 
 the same family. Mibelli, Ducrey and Respighi, and Gilchrist have 
 recorded examples, the last-named reporting the occurrence of no 
 less than eleven cases in four generations. It occurs at all ages, but 
 is most common in adolescents and young adults ; it is somewhat more 
 frequent in males than in females. 
 
 All attempts to demonstrate a causative organism in the lesions 
 have thus far failed. Wende, after numerous failures, succeeded in 
 
HYPERTROPHIES 489 
 
 producing by inoculation, in an individual who already had the malady, 
 a lesion which he believed to be the early stage of the disease. 
 
 All those who have studied the histopathology of the malady, 
 and that includes almost all those who have reported cases, are in 
 practical agreement as to its histology. It is a hyperkeratosis begin- 
 ning in the lower portion of the corneous layer and upper portion 
 of the rete, reaching its greatest development in the ridge which sur- 
 rounds the patches, especially in the neighborhood of the mouths of 
 the sweat-ducts, which are frequently filled with a plug of horny epithe- 
 lium. Mibelli thought it confined to the sweat-pore and for that reason 
 gave it the name porokeratosis, but this has been shown by other 
 observers to be erroneous, the follicles also being invaded. In the 
 centre of the patches the rete shows varying degrees of atrophy. In 
 the derma the blood- and lymphatic-vessels are dilated, and the former 
 are surrounded by an exudation of leucocytes. The coils of the sweat- 
 glands and the ducts are at times dilated, at others atrophied. In 
 the patches on the mucous membranes there are much more decided 
 evidences of inflammation in the papillary and subpapillary portions 
 (Ducrey and Respighi). 
 
 Diagnosis. — The diagnostic features of the affection are the cir- 
 cular or oval shape of the patches ; their situation upon the face, hands, 
 legs, and feet, and the peculiar ridge which surrounds them ; nothing 
 like the last is seen in any other disease. 
 
 Prognosis and Treatment. — It usually pursues a slowly progressive 
 course and rarely disappears, although Mibelli has recorded an instance 
 in which the patches underwent involution. 
 
 No local application has thus far proved of any avail in the treat- 
 ment. Gilchrist curetted a number of patches in the cases under his 
 observation, but they all returned ; in two cases, however, electrolysis 
 was used with excellent results. Small patches may be excised. 
 
 ANGIOKERATOMA 
 
 Synonyms. — Lymphangiectasis (Colcott Fox) ; Fr., Verrues telan- 
 giectasiques (Dubreuilh) ; Ger., Angiokeratom. 
 
 Definition. — An affection characterized by small vascular and 
 horny elevations situated for the most part upon the extremities. 
 
 This rare malady was first recognized by Cottle, who, according 
 to Crocker, reported an example of it in the St. George's Hospital 
 Reports for 1877— '78, but the name by which it is at present most 
 appropriately known was given to it by Mibelli in 1889. 
 
 Symptoms. — It begins as small, red, violaceous, or slate-colored, 
 non-elevated discrete spots, at times quite numerous, with a darker 
 central punctum, situated upon the dorsal surface of the hands and 
 feet, particularly the backs of the fingers and toes, which at first lose 
 their red color, wholly or in part, under pressure. After a time these 
 spots become more or less elevated, slightly hard and rough like ordi- 
 nary warts, but still retaining their red or violaceous color, which can 
 
490 DISEASES OF THE SKIN 
 
 no longer be made to disappear by pressure. Many of them contain 
 minute black points, which can be picked out with a needle, which 
 are small coagula situated between the cells of the horny layer of 
 the epidermis. New lesions appear from time to time, especially 
 during the winter season, at which time the old ones become more 
 noticeable. In most of the cases the patients suffer from chilblains. 
 There are no subjective symptoms. While the affection is in most 
 cases limited to the extremities, it has been observed in other regions, 
 such as the scrotum ; Anderson observed one in which the entire sur- 
 face except the face, palms, and soles exhibited innumerable lesions, 
 and Stiimpke has recently reported one in which the thighs, scrotum, 
 penis, abdomen, and upper extremities were affected. In a number of 
 instances other vascular lesions were present; in a case reported by 
 Zeisler there were naevus-like patches and vascular tumors on the 
 ears, arms, and legs. 
 
 Etiology and Pathology. — Nearly all the reported cases occurred 
 in children and adolescents, but exceptionally it may begin at a much 
 more advanced age, as in the cases of Fordyce and Zeisler. It is 
 apparently but little influenced by sex, although somewhat more fre- 
 quent in males than in females. As already noted, it occurs for the 
 most part in those subject to frost-bite. In a considerable number of 
 cases it exhibited a familial character ; Mibelli saw it in six children 
 of one family, Pringle in four, Dubreuilh observed it in a mother 
 and daughter, and Hartigan in two sisters, so that it is probable 
 that it is to a considerable degree dependent upon heredity. In a 
 small proportion of cases it has been associated with evidences of 
 tuberculosis. 
 
 As to its histopathology, it is a telangiectasis plus a hyperkera- 
 tosis. The vessels of the papillae are widely dilated, forming irregu- 
 lar spaces, at times divided by slender fibrous septa, filled with blood 
 and coagula, which extend upward into the rete. The horny layer is 
 much increased in thickness, and the granular layer is likewise broad- 
 ened. There is a moderate acanthosis, the interpapillary prolonga- 
 tions of the rete being elongated and at times branched. Sutton 
 found notable changes in the elastic tissue. The theory that it is 
 related to tuberculosis finds no support in its histology. 
 
 Diagnosis.— The only affections for which it is likely to be mis- 
 taken are small angiomata or telangiectases and warts. It differs 
 from the former by the more or less marked horny character of the 
 lesions, and from the latter by the very evident vascular alterations 
 as indicated by their red or purplish color, which in the early lesions 
 may be made to disappear by pressure. 
 
 Prognosis and Treatment. — Left to itself, the malady lasts indefi- 
 nitely, and new lesions appear at irregular intervals. As it is unac- 
 companied by annoying symptoms, it is frequently discovered only 
 by accident, and often exists without coming under the physician's 
 observation. 
 
HYPERTROPHIES 491 
 
 The most convenient, and at the same time most effective, treat- 
 ment is electrolysis. The needle attached to the negative pole should be 
 inserted in each lesion and a current of two to three milliamperes allowed 
 to act for twenty to thirty seconds. They may also be quickly destroyed 
 by the galvanocautery, employing one with a fine point. 
 
 ACANTHOSIS NIGRICANS 
 
 Synonyms. — Keratosis nigricans; Fr., Dystrophic papillaire et pig- 
 mentaire (Darier), 
 
 Definition. — A rare disease of the skin characterized by pigmenta- 
 tion and papillary hypertrophy, exhibiting a marked predilection for 
 certain regions and associated in a large proportion of cases with 
 malignant disease of some one of the abdominal viscera. 
 
 Symptoms. — This rare and remarkable disease was first described 
 by Pollitzer and Janovsky independently, in 1890, who gave it the name 
 suggested by Unna, acanthosis nigricans. Three years later Darier re- 
 ported three new cases under the name dystrophic papillaire et pigmen- 
 taire, and called attention to its relationship to abdominal cancer. Up 
 to the present time about sixty cases have been reported by vari- 
 ous observers in Europe and America. It usually begins as a brownish 
 or dirty-gray discoloration of the neck, the axillae, the genitocrural, and 
 perianal regions, which later spreads to other parts, such as the 
 breasts, the umbilical region, the flexures of the elbow, the popliteal 
 spaces, the forearms, and the back of the hands, the parts around 
 the mouth and the eyes. Soon after the appearance of this discolora- 
 tion, or concurrently with it, the skin in these regions becomes thick, 
 its normal furrows more or less exaggerated, and warty and papil- 
 lomatous growths appear, the latter especially in the axillae, in the 
 groins, about the genitalia and anus, and in the mouth. Numerous 
 warty lesions occupy the backs of the hands, while the palms are 
 diffusely thickened and horny. In a few instances small papillomata 
 were present on the edges of the lids and in the canthi, where they 
 formed small confluent patches ; in others the auditory meati were 
 filled with warty growths. The buccal, lingual, and pharnygeal mu- 
 cous membranes likewise exhibit more or less papillary hypertrophy ; 
 the tongue, the hard and soft palate, the gums, and the inner sur- 
 face of the lips are covered w r ith numerous soft papillomatous growths, 
 some of which resemble condylomata. In Pollitzer's case these growths 
 formed considerable blackish masses at the labial commissures. In 
 exceptional instances the laryngeal and nasal mucous membranes 
 have been invaded. While the mucous membranes share in the papil- 
 lary hypertrophy, pigmentation is rarely present ; very recently To- 
 yama has reported a Japanese case in which there were patches of 
 pigment upon the hard palate and upon the conjunctiva. With the 
 progress of the malady the skin generally becomes dry, the nails 
 brittle, and the hair falls. The affection usually advances rapidly, 
 reaching its full development in the course of two or three months. 
 
492 DISEASES OF THE SKIN 
 
 In some instances it began with more or less severe itching; in a 
 case reported by Crocker it began with an outbreak of what appeared 
 to be ordinary warts on the backs of the hands. 
 
 The course of the disease is usually steadily progressive, and a 
 fatal termination occurs at the end of one or two years, usually with 
 symptoms indicative of malignant disease. 
 
 In children and adolescents the symptoms are usually much less 
 marked, and, when once developed, the malady may in these exhibit 
 but little change for years, the general health being but little, if at all, 
 affected. 
 
 Etiology. — The disease has been observed at all ages from two 
 years to seventy-two, but at least two-thirds of all the reported cases 
 occurred after thirty years of age. Sex seems to exert but little influ- 
 ence upon its occurrence, but the number of female cases is slightly 
 in excess of the male cases. In a very large proportion of adult cases, 
 eighty per cent., according to Pollitzer, it has been associated with 
 abdominal cancer, a proportion so large as to indicate some causal 
 relationship between the two affections. Spietschka has reported a 
 case strikingly confirmatory of this relationship. A young woman, 
 twenty years of age, who presented the symptoms of acanthosis nigri- 
 cans, also suffered from a malignant deciduoma for which a total 
 hysterectomy was done ; four and one-half months after the removal 
 of the uterus, all evidence of the cutaneous disease had disappeared. 
 
 Pathology. — Nothing definite is known about the pathogenesis of 
 the affection. Darier thinks it likely that the changes in the skin are 
 the result of some irritant effect produced upon the abdominal sym- 
 pathetic by a malignant growth affecting some one of the abdominal 
 organs; in the juvenile form the same changes may result from a 
 benign growth. 
 
 Marked histological changes are present in the epidermis and 
 corium. The former shows varying degrees of hyperkeratosis with 
 a decided acanthosis, and the cells of the rete, both the upper and 
 basal cells, contain an abundance of brown pigment. The papillae 
 of the corium are greatly elongated, sometimes branched, and con- 
 tain a variable number of fusiform and branched cells filled with 
 pigment, together with considerable numbers of "mastzellen." 
 
 Diagnosis. — The cardinal symptoms are pigmentation and papil- 
 lary hypertrophy ; these, taken together with the marked symmetrical 
 regional arrangement, are so characteristic in well-developed cases 
 as to be almost pathognomonic. The diseases from which it is to be 
 distinguished are Darier's disease (keratosis follicularis), seborrhcea 
 nigricans, ichthyosis, Addison's disease, arsenical pigmentation, and 
 xeroderma pigmentosum ; from all of these it differs by its remarkable 
 predilection for the regions already enumerated and by its symmetri- 
 cal distribution. The association of the symptoms with a demonstrable 
 abdominal tumor would, of course, be still more significant. 
 
 Prognosis. — In adult cases the prognosis is very unfavorable, death 
 
HYPERTROPHIES 493 
 
 occurring usually within a year or two after the appearance of the 
 first symptoms. In juvenile cases, however, the outlook is much more 
 favorable ; the disease may last for years in children without materially 
 affecting the general health. 
 
 Treatment. — But little can be done to remove the disease or stay 
 its progress. In White's case, a juvenile one, considerable improve- 
 ment seemed to follow the administration of thyroid, but the im- 
 provement was not permanent. Locally, ointments and plasters con- 
 taining salicylic acid are sometimes of use in lessening the papillary 
 growths. When these are large and a source of inconvenience they 
 may be removed by excision or by the galvanocautery. 
 
 ICHTHYOSIS 
 
 Synonyms. — Ichthyosis vera; Xeroderma; Xeroderma ichthyoides; 
 Fish-skin disease; Fr., Ichthyose, Ichtyose ; Ger., Fischschuppenaus- 
 schlag. 
 
 Definition. — A congenital affection of the skin, characterized by 
 dryness and varying degrees of scaliness. 
 
 Symptoms. — It presents considerable variation in its appearance 
 and in the degree of its development, and has been divided by authors 
 into a number of varieties, the most generally recognized of which are: 
 Ichthyosis simplex, ichthyosis hystrix, ichthyosis congenita. 
 
 Ichthoysis simplex in its mildest form, known also as xeroderma, 
 occurs as dryness of the skin, accompanied by moderate, fine, branny 
 scaling, most noticeable upon the extensor surfaces of the arms and legs, 
 with an exaggeration of the normal lines about the elbows and knees, 
 owing to slight thickening (Fig. 168). On the outer side of the upper 
 arms and thighs the follicles frequently contain small horny spines, 
 which, projecting above the surface, give the skin a coarse, rasp-like 
 appearance and feel (keratosis pilaris, lichen pilaris). The skin of 
 the trunk, while harsh and dry, scales but little. The skin in the 
 flexures of the elbows, in the popliteal spaces, and in the axillae is 
 unaffected and presents its usual softness and smoothness. The dis- 
 ease is much more noticeable in winter than in summer ; indeed, in 
 the latter season the skin may show but little or nothing. The skin 
 of such individuals is usually very susceptible to cold and readily be- 
 comes inflamed, so that eczema is a common complication. 
 
 In more marked cases the skin everywhere is quite scaly and the 
 extremities are covered with an abundance of white or grayish scales 
 which upon the legs are quite large, polygonal or lozenge-shaped, and 
 separated by shallow fissures which produce a crackled or tessellated 
 appearance, oftentimes very noticeable (Fig. 169). These scales are 
 adherent by their central portion, while the edges are loose and fre- 
 quently turned up; at times they present a certain degree of translucency 
 with a slight lustre {ichthyosis nitida ichthyose nacrce) ; at others they 
 are of a dull dirty-gray. Over the knees and elbows the skin is 
 decidedly thickened and arranged as transverse horny ridges which 
 
494 
 
 DISEASES OF THE SKIN 
 
 are often greenish or blackish in color. In these cases, as in the milder 
 ones, eczematous inflammation is rather frequent in the winter season. 
 In the severest forms the scaling occurs as epidermic plates of 
 varying size and thickness, polygonal or lozenge-shaped, especially 
 marked on the extremities, producing an appearance like the skin 
 of a serpent {ichthyosis serpentina), or, when the plates are quite 
 thick, like that of an alligator ("alligator men"), in the most highly 
 
 Fig. 168. — Ichthyosis simplex. 
 
 developed cases interfering with the flexibility of the joints. The scales 
 are often greenish or black {ichthyosis nigricans, nigra) owing to the 
 accumulation of extraneous matter and to increased pigmentation. 
 Even in these advanced cases the flexures of the joints and the axillae 
 are usually but little affected. 
 
 In the mild cases the face is usually but little involved ; in the 
 severer ones, however, there is often more or less scaling, which is 
 much more noticeable in the winter and apt to be accompanied by 
 
HYPERTROPHIES 
 
 495 
 
 varying degrees of eczematous inflammation ; quite exceptionally there 
 may be a certain degree of ectropion from dryness and contraction of 
 the skin (Crocker). 
 
 Fig. 169. — Ichthyosis. 
 
 The scalp is covered with an abundance of fine white scales and 
 in old cases of the severe type the hair is dry and lustreless and may 
 be somewhat thinned. 
 
496 DISEASES OF THE SKIN 
 
 The secretion of sweat and sebum, especially the former, is sup- 
 pressed or greatly diminished. 
 
 Ichthyosis Hystrix. — This variety differs so much from the preceding 
 one that a considerable number of authors deny its relationship to it. It is 
 characterized by a variable number of circumscribed patches of horny 
 or wart-like elevations and spines, the latter sometimes of consider- 
 able length (hedge-hog skin; "porcupine men"), either alone or asso- 
 ciated with a general dryness and scaliness of the skin, such as are 
 present in the simple type. The extent of these patches varies a good 
 deal ; in exceptional cases they may cover a considerable part of the 
 body. The variety described by authors as ichthyosis hystrix linearis 
 is not an ichthyosis, but a linear nsevus (nczvus unius lateris). 
 
 Ichthyosis Follicularis. — Under this name MacLeod has reported three 
 'cases of an affection characterized by numerous follicular spines, most 
 abundant on the back, sides of the neck, and extensor aspect of the upper 
 arms, associated with total loss of the hair of the scalp, brows, and lashes. 
 The palms and soles were unaffected, but the entire skin was dry and 
 covered with fine scales. 
 
 The exact place of these cases, as well as of other aberrant forms, 
 such as the case reported by Thibierge, in which the mucous mem- 
 branes of the mouth and nose were affected, and those of Jadassohn, 
 Hallopeau, and Jeanselme, in which atrophy of the skin was present, 
 is still a matter of considerable uncertainty. Certain local forms of 
 hyperkeratosis which have been placed among the ichthyoses, such as 
 ichthyosis palmse et plantse, are probably not related to ichthyosis at all, 
 but should be placed among the hyperkeratoses (vid. Keratosis palmaris 
 et plantaris hereditaria). 
 
 Ichthyosis Congenita. — Synonyms. — Harlequins foetus; Ichthyosis 
 sebacea, Hebra. 
 
 In this rare affection the infant, which is frequently prematurely 
 born, is covered at birth with thick, somewhat greasy epidermic 
 plates separated by extensive fissures which extend down to the 
 corium. The movements of the lids and the lips are greatly re- 
 stricted by these epidermic scales, so that the eyes are frequently 
 opened with difficulty and nursing is interfered with. The ears and 
 nose are more or less deformed and atrophied by the pressure of 
 the crusts. The infants are either still-born or die soon after birth, 
 through inability to nurse ; the milder cases may survive for some 
 weeks. 
 
 Etiology. — Ichthyosis affects both sexes alike. In the vast major- 
 ity of cases it is congenital, although it does not as a rule appear be- 
 fore the end of the first year, and in many cases the influence of 
 heredity is demonstrable. Like other inherited affections, it may 
 be confined to one or the other sex and may skip a generation, to 
 reappear in subsequent ones. Kaposi records the case of an ichthyotic 
 woman whose five sons were also ichthyotic, while her three daugh- 
 ters were unaffected. An endemic form has been described by a 
 
HYPERTROPHIES 497 
 
 number of authors as occurring in the East Indian Archipelago and 
 some of the islands of the Pacific ; it has been attributed by some to 
 drinking "kava-kava," a fermented liquor made from the Piper methys- 
 ticitm ; by others to frequent intermarriage ; but the real nature of the 
 affection is still somewhat doubtful ; it is not at all certain that it 
 is ichthyosis. 
 
 Pathology. — Leloir, basing his conclusions upon a histological study 
 of two cases, was of the opinion that ichthyosis is a trophic affection 
 dependent upon degenerative changes in the cutaneous filaments of 
 the peripheral nerves and in the posterior roots of the spinal nerves, 
 but his findings have not been confirmed by other observers. Unna 
 regards it as an "infectious hyperkeratosis tending to parakeratosis" ; 
 Tommasoli believes the changes to be the result of a mild chronic 
 inflammation. 
 
 In the mild forms the horny layer of the epidermis is increased 
 in thickness and its cells are without nuclei ; the granular layer is 
 completely absent and the Malpighian layer somewhat atrophied, its 
 cells smaller and the intercellular spaces narrower than normal. A 
 small amount of yellow granular pigment is present in the lower 
 cells of the rete. The papillae of the corium are somewhat flattened 
 and there are small collections of cells in the vicinity of the vessels. 
 In the more advanced cases the hyperkeratosis is still greater, in ichthy- 
 osis hystrix reaching enormous proportions, and the horny layer in 
 places penetrates the somewhat thickened rete. The granular layer 
 is present and well developed. There is a moderate cellular exudate 
 along the vessels of the derma, with occasional accumulations of 
 plasma cells and an increased number of "mastzellen" (Unna). In 
 old cases the collagenous tissue of the corium is thickened and the 
 coils of the sweat-glands are dilated and their lining epithelium 
 swollen. 
 
 The changes found in ichthyosis congenita, as in the ordinary 
 form, consist essentially of hypertrophy of the stratum corneum. 
 Riecke especially emphasizes the marked cornification of the hair- 
 follicles and the inclusions found in the hypertrophied corneous layer 
 which he regards as snared-off parts of the derma. Bo wen is of the 
 opinion that this variety is due to the persistence of the embryonic 
 epitrichial layer. 
 
 Diagnosis. — Its early appearance, usually in the first or second 
 year of life ; the dryness and scaliness of the skin, worse in cold w r eather 
 and usually accompanied by symptoms of inflammation; the polygonal 
 or lozenge shape of the scales, in the more advanced cases producing 
 a tessellated appearance, especially upon the legs, are features so 
 characteristic that it is readily differentiated from other scaly affections. 
 In the not infrequent cases in which an eczematous condition is super- 
 added to the ordinary symptoms, it may be mistaken for eczema, but 
 an examination of the skin will show a generalized scaling on parts 
 not inflamed. 
 32 
 
498 DISEASES OF THE SKIN 
 
 Prognosis. — The affection when once established usually continues 
 for the remainder of the patient's life, but it does not affect his general 
 health in any way. As already noted ichthyotic subjects are espe- 
 cially liable to eczematous inflammation of the skin, particularly in the 
 winter season. While a cure is not to be expected, much can be done 
 to relieve the condition by appropriate hygienic and therapeutic 
 measures. 
 
 Treatment. — Although the most efficient treatment for ichthyosis 
 is external, there are a few internal remedies which exert a temporary 
 beneficial effect upon the skin. Pilocarpine by its stimulating effect 
 upon the sweat-glands tends to keep the skin soft and pliable. Thy- 
 roid gland has been found useful by a number of authors ; in a case 
 recently under the author's care very decided improvement was ex- 
 perienced while the patient was taking it. 
 
 Frequent baths are of great use in all forms of the disease, and 
 combined with the inunction of bland ointments, such as cold-cream 
 or cold-cream and lanolin in varying proportions, are often sufficient 
 in mild cases to keep the skin soft and free from scales. One of the 
 most efficient ointment bases is eucerin, a derivative of wool-fat intro- 
 duced by Unna ; the author has found this far superior to all others. 
 
 In the marked cases, warm alkaline baths followed by a salicylic 
 acid ointment, two to five per cent., using either lanolin and cold- 
 cream or preferably eucerin as a base, will be found more or less 
 effective, but these must be continued methodically if the skin is to be 
 kept smooth. In the severest types prolonged immersion in warm 
 alkaline baths, and the use of an alkaline soap, such as the sapo viridis, 
 are often necessary to remove the thick accumulation of horny scales. 
 In such cases steam or vapor baths are extremely useful. In cases of 
 the hystrix type, plasters and ointments containing from five to ten 
 per cent, of salicylic acid may be applied continuously for several days 
 to remove the thick scales. Stelwagon finds the addition of resorcin 
 to such ointments and plasters, 3 to 10 per cent., increases their effective- 
 ness, or resorcin may be used as an ointment of 5 to 20 per cent, strength, 
 as recommended by Andeer. Anderson has suggested the wearing of 
 rubber undergarments in obstinate cases for the purpose of macerating 
 the adherent scales. 
 
 VERRUCA 
 
 Synonyms. — Wart ; Fr., Verrue ; Ger., Warze. 
 
 Definition. — An epidermic and papillary benign new-growth. 
 
 Symptoms.— Three varieties of wart are recognized : Verruca vul- 
 garis, verruca plana juvenilis, and verruca senilis. 
 
 Verruca Vulgaris. — The most frequent variety, assumes a number of 
 forms. It occurs as pin-head to pea-sized and larger hemispherical or 
 conical elevations usually sessile, but sometimes pedunculated, with a 
 finely or coarsely granular horny surface. At first the color of the 
 normal skin, they become a dirty-gray, brownish, or blackish as they 
 
HYPERTROPHIES 499 
 
 grow older, and as they increase in size the surface is frequently- 
 divided by fissures which give them the appearance of small papillo- 
 mata. This form is seen most commonly upon the backs of the hands 
 in children either as a solitary lesion or, what is far more frequent,, 
 as irregular groups or patches, sometimes confluent, containing from 
 three or four to a dozen or more. They may also occur on other parts,, 
 such as the face and scalp, but are rare upon the trunk ; they are also 
 seen in adults, but much less frequently than in children. As was 
 pointed out by Vidal, they are apt to begin with a single lesion, the 
 " mother wart," around which a number of others appear later. Not 
 infrequently they are situated along the lateral borders of one or more 
 nails, or beneath the free border, particularly in adults, where they 
 
 Mi 4m 
 
 FlG. 170. — Verrucas digitate. 
 
 give rise to considerable disfigurement and much discomfort. Quite 
 exceptionally they have been noted upon the mucous membrane of 
 the lips (Eliot). 
 
 When situated upon the palms and soles, they present an appear- 
 ance somewhat different from the foregoing. In the latter region they 
 occur as pea-sized and larger flat fissured elevations in the centre of 
 a callosity, and are often mistaken for corns or callosities. The most 
 frequent sites are parts especially exposed to pressure, such as the base 
 of the great toe and the heel, and they are commonly the source of 
 much pain and discomfort, interfering seriously with walking. 
 
 Warts frequently occur upon the scalp, where they are apt to occur 
 as small growths covered with slender, often rather soft papillae (ver- 
 ruca digitata). Although such digitate lesions are more frequent irt 
 the scalp than upon other parts, they may also occur upon the hands 
 and face (Fig. 170). 
 
500 
 
 DISEASES OF THE SKIN 
 
 Occasionally there may be but one or two slender thread-like 
 growths situated upon some portion of the face, sometimes upon the 
 edge of an eye-lid, from 3 to 4 mm. long or longer (verruca filiformis). 
 
 Verruca Plana Juvenilis. — This differs considerably in its appearance 
 from the foregoing. The lesions are usually numerous, quite flat, with 
 very little elevation, whitish or pinkish in color, with smooth or finely 
 granular surface. Not infrequently a number of them are angular or 
 irregular in outline and resemble more or less the papules of lichen planus. 
 They vary in diameter from 2 to 3 mm. to 1 cm. or more, may be discrete 
 
 Fig. 171. — Verrucas planas. 
 
 or partly confluent, forming irregular patches of varying extent. They 
 are situated most frequently upon the backs of the hands and upon the 
 face, less commonly upon the palms and in the scalp, and exception- 
 ally upon the legs and genitalia (Gemy, Dubreuilh). They are seen 
 usually in children and adolescents, but are by no means uncommon in 
 older subjects (Fig. 171). 
 
 Verruca Senilis. — Synonyms. — Verruca plana seniorum ; Verruca 
 seborrhoeica ; Senile wart. This is found, as a rule, as its name indicates, 
 in elderly individuals. It occurs as round, flat, yellowish, brownish, or 
 blackish elevations varying in diameter from 2 to 3 mm. to 1 to 2 cm., 
 
HYPERTROPHIES 501 
 
 covered with a friable greasy scale or crust, beneath which is a somewhat 
 granular or papillomatous surface. It is situated most frequently 
 upon the upper part of the back, less commonly upon the upper chest, 
 upper arms, and the face, and is often present in considerable num- 
 bers. It is often associated with evidences of senile degeneration of 
 the skin, and may be accompanied by considerable itching. 
 
 Etiology. — Childhood and adolescence are active predisposing fac- 
 tors in both verruca vulgaris and verruca plana; as already remarked, 
 they are much more frequently met with at these periods than in adult 
 age. Warts have long been regarded as contagious, and there is con- 
 siderable clinical evidence in support of this opinion, such as acci- 
 dental inoculation (Payne), and occurrence in several members of 
 the same family. Recently successful inoculation experiments carried 
 out by Jadassohn and others have established the infectious nature of 
 these growths. Crocker and others regard the plantar wart as the 
 result of traumatism from wearing ill-fitting shoes, etc., but these only 
 serve in all probability as predisposing causes. 
 
 Pathology. — All the layers of the epidermis are more or less in- 
 creased in thickness : there is hyperkeratosis, sometimes with more 
 or less parakeratosis ; the granular layer is increased in breadth and 
 unusually well defined ; there is a decided acanthosis, the rete cells 
 being enlarged and the intercellular spaces widened, with numerous 
 mitoses in the cells of the basal layer and those immediately adjacent. 
 The papillae of the corium are greatly increased in length, but other- 
 wise show but little change ; occasionally there are evidences of inflam- 
 mation in the shape of a moderate round-cell exudate in the neighbor- 
 hood of the vessels. These changes vary according to the type of 
 lesion; in some the hyperkeratosis, in others the acanthosis, in still 
 others the papillary hypertrophy predominates. There is some dif- 
 ference of opinion as to whether the changes in the rete or those in the 
 papillary layer are the primary ones. 
 
 In the senile or seborrhceic wart, according to Pollitzer, there is a 
 slight increase in the thickness of the horny layer, some hypertrophy 
 of the rete, and groups and lines of epithelioid cells in the papillary 
 and subpapillary portions of the corium. There is likewise a peculiar 
 fatty infiltration of the epithelium of the coil-glands, of the papillary 
 and subpapillary layers of the corium, and of the cells of the rete. 
 This last finding, however, Dubreuilh was unable to confirm. The 
 presence of epithelioid cells in the papillae and their peculiar arrange- 
 ment lead Pollitzer to place these growths among the naevi. 
 
 Diagnosis. — The common w r art, verruca vulgaris, such as occurs 
 so commonly upon the hands and in the scalp, is usually readily recog- 
 nized. When situated upon the sole, they are frequently mistaken for 
 corns or callosities, but a careful examination will soon disclose their 
 true character. The plane wart, as already noted, may be mistaken 
 at times for the papules of lichen planus, but the violaceous color, the 
 flat shining top which characterize the latter, are absent. They may 
 
502 DISEASES OF THE SKIN 
 
 at times be confounded with the little tumors of epithelioma (mollus- 
 cum) contagiosum, but they never present the small central opening 
 found in such growths. 
 
 Prognosis. — -Warts are altogether benign growths, although in 
 -exceptional cases they may, when subjected to long-continued irrita- 
 tion, undergo epitheliomatous degeneration. The common wart often 
 pursues a most erratic course, particularly in children ; after lasting 
 many months, it may quite suddenly disappear, leaving no trace of its 
 ■existence. In adults they may continue to enlarge for a time and then 
 remain unchanged indefinitely. The senile variety, when once de- 
 veloped, may last for years, showing no tendency to spontaneous 
 disappearance. Occasionally they become epitheliomatous ; Du- 
 breuilh, however, asserts that this is incorrect, the error arising 
 through confounding them with senile keratosis. 
 
 Treatment. — A number of internal remedies have been recom- 
 mended at various times as exerting some curative effect. A number 
 of authors have testified to the beneficial effect of arsenic in both 
 the common and plane varieties, and there seems to be but little doubt 
 that this remedy does exert some influence upon them. Herxheimer, 
 however, asserts that it is useful only in the plane wart and uses this 
 as an argument for separating this variety from the common form. 
 Colrat asserted that magnesium sulphate given internally caused their 
 disappearance, and Crocker confirmed this statement, but other obser- 
 vers, among whom may be included the author, have found it altogether 
 without effect. Quite recently White has reported the disappearance 
 of plane warts after the internal use of protiodide of mercury given 
 in doses of one-quarter of a grain (0.016) three times a day. In view, 
 however, of the frequent spontaneous disappearance of these growths, 
 it is very difficult to determine the real value of any internal treatment 
 without a very large experience with it. 
 
 Warts of the common type may be removed by the use of caustics, 
 such as glacial acetic acid, trichloracetic acid, or chromic acid ; or they 
 may be destroyed by freezing with solid carbon dioxide, when not too 
 large. Lesions of moderate size may be very conveniently and readily 
 removed by electrolysis. The base of the growth should be trans- 
 fixed in several directions by a needle attached to the negative pole, 
 using a current strength of about five milliamperes. About the nails 
 they are frequently most troublesome, but may be readily removed 
 by the curette, first freezing them with ethyl chloride and afterward 
 cauterizing the base with trichloracetic acid to prevent recurrence, 
 which is very apt to happen unless this is done. Small flat growths 
 may be removed by repeated painting with a solution of salicylic acid 
 in collodion, ten to twenty per cent. ; the softened epithelium should 
 be thoroughly rubbed off each time before making a fresh application, 
 which should be done every second or third day. 
 
 The plantar wart is often most resistant to treatment. The con- 
 tinuous application of a 10 to 20 per cent, salicylic-acid plaster will often 
 
HYPERTROPHIES 503 
 
 eventually cause their disappearance, but in the larger and deep-seated 
 lesions it frequently fails. If not too large nor too deep-seated, they may 
 be destroyed by freezing with the carbon dioxide " snow " ; or they 
 may be frozen and curetted out, cauterizing the wound with nitrate of 
 silver or trichloracetic acid. They may be very speedily destroyed by 
 the high-frequency spark, this being especially applicable to the larger 
 lesions. The filiform warts should be cut off with curved scissors, and 
 the wound cauterized. 
 
 When the lesions are so numerous and so widely distributed as 
 to preclude any of the foregoing measures, ointments of sulphur or 
 salicylic acid either alone or combined, 2 to 3 per cent, of each, may 
 be applied twice a day, although very prompt results are hardly 
 to be expected from this treatment. Radiotherapy is much more 
 promising in such cases, and should be tried, especially in the plane 
 and senile varieties. 
 
 CONDYLOMA ACUMINATUM 
 
 Synonyms. — Verruca acuminata ; Venereal wart ; Moist wart ; Fr., 
 Condylome acumine ; Ger., Spitzencondylom, Spitzenwartze. 
 
 Definition. — A benign epithelial new-growth of wart-like appear- 
 ance, situated chiefly, but not exclusively, upon the genitalia and 
 neighboring parts. 
 
 Symptoms. — Although these grow r ths are closely related to and 
 resemble the ordinary warts in many respects, they differ from them 
 considerably both clinically and histologically. 
 
 They occur as small elevations w T ith a granular surface, or as tufted 
 and lobulated, sessile or pedunculated tumors of variable dimensions. 
 Upon mucous surfaces they are pink or red, moist, or, when macer- 
 ated, as is frequently the case, a dirty-gray or yellowish, covered with 
 an abundant muco-purulent secretion with a most offensive odor, which 
 sometimes dries sufficiently to form a thick yellowish or brownish 
 crust. Upon cutaneous surfaces they are dry and the color of the skin, 
 or when in regions where they are exposed to heat and friction they 
 are covered with a grayish or yellowish moist coating. They fre- 
 quently grow quite rapidly and may reach the size of a walnut or an 
 egg. The seats of election are the genitalia, less frequently the 
 perineum and anus, but they may also be found upon parts more or 
 less remote from these, as the umbilicus, the axillae, between the toes, 
 and in and about the mouth. Upon the penis a common, perhaps the 
 most frequent, site is the furrow behind the corona glandis, where 
 they may be so numerous as to form an almost continuous ring ; they 
 are also common about the frenum, and on the inner surface of the 
 prepuce ; less frequently they are situated on the perineum and around 
 the anus. In women they occur upon all parts of the genitalia, but 
 especially upon the labia minora and at the introitus vaginae ; the 
 perineum and the anus are much more frequently affected than in men, 
 the lesions in this region usually following those upon the genitalia. 
 
504 DISEASES OF THE SKIN 
 
 Etiology.— Although there is but little doubt that these growths 
 are the result of some infection, the infecting agent is not yet known. 
 In much the largest proportion of cases they are associated with some 
 irritating discharge, and are commonly seen in those suffering from 
 gonorrhoea, hence the name venereal wart, by which they are com- 
 monly known. 
 
 Pathology. — According to Unna, the pointed condyloma is a pure 
 acanthoma, and differs from the ordinary wart by the complete absence 
 of hyperkeratosis ; indeed, the horny layer is not infrequently thinner 
 than normal. The rete is markedly hypertrophied, its cells being 
 several times the normal size and containing numerous mitoses, not 
 only in the basal layer but in the layers above it; the interpapillary 
 spaces are much wider than normal and the intercellular fibres, or 
 prickles, are unusually well developed. The papillae are greatly in- 
 creased in length and are frequently branched; their blood-vessels 
 and lymph-spaces are dilated to a marked degree, the connective-tissue 
 cells are increased in numbers, and there is a more or less considerable 
 exudation of leucocytes with plasma-cells and a considerable number of 
 " mastzellen." 
 
 Diagnosis. — Their appearance and situation upon the genitalia are 
 so characteristic that they are not likely to be mistaken for other 
 growths. They are to be distinguished chiefly from the syphilitic flat 
 condylomata, but the latter are usually associated with other syphilitic 
 lesions such as cutaneous eruptions and mucous patches. 
 
 Prognosis. — The pointed condylomata are quite benign growths, 
 but are often the source of much annoyance and frequently cause the 
 patient great disquietude, as they are commonly mistaken for syphilitic 
 lesions. Although at times resistant to treatment, they are curable, 
 but recurrences are common. 
 
 Treatment. — Cleanliness is of the first importance and is best main- 
 tained by the frequent and liberal application of some mild antiseptic 
 solution, such as a saturated solution of boric acid, weak solutions 
 of carbolic acid, bichloride of mercury, or permanganate of potash, 
 this last being one of the most effective. Small lesions may be made 
 to disappear by the daily application of liquor ferri chloridi or pow- 
 dered alum. One of the most effective applications is resorcin (Joseph, 
 Riecke) which should be dusted on the lesions two or three times daily 
 until a slough forms, which usually requires three or four days ; they 
 should then be dusted with some drying powder, such as equal parts 
 of boric acid and subgallate of bismuth, until the eschar falls. For the 
 larger lesions Joseph recommends the application of formalin, first 
 cocainizing them, since the application is quite painful. Large growths 
 may be excised, but, as they are usually very vascular, bleeding is apt 
 to be profuse, and for this reason the thermocautery is preferable 
 to excision. 
 
HYPERTROPHIES 505 
 
 SCLERODERMA 
 
 Synonyms. — Sclerema ; Scleriasis ; Scleroma adultorum ; Ger., 
 Sklerodermie ; Fr., Sclerodermic ; Sclereme des adultes. 
 
 Definition. — A chronic disease characterized by a peculiar leathery 
 induration of the skin, occurring diffusely or in patches. 
 
 Diffuse Scleroderma. — The diffuse form may begin acutely or may 
 appear so gradually that the patient cannot fix definitely the time of its 
 beginning. Pronounced or characteristic prodromal symptoms are usually 
 absent, but ill-defined muscular and arthritic pains, neuralgia or pares- 
 thesia, may precede for a variable time the appearance of the cutaneous 
 symptoms. At first there is slight stiffness of the skin with some cedema, the 
 skin pitting slightly on firm pressure, the cedema being most pronounced in 
 the cases which begin acutely, although it is probably present to some 
 degree in most, if not all, cases in the earliest stages. The induration, 
 which is always symmetrically distributed, usually spreads slowly, 
 sometimes rapidly, until considerable areas may be involved, such as 
 the entire face, the whole of a limb — both arms or both legs — or a large 
 part of the skin of the trunk. When fully developed the skin is hard 
 and leather-like to the touch and bound down to the underlying tissues 
 so that it can no longer be picked up between the fingers. In the early 
 stages the color may be but little changed, but later it is usually whitish 
 or yellowish-white like old ivory, and in the final stages is frequently 
 irregularly pigmented. 
 
 While no portion of the skin is entirely exempt, the palms and soles 
 are rarely attacked ; the face, neck, upper extremities, and upper half 
 of the trunk are the regions most frequently affected. When the face 
 is attacked, it presents a mask-like appearance, owing to the immobility 
 of the facial muscles produced by the induration of the overlying 
 skin. The nose is shrunken and pointed, the lips thin, and the mouth 
 narrowed, so much so in advanced cases that it is opened with some 
 difficulty; the eyes are staring or only partly opened, owing to the 
 stiffness and induration of the upper lids. When considerable areas 
 over the thorax are affected, the respiratory movements may be con- 
 siderably interfered with. Occurring about the joints, it interferes more 
 or less with their movements and may lead to more or less complete 
 ankylosis. When the hands are affected, the fingers become thin and 
 pointed, are partly flexed, and are moved with difficulty, a condition 
 to which the name sclerodactylia has been applied. In a certain num- 
 ber of cases the disease begins in this region with the symptoms of 
 Raynaud's disease, such as cyanosis of the fingers followed by extreme 
 local ischsemia and ulceration. 
 
 Exceptionally it has been observed to attack the mucous mem- 
 branes of the mouth, pharynx, larynx, and vagina, which exhibit an 
 induration similar to that seen in the skin. 
 
 Constitutional symptoms are absent, as a rule, but in the cases 
 which begin acutely with pronounced cedema of the skin there may 
 
506 DISEASES OF THE SKIN 
 
 be chills and elevation of temperature, which precede or accompany 
 the early stages. 
 
 Subjective symptoms may be altogether absent, but there is usually 
 a pronounced feeling of stiffness or tension, and sometimes itching, but 
 rarely enough to occasion any considerable amount of annoyance. 
 The sense of touch is usually unchanged, but there may be varying 
 degrees of hyperesthesia or anaesthesia. 
 
 The course of the malady is a chronic one, but its duration varies 
 within considerable limits. After reaching a considerable develop- 
 ment it may show but little change for months or years and then 
 retrogress slowly until complete recovery has taken place. Or it may 
 exhibit irregular periods of retrogression and exacerbation, new areas 
 becoming involved during the latter, before recovery is eventually 
 established. Not uncommonly it pursues a steadily progressive course ; 
 the skin becomes extremely atrophied and adherent to the underlying 
 connective tissue and muscles which also undergo atrophy; fibrous 
 ankylosis of the joints, particularly of the smaller ones, occur; and 
 ulceration over bony prominences and parts subjected to pressure or 
 friction is not uncommon. In long-standing and widespread cases 
 which pursue such a course the patient may die from exhaustion or 
 fall an easy victim to some intercurrent affection. 
 
 Circumscribed Scleroderma.— Synonyms. — Morphcea; Keloid of 
 Addison (Plate XXXIII). 
 
 Symptoms. — The circumscribed variety of scleroderma is charac- 
 terized by pale pink or white or yellowish-white, round, oval, or ribbon- 
 like circumscribed patches varying in size from a pea to the palm of the 
 hand or even larger, which are frequently surrounded by a narrow 
 violaceous border, which on close inspection is seen to be made up of 
 numerous minute capillaries. They are firm and inelastic to the 
 touch, usually quite smooth and on a level with, or slightly depressed 
 below the normal skin, although in the earliest stages they may be 
 for a time slightly elevated. In old patches there is often a moderate 
 amount of scaling with pigmentation, and the centre is occasionally 
 occupied by a number of small pits resembling the dilated mouths of 
 the sebaceous gland-ducts, with which, however, they have no relation. 
 The number of patches varies from a single one to two, three, or more, 
 but the number is rarely large. The affection exhibits a marked 
 preference for certain regions, such as the face, especially the fore- 
 head, the breasts in women, the arms, and the thighs. In a certain pro- 
 portion of cases the malady exhibits a zoster-like arrangement, the 
 patches being distributed over the course of some nerve, most fre- 
 quently over the branches of the fifth pair, along the distribution of the 
 brachial plexus (Fig. 172), the intercostals, or down the posterior sur- 
 face of the thigh. In rare instances it is limited to one side of the face 
 and is then frequently accompanied by marked atrophy of all the 
 tissues (hemiatrophia facialis). 
 
 The affection described by a number of authors under the name 
 
PLATE XXXIII 
 
 Circumscribed scleroderma. 
 
HYPERTROPHIES 
 
 507 
 
 " white-spot " disease, characterized by a variable number of shot- to 
 pea-sized, rarely larger, chalk-white spots, situated in most cases on 
 the neck and upper part of the chest and back, is a variety of circum- 
 scribed scleroderma. 
 
 Subjective symptoms are usually trivial and often entirely absent; 
 there may be, however, some itching or burning or neuralgic pain in 
 the patches. 
 
 The course of the disease is usually quite irregular, continuing for 
 an indefinite period. The patches may slowly increase in size for a 
 time, then become stationary, showing little or no change for some 
 
 Fig. 172. — Circumscribed scleroderma (morphcea). 
 
 months, and finally gradually disappear, leaving little or no trace of 
 their existence. In a certain proportion of cases, the atrophy of the 
 skin becomes extreme- — it is thin, wrinkled, scaly, and bound down to 
 the parts beneath, exhibiting (especially in the band-like patches) a 
 markedly scar-like appearance. When such atrophic patches are situ- 
 ated about a joint, particularly about small ones, they may interfere 
 considerably with movement. 
 
 Etiology. — Both varieties of scleroderma are decidedly more fre- 
 quent in women than in men. In a series of 435 cases collected by 
 Lewin and Heller, 67 per cent, occurred in women. Although most 
 frequent between the ages of twenty and fifty, it occurs at all periods of 
 
508 DISEASES OF THE SKIN 
 
 life from early childhood to advanced old age. The direct cause is 
 absolutely unknown, but exposure to cold and damp and functional 
 disturbance of the nervous system such as may arise from worry, grief, 
 and mental shock, seem occasionally to be predisposing causes in the 
 diffuse form. In the circumscribed variety, long-continued irritation 
 of the skin, the pressure of a garter or of a stay, or an injury to a 
 nerve has been noted to precede the appearance of the disease in a 
 certain number of cases. 
 
 It has been observed as a complication of a number of diseases 
 of various kinds which in some instances seem to have had a causal 
 relationship to it. Its association with Raynaud's disease has already 
 been referred to. In a case of diffuse scleroderma, Hektoen found 
 that the thyroid gland had undergone a fibrous atrophy which had 
 destroyed the glandular structure, and more recently Roques, in a 
 series of 31 cases, found changes in the size of this gland in no less 
 than 70 per cent. Whitehouse and others obtained a positive Was- 
 sermann reaction in a small proportion of cases, but these observations 
 are still too few to permit any positive inference to be drawn as to the 
 possible syphilitic origin of the affection. 
 
 Pathology. — The most commonly accepted view of the nature of 
 scleroderma is that it is a trophoneurosis. Its occasional occurrence 
 after mental shock, or injury to a nerve, and the occasional distribution 
 of the circumscribed variety over some nerve trunk in a zoster-like 
 manner, are features which lend considerable support to such a view. 
 In recent years the possibility of its being the result of some alteration 
 or disturbance in some internal secretion, as has been suggested by 
 Osier, has attracted some attention. As has already been observed, it 
 is associated in a considerable proportion of cases with alterations in 
 the thyroid gland. 
 
 The essential feature of its histopathology is a hypertrophy of the 
 collagenous tissue. The epidermis is usually but little altered. There 
 is occasionally a moderate hyperkeratosis, a shortening of the inter- 
 papillary prolongations of the rete sometimes amounting to their 
 complete disappearance, and a deposit of pigment granules in the 
 lower or basal-cell layer and in the lymph-spaces. The papillae of the 
 corium are flattened out and their vessels narrowed and in places 
 obliterated. In the deeper portions the vessels are in places sur- 
 rounded by a moderate cellular exudate of round cells, are narrower 
 than normal and in places are obliterated by a thrombus. About the 
 borders of the circumscribed patches the vessels, particularly the veins, 
 are dilated as a consequence of a collateral hyperemia ; this explains 
 the narrow lilac-colored zone which frequently surrounds such patches. 
 In the advanced stages sweat and sebaceous glands show varying 
 degrees of atrophy as a consequence of pressure from the hypertrophied 
 collagenous fibres. The elastic tissue, according to Unna, shows no 
 change. 
 
HYPERTROPHIES 509 
 
 Diagnosis. — The peculiar leathery induration of the skin, which is 
 the essential feature of scleroderma, is so characterized that the diag- 
 nosis may be made without any difficulty in well-developed cases. In 
 circumscribed scleroderma or morphcea, the circumscription of the 
 patches, their ivory-white or yellowish-white color, the lilac-colored 
 border which frequently surrounds them, and the induration are so 
 characteristic that they are not likely to be mistaken for any other 
 affection. By the inexperienced they might be mistaken for the white 
 patches of vitiligo, but in that affection there is no palpable alteration 
 of the skin. 
 
 Prognosis. — The prognosis in diffuse scleroderma is unfavorable. 
 While the general health is commonly unimpaired, in extensive cases 
 in which ulceration occurs •death from exhaustion may follow. It is 
 usually of long duration, even in the cases in which recovery eventually 
 takes place. Of 251 cases collected by Lewin and Heller, a cure took 
 place in 16 per cent. ; improvement in 30 per cent., and in 25 per cent, 
 death resulted. In children the prognosis is much more favorable. 
 In the circumscribed variety the prognosis is much more favorable and 
 recovery frequently occurs, although often only after a duration of 
 months or years. In either form, when marked atrophy has taken 
 place, a return of the skin to its normal condition rarely occurs. 
 
 Treatment. — Every effort should be made to improve the patient's 
 general health. He should have a liberal diet and should be clothed 
 in such a manner as to protect him from sudden atmospheric changes, 
 and particularly from cold and damp. Quinine, iron, arsenic, cod- 
 liver oil may be given in moderate doses for their tonic effect, although 
 they have no direct influences upon the malady. Thyroid gland has 
 been employed by a number of authors with asserted good results. 
 Roques reports the successful use of this substance in something over 
 6y per cent, of a series of 67 cases collected from the literature. Other 
 observers, however, have been less successful with this treatment. It 
 should always be tried, especially in the cases in which any alteration 
 in the size of the gland is present. 
 
 Locally, massage and frictions with bland ointments, such as equal 
 parts of oleum adipis and lanolin, should be diligently employed and 
 inunctions of cod-liver oil, although disagreeable, are also of service. 
 Mild galvanic currents are at times apparently of use in improving the 
 nutrition of the skin and in preventing atrophy. In morphcea (cir- 
 cumscribed scleroderma), in addition to the measures just mentioned, 
 electrolysis, as advised by Brocq, may be tried in small patches, using 
 the needle as in the removal of superfluous hairs, with a current of 
 one to three or four milliamperes. In some instances I have observed 
 decidedly favorable results after the use of the X-ray, employing 
 moderate exposures at intervals of five days. The hypodermatic use 
 of a 15 per cent, alcoholic solution of thiosinamin, as recommended 
 by Hans Hebra, has met with little favor, although Neisser speaks 
 favorably of it. 
 
510 DISEASES OF THE SKIN 
 
 SCLEREMA NEONATORUM 
 
 Synonyms. — Induratio telse cellulosae ; Fr., Algidite progressive ; 
 l'Endurcissement athrepsique ; Ger., Sclerem der Neugeborenen ; Fett- 
 sclerem. 
 
 Definition. — A diffuse induration of the skin occurring in new-born 
 infants. 
 
 Although this rare malady was first accurately described by Under- 
 wood in 1784, the first recorded case was observed by Usenbenzius 
 in the Stockholm Hospital, in 1718. At first it was confused with a 
 similar induration of the skin accompanied by oedema occurring also 
 in the new-born, but it was definitely separated from oedema neona- 
 torum by the observations of Clementowsky and Parrot in 1873 an d 
 
 i8 74 . 
 
 Symptoms. — Although it may be present at birth, it usually begins 
 shortly after, within the first ten days ; in rare instances it may appear 
 as late as the second month. The induration begins in the majority 
 of cases upon the lower extremities and rapidly spreads upward so that 
 in the course of three or four days the entire surface may be affected. 
 In exceptional cases it first appears in the face and spreads downward. 
 At first the skin is yellowish-white and wax-like, but later it is some- 
 what livid. When fully developed the natural lines of the skin are 
 more or less effaced, the cheeks and lips are stiff so that the infant 
 nurses with difficulty or cannot nurse at all ; the limbs are rigid and 
 the infant looks as if frozen. The surface is cool, pulse and respiration 
 markedly slowed and the latter shallow and sighing. Death usually 
 occurs in the course of five to ten days, although in the exceptional 
 cases in which only a part of the surface is involved the affection may 
 last for some months and recovery eventually take place. 
 
 Etiology. — The disease is most frequently observed in lying-in 
 hospitals and in foundling asylums, in other words, in ill-developed and 
 ill-nourished infants. In the congenital cases there is usually no dis- 
 coverable cause, but in those in which it appears after birth there is 
 commonly some affection of the gastro-intestinal tract, of the lungs, or 
 of the heart which has seriously impaired the infant's vitality. 
 
 Pathology. — The nature of this peculiar and rare disease is still 
 obscure. The researches of Langer and Knopfelmacher have appar- 
 ently shown that the subcutaneous fat of the new-born infant solidi- 
 fies at a higher temperature than that of adults, owing to its smaller 
 content of oleic acid, and Bayer, who has recently studied the chemistry 
 of the fat of infants dying from sclerema is definitely of trie opinion 
 that in such infants there is a congenital specific diminution in the 
 oleic-acid content of the subcutaneous fat, permitting it to solidify 
 at the low bodily temperature present in these cases. Parrot be- 
 lieved it to be the result of a draining of the tissues of fluids by pre- 
 vious exhausting disease. He found the skin thinned, its blood 
 vessels, particularly in the papillae, contracted, and the fat diminished. 
 These findings have been confirmed by Ballantyne, who also found 
 an increase in the connective tissue. 
 
HYPERTROPHIES 511 
 
 Diagnosis. — Sclerema is to be distinguished from scleroderma and 
 from oedema neonatorum. The early age at which it occurs, the rigid- 
 ity of the limbs and face, and its rapid course to a fatal issue distinguish 
 it readily from the former; from the latter it is to be distinguished 
 by the absence of pitting (absence of oedema) and the more general 
 distribution of the induration. 
 
 Prognosis. — Recovery is the rare exception, death usually occurring 
 in the course of a few days. In the infrequent cases in which only a 
 part of the surface is attacked, the prognosis is somewhat more 
 favorable. 
 
 Treatment. — Every effort should be made to raise the bodily tem- 
 perature to the normal and maintain it there. The infant should be 
 well wrapped up and surrounded by hot water bags or placed in an 
 incubator, and should be supplied with as much nourishment of a 
 proper kind as can be given to it. Since it cannot nurse, it must be 
 fed by enema or by a tube passed into the stomach. 
 
 CEDEMA NEONATORUM 
 
 Synonyms. — CEdema of the new-born; Fr., CEdeme des nouveau- 
 nes; Ger., das Sklerodem. 
 
 Definition. — A disease of new-born infants, characterized by indura- 
 tion of the skin with oedema. 
 
 Symptoms. — The disease usually first appears within two or three 
 days after birth, although in exceptional cases it may be present at 
 birth. It begins with drowsiness and swelling and induration of the 
 feet and legs, which extend upward to the thighs, buttocks, genitalia, 
 hands, and arms, the swelling being most marked in dependent parts. 
 Much less frequently the induration and oedema begin in the face 
 or upper part of the trunk and spread downward, and in rare cases 
 the entire cutaneous surface may be involved. The skin is pale or 
 livid, very firm to the touch, and pits upon pressure. The body tem- 
 perature is usually subnormal, although in rare cases it may be more 
 or less elevated; the respiration is shallow and the circulation weak. 
 The infant becomes increasingly feeble ; the respiration and circulation 
 fail ; the temperature continues to decline and death usually occurs 
 at the end of five or six days, sometimes preceded by diarrhoea or 
 convulsions. 
 
 Etiology. — (Edema neonatorum occurs almost without exception 
 in prematurely born, imperfectly developed infants, or in those en- 
 feebled by pulmonary or cardiac disease. Undue exposure to cold 
 at the time of birth and improper or insufficient nourishment are also 
 among the predisposing causes. 
 
 Pathology. — There is an abundant serous effusion in the skin, sub- 
 cutaneous tissues, and the muscles, and, in advanced cases, in the tho- 
 racic and abdominal cavities and in the ventricles of the brain. Ac- 
 cording to Luithlen, the oedema does not differ in any respect from 
 ordinary oedema of the skin. He finds that the skin of infants suffer- 
 
512 DISEASES OF THE SKIN 
 
 ing from this affection is not normally developed, but corresponds to 
 the skin of a six to eight months foetus ; and, in consequence of its 
 unusually delicate and loose structure, offers conditions especially favor- 
 able to the occurrence of oedema. 
 
 Diagnosis. — The only affection for which it is likely to be mistaken 
 is sclerema of the new-born, which it closely resembles and with which 
 it was formerly confounded. It differs from that affection, however, 
 in its less general distribution, in the involvement of the palms and 
 soles, which are, as a rule, exempt in sclerema, and in the presence 
 of pitting after pressure (presence of oedema). 
 
 Prognosis and Treatment. — The prognosis is most unfavorable, 
 death occurring almost invariably in the course of five to six days. 
 The treatment is essentially the same as for sclerema neonatorum. 
 
 MYXCEDEMA 
 
 Synonyms. — Cretinoid oedema ; Cachexia thyropriva ; Cachexie 
 pachydermique ; Fr., Myxcedeme ; Ger., Myxoedem. 
 
 Definition. — A chronic constitutional disease due to suppression of 
 the functions of the thyroid gland, characterized by a peculiar oedema 
 of the skin, accompanied by mental symptoms. 
 
 Symptoms. — This rare affection was first recognized as an inde- 
 pendent disease by Gull, who in 1875 described it as a cretinoid 
 state affecting women. A few years later (1878) Ord, as the result 
 of his study of its clinical symptoms and pathology, proposed to 
 call it myxoedema, a name by which it has since been generally 
 known. 
 
 The early symptoms are usually slight and ill defined ; there is a 
 moderate anaemia with poor appetite, some loss of strength, unusual 
 susceptibility to cold, and mental sluggishness. When fully estab- 
 lished, the skin is everywhere oedematous, firm to the touch, but 
 does not pit on pressure as in ordinary oedema. This swelling is 
 most noticeable in the face, imparting to the patient a peculiar apathetic 
 expression partly the result of obliteration of the normal lines and 
 partly due to his mental state. The lids are thick and hang in folds 
 so that an effort is necessary to keep the eyes open ; the nose is broad- 
 ened as the result of thickening of the alse, and the lips are swollen, 
 the lower one frequently everted so that the saliva escapes from the 
 mouth. While the swelling of the skin is general, it is not uniform, 
 being more noticeable in some regions than in others, as in the supra- 
 clavicular region, where there may be ill-defined swellings partly 
 due to oedema, partly due to deposit of fat. The hands and feet are 
 larger than normal, the former presenting a peculiar flattened, "spade- 
 like " (Gull) appearance. Because of the diminished activity of the 
 sweat- and sebaceous-glands the skin is harsh, dry, and finely desquamat- 
 ing. The hair loses its lustre, becomes brittle, breaks, and falls out, and 
 the nails are brittle and broken at their free border. 
 
 The mucous membranes of the mouth, pharynx, and larynx are 
 
HYPERTROPHIES 513 
 
 also oedematous, and the tongue is more or less swollen, sometimes 
 excessively so. 
 
 Along with the cutaneous symptoms there is notable alteration 
 of the patient's mentality. She is dull and listless, speaks slowly with 
 expressionless voice, the alteration in speech being due in part to 
 the swelling of the vocal cords, the tongue, and lips, and in part to 
 the slowing of her mental processes. Her disposition is usually more 
 or less altered ; she is usually irritable, and symptoms of insanity ap- 
 pear in a certain proportion of cases. 
 
 The course of the malady is a very chronic one. The strength 
 gradually fails, the patient becomes more apathetic, a marasmic condi- 
 tion ensues, which eventuates in death ; or some intercurrent affec- 
 tion, such as nephritis or tuberculosis, carries her off. 
 
 Etiology. — The disease is one of adult life, although it may occur 
 rarely in children. It is much more common in females than in males, 
 fully 90 per cent, of the cases occurring in women. It is due to 
 suppression, partial or complete, of the functions of the thyroid gland, 
 but the cause of the thyroid disease is unknown. As Reverdin, Kocher, 
 and others have shown, symptoms resembling those of myxcedema 
 may follow extirpation of the thyroid (cachexia strumipriva). 
 
 Pathology. — The thyroid gland is usually atrophied, its secreting 
 structure replaced by fibrous tissue, or it is at times larger than nor- 
 mal, but in such cases the glandular tissue is diminished, as in the 
 atrophied gland, the enlargement being due to deposits of inflam- 
 matory exudate or other material which have destroyed the gland 
 tissue. A mucoid material is deposited in the corium and subcutane- 
 ous tissue, the nature of which is still undetermined. Unna found 
 both the collagenous and elastic tissue of the corium altered in their 
 staining reactions, indicating degeneration of these. 
 
 Diagnosis. — The patient's mental condition, her slow, halting 
 speech and expressionless voice, the wide extent and peculiar quality 
 of the cutaneous oedema are so characteristic in the developed affec- 
 tion that the diagnosis usually presents but little difficulty. The oedema 
 may be mistaken for that which accompanies chronic nephritis, but 
 freedom of the urine from albumin and the absence of pitting will 
 serve to distinguish it from that affection. 
 
 Prognosis. — Unless stayed by appropriate treatment, the disease 
 steadily progresses to a fatal termination, although death may be 
 postponed for many years. If proper treatment is instituted at a 
 sufficiently early period, the outlook as to a practical cure or great 
 improvement is quite favorable. 
 
 In very advanced cases, however, the best directed measures may 
 fail to do more than produce a slight and temporary improvement in the 
 patient's condition. 
 
 Treatment. — Patients with myxcedema should be protected as much 
 as possible from cold, to which they are very sensitive, and should 
 be given thyroid gland either in substance, in dry extract, or fluid 
 33 
 
514 DISEASES OF THE SKIN 
 
 extract, the last hypodermatically. Some care should be taken not 
 to beg-in with too large a dose, lest disagreeable symptoms, such as 
 restlessness, shortness of breath, and rapid pulse (thyroidism) ap- 
 pear; as a rule, the beginning dose should not exceed one or two 
 grains three times a day, but this may be gradually increased until 
 fifteen or twenty grains a day are taken. Under this treatment 
 marked improvement in all the symptoms usually appears promptly ; 
 the oedema diminishes, the sweat- and sebaceous-glands resume their 
 functions, and the skin becomes soft and supple, the hair begins to 
 grow, and the nervous and mental symptoms disappear. 
 
 ELEPHANTIASIS 
 
 Synonyms. — Elephantiasis Arabum ; Pachydermia; Elephant leg; 
 Barbadoes leg; Cochin-China leg; Bucnemia tropica; Spargosis. 
 
 Definition. — A chronic affection occurring endemically in many 
 tropical and subtropical countries, sporadically in most parts of the 
 world, characterized by extensive hypertrophy of the skin and sub- 
 cutaneous tissues, situated most frequently, but not exclusively, upon 
 the lower extremities and genitalia. 
 
 Symptoms. — Although in the fully developed disease there is little 
 difference between the endemic and sporadic forms, the symptoms of 
 the early stages are much more pronounced in the former. The en- 
 demic variety as seen in tropical countries usually begins with more 
 or less decided constitutional disturbances, such as elevation of tem- 
 perature, chills, pains in the limbs associated with a localized inflam- 
 mation of the skin situated in most cases upon one, much less fre- 
 quently both, lower extremities. This inflammation is commonly 
 of an erysipelatous character and is frequently associated with symp- 
 toms of lymphangitis, red lines extending up and down the limb, with 
 swelling and pain, and swelling of the lymphatic glands. These acute 
 symptoms gradually subside, but the swelling does not entirely dis- 
 appear. After an interval of some weeks or months a new attack, 
 accompanied by the same symptoms, occurs, followed by an in- 
 crease in the permanent swelling, and these are repeated until the 
 girth of the limb finally may become three or four times greater 
 than normal. 
 
 When fully developed, the foot is transformed into a cushion-like mass 
 separated from the leg at the ankle by a deep narrow circular fissure ; 
 the leg is either uniformly cylindrical in shape, several times its 
 normal diameter, or a huge tumor-like mass divided by deep sulci, 
 exaggerated normal furrows, from which escapes a foul-smelling fluid 
 composed of decomposed sweat, sebum, and macerated epidermis. 
 The skin may be dry, smooth, tense, and shining, or rough, uneven, 
 covered with warty patches and papillomatous growths, and more 
 or less deeply pigmented. 
 
 When the superficial lymphatics are involved they form vari- 
 cosities upon the surface or vesicles, which, when ruptured, either 
 
HYPERTROPHIES 515 
 
 spontaneously or by violence, discharge lymph for a considerable 
 time (lymphorrhcea). The surface of the leg is at times covered 
 with oozing eczematous patches, excoriations, or ulcers with con- 
 siderable crusting. 
 
 Next to the lower extremities the male genitalia are the parts 
 most frequently attacked, usually the scrotum, less frequently the 
 penis. In women the labia and clitoris are occasionally affected. 
 
 On the scrotum the disease usually begins, as upon the legs, with 
 febrile attacks and local inflammation, accompanied by swelling and 
 pain, the latter at times being quite severe, usually more so than 
 upon the legs. In the course of time the scrotum is transformed into 
 a large dependent tumor whose surface is furrowed and fissured and 
 in places superficially ulcerated, which may reach to the knees and 
 below, and may weigh many pounds. If the penis is not likewise 
 affected it gradually disappears from view at the bottom of a deep 
 canal from which it cannot be withdrawn. 
 
 Upon the labia and clitoris it presents much the same features, 
 although it seldom reaches the enormous proportions seen in the 
 scrotum. 
 
 The affection known as lymph scrotum is closely related to ele- 
 phantiasis. The scrotum is enlarged, but much less so than in ele- 
 phantiasis, its surface usually smooth, but beset with lymphatic varices 
 and vesicles which rupture and discharge at times a milky, at others 
 a clear, straw-colored, coagulable fluid. 
 
 Attacks of fever and erysipelatous inflammation occur from time 
 to time, and in a certain proportion of cases it terminates in true 
 elephantiasis. 
 
 In infrequent cases the mammary gland in women is affected, 
 usually along with elephantiasis of an extremity. The breast 
 may reach a huge size, forming a pendulous mass reaching to the 
 pubes. 
 
 Quite exceptionally the arms and face may be attacked, but 
 the enlargement never reaches the proportions observed in other 
 regions. 
 
 In the sporadic form (elephantiasis nostras) febrile attacks such as 
 occur in the tropical variety are seldom seen, or if they do occur are 
 usually much less severe. The hypertrophy of the skin and subcu- 
 taneous tissues is the same in character, but is usually much less 
 pronounced. 
 
 The patient's general condition is in many cases but little affected, 
 although when the febrile attacks are severe and frequently repeated, 
 or when the flow of lymph is abundant and long-continued, exhaus- 
 tion may result. 
 
 In advanced cases the frequently huge overgrowth of the legs or 
 scrotum seriously interferes with locomotion. 
 
 Under the name elephantiasis telangiectodes, Virchow described a 
 congenital condition which undergoes further development, character- 
 
516 DISEASES OF THE SKIN 
 
 ized by a more or less pronounced localized overgrowth of fibrous and 
 vascular tissues. This condition, while elephantoid, is not, strictly 
 speaking, elephantiasis. 
 
 The permanent swelling of the lids and upper lip which sometimes 
 follows repeated attacks of an erysipelatous character, to which Sir 
 Jonathan Hutchinson some years ago gave the name solid oedema, is 
 closely related to, if not identical with, elephantiasis. 
 
 Etiology. — Elephantiasis is infrequent in children, and is much 
 more common in men than in women, occurring in the proportion 
 of three, according to some authors five, of the former to one of the 
 latter. It is seen in the dark-skinned races much more frequently 
 than in Europeans. As already observed, it is endemic in many tropi- 
 cal and subtropical countries — in India, Cochin-China, the South Sea 
 Islands, and the West Indies. 
 
 The direct cause is a microscopic worm-like parasite, the Filaria 
 sanguinis hominis, infection taking place through the bite of certain 
 species of mosquito, commonly the Culex fatigans, which serve as the 
 intermediate host in which it completes its development. Entering 
 the lymphatics, the mature filaria gives rise to inflammatory changes 
 and consequent interference with the lymph circulation. The larvae, 
 which are about 0.3 mm. in length and 0.008 to 0.011 mm. in diam- 
 eter, exhibit a remarkable nocturnal periodicity. Disappearing more 
 or less completely from the peripheral circulation during the day, they 
 begin to return with the approach of night, increase in numbers until 
 midnight, when they may be present in enormous quantities, and 
 then diminish again. Manson found them in great numbers in the 
 large blood-vessels and the lungs during the day, when they were 
 absent from the peripheral vessels. 
 
 The sporadic or non-filarial form is the sequel of repeated or long- 
 continued inflammations of the skin and subcutaneous tissues, usually 
 of an erysipelatous character, which result in a blocking of the lymph 
 channels. Unna regards such cases as the result of persistent strepto- 
 coccic infection, and suggests for it the name elephantiasis strepto- 
 genes. 
 
 Pathology.— The principal pathological alteration is an enormous 
 increase in the collagenous tissue affecting all parts of the derma, 
 but especially the lowest part, and the subcutaneous connective tissue. 
 There is a pronounced increase in the size and number of the connec- 
 tive-tissue cells, many of which are provided with long processes. 
 Scattered through the derma, as evidence of chronic inflammation, 
 are localized, usually perivascular, accumulations of round and plasma 
 cells with giant cells and "mastzellen," the last being unusually large. 
 Changes in the vessels are usually considerable ; the walls of both 
 arteries and veins are much thickened, and the lumina of the latter 
 are frequently occluded by thrombi composed of leucocytes. The 
 
HYPERTROPHIES 517 
 
 lymph vessels and the lymph spaces are dilated and the walls of 
 the former increased in thickness. Most observers have noted a 
 marked increase in the elastic tissue, but Unna found it decidedly 
 diminished. 
 
 The changes in the epidermis are secondary to those in the derma. 
 In the earlier stages there may be considerable thickening of the 
 rete, later atrophy and hyperkeratosis. The hair-follicles, sebaceous 
 glands and the sweat-glands are at first unaffected, but later they undergo 
 atrophy from pressure of the fibrous tissue. Considerable deposits of 
 pigment granules are present in the lowest cells of the rete and in the 
 upper portion of the corium in many cases. 
 
 Diagnosis. — The picture presented by a fully developed case of 
 elephantiasis, even when of moderate extent, is so characteristic that 
 it is usually recognizable at once. In regions in which the affection 
 is endemic, repeated attacks of local inflammation of the skin, ac- 
 companied by decided constitutional disturbance, even with but little 
 swelling, should lead to examination of the blood for filariae, remem- 
 bering, of course, that the organism is to be found most readily, indeed 
 often only, at night. 
 
 Prognosis.— The prognosis as to cure is unfavorable, the disease 
 usually slowly but steadily progressing for an indefinite period. If, 
 however, the patient can be removed to a region where it does not 
 prevail endemically, and appropriate treatment is instituted early, 
 much may be done to stay its progress. When the parts affected are 
 so situated that they can be completely removed, such as the scrotum, 
 a radical cure may follow surgical treatment. 
 
 Treatment. — Removal from regions in which the malady is en- 
 demic should always be advised as a measure of value in arresting 
 or at least delaying its progress. During the febrile attacks, espe- 
 cially in the endemic variety, rest in bed, quinine in considerable doses, 
 and the continuous application to the inflamed skin of compresses wet 
 with a saturated solution of boric acid or with lead water and lauda- 
 num are useful. 
 
 When the disease is situated upon the legs, rest in the recumbent 
 position, massage, and the continuous application of an elastic band- 
 age, more particularly the rubber bandage, are the measures most 
 likely to produce favorable results, especially in the earlier stages 
 before the hypertrophy has reached large proportions. Castellani 
 has reported favorable results from daily injections of fibrolysin com- 
 bined with the foregoing. Portions of the redundant tissue may 
 be removed surgically, and in elephantiasis of the scrotum this is 
 probably the best form of treatment. Cutting off the blood supply 
 by ligation of the principal vessel supplying the affected region, and 
 division or stretching of the nerve trunk, have in some instances 
 been followed by more or less improvement, but these procedures are 
 always uncertain in their results. 
 
518 DISEASES OF THE SKIN 
 
 DERMATOLYSIS 
 
 Synonyms. — Cutis laxa ; Loose skin ; Cutis pendula ; Pachydermato- 
 cele ; Chalazodermia. 
 
 Symptoms. — Under the term dermatolysis two quite distinct con- 
 ditions of the skin have been described by authors. The first is dis- 
 tinguished by more or less thickening and laxness of the skin, which 
 in one or more regions presents pendulous folds which at times reach 
 enormous size, producing extraordinary deformity. Occasionally the 
 skin is coarse, somewhat pigmented, and the mouths of the follicles 
 unusually patulous. While any region may be affected, the condi- 
 tion is seen most frequently on the scalp, particularly the occipital 
 region, the neck, the upper arm, and the thigh. The affection is 
 probably nothing more than an exaggerated form of soft fibroma, 
 fibroma molluscum, with the ordinary form of which it is occasion- 
 ally associated (q.v.) 
 
 In the second form, cutis laxa, elastic skin, cutis _ hyperelastica 
 (Unna), dermatolysis proper, the skin presents no visible alteration 
 in its structure, but is remarkably extensible and elastic so that it 
 may be picked up and drawn out sometimes to an extraordinary ex- 
 tent, and, when relaxed, retracts, sometimes with an audible snap. 
 This unusual elasticity may be limited to certain regions or be pres- 
 ent in the entire skin. In some of the reported cases the skin of the 
 chest could be drawn up over the face, the skin of the forearm down 
 over the hand. These are the "elastic skin men," "India rubber skin 
 men," of the museums. Cases have been observed by Duhring, Kopp, 
 Seifert, and Du Mesnil. 
 
 The histology of the affection has been studied by Du Mesnil, 
 Williams, and Unna. Du Mesnil did not find any increase in the 
 elastic fibres, as was thought likely by Kopp, but these were irregu- 
 lar and more twisted than in normal skin ; he likewise found a myxo- 
 matous condition of the cutis. Williams and Unna agree in attribut- 
 ing considerable importance to the abnormal windings of the vessels 
 and nerves. The latter found extreme splitting of the collagenous 
 substance which he regards as an important factor in producing the 
 unusual extensibility of the skin. 
 
 The condition is a congenital one, and is irremediable. 
 
 CUTIS VERTICIS GYRATA 
 
 Attention was first directed to this rare and very curious anomaly 
 of the scalp by Jadassohn, who saw four cases of it. Other cases have 
 since been reported by Unna, who proposed for it the name cutis verticis 
 gyrata; by Gogrow, von Veress, and a few others. 
 
 It consists of a variable number of folds and furrows involving 
 the entire thickness of the scalp, arranged in irregular convolutions 
 resembling the cerebral convolutions, or less frequently in several 
 
HYPERTROPHIES 519 
 
 parallel straight lines. It affects most frequently the vertex and occip- 
 ital region, but also may occur in the parietal region. 
 
 In a case seen by the author some years ago in the Skin Dis- 
 pensary of the University Hospital, in the person of a young negro, 
 twenty-two years old, there were four parallel folds as thick as a 
 finger in each parietal region, running anteroposteriorly (Fig. 173). 
 
 Von Veress has very recently reported no less than eleven cases, 
 two of which he was able to study histologically. In one case there 
 
 V'. ■>:■'■ 
 
 Fig. 173. — Cutis verticis gyrata (negro). 
 
 were traces of decided inflammation at the bottom of the furrow, and 
 in both there was pronounced atrophy of the sebaceous- and sweat- 
 glands. He concludes that the condition is probably the result of a 
 chronic inflammation of the scalp, although he admits the possibility 
 of its congenital origin. 
 
 No subjective symptoms of any kind are present. 
 
 The only way in which the deformity can be removed is by ex- 
 cision. 
 
CHAPTER XIII 
 
 ATROPHIES— ATROPHLE 
 
 DERMATITIS CHRONICA ATROPHICANS 
 
 Synonyms. — Atrophia cutis idiopathica; Diffuse idiopathic atrophy 
 of the skin ; Acrodermatitis chronica atrophicans ; Dermatitis atrophi- 
 cans maculosa. 
 
 Definition. — A chronic inflammation of the skin, terminating in 
 atrophy. 
 
 Symptoms. — Beginning with Buchwald in 1883, a number of au- 
 thors (Neumann, Pick, Pospelow, Jadassohn, Herxheimer and Hart- 
 mann, Beck, and a few others) have from time to time reported exam- 
 ples of a cutaneous affection the chief characteristic of which is a 
 diffuse, pronounced, and progressive atrophy of the skin. While these 
 cases presented considerable variation in their clinical features, they 
 closely resembled one another in the marked atrophy which char- 
 acterized the final stage; and in all probability they represented vari- 
 ants of the same malady rather than separate affections. The erythro- 
 melie of Pick and the erythema paralyticum of Neumann are regarded 
 by most recent authors as belonging in the same category. Quite re- 
 cently Finger and Oppenheim have carefully reviewed the whole sub- 
 ject in a monograph containing reports of cases of their own and those 
 collected from the literature. 
 
 The disease usually begins with the appearance of a variable num- 
 ber of patches varying from bright to dark red, which, slowly enlarg- 
 ing, coalesce to form more or less extensive diffuse areas with smaller 
 patches and streaks which eventually exhibit a more or less pro- 
 nounced atrophy. When the affection has reached its acme, the skin 
 in the affected regions is thin and wrinkled like "crumpled cigarette 
 paper" (Fig. 174), dark or brownish red, and more or less translucent, 
 so that the vessels are readily perceived through it, with here and 
 there small scar-like white patches from which the pigment has 
 disappeared. On the extremities the skin lies in thin longitudinal 
 and oblique folds except over and around the joints, where the folds 
 are transverse. The hair is thinned or lost in the affected regions, and 
 there is frequently a fine branny desquamation owing to the dryness 
 of the skin resulting from suppression of the functions of the sweat- 
 and sebaceous-glands. In rare cases the disease begins as pinkish 
 macules or maculo-papules or nodules, which are replaced in time 
 by a macular atrophy (Jadassohn). 
 
 In the majority of cases it begins upon the extremities (hence 
 the name "acrodermatitis" proposed by Herxheimer and Hartmann), 
 and may be confined to these, but it occasionally spreads to the trunk. 
 The inflammatory early stage is often so little pronounced and de- 
 void of symptoms that it usually escapes notice, and the atrophy is 
 520 
 
ATROPHIES 
 
 521 
 
 J** 
 
 .':" 
 
522 DISEASES OF THE SKIN 
 
 usually the first symptom to attract attention; for this reason the 
 latter was regarded by the early observers as the primary condi- 
 tion. Subjective symptoms are, as a rule, absent, but there may be 
 at times itching and burning. 
 
 Etiology and Pathology. — The limited number of cases thus far 
 observed have occurred chiefly in middle-aged adults and somewhat 
 more frequently in women than in men. Practically nothing is 
 known about its primary cause. Finger and Oppenheim are inclined 
 to attribute considerable importance to heat and cold and the weather. 
 Fordyce observed an example in a syphilitic woman, but there was no 
 conclusive evidence that this was more than a coincidence. 
 
 According to Finger and Oppenheim, the malady is a chronic 
 inflammation of the skin characterized by dilatation of the vessels, 
 oedema, cell exudation, and principally by early disappearance of 
 the elastic tissue. 
 
 Diagnosis. — When the atrophy is fully developed, the affection 
 is not likely to be mistaken for any other. It may at times be con- 
 founded with scleroderma, but the soft wrinkled skin of the atrophic 
 patches is altogether unlike the firm, leather-like, ivory-white patches 
 characteristic of the latter. 
 
 Prognosis and Treatment. — The prognosis as to the arrest of the 
 disease and restoration of the skin to the normal condition is very 
 unfavorable ; in rare instances, however, complete recovery has been 
 noted (Pick, Finger, and Oppenheim). The patient's general condi- 
 tion is in no way affected. 
 
 The skin should be protected against cold by proper clothing, 
 and an endeavor made to improve its nutrition by warm baths, mas- 
 sage, electricity, and inunctions of some bland ointment, such as 
 equal parts of cold cream and lanolin, or lanolin and oil of sesame. 
 
 ATROPHIA CUTIS SENILIS 
 
 Synonyms. — Atrophoderma senilis ; Senile atrophy of the skin. 
 
 Definition. — Atrophy and degeneration of the skin, peculiar to old 
 age. 
 
 Symptoms. — With increase in years, the skin, like other tissues of 
 the body, undergoes certain structural changes. It loses its normal 
 lustre and color, becomes yellowish or brownish, it is thin and 
 wrinkled, in places hanging in loose folds, owing in part to diminu- 
 tion or disappearance of the subcutaneous fat, and has to a consider- 
 able extent lost its elasticity, so that when stretched it retracts slowly. 
 In extreme cases it is very thin and partly translucent, so that the 
 vessels beneath it can be readily seen. Upon parts exposed to sun 
 and wind, such as the hands and face, smooth non-elevated brown or 
 blackish freckle-like patches often appear in varying number, such 
 deposits of pigment being especially common on the backs of the 
 hands. Other brown or blackish patches covered with a horny adher- 
 ent crust are common also upon the back of the hands and in the 
 
ATROPHIES 523 
 
 face, in the latter region especially upon the forehead and over the 
 malar eminences, which show a decided tendency to undergo epithelio- 
 matous change in time (senile keratoses). Occasionally, here and 
 there, small scar-like white patches appear owing to disappearance of 
 the normal pigment. On the trunk, particularly on the upper half 
 of the back, numbers of wart-like elevations covered with fatty crusts 
 which are readily removed are often present (senile warts, sebor- 
 rhceic warts), which, like the senile keratoses, occasionally become 
 epitheliomatous. Vascular changes, such as telangiectases and small 
 angiomata varying in size from a pin-head to a split pea, are likewise 
 common in the senile skin ; purpuric patches are occasionally noticed 
 on the back of the hands and more especially upon the lower extremi- 
 ties, which may be spontaneous or the result of trifling unnoticed 
 injury (purpura senilis). Quite commonly the skin of the aged is 
 dry and finely desquamating, owing to the atrophy of the sweat- 
 and sebaceous-glands. 
 
 Pathology. — According to Neumann, there may be a simple senile 
 atrophy of the skin, characterized by quantitative changes only, but 
 in most cases there are qualitative changes as well. There is a 
 more or less pronounced thinning of the epidermis affecting the rete 
 chiefly, the cells of which are smaller than normal ; its interpapillary 
 prolongations are greatly shortened or have in large part disap- 
 peared, corresponding with a like shortening of the underlying papillae. 
 In places there is a circumscribed increase in the thickness of the 
 horny layer. There is an increased amount of pigment present in 
 both the epidermis and corium. The follicles and glands show more 
 or less pronounced atrophy. In addition to these quantitive changes 
 the corium frequently exhibits certain qualitative changes. The elastin 
 is transformed into elacin, and the collagen into collacin and col- 
 lastin, changes which are indicated by alterations in the structure and 
 tinctorial properties of these tissues. 
 
 Treatment. — Although senile changes cannot be altogether pre- 
 vented, nor the skin restored to its former condition when they have 
 occurred, much may be done to delay their appearance by proper 
 hygiene and the use of a nutritious diet containing an abundance of 
 easily digested fat, together with cod-liver oil. Massage and warm 
 baths followed by inunctions of some bland fat, such as lanoline di- 
 luted with oil of sweet almond or oil of sesame, are useful in promoting 
 the nutrition of the skin. 
 
 Senile keratoses and seborrhceic warts, when present, should re- 
 ceive special attention, owing to the possibility of epitheliomatous 
 degeneration taking place in them. 
 
 STRLE ET MACULE ATROPHICA 
 
 Synonyms. — Atrophia striata et maculosa ; Atrophoderma striatum 
 et maculatum. 
 
 Definition. — Atrophy of the skin, occurring in streaks and patches. 
 
524 DISEASES OF THE SKIN 
 
 Symptoms. — Atrophic striae appear as stripes of varying length 
 and breadth, which, when recent, are slightly livid, but later become 
 pinkish, white, or pearly-white, and sometimes, when old, slightly 
 pigmented. They are somewhat depressed below and visibly thinner 
 than the normal skin, with a slightly wrinkled surface, and vary in 
 breadth from 2 to 6 mm. and in length from 1 to 6 or 8 cm. They 
 are usually multiple, and those in the same region are arranged more 
 or less parallel with one another, although this is not invariably the 
 case. They are situated most frequently in regions in which the 
 panniculus adiposus is well developed, especially the abdomen, the 
 inner and anterior surface of the upper thighs, the upper arm ; much 
 less frequently they are situated about the joints, especially the knees 
 (striae patellores). Upon the abdomen they are common in women 
 who have been pregnant (linecu albicantes, vergeturcs, Schzvanger- 
 schaftsnarben) , and similar stripes occur in the breasts as the result 
 of lactation ; they may also follow ascites and abdominal tumors. 
 In the former region they are arranged horizontally at the level of 
 the umbilicus, but run obliquely, parallel with the line of the groins, 
 on the lower abdomen ; on the breasts they are arranged radially. 
 The direction of the stripes is in general at right angles to the direc- 
 tion of the greatest tension in the skin. As a rule they appear grad- 
 ually and are unaccompanied by subjective symptoms. Evans has 
 very recently reported a case, however, in which they appeared quite 
 suddenly on the back in the course of two or three days. 
 
 Similar alterations of the skin occurring as whitish spots or patches 
 are also observed either in association with the striae or indepen- 
 dently of these (maculae atrophicae). Liveing, Duhring, Jadassohn, and 
 a few others have described cases of macular atrophy in which the 
 patches were numerous, varying in size from a lentil to a coin, and 
 were preceded by erythema and some infiltration. Jadassohn pro- 
 posed the name anetodermia erythematodes for the affection he de- 
 scribed. There is little or no doubt that these cases represent a 
 pathological process quite distinct from that occurring in atrophic 
 striae. 
 
 Etiology and Pathology. — Atrophic striae are in the majority of 
 cases produced by rapid overdistention of the skin such as occurs 
 in the mammae and abdomen of women in pregnancy, in ascites and 
 rapidly growing or very large abdominal tumors. They also occur 
 in those who have grown stout rapidly and are often then situated 
 not only on the abdomen, but on the upper thighs, the upper arms, 
 and on the buttocks. Not all, however, are of this origin. A certain 
 proportion follow severe acute illness, such as typhoid fever, as in 
 the case observed by Shepherd, in which extensive striae occurred 
 over and in the neighborhood of the patellae ; they have also been ob- 
 served after scarlet fever (Osier, Bleibtrau, Silberstein). The origin 
 of the macular lesions is for the most part unknown. 
 
 Troisier and Menetrier, whose observations have been confirmed 
 
ATROPHIES 525 
 
 by Unna, found striking changes in the elastic tissue in the striae. 
 In the centre of the striae it had disappeared, while it was increased 
 about the borders, and many of its fibres were ruptured. Unna found 
 that numerous elastic fibres had undergone transformation into elacin 
 (basophilic elastin). As the result of tension, the collagen bundles 
 of the corium no longer interlace, but are stretched out parallel with 
 the direction of the tension. The follicles and glands are more or 
 less atrophied or absent. In the cases of macular atrophy described 
 by Jadassohn there was complete absence of elastic tissue in the 
 patches. 
 
 Diagnosis. — The appearance of the striae is so characteristic that 
 errors in diagnosis are not likely to occur. The macular lesions are 
 to be differentiated from scars and from circumscribed scleroderma 
 (morphoea). 
 
 The condition is irremediable. 
 
 KRAUROSIS VULV^ 
 
 Definition. — A disease characterized by atrophy of the skin and 
 mucous membrane of the vulva. 
 
 Symptoms. — This infrequent malady was first described by Breisky 
 under its present name in 1885, although cases of what was probably 
 the same affection had been previously described by Weir and Lawson 
 Tait, by the latter as a vascular degeneration of the vulva with atrophy 
 of its mucous membrane. Cases have since been reported by Janovsky, 
 Ohmann-Dumesnil, Baldy and Williams, Jayle, Thibierge, and a few 
 others. 
 
 The disease usually begins insidiously without any very definite 
 symptoms, although in a certain proportion of cases pruritus pre- 
 cedes the atrophy and may be a marked symptom. The labia majora 
 are wrinkled and atrophic, the hair thin or lost, the mucous surface 
 smooth, yellowish, or whitish, with occasional patches of leucoplakia 
 or small vascular areas ; the labia minora are reduced to small vertical 
 folds, or may completely disappear, and the prceputium clitoridis is 
 similarly atrophied. The ostium vagincc is narrowed, at times so 
 greatly as to scarcely admit the finger, and has lost its elasticity 
 so that it is no longer distensible, making coitus difficult and very 
 painful. Jayle, who has recently studied the malady very thoroughly, 
 recognizes four forms — Leukoplasic kraurosis, corresponding with the 
 form described by Breisky; inflammatory kraurosis, of which the af- 
 fection described by Lawson Tait was an example ; senile kraurosis ; 
 and operative kraurosis, that which follows removal of the ovaries. 
 
 Etiology and Pathology. — The causes and origin of this malady 
 are obscure. It occurs in women past the menopause, or in those 
 who have had their ovaries removed surgically. As already observed, 
 pruritus frequently accompanies it and the irritation and inflamma- 
 tion produced by scratching are regarded by some authors as having 
 a causative relationship to it. In the majority of cases there is a 
 
526 DISEASES OF THE SKIN 
 
 vaginal discharge, either an ordinary leucorrhcea or gonorrhoea. Finger 
 regards it as closely related to chronic lichen. According to Perrin, 
 leucoplakia and kraurosis vulvae are only different degrees of the same 
 affection. There is little doubt that simple senile kraurosis is nothing 
 more than an atrophic process such as is common to the skin and mucous 
 membranes in old age. 
 
 Breisky found in sections of the labium minus a thinning of the 
 rete, and in the deeper portion of the corium a small-celled infiltra- 
 tion. The papillary body and the upper portion of the corium were 
 sclerosed. 
 
 Prognosis and Treatment. — The disease is usually a slowly progres- 
 sive one and is but little influenced by treatment. In the cases in 
 which leucoplasic patches are present upon the mucous surface, 
 epithelioma occasionally follows. Baldy and Williams advise the total 
 extirpation of the affected region. 
 
 AINHUM 
 
 Definition. — An endemic disease of the tropics characterized by a 
 constricting furrow surrounding one or more toes, terminating in 
 spontaneous amputation. 
 
 This affection was first described by Clark as a disease endemic 
 among the negroes of the west coast of Africa, and somewhat later 
 independently by Da Silva Lima, who observed it among the negroes 
 of Brazil. 
 
 Symptoms. — It begins as a furrow situated at the base of the little 
 toe, on the inner and plantar surface, which gradually increases in 
 depth and extends to the outer side and dorsal surface until it com- 
 pletely encircles the member. As the furrow deepens, the toe be- 
 comes greatly swollen, looking as if encircled by a tight ligature, 
 and ulceration is apt to occur in the bottom of the furrow, which is 
 accompanied by pain and an offensive discharge. After some years 
 the toe is attached only by a flexible pedicle and is occasionally acci- 
 dentally knocked off, or is amputated because of the interference with 
 walking; if left to itself, it eventually is completely detached by the 
 progress of the disease. Until ulceration occurs it is usually painless, 
 although exceptions are occasionally observed. As already noted, the 
 disease in the great majority of cases attacks the little toe, but may 
 also affect the fourth, but very rarely the other toes. It may be 
 limited to one foot, or both little toes may be affected either simul- 
 taneously or one after the other. In rare instances a similar con- 
 stricting furrow has been observed on the fingers (Stelwagon, a case 
 affecting the little finger). 
 
 Etiology and Pathology. — The cause of this very curious affection 
 is altogether unknown. It occurs almost exclusively in the dark races, 
 especially in negroes, but a few cases have been reported in Europeans. 
 It is confined for the most part to the west coast of Africa and to 
 Brazil, but sporadic cases are occasionally seen in some of the islands 
 
ATROPHIES 527 
 
 of Polynesia and among the negroes of the southern United States. 
 It is a disease of early adult life, but is rare in children and the old ; 
 males are more often attacked than females. Da Silva regarded hered- 
 ity as an important predisposing factor; he saw families of negroes 
 in which all the members were affected. Both parents of Duhring's 
 patient had the disease. It may be pointed out, however, that such 
 occurrences may as readily be explained by infection as by heredity. 
 Manson thinks it probably the result of injury which occurs so readily 
 and so frequently in those who go barefoot, and Wellman thinks that 
 it may be produced by jiggers. The former makes the observation 
 that a similar affection occurs in the tail of a certain species of monkey. 
 
 The nature of the malady is very obscure. By some authors it 
 is regarded as a trophoneurosis, by others an unusual form of sclero- 
 derma; Manson saw a negro in whom one little toe presented a sclero- 
 derma while the other presented a well-marked ainhum. Zambaco 
 Pasha thinks it a modified form of leprosy, but there is little evidence 
 to support this opinion. 
 
 The histopathology has been studied by a number of observers 
 (Eyles, Wile, Moreira, and others), who practically agree in their 
 findings. All the layers of the epidermis are greatly hypertrophied ; 
 the papillae contain an abundant exudation of cells and the deeper 
 vessels of the cutis and the hypoderm present alterations character- 
 istic of obliterating endarteritis. In the furrow there is a fibrous 
 hypertrophy of the collagen. The furrow may surround the joint or 
 occur at the metatarso-phalangeal joint, or in the continuity of the 
 phalanx which presents the changes indicative of a rarefying osteitis. 
 
 Prognosis and Treatment. — The course of the malady is a steadily 
 progressive one and almost invariably terminates in the loss of the 
 toe, which takes place after five to ten years. 
 
 In advanced cases the toe should be amputated, since nothing can 
 be done to stay the progress of the malady ; the toe is only a hindrance 
 in walking, and the source of great pain and discomfort when ul- 
 ceration has occurred. In the very early stages Da Silva Lima found 
 that transverse division of the furrow arrested the process. 
 
 PERFORATING ULCER OF THE FOOT 
 
 Synonyms. — Malum perforans pedis ; Fr., Mai perforant du pied ; 
 Ger., Perforirendes Fussgeschwiir. 
 
 Definition. — An ulcer of trophic origin situated upon the sole of 
 the foot. 
 
 Symptoms. — This infrequent affection, which was first described 
 by Nelaton, and given the name by which it is generally known by 
 Vesignie, is situated upon some portion of the sole exposed to pres- 
 sure, in most cases at the metatarso-phalangeal joint of the great or 
 little toe. It begins as a callosity, beneath which after some time 
 ulceration occurs ; the callosity is then cast off, disclosing an ulcer 
 which communicates with the deeper tissues by a sinus which may 
 
528 DISEASES OF THE SKIN 
 
 extend down to and lay bare the bone which undergoes necrosis. 
 The margins of the ulcer are surrounded by a thick layer of horny 
 epidermis and the bottom is occasionally covered with granulations. 
 At times all parts of the sole exposed to pressure exhibit a more 
 or less marked degree of hyperkeratosis. The ulcer is, as a rule, 
 painless, and there is usually more or less anaesthesia of the parts 
 surrounding it ; walking, however, is frequently painful, and in ex- 
 ceptional cases there is spontaneous pain in the foot. Occasionally 
 the foot is cold and livid and perspires abundantly, the perspiration 
 having a disagreeable odor. The ulcer is usually single, but there 
 may be two or more, either on the same foot or on both. In rare 
 instances it has been seen upon the hand (Terrillon, quoted by 
 Crocker). The disease pursues a slow, indolent course, and, if the 
 foot is put at rest, healing may in time take place, but the ulcer re- 
 appears when the foot is used. 
 
 Etiology and Pathology. — Perforating ulcer is observed far more 
 frequently in men than in women ; of ninety-one cases collected by 
 Gasquel, eighty-four were males. It is most common between the 
 ages of thirty and fifty and is infrequent before twenty. In a large 
 proportion of cases it is associated with some disease of the central 
 or peripheral nervous system, such as locomotor ataxia, leprosy, pe- 
 ripheral neuritis. Of Gasquel's 91 cases, 69 had some disease of the 
 central nervous system, 32 of them tabes. In a few instances it has 
 been observed to follow diabetes. 
 
 Savory and Butlin, who made a careful study of five cases, were 
 of the opinion that it was the result of pressure upon, or injury to, 
 tissues whose vitality had been impaired by defective nerve supply, 
 an opinion which has been generally accepted as correctly explaining 
 the origin of the malady. These investigators, who examined sec- 
 tions of the anterior and posterior tibial nerves in the foot, found the 
 epineurium, perineurium, and endoneurium much thickened, the nerve 
 fibres smaller than normal, the ultimate fibrils atrophied, and the 
 smallest completely obliterated. 
 
 Diagnosis. — The malady is to be distinguished from simple ulcer, 
 from suppurating corns, and callosities. From these it is usually read- 
 ily differentiated by the painless character of the ulcer, its sluggish 
 course, the presence of a sinus leading down to the bone, and its asso- 
 ciation with some affection of the nervous system. 
 
 Prognosis and Treatment. — The prognosis is unfavorable ; even 
 when healing does take place, it is only temporary, the ulcer reappear- 
 ing with the resumption of the use of the foot. Even amputation of 
 a part or the whole of the foot is apt to be followed in time by recur- 
 rence in the stump. Treves recommends the removal of the thick 
 horny epidermis around the ulcer by paring, and poultices and filling 
 the sinus with a cream of salicylic acid and glycerin containing ten 
 minims (0.65) of carbolic acid to the ounce (32.0). After healing has 
 taken place, a perforated felt pad should be worn over the site of 
 
ATROPHIES 529 
 
 the ulcer. Stretching of the sciatic or posterior tibial nerve has also 
 been advised (Bevan Rake). 
 
 GLOSSY SKIN 
 
 Synonyms. — Glossy nngers ; Atrophoderma neuriticum ; Liodermia 
 neuritica. 
 
 Definition. — An atrophic condition of the skin affecting in most in- 
 stances the fingers. 
 
 Symptoms. — Attention was first specially called to this affection 
 by Paget under the name of "glossy fingers," and it was described 
 later by Mitchell, Morehouse, and Keen as a sequel of gunshot wounds 
 and other injuries to nerves. The condition had been previously noted, 
 however, by Romberg and others. The skin of one or more fingers 
 is red, smooth, and shining, the normal lines of the skin more or 
 less completely effaced. At times the color is dusky or somewhat 
 livid and mottled, as in chilblain, which the affection may resemble 
 in appearance quite closely. After a time the fingers become thin 
 and tapering, often slightly flexed, the nails are curved from side to 
 side and over the ends of the fingers, and occasionally the skin is 
 retracted from the matrix, leaving it exposed ; upon the toes painful 
 fissures and ulcers may thus arise. The skin is, as a rule, abnormally 
 dry, but exceptionally there may be hyperidrosis ; the hair usually 
 disappears from the affected region. Neuralgic pain or severe burn- 
 ing (causalgia) frequently precedes and accompanies the changes in 
 the skin, and the parts are sensitive and extraordinarily susceptible 
 to trauma. In a case under the author's care, occurring in a house- 
 maid, in which the affection had followed a partial severance of the 
 ulnar nerve, the use of a broom or a dusting-brush for a short time 
 was always followed by ulcers on the ring and little fingers which 
 were weeks in healing. 
 
 Etiology and Pathology. — The affection is essentially a neuritis, 
 which, interfering with the trophic function of the nerves supplying 
 the affected region, leads to atrophy of the skin and its appendages. 
 In the great majority of cases the neuritis is the consequence of trauma, 
 but it may also follow a non-traumatic neuritis, such as may occur 
 in gout, rheumatism, leprosy, and syphilis ; in a few instances it has 
 been observed to follow a chronic inflammation of the cord. In a 
 case limited to the index finger under the author's observation for 
 many years, it followed a puncture with an awl. 
 
 Prognosis and Treatment. — The prognosis depends very largely 
 upon the nature of the nerve lesion which has produced it. As a 
 rule, the tendency is to recovery, but the recovery is usually slow, 
 requiring months or even years, and occasionally the trophic changes 
 continue indefinitely. 
 
 The treatment is essentially that of neuritis. The parts should 
 be carefully protected from cold and injury. 
 34 
 
CHAPTER XIV 
 
 ANOMALIES OF PIGMENTATION— ANOMALLE 
 PIGMENTATIONIS 
 
 LENTIGO 
 
 Synonyms. — Ephelis ; Freckle ; Fr., Ephelide, Lentille, Tache de 
 rousseur ; Ger., Linsenflecke, Sommersprosse. 
 
 Definition. — A pigmentary disorder of the skin characterized by 
 light to dark-brown spots, varying in size from a pin-head to a pea, 
 situated for the most part upon uncovered parts, such as the face 
 and hands. 
 
 Symptoms.— Freckles vary in color from light to dark brown, or, 
 in dark-skinned subjects, to black. They are round, oval, or irregu- 
 lar in shape and vary in size from a pin-head to a pea, small and large 
 ones usually intermingled, but occasionally they are all very small 
 or all quite large. They vary greatly in numbers ; at times they are 
 few and widely separated, at others they are very numerous and 
 almost confluent, covering the greater part of the face and backs of 
 the hands. While in most cases confined to the face, hands, and 
 forearms, they also occur occasionally upon the trunk, the buttocks, 
 thighs, and penis (Duhring) ; in these covered regions they are popu- 
 larly known as "cold freckles." Crocker saw a case in which they 
 appeared first upon the thighs, to which they remained limited for a 
 considerable time, but eventually they also appeared upon the face. 
 In rare cases they may be unilateral (cases of Robinson, Pernet). 
 They are occasionally associated with multiple soft fibrous tumors, 
 fibroma molluscum (von Recklinghausen's disease), and are one of 
 the symptoms of xeroderma pigmentosum. They are frequently ob- 
 served upon the backs of the hands of elderly or aged individuals, 
 often associated with senile warts and senile keratoses. They often 
 appear quite suddenly, in the summer season as a rule, and are much 
 darker in summer than in winter ; in the latter season they fade noticeably, 
 and when light in color they disappear entirely until the return 
 of summer. They are not accompanied by subjective symptoms of 
 any kind. 
 
 Etiology and Pathology. — There is no difference in the frequency 
 with which the two sexes are affected. They are seen much more 
 frequently in those with fair complexions than in dark-skinned sub- 
 jects, but the latter are by no means immune. Individuals with red 
 hair are especially apt to have them ; indeed, they almost invariably 
 present some degree of freckling. They are rarely seen in quite young 
 children, but usually appear about the eighth to the tenth year. A 
 number of cases of congenital freckles have been reported, but these 
 properly belong to the class of pigmented naevi. 
 530 
 
ANOMALIES OF PIGMENTATION 531 
 
 The chief cause is exposure to light, but that this is probably not 
 the only etiological factor is indicated by the not very rare occurrence 
 of freckles upon the covered parts of the body. 
 
 The only histological change is an increase of pigment in cir- 
 cumscribed areas of the epidermis, in the lower layers of the rete, 
 both between and within the cells. A few pigment-containing cells 
 are also present in the papillae and in the subpapillary portion of 
 the corium, chiefly in the neighborhood of the vessels. 
 
 Treatment. — The pigment may be removed by producing an active 
 desquamation of the epidermis, but in the great majority of cases 
 it returns sooner or later and the treatment must be repeated. One 
 of the most commonly employed and at the same time most effective 
 remedies is bichloride of mercury, in aqueous or alcoholic solution, 
 from one to five grains (0.065 to 0.32) to the ounce (0.32). This 
 should be applied frequently with a bit of absorbent cotton or gauze 
 until a mild dermatitis is produced, when it should be suspended ; 
 with the desquamation which follows, the pigment disappears. When 
 it is desired to produce a more rapid result and deeper effect the 
 stronger solutions may be applied continuously on gauze for some 
 hours until vesication is produced ; an abundant desquamation fol- 
 lows. This latter method should be used with great care, as there 
 is considerable risk of producing a severe inflammation which may 
 be followed by scarring. Salicylic acid is equally effective and much 
 less likely to be followed by undesirable results. It may be used 
 as an alcoholic solution of 4 to 5 per cent, strength, which should 
 be applied several times a day until scaling occurs ; or it may be 
 used as a 10 to 20 per cent, paste or plaster, which should be applied 
 continuously for several days until peeling begins. Pure carbolic 
 acid may be lightly painted on the spots for the purpose of producing 
 desquamation. When the freckles are light colored, an ointment of 
 ammoniated mercury and subcarbonate of bismuth, one drachm (4.0) 
 each to the ounce (32.0), is often of service. The frequent applica- 
 tion of hydrogen peroxide will often produce a decided bleaching, but 
 it must be continued. When the freckles are limited in number, 
 they may be removed by electrolysis, using a current of one or two 
 milliamperes and inserting the needle into the epidermis only a short 
 distance, at several points, for three to five seconds. 
 
 CHLOASMA 
 
 Synonyms. — Melanoderma; Melasma; Liver spots. 
 
 Definition. — Increased pigmentation of the skin occurring as vari- 
 ously sized patches or in diffuse areas. 
 
 Symptoms. — The discoloration varies from a pale yellowish-brown 
 to dark brown or black ; it occurs in patches of varying size and shape, 
 usually with ill-defined margins, or it may occupy the whole of a 
 region, such as the face or the trunk, or even the entire surface of 
 the body. It may occur as an independent affection, chloasma idio- 
 
532 DISEASES OF THE SKIN 
 
 pathicum, or it may be secondary to or accompany some visceral or 
 general disorder, chloasma symptomaticum. It may appear somewhat 
 suddenly or gradually , it may be transient or permanent, in the 
 former event its duration varying from few to many months. The 
 affected areas show no structural alteration of the skin, and there 
 are no subjective symptoms resulting from the discoloration. In 
 idiopathic chloasma the discoloration is usually limited in extent, and 
 in the majority of cases occupies the exposed regions, but excep- 
 tions are not uncommon. In long-standing pediculosis corporis the 
 entire trunk and extremities at times assume a dark brown or almost 
 black discoloration as the result of the long-continued irritation pro- 
 duced by the parasite and more particularly by the scratching (pityri- 
 asis nigra, Willan). In the symptomatic variety the pigmentation is 
 frequently more or less general, although, like the idiopathic form, it 
 may be limited to certain regions. One of the most frequent forms 
 of symptomatic chloasma occurs in pregnancy or in association with 
 uterine disease, chloasma uterinum. It is distinguished by yellowish- 
 brown or dark-brown patches with ill-defined margins, situated upon 
 the forehead and cheeks, which make their appearance in the early 
 months of pregnancy and become more pronounced in color as the 
 pregnancy advances. In the majority of cases the discoloration slowly 
 disappears after the termination of the pregnancy, but may remain 
 and increase in depth with each succeeding one. When associated 
 with disease of the uterus or its appendages, its course and duration 
 are somewhat indefinite. Much less frequently the pigmentation is 
 not limited to the face, but extends upon the neck and various parts 
 of the trunk. During pregnancy parts which are normally somewhat 
 pigmented, such as the areola of the nipple, become decidedly darker. 
 Etiology and Pathology.— Idiopathic chloasma is in most instances 
 the consequence of prolonged local irritation of the skin. It may 
 follow exposure to the rays of the sun or to the X-ray, or to heat, 
 as in the pigmentation which may follow the prolonged exposure 
 of the legs to the heat of a fire or the long-continued application of 
 a hot-water bag. It may result from the application of a sinapism or 
 blister. Occasionally it results from prolonged pressure, as when it 
 occurs about the waist from a tight corset, or on the legs from the 
 garters. Pigmentation arising from these local causes is usually tran- 
 sient, although its disappearance may be slow, and exceptionally it 
 may be permanent. More or less permanent pigmentation frequently 
 follows chronic inflammations of the skin, especially when situated 
 upon the lower extremities, and in the same region may follow pro- 
 longed venous stasis without actual inflammation. Pigmentation 
 which may be transient or permanent frequently follows syphilitic 
 eruptions and is a common sequel of lichen planus, in which it may 
 be of the most pronounced character, at times being almost black. 
 Pigmentation, usually of a patchy character, also occurs in leprosy and 
 in xeroderma pigmentosum. 
 
ANOMALIES OF PIGMENTATION 533 
 
 A small number of systemic or visceral diseases are accompanied 
 by pigmentation of the skin, which is usually of a diffuse character. 
 In Addison's disease the skin is more or less markedly discolored, 
 and deposits of pigment occur in the mucous membranes. In hsemo- 
 chromatosis, or bronze diabetes, the skin is extensively and markedly 
 pigmented, the color varying from brown to blue-black, and in the 
 rare disorder known as ochronosis, characterized by blackening of the 
 cartilages and fibrous tissues with alkaptonuria, the skin is at the same 
 time pigmented, either diffusely or in limited regions. Reference has 
 already been made to the influence of pregnancy and diseases of the 
 uterus and its adnexa upon the occurrence of chloasma. 
 
 A general pigmentation, usually of moderate degree, frequently 
 occurs in the later stages of wasting diseases such as tuberculosis 
 and malignant neoplasms (chloasma cachecticorum). 
 
 The prolonged use of arsenic is at times followed by extensive 
 pigmentation of the skin, which is of a dirty grayish-brown and pre- 
 sents a mottled appearance (melanosis arsenicalis) ; it is at times 
 accompanied by other evidences of arsenicism, such as palmar and 
 plantar keratosis and peripheral neuritis, as in a case recently seen 
 by the author. 
 
 The pigment present in chloasma is with very few exceptions 
 melanin, which is normally present in the skin ; in hemochromatosis 
 it is hemosiderin, a pigment containing iron. It is situated in the basal- 
 cell layer of the rete and in the layers immediately above. In the 
 papillae and between the cells of the lower portion of the rete are an 
 abnormal number of large branched pigment-containing cells, the 
 melanoblasts of Ehrmann. No other changes are present. 
 
 Diagnosis.— The affections with which chloasma is most likely to 
 be confounded are vitiligo and tinea versicolor. In the former the 
 pigmentation surrounds depigmented white areas and presents a 
 sharply defined concave border, while in chloasma it occurs as patches 
 with ill-defined convex borders. The patches of vitiligo are usually 
 symmetrically distributed, those of chloasma show no such arrange- 
 ment. In tinea versicolor the discoloration is seated in the horny layer 
 of the epidermis, which may be readily scraped off with the nail, and 
 in the scrapings the microsporon furfur is readily demonstrated with 
 the microscope. 
 
 Prognosis and Treatment. — The prognosis depends largely upon 
 the cause of the pigmentation. In many of the cases arising from 
 local irritation the discoloration disappears eventually w r hen the cause 
 is removed, but exceptions are not rare. Uterine chloasma usually 
 disappears after the termination of the pregnancy or the removal of 
 the uterine disease with which it is associated. The prognosis of the 
 general pigmentation which occurs with Addison's disease or other 
 general disorders is, of course, the same as that of the latter. Arsenical 
 pigmentation usually disappears with the suspension of the drug, but 
 may persist for a considerable time. 
 
534 
 
 DISEASES OF THE SKIN 
 
 The treatment of chloasma is essentially the same as that for 
 lentigo, to which the reader is referred. 
 
 VITILIGO 
 
 Synonyms. — Leukoderma; Leukopathia; Leukasmus acquisitus. 
 
 Definition. — An acquired defect of pigmentation characterized by 
 circumscribed milk-white patches with more or less hyperpigmented 
 margins, symmetrically distributed. 
 
 Symptoms. — The disease usually begins quite insidiously with the 
 appearance of a variable number of small oval or round white patches 
 which gradually increase in size. According to Unna, the loss of 
 pigment is always preceded by a diffuse hyperpigmentation, but this 
 early stage almost invariably escapes notice. Exceptionally the affec- 
 
 Fig. 175. — Vitiligo. 
 
 tion begins quite suddenly and extends rapidly. As the patches 
 slowly enlarge peripherally, several of them unite to form larger 
 areas with serpiginous or polycyclic borders, and in time the greater 
 part of the pigment of the entire surface may disappear, leaving the 
 skin milky-white or pink. In this manner an apparent spontaneous 
 cure takes place, since the characteristic contrast between the pig- 
 mented and depigmented areas no longer appears, and the patient 
 has apparently nothing more than a very white delicate skin. The 
 skin about the borders of the white patches is usually darker than 
 normal, as if the pigment had been crowded out of the centre to 
 the periphery of the patches. On exposed parts, such as the backs 
 of the hands (Fig. 175), the sides of the neck, and the face, the dis- 
 ease is much more noticeable in the summer than in the winter, owing 
 to the darkening of the skin about the depigmented areas which are 
 unaffected by the light. The number of patches present is quite vari- 
 able ; they may be few or very numerous, and usually show a pro- 
 
ANOMALIES OF PIGMENTATION 535 
 
 nounced preference for certain regions, such as the backs of the hands, 
 a very common site, the sides of the neck, the face, and the genital 
 region, but may occur in any region. In the great majority of cases 
 they are distributed symmetrically, as on the backs of both hands, 
 both sides of the neck, and on both sides of the trunk in the same 
 regions. The hair in the white patches is also white, and occasion- 
 ally the scalp shows one or more white tufts of hair, or the brows 
 may be white, as in a case under the author's observation at the pres- 
 ent moment. The malady is usually progressive, the old patches 
 growing larger and new ones appearing, until a large part of the 
 skin, or even all of it, may be depigmented. In a negro between fifty 
 and sixty years of age under the author's observation some years ago, 
 every vestige of the black pigment had disappeared except a half-dollar- 
 sized patch over the malar eminences, a region which is usually the 
 last to lose its pigment in these practically universal cases. In a 
 small minority of cases the patches, after reaching a certain size, no 
 longer enlarge, but remain unaltered indefinitely. There are no sub- 
 jective symptoms. 
 
 Etiology and Pathology. — Little or nothing is known about the 
 direct cause of vitiligo. It is infrequent, but not unknown, in child- 
 hood ; Crocker saw a case in a child four years old. It is most fre- 
 quently seen in the second and third decades of life. Sex exerts little 
 or no influence upon its incidence. It is considerably more common 
 in the dark races than in the white ; according to Forel, it is very 
 common in certain districts of Colombia situated on the north coast, 
 the inhabitants of which are a mixture of negroes, Spaniards, and 
 Indians. In some instances it has been observed to follow nervous 
 disturbances, such as mental shock or injury to a nerve branch. Occa- 
 sionally it follows long-continued local irritation. It is believed by 
 some authors, especially the French, to be occasionally due to syphilis. 
 In some instances heredity seems to have been a predisposing factor. 
 In a considerable proportion of cases it is associated with such dis- 
 eases as Graves's disease, or with other cutaneous diseases, such as 
 alopecia areata, lichen planus, and psoriasis. Its association with the 
 last-named affection is not very infrequent; in an extensive case of in- 
 veterate psoriasis under the author's care for a number of years an 
 extensive vitiligo has developed (Fig. 176). In a small number of 
 instances the author has observed it follow a long-continued pruritus 
 of the scrotum and perineum, the loss of pigment occurring only in the 
 pruritic areas. 
 
 Most pathologists are agreed in regarding vitiligo as a purely 
 pigmentary trouble, but Darier found in a case of vitiligo affecting 
 the prepuce considerable cellular exudate in the upper portion of 
 the cutis at the hyperpigmented margin of the patches. Pigment 
 is entirely absent in the rete of the white areas, but is still present 
 in diminished quantity in the cutis. At the hyperpigmented margin 
 of the depigmented areas both the epidermis and the cutis contain 
 
536 
 
 DISEASES OF THE SKIN 
 
 large quantities of dark-brown or black pigment, which in the former 
 is situated both within and between the epithelial cells, and in the 
 latter is contained in large, round, oval, and stellate cells, most numer- 
 ous in the papillae and around the vessels, follicles, and glands. Darier 
 found the accumulation of pigment in the epidermis most abundant 
 
 Fig. 176. — Vitiligo, following psoriasis; patches of the latter are present in lumbar and gluteal regions. 
 
 in the lower layers of the interpapillary prolongations of the rete, 
 much more so than over the summits of the papillae. 
 
 Diagnosis. — Vitiligo is occasionally mistaken for chloasma, but the 
 latter is an increase of pigment unaccompanied by white patches, is 
 situated upon the face, usually the forehead and cheeks, and in the great 
 majority of cases the patches have ill-defined margins with convex 
 
ANOMALIES OF PIGMENTATION 537 
 
 borders, the reverse of what occurs in the hyperpigmentation about 
 the white patches of vitiligo. 
 
 Vitiligo and tinea versicolor are occasionally confounded, but the 
 latter is almost invariably confined to the covered parts, chiefly the 
 trunk, the brown patches readily scale off upon scraping with the 
 nail, and in the scales thus removed the microsporon furfur, the causa- 
 tive fungus, is readily demonstrated microscopically. 
 
 The patches of circumscribed scleroderma (morphoea) and certain 
 cicatrices may resemble superficially the white areas of vitiligo, but 
 there is always more or less evident structural alteration in these, 
 which is never present in the latter. 
 
 Depigmented areas frequently occur in lepra, but these are more 
 or less decidedly anaesthetic and are accompanied by other symptoms 
 of leprosy. 
 
 The white, pigmentless areas characteristic of partial albinism re- 
 semble those of vitiligo, but the former are congenital and stationary, 
 the latter are acquired and almost always progressive. 
 
 Prognosis and Treatment. — As already noted, the tendency of the 
 patches is to grow larger ; in rare instances, after enlarging for a 
 time they become stationary and remain so indefinitely. When large 
 areas have been deprived of pigment, an apparent cure takes place 
 through loss of contrast between the white areas and the normal or 
 hyperpigmented skin which surrounds them. Very exceptionally the 
 pigment returns and the skin resumes its normal condition. 
 
 Treatment is very unsatisfactory ; as a rule, to which there are very 
 few exceptions, nothing can be done to restore the pigment, but occa- 
 sionally the long-continued administration of arsenic in considerable 
 doses seems to favor its return. Buschke observed a partial return 
 of pigment in the depigmented areas after exposure to the light of 
 the quartz lamp, especially about the follicles, but the restoration was 
 not permanent. 
 
 ALBINISMUS 
 
 Synonyms. — Albinism ; Leukoderma congenita ; Leukopathia con- 
 genita; Achromia congenita. 
 
 Definition. — Congenital absence of pigment in the skin, hair, and 
 choroid, partial or complete. 
 
 Symptoms. — Albinos, as the subjects of albinism are called, have 
 a milky-white skin, white, fine, silky, or yellowish-white, flaxen hair, 
 light blue or pinkish irides, and the pupils show a pink or red reflex 
 from the non-pigmented choroid behind. Owing to the absence of 
 pigment in the structures of the eye, there is usually a more or less 
 pronounced photophobia, the patient partially closing the lids in the 
 endeavor to moderate the light, often accompanied by more or less 
 nystagmus. The defect is a permanent one and shows no change 
 during the subject's lifetime. In many instances the albino is below 
 the normal, both mentally and physically, but there are many excep- 
 tions to this rule. 
 
538 DISEASES OF THE SKIN 
 
 Partial albinism is characterized by congenital absence of pig- 
 ment in one or several circumscribed areas, producing a piebald ap- 
 pearance. In these areas, as in the universal form, the skin is milky- 
 white or pink, and the hair in them, as a rule, but not invariably, is 
 also without pigment. They are of various sizes and shapes, and 
 occasionally are limited to the area of distribution of certain nerves 
 (Lesser, Hutchinson). Occasionally the absence of pigment is con- 
 fined to a circumscribed area in the scalp, giving rise to a white tuft 
 of hair (poliosis circumscripta), a peculiarity frequently inherited; 
 Strieker has recorded an instance in which such a white tuft was 
 present in six generations of one family (quoted by Lesser). In 
 partial albinism the pigmentary structures of the eye are unaffected. 
 As in the universal form, the absence of pigment is permanent; in 
 a few instances the patches have been observed to increase in size. 
 
 Etiology and Pathology. — The only etiological factor of which we 
 have any definite knowledge is heredity, which plays a very promi- 
 nent, if not the most important, role in its production. It is very 
 apt to appear in successive generations of certain families, and its 
 transmission and distribution take place according to Mendelian prin- 
 ciples. Sym has recorded the case of a family of seven children in 
 which every alternate child, beginning with the first, was an albino. 
 It is to a considerable extent a racial peculiarity, negroes being much 
 more liable to it than the white race, the partial form being especially 
 peculiar to them (piebald negroes). Seligman states that there is a 
 race of albinos among the Papuans. It is not confined to man, but 
 also frequently appears in some of the lower animals, a very familiar 
 example being the albino rabbit. 
 
 Apart from the absence of pigment, the skin presents nothing 
 abnormal. 
 
 The condition is irremediable. 
 
 ARGYRIA 
 
 The long-continued internal use of silver nitrate may be followed 
 by a peculiar slate-colored or bluish discoloration of the skin which 
 affects not only the entire cutaneous surface, but the visible mucous 
 membranes as well. While in most cases due to the prolonged inter- 
 nal administration of the drug, it has been in a few instances ob- 
 served after the frequently repeated and long-continued use of solu- 
 tions or the solid stick to the throat ; it may also occur in those who 
 handle silver (trade argyria). The discoloration, while general, is 
 much more noticeable upon exposed parts, owing to the well-known 
 effect of light upon the salts of silver. Since nitrate of silver has been 
 replaced by the bromides in the treatment of epilepsy, argyria is 
 much less frequently seen than formerly. A considerable quantity 
 of the silver salt is necessary to produce the discoloration ; according 
 to Krahmer (quoted by Crocker), the smallest quantity known to have 
 produced it is 450 grains (30.0). According to Branson, the appear- 
 
ANOMALIES OF PIGMENTATION 539 
 
 ance of the discoloration in the skin is preceded by a blue line at the 
 margin of the gums like that seen in plumbism. 
 
 The silver is deposited in the skin at the junction of the rete and 
 the papillary layer of the corium, where it forms a dark-brown or 
 blackish line of varying width. It is also deposited in the membrana 
 propria of the sweat- and sebaceous-glands, and to a slight degree 
 in the ducts of the former, As has been shown by Neumann and 
 Blaschko, it has a special affinity for the elastic fibres, on which it is 
 abundantly deposited. Neither the epithelium of the rete nor that 
 of the glands is affected. 
 
 The condition is irremediable, although a few isolated instances 
 of a lessening of the discoloration and its disappearance have been 
 reported. Yandell noted its disappearance in two syphilitic subjects 
 who had been treated by potassium iodide and mercurial vapor baths. 
 
 TATTOOING 
 
 Synonyms. — Fr., Tatouage ; Ger., Tatowierung. 
 
 In tattooing, various vegetable and mineral pigments are intro- 
 duced into the skin to form designs according to the fancy of the 
 subject or the operator. The chosen design is first pricked into the 
 skin with a needle or bunch of needles, and the coloring-matter imme- 
 diately rubbed into the punctures. The pigments commonly employed 
 are India ink, carbon (usually as gunpowder), and indigo for blue, 
 and vermilion (mercuric sulphide, cinnabar), and carmine for red. 
 The colors are permanent and can only be removed, if at all, with 
 difficulty. Nearly all the methods employed for the removal of tat- 
 tooing have for their aim the production of a superficially destructive 
 inflammation of the skin by which a superficial eschar is formed, 
 which, when it falls, takes with it more or less of the coloring matter 
 and usually leaves a scar. When the pigmented area is small it may 
 be most readily removed by excision. Stelwagon has used electro- 
 lysis with success in small patches ; a small eschar is produced by 
 introducing the needle obliquely into the skin all around the pig- 
 mented area, at intervals of about an eighth of an inch, using a cur- 
 rent of four to five milliamperes. Variot tattoos into the design a 
 strong solution of tannic acid, and then rubs into the surface thus 
 treated nitrate of silver stick; a black eschar is formed, which falls 
 in a week or two, removing the pigment. Brault pricks into the skin 
 a strong solution of zinc chloride, thirty parts in forty of water; 
 this produces a moderate inflammatory reaction with the formation 
 of a crust, which falls after some days, leaving only a slight scar, unless 
 the needle has been introduced too deeply. Ohmann-Dumesnil tat- 
 toos in glycerol of papoid or of caroid in a similar manner. Recently 
 Dubreuilh has recommended shaving off the pigmented area with a 
 razor and applying to the denuded surface Thiersch grafts. Stelwagon 
 has recently employed with moderate success, when the pigment is 
 not too deep, freezing with carbon dioxide snow. 
 
540 DISEASES OF THE SKIN 
 
 A blue pigmentation is frequently produced by explosions of gun- 
 powder which drive unburned powder grains into the skin; a similar 
 discoloration is common in coal-miners as the result of the introduc- 
 tion of small particles of coal through wounds and abrasions. The 
 removal of such pigmentation is only practicable when the area in- 
 volved is limited, and the same methods are applicable as in tattooing. 
 
 A slate-colored discoloration of the skin is occasionally observed 
 in morphine and cocaine habitues, usually on the arms, who use these 
 drugs hypodermaticaliy, the discoloration being produced by metallic 
 salts resulting from corrosion of the needle. In a morphine habitue 
 seen by the author some little time ago, both upper arms were cov- 
 ered with a mottled bluish discoloration with innumerable punctate 
 scars produced by the needle of the syringe. 
 
 TINEA VERSICOLOR 
 
 Synonyms. — Pityriasis versicolor; Chromophytosis ; Dermatomy- 
 cosis furfuracea ; Fr., Pityriasis versicolore ; Ger., Kleienflechte. 
 
 Definition. — Tinea versicolor is a parasitic disease of the skin due 
 to the invasion of the upper layers of the epidermis by a fungus, and 
 is characterized by non-elevated, slightly scaly patches of varying 
 shades of brown. 
 
 Symptoms. — It begins with the appearance of small yellowish-brown 
 macules, situated for the most part about the mouths of the follicles, 
 which slowly enlarge until by the coalescence of the smaller patches 
 a diffuse sheet of discoloration is produced, about the well-defined 
 borders of which are numerous outlying small patches. There is 
 usually a slight, but easily perceptible, amount of scaling except in 
 those with moist or greasy skins, but even in these light scratching 
 with the finger-nail readily loosens the superficial horny layer, which 
 comes off in bran-like scales. The color of the patches varies from a 
 chamois to a dark-brown; in exceptional cases they may be quite 
 black. Occasionally the color is a yellowish-pink owing to the pres- 
 ence of a slight hyperemia. In the dark-skinned races the color of 
 the diseased skin, instead of being darker than normal, is lighter; in 
 the negro the patches are frequently an ashy gray. 
 
 The disease is in the great majority of cases confined to the cov- 
 ered parts of the body, chiefly the upper portion of the trunk, front 
 and back, and the upper arm (Fig. 177). It commonly begins over 
 the sternum and beneath the clavicles anteriorly and over the scapulae 
 posteriorly, spreading thence to other portions of the trunk Not in- 
 frequently it begins in the pubic region and groins as quite small, 
 round, brown macules with a hair in the centre, showing but little 
 tendency to coalesce into sheets as upon the chest. In rare instances 
 the uncovered parts, such as the neck, face, and hands, may be af- 
 fected. 
 
 The extent of surface involved varies greatly ; there may be but 
 a few coin-sized patches upon the chest and back, or the greater part 
 
(4 ■ 
 
 Fig. 177. — Tinea versicolor. 
 
ANOMALIES OF PIGMENTATION 541 
 
 of the trunk and arms may be covered, and in exceptional cases it 
 may extend downward upon the thighs as far as the knees. 
 
 The course of the malady is a very chronic one. It usually spreads 
 slowly and lasts, as a rule, for an indefinite period unless removed by 
 treatment. 
 
 Subjective symptoms are, as a rule, absent; there may, however, 
 be slight itching, especially in those cases in which there is some 
 hyperemia, but rarely enough to occasion the patient any real annoy- 
 ance. 
 
 Tinea versicolor is very common in the tropics, where it is apt 
 to exhibit features not seen in the temperate zones. Castellani has 
 described several varieties of the tropical forms, to the two most im- 
 portant of which, seen in Ceylon and India, he has given the names 
 pityriasis versicolor flava and pityriasis versicolor nigra. In the former, 
 which, unlike the European variety, occurs commonly upon the face 
 as well as the trunk, the patches vary in color from a canary-yellow 
 to a deep orange-yellow; in the latter they are of a dull black color 
 and seldom occur upon the face. Both are, as a rule, seen only in 
 natives, although Europeans are not entirely immune. 
 
 The affection is rarely seen in children, and is infrequent in the 
 old, its greatest incidence being between twenty and forty. It is only 
 very feebly contagious ; examples of its transmission even to those 
 in frequent contact with those who have it are decidedly uncom- 
 mon. It is apparently more frequent in those whose nutrition is 
 much below par than in individuals in good health, although it is often 
 observed in the robust ; it is frequently seen upon the chests of those 
 with pulmonary tuberculosis; indeed, Daguet and Hericourt thought 
 the fungus of tinea versicolor produced pulmonary phthisis, an opin- 
 ion which altogether lacks confirmation. 
 
 Etiology and Pathology. — Tinea versicolor is due to a parasitic 
 fungus, the Microsporon furfur (Fig. 178), discovered by Eichstedt 
 in 1846. The fungus is composed of rather short, irregularly septate, 
 curved, and bent mycelial tubes and spores, the latter arranged in 
 small masses or groups. The mycelia have an average diameter of 
 3 microns, while the spores, which are round and of unequal size, 
 vary from 2 to 5 microns in diameter. The fungus is found in the horny 
 layers of the epidermis, where it exists in great abundance, and in the 
 follicles of the lanugo hairs. Most authors assert that the latter 
 are not invaded, but in sections made from a patch on the back we 
 found numerous spores far down on the walls of a follicle of a lanugo 
 hair which by good fortune we had cut throughout its length. Culti- 
 vation does not readily succeed, but Spietschka, Matzenauer, Gastou 
 and Nicolau, and others have grown it on various media. 
 
 In pityriasis versicolor flava an organism which has been named 
 Microsporon tropicum by Castellani is present. The mycelial tubes 
 of this organism are comparatively thick and show numerous swell- 
 ings and constrictions, while the spores are somewhat larger than 
 
542 DISEASES OF THE SKIN 
 
 those of the Microsporon furfur, 3.50 to 4.50 microns in diameter. 
 Cultivation of this organism has not yet succeeded. Pityriasis versi- 
 color nigra is due to a fungus, the Microsporon Mansoni, a name like- 
 wise given it by Castellani. The mycelia of this fungus, as to size, 
 are much like those of the Microsporon furfur, but contain an abun- 
 dance of dark pigment; the spores are much larger, from 5 to 7.5a 
 microns in diameter. On maltose agar this organism grows rather 
 rapidly, producing hemispherical black colonies. 
 
 According to Unna, who regards the M. furfur as a saprophyte, 
 the cells of the middle and upper layers of the stratum corneum swell 
 up under the action of the fungus and are loosened from the lowest 
 
 Fig. 178. — Microsporon furfur. 
 
 layer, thus giving rise to the slight desquamation which usually ac- 
 companies the disease. No other structural alterations occur in most 
 cases, although Waelsch found a moderate hyperaemia of the super- 
 ficial capillaries, with slight exudation about them in the papillae, 
 especially where the fungus is most abundant. 
 
 Diagnosis. — The yellowish-brown color, the slight branny desqua- 
 mation, the limitation of the discoloration to the covered parts of 
 the skin, and the absence of all inflammatory symptoms distinguish 
 it from those affections with which it is most likely to be confounded, 
 such as chloasma, seborrhoeic dermatitis, and pityriasis rosea. In 
 chloasma, which is far more frequent in women than in men, and is 
 situated as a rule upon the face, there is no desquamation and the 
 pigmentation is in, not on, the skin. In seborrhoeic dermatitis and in 
 pityriasis rosea there is always more or less inflammation, and the 
 
ANOMALIES OF PIGMENTATION 543 
 
 latter runs an acute course. The microscopic examination of scrap- 
 ings from the skin will readily resolve doubtful cases, since the fungus 
 is easily demonstrated when present. 
 
 In making this examination a small quantity of the scales is placed 
 upon a slide with a drop of liquor potassse and covered with a cover- 
 glass just as in examining scales for the ringworm fungus. 
 
 Treatment. — An altogether satisfactory method of treatment is to 
 thoroughly mop the patches night and morning with a solution of 
 sodium hyposulphite in water, one drachm (4.0) to the ounce (32.0), 
 with a half drachm (2.0) of glycerin in each ounce (32.0) of solu- 
 tion, allowing the solution to dry on ; every four or five days the 
 patches should be thoroughly scrubbed with tincture of green soap 
 and hot water, or with some one of the many sulphur soaps which are 
 to be found in the market. The treatment should be continued until 
 every trace of the disease has disappeared. The effectiveness of this 
 solution is somewhat increased by following its application immedi- 
 ately with very dilute acetic acid, which by decomposing the hypo- 
 sulphite sets free nascent sulphurous acid. An ointment of precipi- 
 tated sulphur, one drachm (4.0) to the ounce (32.0), well rubbed in 
 once a day, or tincture of iodine painted over the patches every day 
 or two, is likewise an efficient application. During the treatment the 
 underclothing should be thoroughly disinfected by boiling or dry heat 
 to prevent reinfection. 
 
 While the disease is readily cured by any one of a number of 
 parasiticide ointments and lotions, relapses are frequent, probably be- 
 cause the remedies do not always reach the fungus in the follicles. 
 
CHAPTER XV 
 
 NEW GROWTHS-NEOPLASMATA 
 EPITHELIOMA (MOLLUSCUM) CONTAGIOSUM 
 
 Synonyms. — Molluscum contagiosum ; Molluscum epitheliale ; Mol- 
 luscum sebaceum; Acne varioliformis (Bazin). 
 
 Definition. — A contagious epithelial neoplasm distinguished by 
 small tumors the color of the normal skin, or less frequently pink or 
 red, with a small central opening. 
 
 This infrequent and comparatively trivial affection, which was 
 first described by Bateman, who gave it one of the names by which 
 it is best known, molluscum contagiosum, has attracted an amount 
 of attention apparently out of all proportion to its importance, largely, 
 no doubt, because it is one of the very few examples known of a con- 
 tagious new-growth. 
 
 Symptoms. — The tumors which characterize the affection are 
 usually quite small, varying in size from a large pin-head to a pea, 
 are most frequently the color of the skin, but often become pinkish 
 or bright red as they increase in size, are as a rule sessile, but occasionally 
 pedunculated, and in most instances have a small depressed opening 
 in the centre (Fig. 179). They are quite solid, and when firmly pressed 
 between the thumb and finger a white cheesy material escapes from 
 the central opening ; occasionally this material is extruded spontane- 
 ously in the shape of a small soft spine. In the majority of cases they 
 are situated on the face, often about the eyelids, and upon and in 
 the neighborhood of the genitalia, but they may be found anywhere 
 upon the skin, although very rarely upon the palms and soles. While 
 the above regions are those in which the tumors are most frequently 
 situated, they are occasionally limited to the trunk, as in a very ex- 
 tensive epidemic observed by the author a few years ago. In this 
 epidemic the face was in almost every instance free, although there 
 were scores and hundreds upon the trunk (Fig. 180). The number 
 is commonly small, varying from one or two to a half-dozen or a dozen, 
 but, as noted above, they may be very numerous. Usually discrete, oc- 
 casionally several coalesce, and in rare instances plaques of considerable 
 size may be formed. Not very infrequently the lesions are arranged 
 linearly as the result of the infection of a superficial scratch (Fig. 181). 
 
 In a considerable number of cases as the lesions increase in size 
 they become inflamed, suppurate, and are thus destroyed. While they 
 seldom reach a size much beyond that of a large pea, instances have 
 been observed in which they attained the size of a small orange or of 
 the fist (Laache, Walter Smith). In most cases there are no sub- 
 jective symptoms, but occasionally there is itching, which may be 
 quite severe, as in the epidemic already alluded to. The duration of 
 544 
 
NEW GROWTHS 545 
 
 the lesions is somewhat indefinite ; very commonly they last for sev- 
 eral months, but they may remain without much change for a year, 
 as in a case under the author's observation, or even for several or many 
 years in rare instances. 
 
 In a few cases tumors have been seen upon mucous membranes. 
 Abrahams observed a case in which, in addition to numerous lesions 
 upon the skin, there was a white patch upon the tongue resembling 
 
 :J^" 
 
 Mliillll ■fill IM^^MMfiMWM&gH 
 
 Fig. 179. — Epithelioma (molluscum) contagiosum. 
 
 leucoplakia, in which "molluscum bodies" were found, and the author 
 has recently seen a persistent folliculosis of the lower lid which was 
 almost certainly due to this infection, since it was associated with 
 a small tumor on the edge of the lid. 
 
 Etiology. — The malady is much more frequent in children than in 
 adults, and is in many cases acquired through the bath, especially 
 the Turkish bath, and through the use of infected towels and other 
 articles of the toilet. In a limited number of cases it is due to direct 
 contact with an affected individual, as when it is transmitted to the 
 35 
 
546 
 
 DISEASES OF THE SKIN 
 
 breast of a mother by her nursing infant with lesions on the face. A 
 remarkable example of direct infection by a surgeon with tumors on 
 the hand has been reported recently by Paton, the operation wound 
 having been thus infected in seven cases ; tumors appeared in the 
 scar or its neighborhood after an incubation period of several months. 
 The occurrence of a similar disease in animals, and especially in do- 
 
 ■i 
 
 Fig. 180. — Epithelioma (molluscum) contagiosum. Lesions unusually abundant and accompanied 
 by severe itching. One of several hundred cases occurring in an institution for young men. 
 
 mestic fowls and birds such as the pigeon, has been well established, 
 and a few authentic instances are on record in which the affection has 
 been transmitted from these to human subjects. Sir Jonathan Hutch- 
 inson observed a case in a young woman which was traced to a pet 
 dog, the nature of the tumors in the dog having been established 
 by microscopic examination ; Salzer has reported one contracted from 
 a diseased pigeon, and Jiirgens acquired a tumor on the thumb as the 
 result of accidental inoculation with the avian disease. 
 
NEW GROWTHS 
 
 547 
 
 Pathology. — The well-established occurrence of the malady in 
 epidemics, especially in institutions for children, its occasional acci- 
 dental inoculation, and particularly the successful experimental inocu- 
 lations of Retzius, Pautry (a pupil of Vidal), Haab, Pick, and a 
 number of other experimenters, furnish incontrovertible proof of its 
 infectious nature. The infecting agent, however, has as yet escaped 
 detection. Neisser regards the so-called " molluscum bodies " as pro- 
 tozoan organisms and the cause of the disease, but these have been 
 
 Fig. 181. 
 
 -Epithelioma (molluscum) contagiosum. Note linear arrangement on chest where infection 
 occurred in scratch. 
 
 quite definitely proven to be degenerated epithelial cells. Juliusberg 
 has apparently demonstrated that the virus is a filterable one ; and 
 quite recently Lipschiitz has described a very minute organism which 
 he has found in the degenerated epithelial cells of the tumor, for which 
 he has proposed the name Strongylo plasma hominis, which he be- 
 lieves to be the infecting agent. As the tumors are frequently seen 
 in the region of the genitalia in association with pediculosis pubis, 
 Ehrmann has suggested the possibility that the pediculus serves as the 
 intermediate host for the infecting organism. The incubation period 
 of the infection varies from eight or ten weeks to three or four months 
 
548 
 
 DISEASES OF THE SKIN 
 
 or more, the shorter period having been observed in the experimental 
 inoculations. 
 
 The tumors are epithelial neoplasmata, having their origin in the 
 rete. They are surrounded by a narrow fibrous capsule and are com- 
 posed of a variable number of oval or pyriform lobules made up of 
 epithelial cells, separated by thin fibrous septa, which open into a 
 central cavity opening upon the surface (Fig. 182). The cells in the 
 
 Fig. 182. — Epithelioma (molluscum) contagiosum. Section of a two-lobed tumor. 
 
 periphery of the lobules are of the type found in the basal-cell layer of 
 the rete, while those more centrally situated are oval, and many of 
 them exhibit a peculiar form of degeneration, the so-called " molluscum 
 foodies " or "molluscum corpuscles" (Fig. 183). Three varieties of 
 ■degenerated cell may be distinguished : First and most numerous, large 
 round bodies with double-contoured walls and granular segmented 
 contents, in which the nucleus is eccentric (Figs. 184 and 185) much 
 distorted and frequently flattened out against the inner wall of the 
 cell; second, oval cells lying in the midst of normal epithelium, with thick 
 laminated walls, filled with a felt-like mass of fine short fibres and with 
 a nucleus lying in a cavity at one pole of the cell ; and, third, com- 
 pletely degenerated cells which appear as oval, deeply stained, struc- 
 
NEW GROWTHS 
 
 549 
 
 tureless bodies. In a somewhat extensive study made by the author 
 a few years ago, a previously undescribed form of cell was seen in 
 small numbers. This cell was much smaller than those above de- 
 scribed, was perfectly oval in shape, had a double wall, was filled with 
 a mass of fine fibrils and was without a nucleus. The nature of the 
 degeneration of the epithelium is still a matter of debate. Unna be- 
 lieves it a colloid or hyaline alteration, but White is quite convinced 
 that it is an extraordinary metamorphosis of rete cells into keratin. 
 
 Fig. 183. — Epithelioma (molluscum) contagiosum. A single lobule of tumor; "molluscum bodies" at 
 
 A, B, C. 
 
 Diagnosis. — The little tumors are usually so characteristic in 
 appearance that the affection is readily recognized; it is only when 
 it departs from the ordinary type that errors are likely to occur. 
 When the lesions are red or inflamed and situated upon the upper part 
 of the trunk, with a very small central opening, they may be mistaken 
 on a cursory examination for the papules of acne, but a close examina- 
 tion and the presence of other characteristic tumors will disclose their 
 true nature. 
 
 When situated upon the genitalia, they are sometimes regarded 
 
550 
 
 DISEASES OF THE SKIN 
 
 by the inexperienced as syphilitic, most frequently as condylomata, but 
 even a cursory examination will distinguish them from these lesions. 
 
 When solitary the larger tumors may 
 resemble epithelioma of the rodent ulcer 
 type, as in a case observed by Pringle 
 and in one under the author's care ; in 
 the latter in which the lesion was situ- 
 ated upon the forehead of an elderly 
 woman and was of a year's duration, 
 the error in diagnosis was only discov- 
 ered by the microscopic examination of 
 the sections made from the excised 
 tumor. 
 
 Prognosis. — The affection is usually 
 a trivial one, and responds readily 
 to treatment. As has already been 
 observed, a considerable number of 
 the tumors disappear spontaneously, 
 usually with symptoms of inflammation. 
 
 Treatment. — An effective method of treatment is incision with a 
 small bistoury or tenotome, and expression of the contents. Pure carbolic 
 acid applied with a needle, or with a small pointed stick, such as a wooden 
 
 
 Fig. 184. 
 
 Molluscum bodies." A, double 
 wall surrounding the cell; B, nucleus of the 
 cell flattened against the cell-wall. 
 
 »>*• 
 
 Fig. 185. — Epithelioma (molluscum) contagiosum. A, large "molluscum body" in which is a second. 
 
 tooth-pick, which should be bored into the central opening, will likewise 
 cause their disappearance. The larger growths, particularly the peduncu- 
 lated ones, may be snipped off with a pair of scissors. When the lesions 
 are numerous or are limited to a small region, Stelwagon has found a 
 
NEW GROWTHS 551 
 
 parasiticide ointment, one containing ammoniated mercury or sulphur, 
 twenty to forty grains (1.35 to 2.65) to the ounce (32), effective. As a 
 prophylactic measure, particular attention should be paid to the bath and 
 the towels, which are frequently a source of contagion. 
 
 TRICHOEPITHELIOMA 
 
 Synonyms. — Trichoepithelioma papulosum multiplex; Epithelioma 
 adenoides cysticum ; Benign cystic epithelioma. 
 
 Definition. — A benign epithelial new growth having its origin in 
 the hair-follicles, distinguished by shot- to pea-sized tumors situated in 
 most instances upon the face. 
 
 Under the name epithelioma adenoides cysticum, Brooke, in 1892, 
 reported four cases of a small epithelial neoplasm situated in the face, 
 which he believed identical with the affection described five years before 
 by Jacquet and Barrier as a sweat-gland adenoma {hydradenomes 
 eruptifs), but which Jacquet later proposed to call benign cystic epi- 
 thelioma (epitheliome kystique benin), having failed to demonstrate 
 its relationship with the sweat-glands. About the same time Fordyce 
 reported two cases of a similar kind. Somewhat later Jarisch pro- 
 posed to call the neoplasm trichoepithelioma papulosum multiplex, 
 because of its demonstrable origin in the hair-follicles, a name which 
 seems to the author the most appropriate of the many proposed for 
 the affection. 
 
 Symptoms. — The affection is distinguished by small nodules vary- 
 ing in size from a hemp-seed to a pea, rarely larger, yellowish, yellow- 
 ish-pink, sometimes differing but little from the color of the normal 
 skin, situated for the most part upon the forehead, temples, root of 
 the nose, lids, less frequently upon the lower part of the face, and 
 exceptionally upon the upper and anterior part of the trunk (Fig. 186). 
 Many of the lesions are quite translucent, looking not unlike vesicles, 
 but puncture shows them to be solid ; a considerable number show 
 whitish points looking like milia, others have blackish or slate- 
 colored dots in their centres which are small tufts of vessels in the 
 interior of the nodule ; occasionally the larger ones have a few fine 
 arborescent capillaries coursing over their surface. The number of 
 lesions varies from two or three to scores ; they are usually discrete, 
 but sometimes are arranged in small coalescent groups of two or three. 
 They usually appear first in childhood or youth and new nodules con- 
 tinue to appear from time to time for some years. They at first slowly 
 increase in size, then become stationary and remain with little or no 
 change for an indefinite time. Occasionally, however, ulceration of one 
 or more of the lesions occurs, examples of this having been observed 
 by Hallopeau, White, Jarisch, Stelwagon, and the author. 
 
 Etiology. — Its cause is unknown. It is more frequent in women 
 than in men, and begins as a rule in childhood or early adult life, but 
 is not confined to this period. In many instances it is apparently 
 hereditary, occurring in several members of the same family, as in the 
 cases reported by Brooke and Fordyce. 
 
552 DISEASES OF THE SKIN 
 
 Pathology. — It is an epithelial new-growth, pursuing, as a rule, a 
 benign course, but, as already noted, it at times undergoes ulceration 
 and shows a tendency to recurrence after removal, as was observed 
 in a case under my care some years ago. 
 
 The neoplasm occupies the corium, but little change taking place 
 in the epidermis. It is made up of numerous round, oval, and irregular, 
 sometimes branching, masses of epithelial cells of the columnar type 
 in which are variously sized cyst-like cavities containing granular debris 
 
 1 
 
 I 
 
 -mm 
 
 Fig. i 86. — Trichoepithelioma (benign cystic epithelioma). 
 
 (Fig. 187). About the borders of these masses the cells are frequently 
 arranged radially, presenting a palisade-like appearance as described 
 by Brooke. In places these epithelial masses seem to be connected 
 with the basal layer of the overlying epidermis, but this is a simple 
 fusion of the upward growing mass with the epidermis and not a 
 downgrowth of the basal layer. When followed in a series of sections 
 the connection of the neoplasm with, and its origin in, the hair-follicles 
 can usually be demonstrated. 
 
 Diagnosis. — The affection may be mistaken for syringocystoma, 
 for hidrocystoma, and for adenoma sebaceum. The first of these is 
 situated as a rule upon the trunk, the nodules are usually larger and 
 not translucent like those of trichoepithelioma; at times, however, 
 a biopsy may be necessary to make a positive differential diagnosis. 
 The lesions of hidrocystoma are much more transparent than those of 
 trichoepithelioma and contain fluid. Adenoma sebaceum is limited to 
 
NEW GROWTHS 
 
 553 
 
 the face, occurs in very early life, is frequently of a red or brown-red 
 color, and the lesions are opaque. 
 
 Treatment. — The lesions, when not too numerous, may be removed 
 by excision, by curettement, by freezing with solid carbon dioxide. 
 In one case under the author's care many of the nodules disappeared 
 under X-rav treatment. 
 
 k 
 
 Fig. 187. — Trichoepithelioma. .4, cystic area of columnar epithelium having its origin from the greatly 
 enlarged and distorted hair-follicle, F, to which is attached the erector pili muscle, B. 
 
 SYRINGOCYSTOMA 
 
 Synonyms. — Hydradenomes eruptifs ; Syringocystadenoma ; Epi- 
 theliome kystique benin ; Hemangioendothelioma tuberosum multi- 
 plex; Lymphangioma tuberosum multiplex; Nsevus cystepithelio- 
 matosus. 
 
 In 1887 Jacquet and Darrier described an affection of the skin con- 
 sisting of numbers of discrete papules and tubercles situated on the 
 anterior and upper surface of the trunk and on the inner surface of the 
 arms to which they gave the name hydradenomes eruptifs, believing 
 it to be a neoplasm connected with the sweat-glands ; but some time 
 later Jacquet proposed to call it benign cystic epithelioma (epitheliome 
 kystique benin) since he had failed to establish its relationship to the 
 
554 
 
 DISEASES OF THE SKIN 
 
 sudoriparous apparatus. A small number of similar cases have since 
 been reported under a variety of names, most of which indicate the 
 reporters' belief in the origin of the neoplasm in some part, usually 
 the duct, of the sweat-glands. 
 
 Symptoms. — This rare malady (which is identical with the affec- 
 tion described years ago by Kaposi as lymphangioma tuberosum multi- 
 plex) is characterized by numbers of pin-head to split-pea-sized, slightly 
 elevated, flat, pinkish and yellowish, occasionally brownish, opaque 
 
 Fig. i 88. — Syringocystoma. The author believes syringocystoma to be only a variant of tricho- 
 epithelioma, the duct-like epithelial tracts originating in lateral offshoots, A, A, of the hair-follicle. Note 
 numerous long, branching tracts of columnar epithelium and numerous cysts. 
 
 nodules situated in most instances upon the chest and upper extremi- 
 ties, much less frequently in other regions, such as the face. These 
 are usually present in considerable numbers and are unattended by any 
 subjective symptoms. The patients, as a rule, are young adults and 
 in most cases women. The disease pursues an indefinite course, 
 usually lasting for years, with practically no change in the appearance 
 of the nodules when once fully developed. 
 
 Etiology. — Nothing whatever is known about the causation of the 
 affection. 
 
 Pathology. — By most authors it is regarded as an epithelial neo- 
 
NEW GROWTHS 555 
 
 plasm, having its origin in the ducts of the sweat-glands. Jarisch, 
 Walters and others, however, consider it an endothelioma originating 
 in the endothelium of the blood-vessels. Gassmann and Winkler look 
 upon it as a variety of nsevus and have given it a name indicative 
 of this view, viz., nccvus epitheliomatosus. 
 
 The author on several occasions has expressed the opinion, which he 
 still holds, that it is an epithelial new-growth which has its origin in 
 the slender lateral offshoots often normally present in the lanugo fol- 
 licles ; in other words, it is a variety of trichoepithelioma. The nodules 
 are composed of numerous straight and branching slender tracts of 
 epithelial cells of the columnar type (Fig. 188) situated in the corium, 
 and round or oval cysts with epithelial walls filled with hyaline material 
 
 Fig. 189. — So-called syringocystoma. A, duct-like tracts of cylindrical-celled epithelium growing 
 from lateral portion of hair-follicle. 
 
 frequently presenting a laminated arrangement. The epithelial tracts 
 are usually quite narrow, often not more than two or three rows of cells 
 wide, recalling in appearance the ducts of the sweat-glands, but without 
 a lumen. The cysts, which are frequently of considerable size, are 
 sometimes connected with the epithelial tracts; occasionally they are 
 situated within the follicles. In a case which I had the opportunity 
 to study some years ago, the slender, duct-like tracts of epithelium 
 could be definitely traced to the lanugo follicles and their origin from 
 the lateral epithelial spurs of these clearly demonstrated (Fig. 189). 
 Actual connection of the neoplasm with the sweat-gland ducts was not 
 established in any of the published cases, but was inferred from the 
 somewhat duct-like arrangement of the growth. 
 
 Diagnosis. — The diseases for which syringocystoma may be mis- 
 
556 DISEASES OF THE SKIN 
 
 taken are trichoepithelioma (benign cystic epithelioma) and xanthoma. 
 Trichoepithelioma is situated in most cases upon the face, while 
 syringocystoma occurs upon the trunk; the nodules of the former 
 are usually more or less translucent, while those of the latter are 
 opaque. In xanthoma, which it may at times resemble, the nodules 
 are, as a rule, much more widely distributed, and are of a very decided 
 yellow color. 
 
 Treatment. — The lesions may be destroyed by electrolysis, by caus- 
 tics, preferably trichloracetic acid, and by freezing with carbon dioxide 
 " snow." In a few cases the X-ray has been used successfully. 
 
 ENDOTHELIOMA CUTIS 
 
 Synonyms. — Sarcoma capitis ; Endothelioma capitis ; Multiple be- 
 nign epithelioma of the scalp ; Turban tumors. 
 
 Symptoms. — According to Crocker, the first recorded case of this 
 affection was observed by Morrant Baker, who described it as " wither- 
 ing sarcoma of the scalp." Some twelve or fourteen cases have been 
 reported by Poncet, Kaposi, Spiegler, Ancell, Cohn, Barret, and Du- 
 breuilh and Auche, the last-named describing their case as benign 
 epthelioma of the scalp. 
 
 It occurs as multiple tumors situated upon the scalp, varying in size 
 from a pea to an orange, pale, dark-red or violaceous in color, sessile 
 or pedunculated. They are smooth, hairless, and vary in numbers 
 from a half-dozen to scores, in the latter case forming a bosselated, 
 turban-like mass covering the entire scalp. When the number is large, 
 the surfaces in contact are moist, the epidermis macerated, with 
 occasional superficial ulceration attended by the discharge of a fetid 
 fluid. Occasionally a few similar, but usually much smaller, tumors 
 are also found upon the face, neck, and trunk. The disease lasts indefi- 
 nitely, the tumors slowly increasing in size and numbers, without 
 affecting the patient's general condition. 
 
 Etiology. — The great majority of the cases thus far observed have 
 occurred in women, according to Dubreuilh and Auche, 12 out of 14; 
 and in a considerable proportion an injury of some sort preceded the 
 appearance of the tumors. In a relatively large number it was noted 
 in several members of the same family and in two or three successive 
 generations. 
 
 Pathology. — The nature of the neoplasm is still a matter of some 
 uncertainty. As already noted, the earlier cases were regarded as a 
 form of sarcoma, but this view is no longer entertained. In its pro- 
 longed and benign course and in its histopathology it is quite unlike 
 any of the varieties of that neoplasm. Most recent authors agree with 
 Spiegler in classifying it as an endothelioma. Quite recently, how- 
 ever, Dubreuilh and Auche, who have studied its histopathology with 
 great care and minute detail, expressed the opinion that it is a variety 
 of multiple benign epithelioma having its origin in the epidermis and, 
 
NEW GROWTHS 557 
 
 perhaps the hair-follicles, and resembling much, in the character of the 
 cells which compose it, rodent ulcer. 
 
 According to Spiegler, the tumor is composed of branching and 
 intersecting cylindrical tracts of cells resembling small epithelial cells 
 occupying the derma. About the margin of these tracts, which are 
 surrounded by a fine fibrous capsule and contain numerous small round 
 and oval masses of hyaline material, the cells are of the columnar type 
 and are arranged radially, while those in the interior are round or 
 polygonal. 
 
 Treatment. — The only effective treatment is the removal of the 
 tumors surgically. Possibly the prolonged and careful use of the 
 X-ray or of radium might be of service. 
 
 ADENOMA SEBACEUM 
 
 Synonyms. — Vegetations vasculaires (Rayer) ; Naevi vasculaires et 
 papillaires (Vidal) ; Adenomes sebaces (Balzer et Menetrier). 
 
 Definition. — A small tumor composed of sebaceous-gland tissue, 
 probably congenital in origin, situated for the most part in the face. 
 
 First described by Rayer, Addison, and Gull (Crocker), who, how- 
 ever, did not recognize its nature, it was later described by Balzer in 
 connection with Menetrier and Grandhomme, who gave it the name 
 sebaceous adenoma. A limited number of cases have since been 
 reported by other observers (Pringle, Caspary, Crocker, and others). 
 It is quite certain, however, that not all the cases reported under this 
 or similar titles represent the same affection, some of them being with- 
 out doubt examples of trichoepithelioma (epithelioma adenoides cysti- 
 cum, benign cystic epithelioma). 
 
 Symptoms.— The tumors vary in size from a millet seed to a hemp 
 seed, and occasionally reach the size of a small pea, the larger ones 
 presenting at times a verrucous appearance. They may be the color 
 of the normal skin, yellowish, or, what is commonly the case, a bright 
 red, owing to the presence of minute capilliaries over and around them. 
 They usually occur in considerable numbers, often closely crowded 
 together, chiefly upon the nose, especially the alae, upon the cheeks 
 adjoining, in smaller numbers at the root of the nose, on the forehead 
 and upper lip, and exceptionally as isolated lesions upon the neck and 
 in the scalp. They are in most cases symmetrically distributed on both 
 sides of the nose and on both cheeks, but they may be asymmetrically 
 arranged, as in the cases reported by Crocker and Pollitzer. Telangiec- 
 tases, vascular and pigmented nsevi, and soft fibromata situated on various 
 parts of the body are frequently associated with them. 
 
 Etiology. — The congenital origin of the tumors is quite generally 
 accepted, although they may not appear until puberty or even con- 
 siderably later. In the majority of cases they are first noticed in early 
 childhood, and exceptionally a few lesions may be present at birth. 
 There is commonly a decided increase in their number about the time 
 of puberty. A very considerable proportion of the cases occur in 
 
558 
 
 DISEASES OF THE SKIN 
 
 those who show more or less marked signs of arrested mental develop- 
 ment, in epileptics and imbeciles, Crocker and Colcott Fox stating that 
 the affection is not at all uncommon in idiot asylums in England ; there 
 are notable exceptions, however, to this rule. 
 
 Pathology. — Sebaceous adenoma is a hyperplasia of the sebaceous 
 glands. Pringle found but little change in the epidermis beyond a 
 lengthening of the interpapillary processes of the rete and a corre- 
 sponding increase in the size of the papillae of the corium. The chief 
 change consisted in " an enormous increase in the number and com- 
 
 Fig. 190. — Adenoma sebaceum. 
 
 plexity of the sebaceous glands " (Fig. 190). Balzer thought that some 
 of the tumors in one of his cases had their origin in the sweat-glands, 
 but, as Unna has pointed out, this case was almost certainly not ade- 
 noma sebaceum, but benign cystic epithelioma (epithelioma adenoides 
 cysticum, Brooke). Crocker, believing all the appendages of the skin 
 involved, regarded it as a " pilosebaceous hidradenoma." 
 
 Diagnosis. — The affection with which it is most likely to be con- 
 founded is trichoepithelioma (benign cystic epithelioma), but its earlier 
 appearance, its decided predilection for the nose, the red color of the 
 tumors, and the absence of ulceration which occurs in a certain pro- 
 
NEW GROWTHS 559 
 
 portion of cases of the latter sooner or later, will serve to distinguish 
 it from that disease. When the lesions are few and of the color of 
 the skin, the distinction certainly can only be made by biopsy. 
 
 Prognosis and Treatment. — The tumors are benign growths and 
 after a certain period are likely to remain indefinitely with little altera- 
 tion. Exceptionally some of the nodules undergo spontaneous involu- 
 tion, leaving superficial scars. 
 
 The larger lesions, when not too numerous, may be excised or 
 removed by the curette, but in the majority of cases electrolysis is the 
 most satisfactory method of treatment. A single puncture with a 
 needle attached to the negative pole will usually destroy, in ten to 
 twenty seconds, the small nodules ; the larger ones may require two or 
 three punctures. 
 
 LYMPHANGIOMA 
 
 Definition. — A new-growth composed chiefly of new-formed and 
 enlarged lymphatic channels. 
 
 Under the term " lymphangioma " are included a number of new- 
 growths which differ a good deal in their clinical features. They may 
 occur as well-defined tumors, or, more frequently, as ill-defined diffuse 
 enlargements. All varieties are infrequent, and the tumor forms are 
 decidedly rare and usually concern the surgeon much more than the 
 dermatologist. 
 
 LYMPHANGIOMA CIRCUMSCRIPTUM 
 
 Synonyms. — Lymphangiectodes (Tilbury Fox) ; Lupus lymphati- 
 cus (Hutchinson); Lymphangioma cavernosum ; Lymphangioma 
 capillaire varicosum; Lymphangioma superficiale simplex (Unna). 
 
 Definition. — A disease of the superficial lymphatics characterized 
 by patches of non-inflammatory vesicles. 
 
 Symptoms. — This affection, which was first described by Tilbury 
 Fox under the name lymphangiectodes, is decidedly uncommon. It 
 occurs as one or more patches, usually a single patch, of deep-seated, 
 thick-walled, usually discrete, but often closely aggregated vesicles 
 with transparent contents and a lesser number of opaque, small, wart- 
 like lesions. The patches vary in size from a coin to half the palm, 
 are usually irregular in shape, and may contain from a dozen to fifty 
 or more lesions. The greater number of the vesicles are pearly or 
 bluish in color, but a variable number are red, or purplish, owing 
 to the presence of minute tufts of blood-vessels in their interior; 
 and some of the opaque lesions frequently have arborescent vessels 
 over their surface. If punctured, a clear yellowish fluid escapes which 
 may continue to flow for some hours/or in the cases of the larger lesions 
 for several days. No subjective symptoms of any kind accompany the 
 affection, but occasionally the patches are subject to repeated attacks of 
 an erysipelatous or erysipelatoid inflammation. The malady pursues 
 an extremely chronic course, lasting many years, the patch usually 
 slowly enlarging by the addition of new lesions at its borders. Occa- 
 
560 
 
 DISEASES OF THE SKIN 
 
 
 sionally the contents of some of the vesicles are absorbed and the lesions 
 disappear, often leaving a faint scar and some pigmentation. In a case 
 under the author's observation for some years the patch was situated 
 above the spine of the scapula at first, but in the course of a year or 
 two it had moved to the top of the shoulder, the vesicles on the lower 
 side disappearing while new ones appeared at the upper margin, the 
 site of the old lesions showing slight atrophy of the skin with faint 
 pigmentation. The malady may occur on any portion of the body, but 
 is most common in the region of the neck, the shoulders, and the 
 axilla. In most cases the skin presents no other abnormality, but 
 
 " n 
 
 Fig. 191. — Lymphangioma. Along with the vesicles on the thigh there was dilatation of the deep 
 lymphatics and swelling of the whole extremity. 
 
 occasionally the lymphatic affection is associated with vascular nsevi or 
 varicose veins. In a few instances it has been seen upon the tongue, 
 where it occurs as a patch of closely aggregated pin-head-sized to shot- 
 sized translucent and opaque whitish or red vesicles situated either 
 upon the dorsum or tip of the organ. As in the lesions upon the skin, 
 the red color of some of the vesicles is due to the presence of vascular 
 tufts in them. At the present time the author has under his observation 
 a marked example of this form of the malady, the entire anterior third 
 of the tongue being occupied by a wart-like mass of closely aggregated 
 vesicles. 
 
 Etiology. — The affection in most instances begins in childhood, often 
 within the first few months, and in a few cases it seems to have been 
 
NEW GROWTHS 
 
 561 
 
 congenital ; in the author's case above referred to, it was first noticed 
 in the second or third month after birth. As already noted, it is some- 
 times associated with changes in the blood-vessels. 
 
 Pathology. — Formerly there was considerable difference of opinion 
 as to whether the malady was a simple dilatation of preexisting lymph 
 channels or a formation of new ones, but the studies of Torok have 
 shown quite conclusively that both processes are present. Oval and 
 irregularly shaped cavities (Fig. 192) are found in the papillary and 
 subpapillary portions of the corium which are lined with endothelium 
 
 % 
 
 '■y ■'--. 
 
 f£*. 
 
 Fig. 192. — Lymphangioma circumscriptum. 
 
 and contain small quantities of coagulated lymph and a few leucocytes. 
 Occasionally a moderate exudate of round cells is found about the 
 margins of the more recent cavities. A variable number of dilated 
 and new-formed capillaries are also present in the corium, and in certain 
 cases the vascular element is quite pronounced (hsemolymphangioma). 
 Diagnosis. — The affection, although an uncommon one, usually pre- 
 sents such characteristic features that it is recognized without diffi- 
 culty. The non-inflammatory character of the vesicles, many of which 
 contain small tufts of vessels, plainly visible to the naked eye, giving 
 them a red or purple color, the absence of any subjective symptoms, 
 36 
 
562 DISEASES OF THE SKIN 
 
 and its occurrence for the most part in childhood are the features 
 which distinguish it from other vesicular affections. 
 
 Prognosis. — The duration of the malady is indefinite and the 
 patches usually slowly enlarge. As already observed, the malady is 
 occasionally subject to repeated attacks of erysipelatoid inflammation. 
 
 Treatment. — When moderate in extent, the patch may be excised, 
 but care should be taken to remove every portion of it, otherwise a 
 recurrence is likely at the border of the scar ; it may also be destroyed 
 by caustics or by the galvanocautery. 'If the patch is small and the 
 lesions few, it may be removed by electrolysis. The X-ray, however, 
 is probably the remedy of choice, a number of instances of its success- 
 ful employment having been reported (Engman and Mook, Ormsby, 
 Dore, and the author). 
 
 Closely related to the foregoing in most of its clinical features is 
 a variety of lymphangioma in which the cutaneous affection is asso- 
 ciated with dilatation of the deep lymphatic channels, the '/lymphan- 
 gioma superiiciale of Unna. In this variety there are a variable num- 
 ber of deep-seated pin-head to pea-sized and occasionally considerably 
 larger vesicles scattered irregularly over a swollen area, with or with- 
 out more or less thickening of the skin. The regions most frequently 
 affected are the lower extremity and the genitalia. In a case of this kind 
 recently under the author's care the whole right thigh and leg were 
 markedly swollen, and numerous pin-head to pea-sized vesicles were 
 scattered over the inner surface of the thigh and down the leg, the 
 latter having appeared some time after the swelling (Fig. 191) . On several 
 occasions the patient punctured some of the vesicles, and an abundant 
 flow of lymph followed, which lasted for some days. When it occurs 
 upon the vulva, there is usually a marked enlargement of the whole 
 vulvar region, which is covered with numerous vesicles. 
 
 Dilatation of lymph channels, lymphangiectasis, occasionally occurs 
 as a congenital affection, giving rise to diffuse swelling or enlargement 
 of limited regions such as the lip (macro cheilia) or the tongue (macro- 
 glossia). In these, as in the affection already considered, there may 
 be scattered vesicles of the type previously described, but usually in 
 very much smaller numbers. It also occurs as an acquired affection, 
 following injury (Elliot, Besnier), or repeated attacks of erysipelatous 
 dermatitis, or infection ( filiariasis) , as in elephantiasis. In the last 
 there is not only dilatation of the lymphatics, but more or less extensive 
 hypertrophy of the hypoderm. 
 
 FIBROMA 
 
 Definition. — A benign new-growth composed of fibrous connective 
 tissue, occurring as variously sized soft or hard tumors. 
 
 Two varieties of fibroma are recognized, soft fibroma (fibroma 
 molle) and hard fibroma (fibroma durum), which differ considerably 
 in their clinical aspects and in their histopathology. Both forms are 
 infrequent, comprising, according to the statistics of the American 
 
NEW GROWTHS 
 
 563 
 
 Dermatological Association, something less than one-tenth of one per 
 cent, of all diseases of the skin. Of the two varieties the soft is much 
 the more frequent. 
 
 FIBROMA MOLLUSCUM 
 
 Synonyms. — Molluscum fibrosum ; Molluscum simplex ; Mollus- 
 cum pendulum; Soft fibroma; Neurofibroma; v. Recklinghausen's 
 disease. 
 
 Symptoms. — This variety of fibroma is characterized by soft tumors 
 
 
 ..\; ; ; ";;. 
 
 Fig. 193. — Fibroma molluscum. 
 
 varying in size from a small pea to an orange, or in exceptional cases 
 as large as an infant's head (Fig. 193). The small ones are often quite 
 deep-seated, hemispherical and sessile, while the larger ones are round, 
 cylindrical, or pear-shaped, pendulous and frequently provided with a 
 narrow pedicle. They are most frequently the color of the skin, but 
 are often pinkish or bluish in their early stages and when old are apt 
 
564 DISEASES OF THE SKIN 
 
 to be more or less pigmented. The skin over them is as a rule normal 
 in appearance, but over the large tumors the mouths of the ducts of 
 the sebaceous glands are often patulous and occasionally filled with 
 plugs of sebum, forming comedones of unusual size. The number 
 varies from a single one, which is unusual, to hundreds and even 
 thousands, Hashimoto having observed a case in which there were 
 4500 (quoted by Joseph, Mracek's *' Handbuch ") ; as a rule they exist 
 in considerable numbers. While they may appear on any portion of 
 the skin they are apt to be most abundant upon the trunk, more so 
 upon the anterior than upon the posterior surface, are common on the 
 scalp, less so upon the extremities, and rare upon the palms and soles. 
 After reaching a certain size they may show but little change for an 
 indefinite period, but in some of them the contents are gradually 
 absorbed, so that after a time nothing is left but an apparently empty, 
 flaccid sac. Occasionally as the consequence of pressure, friction, or 
 other mechanical injury or as the result of overdistention from rapid 
 growth, a tumor may inflame, ulcerate, or become gangrenous and 
 be thus destroyed. Patches of pigment, varying in hue from a light 
 sepia to black, for the most part small and freckle-like, but occasion- 
 ally coin- to palm-sized, accompany the tumors in a certain proportion 
 of cases; telangiectases and hairy nsevi are likewise occasionally pres- 
 ent. Instead of numerous small or moderate-sized tumors, there may 
 be but one or a few large ones, forming pendulous masses, situated 
 most frequently upon the scalp, sides of the neck, the axillae, the but- 
 tocks, the thighs, or the labia (fibroma pendulum). At times these 
 tumors occur as large pendulous folds of skin, a condition to which the 
 term " dermatolysis " is sometimes improperly applied. 
 
 In rare cases tumors like those upon the skin are present upon the 
 mucous membranes of the cheeks, the tongue, the palate, and the 
 rectum. 
 
 The soft, small, flaccid tumors, usually with slender pedicle, com- 
 mon upon the trunk of elderly individuals, known as acrochordon, 
 soft warts, " vermes chamues" are commonly regarded as a form 
 of soft fibroma closely related to fibroma molluscum, if not identical 
 with it, but these lesions are most probably soft nsevi. 
 
 Fibroma durum, hard fibroma, desmoid, is a rare new-growth of the 
 skin much less common than fibroma molluscum. It occurs as a small, 
 very firm, deep-seated, usually solitary, but occasionally multiple hemi- 
 spherical tumor, pink, or the color of the skin. It usually grows very 
 slowly, seldom attains any considerable size, and after reaching a certain 
 stage of development may remain without much change for an indefinite 
 period. It is unaccompanied by any subjective symptoms. 
 
 Etiology. — As in a certain proportion of cases it, especially the soft 
 form, has been observed in two or more successive generations and in 
 several members of the same family (Virchow, Atkinson, Octerlony), it 
 seems probable that heredity plays some role in its production. In the 
 
NEW GROWTHS 565 
 
 majority of cases it begins in early childhood and may be congenital; 
 exceptionally it does not appear until puberty or after, this being the case 
 more particularly in fibroma pendulum. Tn a few instances traumatism 
 seems to have been a predisposing factor (Taylor). Hebra called attention 
 to the fact that it is frequently associated with defective bodily and mental 
 development, an observation amply corroborated by subsequent observ- 
 ers, but there are numerous exceptions to this rule. Some years ago 
 Brickner called attention to a variety to which he gave the name 
 fibroma molluscum gravidarum, in which the tumors appeared only 
 during pregnancy and disappeared upon its termination. Hirst has 
 reported a case of this kind which the author had the opportunity of 
 seeing in the University Hospital 
 
 Pathology. — According to von Recklinghausen, molluscum fibrosum 
 is a neurofibromatosis, the tumors having their origin in the connective 
 tissue of the sheaths of the nerves ; with this view Unna, Darrier and 
 other recent observers are in full accord. The epidermis shows no 
 change beyond the disappearance of the interpapillary pegs of the 
 rete, the result of the pressure from below of the growing tumor. 
 The corium, except a narrow zone immediately beneath the epidermis, 
 is entirely replaced by a finely fibrous tissue containing numerous 
 nuclei. In the old lesions the centre of the tumor is quite compact, 
 while the peripheral portion forms a loose, fibrous meshwork. Unna 
 has called attention to a peculiar variety of " mastzell " present which 
 is much larger than the ordinary variety and is surrounded by a wide, 
 structureless halo. Elastic fibres are not present in the tumor, but are 
 well maintained about its borders. 
 
 Hard fibroma is composed of bundles of collagenous tissue contain- 
 ing few cells, which cross one another at all angles. Very few vessels 
 are present in the growth, and the elastic tissue has almost entirely 
 disappeared. 
 
 Diagnosis. — The picture presented by the ordinary case of fibroma 
 molluscum is so strikng that it is usually recognized at once. The 
 tumors may at times be mistaken for lipoma, but this neoplasm is 
 usually lobulated, elastic, never pedunculated, and seldom exists in 
 such numbers as fibroma. The very small lesions may be mistaken for 
 epithelioma (molluscum) contagiosum, but are readily distinguished 
 from that affection by their softer consistency and by the absence of a 
 central opening. From sarcomatosis the affection is to be distin- 
 guished by the much greater softness of the tumors and their benign 
 course. 
 
 Prognosis. — The affection usually continues indefinitely, lasting dur- 
 ing the patient's lifetime, but in the great majority of cases in no way 
 impairing his general health. When the tumors are large and situated 
 about the face, scalp, or the genitalia they may cause considerable 
 disfigurement or inconvenience. As has already been noted, they may 
 become inflamed and ulcerate, and in exceptional cases the ulceration 
 
566 
 
 DISEASES OF THE SKIN 
 
 terminates in malignant disease. Garre asserts that at least twelve 
 per cent, become sarcomatous. 
 
 Treatment. — Whitehouse has reported a case in which a consider- 
 able number of the tumors disappeared while the patient was taking- 
 arsenic, but as some of the tumors at times disappear spontaneously 
 it may be doubted whether the improvement was due to the remedy. 
 The tumors may be removed by excision, which is the method of choice 
 when they are of large size, and by the galvanocautery loop, this last 
 being a ready and effective method of disposing of those of moderate 
 size with a pedicle. Care should be taken to remove the entire tumor, 
 otherwise it is likely to return. When they are very numerous, only 
 the largest or those which incommode the patient should be removed. 
 
 KELOID 
 
 Synonyms. — Cheloid; Keloid of Alibert; Fr., Chelo'ide. 
 
 Definition.— A benign connective-tissue new-growth situated in 
 the corium, characterized by smooth pink or red rounded or flat, fre- 
 quently scar-like tumors, in most, if not in all, cases following 
 traumatism. 
 
 Symptoms. — Alibert, who first gave the affection the name " keloid,*' 
 divided it into two varieties — spontaneous or true keloid and cica- 
 
 Fig. 194- — Keloid. 
 
 tricial or false keloid — a distinction still maintained by many authors, 
 although it is extremely probable that there is no such thing as spon- 
 taneous keloid. 
 
 It usually begins as a small pinkish or red firm nodule rather deeply 
 embedded in the skin, which slowly increases in size, forming a button- 
 like, rounded tumor (Fig. 194) or more frequently an irregularly shaped, 
 well-circumscribed, more or less elevated plaque with a number of 
 claw-like processes extending from its borders, and it is to these that the 
 affection owes its name "keloid" (from x 1 )* 7 }* a claw). In most in- 
 stances the tumors are of moderate size, varying from a pea to a nut, 
 
NEW GROWTHS 
 
 567 
 
 but occasionally they reach much more extensive proportions, as large 
 as a small orange or as the fist or even larger. The surface is usually 
 smooth, pink or red in color, sometimes violaceous owing to the pres- 
 ence of fine arborescent vessels. In many cases there are no subjective 
 symptoms, but not very infrequently the tumors are decidedly sensitive 
 to pressure and in a few cases are the seat of more or less spontaneous 
 pain, which may be severe enough at times to demand measures for its 
 relief. The number of lesions is a variable one : often there is but a 
 single tumor; not uncommonly they are multiple and exceptionally 
 numerous (Fig. 195). When they are multple they sometimes exhibit 
 
 Fig. 195. — Keloid. (Negro.) 
 
 a certain amount of symmetry in their distribution, a feature which 
 is regarded by many authors as characteristic of the so-called " spon- 
 taneous keloid." While the tumors may occur in any region, there 
 are certain localities for which they exhibit a well-marked predilection ; 
 these are, in the order of frequency, the sternum, where they usually 
 present the characteristic claw-like configuration, the lobes of the 
 ears, where they are apt to occur as the sequel of piercing of the ears ; 
 the nape of the neck, and the back. 
 
 Cicatricial keloid, or the so-called " false keloid," does not present 
 any symptoms by which it may be distinguished from that which is 
 supposed to arise spontaneously, except that it develops at the site of 
 
568 
 
 DISEASES OF THE SKIN 
 
 a scar. A distinction must be made, however, between this form 
 and the hypertrophic scar, such as develops so frequently in the scars 
 of burns (Figs. 196 and 197). The former, although beginning in a 
 scar, does not remain limited to it, but extends into the neighboring 
 sound skin, while the latter remains strictly limited to the cicatricial 
 tissue. 
 
 Etiology. — The primary cause of keloid is unknown. Age and sex 
 have little or no effect upon its incidence, although it is much more 
 frequent in men than in women, because the former are much more 
 exposed to injuries of the skin than the latter. Heredity seems at times 
 
 > 
 
 m 
 
 Fig. 196. — Hypertrophic scar (scar keloid) following a burn. 
 
 to have some influence in predisposing to it, since it is occasionally 
 observed in two or more members of the same family. Race exercises 
 a decided predisposing effect, the negro being much more liable to it 
 than the Caucasian. In the vast majority of cases, if not in all, it 
 follows an injury to the skin, beginning in a scar the consequence 
 of a punctured or incised wound or the result of diseases of the skin, 
 such as acne or the pustular syphiloderm. That a special predisposi- 
 tion is necessary, however, to call it forth is quite evident, since every 
 individual suffers from numerous injuries to his skin and has scars in 
 consequence, while very few suffer from keloid. Since very trivial 
 injuries may be sufficient in predisposed individuals to produce it, it 
 
NEW GROWTHS 
 
 569 
 
 is more than probable that the so-called spontaneous form follows in- 
 juries so slight that they escape notice. Crocker saw a most extensive 
 case follow prickly heat. That some special quality in the irritant 
 may be necessary is suggested by the very remarkable case observed 
 by Welander (quoted by Unna, " Histopathology of the Diseases of 
 the Skin") in which keloid developed in a tattooed figure in the red 
 portions only, while those in which blue pigment was used escaped. 
 
 FlG. 197. — Keloid, back (followed burn with a cupping-glass). 
 
 Pathology. — Keloid is essentially a fibroma having its origin in the 
 deeper portions of the corium ; and there is no demonstrable histological 
 difference between the true and the so-called false or cicatrical forms. 
 It is composed of bundles of fibres which for the most part run parallel 
 with the long axis of the tumor, and in its early stages contains a 
 considerable number of small round cells most abundant in the neigh- 
 borhood of the vessels, which extend along these sometimes, according 
 to Warren and Crocker, some distance bevond the visible limits of 
 
570 DISEASES OF THE SKIN 
 
 the growth. The older lesions are poor in cells and their vessels 
 are markedly atrophied, even to the point of complete disappearance 
 at times. Neither follicles, glands, nor elastic tissue is as a rule present 
 in the tumor, the two former having been pushed to one side. Accord- 
 ing to Warren, Kaposi, Vidal, Joseph, and others, who maintain a dis- 
 tinction between spontaneous and scar keloid, the papillary body and the 
 corresponding interpapillary prolongations of the rete are present in the 
 former, absent in the latter, but the observations of Babes, Crocker, 
 and others have shown quite conclusively that this is by no means always 
 the case, the reverse sometimes being true. 
 
 Diagnosis. — The peculiar scar-like appearance of the growth, its 
 frequent situation over the sternum, and its usual association with 
 cicatrices are features which enable it to be easily recognized. From 
 the hypertrophic scar it may be distinguished by its involvement of the 
 neighboring sound skin. 
 
 Prognosis.— As a rule to which there are very few exceptions, keloid 
 continues indefinitely, but after reaching a certain stage of develop- 
 ment it frequently remains stationary. In rare cases it exhibits a 
 tendency to spontaneous involution and may eventually disappear. 
 Hypertrophic scars, after a duration of two or three years, usually 
 flatten down considerably, and may eventually assume the characters 
 of the ordinary cicatrix. 
 
 Treatment. — Operative treatment is rarely, if ever, to be advised, 
 since with rare exceptions it only results in an increase in the size 
 of the tumor when it returns, as it almost invariably does. Electrolysis 
 has been used with some success in a limited number of cases, Crocker 
 regarding it as one of the most useful methods of treatment. Vidal 
 recommended repeated linear scarification followed by the application 
 of antiseptic dressings. In small growths the author has seen improve- 
 ment follow the continued application of lead plaster diluted somewhat 
 with petrolatum, at the same time applying moderate pressure with 
 a roller bandage. Crocker and Pernet obtained a certain amount of 
 improvement from injections of a 10 per cent, solution of thiosinamin 
 in alcohol or in equal parts of water and glycerin, made into the tumor, 
 giving ten to twenty minims at each injection. The most useful 
 remedy is the X-ray, Pusey, Ormsby and others reporting not only 
 improvement, but cure in a number of instances ; and the author has 
 in a small number of cases under his own observation noted a decided 
 diminution in the size of the growth after such treatment. 
 
 CICATRIX 
 
 Synonyms. — Scar; Fr., Cicatrice; Ger., Narbe. 
 
 Definition. — A connective-tissue new-growth replacing a loss of 
 substance involving the corium. 
 
 Symptoms. — Scars are perhaps the commonest of all the lesions 
 
NEW GROWTHS 571 
 
 met with upon the skin, indeed there are few, if any, adult individuals 
 who cannot show more than one. They may be found on any part of 
 the body and vary greatly in their appearance. They may be round, 
 linear, or irregular in shape ; they may be thin, smooth, soft, and pliable, 
 or thick, uneven, hard, and unyielding ; they may be elevated, depressed, 
 or level with the sound skin. Fresh scars are usually red or violaceous 
 in color, while old ones are white, often whiter than normal skin ; less 
 frequently they are livid or pigmented. The thicker scars often ex- 
 hibit a more or less marked tendency to contraction, and in consequence 
 may give rise to deformity and to interference with the functions of 
 movable parts. They vary much in their characteristics according 
 to their causes : as is well known, the scars of burns are especially prone 
 to contraction. In the face contracting scars frequently cause ectro- 
 pion and distortion of the mouth ; and upon the neck, when extensive, 
 they may pull the chin down upon the chest and interfere with the 
 free movement of the lower jaw. The scars of syphilis are usually 
 quite round, soft, and pliable, are often more or less pigmented, espe- 
 cially about their borders, while those which result from tuberculous 
 ulceration are irregular in shape, uneven, and at times quite hard. A 
 knowledge of these peculiarities is frequently of much service in 
 diagnosis. 
 
 Etiology. — Scars are in most cases the result of such injury or 
 ulcerative disease as produces a break in the continuity of the skin 
 involving the corium ; they may also follow the absorption of inflam- 
 matory or other products deposited in the skin without any external 
 break, as frequently happens in certain of the lesions of acne and 
 syphilis. 
 
 Pathology. — The scar is the product of a reparative process ; be- 
 ginning as granulation tissue, it varies much in its histological features 
 according to its age. Recent scars are made up of fibrous connective 
 tissue in which are many leucocytes, young connective-tissue cells, 
 and numerous new-formed capillaries. Old lesions contain but few 
 cells and are composed chiefly of bundles of collagen fibres with some 
 new-formed delicate elastic-tissue fibres. The epidermis is thinner 
 than normal and its lower margin, instead of presenting the usual 
 markedly undulatory line, is quite straight or only very slightly 
 wavy owing to the absence of the papillary body of the corium. While 
 it is commonly stated that the latter is never reproduced in scars, 
 this is only measurably true, since in many scars small papillae are 
 present. Hair-follicles and glands are absent. 
 
 Treatment. — Scars may require treatment for cosmetic reasons or 
 because they interfere with important functions. Small lesions may 
 sometimes be sucessfully dealt with by electrolysis, by injections of 
 thiosinamin, or occasionally by massage. The X-ray occasionally 
 renders good service in the treatment of unsightly scars, but should be 
 used with caution, lest a radiodermatitis be excited, which is apt to be 
 followed by disfiguring telangiectases. Mercier has very recently 
 
572 
 
 DISEASES OF THE SKIN 
 
 reported excellent results from the Rontgen ray in the treatment of 
 cicatrices interfering with the movements of the fingers, hand, and 
 arm, following wounds ; eight to twelve treatments were givem In 
 many cases excision is the remedy of choice, closing the defect, when 
 it is considerable, by skin grafting or by the transplantation of skin 
 from the neighboring parts. 
 
 GRANULOMA ANNULARE 
 
 Synonyms. — Ringed eruption (Colcott Fox) ; Eruption chronique 
 circinee de la main (Dubreuilh) ; Lichen annularis (Galloway) ; Be- 
 nign sarcoid (Galewski) ; Neoplasie circinee et nodulaire (Brocq) ; 
 Erythemato-sclerose du dos des mains (Audry) ; Stereo-phlogose nodu- 
 laire et circinee (Pellier) ; Helodermia simplex et annularis (Vomer) ; 
 Erythema elevatum diutinum (Crocker). 
 
 Definition. — A benign new-growth occurring in small annular 
 
 Fig. 198. — Granuloma annulare. 
 
 and crescentic patches situated principally upon the extremities, most 
 frequently upon the hands. 
 
 The credit of having first recognized this affection belongs to 
 Colcott Fox, who, in 1895, reported a case under the name " ringed 
 eruption." Radcliffe Crocker a year before had reported a case as 
 one of lupus erythematosus resembling lichen planus, but, after seeing 
 other cases, recognized his error and suggested for the affection the 
 name granuloma annulare, which has been generally accepted by 
 English and American dermatologists. 
 
NEW GROWTHS 
 
 573 
 
 Symptoms.— It is distinguished by one or more annular or crescen- 
 tic patches from a half to an inch or more in diameter, composed of 
 firm, flat, hemp-seed-sized or larger whitish, pinkish, occasionally vio- 
 laceous, nodules situated most frequently upon the hands (Fig. 198), 
 usually on the backs of the fingers about the joints, less commonly 
 upon the tops of the feet, and exceptionally upon the trunk. The skin 
 in the centre of the patches may be quite normal in appearance, or 
 somewhat depressed and atrophic. There is often but a single patch, 
 but two or three are not uncommon, and exceptionally there may be 
 
 Fig. 199. — Granuloma annulare. C, cellular exudate made up of cells chiefly of connective-tissue type; 
 D, central area of necrosis; 5, sweat-duct. 
 
 as many as a dozen or twenty. In a case under the author's obser- 
 vation, occurring in a child 3 years old, there were six or eight dime- 
 sized rings on the arms, abdomen, and legs. The affection often appears 
 quite suddenly without any premonitory signs, and when once fully 
 developed may persist indefinitely. In rare instances, instead of annu- 
 lar patches, the disease occurs as firm, flat, pinkish, pea-sized nodules 
 or finger-nail-sized plaques, a form described by Crocker as erythema 
 elevatum diutinum. In a case of this kind seen by the author some 
 years ago there w r ere three small, oval and irregularly shaped plaques 
 the size of a finger nail, one upon the side of the neck, another upon 
 
574 DISEASES OF THE SKIN 
 
 the back of the hand, and a third upon the side of the leg. Occasionally 
 both annular patches and flat plaques or nodules may be present at the 
 same time, as in the author's first case ; or it may begin with nodules 
 which by central involution and simultaneous peripheral extension 
 become ring-shaped and crescentic patches, as in the case reported 
 by Wende. 
 
 No subjective symptoms of any kind accompany the affection, as 
 a rule. 
 
 Etiology and Pathology. — The malady is seen chiefly, but not ex- 
 clusively, in children and young adults. Graham Little, who has made 
 an extensive study of it based upon fifty cases, is strongly of the 
 opinion that it is in some way closely related to tuberculosis, but the 
 evidence for this is, to say the least, not convincing, and the author's 
 experience is altogether against it. 
 
 The histopathology is quite characteristic. The epidermis is but 
 little or not at all altered. Beginnng in the subpapillary portion of 
 the corium and extending down to the hypoderm there is a fairly well- 
 circumscribed cellular exudate composed largely of spindle cells of 
 the connective-tissue type, lymphoid cells, and a few large epithelioid 
 cells, densest about the vessels, and the coil-glands and their ducts. 
 The most striking and characteristic feature is an area of necrosis 
 (Fig. 199) occupying the centre of the exudate in which every trace 
 of cellular structure has disappeared and about the borders of which 
 the cells are arranged in radiating lines. This necrotic area is small in 
 recent lesions, but much more extensive in the older ones. 
 
 Examination of sections made from the plaque on the back of the 
 hand of the case of erythema elevatum diutinum referred to above, 
 showed the same histological features characteristic of granuloma 
 annulare and left no room for doubt in the author's mind that the two 
 maladies are identical. 
 
 Diagnosis. — The frequent localization on the hands, particularly 
 about the joints of the fingers, the firmness of the nodules, the ringed 
 arrangement of the patches, the youth of the patient, the absence of 
 subjective symptoms of any sort, and the indefinite duration of the 
 lesions are distinctive features. It may be mistaken for the annular 
 form of lichen planus, but the nodules never present the peculiar 
 flat tops with occasional umbilication seen in that affection and are 
 decidedly harder. 
 
 Prognosis and Treatment. — When left to itself it may continue for 
 many months or even indefinitely ; in a very considerable proportion of 
 cases, however, the nodules disappear spontaneously, leaving neither 
 pigmentation nor scarring. 
 
 Jadassohn (quoted by Little) thought the internal adminstration 
 of arsenic exercised a beneficial effect upon the disease. Graham Little 
 found salicylic acid in ointment or plaster and ointments of ichthyol 
 and resorcin satisfactory. The author has found X-ray treatment the 
 most satisfactory method of dealing with the affection. 
 
NEW GROWTHS 575 
 
 PARAFFINOMA 
 
 Definition. — A tumor-like formation due to the injection of paraffin 
 into the skin. 
 
 Symptoms. — Since the introduction of paraffin prosthesis by Ger- 
 suny in 1900, injections of paraffin have been largely employed for the 
 correction or removal of facial deformities and blemishes. In a con- 
 siderable number of instances these injections have been followed, after 
 an interval varying from some months to one or two years, by the 
 formation of firm tumor-like masses at the site of the injection. These 
 vary in size from a small to a large nut, are smooth or nodular, and 
 are red or violaceous, often with dilated capillaries over their surface. 
 They are usually quite firm and at times bear some resemblance to 
 keloid. They are situated usually about the angles of the mouth, 
 beneath the eyes, and about the alse of the nose, regions in which the 
 injections have been made to fill up hollows or smooth out wrinkles. 
 At times there is considerable oedema of the surrounding parts, espe- 
 cially when they are situated in the neighborhood of the eyes. The 
 amount of deformity produced is frequently considerable, but they are 
 not accompanied by any annoying or painful subjective symptoms. 
 
 Pathology. — According to Heidingsfeld, who has made a careful 
 study of the histopathology of two cases, the paraffin acts as a foreign 
 body, setting up an inflammatory reaction, with exudation of leucocytes 
 and the formation of many giant-cells. The paraffin gradually disap- 
 pears and is replaced by fibrous connective tissue which presents a 
 honeycombed appearance, the cavities representing the spaces formerly 
 filled by the paraffin. 
 
 Diagnosis. — Paraffinoma may at times resemble keloid or lupus 
 vulgaris, but is usually much less firm than the former and does not 
 present the small brownish-red nodules with ulceration which distin- 
 guish the latter. Due regard being paid to the history, there is usually 
 but little difficulty in recognizing the nature of the tumors. 
 
 Treatment. — The mass should be thoroughly removed by excision, 
 taking especial care to remove all the paraffin to prevent recurrences. 
 The excision should be followed by X-ray treatment. 
 
 LIPOMA 
 
 Synonym. — Fatty tumor. 
 
 Definition. — A new-growth composed of fat-tissue characterized by 
 soft, usually somewhat elastic tumors of variable size. 
 
 Symptoms. — Lipoma may occur as a solitary growth or as multiple 
 tumors which are usually rather soft and elastic, sessile and indis- 
 tinctly lobulated. They grow slowly and reach a size varying from a 
 nut to the fist or even larger. The large tumors are commonly solitary 
 and occasionally attached by a pedicle ; the multiple growths vary in 
 size from a small nut to an egg, but rarely reach the dimensions 
 attained by the single tumors. Except in regions where they are 
 exposed to constant pressure or friction they are painless and freely 
 
576 DISEASES OF THE SKIN 
 
 movable with the skin. The skin over them is in most cases normal, 
 although in old lesions it may be somewhat pigmented. As a rule, 
 after reaching a certain size they cease to grow, but in exceptional 
 cases they may continue to enlarge indefinitely and eventually reach 
 a size of several pounds. Instead of occurring as well-defined tumors, 
 they may assume the shape of ill-defined diffuse infiltrations some- 
 times of considerable extent, the result of the fusion of a number of 
 smaller masses, a notable example of this form being the so-called 
 "fatty neck" (Fig. 200). Although fatty tumors may occur on any 
 portion of the body, the most frequent site is the back, the least fre- 
 quent the scalp. 
 
 In this connection mention may be made of the affection first 
 
 Fig. 200. — Lipoma. 
 
 described by Dercum as " adiposa dolorosa," in which there are irregu- 
 lar fatty deposits distributed over various parts of the body, sometimes 
 symmetrically with marked debility, alterations of tactile and tem- 
 perature sense, tenderness, and pain. In most instances the patients 
 have been women in middle life. 
 
 Etiology.— Lipoma is a disease of adults, occurring in most in- 
 stances in middle-aged individuals, although a few examples of its 
 congenital occurrence have been observed (Jacobi). Women are much 
 more frequently affected than men, but the diffuse form is confined 
 almost exclusively to the latter. In a few instances it seems to have 
 been inherited (Murchison, Blaschko). 
 
 Pathology. — The tumors are composed of fat-tissue which does 
 
NEW GROWTHS 577 
 
 not differ essentially from that of the subcutaneous fat, although the 
 cells are somewhat larger. They are surrounded by a fibrous capsule 
 and divided into lobules by fibrous septa which contain the blood- 
 vessels which supply the tumor. Occasionally fibrous tissue is present 
 in considerable amount (fibrolipoma) and may contain calcareous or 
 osseous deposits. In a small number of cases of multiple lipoma and 
 in two cases of adiposa dolorosa, alterations of the thyroid gland were 
 observed (in the latter, induration and calcification). 
 
 Diagnosis. — The features which distinguish them from other neo- 
 plasms are : their soft elastic quality, their lobulated structure, and 
 their slow growth and painlessness. 
 
 Prognosis. — Although they occasionally produce considerable dis- 
 figurement or inconvenience when they are numerous or large, they 
 are altogether without influence upon the patient's general condition. 
 When subjected to long-continued pressure they may ulcerate. 
 
 Treatment. — Large single tumors may be removed by excision. 
 In multiple tumors Joseph recommends injections of absolute alcohol 
 made directly into the tumor at several points, at intervals of a few 
 days; this is followed by softening of the fat which may then be 
 evacuated by incision. 
 
 DERMATOMYOMA 
 
 Synonyms. — Myoma ; Leiomyoma ; Myoma levicellulare ; Fr., My- 
 ome ; Ger., Myom. 
 
 Definition. — A new-growth composed of unstriped muscle, situated 
 in the corium, characterized by small solitary or multiple tumors. 
 
 Symptoms. — Myoma is a rare neoplasm and may be solitary or 
 multiple. The solitary form, the myome dartoique of Besnier, which 
 is the more frequent, occurs as a small firm tumor which varies in size 
 from a small nut to the fist, is sessile or pedunculated, is more or less 
 vascular, and when irritated or exposed to changes of temperature 
 exhibits some degree of contractility. Although usually painless, in 
 exceptional cases it may be the seat of severe pain. In the great 
 majority of the cases observed, the tumor was situated upon the breast, 
 in the areola of the nipple, on the scrotum or the labia ; it has been 
 seen, however, in other regions. 
 
 Multiple myoma is characterized by a variable number of hemp-seed- 
 to pea-sized, rarely larger, firm nodules embedded in the skin, pinkish 
 or brownish-red in color. The number of lesions is usually limited, 
 but in exceptional cases large numbers have been observed. While 
 they frequently occur in irregular groups or patches, they, as a rule, 
 exhibit no definite arrangement or distribution, and may be found 
 on any portion of the body. At first painless, they after a time be- 
 come sensitive, and in about one-half the cases are subject to par- 
 oxysms of severe pain lasting from a few minutes to some hours, 
 the pain appearing spontaneously or after exposure to cold. In the 
 cases reported by Jarisch and Jadassohn, severe itching was like- 
 37 
 
578 DISEASES OF THE SKIN 
 
 wise present along with the pain. The tumors grow very slowly, but 
 rarely reach any considerable size, and after a time cease to grow; 
 new tumors, however, continue to appear at irregular intervals. 
 
 Etiology. — We are in complete ignorance of the cause of the mal- 
 ady. Age and sex apparently exert little or no influence in its causa- 
 tion. In the great majority of cases the tumors have appeared al- 
 most imperceptibly, without any previous alteration of the skin ; but 
 in the case reported by Brigidi and Marcacci, swelling of the hands 
 preceded the appearance of tumors in this region. Wolters has re- 
 ported a case of multiple myoma in which the tumors appeared rather 
 suddenly in a diabetic subject, but there seems to be some doubt as 
 to the correctness of the diagnosis — the lesions were much like those 
 of xanthoma. 
 
 Pathology. — The tumors are situated in the reticular portion of 
 the corium and are composed of interlacing bundles of smooth-muscle 
 fibres and an abundant network of elastic tissue. The larger soli- 
 tary tumors occasionally, in addition to muscle fibres, contain a con- 
 siderable amount of fibrous tissue (fibromyoma), at times are very 
 vascular (angiomyoma), or contain numerous dilated lymphatics 
 (lymphangiomyoma). The small multiple tumors take their origin 
 in the arreactores pilorum, while the solitary and larger growths orig- 
 inate in the deeper muscular structures of the skin, such as the mus- 
 cular coat of the vessels or the muscular fibres in the sudoriparous 
 
 glands. 
 
 Diagnosis.— Dermatomyomata are to be distinguished chiefly from 
 neurofibroma and neuroma, but the differential diagnosis can rarely, 
 if ever, be positively made without the aid of a biopsy. 
 
 Prognosis. — The affection is a benign one, but is likely to continue 
 indefinitely, although both Jadassohn and Lukasiewicz observed partial 
 spontaneous involution of the tumors. 
 
 Treatment. — Small lesions may be destroyed by electrolysis; for 
 the larger ones excision is the only remedy. 
 
 NEUROMA 
 
 Synonyms. — Nerve tumor ; Fr., Nevrome ; Ger., Neurom. 
 
 Definition. — A new-growth composed of connective tissue and 
 nerve fibres situated in the corium and distinguished by multiple pain- 
 ful tubercles and small tumors. 
 
 Tumors made up of nerve tissue are occasionally found on the 
 severed ends of nerves in amputation stumps or upon nerve trunks 
 as nodules and fusiform swellings (plexiform neuroma), but as these 
 are not situated in the skin we shall not consider them here. Neu- 
 roma of the skin is an extremely rare affection, there being but two 
 well-characterized examples in dermatological literature, viz., the cases 
 of Duhring and Kosinski ; to these two cases may perhaps be added 
 the case of extremely tender multiple tumors on the back of a woman 
 presented by Cavafy before the Dermatological Society of London 
 
NEW GROWTHS 579 
 
 in 1893. The cases of Duhring and Kosinski were characterized by 
 multiple pea-sized and somewhat larger pinkish or slightly violace- 
 ous, closely aggregated nodules and tumors situated in the one in- 
 stance over the scapula, shoulder, and upper arm, in the other over 
 the buttock and the posterior surface of the thigh. In both cases the 
 lesions were at first painless, but after a time, three years in Duhring's 
 case, they became very sensitive and subject to paroxysmal attacks 
 of severe pain lasting several hours. 
 
 Etiology. — The cause of the affection is altogether unknown. Duhr- 
 ing's patient was a man in apparently good health, sixty years of age ; 
 Kosinski's case occurred in a youth of sixteen. 
 
 Pathology. — In both Duhring's and Kosinski's cases the tumors 
 were found to contain both fibrous connective tissue and non-medu- 
 lated nerve fibres, i.e., they were neuroflbromata. In the former a 
 careful dissection failed to discover any connection with the nerve 
 trunks, although excision of a portion of the brachial plexus was fol- 
 lowed by great, although temporary, relief. In the latter the tumors 
 were found to be supplied with filaments from the small sciatic and 
 external cutaneous nerves. 
 
 Diagnosis. — Cutaneous neuroma is to be distinguished from plexi- 
 form neuroma and from the affection described by Wood as "pain- 
 ful subcutaneous tubercle." Both the latter are distinctly subcutaneous; 
 plexiform neuroma is situated along the trunks of nerves, while the 
 subcutaneous tubercle, which is almost without exception solitary, 
 occurs in the neighborhood of a joint. 
 
 Treatment. — The only treatment which has proven effective is 
 excision of a portion of the nerve supplying the affected region. As 
 already observed, Duhring's patient obtained decided, although only 
 temporary, relief from excision of a portion of the brachial plexus, 
 the return of the pain being due to the union of the severed ends of 
 the nerve, as shown at the autopsy. In Kosinski's case, immediate 
 cessation of the pain followed resection of the small sciatic nerve, 
 and the tumors almost completely disappeared. 
 
 OSTEOMA CUTIS 
 
 Synonym. — Osteosis cutis. 
 
 In a few instances deposits of bone in the skin have been observed, 
 either as flat plaques or more commonly as hard nodules, usually of 
 small size. Examples have been reported by Salzer, Coleman (Sher- 
 well's case), Pusey (case observed by Harris), Taylor and Mackenna, 
 and Heidingsfeld. In most of the reported cases there was but a 
 single tumor, and the overlying skin presented nothing abnormal, 
 but in the case reported by Taylor and Mackenna there were nine 
 or ten plaques and nodules scattered over the extremities, trunk, and 
 scalp, over which the skin was purplish. In Harris' case the deposit 
 was situated in a laparotomy scar, in Heidingsfeld's a nodule the size 
 of a bean was present in a hairy naevus on the chin. 
 
580 DISEASES OF THE SKIN 
 
 A positive diagnosis can only be made by excision and microscopic 
 examination. 
 
 The treatment is wholly surgical. 
 
 XANTHOMA 
 
 Synonyms. — Xanthelasma ; Vitiligoidea ; Fibroma lipomatodes ; 
 Molluscum cholesterique ; Plaques jaunatres des paupieres (Rayer) ; 
 Fr., Xanthome ; Ger., Xanthom. 
 
 Definition. — A benign new-growth characterized by yellow nodules, 
 tumors, flat plaques, and striae situated upon various parts of the skin. 
 
 Three varieties of this affection are commonly recognized, viz., 
 xanthoma planum, confined to the lids; xanthoma tuberosum, and 
 xanthoma diabeticorum. These, while resembling one another in 
 a general way, differ sufficiently to require separate consideration. 
 
 Xanthoma Planum ; Xanthoma Palpebrarum. — Symptoms. — This is 
 a by no means infrequent affection, and consists of yellowish or chamois- 
 colored patches situated upon the lids, usually upon the inner half, although 
 the entire lid may be affected. It begins commonly at the inner canthus, 
 as one or more quite small yellow spots, which slowly enlarge and coalesce 
 until they may occupy the greater part or all of the surface. The skin 
 is soft, smooth, and pliable, and apparently but little changed except in 
 its color. Much less frequently the patches are decidedly infiltrated and 
 project above the surface as flat nodules or elongated bands of a bright 
 yellow or orange color. In a young woman under the author's care a few 
 years ago a distinctly elevated bright-yellow band about 3 mm. wide occu- 
 pied the free borders of both upper lids, producing a very bizarre 
 disfigurement. The affection is always symmetrical; although it 
 may begin on one side, both sides are eventually involved. The color, 
 while in the great majority of cases some shade of yellow, may be 
 whitish or may be quite dark or even brown. There are no subjective 
 sensations, as a rule. 
 
 Xanthoma Tuberosum.— Synonyms. — Xanthoma tuberculatum ; Xan- 
 thoma tuberosum multiplex. 
 
 Symptoms. — This variety of xanthoma, which is much less fre- 
 quent than the preceding, indeed, a rare disease, is characterized by 
 shot- to pea-sized nodules, and tumors varying in size from a nut 
 to a small orange, usually a pronounced yellow in color, situated most 
 frequently about the joints, such as the knuckles, elbows, and knees, 
 l)ut also on other parts of the limbs, trunk, and face. These nodules 
 and tumors are usually firm and elastic, but are occasionally quite 
 soft, and vary in numbers from two or three to scores. While usually 
 scattered about discretely, they may be closely aggregated, forming 
 nodular masses or plaques with uneven nodular surface, sometimes 
 of considerable extent. Upon the palms and soles, especially the 
 former, it occurs as yellow or chamois-colored somewhat elevated 
 
PLATE XXXIV 
 
 Xanthoma tuberosum. 
 
NEW GROWTHS 581 
 
 bands situated in the normal furrows (Plate XXXIV) Nodules are 
 occasionally found in the sheaths of the tendons and in the mucous 
 membranes of the lips, gums, and in rare instances upon the con- 
 junctiva. 
 
 The course of the malady is usually slow ; new nodules may con- 
 tinue to appear from time to time, while the old ones, after slowly 
 increasing m size for a variable period, become stationary and undergo 
 little or no change in their appearance for an indefinite period Quite 
 exceptionally spontaneous involution with the complete disappearance 
 of the lesions has been observed. 
 
 In a very large proportion of cases— 50 to 75 per cent.— a more or 
 less marked jaundice, the result of hepatic disease or obstruction of 
 the biliary passages, precedes or accompanies the cutaneous affection 
 In children, however, in whom the disease is rare, jaundice is never 
 present. 
 
 Xanthoma Diabeticorum.— Symptoms.— This is much less frequent 
 than either of the other forms of xanthoma and differs from them mate- 
 rially in its symptoms and course. It is apt to appear rather suddenly as 
 an eruption of dull-red papules, many of which have vellow tops, so that 
 they resemble pustules somewhat, but they contain no' fluid and are quite 
 firm to the touch. The eruption varies much in the number of lesions 
 and in its distribution. At times the papules are few in number and 
 confined to the extremities, usually the extensor surfaces; at other 
 times they are extremely numerous and distributed over the neater 
 part of the trunk, extremities, and face, but, unlike the other varieties 
 almost never upon the lids. Occasionally when the eruption is very 
 abundant, the lesions may coalesce to form plaques of considerable ex- 
 tent, and may be found m the mouth. There are usually some itching 
 and burning, and at times these may be sufficiently pronounced to 
 cause the patient considerable discomfort. In exceptional cases the 
 yellow hue of the eruption is quite pronounced, as much so as in the 
 nodular variety. 
 
 After a duration varying from a few months to a year or two, the 
 eruption usually disappears, sometimes within a very short time.' In 
 some cases it pursues a somewhat irregular course, the eruption com- 
 ing and going, at times almost completely disappearing, then reap- 
 pearing. 
 
 In the great majority of cases, but not invariably, glycosuria is 
 present, either continuously or intermittently. 
 
 Etiology.— Xanthoma of the lids is somewhat more common in 
 women than in men, according to Hutchinson, in the proportion of 
 three to two. It is seen chiefly in adults, although it may in rare 
 cases occur in children. A number of authors, among them Church, 
 Fagge, Torok, have noted its occurrence in several members of the 
 same family and in successive generations, so that it seems probable 
 
582 DISEASES OF THE SKIN 
 
 that heredity plays some part in its production. It has been observed 
 in association with migraine, gout, uterine disease, and disease of 
 the liver, but with the exception of the last-named the causal relation- 
 ship of these to the affection is very doubtful. 
 
 In xanthoma tuberosum, jaundice is present in so large a percent- 
 age of cases that it can scarcely be doubted that there is an intimate 
 relationship of some sort between the two diseases. Pinkus and Pick 
 are of the opinion that a deposition of cholesterin-fatty-acid-ester, 
 which is present in considerable quantity in the blood of patients with 
 icterus and glycosuria, takes place in the connective tissue and endo- 
 thelial cells, and that this is the essential characteristic of xanthoma ; 
 and Schmidt succeeded in demonstrating a considerable cholesteri- 
 nsemia in xanthoma patients. Pollitzer and Wile believe it due to the 
 irritative effects of cholesterol-fatty-acid-ester upon the connective 
 tissue. It would seem that the causal relationship of this lipoid to 
 the malady is pretty well established by these studies. 
 
 Pathology. — Xanthoma is a connective-tissue hyperplasia accom- 
 panied by a deposition of a peculiar fat-like substance in the con- 
 nective-tissue cells, in the lymph spaces, and between the fibres of the 
 corium, which gives to the lesions their characteristic yellow color. 
 While many authors regard the several forms of the malady as prac- 
 tically identical in their histological features, Unna, and still more 
 recently Pollitzer, deny that xanthoma of the lids (xanthoma planum) 
 is in any way related to the nodose form ; the latter regards it, not 
 as a hyperplasia, but as a special form of fatty degeneration of the 
 muscle fibres of the lids. In lid xanthoma the epidermis shows little 
 or no change, but in the nodular variety it is at times somewhat 
 thinned as the result of pressure from beneath by the growing tumor. 
 In the derma are numerous peculiar large round and oval cells with 
 a granular protoplasm and one or several round or oval nuclei arranged 
 in elongated tracts or rounded " nests " situated between the collagenous 
 fibres of the corium ; these, which are derived from the connective-tissue 
 cells, are the so-called " xanthoma cells." Here and there large round 
 multinuclear cells, xanthoma giant-cells, are scattered throughout the 
 growth (Fig. 201). 
 
 In xanthoma diabeticorum the histological changes are much more 
 indicative of inflammation than in the other forms. There are peri- 
 vascular collections of lymphoid, plasma, and connective-tissue cells 
 along with xanthoma cells, the last being less numerous than in the 
 nodular and plane varieties. 
 
 The sweat- and sebaceous-glands and the elastic tissue are in all 
 the forms practically unaffected. 
 
 Diagnosis.- — The symptoms of all the forms of xanthoma are usually 
 so striking and characteristic that the diagnosis rarely, if ever, offers 
 any difficulty. In children when the lesions are numerous and flat 
 there may be a superficial resemblance to urticaria pigmentosa, but 
 wheals are never present and the eruption is distinctly yellow. In 
 
NEW GROWTHS 
 
 583 
 
 xanthoma diabeticorum the yellow-topped papules and the presence 
 of glycosuria are distinguishing features. 
 
 Prognosis. — Xanthoma of the lids and xanthoma tuberosum usually 
 last indefinitely ; although a few cases of spontaneous disappearance 
 of the latter have been reported, this is altogether exceptional. In 
 xanthoma diabeticorum the outlook for eventual recovery is more 
 favorable ; after lasting some months or years, the eruption usually 
 disappears, but relapses may occur. 
 
 '-f&rZm 
 
 Fig. 201. — Xanthoma tuberosum. X, Large so-called "xanthoma cells." 
 
 Treatment. — Painting the patches lightly with trichloracetic acid 
 is often an effective method of dealing with xanthoma of the lids ; 
 the patches may also be destroyed by electrolysis, but relapses or a 
 further extension of the disease is not at all infrequent after both these. 
 In the nodular variety the larger x lesions may be removed by excision 
 or by applying a 25 per cent, plaster of salicylic acid, as recommended 
 by Morrow. In xanthoma diabeticorum, a diet appropriate to the glyco- 
 suria should be employed ; and when itching is a pronounced symptom, 
 a lotion of phenol, 1 to 2 per cent., in water may be applied two or 
 three times a day. 
 
584 DISEASES OF THE SKIN 
 
 PSEUDOXANTHOMA ELASTICUM 
 
 Synonym. — Xanthoma elasticum. 
 
 This rare affection, which was first described by Balzer, resembles 
 xanthoma in some of its clinical features. It consists of yellowish 
 macules and flat, slightly elevated nodules varying in size from a 
 pin-head to a split pea, discrete or confluent, in the latter case form- 
 ing variously sized patches. The lesions are symmetrically distrib- 
 uted, most commonly in the subclavicular, axillary, and abdominal 
 regions and in the flexures of the extremities, usually avoiding the 
 regions commonly affected by xanthoma, although in one or two of 
 the reported cases the face was slightly affected. In most cases it 
 is unaccompanied by any subjective symptoms, although occasionally 
 itching of a more or less pronounced character is present. In a series 
 of fourteen cases recently collected by Herxheimer and Hell, the pa- 
 tients were of all ages ; although the majority were middle-aged, it 
 likewise occurred in children and in the aged. 
 
 Pathology. — The histopathology, which has been studied by Balzer, 
 Darrier, Bodin, and others, who are in practical agreement as to the 
 changes present, is quite characteristic, and is indicative of degenera- 
 tion of the elastic tissue. Areas of granular material situated between 
 the fibres of the corium are scattered through the derma, and these 
 exhibit the staining reaction characteristic of elastin. The collagen 
 fibres show no change. Bodin found in a case which he studied giant- 
 cells situated at the periphery of the lesions near the vessels with 
 the perithelial layer of which they seemed to be in relation. The 
 affection is apparently closely related pathologically to colloid de- 
 generation of the skin, if it is not identical with it. 
 
 Diagnosis. — The affection is to be distinguished from xanthoma by 
 the less yellow color of the lesions and by the locations affected, which, 
 as already noted, are different from those of the former malady. 
 
 Treatment. — The treatment is unsatisfactory. When the lesions 
 are few and the patches small, painting them lightly with tricholora- 
 cetic acid or electrolysis might be tried as in xanthoma planum. 
 
 COLLOID DEGENERATION OF THE SKIN 
 
 Synonyms. — Colloid milium; Colloidoma miliare ; Hyaloma. 
 Definition. — A benign neoplasm distinguished by pin-head-sized yel- 
 low nodules resembling milium, situated for the most part upon the 
 
 face. 
 
 Symptoms.— This disease, which was first described by Wagner 
 in 1886, under the misleading name "colloid milium," is a very infre- 
 quent affection, not more than a score of cases having thus far been 
 observed. 
 
 It consists of numerous pin-head- to shot-sized, occasionally larger, 
 discrete and confluent, translucent elevations varying in color from a 
 bright lemon-yellow to a brownish yellow, situated mostly upon the face, 
 
PLATE XXXV 
 
 Colloid degeneration of the skin. 
 
NEW GROWTHS 585 
 
 especially both malar eminences and over the bridge of the nose- less 
 frequently the backs of the hands and the ears exhibit similar elevations 
 Owing to their translucency, they resemble vesicles in appearance, but they 
 are quite firm to the touch, and when pricked no fluid escapes from them. 
 After incision a pale yellowish material may be expressed resembling 
 glycerin jelly. In exceptional cases the conjunctiva may be the seat of 
 yellowish patches resembling pterygium, and in one case at least the 
 mucous membrane of the lip was the seat of lesions like those upon the 
 cheeks. The course of the affection is a chronic one ; in most of the cases 
 
 
 V 
 
 e 
 
 ;../-"■- 
 
 
 V 
 
 Fig. 202.— Colloid degeneration of the skin, so-called colloid milium. C, colloid masses replacing the 
 rete mucosum and papillary body of the corium. 
 
 reported it had lasted for several years, showing but little change when 
 once established. In a small number of instances, however, the lesions 
 undergo spontaneous involution, and the entire disease may disappear 
 completely in the course of a variable period of time. There are no 
 subjective symptoms of any importance (Plate XXXV). 
 
 Etiology. — The cause of colloid degeneration of the skin is un- 
 known. In about one-half of the reported cases the patients were 
 between forty and seventy years of age and had been much exposed 
 to the weather, the skin exhibiting considerable pigmentation of the 
 
586 DISEASES OF THE SKIN 
 
 exposed parts upon which the disease was situated. Although so 
 large a proportion of those affected were middle-aged or old, the 
 malady is by no means confined to these, but may occur in children, 
 one case having been observed in a boy nine years of age. 
 
 Pathology. — The malady is a peculiar degeneration of the skin 
 which results in the formation of a jelly-like material, colloid. Those 
 who have studied the pathology and morbid anatomy of the malady 
 differ somewhat in their views as to what tissues are affected and 
 where the degeneration begins. Some, such as Jarisch and Pelizarri, 
 believe it a degeneration of the elastic tissue chiefly, but the author's 
 own studies lead him to agree with those who think both the collagen 
 and elastin equally involved in the degeneration. The principal morbid 
 changes are situated in the upper and middle portions of the corium. 
 The papillary and subpapillary layers are entirely replaced by an amor- 
 phous granular material which reacts to the various staining reagents 
 in a manner characteristic of colloid (Fig. 202) ; the elastic tissue has 
 either entirely disappeared or is in various stages of degeneration. 
 Exceptionally the prickle-cells of the epidermis share in the colloid 
 transformation, although, as a rule, the cellular elements exhibit a 
 somewhat remarkable immunity. 
 
 Diagnosis. — The peculiar yellow color of the lesions, their vesicle- 
 like translucency, their situation upon the face, particularly over the 
 zygoma and the bridge of the nose, the absence of subjective symp- 
 toms, and the presence of a jelly-like material in their interior which 
 may be readily expressed after incision, are features which will serve 
 to distinguish it readily from other similar affections. 
 
 Treatment. — The lesions may be removed by the curette, or, what 
 is preferable, by electrolysis. In employing the latter method of 
 treatment, the platinum or iridium needle attached to the negative 
 pole is thrust into the centre of each lesion and a current of five to 
 ten milliamperes allowed to flow for thirty to forty seconds. In a 
 case under the author's observation the X-ray seemed to influence fa- 
 vorably the affection, but the patient was quite irregular in his at- 
 tendance, so that no definite conclusion could be drawn as to the 
 real usefulness of this agent. 
 
 ANGIOMA 
 
 Definition. — A new-growth composed principally of blood-vessels. 
 
 The angiomata vary greatly in size, structure, and mode of pro- 
 duction. They may be arterial or venous or both ; they may consist 
 of new-formed vessels or may arise from dilated preexisting ones ; 
 or, what is frequently the case, both new-formed and dilated vessels 
 are present in the growth. According to their clinical or histological 
 peculiarities, they are commonly divided into a number of groups. 
 Kaposi arranged them in four, viz., Telangiectasis, naevus vascularis, 
 angio-elephantiasis, and tumor cavernosus. Unna separates the vas- 
 cular nsevi from the angiomata proper because the former represent 
 
NEW GROWTHS 587 
 
 a primary dilatation of the vessels and not a new growth of capil- 
 laries, and, unlike the latter, do not increase in size. Although ad- 
 mittedly much less accurate scientifically, they may for practical pur- 
 poses be divided into two groups, viz., vascular nsevi, including under 
 this term all vascular growths present at or appearing shortly after 
 birth, and acquired growths, the telangiectases, and angioma caverno- 
 sum which properly belongs to surgery rather than dermatology. 
 
 NiEVUS VASCULARIS 
 
 Synonyms. — Nsevus vasculosus ; Nsevus sanguineus ; Angioma sim- 
 plex; Fr., Nsevus vasculaire, Tache de feu; Ger., Gefassmal, Feuermal. 
 
 Definition. — A vascular new-growth characterized by flat patches 
 or variously sized tumors of red or violaceous color, in most instances 
 congenital or appearing shortly after birth. 
 
 Vascular nsevi present great variations in their size and appear- 
 ance. The commonest variety is the so-called "port-wine stain" 
 (naevus ftammes, tache de feu, Gefassmal), which occurs as variously 
 sized and shaped non-elevated, usually smooth patches which vary in 
 color from pale pink to bright crimson or dull violaceous, the color 
 depending upon the degree of vascularity and the depth at which the 
 vessels are situated in the skin. They are usually present at birth 
 and rarely show any increase in size, but in very exceptional cases 
 they may extend considerably (Crocker). Instead of being smooth 
 and non-elevated, they may be more or less raised and studded over 
 with pin-head- to pea-sized red tumors or wart-like growths, some of 
 which may be attached by a short slender pedicle. Crying, cough- 
 ing, or straining, by increasing the amount of blood in the patches, 
 makes them a deeper color ; by pressure the vessels may be completely 
 emptied, leaving the skin slightly yellowish or faintly pigmented. 
 
 This variety of naevus is most frequently situated upon the face, 
 the neck, and the extremities, and may be no larger than a coin or may 
 cover the half or more of the face or the greater part of an extremity. 
 Its most frequent site is the occipital region, where it occurs as a 
 usually rather pale red stain just within the hair, sometimes extend- 
 ing down upon the neck. According to Depaul, one-third of all 
 new-born infants present a nsevus in this situation, and Unna observed 
 it in from 10 to 20 per cent. The author's own observations fully 
 confirm the frequency of its occurrence in this region. Another fre- 
 quent site is the centre of the forehead between the eyes, where it 
 forms a pale pink patch, which becomes a bright crimson when the 
 infant cries; the less marked patches frequently disappear after some 
 months. 
 
 Somewhat less frequent than the foregoing are small red or purplish 
 flat or hemispherical tumors varying in size from a pea to an English 
 walnut or larger, with smooth or lobulated surface, situated on the 
 face, scalp, or, less frequently, the extremities (angioma simplex, angi- 
 oma glomeraliforme, Unna). They are soft and compressible and 
 
588 
 
 DISEASES OF THE SKIN 
 
 may be more or less completely emptied of blood by moderate pres- 
 sure, the blood returning slowly when the pressure is removed. Cough- 
 ing or straining causes them to become turgescent, and occasionally 
 they are pulsatile. They are usually congenital or appear a few weeks 
 after birth, commonly continue to grow for some time after their 
 appearance, and in infrequent cases reach extensive proportions, in- 
 volving, it may be, the greater part of a limb, which is usually en- 
 larged and irregularly lobulated (elephantiasis telangiectodes) (Fig. 
 203). Occasionally they spontaneously ulcerate, and in this man- 
 ner may be completely destroyed. In a case under the author's ob- 
 servation an angioma of this variety occupying the whole of the 
 upper arm of an infant a few months old was thus removed in the 
 course of two or three months and replaced by an extensive scar. 
 
 Fig. 203. — Nasvus vascularis occupying the hand, forearm and a part of the upper arm. 
 
 Etiology. — The causes of vascular nsevi are extremely obscure. 
 They occur much more frequently in females than in males, accord- 
 ing to Gessler, in the proportion of two to one. Virchow believed 
 that they occurred most frequently in the region of the embryonic 
 branchial clefts, probably as the result of some slight irritation during 
 the development of the foetus. Unna thinks it likely that they are 
 the result of continued pressure on certain regions by the mother's 
 bony pelvis during intrauterine life. The popular notion that they 
 are due to prenatal maternal impressions lacks trustworthy evidence. 
 
 Pathology. — In nsevus flammeus ("port-wine stain"), the middle 
 and upper portions of the corium are occupied by numerous tortuous 
 and dilated capillaries lined by flat epithelium. In simple angioma, 
 which, as already remarked, Unna separates from the vascular nsevi, 
 although it is practically always congenital, the tumor is made up 
 
NEW GROWTHS 589 
 
 of new-formed and dilated arterial capillaries, most abundant in the 
 neighborhood of the hair-follicles and suboriparous glands. 
 
 Diagnosis. — The vascular character of the growth is usually so 
 apparent, even on superficial examination, that the diagnosis may 
 be made very readily. The faint nsevi which are so common in the 
 occipital region may in infants be mistaken for patches of mild der- 
 matitis, but a careful examination will soon rectify this error. 
 
 Prognosis. — The port-wine mark is of importance only because of 
 the very great disfigurement which it causes when at all extensive ; 
 it never occasions the patient any physical discomfort and seldom in- 
 creases after birth, although it may do so in exceptional cases. The 
 simple angioma may occasionally be the seat of hemorrhage, but 
 rarely profuse enough to endanger the infant's life. It not infre- 
 quently, however, continues to grow for some time after birth, and 
 may at times reach extensive proportions. As already noted, in a 
 small number of cases spontaneous ulceration occurs, and may totally 
 destroy it in the course of a few months. 
 
 Treatment. — Many methods of treatment have been employed for 
 the removal of port-wine stain, but none of them has proven entirely 
 satisfactory. Radiotherapy probably gives the most satisfactory re- 
 sults from the cosmetic point of view. The use of radium, as advo- 
 cated by Wickham and Degrais, frequently removes the stain with 
 scarcely perceptible scarring; and much the same results may occa- 
 sionally be obtained by exposure to the X-ray. The latter should 
 be used with caution, however, lest atrophy of the skin or disfiguring 
 telangiectases result. When the patches are small, freezing by solid 
 carbon dioxide or by liquid air sometimes gives satisfactory results, 
 but care must be taken not to freeze the parts too deeply, otherwise 
 disfiguring scarring will follow. The " snow " should be applied for 
 ten to tw r enty seconds with only moderate pressure. The patches may 
 also be destroyed by electrolysis, using an irido-platinum needle 
 attached to the negative pole and a current of three to five milliam- 
 peres. Numerous punctures are made in the patch a short distance 
 apart, allowing the current to act for twenty to thirty seconds. The 
 method is extremely tedious and is suitable only for small patches. 
 When used with judgment, the high-frequency spark may be em- 
 ployed with excellent effect, but this, too, is best adapted to patches 
 of moderate extent. 
 
 Angiomata may be destroyed by electrolysis, by caustics, by the 
 galvano- or thermo-cautery, by freezing with liquid air, or solid carbon 
 dioxide, and by radiotherapy ; and the choice of any one of these 
 will depend largely upon the size, number, and situation of the growths. 
 Lesions of moderate size may often be successfully dealt with by 
 freezing with solid carbon dioxide, the amount of pressure employed 
 and the length of the application being regulated by the size of the 
 tumor. Thirty to forty seconds with moderately firm pressure are 
 usually sufficient in the smaller growths. When the crust falls, the 
 
590 DISEASES OF THE SKIN 
 
 freezing may be repeated if the first one has not been sufficient to com- 
 pletely destroy the lesion. They may also be destroyed by electrolysis, 
 inserting both needles in the growth at various points, taking care 
 that they do not touch, using a current of from ten to twenty mil- 
 liamperes; both needles should be irido-platinum or gold-plated to 
 avoid the staining which occurs at the positive pole when steel is 
 used. This is often an effective method, but it is painful and there- 
 fore requires an anaesthetic. One of the most satisfactory methods 
 of treatment, when the growths are situated upon the face and of 
 moderate size, is by radium. In a case under the author's observa- 
 tion a few years ago, in which the tumor was situated upon the lip 
 of a six-months-old infant, this agent was employed with the most 
 satisfactory results. 
 
 TELANGIECTASIS 
 
 Definition. — Permanent dilatation and new formation of cutaneous 
 capillaries usually occurring in circumscribed areas. 
 
 Symptoms. — While, strictly speaking, the term "telangiectasis" 
 should be applied only to dilated capillaries, it is also used to desig- 
 nate certain vascular affections characterized by new-formed as well 
 as dilated capillaries. 
 
 Capillary dilatation very frequently occurs in connection with cer- 
 tain diseases of the skin of an inflammatory or other nature, such 
 as acne rosacea, lupus erythematosus, circumscribed scleroderma, 
 xeroderma pigmentosum, radiodermatitis, and cicatrices resulting from 
 injury or disease. In acne rosacea the dilated vessels are situated 
 for the most part upon the nose, particularly the alae, upon the malar 
 eminences, and are usually associated with papules and pustules, the 
 usual inflammatory lesions of that affection ; or the telangiectases 
 may occur in these regions unaccompanied by eruption, particularly 
 in those who are much exposed to the weather. The author has in 
 a few instances observed patches made up of very fine capillaries upon 
 the sides of the neck in women much addicted to outdoor sports, 
 which gave rise to considerable disfigurement. 
 
 In recent years most extensive telangiectasis has been frequently 
 observed as the consequence of X-ray dermatitis. While it is most 
 common after ulceration, in the scar, it may also occur without any 
 destruction of the skin when X-ray treatment has been prolonged 
 over a considerable period. 
 
 Not very infrequently intrathoracic or intra-abdominal disease is 
 associated with arborescent patches of vessels on the sides of the 
 thorax and at the borders of the ribs, owing to interference with the 
 local circulation. Hyde has called attention to the occasional occur- 
 rence of telangiectases with Graves's disease. 
 
 As an independent affection, telangiectasis may occur as small 
 stellate patches with a small red dot in the centre, from which radiate 
 a number of fine, somewhat tortuous and branched vessels, a variety 
 known as spider nccvus, ncevus araneus, spider cancer. It occurs 
 
NEW GROWTHS 591 
 
 somewhat more frequently in children than in adults, usually as a 
 single patch, although there may be several and in rare instances 
 many patches. Crocker observed a case in which the lower two- 
 thirds of the face and the forearms and hands were covered, and a 
 still more extensive case has been recorded by Mandelbaum. The 
 most common situation is the face, although it occasionally occurs 
 upon the trunk. Occasionally the patches disappear spontaneously 
 after a time, but as a rule they continue indefinitely. 
 
 A form frequently observed in elderly and old individuals occurs 
 as pin-head- to split-pea-sized crimson or purple flat elevations situated 
 more frequently upon the trunk than elsewhere, although sometimes 
 seen upon the face {nccvus sanguineus, papillary varices). 
 
 As "inherited hemorrhagic telangiectasis," Osier has described an 
 affection characterized by numerous telangiectases situated in the 
 skin and mucous membranes associated with frequent and at times 
 severe or even dangerous hemorrhage. The disease exhibits a mark- 
 edly familial character, two or more members of the family being af- 
 fected. Although rare, Gjessing, who has recently reported a marked 
 example, was able to collect from the literature nineteen families in 
 which the malady had been observed. 
 
 Etiology. — As already noted, dilatation and the new formation of 
 cutaneous capillaries are frequent concomitants of a number of in- 
 flammatory diseases of the skin and of circulatory troubles associated 
 with visceral disease. In the generalized forms it seems probable, 
 as Stokes has recently suggested, that syphilis, plumbism, alcoholism, 
 and other forms of toxaemia play an important role in the production 
 of the affection. In the malady described by Osier, heredity is ap- 
 parently the most important etiological factor. 
 
 Treatment. — The most effective and convenient method of deal- 
 ing with telangiectases occurring in limited areas is to destroy them 
 by electrolysis. A needle attached to the negative pole is thrust 
 through the vessels at a number of points in their course, and a 
 current of two or three milliamperes allowed to act for ten to twenty 
 seconds ; this is soon followed by blanching and occlusion of their 
 lumen. In the stellate telangiectases (spider nsevus), the needle should 
 be inserted in the central dot ; a single puncture is usually sufficient, 
 but if it fails to occlude all the vessels the little operation may be re- 
 peated after four or five days. In the inherited hemorrhagic telangiec- 
 tasia the bleeding vessels may be destroyed by cauterization, as ad- 
 vised by Osier. In the very extensive forms but little can be done 
 in the way of their removal. 
 
 ANGIOMA SERPIGINOSUM 
 Synonyms. — Infective angioma; Naevus lupus (Hutchinson). 
 Definition. — A disease of uncertain nature distinguished by spread- 
 ing patches of bright-red puncta. 
 
 Symptoms. — This affection is of decidedly rare occurrence, some 
 twenty-five cases only having been reported since Hutchinson first 
 
592 DISEASES OF THE SKIN 
 
 called attention to it in 1890. It is distinguished by annular, cres- 
 centic, or retiform patches of bright-red dots, " like grains of cayenne 
 pepper," some of which are slightly elevated, which very slowly but 
 steadily spread in all directions. From time to time new dots appear 
 beyond the borders of the patches, the ''infective satellites" of Hutch- 
 inson, which become the starting point for new patches. In this man- 
 ner the disease gradually extends until it occupies considerable areas ; 
 in exceptional cases, such as, for example, the one recently reported 
 by Wise, the greater part of the cutaneous surface may be affected. 
 While the patches usually exhibit a more or less noticeable circinate 
 or retiform arrangement, they may be without any definite configura- 
 tion and may be associated with areas of diffuse redness in which no 
 dots are visible. In a few cases there was slight desquamation, and 
 in others slight atrophy of the skin and scarring occurred. The course 
 of the malady is a slowly progressive one, the patches enlarging al- 
 most imperceptibly; occasionally it comes to a standstill for a time 
 and then advances again; or it may slowly disappear, leaving the 
 skin quite normal in appearance. In a few cases moderate itching 
 was noted, but, as a rule, there are no subjective symptoms worthy 
 of note. 
 
 Etiology. — Nothing is known concerning its causation. Neither 
 age nor sex seems to have any influence upon its occurrence ; it has 
 been observed at all periods of life between infancy and sixty years 
 of age. In a considerable proportion of cases it was associated with 
 some form of vascular nsevus, either originating in or near such a 
 lesion. 
 
 Pathology. — In White's case Bowen and Councilman found feat- 
 ures characteristic of angiosarcoma. Cells of young connective-tissue 
 type were found along the vessels, the capillaries were dilated, and 
 there was proliferation of the endothelium and the perithelium. Dar- 
 rier, who also examined the case, practically agreed with the findings 
 of Bowen and Councilman and suggested the name " reticulated angio- 
 plasty sarcoma" for it. In a study of the histopathology of the very 
 extensive case reported by Wise, already referred to, Pollitzer found 
 a progressive infiltration about the vessels in circumscribed areas in 
 the papillary and subpapillary portions of the corium, with prolifera- 
 tion of the capillaries. The elastic tissue was unchanged. In the 
 epidermis there were secondary changes, such as marked inter- and 
 intra-cellular oedema. He did not regard the case as an angioma, but as 
 a low-grade inflammation affecting primarily the capillary areas of the 
 papillary and subpapillary regions. 
 
 Diagnosis. — The affection is to be differentiated from certain forms 
 of vascular naevus, from telangiectases, and from the affection de- 
 scribed by Majocchi as "purpura annularis telangiectodes." From 
 nsevus it is distinguished by the annular or retiform arrangement of 
 the patches and their steady extension ; in telangiectases the vessels 
 are usually clearly visible and usually present a stellate arrangement ; 
 
Fig. 204. — Xaevus pigmentosus. 
 
NEW GROWTHS 
 
 593 
 
 i 
 
 from the last-named disease it differs by the absence of purpuric patches 
 and its occurrence upon regions other than the legs. 
 
 Prognosis.— The malady usually persists for long periods and 
 steadily invades new areas, although it may in exceptional cases cease 
 to spread and may even disappear. 
 
 Treatment.— Treatment is unsatisfactory. Small patches may be 
 destroyed by electrolysis, larger ones by the galvanocautery, but it 
 is apt to reappear at the margins of the scar. In view of the well- 
 known effect of the X-ray upon vascular tissues, it might be worth 
 while to try this agent. 
 
 NiEVUS PIGMENTOSUS 
 
 Synonyms.— Mole ; Pigmentary mole; Fr., Nsevus pigmentaire ; 
 Ger., Fleckenmal, Linsenmal. 
 
 Definition. — A circumscribed increase in the cutaneous pigment 
 frequently associated with an increase of some of the other elements 
 of the skin, usually congenital, 
 but also appearing some time 
 after birth. 
 
 Symptoms. — The pigmented 
 nsevi present great variation in 
 their color, size, shape, num- 
 bers, and arrangement. They 
 vary in color from a pale cafe- 
 au-lait to a dark brown or black. 
 They may be no larger than a 
 pin-head, are frequently as large 
 as a coin, and in exceptional 
 cases may cover a considerable 
 part of the body. They are 
 visually round or oval, but are 
 eften irregular in outline and 
 vary in number from a single 
 lesion, which is unusual, to 
 scores or even hundreds scat- 
 tered about on various parts of 
 the skin, in most cases with- 
 out any definite arrangement, 
 but sometimes arranged in 
 lines. By far the commonest 
 form occurs as one or more FlG " 2 °s.-N*vus pigm e,tosus. 
 
 smooth patches of variable size (Fig. 204) and shape, of varying shades 
 of brown, little or not at all elevated above the surrounding parts 
 (ncevus spilus) ; they may be more or less elevated, with a somewhat 
 uneven, wart-like surface (ncevus verrucosus) (Fig. 205) ; or they 
 may be distinctly papillomatous in appearance (ncevus papillomatosus). 
 In many instances, in addition to the increase in the pigment, there is 
 38 
 
 i 
 
594 
 
 DISEASES OF THE SKIN 
 
 a more or less abundant growth of hair, which may be thick and 
 dark, or fine and colorless (ncuvus pilosus) (Fig. 206). Much less fre- 
 quently the pigmentary changes are accompanied by an increase in 
 the fatty and connective tissues, forming soft lobulated growths, 
 sometimes of considerable size (ncevus lip omat odes). While the vast 
 majority of pigmented ngevi are of moderate size, seldom exceeding 
 
 Fig. 206. — Hairy nasvus (naevus pilosus). 
 
 an inch or two in diameter, in rare cases they may cover a considerable 
 part of the body, as in the so-called " bathing-trunk " naevus, in which 
 the lower part of the trunk, the hips, and the upper part of the thighs 
 are covered by a pigmented, frequently hairy, growth. 
 
 In rare instances they exhibit a marked linear arrangement, occur- 
 ring as one or more bands or lines, sometimes of considerable length, 
 
NEW GROWTHS 
 
 595 
 
 composed of shot- to pea-sized, smooth, or more frequently horny 
 elevations, limited, as a rule, but not invariably, to one side of the body 
 (ncevus unius lateris, linear ncevus, nerve nccvus, systematized ncevus). 
 In a case of this kind recently under the author's observation in the 
 Philadelphia Hospital, a band of 
 small wart-like lesions extended 
 down the posterior surface of the 
 right thigh, following roughly 
 the course of the sciatic nerve 
 (Fig. 207). 
 
 Etiology. — Pigmented nsevi 
 are extraordinarily common ; in- 
 deed, there are very few, if any, 
 individuals who do not possess 
 one or more of them. They are 
 somewhat more frequent in 
 women than in men and are 
 usually congenital, although 
 there is but little doubt that they 
 also appear after birth, even some 
 years after. 
 
 Pathology. — In the smooth 
 naevi the epidermis shows but lit- 
 tle change beyond an increase in 
 pigment in the lower cells (Fig. 
 208) ; in those with warty surface 
 there is more or less hyperkera- 
 tosis. The papillary and subpapil- 
 lary portions of the corium are 
 occupied by nests and columns of 
 round cells resembling the epithe- 
 lial cells of the rete, but smaller 
 and without prickles, with large 
 centrally situated vesicular nuclei. 
 Except in the deeper portions of 
 the corium they are closely packed 
 together without any intercellular 
 substance and contain brown gran- 
 ular pigment (melanin), which 
 Ehrmann believes they obtain 
 from certain other pigment-bear- 
 ing cells which he calls " melano- 
 blasts." The great majority of the 
 cells contain but a single nucleus, but a few, larger than those already 
 described, are multinucleated (nsevus giant-cells). Demievill and 
 von Recklinghausen believed the nsevus cells to be endothelial, hav- 
 ing their origin in the endothelium of the blood vessels and lym- 
 
 ■ 
 
 Fig. 207. — Nasvus unius lateris. 
 
596 
 
 DISEASES OF THE SKIN 
 
 phatics ; but the more recent studies of Unna, Gilchrist, W. S. Fox, 
 and others seem to have established their epithelial character and 
 epidermal origin. Fox, however, believes that certain nsevi in which 
 the typical nsevus arrangement of the cells is absent, may be of meso- 
 blastic origin. The author is very decidedly in agreement with the 
 view that they are epithelial growths, and that therefore the pig- 
 mented malignant neoplasms which occasionally originate in them 
 are carcinoma and not sarcoma. 
 
 The histological changes found by various observers in linear naevus 
 
 Fig. 208. — Flat, smooth pigmented naevus. The corium is filled with large spindle-shaped and branch- 
 ing cells containing brown pigment. 
 
 have been by no means uniform ; indeed, they differ so much that it 
 is difficult to believe that they have all been describing the same 
 affection. In one of the two cases examined by Unna there was little 
 beyond some hypertrophy of the prickle layer of the epidermis, with 
 some hyperkeratosis; in the other there were evidences of inflamma- 
 tion, the lesion resembling histologically a papule of eczema (Fig. 209). 
 A number of theories have been proposed to explain the peculiar 
 distribution of linear naevus. Barensprung, who first directed atten- 
 tion to the subject, thought they followed the nerves, hence the term 
 
NEW GROWTHS 
 
 597 
 
 "nerve nsevus" sometimes applied to them. Other theories are that 
 they follow the blood-vessels ; the lines of cleavage of the skin ; the 
 lines which bound the several nerve areas (Voigt's lines) ; that their 
 distribution is metameric, and, lastly, that they follow the embryonic 
 sutures ; none of these, however, fits all the cases. Montgomery be- 
 lieves that the last is the- most satisfactory. 
 
 Diagnosis. — Their usually congenital origin and their general ap- 
 pearance. are so distinctive in most cases that the diagnosis is usually 
 made with ease. 
 
 
 •:'.'-> 
 
 Pig. 209. — Naevus unius lateris. Interpapillary processes of the rete mucosum greatly elongated; num- 
 erous connective-tissue cells in the papillae of the corium. Section from case shown in Fig. 207. 
 
 Prognosis. — In the great majority of cases naevi remain stationary 
 after their appearance, but they occasionally become darker and more 
 hairy with years ; in exceptional cases they increase in size. At times 
 when situated in regions where they are subject to constant irrita- 
 tion or frequent injury, as in the face where they are frequently cut 
 in shaving, or less frequently spontaneously, they undergo malignant 
 degeneration. Growths of this kind (naevocarcinoma) are among the 
 most rapidly fatal of all the malignant neoplasms. 
 
 Treatment. — Small, flat, hairless or downy lesions may be readily 
 and conveniently destroyed by freezing with solid carbon dioxide. 
 
598 DISEASES OF THE SKIN 
 
 Those containing stiff hairs usually diminish greatly in size or even 
 disappear after removal of the hairs by electrolysis. This method 
 may also be employed to remove the larger lesions. The needle should be 
 thrust repeatedly into the nsevus parallel with the surface of the skin, and 
 the current allowed to act until the overlying skin turns white ; when 
 the crust falls, after a week or ten days, the operation may be re- 
 peated if necessary. They may also be removed by caustics, one of 
 the most satisfactory being trichloracetic acid. This should be painted 
 over the lesion until it turns white, repeating the application after the 
 falling of the crust as often as may be necessary. In large hairy nsevi 
 the X-ray, either alone or combined with freezing by carbon dioxide, 
 may be used (Ormsby). When nsevi which have been irritated or 
 injured exhibit the slightest signs of growth, they should be excised 
 at once, making sure that every portion is removed. 
 
 CARCINOMA CUTIS 
 
 Carcinoma may occur in the skin either as a primary or as a second- 
 ary affection, in the latter case spreading from adjacent organs or 
 tissues or reaching the skin through metastasis from a focus more 
 or less remote. Primary carcinoma, which is more frequent than 
 the secondary form, and the one with which the dermatologist is 
 chiefly concerned, presents a number of varieties which differ from 
 one another in their clinical symptoms, course, and histopathology. 
 
 EPITHELIOMA 
 
 Synonyms. — Epithelial cancer ; Cancer of the skin ; Cancroid ; Ro- 
 dent ulcer. 
 
 Definition. — An epithelial new-growth characterized by destructive 
 ulceration and a marked tendency to recurrence after removal. 
 
 For purposes of description, epithelioma (Plate XXXVI) may be 
 divided into two varieties — the flat or superficial, and the deep or 
 infiltrating ; but it should be kept in mind that this is a somewhat arbi- 
 trary division and that often no sharp line can be drawn between these 
 two' forms, since the superficial variety may after a time invade the 
 deeper tissues. 
 
 Flat or superficial epithelioma may begin in a variety of ways. It 
 frequently commences as a dirty yellow or brownish pea- to finger- 
 nail-sized scaly or horny patch, senile keratosis, situated most fre- 
 quently upon the face, occasionally upon the neck, the external ear, or 
 back of the hands. Such patches frequently show but little change 
 for years beyond a slight increase in thickness, but sooner or later 
 the skin about the edges of the crust becomes slightly reddened, and 
 when the crust is forcibly removed a shallow ulcer with a finely 
 granular surface is revealed, which slowly but steadily grows in cir- 
 cumference, but usually remains comparatively shallow. 
 
 It may begin as a small pinkish, opaque, or bluish-white, partly 
 translucent nodule, or two or three small confluent nodules, which 
 
Epithelioma. 
 
NEW GROWTHS 
 
 599 
 
 very slowly increases in size, and after a year or two, or it may be 
 many years, begins to ulcerate, the ulcer being sharp-cut with slightly 
 infiltrated "bead-like" border. This form of ulcer was first described 
 by Jacob of Dublin, hence sometimes called Jacob's ulcer, but it is 
 better known, especially in England, as rodent ulcer. This form is 
 frequently very superficial, but it steadily advances and in the course 
 of years may produce the most extensive destruction, destroying in 
 its progress not only the soft tissues, but bone and cartilage. (Fig. 210.) 
 
 Fig. 210. — Epithelioma (.rodent ulcer). 
 
 Under the name "crateriform ulcer," Sir Jonathan Hutchinson de- 
 scribed some years ago a variety of epithelioma resembling in some 
 of its features rodent ulcer, but differing from it in the much more 
 rapid course which it pursues, in the greater depth of the ulcer, and 
 the eventual implication of the lymphatic glands. This form may 
 develop from the ordinary so-called rodent ulcer or it may occur as 
 
 a primary lesion. 
 
 An unusual form of flat epithelioma to which Danlos first directed 
 attention, and for which I suggested a few years ago the name 
 
600 DISEASES OF THE SKIN 
 
 "morphcea-like epithelioma/' begins as a small rounded or oval yel- 
 lowish or. yellowish-pink, sometimes atrophic, at other times slightly 
 infiltrated, patch, the borders of which are traversed by numerous fine 
 vessels; after a variable duration, ulceration occurs, usually beginning 
 at the border of the patch. (Figs. 211 and 212.) 
 
 Occasionally epithelioma begins as a small wart-like or papillo- 
 matous nodule with an infiltrated base, which slowly increases in size, 
 the papillae enlarging until a cauliflower-like vascular growth is pro- 
 duced. After a variable time the centre of the papilloma ulcerates, 
 and a round, oval, or irregularly shaped ulcer is produced with firm 
 infiltrated base and border. The lesion, while usually sessile, may 
 have a distinct pedicle. Although superficial in the early stages, these 
 growths after a time commonly extend to the deeper tissues, and 
 the neighboring lymphatic glands become involved in the cancerous 
 
 — - 
 
 i 
 
 m 
 
 Fig. 211. — Morphoea-like epithelioma. Yellowish-white patch with small point of 
 ulceration at border. 
 
 process. In a certain proportion of cases the papillomatous epithelioma 
 is a development of the flat variety, the papilloma developing either 
 before or after ulceration. 
 
 The deep-seated or infiltrating form of epithelioma may be the 
 sequel of the superficial form, or it may begin as an intradermic 
 or subcutaneous nodule which steadily increases in size until it 
 reaches the dimension of a small nut, when softening and ulcera- 
 tion occur. The resulting ulcer is seated upon an extensively infil- 
 trated base and its edges are firm and thick. The ulcer rapidly ex- 
 tends in circumference and depth, and involvement of the lymphatic 
 glands is apt to occur early. 
 
 While in most cases the lesions of epithelioma are single, it not 
 uncommonly happens that there are two or more, multiple lesions 
 being especially common in that variety which follows senile kera- 
 
 ■■\ 
 
NEW GROWTHS 
 
 601 
 
 tosis and in the cancers which occur in the workers in tar, paraffin, 
 and similar substances. 
 
 The course pursued by the flat or superficial varieties of epi- 
 thelioma is usually a very prolonged one ; they may exist for years 
 as quite insignificant lesions, as many as ten, fifteen, or twenty years 
 before they produce any considerable degree of ulceration. Event- 
 ually, however, extensive destruction of the skin is produced unless 
 the progress of the disease is stayed by treatment. In the cases in which 
 infiltration begins, however, the lesion loses its comparatively benign 
 character and becomes rapidly destructive. 
 
 The deep forms pursue a much more rapid course than the superficial 
 
 Fig. 212. — Morphoea-like epithelioma, side of thorax. 
 
 and may cause extensive destruction of tissue in the course of a few 
 months.* 
 
 The superficial variety of epithelioma is situated, in the largest 
 proportion of cases, upon the face, usually in the upper half, this 
 being especially true of the variety known as rodent ulcer, the favorite 
 sites being the cheek, the inner canthus, and the nose. Less fre- 
 quently it occurs upon the neck, the ear, and the hands. The trunk, 
 while not immune, is much less frequently attacked. 
 
 The lower lip is a frequent site, the lesion beginning as a super- 
 ficial erosion, fissure, or small nodule which eventually undergoes 
 
 * Implication of the lymphatic glands and metastases are very infrequent in the 
 superficial variety, while these always occur sooner or later in the deep forms. 
 
602 DISEASES OF THE SKIN 
 
 ulceration. While often, although by no means always, of the super- 
 ficial type in the beginning, infiltration of the deeper tissues occurs 
 sooner or later with involvement of the lymphatic glands beneath 
 the jaw. In this situation epithelioma is frequently the sequel of a 
 long-standing leukoplakia. 
 
 N^JVOCARCINOMA 
 
 Pigmented nsevi may undergo cancerous change, giving rise to 
 a form of cutaneous cancer which presents a number of special clin- 
 ical and histological features. As the result of traumatism, often 
 slight, or from some unknown cause, the nsevus begins to increase in 
 size and after a variable time, usually short, ulceration takes place, 
 speedily followed by enlargement of the neighboring lymphatic glands, 
 the appearance of secondary nodules in the immediate neighborhood 
 of the primary lesion, or at points some distance from it, and shortly 
 by widespread metastases. The color of the primary and secondary 
 growths, according to the amount of pigment in them, varies from 
 a light brown to a slaty blue or black, and the degree of malignancy 
 seems to be in direct proportion to the amount of pigment present. 
 This represents one of the most malignant and rapidly fatal of all the 
 forms of cancer. Recurrence promptly follows its removal, metastases are 
 usually numerous and widespread, and it runs a rapidly fatal course. 
 
 CARCINOMA LENTICULARE 
 
 or lenticular cancer is usually a secondary form, although it may 
 exceptionally occur as a primary affection. It is in most cases sec- 
 ondary to cancer of the female breast, and occurs as discrete and 
 confluent, shot- to pea-sized and larger, pinkish or red, very firm 
 nodules seated in the skin, usually over the anterior and lateral re- 
 gions of the chest. With the progress of the disease the nodules in- 
 crease in number and size, are thickly crowded together, and in some 
 instances coalesce to form an extensive sheet of dense infiltration 
 with a red or purplish, uneven surface, which may encase the chest so 
 firmly as to interfere with the movements of respiration, the so-called 
 cancer en cuirasse. In the course of some months softening and ul- 
 ceration of the nodules take place, extensive ulcers are formed, vis- 
 ceral metastases- occur, followed by cachexia and death. In excep- 
 tional cases the nodules are disseminated over a wide area, as in 
 the cases reported by Morrow and Pollitzer, and may appear some 
 distance away from the primary focus. In a case under the author's 
 observation some years ago a nodule was found on the back beneath 
 the scapula, the primary focus being in the breast. Owing to block- 
 ing of the lymph channels and consequent interference with the cir- 
 culation of the lymph, the arm of the affected side is sometimes enor- 
 mously swollen. The glands in the axilla are likewise more or less 
 enlarged. The disease is usually accompanied by pain of a stabbing 
 or burning character ; or in exceptional cases severe itching is a pro- 
 nounced and distressing symptom, as in the case reported by Pollitzer, 
 already referred to. 
 
NEW GROWTHS 603 
 
 CARCINOMA TUBEROSUM 
 
 or tuberose cancer of the skin is a rare form and is usually secondary 
 to cancer in some other region, although it sometimes occurs as the 
 primary disease. It begins as deep-seated intrademic or subcutaneous 
 nodules, which grow with more or less rapidity until they reach the size 
 of a nut or an egg, the skin over them becoming red or purplish as 
 they approach the surface. After some months, softening and ulcera- 
 tion take place and invasion of the viscera is not uncommon. The 
 number of nodules present may be considerable, and when numerous 
 and closely aggregated they may form large nodular masses. The 
 affection usually runs a rapidly fatal course. 
 
 Etiology. — Cancer of the skin, like other forms of the malady, is 
 a disease of middle and advanced age ; it is very infrequent before 
 thirty years of age and most common after fifty, although in rare cases 
 it has been observed in young subjects. Some years ago the author 
 saw a rodent ulcer in a boy fourteen years of age, and quite recently 
 Sequeira has reported an example of the same affection in a boy 
 twelve years old. It is about twice as frequent in males as in females. 
 While heredity is no longer believed to play the prominent role for- 
 merly attributed to it in the causation of cancer, yet the disease seems 
 to occur with unusual frequency in certain families, and recent experi- 
 mental studies in the lower animals, such as mice, seem to support 
 the view that heredity exerts a direct influence upon its incidence. 
 
 Many of its features suggest the possibility of its infectious origin, 
 but all attempts to demonstrate an infecting organism have thus far 
 failed, although its discovery has been repeatedly announced. 
 
 The number of cases in which epithelioma has followed directly 
 upon and at the site of a wound is so considerable that it is diffi- 
 cult to deny a causal influence to traumatism. The author has seen 
 so many instances of this that he is fully convinced of the relationship 
 between the two. 
 
 Long-continued irritation, whether of a mechanical or chemical 
 kind, or such as results from certain chronic inflammations of the skin, 
 is one of the most powerful of the causes which predispose to the 
 malady. Examples of this are to be seen in the epithelioma of the 
 lower lip which occurs in smokers, in the so-called chimney-sweep's 
 cancer resulting from the irritation produced by soot, and in the 
 closely related variety which occurs in workers in paraffin and tar. 
 
 It occasionally follows lupus vulgaris and lupus erythematosus, 
 more particularly the former, and occurs in a certain proportion of 
 cases in cicatrices, especially those which follow burns. Maxwell 
 states that epithelioma is unusually frequent in the Vale of Cashmere, 
 a large proportion of the cases occurring upon the abdominal walls 
 and thighs, in the scars of burns produced by a small charcoal brazier, 
 " Kangri," which the natives are in the habit of carrying beneath their 
 clothes, filled with burning charcoal. 
 
604 DISEASES OF THE SKIN 
 
 Senile and other forms of keratosis, such as cutaneous horns and 
 especially arsenical keratosis, frequently serve as the starting points 
 for epithelioma. 
 
 The dermatitis which follows long-continued or frequently repeated 
 exposure to the sun's rays and the X-ray may be followed by cutane- 
 ous cancer. 
 
 Pathology. — Carcinoma is an epithelial neoplasm which may have 
 its origin in any epithelial tissue. In the skin it may arise from the 
 Malpighian layer, from the basal-cell layer of the epidermis, or from 
 the columnar cells which line the hair-follicle and sweat glands. 
 
 Epithelioma may be divided into two classes according to the 
 type of cell present. In one the growth is composed of squamous 
 epithelium derived from the Malpighian layer ; in the other it is made 
 up of columnar-celled epithelium derived from the basal-cell layer 
 of the epidermis, from the cells of the hair-follicles, or from the sweat 
 glands. In the squamous-celled type lobulated masses and branching 
 tracts of squamous epithelium still retaining traces of the prickles 
 grow down into the corium from the epidermis. In the centre of 
 many of the lobules are peculiar bodies composed of concentrically 
 arranged flattened horny epithelial cells, the so-called "cell-nests" or 
 "pearly bodies." Many of the cells undergo degeneration, which trans- 
 forms them into large round or oval bodies with a thick homogeneous 
 or sometimes laminated wall and a central cavity containing one or 
 several nuclei. Such cells were at one time thought to be protozoa, 
 but this was soon disproved. Cell-inclusions are frequently seen, the 
 result of endogenous cell-formation. 
 
 This form is found typically in epithelioma of the lip, in that which 
 follows senile and other keratoses, and in the tar and paraffin cancers. 
 
 In the basal-celled form (Fig. 213), of which rodent ulcer may 
 be taken as the type, long, branching, cylindrically shaped processes 
 composed of small, columnar or cylindrical epithelial cells with scanty 
 protoplasm extend down into the corium. Sometimes these exhibit 
 a retiform arrangement or many form alveoli. The peculiar bodies 
 known as "pearly bodies" and the forms of hyaline degeneration 
 common in the squamous-cell variety are absent as a rule, but degen- 
 eration of the central portion of the cell-masses occasionally occurs, 
 forming cystic cavities containing a small quantity of granular debris. 
 
 In the corium about the epithelial masses is a more or less dense 
 cellular exudate composed of lymphoid and plasma cells. The elastic 
 tissue disappears completely in the regions invaded by the neoplasm. 
 
 Involvement of the neighboring lymphatic glands and metastases 
 occur in the squamous-cell cancers, but are rare, or, if they occur at 
 all, occur late in the basal-cell variety. 
 
 Nsevocarcinoma or pigmented carcinoma of the skin was formerly 
 regarded as sarcoma, but Unna's studies of nsevi and those of Gil- 
 christ have demonstrated that the neoplasms which originate in them 
 are epithelial. These growths exhibit an alveolar structure, the alveoli 
 
NEW GROWTHS 
 
 605 
 
 being filled with large epithelial cells, many of which contain several 
 large nuclei. The pigment which distinguishes them is found in the 
 connective tissue and in and between the epithelial cells. In some 
 instances it is so very abundant that it is difficult to make out the 
 structural details of the growth. According to Unna, the hyaline and 
 other forms of degeneration which occur in epithelioma are not found 
 in nsevocarcinoma. Secondary growths in the skin and widespread 
 metastases are common and usually occur early. 
 
 Diagnosis. — The age of the patient, who is usually fifty or more ; 
 its situation upon the face, often on the nose or lower lip ; the history 
 
 
 
 • 9 .>£S#5jta«'r. iKT>V.' 
 
 
 "V** 
 
 Fig. 213. — Epithelioma baso-cellulare. 
 
 of a horny patch or wart-like nodule having preceded the ulcer for 
 a considerable time, often a number of years ; its slow growth, sev- 
 eral years often elapsing in the flat superficial forms before an ulcer 
 of any dimensions is formed ; and the peculiar " bead-like " border 
 which commonly surrounds it, all are features so characteristic of epi- 
 thelioma that the diagnosis is usually readily made. 
 
 The initial lesion of syphilis, when situated upon the lower lip, 
 may at times bear considerable resemblance to epithelioma, but the 
 induration of the ulcer, the early and marked swelling of the sub- 
 maxillary glands, and the presence or early appearance of a generalized 
 eruption (which should always be looked for, even when denied by 
 
606 DISEASES OF THE SKIN 
 
 the patient), usually enables a positive diagnosis to be made. Exam- 
 ination of scrapings from the suspected ulcer for the spirochseta with 
 dark-ground illumination is a valuable aid in the diagnosis in such 
 cases. 
 
 Epithelioma and the ulcerating lesions of late syphilis may at 
 times be confounded, but the lesions of the latter are often multiple, 
 while the former is usually single ; the latter are often crescentic, reni- 
 form, or serpiginous, while epithelioma rarely assumes such a shape ; 
 and the course of the syphilitic ulcer is usually much more rapid. 
 In doubtful cases a Wassermann test should not be omitted; an un- 
 necessary surgical operation may sometimes thus be avoided. Epi- 
 thelioma is sometimes mistaken for lupus, a mistake which is not 
 likely to occur if any care is exercised. The latter disease begins, in 
 the vast majority of cases, before puberty and practically never at 
 the age at which epithelioma is most common ; and the reddish-brown 
 flat nodules and the very slow ulceration which characterize it are 
 in most cases quite unlike anything which is seen in epithelioma. 
 
 Prognosis. — The prognosis of epithelioma is always serious, but 
 judicious treatment in the more superficial varieties is usually effec- 
 tive when begun early. In advanced cases, however, treatment fre- 
 quently fails to stay the ravages of the disease, and death follows. 
 In the deep infiltrating forms the prognosis is most grave. In the 
 pigmented epithelioma originating in a nsevus, death usually results 
 within a year or two and frequently earlier. 
 
 Treatment. — No internal remedy is as yet known which exercises 
 any demonstrable effect upon the course of carcinoma. The only 
 effective treatment is local treatment, and the earlier this is begun 
 the more likely is it to be effective. 
 
 When the lesion is favorably situated, i.e., when it is in a locality 
 in which it may be completely removed, such as the lip, excision is 
 without doubt the remedy of choice in many, if not in most, cases. 
 The lines of the incision should always include a considerable part 
 of apparently sound skin in order to insure the removal of all the 
 disease. When small, it may be removed with the curette, but unless 
 this is followed by thorough cauterization in order to completely de- 
 stroy it, it is not a method which can be relied upon. 
 
 A large number of caustics have been recommended at one time 
 or another for the destruction of the growth, and some of them are 
 at times most useful when employed with discrimination in properly 
 selected cases ; the most generally useful and effective of these are 
 arsenic, chloride of zinc, and pyrogallol. Arsenic is a very efficient 
 caustic, exercising to some degree a selective action upon the neo- 
 plastic tissues, but gives great pain and frequently produces a most 
 pronounced inflammatory reaction, accompanied by great swelling, 
 particularly when used in the neighborhood of the eye. It should 
 not be applied to extensive surfaces lest arsenical poisoning follow. 
 It may be conveniently employed as Marsden's paste, which is com- 
 
NEW GROWTHS 607 
 
 posed of equal parts of powdered gum arabic and arsenic trioxide, 
 mixed with enough water to make a rather stiff paste ; this may be ap- 
 plied for twenty-four to forty-eight or seventy-two hours, the time de- 
 pending upon the depth of the lesion. 
 
 The author's own preference is for pyrogallol employed as a 40 per 
 cent, plaster, made as follows : 
 
 Pyrogallol gr. xcvj (6.0) 
 
 Cerat. resinas 3 ii (8.0) 
 
 Bals. Peruvian q. s. ut emplast. ft. 
 
 M. 
 
 Before applying the plaster, the surface of the lesion should be 
 lightly rubbed for a few minutes with a stick of caustic potash until 
 the patient complains of slight pain ; the potash should then be neu- 
 tralized w T ith dilute acetic acid, after which the plaster may be applied 
 thickly spread on a piece of kid slightly larger than the lesion, and 
 renewed twice a day. After four to five days its use should be sus- 
 pended, and a pad of gauze or lint wet with a saturated solution 
 of boric acid and covered with oiled silk should be applied continu- 
 ously for twenty-four to forty-eight hours, at the end of which time 
 the slough will have come away. A 2 per cent, salicylic acid oint- 
 ment may now be applied until cicatrization is complete. Some of 
 the best results, both cosmetic and curative, the author has ever 
 seen in the treatment of superficial epithelioma have been obtained 
 by this method. The destruction of the growth is usually complete 
 and the resulting scar is smooth and pliable. 
 
 With the exception of excision, the X-ray and to a less extent 
 radium have largely superseded all other methods of treatment, and 
 there is no longer any doubt about the efficacy of these agents in the 
 treatment of the more superficial forms of cancer of the skin. In the 
 so-called rodent ulcer and in other forms of baso-cellular epithelioma 
 the X-ray is in most cases curative, and it is frequently effective in 
 the flat and superficial forms, such as follow senile keratosis. In 
 the deeper and infiltrating forms, however, it often fails. In such 
 cases the best results are to be obtained by excision followed by X-ray 
 treatment. The X-ray may be employed in one of two ways : An ex- 
 posure of ten to fifteen minutes may be given every three or four 
 days until a mild erythema is produced, when the treatment should 
 be suspended until the reaction has subsided ; or the so-called massive- 
 dose method may be employed, in which an erythema dose is given 
 at once and not repeated until the erythema has disappeared. Both 
 methods have their advocates, but the latter is preferred by many 
 Rontgenologists at the present time. 
 
 PAGET'S DISEASE 
 
 Synonym. — Malignant papillary dermatitis. 
 
 Definition. — A malignant disease of the skin confined in the great 
 majority of cases to the nipple and areola of the female breast, char- 
 
608 DISEASES OF THE SKIN 
 
 acterized by an eczematoid inflammation, followed in time by carci- 
 noma of the mammary gland. 
 
 This affection was first described in 1874 by Sir James Paget in 
 a paper published in the St. Bartholomew Hospital Reports. His ac- 
 count of the disease was based upon fifteen cases, all occurring in 
 women between the ages of forty and sixty. It began with an eczema- 
 toid inflammation of the nipple and areola, accompanied by vesicles, 
 an abundant oozing of a sticky fluid, and crusts. In a few instances 
 the eruption was dry and scaly, resembling to some degree psoriasis. 
 In all these fifteen cases the cutaneous inflammation was followed 
 within one or two years by mammary cancer. Since the publication 
 of Paget's paper the disease has been studied by Butlin, Thin, Duhring 
 and Wile, Crocker, Wickham, Hirschel, and others. 
 
 / 
 
 Fig. 214. — Paget's disease. 
 
 Symptoms. — The disease is in the great majority of cases found 
 upon the female breast (Fig. 214). It begins upon the nipple, spreads 
 to the areola and occasionally beyond it, and exceptionally may coyer 
 the skin of the entire gland. It is as a rule unilateral, and is found 
 more frequently upon the right than upon the left breast. It begins 
 upon the top of the nipple with a small horny crust, firmly attached 
 to the underlying part, and beneath this crust there is at first a red- 
 dened surface, which after a time becomes superficially ulcerated 
 and fissured. In time the areola is invaded ; it becomes red and scaly, 
 or moist, discharging a yellow, viscid fluid, which dries into yellowish 
 crusts. In the fully developed disease the affected parts are red, with 
 a finely granular, in places superficially ulcerated, surface from which 
 more or less oozing takes place. The diseased area is usually irregularly 
 rounded in shape, with well-defined borders, the nipple in the centre, 
 
NEW GROWTH 609 
 
 differing in this respect from the ill-defined margin present in patches of 
 ordinary eczema of this region. Small bluish-white islands of epidermis 
 are scattered over this red and oozing surface, evidences of an attempt at 
 repair. Early in the disease a parchment-like induration, likened by 
 Paget to a penny felt through a cloth, occurs. Itching and burning, 
 frequently severe, and often coming on in paroxysms, are usually present 
 from the very beginning. Retraction of the nipple is a characteristic 
 feature in many cases ; it may be present early and may be followed by 
 its complete disappearance. On the other hand, the nipple may remain 
 prominent throughout the disease. 
 
 After a period varying from some months to several years carci- 
 nomatous change appears, usually beginning upon the ulcerated sur- 
 face as more or less well-defined nodules, or, what is more frequent, 
 as a well-defined lump in the gland tissue, the symptoms then being 
 those usually found in carcinoma of the breast. Deep-seated, stabbing 
 pains, destructive ulceration, and swelling of the axillary lymphatic 
 glands are common symptoms at this stage of the disease. 
 
 Exceptionally it begins elsewhere upon the breast than upon 
 the nipple, as a red, scaly patch with w^ell-defined borders, accom- 
 panied by burning and itching, the whole resembling very closely ordi- 
 nary eczema. The subsequent course of such patches is, however, 
 the same as in those cases in which the affection begins on the nipple 
 and areola. 
 
 While the seat of the disease is in the great majority of cases 
 the female breast, Forrest has reported a case in which a chronic 
 " eczema " situated upon the breast of a man seventy-two years of age 
 was followed by carcinoma. 
 
 The mammary gland is not, however, the only seat of the affec- 
 tion ; it may occur upon other portions of the cutaneous surface. 
 Shortly after the appearance of Paget's communication, in which the 
 disease was described for the first time, other observers began to 
 report isolated cases of an affection presenting the same clinical and 
 histological features as those observed upon the female breast, and 
 up to the present time some eighteen or twenty examples of extra- 
 mammary disease are on record. The back, the arm, the scrotum and 
 penis, the buttocks (Fig. 215) have all been the site of the malady. 
 It is worthy of note that of eighteen cases of extramammary Paget's 
 disease collected by the author in 1910, no less than nine were sit- 
 uated on the external genitalia or in regions immediately adjacent 
 thereto, and five of these nine were situated on the glans penis. These 
 extramammary cases differ but little, if at all, from the disease as 
 found upon the breast. 
 
 It is a somewhat remarkable fact that in no less than 75 per cent. 
 of all the cases observed the right breast was affected. With very few 
 exceptions, it is confined to one side. 
 
 The average time at which cancer of the mammary gland appears 
 39 
 
610 
 
 DISEASES OF THE SKIN 
 
 is from six to seven years after the first cutaneous symptoms, although 
 this period varies within wide limits. In the fifteen cases which served 
 as the basis of Paget' s account of the disease, cancer developed in 
 all within two years, in most of them at the end of one year. Jami- 
 son observed a case in which the first symptom of cancer appeared 
 twenty years after the beginning of the malady, while Duhring has 
 reported one in which a period of ten years elapsed before carcinoma 
 appeared. 
 
 Etiology. — Age and sex are important predisposing causes. Wick- 
 ham found that almost 53 per cent, of the twenty-three cases col- 
 lected by him occurred between the ages of fifty and sixty. It is prac- 
 tically confined to women, its occurrence in men being altogether ex- 
 ceptional, and in most cases it is observed in those past the meno- 
 
 FiG. 215. — Paget 's disease of the buttocks. 
 
 pause, although it may occur very much earlier than this period. Re-, 
 peated or long-continued irritation of any sort, no doubt, plays an 
 important role in the production of the disease. The numerous slight 
 injuries inflicted upon the nipple during nursing are not uncommonly 
 its starting point. At one time it was regarded as due to the invasion 
 of the skin by psorosperms, but this was soon shown to be erron- 
 eous, the so-called psorosperms being nothing more than degenerated 
 epithelium. 
 
 Pathology. — There is considerable divergence of opinion among 
 those who have studied its pathology concerning the nature of the 
 malady and the character of the histological changes present. Butlin, 
 who examined the cases upon which Paget based his early descrip- 
 tion, considered the changes in the epidermis as the same in character 
 as those in the ducts. Thin, who proposed the name malignant papil- 
 
NEW GROWTHS 611 
 
 lary dermatitis for the malady, believed it due to cancerous change 
 beginning near the mouths of the milk-ducts, spreading thence to the 
 mammary gland. In 1889 Darrier announced that the affection was 
 a psorospermosis, and that the peculiar round bodies found in the 
 epidermis were protozoa; in this opinion he was supported by Wick- 
 ham. Subsequent investigation, however, soon proved the erroneous- 
 ness of this opinion. Jacobaeus thinks it carcinoma which has its 
 origin in the epithelial lining of the excretory ducts of the gland ; he 
 regards the peculiar cells in the epidermis, not as degenerated rete 
 cells, but cancer cells which have emigrated into the epidermis from 
 the ducts ; Hirschel is of the same opinion. Unna looks upon it as 
 a disease sui generis, neither cancer nor eczema, which leads onlv 
 
 x: 
 
 
 «£fe&£? 
 
 §2^ 
 
 Fig. 216. — Paget's disease of the breast. Rete mucosum greatly broadened and filled with numerous 
 
 large vacuolated epithelial cells. 
 
 indirectly to cancer. Although at first inclined to agree with this 
 view of Unna, the author's studies of the malady lead him to the 
 conclusion that it is carcinoma from the beginning and that the pecul- 
 iar epitheliar cell-changes should be regarded as cancerous in their 
 nature. 
 
 The earliest changes are found in the epidermis. The rete is 
 greatly broadened and many of its cells exhibit peculiar and char- 
 acteristic changes (Fig. 216). They have lost their prickles and are 
 enormously enlarged, these changes being due, according to Unna, 
 to intracellular oedema. They resemble round or oval cavities in 
 which lie one, two, or three large well-stained nuclei. When a number 
 of adjacent cells undergo this transformation they produce a coarse 
 mesh-work in which are scattered nuclei. At times these areas of cell 
 degeneration are separated from one another by rows of apparently 
 
612 DISEASES OF THE SKIN 
 
 normal cells in such a manner as to give rise to an alveolated ap- 
 pearance of the rete. 
 
 In the very early stages of the disease there is but little change 
 in the corium, but later the papillary and subpapillary regions are 
 occupied by a dense cellular exudate composed of lymphoid cells, 
 plasma cells, and a considerable number of mastzellen. Unna describes 
 this exudate as made up entirely of plasma cells, a pure plasmoma, 
 which acts as a barrier to cancer extension, but in all the sections 
 which the author has examined this was not found to be the case, 
 but lymphoid cells were always present along with plasma cells. 
 
 The cancerous changes which take place in the milk-ducts and 
 in the gland tissue in the final stages of the disease do not differ from 
 those present in ordinary cancer of the breast. 
 
 Diagnosis. — In the early eczematoid stage the differentiation of 
 Paget's disease from eczema of the areola and nipple, the malady for 
 which it is most likely to be mistaken, may at times be extremely 
 difficult, but the former occurs in the majority of cases in those past 
 the menopause, while the latter is seen most frequently during the 
 child-bearing period and especially during lactation. 
 
 In Paget's disease the border of the patch is sharply circumscribed 
 and at times slightly elevated, and upon palpation is found to be 
 slightly indurated, while in eczema the patches are apt to be diffuse 
 and without induration. In Paget's disease the surface of the patch 
 is bright red, granular, with superficial ulcers here and there, while in 
 eczema ulceration is never present. 
 
 When it occurs in regions other than the breast a positive diagnosis 
 may be impossible in the early stages without a biopsy. 
 
 Prognosis. — The prognosis is always serious, but if treatment is 
 instituted early a cure may take place. In cases which have existed 
 for any length of time carcinoma of the gland is almost certain to 
 follow, and the prognosis is then that of cancer of the breast. 
 
 Treatment. — In the early stages of the affection trial may be made 
 of the X-ray or of radium and a symptomatic cure may be obtained. 
 In a few instances permanent cure has followed the employment of the 
 former. In cases which have existed for some time, or if there is 
 the slightest induration in the tissue of the mammary gland, complete 
 removal of the breast should be advised without further delay. 
 
 XERODERMA PIGMENTOSUM 
 
 Synonyms. — Dermatosis Kaposi ; Melanosis lenticularis Progres- 
 siva; Liodermia essentialis cum melanosi et telangiectasia; Atropho- 
 derma pigmentosum ; Epitheliomatose pigmentaire. 
 
 Definition. — A chronic malignant disease distinguished by freckle- 
 like pigmentation followed by atrophy of the skin, telangiectases, and 
 in its final stages, by epitheliomatous tumors. 
 
 This remarkable and grave malady was first described by Kaposi, 
 in 1870, his description being based upon two cases observed in Hebra's 
 
NEW GROWTHS 613 
 
 clinic. Although a rare condition, more than a hundred cases have been 
 reported since Kaposi first called attention to it. 
 
 Symptoms. — Authors differ somewhat in their account of the first 
 symptoms of this affection, most probably owing to the fact that it 
 seldom comes under the physician's observation in its earliest stages. 
 
 In a certain proportion of cases the first manifestation of the dis- 
 ease is a patchy or diffuse redness, or much less commonly an erysipe- 
 latous or eczematoid dermatitis accompanied by vesiculation, situated 
 upon the face and hands. These symptoms are seldom of long dura- 
 tion, a week or two, and are followed by scaling and pigmentation. 
 They are apt to occur in the summer season or after exposure to the 
 rays of the sun ; and sometimes disappear in the winter or at least 
 become much less marked. In most cases, however, the first evidence 
 of the disease noted is pigmentation resembling the ordinary freckle, 
 situated upon exposed parts of the skin, the pigmented patches varying 
 in color from a light fawn color to a decided brown and in size from 
 a pin-head to a large pea. These are scattered over the face, neck, ears, 
 upper part of the chest and back, hands and forearms, and grow darker 
 as they grow older. With the progress of the affection they are no 
 longer limited to the uncovered parts of the skin, but appear upon the 
 trunk and lower extremities ; and by multiplication and increase in size 
 extensive pigmented areas may eventually be formed. In the early 
 stages this pigmentation like ordinary freckles may diminish sensibly 
 in the winter season and be much more noticeable after exposure to the 
 sun, but eventually it becomes permanent, uninfluenced by season. 
 Similar lesions may also occur upon the mucous membranes of the lip 
 and tongue and upon the conjunctiva. 
 
 Coincidently with this pigmentation, or subsequently to it circum- 
 scribed white atrophic patches, sometimes smooth and glistening, or 
 wrinkled, and covered with a thin scanty scale, appear on the face 
 and hands, later on other portions of the cutaneous surface, some- 
 times situated on skin previously normal in appearance at other times 
 in the pigmented areas. These patches increase in numbers and size 
 so that eventually large areas of the skin become atrophic, dry, wrinkled 
 and scaly, giving to the patient's face the appearance of premature 
 senility (senilitas prsecox). 
 
 Along with this atrophy numerous telangiectases make their 
 appearance either in the atrophic patches or about their borders or in 
 the pigmented areas. These are punctate or stellate, occasionally 
 elevated, in the last case forming small angiomata like those fre- 
 quently seen in elderly or old individuals ; and similar vascular lesions 
 may occur upon the mucous membranes of the lips, gums and 
 conjunctiva. 
 
 Keratosic patches resembling those so common on the faces of the 
 aged, wart-like elevations and variously sized tumors of an epithelio- 
 matous character after a variable time, appear the last-named lesions 
 eventually undergoing ulceration. 
 
614 DISEASES OF THE SKIN 
 
 Conjunctivitis with extreme photophobia and lachrymation is an 
 early and frequent symptom ; and this commonly terminates in kera- 
 titis with corneal opacity and serious interference with vision. Ec- 
 tropion is likewise a common condition. 
 
 The course and evolution of the malady present a number of varia- 
 tions. While usually steadily progressive, it is marked at times by 
 periods of quiescence or temporary arrest and the sequence of the 
 various symptoms is not always the same. In some cases the atrophic 
 symptoms may be but little marked while in others they may be the 
 best developed, and in some one or the other of them may be either 
 absent or but little pronounced. The epitheliomatous stage may be 
 long delayed or may be absent as in the cases of Duhring, White and 
 others. Its course is a markedly chronic one usually lasting a number 
 of years, although it may terminate within a year or two. In the vast 
 majority of cases it begins in the first two years of life, sometimes 
 as early as the fifth or sixth month, and according to Pick it may be 
 congenital. Exceptions to this, however, are occasionally observed : 
 Falco saw it in several instances in individuals between the ages of 
 seventy and ninety. In these very old cases the keratosic and atrophic 
 symptoms predominate. 
 
 In the early stages the patient's general health is unimpaired, but 
 with the appearance of the epitheliomatous stage and ulceration a 
 cachectic condition gradually develops which eventually terminates in 
 death. 
 
 Etiology. — Sex is without influence upon its incidence. As already 
 noted the great majority of the cases occur in infancy and childhood. A 
 notable tendency to occur in several members of the same family has 
 been frequently observed, but there is little or no evidence that hered- 
 ity plays any part in its production. We have no knowledge of the 
 direct causes ; but that it is due to some congenital defect in the skin 
 seems most likely. 
 
 The resemblance of the changes in the skin to those seen in those 
 much exposed to sun and wind, sailor's skin of Unna, and more par- 
 ticularly, to the changes which result from chronic X-ray dermatitis, 
 suggest the great probability that light plays an important role in 
 the causation of the disease, and that it may accordingly be due to a 
 congenital deficiency in the skin of the apparatus intended to protect 
 it from the injurious light rays. 
 
 Pathology. — The pathological changes are numerous and varied, 
 as might be expected from the variety of clinical symptoms observed 
 during the course of the disease. 
 
 But few observations are at hand concerning the earliest or hyper- 
 semic stage, as there is seldom opportunity to study it during this 
 period. Leukasiewicz found a collection of round cells about the 
 vessels and glands of the papillary and subpapillary layers of the 
 corium and serous infiltration of the papillary body with dilatation 
 of its capillaries and swelling of their endothelia. 
 
NEW GROWTHS 615 
 
 In the pigmented patches brown pigment granules are found in 
 great abundance in the epidermis situated both intra- and extra-cellu- 
 larly, but most abundant in the basal-cell layer. Pigment is also present 
 in the lymph-spaces of the papillary body and in the connective-tissue 
 cells. 
 
 In the white areas Ehrmann finds evidences of a high degree of 
 degenerative atrophy. There is thinning of the rete Malpighii with 
 increase in thickness of the horny layer. The most marked changes, 
 however, are found in the cutis in which both the collagen and the 
 elastin have undergone extensive degenerative alterations. Unna, 
 however, does not regard the changes found in these patches as indica- 
 tive of atrophy, but thinks they resemble much more those found in 
 certain cases of circumscribed scleroderma. 
 
 The tumors characteristic of the final stage of the malady are 
 according to most authors epitheliomatous, presenting the usual feat- 
 ures of epithelioma, although a considerable number of other new 
 growths have been described by various authors, such as sarcoma, 
 carcinoma and myxoma; and sometimes a mixture of several of these. 
 Pollitzer, who examined a case of Crocker's, found both spindle-celled 
 and round-celled sarcoma with myxoma and carcinoma. 
 
 Diagnosis. — The picture presented by Xeroderma pigmentosum 
 is so remarkable and so characteristic when fully developed, that mis- 
 takes in diagnosis are not likely to occur. The white patches of 
 atrophy bear some resemblance to those of scleroderma, but the latter 
 are quite firm while the former are soft and pliable, sometimes wrinkled 
 and scaly. The early stage at which they occur and their association 
 with more or less marked pigmentary, vascular and atrophic changes 
 will serve to distinguish the epitheliomatous lesions from those of the 
 ordinary type. 
 
 Prognosis. — The prognosis is always serious, death occurring sooner 
 or later, in most cases as the result of the cancerous lesions. The 
 longer, therefore, the tumor stage is delayed the more favorable the 
 outlook for the prolongation of the patient's life. 
 
 Treatment. — The treatment is to the last degree unsatisfactory. 
 No internal treatment has yet been found which exerts any influence 
 upon the course of the disease. Hyde found the hygienic management 
 of decided value in three patients under his care. The X-ray has been 
 used with favorable results in the treatment of the epitheliomatous 
 lesions by Hyde, Balzer and Merle, Nicolas and Favre, and others, 
 but this agent has had little or no influence on the other symptoms 
 of the disease. 
 
 As a prophylactic measure exposure to the rays of the sun should 
 be avoided, since there is apparently little doubt about the injurious 
 effects of such exposure. 
 
 The telangiectases are not new-formed vessels, but the result of a 
 collateral hyperaemia which produces dilatation of the capillaries 
 around and sometimes in the white atrophic patches. 
 
616 DISEASES OF THE SKIN 
 
 SARCOMA CUTIS 
 
 Synonyms. — Sarcoma of the skin ; Sarcome cutane. 
 
 Definition. — A malignant new-growth composed of embryonic 
 connective-tissue cells occurring in the skin and hypoderm as nodules 
 tumors and flat infiltrations. 
 
 Sarcoma of the skin is a rare affection. It may be primary, or second- 
 ary to sarcoma of the viscera or other tissues. The lesions may be soli- 
 tary or multiple, and vary in color from the normal skin through varying 
 shades of red, blue and brown to black, the color depending chiefly upon 
 the degree of vascularity and the presence of pigment. It varies much 
 in its clinical features and course, so that a satisfactory clinical classi- 
 fication is difficult, but for purposes of description the classifications of 
 Perrin or De Amicis, which resemble one another in their principal 
 features, may be followed. De Amicis divides sarcoma of the skin into 
 three groups : First, the non-pigmented forms with a solitary lesion or 
 multiple lesions ; second, melanotic forms ; third, the idiopathic multiple 
 hemorrhagic sarcoma of the type described by Kaposi. 
 
 Non-Pigmented Sarcoma. — Symptoms. — Non-pigmented sarcoma of 
 the skin occurs as rather firm, pea- to nut-sized nodules and tumors situated 
 in the derma or in the subcutaneous tissue. When in the latter situation 
 the skin is usually movable over the lesions at first and is often unchanged 
 in color, but with the growth of the tumors the skin becomes red or 
 violaceous and adherent. They increase in size slowly or rapidly, often 
 slowly in the early rapidly in the later stages, and their number varies 
 from a single one to scores and hundreds. Occasionally the disease exists 
 as a single small tumor for a considerable time, but in most cases 
 new lesions appear sooner or later, either in the immediate neigh- 
 borhood of the primary one or some distance from it ; and in some 
 instances hundreds of tumors appear in every region of the skin 
 constituting a general sarcomatosis. In the earlier stages of the 
 malady some of the tumors occasionally undergo spontaneous invo- 
 lution, disappearing completely ; in the later stages ulceration of 
 some of them takes place, although this is infrequent. 
 
 The course and evolution of the affection varies a good deal. It 
 may remain without much change for months or even a year or two; 
 but usually the tumors multiply, and increase in size, visceral metas- 
 tases occur involving the lungs, kidneys, spleen, liver and brain, and 
 death speedily follows. Unlike carcinoma, sarcoma rarely invades 
 the glandular system ; when it does, it does so only in its latest 
 stages. 
 
 Occasionally sarcoma of the skin follows a visceral sarcoma; and 
 in that event the tumors are usually numerous and widely distrib- 
 uted. In a woman, about forty years of age, under my observation 
 some years ago, who had been ill for some months with obscure 
 symptoms, hundreds of pea- to cherry-sized nodules suddenly ap- 
 peared in the skin and hypoderm along with urgent dyspnoea; death 
 
NEW GROWTHS 617 
 
 followed in a short time, and the autopsy revealed a sarcoma as large 
 as a small orange in the left kidney. 
 
 The affection described by Hutchinson as " recurrent fibroid of 
 the skin " was regarded by Crocker as a form of spindle-celled sar- 
 coma. It usually begins on the lower extremities and spreads slowly. 
 Removal is followed by speedy recurrence ; eventually it becomes 
 generalized, ulceration takes place, and death follows. 
 
 Not uncommonly cases intermediate between those above de- 
 scribed and the hemorrhagic sarcoma of Kaposi occur in which some 
 of the symptoms of both forms are present. In the number, distribu- 
 tion and evolution of the lesions they correspond with the former, 
 but they are more or less pigmented like the latter. Such pigmented 
 forms are to be strictly separated from melanotic sarcoma; the pig- 
 mentation is due to the deposit of blood pigment in the tissues and 
 not to melanin which is found in the melanotic variety, and they are 
 much less malignant. 
 
 Melanotic Sarcoma. — This variety of sarcoma, which represents 
 one of the most deadly of all the malignant growths, when it occurs 
 as a primary affection in the skin, begins in most cases in a pig- 
 mented nsevus which may have existed for many years without show- 
 ing any signs of growth ; or it may be secondary to a sarcoma originat- 
 ing in some normally pigmented tissue such as the choroid. It may 
 begin as a small round or oval, brown or black tumor frequently not 
 larger than a large pea, as a smooth brown or slate-colored non- 
 elevated pigmentation, or as a flat verrucous pigmented patch. In 
 the beginning it is apt to grow slowly, but after a period varying 
 from some months to a year or two, usually as the sequel of some 
 irritation or slight traumatism, it rather suddenly begins to increase 
 in size; secondary lesions appear either in the immediate neighborhood 
 of the primary one or some distance from it, sometimes in great 
 numbers; the lymphatic glands are invaded, visceral metastases occur 
 and death soon follows. 
 
 Formerly all the malignant pigmented growths of the skin having 
 their origin in pigmented nsevi were classified as sarcoma, but the 
 studies of Unna, Gilchrist and others, as has been observed else- 
 where, have shown quite conclusively that most, if not all, of them are 
 epithelial growths and therefore carcinoma, not sarcoma. My own 
 limited studies of such cases have convinced me of the correctness 
 of this view (vid. Nsevocarcinoma). 
 
 As melanotic whitlow Hutchinson described a form of melanotic 
 sarcoma which begins as a chronic inflammation of the nail ; this 
 gradually develops into a fungating slightly pigmented tumor fol- 
 lowed in time by secondary growths. 
 
 Idiopathic Multiple Hemorrhagic Sarcoma (Kaposi). — Kaposi first 
 called attention to this affection in 1872, giving it the name idiopathic 
 multiple pigmented sarcoma which a little later he changed for the name 
 
618 DISEASES OF THE SKIN 
 
 by which it is now known. It begins almost invariably upon the ex- 
 tremities (Fig. 217) as more or less deeply pigmented and infiltrated 
 patches of variable size and shape followed in time by nodules and small 
 tumors which when numerous and closely aggregated form thick plaques 
 of considerable size with uneven surface. Upon the backs of the 
 hands and tops of the feet it usually occurs as a uniform slate-colored or 
 violaceous rather firm infiltration without any indication of tumor forma- 
 tion. Some of the tumors are very vascular, resembling angiomata ; 
 and firm pressure upon them produces a noticeable diminution in 
 their size. 
 
 The mucous membranes are sometimes implicated along with the 
 skin and at a comparatively early period, pigmented patches appear- 
 ing on the inside of the lips, cheeks and on the hard and soft palate. 
 
 Subjective symptoms are usually slight, although quite severe pain 
 sometimes attends the appearance of the lesions which usually sub- 
 sides when they are fully developed. In a case of my own severe 
 itching accompanied the first appearance of the disease upon the feet 
 and continued for some time after the disease was well established, 
 but at no time did the patient complain of pain. 
 
 The extent of the disease varies considerably. In some cases 
 there are a few pigmented patches of moderate size situated usually 
 upon the legs, while in others and in advanced stages not only the 
 extremities, but the face, ears and trunk are affected. 
 
 Its course is usually slow, lasting from three or four to twenty years 
 or even more. In the case above referred to (see Fig. 217) ) it lasted for 
 twenty years without appreciably affecting the patient's general 
 health. New pigmented patches and nodules continue to appear 
 while the old ones slowly increase in size. As in other forms of sar- 
 coma, spontaneous involution of a nodule or tumor sometimes occurs; 
 the pigment begins to fade, the nodule becomes less prominent, the 
 skin over it becomes somewhat scaly, and eventually a depressed scar- 
 like patch is all that remains. In the late stages ulceration may occur, 
 but this is decidedly uncommon. In the final stage metastases in- 
 volving the viscera occur, and the bones may be attacked. Bern- 
 hardt and Hille have reported cases in which some of the tarsal and 
 metatarsal bones were more or less completely destroyed. When 
 visceral metastases take place death soon follows. 
 
 Etiology. — The cause of sarcoma is unknown. It may occur at 
 any age, and both sexes are equally liable to it. In the melanotic 
 variety originating in a pigmented nsevus injury or repeated irritation 
 frequently serves to start it. In hemorrhagic sarcoma of the Kaposi 
 type prolonged exposure to severe cold has preceded the appearance 
 of the malady in a certain proportion of cases (Semenow, Jackson). 
 
 Pathology. — Sarcoma is a connective-tissue neoplasm composed 
 of small or large, round or fusiform cells surrounded by a delicate 
 
NEW GROWTHS 
 
 619 
 
 reticulum. In the non-pigmented forms the cells are as a rule of the 
 small fusiform type, much less commonly they are of the small round 
 variety. In fibrosarcoma there is a considerable amount of fibrous 
 
 Fig. 217. — Idiopathic multiple hemorrhagic sarcoma. 
 
 tissue and the cells are usually fusiform. 
 
 In melanotic sarcoma the cells may be large and round or small 
 
620 
 
 DISEASES OF THE SKIN 
 
 and fusiform. In those which begin in pigmented naevi they are large, 
 round and contained in alveoli, reproducing to some extent the struc- 
 ture of the nsevus in which they have had their origin. In the second- 
 ary form following sarcoma of normally pigmented tissues like the 
 choroid, the cells are of the fusiform variety. The pigment present 
 ■in these growths, known as melanin, occurs as yellowish-brown 
 granules in and between the cells; it is quite distinct from the blood 
 pigment found in the ordinary pigmented variety. 
 
 Fig. 218. — Multiple pigmented hemorrhagic sarcoma. A, spindle-cells; B, lacunae filled with blood. 
 
 Low power. 
 
 As already observed the growths which origiriate in pigmented 
 nsevi are almost certainly not true sarcoma, but carcinoma. 
 
 There is some difference of opinion about the exact place which 
 should be assigned to the Kaposi type. While most agree that it is 
 sarcomatous, a considerable minority believe this doubtful, and some 
 deny it altogether. De Amicis, whose experience with the disease 
 has been large, perhaps larger than any other author, would place it 
 between granuloma and real sarcoma. Bernhardt believes it sar- 
 coma which has its origin in the perithelium of the blood-vessels. 
 The study of my own case leads me to regard it as a sarcoma of special 
 type in which disease of the blood-vessels have a prominent share. 
 
 In the case previously referred to the pathological changes were 
 
NEW GROWTHS 621 
 
 limited to the corium, the epidermis showing but little alteration 
 beyond a moderate increase in the thickness of the horny layer. The 
 papillary layer had disappeared entirely and the reticular portion of 
 the corium throughout its whole extent was occupied by a cavernous 
 tissue resembling under a low power an angioma (Fig. 218). It 
 contained numerous cavities with thin walls lined by endothelial cells 
 rilled with blood. Between these were islets of round and spindle- 
 cells contained in a rather coarse fibrous mesh-work within and be- 
 tween which was a considerable quantity of brown granular pigment. 
 In most instances the spindle-celled areas surrounded capillaries, the 
 long axis of the cells parallel with the long axis of the vessel. Numer- 
 ous interstitial hemorrhages were present in various parts of the 
 tumor. These changes corresponded in all essential particulars with 
 those described by other observers. 
 
 Diagnosis. — Non-pigmented sarcoma is to be distinguished from 
 fibroma, granuloma fungoides and from leukaemia cutis. The nodules 
 of the first-named are considerably harder than those of sarcoma, are 
 usually of very slow growth, and show no tendency to dissemination. 
 From the two latter the differentiation is not always easy, particularly 
 in the early stages, even with the aid of a biopsy, but the evolution and 
 course pursued by sarcoma is as a rule much more rapid. Melanotic 
 and multiple hemorrhagic sarcoma present such characteristic pictures 
 in most instances that errors in diagnosis seldom occur. 
 
 Prognosis. — The prognosis in every variety of the malady is un- 
 favorable, death being the usual termination, although the period at 
 which this occurs varies much. Fibrosarcoma is the least, the mela- 
 notic the most, malignant form, death occurring in the latter in the 
 course of a year or eighteen months, and even earlier. The multiple 
 hemorrhagic variety usually runs a prolonged course of five to ten 
 years or longer, but exceptionally death occurs in the course of a few 
 months. In rare instances, after a considerable duration, spontaneous 
 recovery takes place, as in the cases reported by Hardaway. 
 
 Treatment. — As may be gathered from the foregoing the treatment 
 leaves much to be desired. Surgical removal is usually followed by 
 prompt recurrence, and in the melanotic variety seems to incite the 
 malady to increased activity. Fibrosarcoma is somewhat of an excep- 
 tion, since its thorough removal not uncommonly results in a cure. 
 
 Arsenic given internally seems at times to exert a favorable in- 
 fluence upon the tumors, but as has already been noted these sometimes 
 undergo spontaneous involution ; and it is always difficult to determine 
 just how much of the favorable course of the malady in those taking 
 arsenic is to be attributed to the drug. In recent years a considerable 
 number of cases of sarcoma have been reported in which the neoplasm 
 has disappeared after X-ray treatment. In a case of the multiple 
 hemorrhagic tvpe I observed considerable improvement in all the 
 symptoms for a time ; and others have reported encouraging results 
 from the use of this agent. It should always be given a thorough trial. 
 
622 
 
 DISEASES OF THE SKIN 
 
 LEUKiEMIA CUTIS. PSEUDOLEUKEMIA CUTIS 
 
 Leukaemia and pseudoleukemia are at times accompanied by cuta- 
 neous eruptions of diverse kinds, by tumor-like infiltrations of the skin 
 and by actual tumors situated in the skin and subcutaneous tissues. 
 According to Pinkus the cutaneous lesions of leukaemia may be divided 
 into three groups: first, leukaemic tumors; second, a more or less 
 generalized dermatitis followed in time by tumors, of which the 
 lymphodermia perniciosa of Kaposi is the type ; third, exudative erup- 
 
 Fig. 219- — Leukaemia cutis. Numerous pruritic nodules; patient presented blood-picture character- 
 istic of lymphatic leukaemia. 
 
 tions, mostly of an urticarial type, produced only indirectly by the 
 leukaemia, in which leukaemic tissue is not present and in which tumor 
 formation is rare. For this last group Audry has proposed the name 
 " leucemides." 
 
 In acute lymphatic leukaemia hemorrhages into the skin, varying 
 from petechiae to extensive extravasations, accompanied by hemor- 
 rhages from the mucous membranes of the mouth, nose, bladder, 
 vagina and the gastro-intestinal canal, frequently occur. When these 
 hemorrhages are large they may result in destructive necrosis of the 
 skin and mucous membranes. In chronic lymphatic leukaemia pruritus 
 of varying degrees of severity, and eruptive lesions most commonly 
 
NEW GROWTHS 
 
 623 
 
 of urticarial type, but occasionally erythematous, vesicular, or nodular, 
 may occur (Fig. 219). x\.n extensive dermatitis characterized by dry, 
 red and scaling, or moist and oozing patches resembling eczema, accom- 
 panied or followed by flat, ill-defined, red or brownish-red infiltrated 
 areas and tumors which tend to undergo ulceration — is at times present. 
 This last frequently bears a close resemblance to granuloma fungoides 
 and is probably identical with the affection described by Kaposi under 
 the title lymphodermia perniciosa. Actual tumor formation, the tumors 
 
 Fig. 220. — Leukaemia cutis. Dense infiltrate of lymphoid cells in the corium. Section of nodule 
 
 from case shown in Fig. 219. 
 
 situated most frequently in the face, less commonly on the trunk and 
 extremities, may occur. These are red or violaceous in color, of vary- 
 ing dimensions, and after reaching a certain size usually show but 
 little change for an indefinite period ; as an exceptional occurrence 
 ulceration takes place. 
 
 In myelogenous leukaemia the skin is pale and dry. but eruptions 
 are much less frequent than in the lymphatic variety although nodular 
 lesions and, in rare cases, tumors may occur. 
 
 In pseudoleukemia (Hodgkin's disease) cutaneous symptoms much 
 like those already described as occurring in lymphatic leukaemia are 
 
624 DISEASES OF THE SKIN 
 
 occasionally present. Pinkus regards the former as identical, both 
 clinically and histologically with the latter. 
 
 Etiology. — The eruptions and tumors are dependent upon the gen- 
 eral blood disorder whose cause is unknown. The recent discovery 
 of a diphtheroid bacillus in the blood of individuals suffering from 
 pseudoleukemia makes it probable that this affection is an infection, 
 but the etiological relationship of this organism to the malady is not 
 yet definitely established. 
 
 Pathology. — According to Pinkus leukemic tumors, which are 
 situated in the corium and hypoderm, are lymphatic granulation tissue 
 composed of lymphocytes, which arise from the abnormal growth of 
 traces of lymphatic tissue normally present in the skin. These accu- 
 mulations of lymphocytes are present not only in the infiltrations and 
 tumors, but also in those eruptions which present no symptoms of 
 infiltration (Fig. 220). They are absent, however, as a rule, in the 
 eruptions of the third group. 
 
 Diagnosis. — Since the leukemic eruptions as a rule present nothing 
 characteristic of the general condition with which they are associated 
 their true nature is very apt to be overlooked or misapprehended. 
 The chronic multiform dermatitis with infiltrations and flat tumors, as 
 already observed, bears a very close resemblance to granuloma fun- 
 goides, and can only be differentiated from that affection by a study of 
 the blood, which should never be omitted in such cases. 
 
 Treatment. — The treatment of the cutaneous lesions of leukaemia 
 is, of course, essentially the same as that of the underlying blood dis- 
 order. Quite recently favorable results from the internal administra- 
 tion of benzole (benzene) have been reported by a number of observ- 
 ers, but this remedy is still on trial. The careful and intelligent use 
 of the X-ray is probably the most useful therapeutic measure, especially 
 in the treatment of the tumors and tumor-like infiltrations. 
 
CHAPTER XVI 
 
 NEUROSES 
 
 ANESTHESIA 
 
 Definition. — Loss of sensation. 
 
 Anaesthesia in varying degree accompanies a number of diseases of 
 the skin and those which may affect the skin along with other tissues 
 or systems, such as syphilis and leprosy. It may in rare instances 
 occur as an idiopathic affection, but is usually symptomatic, and is 
 in most instances a symptom of disease of the central or peripheral 
 nervous system. It may be, in exceptional cases, quite general, but 
 is much more frequently limited to certain districts or to the area of 
 distribution of definite nerve branches. It varies all the way from 
 slight numbness to complete loss of sensibility. Occasionally there is 
 dissociation of sensibility, as in Morvan's disease, or syringomyelia, 
 in which with retention of tactile sensibility there is complete loss of 
 temperature sense and sensibility to pain ; or there may be complete 
 tactile anaesthesia with severe pain (anaesthesia dolorosa, Romberg). 
 The loss of sensation may be accompanied by structural changes in the 
 skin or there may be no demonstrable alteration in its structure. It 
 is a common manifestation of hysteria in which it is often complete ; 
 it may occupy the half of the body, hemianaesthesia, or all of it, or it may 
 occur in irregular areas without any definite relation to nerve dis- 
 tribution ; it is apt to shift its location and to vary much in degree 
 from time to time. 
 
 The prognosis depends altogether upon the nature of the affection 
 of which it is a symptom. The treatment belongs to the neurologist 
 rather than the dermatologist. 
 
 HYPERESTHESIA 
 
 Definition.— Abnormal sensibility of the skin. 
 
 Abnormal sensibility of the skin may occur independently of any 
 other manifestation of disease, but is in the great majority of cases 
 symptomatic, usually of some affection of the nervous system, central 
 or peripheral. It presents all degrees of severity from mere discom- 
 fort to acute pain which may be produced by the slightest touch or by 
 contact with the clothing in severe cases. It may occupy small or 
 large areas of the skin, and in exceptional cases may be more or less 
 general. The increased sensitiveness may be confined to the touch, or 
 it may affect the temperature sense as well or exclusively. It is a 
 common symptom of hysteria in which, like all other symptoms of that 
 protean affection, it may exhibit all kinds of variations as to degree, 
 distribution, situation and duration. It may be a temporary symptom 
 or it may last indefinitely. 
 
 40 625 
 
626 DISEASES OF THE SKIN 
 
 The prognosis and treatment are essentially the same as those of 
 the diseases with which it is associated. 
 
 PRURITUS 
 
 Synonym. — Itching. 
 
 Definition. — An affection characterized by itching without visible 
 or palpable signs of disease in the skin. 
 
 Symptoms. — Itching is a very frequent concomitant of many dis- 
 eases of the skin, chiefly those of an inflammatory character, such as 
 eczema, lichen planus, urticaria, and is one of the principal symptoms 
 of such parasitic diseases as scabies and pediculosis ; but it may occur 
 quite independently of such, without other symptoms, constituting a 
 disease in itself. Pruritus as a primary or independent affection may 
 affect the entire cutaneous surface more or less, Pruritus universalis, 
 or it may be confined to certain regions, Pruritus localis ; the latter is 
 much the more frequent variety and shows a decided preference for 
 certain localities. 
 
 Pruritus Universalis. — The affection usually comes on quite in- 
 sidiously with sensations of itching, stinging, creeping, formication, 
 which may be more or less continuous, but are much more apt to occur 
 in paroxysms coming on at irregular intervals, and which are almost 
 invariably greatly aggravated at night, beginning often with the 
 removal of the clothing upon retiring. Not all portions of the skin 
 are affected at the same time, but the itching shifts about, now affecting 
 the face, now some portion of the trunk, and again the extremities. It 
 exhibits the widest variation in its intensity; in mild cases it is but a 
 trifling annoyance, in severe ones it makes sleep and rest well-nigh 
 impossible and drives the patient to the most violent scratching in his 
 efforts to obtain relief which is only obtained, and then for but a brief 
 period, when the skin is torn and bleeding. In the latter case parts 
 accessible to the patient's fingers are covered with linear excoriations, 
 and sooner or later eczematous patches which ooze and crust, thicken- 
 ing and pigmentation appear as the result of the long-continued violent 
 irritation. A more or less generalized pruritus is common in the 
 elderly and aged, pruritus senilis. It is often of a severe type, causing 
 the patient great distress, and may or may not be associated with more 
 or less pronounced evidences of senile change in the skin. 
 
 Under the name pruritus hiemalis Duhring some years ago de- 
 scribed a form of itching which, coming on in the autumn, continues 
 until the return of warm weather. Although usually most pronounced 
 on the legs, it is not confined to these regions, but occurs upon the 
 trunk and upper extremities as well. It is commonly quite severe 
 and is frequently followed by eczematous changes, especially upon 
 the legs, the result of scratching. " Prairie itch," " swamp itch," " lum- 
 berman's itch," are in all probability examples of the same affection. 
 
 As bath pruritus Stelwagon has called attention to a form which 
 follows bathing. The itching usually comes on immediately after 
 leaving the bath, and may be slight or severe. While it may be limited 
 
NEUROSES 627 
 
 to the lower extremities it frequently affects the trunk or the entire 
 body, and may last from a few minutes to two or three hours. In a 
 case under the author's care the itching was well-nigh intolerable and 
 lasted for three or four hours so that bathing was a severe ordeal. 
 
 Pruritus Localis. — As already observed, the local forms of pruritus 
 are especially prone to affect certain regions, those most frequently 
 affected being the anus and the genital region of both sexes ; much less 
 commonly the itching is confined to the legs, to the palms and soles, 
 to the face, especially about the nose, and to the scalp. 
 
 Pruritus Ani. — This is one of the commonest forms of localized 
 pruritus. The itching is often of the severest character, coming 
 on in paroxysms which compel the patient to scratch regardless of 
 place and surroundings. As a result of this violent scratching the 
 anus and the parts immediately around are excoriated, the skin is thick- 
 ened and forms radiating folds at the muco-cutaneous junction, which 
 are often whitish from maceration. The itching frequently extends 
 forward to the perineum w T here the same eczematous changes are 
 soon produced. The scrotum is likewise often the seat of pruritus, 
 pruritus scroti, but, owing to the delicacy of the skin in this region, 
 inflammatory changes with thickening and oozing soon appear. 
 
 Pruritus Vulvas. — One of the most distressing of all the local forms 
 of pruritus occurs on the vulva. The itching affects not only the 
 cutaneous surface, but the mucous membrane of the labia and the 
 parts about the clitoris and occasionally extends well within the vagina. 
 It usually comes on paroxysmally and is often atrocious, driving the 
 patient during the paroxysms almost insane, and often making a com- 
 plete nervous wreck of her. 
 
 Etiology and Pathology. — Generalized pruritus is in many cases, if 
 not in most, due to toxic substances of unknown nature, either formed 
 in and absorbed from the gastro-intestinal canal or produced in the 
 economy by metabolic disturbances. It is frequently associated with 
 hepatic disease, functional or organic, and is a frequent concomitant of 
 jaundice ; it is also at times associated with disease of the kidneys, of 
 the uterus and ovaries, and with pregnancy. In the last-named it may 
 be reflex, or what is more common, the result of the formation and 
 retention of toxic substances which occur so frequently in this con- 
 dition. In a certain proportion of cases it is due to the ingestion of 
 certain articles of food, especially shell-fish, and to drugs, such as opium 
 and its alkaloids and cocaine, the last-named at times producing all 
 kinds of anomalous sensations of creeping and crawling accompanied 
 by delusions of insects or foreign bodies in the skin. In a case of 
 severe general pruritus under the author's care some years ago it was 
 learned that the patient was in the habit of taking one or two small 
 doses of opium daily for the control of a chronic diarrhoea; with the 
 suspension of the opium the pruritus which had tormented the patient 
 for many years completely disappeared. Tea, coffee, alcohol and 
 tobacco are in many cases predisposing, if not direct, causes of both 
 local and general itching. The author has knowledge of an instance 
 
628 DISEASES OF THE SKIN 
 
 in which the smoking of a strong cigar after dinner in the evening was 
 invariably followed by pruritus of the anus lasting throughout the 
 night. In a small proportion of cases the itching is associated with dis- 
 ease of the central nervous system. Kobner has reported a case of 
 severe unilateral itching with suppression of sweat on the paralyzed 
 side after cerebral embolism ; and Sarbo (quoted by Sack) observed 
 incoercible pruritus in several cases of beginning progressive paralysis 
 Senile pruritus is commonly attributed to senile changes in the skm, 
 but in many cases the skin presents no visible abnormality. In pruri- 
 tus ani and pruritus vulvae some local disease may be the exciting 
 cause ; in the former haemorrhoids, fissure ascarides, in the latter, 
 leucorrhcea may be the exciting cause. Pruritus vulvae may occur 
 at the menopause as a reflex symptom. Only too often, however, 
 no cause can be found in both the universal and local forms. 
 
 The affection is a functional disturbance of the nerves of the skin 
 unattended by any discoverable alteration — a sensory neurosis. As 
 has already been pointed out, in long-standing cases inflammatory 
 changes appear sooner or later in the skin as the result of scratching. 
 
 Diagnosis. — Itching without any eruption of any sort is so charac- 
 teristic of the affection that the diagnosis in uncomplicated cases is 
 made without difficulty. General pruritus is most likely to be mis- 
 taken for pediculosis corporis, but the absence of the linear excoria- 
 tions over the shoulders and buttocks so characteristic of the latter, 
 and failure to find the parasite, which should always be looked for in 
 cases of general itching, will serve to exclude the parasitic affection. 
 Urticaria may at times be mistaken for pruritus owing to the absence 
 of the characteristic wheals at the time of the examination, but there 
 is usually a clear history of an eruption which comes and goes in the 
 former. In pruritus ani and pruritus vulvae, as in other forms of local 
 pruritus, the absence of visible change in the skin is diagnostic, but 
 when a secondary eczema has appeared it is often next to impossible 
 to say whether the primary affection was an eczema or pruritus unless 
 the history is very clear. Particular care should always be taken to 
 exclude pediculosis pubis in itching about the genitalia before making 
 a diagnosis of pruritus. 
 
 Prognosis and Treatment. — Pruritus in all its forms is often most 
 rebellious to treatment and usually taxes our therapeutic resources to 
 the limit. Senile pruritus and pruritus of the anus and of the vulva 
 are the most intractable varieties. The last frequently drives its unfor- 
 tunate victims to the verge of insanity, and sometimes over it. When 
 the cause is discoverable and removable the outlook is, of course, much 
 more favorable than when the contrary is the case. 
 
 Treatment should be both general and local. Careful search should 
 always be made for evidence of gastro-intestinal, hepatic or renal dis- 
 ease, and if any of these are present, they should receive appropriate 
 treatment. The urine should invariably be examined for sugar, and if 
 this is present a proper dietary should be adopted. The diet in any 
 case should be most carefully ordered, excluding such articles of food 
 
NEUROSES 629 
 
 as are known to excite at times disturbance in the skin, such as salt- and 
 shell-fish, fresh pork, strong cheeses; complete abstinence from tea, 
 coffee, alcohol and tobacco should be insisted upon. In pruritus ani 
 and vulvae all possible local causes should be carefully looked for, 
 such as haemorrhoids, ascarides, especially in children, anal fissure, 
 and in women disease of the uterus and ovaries, and if found should 
 be given careful attention. 
 
 While internal treatment only too often fails to produce curative 
 effects a number of drugs are more or less serviceable in affording relief 
 from the itching. Cannabis Indica, % to y 2 gr. (0.65 to 0.03) of the 
 extract, three times a day, has often proven of decided value in the 
 author's hands: antipyrin, acetphenetidin, aspirin, or some other form 
 of salicylic acid, are also more or less useful at times in lessening the 
 itching. Sodium bromide, in considerable doses, 20 to 30 grs. (1.30 
 to 2.0) several times a day, is also a useful remedy, and its usefulness 
 may be considerably increased by combining it with cannabis indica. 
 Carbolic acid given carefully in increasing doses, may be employed with 
 good effect ; it should be carefully watched to avoid toxic effects. In 
 some cases pilocarpin has produced good results. Quite recently cal- 
 cium chloride or lactate, in doses of 15 to 20 grains (1.0 to 1.30) three 
 or four times a day, has been highly recommended as a remedy for itch- 
 ing, but the author, who has given it considerable trial, is rather scep- 
 tical about its usefulness. Hypnotics, such as chloral, sulphonal, 
 trional and veronal, may be given, but they usually fail to produce relief 
 unless given in large doses. In the author's opinion opium and its 
 alkaloids are to be used only under very exceptional circumstances ; 
 as is well known, these frequently produce pruritus in certain indi- 
 viduals, and what is much more important, the danger of acquiring 
 the opium habit is too great to justify their use in most instances. 
 Indeed, habit-forming drugs of any kind should be prescribed in so 
 distressing and chronic an affection as pruritus, only after due con- 
 sideration of the dangers attending their use. 
 
 Local treatment is always necessary and is frequently much more 
 effective than the internal treatment. Warm baths, either plain or 
 made alkaline by the addition of bicarbonate or biborate of soda, J4 lb- 
 (80.0), to the bath, are often useful, especially in senile pruritus and 
 their good effects are often considerably enhanced by following them 
 with inunctions of some bland ointment such as cold-cream, or, better, 
 cold-cream and lanoline. In bath pruritus the skin should be quickly 
 and thoroughly dried after the bath and liberally dusted with talcum 
 powder, plain or containing one-half of one per cent, menthol. Woolen 
 underwear should never be worn next the skin, but cotton or silk over 
 which a woolen garment may be worn in cold weather; this is especially 
 important in that form of pruritus which comes on in cold weather 
 (pruritus hiemalis), a form which is most effectively treated by removal 
 to a warmer climate during the winter season. 
 
 By far the most useful local remedies are carbolic acid and menthol ; 
 these may be used as lotions or ointments, the form adopted depending 
 
630 DISEASES OF THE SKIN 
 
 largely upon the extent of surface, to which they are to be applied. 
 The first may be used as a lotion in aqueous solution, varying in 
 strength from 3 to 5 per cent., and it is usually more effective if a small 
 quantity of glycerin is added to it (3 to 4 per cent.). This solution 
 should be mopped or sprayed on the surface several times a day and 
 may be followed by a dusting powder of talc and subcarbonate of 
 bismuth. The antipruritic effect of carbolic acid is usually more pro- 
 nounced when used as an ointment which may be of a strength varying 
 from 2 to 4 per cent., but the ointment should not be applied to large 
 surfaces without caution since toxic effects may be produced by absorp- 
 tion. Bronson advises the following oil containing a large percentage 
 of carbolic acid : 
 
 Acid, carbolic 3i-3H (4-8) 
 
 Liq. potassse f3i (4) 
 
 Ol. lini fSi (32) 
 
 M. 
 
 This mixture should be thoroughly shaken before applying it and 
 should not be applied over very large areas for fear of toxic effects. 
 
 Although menthol is only very slightly soluble in water the follow- 
 ing lotion will often afford great relief from itching, and has the very 
 great merit that it never irritates as many other antipruritic 
 remedies do. 
 
 Mentholis gr. viii (0.5) 
 
 Sodii biborat 3ss (2.0) 
 
 Glyceri f 3ii (4.0) 
 
 Aq. destil . fBviii (250.0) 
 
 M. Filtra. 
 
 Sig. Apply with an atomizer. 
 
 The following ointment is highly recommended by Sack: 
 
 Ung. zinci oxid gr. ccc (20.0) 
 
 Adipis lanae 3ijss (10.0) 
 
 Mentholis gr. xv (10.0) 
 
 Aq. acid, carbolic (6%) fSi (30.0) 
 
 M. 
 
 Lotions of chloral, 2 to 4 per cent., of thymol, 5 per cent., of resorcin, 
 2 to 4 per cent, are likewise more or less useful, especially if they are 
 made up with some alkaline menstruum, such as lime-water. 
 
 Coal tar, as the liq. carbonis detergens, is frequently of great service 
 in relieving itching, especially if combined with carbolic acid or men- 
 thol. The following is a useful formula : 
 
 Liq. carbonis detergentis : fSii (60) 
 
 Mentholis gr. iv (0.25) 
 
 M. et adde 
 
 Glycerin f3ij (8.0) 
 
 Liq. calcis q.s. ad fSiv (120.0) 
 
 In pruritus ani and pruritus vulvae the same local remedies are 
 to be employed. A paste containing from 2 to 4 per cent, of carbol- 
 
NEUROSES 631 
 
 camphor is one of the most valuable local remedies in these most dis- 
 tressing affections. In pruritus vulvae douching the parts with water 
 as hot as can be borne will occasionally bring relief lasting for some 
 hours. Painting the parts with a solution of silver nitrate in spt. 
 etheris nitrosi, 2 to 5 per cent., will occasionally succeed after other 
 remedies have failed, but it, too, often fails. Marked, and occasionally, 
 permanent relief is at times obtained from the X-ray. Lastly, when 
 all other measures have failed to bring relief, divisions or exsection of 
 the nerves supplying the parts may be resorted to. 
 
 DERMATALGIA 
 
 Synonyms. — Neuralgia of the skin ; Rheumatism of the skin ; Fr., 
 Dermalgie. 
 
 Symptoms. — The affection is characterized by pain, unassociated 
 with any visible change in the skin, which is in most cases confined 
 to limited areas of varying extent. The severity of the pain varies 
 from moderate discomfort to excruciating torture, and is described 
 hy the patient as stabbing, burning, or tearing in character. It usually 
 comes on spontaneously, but contact with some foreign body or move- 
 ment may precipitate an attack. The pain may be continuous but is 
 .more frequently paroxysmal and is in most cases decidedly worse at 
 night. More or less hyperesthesia frequently accompanies the 
 neuralgia. 
 
 The term causalgia was employed by Weir Mitchell to designate 
 the peculiar burning pain which accompanies certain affections asso- 
 ciated with disease of the peripheral nerves, such as glossy skin. The 
 author has seen in two instances severe and persistent burning pain 
 in the skin occur as a sequel of zoster which appeared after all visible 
 evidences of disease had entirely disappeared, and persisted for months. 
 The sensation was likened by the patients to that produced by holding 
 a hot iron close to the skin. 
 
 Etiology. — The causes of neuralgia of the skin are frequently 
 obscure. It is more frequent upon the hairy skin than upon smooth 
 parts and usually occurs in middle-aged subjects who are more often 
 women than men. It occasionally follows exposure to cold and is at 
 times associated with rheumatism, chlorosis and hysteria. In a con- 
 siderable proportion of cases it is a concomitant of disease of the cord, 
 such as locomotor ataxia, or of some affection of the peripheral nerves. 
 
 Diagnosis. — It is to be distinguished from hyperesthesia by the 
 existence and continuance of pain independent of contact with some 
 foreign body ; but as in a certain proportion of cases of neuralgia there 
 is also more or less pronounced hyperesthesia an accurate differentia- 
 tion of the two is not always possible. It is also to be differentiated 
 from muscular rheumatism. 
 
 Prognosis and Treatment. — In most instances the affection pursues 
 an irregular and chronic course with periods of remission and exacer- 
 bation. In a certain proportion of cases, however, after some weeks 
 or a month or two it disappears spontaneously. 
 
632 DISEASES OF THE SKIN 
 
 The general treatment is to be directed to the condition with 
 which it is associated. In rheumatic subjects the salicylates should be 
 given, especially aspirin, which often acts most effectively in relieving 
 pain. When the patient is chlorotic, iron, arsenic and cod-liver oil are 
 indicated. When disease of the cord or peripheral nerves is the under- 
 lying affection these are to be treated in an appropriate manner. 
 
 Relief is often afforded by local remedies. The prolonged application 
 of hot water or frictions with liniments containing aconite or chloroform 
 are frequently of service, although the relief thus obtained is apt to be 
 only temporary. Lightly blistering the painful areas will at times pro- 
 duce a favorable effect which is occasionally permanent. 
 
 ERYTHROMELALGIA 
 
 Definition. — A disease characterized by pain and flushing of the 
 extremities. 
 
 Symptoms. — This rare affection was first described by Weir 
 Mitchell, in 1872, as a " rare vaso-motor neurosis " of the extremities, and 
 in a subsequent communication, in 1878, he proposed for it the name 
 erythromelalgia, the name by which it has since been known. 
 
 It is characterized by pain of a burning character in one or both 
 feet, usually some part of the sole, such as the ball of the great toe or 
 the heel, which comes on after walking or prolonged standing. After 
 a time the pain is followed or accompanied by flushing of the affected 
 part which becomes a bright or dusky, mottled red when the patient 
 assumes the erect position ; the superficial vessels stand out promi- 
 nently, the pain becomes of a throbbing character and the temperature 
 of the foot is elevated one or two degrees. When the horizontal posi- 
 tion is resumed the pain and vascular symptoms disappear. The 
 attacks usually, at first come on in the evening, but as the disease 
 continues they appear during other parts of the day. The affection 
 usually comes on gradually, but it may appear quite suddenly, as in a 
 case reported by Gerhardt in which it began in the night with head- 
 ache and vomiting. It is as a rule slowly progressive up to a certain 
 point and then becomes stationary. The pain may be mild or severe, 
 may be limited to the foot, or exceptionally, may extend to the leg. 
 In a few instances the hands as well as the feet have been affected 
 (Gerhardt, Senator). Trophic changes occasionally are observed; 
 Mitchell saw ulceration of the toe occur and Morel-Lavallee has 
 reported trophic changes in the nails, but this case was quite atypical 
 and a doubtful one. 
 
 Etiology and Pathology. — The disease occurs far more frequently 
 in men than in women, and its subjects are usually young adults. It 
 is usually, but not always, worse in summer, and improves with the 
 appearance of cold weather. In a certain proportion of cases it occurs 
 independently of any other discoverable affection, in others it is asso- 
 ciated with symptoms of disease of the cord or of the peripheral nerves. 
 In a number of cases symptoms of Raynaud's disease have also been 
 
NEUROSES 633 
 
 present; indeed, it is occasionally difficult to draw a hard and fast line 
 between the two affections. It has been observed to follow trauma- 
 tism ; in a case recently under the author's observation it followed 
 an injury to the foot. 
 
 Mitchell and Spiller in the histological examination of a toe which 
 had been amputated for ulceration following erythromelalgia found 
 marked degeneration of the nerves ; the connective tissue surrounding 
 the nerve bundles was greatly thickened and many of the nerve 
 fibres had disappeared. There was likewise great thickening of the 
 walls of the arteries and veins, the lumen of the former being occasion- 
 ally occluded. 
 
 Diagnosis. — It may be confounded with gout and rheumatism, but 
 these affections are unaccompanied by the peculiar vascular phenomena 
 which characterize erythromelalgia. At times it may be difficult to 
 differentiate it from Raynaud's disease since, as already noted, symp- 
 toms of both may be present. 
 
 Prognosis and Treatment. — The prognosis as to recovery is un- 
 favorable, but in many instances the affection comes to a standstill. 
 
 The treatment is largely symptomatic, since we know of no remedy 
 which is curative. Antipyrin, phenacetin and aspirin are frequently of 
 decided service in relieving the pain. In a case under the author's care 
 the first-named kept the patient free from pain as long as he continued 
 to take it ; Senator also found it of service. Recently Kanoky and 
 Sutton found short exposures to the X-ray, using a soft tube, useful. 
 
 MERALGIA PARESTHETICA 
 
 Definition. — An affection characterized by abnormal sensations in 
 the region of distribution of the external cutaneous nerve. 
 
 This rare condition which was first described by Bernhardt, in 
 1895, an d shortly afterwards given the name meralgia paresthetica by 
 Roth, is distinguished by sensations of tingling, pricking, tearing, cold 
 or heat, less frequently, itching and pain, situated on the outer surface 
 of the thigh in the region supplied by the branches of the external 
 cutaneous nerve. There is usually some diminution of tactile sensi- 
 bility in the same region. These abnormal sensations usually come 
 on while walking or standing and vary much in degree from mere 
 annoyance to severe discomfort. 
 
 The affection is much more frequent in men than in women ; of 
 iqo cases collected by Musser and Sailer, 75 were men. It has been 
 noted to follow lead-poisoning (Bernhardt), exposure to cold, infec- 
 tious fevers, such as typhoid, and in a considerable proportion of 
 cases, traumatism. All of Oppenheim's cases (quoted by White) 
 occurred in alcoholics. In women it may follow pregnancy. 
 
 Treatment is usually without much effect. In some cases massage 
 has been found useful. Excision of the nerve where it passes under 
 Poupart's ligament has given good results (Osier). Goldberger ob- 
 tained prompt relief in his own person by wearing a metal plate in 
 his shoe for the correction of flat foot. 
 
CHAPTER XVII 
 
 DISEASES OF THE APPENDAGES— MORBI 
 APPENDICIUM 
 
 DISEASES OF THE NAILS 
 
 Diseases of the nails may be congenital or acquired; they may 
 occur independently of other morbid conditions, but are far more 
 frequently secondary to diseases of the skin, for the most part of 
 an inflammatory character. Alterations of the nail itself are, with but 
 very few exceptions, secondary to or a part of pathological changes 
 in the nail-bed or matrix or in the surrounding nail-wall. Such changes 
 may result from injury, may be due to acute local disease, may fol- 
 low acute or chronic general diseases, or may be a part of such gen- 
 eral infections as tuberculosis, syphilis, leprosy. Diseases of the nails 
 occasionally accompany chronic affections of the circulatory system, 
 or follow disease or injury of the central or peripheral nervous systems 
 as a consequence of disturbance of trophic functions. Owing to the 
 very varied character of their etiology, and more particularly because 
 the same condition may arise from diverse causes, the etiological 
 diagnosis is frequently a matter of considerable difficulty. 
 
 ONYCHAUXIS 
 
 Definition. — Overgrowth of the nail. 
 
 Symptoms. — While the nail may be increased in all three direc- 
 tions, the increase is usually most marked in the direction of its 
 length and thickness. The nail-plate is hard, ridged, or quite smooth 
 and shining, and of a yellowish or brownish color. Quite often it 
 is separated from the nail-bed by a considerable accumulation of ill- 
 smelling dry or moist horny epithelial scales, which may be readily 
 scraped out. When the increase in length is considerable, and it 
 may in exceptional cases amount to as much as 6-y cm., the nail is 
 usually twisted on its long axis or curved like a sheep's horn (onycho- 
 gryphosis) (Fig. 221). While the nails of both fingers and toes may 
 exhibit this deformity, it is most frequent upon the latter and usually 
 most marked upon the great toe, to which it may be confined. When 
 the increase in breadth is marked, one or both lateral nail-folds are 
 frequently inflamed and ulcerated owing to the pressure of the edge 
 of the nail-plate (ingrowing nail). 
 
 The number of nails is in rare cases increased, but only as a rule 
 to which the exceptions are extremely rare, in connection with super- 
 numerary fingers and toes. The nails are usually well-developed, 
 but in exceptional cases may be more or less deformed. Occasion- 
 ally nails of abnormal size are observed in syndactylism, a single 
 nail covering two or more fingers. 
 634 
 
DISEASES OF THE APPENDAGES 635 
 
 Etiology. — Onychauxis may be congenital or acquired, the latter 
 being much the more frequent. Wilson has reported a remarkable 
 instance of the congenital variety, corresponding to the hyperkera- 
 tosis subungualis of H. Hebra, occurring in three generations. The 
 nails of all the ringers and toes were thickened and lifted up from the 
 nail-bed by a friable horny mass beneath them ; the condition was 
 present from birth. While the acquired form may occur at almost 
 any age, it is much more frequently seen in the old and feeble, in 
 whom it is often the result of neglect rather than of disease. It 
 occasionally follows injury, some local inflammatory affection of the 
 matrix, or some inflammatory disease of the skin, such as eczema 
 or psoriasis. In chronic disease of the circulatory apparatus in which 
 clubbing of the fingers takes place, there may be a coincident enlarge- 
 ment of the nails ; and thickening and deformity may follow disease 
 or injury of the peripheral nerves. 
 
 Treatment. — The redundant portion of the nail may be removed 
 
 Fig. 221. — Onychogryphosis. 
 
 by the knife or stout scissors when not too thick and hard, first soak- 
 ing the nail thoroughly in a warm solution of bicarbonate of soda 
 or borax. If the nail is very thick it may be necessary to use a small 
 saw or bone-cutting forceps. To prevent recurrence, the nail should 
 be frequently trimmed, and shoes which fit properly and do not 
 press upon the toe unduly should be worn. When the overgrowth 
 is secondary to some inflammatory affection of the nail-bed or to 
 some disease of the skin these should have appropriate treatment. 
 Ointments of tar, of salicylic acid, or of ammoniated mercury will 
 often be found useful in such cases. 
 
 ATROPHIA UNGUIUM 
 
 Synonyms. — Onychatrophia; Atrophy of the nails. 
 
 Symptoms. — In rare cases the nails may be partially or wholly 
 absent at birth (anonychia), or exist only in a rudimentary condi- 
 tion. Eichhorst has reported a case in which the nails of the fingers 
 and toes were totally lacking at birth; Jacob one in which the nails 
 

 
 636 DISEASES OF THE SKIN 
 
 were only rudimentary, two of the patient's sisters exhibiting the 
 same deformity; and Hutchinson observed a brother and sister in 
 whom there was congenital absence of all the nails along with alopecia ; 
 the nails, however, grew later. 
 
 In the acquired forms of nail atrophy the nail-plate presents vary- 
 ing degrees of thinning or disorganization ; it may be dry and friable, 
 as when it is invaded by fungi, or in extreme cases it may be reduced 
 to a soft parchment-like layer of confined epithelial cells which barely 
 cover the nail-bed (hapalonychia). Occasionally the thinned nails 
 are concave instead of convex, the so-called "spoon-nails" (koilony- 
 chia). As onychorrhexis Dubreuilh and Freche have described an 
 atrophic condition of the nails characterized by fine longitudinal fur- 
 rowing of the nail-plate and extreme brittleness. 
 
 At times the nail-plate becomes partly detached from the nail- 
 bed without obvious cause (Onycholysis, decollement des ongles). 
 It becomes yellowish or brownish either at the anterior free border 
 or at one of the lateral margins, and gradually becomes separated 
 from the nail-bed, at times as far as the matrix. 
 
 At other times it is completely detached and cast off (shedding 
 of the nails, onychomadesis). Montgomery has reported a case in 
 which one or more of the nails was constantly being shed ; the affec- 
 tion was hereditary, the mother of the patient and several of the 
 maternal aunts and uncles suffering in like manner. 
 
 Transverse furrowing of the nails is seen with considerable fre- 
 quency after acute illness and sometimes after quite trivial disturb- 
 ances. The author has noted such furrowing in his own nails after 
 two or three days of sea-sickness. The furrow is most marked in 
 the thumb-nail and in the nails of the index and middle fingers, and 
 much less so in the nail of the little finger. 
 
 Chalk-white patches frequently occur in the nails (leukonychia, 
 leukopathia unguium, canities unguium, flores unguium). They may 
 appear as small spots, leukonychia punctata; as transverse bands, leu- 
 konychia striata ; and in rare instances the entire nail becomes white, 
 leukonychia totalis. One or several nails may be affected at the same 
 time or in succession, and in rare instances all the nails of both fingers 
 and toes. 
 
 Etiology. — As may be gathered from the foregoing, the causes of 
 atrophy of the nails are many and various. As already noted, it is 
 in rare cases congenital, but far more frequently it is a sequel or 
 accompaniment of some inflammatory affection of the nail-bed or 
 matrix, or some disease of the skin ; it may follow eczema, psoriasis, 
 pityriasis rubra pilaris, epidermolysis bullosa, syphilis. In a case 
 reported by the author some years ago extreme atrophy of the nails 
 was associated with an arthritis of the fingers resembling arthritis 
 deformans. The nails are occasionally shed after severe scarlatina 
 with abundant desquamation ; they are sometimes lost in certain dis- 
 eases of the central nervous system, as locomotor ataxia. 
 
DISEASES OF THE APPENDAGES 637 
 
 Leukonychia may result from traumatism, as was observed by 
 Heller in his own person, but in the majority of cases the cause is 
 not known. In the case of total leukonychia reported by Giovanni, 
 it followed typhoid fever, and in another, involving all the nails, 
 reported by Weber and Krieg more recently, the patient suffered from 
 a rheumatic cardiac affection. The white color is regarded by most 
 authorities as due to accumulations of air bubbles between the cells 
 of the nail-plate, but Heidingsfeld was unable to demonstrate this 
 in sections of nails which he studied. Unna does not regard the 
 presence of air as the primary condition, but secondary to abnormal 
 softness and swelling of the nail-cells. 
 
 Treatment. — The treatment of the various forms of atrophy of the 
 nails depends altogether upon the causation. When secondary to 
 some disease of the skin, such as eczema or psoriasis, these must be 
 appropriately treated. If the result of syphilis, mercury, salvarsan, 
 and the iodide of potassium together with the use of mercurial oint- 
 ments locally may be confidently relied upon to favorably influence 
 the disease. In those cases in which there is no demonstrable local 
 or general disease to which the affection of the nails can be traced, 
 the internal administration of arsenic will at times produce favorable 
 results, although it more often fails. 
 
 ONYCHIA 
 
 Synonym. — Onychitis. 
 
 Definition. — Inflammation of the nail-bed and nail-walls. 
 
 Symptoms. — To be strictly accurate, there is no such thing as 
 inflammation of the nails, what is so called being inflammation of 
 the soft parts to which the nail-plate is attached, the nail-bed and the 
 nail-walls. 
 
 Onychia may be acute or chronic, the course it pursues being largely 
 dependent upon the cause. In the former the distal phalanx becomes 
 red, swollen, and painful, and suppuration of the nail-bed frequently 
 occurs, often with inflammation of the nail-walls, followed by loosen- 
 ing of the nail, which may be completely detached, leaving a red 
 granulating surface covered with pus. In the chronic form the in- 
 flammatory symptoms are usually less marked and the nail is thick 
 and uneven. 
 
 In tuberculous and syphilitic children, much less frequently in 
 adults, a rare form of onychia occurs, characterized by extreme chro- 
 nicity (onychia maligna). It begins with inflammation of the nail-bed, 
 which terminates in painful ulceration, continuing for many months 
 or even years. Exceptionally the inflammation is unusually marked 
 and may be accompanied by lamphangitis. 
 
 Along with the soft parts to which the nail is attached, the nail- 
 wall, and the nail-bed, the deeper tissues surrounding the nail may 
 also be inflamed, the inflammation at times extending down to the 
 periosteum and terminating in suppuration (paronychia, panaritium, 
 whitlow). 
 
638 DISEASES OF THE SKIN 
 
 One of the niost frequent forms of inflammation of the nail is 
 that commonly known as ingrowing nail (Unguis incarnatus, Onychia 
 lateralis). Owing to continued pressure upon the nail-wall by the 
 edge of the nail, the former becomes painful, red, and swollen, and 
 sooner or later ulceration occurs in the nail furrow. The ulcer is 
 frequently covered with flabby granulations and shows no tendency 
 to heal. Occasionally the ulceration extends beneath the nail, and 
 in rare cases necrosis of the phalanx occurs. The affection is con- 
 fined to the toes, in the great majority of cases to the inner border 
 of the great toe. 
 
 Alterations occasionally occur in the nail as the result of syphilis. 
 In infrequent cases one or more of the nails gradually lose their trans- 
 lucency and lustre, become yellowish, brittle, uneven, and fissured 
 (Fig. 222), and in time are partially or completely detached from 
 the nail-bed (onychia sicca syphilitica, scabrities unguium syphilitica, 
 onyxis craquele). The affection is usually a symptom of the later 
 
 Fig. 222. — Syphilis of the nails. 
 
 stages, but is seen exceptionally in the earlier period of the infection. 
 
 More frequently the nail-walls become red and swollen and ulcera- 
 tion follows, which at times extends beneath the nail-plate, which 
 may be lost, leaving frequently a sluggish, very painful ulcer occupy- 
 ing the nail-bed (paronychia syphilitica). In most cases several nails, 
 either of the fingers or of the toes, and not infrequently the majority 
 of both, are affected. Heller attaches considerable importance to the 
 multiplicity of the lesions as a diagnostic symptom. Syphilitic parony- 
 chia usually occurs in the secondary period and is apt to run a pro- 
 longed course. 
 
 As isolated papule of the nail-bed Heller describes a syphilitic 
 affection of the nail occurring in the secondary stage, characterized 
 by the appearance coincidently with the eruption of an intensely red 
 spot beneath the nail, over which the nail-plate becomes increasingly 
 thinner and finally gives way without suppuration. 
 
 Etiology. — A number of the causes of inflammation of the nails 
 and the soft parts immediately connected with them have already 
 
DISEASES OF THE APPENDAGES 639 
 
 been alluded to in the account of symptoms. Injuries and infection 
 secondary to them are frequent causes of onychia and paronychia. 
 Infections such as syphilis and tuberculosis have already been re- 
 ferred to as occasional causes. Disease of the spinal cord may in 
 rare instances be followed by paronychia; a painless recurrent parony- 
 chia is a characteristic symptom of Morvan's disease or syringomyelia. 
 
 Treatment. — In acute onychia following traumatism or local in- 
 fection, moist dressings of a saturated solution of boric acid or of 
 bichloride of mercury, i : 2000, should be applied continuously until 
 the acute symptoms have subsided, when an ointment of ammoniated 
 mercury or of calomel, 2 to 5 per cent., should be gently rubbed 
 in twice a day. In the chronic forms and in those associated with 
 eczema or other inflammatory disease of the skin, the same ointments 
 may be used alone. 
 
 The treatment of paronychia is essentially surgical. When the 
 inflammation is severe and extends deeply, a deep and free incision 
 should be made into the inflamed parts and one of the above solu- 
 tions applied. 
 
 In ingrowing nail the portion of the nail-plate pressing upon the 
 inflamed nail-fold should be lifted up by gently insinuating a small 
 pledget of absorbent cotton or gauze beneath it, at the same time 
 trimming off as much of the nail as possible with the scissors. Should 
 this fail to relieve the condition, the nail should be split and 
 the part pressing upon the nail-wall removed. Properly fitting shoes 
 must be worn to prevent a speedy return of the trouble, as it is in 
 most cases due to the pressure of an ill-fitting shoe. 
 
 The treatment of syphilis of the nails does not differ from the 
 treatment of. syphilis of other parts 
 
 ONYCHOMYCOSIS 
 
 Definition. — Disease of the nails due to the vegetable parasites, 
 the trichophyton, and the Achorion Schonleinii. 
 
 Symptoms. — Notwithstanding the frequency of ringworm of the 
 scalp and of non-hairy parts, ringworm of the nails (onychomycosis 
 trichophytica, trichophytosis unguium) is an uncommon disease. It 
 begins at the free border of the nail, which becomes yellowish or 
 dirty gray, opaque, and brittle. As it extends backward toward the 
 lunula the nail-plate becomes thickened and fissured and is separated 
 from the nail-bed by a dry friable mass of dirty gray color, consist- 
 ing of elements of the fungus and cornified epithelial cells (Figs. 
 223 and 224). After a time the greater part or the whole of the nail- 
 plate is disorganized and may be lost. Although as a rule, to which 
 the exceptions are rare, the disease' is unaccompanied by inflammatory 
 symptoms, inflammation, and still less frequently suppuration, of the 
 nail-walls and nail-bed may occur, probably as the consequence of a 
 secondary staphylococcic infection. One or several nails may be 
 affected, and in rare cases all of them. While confined in the great 
 
640 
 
 DISEASES OF THE SKIN 
 
 majority of cases to the fingers, the nails of the toes do not always 
 escape. Exceptionally the nails alone are affected, but in most cases 
 ringworm of the scalp or of other regions is also present; Heller, how- 
 ever, observed an instance in which the nails of the fingers and 
 toes were attacked alone. Unless arrested by treatment, the disease 
 
 Fig. 223. — Onychomycosis, ringworm of the nails. 
 
 pursues a very chronic course and may last for several years. Unlike 
 other forms of ringworm, it is relatively frequent in adults, and even 
 in old age. Heller collected records of four cases in men over sixty- 
 nine years of age. 
 
 Favus of the nails (onychomycosis favosa), although a rare affec- 
 tion, is relatively less so than ringworm of the nails. It very rarely 
 
 Fig. 224. — Ringworm of the nail, thumb. 
 
 occurs as an independent malady, but is almost always associated 
 with favus of other regions, usually the scalp. It begins as one or 
 more pale yellow spots beneath the free border of the nail-plate, 
 which enlarge, extending backward toward the root until the greater 
 part or the whole of the nail is affected. The nail-plate, which be- 
 comes opaque, thick, uneven, fissured, and brittle, is separated from 
 the nail-bed by a yellowish friable, sometimes dry and powdery, mass 
 
DISEASES OF THE APPENDAGES 641 
 
 of mycelia and spores mixed with horny epithelial cells. The disease 
 is confined in the great majority of cases to the nails of the fingers, 
 although in rare instances the nails of the toes may be attacked. It 
 may last for years and may eventually completely disorganize the 
 nail. 
 
 Diagnosis. — The diagnosis of ringworm of the nails can only be 
 made with certainty by the microscope, especially when it exists inde- 
 pendently of ringworm of other regions, since its clinical features are 
 by no means sufficiently characteristic to differentiate it from other 
 dystrophic conditions of the nails. The fungus is usually, but not 
 always, readily found in scrapings from beneath the nails (Fig. 225) 
 which have been subjected to the action of liquor potassse for a few 
 
 
 
 
 * 
 
 Fig 225. — Ringworm of the nails. Scrapings from beneath the nail, containing great abundance of 
 jointed mycelium, from case shown in Fig. 223. 
 
 minutes. Favus of the nails is usually more readily recognized owing 
 to the decidedly yellow color of the subungual accumulation and to 
 its almost invariable association with favus of other regions, particu- 
 larly the scalp. The achorion is easily demonstrated in the scales 
 beneath the nail-plate. 
 
 Prognosis and Treatment. — Neither ringworm nor favus of the 
 nails shows any tendency to spontaneous recovery ; if left to them- 
 selves, they may continue for years, eventually destroying the nail. 
 A cure is only to be obtained by persistent treatment. 
 
 In order to enable the parasiticides to reach the fungus, which is 
 protected by the hard and almost impermeable nail-plate, as much as 
 possible of the diseased nail should be trimmed off with the knife 
 or scissors and the remainder scraped very thin with a dull knife- 
 blade, or, better, with a piece of glass. The affected fingers or toes 
 41 
 
642 DISEASES OF THE SKIN 
 
 should then be soaked in a hot solution of bichloride of mercury, 
 i : iooo, for fifteen to twenty minutes daily, and afterwards dried and 
 an ointment of ammoniated mercury, 5 to 10 per cent., applied. 
 Sabouraud recommends the application of a dressing soaked in the 
 following solution of iodine and potassium iodide: Iodine, gr. 5 / ft 
 (0.05) ; Potassium iodide, gr. 15 (1.0) ; distilled water, 3 ounces (100.0). 
 The dressing should be covered with a protective and should be con- 
 tinued for six months. As a last resort in obstinate cases, the dis- 
 eased nails may be removed and tincture of iodine applied to the nail-bed. 
 
 DISEASES OF THE HAIR AND HAIR-FOLLICLES. 
 HYPERTRICHOSIS 
 
 Synonyms. — Hirsuties ; Polytrichia ; Trichauxis ; Hypertrophia 
 pilorum ; Superfluous hair ; Fr., Poils accidentels. 
 
 Definition. — Excessive development of hair. 
 
 Symptoms. — Abnormal development of hair may occur as a con- 
 genital anomaly or as an acquired condition ; it may affect the entire 
 hairy system or may be confined to certain regions, either those 
 normally hairy or those in which lanugo is present under normal 
 conditions. When it is general it is commonly designated universal 
 hypertrichosis, but, strictly speaking, this is incorrect, since certain 
 regions, such as the palms and soles, are invariably free from hair 
 no matter how extensive the development may be. 
 
 Congenital hypertrichosis may be general or partial. In the former 
 the abnormal growth of hair may be present at birth as a downy 
 growth or less frequently pigmented, covering every part of the skin 
 except the palms and soles ; or, what is less common, the abnormal 
 development may not take place until some months or a year or two 
 after birth. Although a very rare anomaly, some remarkable exam- 
 ples of congenital universal hypertrichosis have been observed at 
 various times. Among the best known and most striking are the 
 Burmese family, of Shwe Maon, in which excessive and general 
 hairiness was present in three generations ; the Russian " dog-faced 
 man," Jeftichjew, and his son, and the Burmese child, Krao, exhib- 
 ited some years ago in various parts of Europe and America. In 
 such cases the excessive development of hair is frequently associated 
 with defective development of the teeth. According to Michelson, the 
 grandfather of the hairy Burmese family was entirely without molars 
 and had but one canine; Jeftichjew had no teeth in the upper jaw, 
 and the son, who was examined when he was sixteen years old by 
 Jackson, had but five teeth at that time. 
 
 More frequently the abnormal growth of hair is limited to cer- 
 tain regions in which hair does not normally grow. Many of the 
 cases of partial congenital hairiness are examples of hairy naevus, 
 the hair growing, not upon normal, but upon pigmented or otherwise 
 altered skin. Occasionally the abnormal growth is situated in the 
 lumbar region over a concealed spina bifida. 
 
DISEASES OF THE APPENDAGES 643 
 
 Acquired partial hypertrichosis may affect regions in which nor- 
 mally the hair is but little developed, or exists as lanugo, such as the 
 upper lip, chin, and cheeks in women ; or hair may develop prematurely 
 in regions which are normally hairy only in adult age, such as the 
 cheeks, chin, and upper lip in male children and the genitalia in children 
 of both sexes. Beigel saw a girl, six years old, in whom the genitalia 
 were developed and covered with hair like a woman of twenty; and 
 boys are in rare instances seen with a beard, usually associated with 
 precocious development of the sexual apparatus. 
 
 The hair of the beard and scalp in exceptional cases undergoes 
 unusual development and may reach an extraordinary length. All- 
 worthy has reported a case in which the beard reached the length of 
 130 inches; the carpenter of Edam had one nine feet long. Beigel 
 relates that Negreni, a female dancer, had hair over nine feet long, 
 the increase in length following an acute illness. The axillary and 
 pubic hair may likewise grow to an unusual length. 
 
 A partial hypertrichosis, usually of a transient character, occasion- 
 ally follows local irritation, such as may result from the application 
 of a blister, or repeated friction (Boyer, Raver, Osiander, quoted by 
 Kaposi) ; Kaposi relates the case of a woman in whom an abnormal 
 growth of hair occurred upon the back of the hand after rubbing 
 in mercurial ointment for three weeks. The author has knowledge 
 of a case in which frictions with cosmoline after a fracture of the 
 forearm was followed by a vigorous growth of hair in the region 
 rubbed; the hair reached a length of three or four inches, but soon fell 
 off when the frictions were stopped. 
 
 Etiology and Pathology. — Congenital general hypertrichosis fre- 
 quently exhibits a markedly hereditary character, and the same is 
 true, but to a less degree, perhaps, of some of the acquired partial 
 forms, such as those which affect the beard and scalp. The facial 
 hypertrichosis of women is, according to Jackson's statistics, fre- 
 quently hereditary; out of 350 cases this author found hirsuties on 
 the maternal side in 41 per cent. Derangement of the sexual apparatus 
 is likewise a predisposing factor in this form of hypertrichosis. In 
 many instances there is a decided increase in the growth of hair in 
 the face after the menopause. As illustrative of the influence of 
 disease of the sexual organs upon the growth of facial hypertrichosis, 
 the case reported by Hyde may be referred to. A woman thirty-five 
 years old, the mother of three children, ceased to menstruate, and 
 developed a general and facial hirsuties, the latter resulting in the 
 growth of a full beard and mustache. Two or three years later 
 menstruation returned, and with its reappearance the general hyper- 
 trichosis spontaneously disappeared. 
 
 The association of certain cases of local hypertrichosis, affecting 
 the lumbar and sacral regions, with spina bifida has already been 
 referred to. In a small number of cases an abnormal growth of hair 
 
644 DISEASES OF THE SKIN 
 
 has been observed to follow spinal paralysis or injury to peripheral 
 nerves (Schiefferdecker and others). 
 
 According to Unna, congenital hypertrichosis is to be regarded as 
 an arrest of development of the hair, a trichostasis. The foetal hair, 
 instead of falling, continues to develop, producing a general hairiness. 
 
 Treatment. — The circumscribed forms, such as hairy moles and 
 facial hypertrichosis, alone are amenable to treatment, and it is chiefly 
 these for which the physician's advice is sought. Although various 
 methods have been devised for the destruction of the superfluous 
 hairs, there are practically but three methods to be considered, viz., 
 the use of depilatories, electrolysis, and the X-ray. The use of de- 
 pilatories is only a temporary expedient, as the hair grows again and 
 the depilatory must be reapplied at intervals of a week or two. The 
 following, in which barium sulphide is the active agent, is a useful 
 formula : 
 
 Barii sulphid 3iij (12.0) 
 
 Pulv. zinci oxid. 
 
 Pulv. amyli aa Sss (16.0) 
 
 M. 
 
 Sig. Mix with water and apply as a paste. 
 
 When slight burning is perceived the paste is to be removed, scraped, 
 or washed off, and cold cream or a dusting powder applied for a short 
 time, as more or less irritation is produced. Some degree of caution 
 is necessary in the use of all depilatories, as considerable inflammation 
 of the skin may follow their employment unless due care is exercised. 
 In the vast majority of cases electrolysis is the method of choice; 
 indeed, it is the only safe practicable method of permanently destroy- 
 ing the hair. Very briefly, the method consists in the electrolytic de- 
 struction of the hair papilla by inserting into the follicle a fine needle 
 fixed in a suitable handle, connected with the negative pole of a gal- 
 vanic battery. It was first suggested by Michel, of St. Louis, in 1875, 
 for the removal of hairs in trichiasis, and was shortly afterwards used 
 by Hardaway in the treatment of hypertrichosis. While any form 
 of galvanic battery will answer the purpose, some form of dry cell 
 will be found most satisfactory. The current may be controlled by 
 a rheostat and measured by a milliamperemeter, but these are not 
 absolutely necessary. A current-strength of two to three milliamperes 
 is usually quite sufficient to destroy the papilla. If a milliamperemeter 
 is not used, the current from five to ten ordinary dry cells or from 
 ten to fifteen chloride of silver cells will be found sufficient. The most 
 satisfactory form of needle is one made of irido-platinum, although 
 a fine steel needle or a jeweler's "broach" will serve the purpose, 
 the latter being preferred by Jackson. When steel needles are used 
 care should be taken not to connect them with the positive pole acci- 
 dentally, as oxidation of the needle will occur, producing a small black 
 dot at the point of insertion. When the face is the region to be oper- 
 ated upon, as it is in the great majority of cases, the patient should 
 
DISEASES OF THE APPENDAGES 645 
 
 be placed in a reclining chair in a good light, holding in her left hand 
 by its non-conducting handle a wet sponge electrode, which should 
 be at least three inches in diameter, connected with the positive pole 
 of the battery. The needle is gently inserted in the follicle, using it 
 as a probe to enter an already existing passage, and not to force a 
 new one, and when the bottom of the follicle is reached, which is 
 indicated by a slight increase in resistance to the needle, the patient 
 is directed to grasp the sponge with her right hand, thus completing 
 the circuit. Within a few seconds slight frothing appears at the mouth 
 of the follicle, and after twenty to thirty seconds the circuit should 
 be broken by removing the hand from the sponge, when the needle 
 may be withdrawn ; if the needle is withdrawn first a slight shock is 
 apt to be produced. If the papilla has been destroyed the hair will 
 be found to be quite loose so that it may be extracted easily with 
 forceps ; if, on the contrary, it is still firmly fixed in the follicle the 
 operation has been a failure and must be repeated at another sitting. 
 The operation usually gives rise to some pain, which, however, is rarely 
 severe enough to cause the patient real distress. From forty to fifty 
 hairs may be removed at a sitting, but they should not be removed 
 too close together at the same sitting, since scarring may result from 
 neglect of this precaution. After the operation the part operated on 
 should be bathed for a few minutes in hot water and afterwards an- 
 nointed with cold cream or covered with some dusting powder. 
 
 When the number of hairs is very great, their removal by electro- 
 lysis is -practically impossible, owing to the length of time required; 
 under such circumstances the X-ray may be used, giving an exposure 
 just sufficient to produce a mild erythema, measuring the exposure 
 by means of a meter, such as the Holzknecht or the Sabouraud-Noire 
 pastile. This agent is to be employed, however, with the utmost 
 care, since great harm may be done with it even in the "hands of 
 an experienced operator. Ill effects, such as a persistent dermatitis, 
 followed by disfiguring telangiectases, and atrophy of the skin, may 
 appear months or even years after its employment. 
 
 The fine cylindrical knives devised by Kromayer and the fine ther- 
 mocautery, microbrenner, employed by Unna are so far inferior to 
 electrolysis in every respect that while they are mentioned they are 
 not recommended. 
 
 ATROPHIA PILORIUM PROPRIA 
 
 FRAGILITAS CRINIUM 
 
 Synonyms. — Scissura pilorum ; Fissura pilorum ; Trichoptilosis. 
 
 Definition. — Abnormal dryness with brittleness of the hair. 
 
 Symptoms. — The hair may be abnormally dry and break readily 
 
 as a symptom of disease of the hair itself, such as ringworm or favus, 
 
 or of some chronic inflammatory affection of the scalp, such as eczema, 
 
 psoriasis, seborrhceic dermatitis ; or the abnormal dryness may be 
 
 secondary to some general constitutional disease, such as typhoid 
 

 
 
 646 DISEASES OF THE SKIN 
 
 fever, syphilis, tuberculosis, leprosy, which seriously impairs the gen- 
 eral nutrition. Much less commonly it occurs as an idiopathic affec- 
 tion unaccompanied by any manifest or discoverable local or general 
 disease. 
 
 In the symptomatic form the hair is abnormally dry, without its 
 accustomed lustre, and often much thinned, owing to the readiness 
 with which it splits up and breaks off with handling or even spontane- 
 ously. In the idiopathic form longitudinal splitting of the shaft fre- 
 quently takes place at the ends, in its continuity, or within the follicles, 
 the last only rarely. A splitting of the ends of the hair of the scalp 
 which may extend some distance is common in the long hair of women ; 
 much less frequently a similar condition is seen in the hair of the 
 beard. In rare cases the splitting begins in the bulb, as in those 
 reported by Duhring, Parker, Hyde, and Crocker. In Duhring's case 
 the disease occurred in the beard and was accompanied by great irri- 
 tation and inflammation of the follicles. It may affect hairs irregu- 
 larly scattered throughout the scalp or beard, or it may be confined to 
 certain limited areas. 
 
 Etiology and Pathology. — As already observed, the symptomatic 
 form may result from the invasion of the hair by parasitic organisms, 
 or may be the result of a lowering of the nutrition of the scalp from 
 local or general causes. The cause of the idiopathic form is for the 
 most part unknown. Kaposi attributed the splitting of the ends of 
 the hair to its comparative remoteness from the papilla, the source of 
 its nutrition, but since short hairs are at times affected as well as 
 long ones, this is hardly an adequate explanation. Doubtless mis- 
 handling of abnormally dry hair by the patient herself or by hair- 
 dressers is frequently responsible for the condition in women. 
 
 Beyond the dissociation of the fibres of the shaft, but little is 
 to be seen microscopically in most cases ; in the case reported by 
 Duhring, however, there was a decided atrophy of the bulb. Spiegler 
 has announced the finding of a bacillus in the hair with which he 
 succeeded in reproducing the affection, but this finding still awaits 
 confirmation by other investigators. 
 
 Treatment. — The affection is apt to be persistent. When it is 
 secondary to some other local or general disease, this must receive 
 attention. The scalp should be washed at intervals of two or three 
 weeks, avoiding much rubbing, and the cleansing followed by inunc- 
 tions of small quantities of vaseline, oil of sweet almond, or oil of 
 sesame. The split ends of the hairs should be cut off, and when the 
 beard is affected daily shaving for a time should be advised. 
 
 TRICHORRHEXIS NODOSA 
 
 Synonyms. — Clastothrix; Trichoclasia ; Trichoptilose (Devergie) ; 
 Auftreibung und Bersten der Haare (Beigle). 
 
 Definition. — An affection of the hair characterized by longitudinal 
 splitting and nodose swelling of the shaft. 
 
DISEASES OF THE APPENDAGES 647 
 
 Symptoms. — As "swelling and bursting of the hair" Beigel de- 
 scribed this affection in 1855, although it had been recognized pre- 
 viously by Wilson and Wilks, the former giving it the name fragilitas 
 crinium. The name by which it is generally known at present was 
 given it by Kaposi in 1881. 
 
 It is characterized by one or more grayish or whitish nodose swell- 
 ings of the hair-shaft, which at a little distance may be mistaken for 
 the ova of pediculi, but which on nearer examination are seen to in- 
 volve the entire thickness of the hair instead of being attached to it. 
 They are produced by the longitudinal splitting and spreading out of 
 a small section of the shaft, producing an appearance which has 
 been aptly likened to the interlocking of two small brushes which have 
 been pushed together (Fig. 226) ; the shaft is frequently broken off at 
 the site of the nodes, leaving brush-like ends. In the great majority 
 of cases the disease is limited to the mustache and beard, although it 
 may also occur in the scalp, axillary, and pubic hairs. Hodara has 
 described a form observed frequently in the hair of the scalp of women 
 in Constantinople, which differs slightly from the ordinary form in 
 
 Fig. 226. — Trichorrhexis nodosa. 
 
 that the nodes are quite small and splitting of the shaft occurs not 
 only at but between the nodes. As a rule it is the distal third of the 
 shaft that is affected, the proximal portion being free and firmly fixed 
 in the follicle ; the number of nodes on a hair varies from one to eight 
 or ten, placed at irregular intervals. No subjective symptoms accom- 
 pany the affection, which is usually discovered accidentally in handling 
 the beard or mustache. 
 
 Etiology and Pathology. — The malady is infrequent, although prob- 
 ably not so rare as commonly stated, since, owing to its comparatively 
 trivial character and the absence of subjective symptoms, it is fre- 
 quently overlooked by the patient and seldom brought to the notice 
 of the physician. As already observed, it is much more frequent in 
 men than in women, although Raymond found it present in the hair 
 of the labia majora of a large proportion of women examined, and 
 Hodara has noted its frequent occurrence in the scalp hair of the 
 -women of Constantinople. Its direct cause has not yet been definitely 
 determined. Of the earlier observers, Beigel thought it due to the 
 accumulation of a gas in the hair which burst it, while Wilson re- 
 garded it as the result of some nutritive disturbance. McCall Ander- 
 son observed it in parents and children, and concluded that heredity 
 
648 DISEASES OF THE SKIN 
 
 played a part in its production, but, as Raymond has pointed out, 
 this can just as reasonably be attributed to contagion as to heredity. 
 In recent years a number of investigators (Raymond, Hodara, Spieg- 
 ler, v. Essen, Markusfeld, de Keyser) have found microorganisms 
 in the nodes, which they have regarded as the etiological factor. Ho- 
 dara found a small bacillus which he named the bacillus multiformis 
 trichorrhexides, with cultures of which he succeeded in producing the 
 affection experimentally. Ravenel, who suffered from it himself in 
 his mustache, records the interesting fact that his tooth-brushes and 
 shaving-brushes presented nodes similar to those in his mustache ; 
 other observations of a similar kind have been made by Blaschko, 
 Jadassohn, and others, who found nodes in the brushes of hair-dressers. 
 Wolfberg, Sabouraud, Brocq, and others believe it due to mechanical 
 injury of the shaft occurring in those with abnormally dry hair. 
 
 According to Kaposi, the affection begins with a longitudinal split- 
 ting of the cortex and an increase in the thickness of the medulla. 
 After a time the medulla disappears and fracture of the shaft occurs 
 at the site of the node. Eichhorst found numerous droplets of fat 
 between the cells of the medulla, and numerous particles of extraneous 
 matter are entangled in the fine fibres of the nodes. 
 
 Prognosis and Treatment. — The malady is a very intractable one 
 and often refuses to yield 'to the best-directed treatment. When it 
 affects the beard and mustache, daily shaving should be advised and 
 continued for some time. In view of its probable infectious nature, 
 parasiticide lotions and ointments may be employed. Sabouraud rec- 
 ommends the following lotion : 
 
 Hydrarg. bichlorid gr. vijss (0.50) 
 
 Sp. setheris, 
 
 Alcoholis aa fS iv (125.0) 
 
 Resorcini 3ss (2.0) 
 
 Acid, tartaric 3ss (2.0) 
 
 Schwimmer advises the use of a 3 per cent, ointment of sulphur, while 
 Jadassohn recommends a 1 per cent, ointment of pyrogallol. Besnier 
 applied tincture of cantharides, pure or diluted, according to the amount 
 of irritation produced. Sack thinks epilation a useful auxilliary. Joseph, 
 who believes the nodes produced mechanically, forbids washing the hair, 
 and applies daily oil of sweet almond or castor oil largely diluted with 
 alcohol. 
 
 MONILETHRIX 
 
 Synonyms. — Aplasia pilorum intermittens; Fr., Nodosite des poils ; 
 Ger., Spindelhaare. 
 
 Definition. — A congenital affection of the hair distinguished by 
 constrictions occurring at regular intervals throughout its entire 
 length. 
 
DISEASES OF THE APPENDAGES 
 
 649 
 
 Symptoms. — This rare affection was first described in 1879 inde- 
 pendently by Walter Smith and Luce ; since then cases have been 
 reported by Behrend, Lesser, Hallopeau, Sabouraud, Gilchrist, Rug- 
 gles, and a number of other English, French, German, and American 
 observers. Quite recently MacKee and Rosen have published a very 
 thorough study of its clinical features and histopathology. 
 
 It is characterized by constrictions of the hair-shaft regularly placed 
 at intervals of about a millimetre throughout its entire length, includ- 
 
 FiG. 227. — Monilethrix. (Dr. Geo. M. MacKee.) 
 
 Although 
 
 ing the root, giving to the hair a beaded appearance, 
 commonly described as consisting of alternate constrictions and fusi- 
 form swellings or nodes, it is only the former that are pathological, 
 since the so-called nodes are in fact portions of the normal hair- 
 shaft which present a deceptive appearance of nodes or swellings 
 in contrast with the constrictions. When viewed by transmitted 
 light the fusiform portions of the shaft are dark, while the constric- 
 tions are lighter in color or white and translucent. Fracture of the 
 shaft occurs readily at the constrictions, and in consequence the 
 
650 
 
 DISEASES OF THE SKIN 
 
 hair is quite short, and partial or in exceptional eases complete bald- 
 ness results. The entire scalp is usually affected, but it may be for 
 a time limited to certain parts of it, and exceptionally the brows or 
 the hair of extremities may be affected ; in the cases reported by 
 
 Gilchrist and Ruggles it was lim- 
 ited to the legs. In most of the 
 cases a more or less marked kera- 
 tosis pilaris accompanies the dis- 
 ease, the follicles being filled with 
 small plugs of horny epithelium. 
 In exceptional cases the scalp is 
 scaly and inflammation of the 
 follicles is present (Fig. 227). 
 
 Etiology and Pathology. — 
 Both sexes are alike affected. In 
 a large proportion of the reported 
 cases it was congenital or ap- 
 peared shortly after birth ; in a 
 much smaller proportion it ap- 
 peared for the first time some 
 years after birth. Anderson has 
 reported the occurrence of four- 
 teen cases among twenty-seven in- 
 dividuals in six generations of one 
 family; Sabouraud found seven- 
 teen cases in five generations, and 
 other, but less striking, examples 
 of its hereditary character have 
 been observed by Payne, Lesser, 
 Hudelo, Tenneson, and others. 
 There is, accordingly, but little 
 doubt that heredity plays an im- 
 portant role in its production. 
 
 The pathogenesis of the af- 
 fection still awaits a satisfactory 
 explanation. Smith and Virchow 
 attributed it to periodic variations 
 in the formative activity of the 
 cells of the hair-bulb. Bonnet and 
 Unna explain the formation of 
 the constrictions by supposing a 
 periodic contraction of the follicles, due to variations in the tonicity of 
 their muscular and elastic elements. 
 
 The pathological alterations of the hair are limited to the con- 
 strictions, the so-called nodes being, as already noted, normal portions 
 of the shaft. At the site of the constrictions the medulla has disappeared 
 and fracture is common. MacKee and Rosen found the upper part of the 
 
 Fig. 228.— Monilethrix. Section of follicle containing 
 twisted hair with nodes. (Dr. Geo. M. MacKee.) 
 
DISEASES OF THE APPENDAGES 651 
 
 follicles dilated, with a marked increase in keratinization, producing large 
 hyperkeratotic masses, which occluded the follicle and compelled the hair, 
 which was rotated upon its axis, to take a tortuous course. (Fig. 228.) 
 Both the external and internal root-sheaths were well developed. The 
 inner sheath was apparently normal in the region of the bulb, its two 
 layers well differentiated, but as it ascended the nuclei and keratohylin 
 granules disappeared from Huxley's layer and the sheath became homo- 
 geneous. The superficial vessels of the corium were slightly dilated and 
 surrounded by a moderate exudate of small lymphocytes. 
 
 Diagnosis. — Monilethrix is to be differentiated from trichorrhexis 
 nodosa, from intermittent graying of the hair (ringed hair), and from 
 ringworm of the scalp. In the first of these affections fractures occur 
 at the nodes and not in the thin parts of the hair-shaft, as in moni- 
 lethrix : in intermittent graying of the hair there are no nodes, but 
 alternate sections of white and dark hair ; ringworm usually occurs 
 in patches and the trichophyton is readily found in the hair ; lastly, 
 none of these diseases is congenital. 
 
 Prognosis and Treatment. — Spontaneous recovery never occurs, 
 although improvement has been noted in rare cases. Treatment has 
 but little, if any, effect. Stimulating lotions and ointments of sulphur 
 and salicylic acid may, however, be found useful. 
 
 PLICA 
 
 Synonyms. — Plica Polonica ; Ger.. Weichselzopf ; Fr., Plique polo- 
 naise. 
 
 Definition. — A matted condition of the hair of the scalp. 
 
 Symptoms. — The early authors devoted considerable space to the 
 consideration of plica, and, according to the appearances presented, 
 divided it into a number of varieties. Hebra and Kaposi, however, 
 showed quite conclusively that it was not a disease, but a condition 
 arising from neglect. The entire scalp may be covered with a mass 
 of hair inextricably tangled together, filled with swarms of pediculi 
 and innumerable ova, giving off an exceedingly disagreeable rancid 
 odor. The scalp beneath may be quite normal in appearance, or it 
 may be red and crusted, or moist and oozing, owing to the irritation 
 produced by the presence of pediculi and scratching. 
 
 As plica neuropathica a small number of cases have been reported 
 (Le Page, Pestonji, De Amicis, Stelwagon, and a few others) in which 
 matting of the hair was confined to a limited area of the scalp which 
 showed no evidences of neglect, and in a few instances appeared quite 
 acutely. In the case observed by Le Page the condition appeared 
 shortly after washing the hair in warm water, and Pestonji has re- 
 ported a case having a similar origin. Ohmann-Dumesnil has re- 
 ported a case in a girl sixteen years old in whom matting of the 
 hair followed suppression of the menses. In Stelwagon's case, which 
 was seen by the author, the matting w r as confined to an area in the 
 
652 DISEASES OF THE SKIN 
 
 occipital region about the size of a silver dollar and formed a rope- 
 like lock four feet long ; the scalp was perfectly clean and free from 
 pediculi. 
 
 Etiology. — As already observed, the condition is commonly the 
 result of neglect ; the nervous origin of the neuropathic form is purely 
 hypothetical. 
 
 Treatment. — Thorough soaking of the tangled mass with olive 
 oil or oil of sweet almond and the patient use of the comb will usually 
 disentangle the hair. When the condition is limited to a circumscribed 
 area the quickest way to get rid of it is to cut off the matted hair 
 with the scissors, but not infrequently, owing to some superstitious 
 notion, the patient will not permit this to be done. 
 
 PIEDRA 
 
 Synonyms. — Trichosporie (Vuillemin) ; Piedra nostras (Unna) ; 
 Tinea nodosa (Morris and Cheadle) ; Trichomycose nodulaire Quhel- 
 Renoy). 
 
 Definition. — A parasitic affection of the hair endemic in Colombia, 
 but also occurring sporadically in rare instances in Europe, character- 
 ized by minute hard concretions attached to the hair-shaft. 
 
 Symptoms. — First described by Osorio, this affection occurs in 
 two forms, one endemic in Colombia, where it is found almost ex- 
 clusively in the valleys of Cauca, and a second, which has been met 
 with sporadically in various parts of Europe. 
 
 The endemic Colombian variety is confined almost exclusively to 
 the hair of the scalp in women, although it is in exceptional cases 
 seen in the mustache and beard in men. It is characterized by minute 
 dark or black concretions of stony hardness, situated on the shaft of 
 the hair at intervals of one-half to two centimetres, beginning about 
 a centimetre from the surface of the scalp. When the concretions 
 are numerous, combing or shaking the hair produces a rattling sound. 
 
 In the European variety, or piedra nostras (tinea nodosa), similar, 
 but somewhat larger and softer, nodules and sheath-like deposits occur 
 upon the hair-shaft of the hair of the mustache and beard, to which 
 regions it is limited. 
 
 The affection described by Beigel in 1869 as "chignon disease" 
 is regarded by Behrend and others as identical with piedra. 
 
 Etiology and Pathology. — Morris believes the probable cause of 
 the malady, as observed in Colombia, is to be found in a mucilaginous 
 oil which the native women apply to the hair of the scalp for cosmetic 
 purposes ; other authorities think it possibly due to the peculiar muci- 
 laginous properties of the water of certain sluggish streams in the 
 regions in which the affection is endemic. The parasitic nature of 
 the disease, however, has been established by the studies of Behrend, 
 Juhel-Renoy, Unna, and others, who found various forms of spores 
 in the nodular masses. The Colombian variety is due to the trichospo- 
 rum giganteum; piedra nostras to a somewhat similar organism, the 
 
DISEASES OF THE APPENDAGES 653 
 
 Trichosporum ovale. It is altogether likely that the various organisms 
 described are variations of one pleomorphic fungus. The spores which 
 form the nodules are held together by a glutinous material which 
 Yuillemin believed was produced by the fungus. The hair-shaft is 
 as a rule but little or not at all affected, since the spores are situated 
 on the outside and do not penetrate its substance. 
 
 Treatment. — An entirely satisfactory method of treatment is to 
 wash the hair with a hot I : iooo solution of bichloride of mercury. 
 Besnier suggested adding i per cent, acetic acid to this solution. The 
 washing should be followed by combing with a fine-tooth comb. 
 
 Diagnosis. — The affection for which it is most likely to be mis- 
 taken is lepothrix, but that malady is confined to the hair of the axillae, 
 scrotum, and perineal region, and the nodules frequently contain an 
 orange-colored pigment soluble in the sw r eat which stains the under- 
 wear. 
 
 LEPOTHRIX 
 
 Synonyms. — Trichomycosis nodosa (Patterson) ; Trichomycosis 
 palmellina (Pick). 
 
 Definition. — An affection of the axillary, scrotal, and perineal hairs 
 characterized by fungous incrustations attached to the hair-shaft. 
 
 Fig. 229. — Lepothrix, axillary hair. 
 
 Symptoms. — This affection, which was first described by Paxton 
 in 1869, and later given the name lepothrix by Erasmus Wilson, is 
 
654 
 
 DISEASES OF THE SKIN 
 
 distinguished by minute nodular masses and sheath-like incrustations 
 on and around the hair-shafts of the axillary region, and less fre- 
 quently the hairs of the scrotum and perineum. The incrustations 
 are grayish or red-brown in color, and although rather soft on hairs 
 moist with perspiration are quite hard on dry hairs. The affected 
 hairs are usually quite brittle and frequently break with a brush-like 
 fracture. When the nodules are red-brown (Fig. 229) they contain 
 a pigment which, soluble in perspiration, stains the underwear a bright 
 orange, which is oftentimes the first and only symptom to call the 
 patient's attention to the condition. The malady is a common one, 
 Behrend finding it in 90 per cent, of his dispensary patients, but as 
 it is unaccompanied by any subjective symptoms, medical advice is 
 rarely sought for it. It is more frequent in blondes than in brunettes, 
 
 I 1 i 
 
 
 *"i\£X*. 
 
 Fig. 230. — Lepothrix. Micrococci from a brownish incrustation on hair which produced orange-colored 
 staining of the underwear — so-called red sweat. 
 
 and in those who perspire freely, but neglect of the toilet is not a cause, 
 as is stated by some authors. 
 
 Under the names trichomycosis flava, trichomycosis nigra, and 
 trichomycosis rubra, Castellani has described an affection of the axil- 
 lary hairs in Ceylon resembling lepothrix and probably closely related 
 to it. The incrustations are quite abundant and soft, and in exceptional 
 cases two of the three varieties may be found on the same hair, or 
 one axilla may present one variety, the other another. 
 
 The incrustations consist of masses of a short bacterium held 
 together by a gloea, which penetrates the cortex of the hair-shaft so 
 that it readily breaks off. In a study of red nodules obtained in one 
 case from the axillary hairs, in another from hairs in the perineum, 
 the author found masses of a micrococcus (Fig. 230) which in cultures 
 was arranged in tetrads or groups of four. In the Ceylon affection 
 
DISEASES OF THE APPENDAGES 655 
 
 Castellani found great numbers of bacilli in the yellow variety and 
 cocci in the black and red forms. 
 
 The affection is readily recognized. Its limitation to the axillary 
 and scrotal hairs and the presence of the incrustations, which when 
 of the red-brown variety stain the underwear, are sufficiently character- 
 istic to prevent its being mistaken for any other condition. 
 
 Treatment. — Although commonly regarded as readily curable by 
 the use of parasiticide lotions, such as a solution of bichloride of mer- 
 cury, i : iooo, this has not been the author's experience. Unless the 
 use of such lotions is preceded by shaving of the affected regions but 
 little can be accomplished, and it is likely to persist for an indefinite 
 period. Castellani applies a 2 per cent, solution of formalin in alco- 
 hol two or three times a day, and a 2 per cent, ointment of sulphur 
 at night. The formalin solution should be used somewhat cautiously, 
 as it is likely to cause considerable dermatitis after a little while. 
 
 ALOPECIA 
 
 Synonyms. — Calvities ; Baldness; Fr., Alopecie; Ger., Kahlheit. 
 
 Definition. — Baldness, especially of the scalp, but also affecting 
 other hairy regions. It may be local or general, partial or complete, 
 congenital or acquired. 
 
 According to its causes, course, and clinical symptoms, it pre- 
 sents a number of varieties, of which the following are those gener- 
 ally recognized by authors: alopecia congenita; alopecia prematura; 
 alopecia senilis ; alopecia areata. 
 
 ALOPECIA CONGENITA 
 
 Synonyms. — Alopecia adnata ; Hypotrichosis ; Oligotrichosis ; Fr., 
 Alopecie congenitale. 
 
 Symptoms. — In congenital alopecia, which is a rare variety, the 
 hair may be entirely absent at birth, or, what is more frequent, it is 
 scanty, patchy, or imperfectly developed. In the cases in which it 
 is entirely wanting there is commonly some associated anomaly of 
 development of the teeth and nails. Occasionally the hair is present 
 in normal quantity and quality at birth, but shortly falls, and is not 
 reproduced, or is reproduced imperfectly and incompletely (hypotri- 
 chosis). In certain other cases of congenital alopecia the baldness 
 is not permanent, but is due to delayed development of the hair, which 
 eventually is produced in normal quantity. Congenital alopecia fre- 
 quently presents a more or less marked familial character, and the 
 number of instances in which it has been observed in two or more 
 members of the same family or in succeeding generations is relatively 
 large. A striking example of this peculiarity is furnished by Nicolle 
 and Halipre, who have reported the occurrence of thirty-six cases 
 of defective development of the hair and nails in six generations of 
 one family ; Charles J. White has reported a similar, though less 
 extensive, series (seven cases in four generations). Congenital ab- 
 

 656 DISEASES OF THE SKIN 
 
 sence of hair may be a racial peculiarity ; Hill has reported the existence 
 of a hairless tribe of Australian aborigines. 
 
 Etiology and Pathology. — The only etiological factor of which we 
 have any definite knowledge is heredity, and there is apparently but 
 little doubt that in a very large proportion of the cases of this va- 
 riety of alopecia this is the chief, if not the only, cause. 
 
 Congenital alopecia is to be regarded as an anomaly of develop- 
 ment rather than a disease. Its histopathology has been studied by 
 Schiede, Jones and Atkins, and Ziegler. In the cases studied by the 
 last-named, hair and hair papillae were entirely absent, but the sweat- 
 and sebaceous-glands were quite normal in appearance. In the neigh- 
 borhood of the sebaceous glands were epithelial tubes surrounded by 
 circularly arranged connective-tissue tracts in which terminated smooth 
 muscle fibres resembling those of the arrectores pilorum ; Ziegler re- 
 garded these tubes as "rests" of external root-sheaths. 
 
 ALOPECIA SENILIS 
 
 Symptomatology. — Senile alopecia, or that which appears after fifty 
 years of age, usually begins on the vertex, but may begin on the ante- 
 rior portion of the scalp. The hair loses its lustre, becomes thin and 
 fine, and sooner or later a bald patch is formed, which spreads in all 
 directions, until in many cases a large part of the scalp is bare. The 
 bald area is usually quite smooth, oily, and shining, but may be slightly 
 scaly and dry from a mild seborrhcea. In a certain proportion of cases 
 the hair on other parts of the body, such as the beard and the pubic 
 region, is less vigorous than in early life and may also fall to some 
 extent. The loss of hair is in most cases accompanied by other senile 
 changes, such as whitening of the hair and atrophy of the skin. It 
 is much less frequent in women than in men, and when it does occur 
 is usually much less extensive. 
 
 Senile alopecia is a part of the atrophic changes which take place 
 with advancing years. Unna, however, has called attention to the 
 fact that the hair on other parts of the body frequently becomes 
 stiffer and stronger in old age, and thinks it possible that the loss 
 of hair upon the scalp in the aged is the result of a mild unrecognized 
 seborrhoea. 
 
 Michaelson found a fibrous endarteritis of the vessels of the scalp 
 which narrowed their lumen and led to partial destruction of the capil- 
 lary network surrounding the hair-follicles, which were shrunken and 
 filled with horny epithelium. Unna found practically the same changes 
 but does not believe that the hair loss is produced by the endarteritis. 
 
 ALOPECIA PREMATURA 
 
 By alopecia prematura is understood loss of hair occurring in young 
 subjects, i.e., before twenty-five or thirty years of age. It may occur 
 
DISEASES OF THE APPENDAGES 657 
 
 independently of any recognizable disease of the scalp or general dis- 
 turbance, alopecia prematura idiopathica ; or it ma)' be the result of 
 some local affection of the scalp, or secondary to some constitutional 
 disease, alopecia prematura symptomatica. 
 
 Alopecia Prematura Idiopathica. — The idiopathic form of premature 
 alopecia usually begins at the temples and on the vertex, or in one or the 
 other of these regions. The hair fall is increased and coincidently there 
 is a progressive enfeeblement of the new-growth until there is nothing 
 but a fine and scanty down which, too, in turn disappears, leaving the 
 greater part of the scalp bare, smooth and shining. Quite commonly the 
 loss of hair is rapid, more or less complete baldness appearing in the course 
 of some, sometimes a few, months. When it begins upon the vertex it 
 produces a circular tonsure-like patch which spreads in all directions ; 
 when it begins at the temples the hair recedes on both sides, often leaving 
 a central patch, which may persist for some time after the remainder 
 of the scalp is quite bald. In advanced cases the greater part of the 
 scalp may be bare, a narrow fringe remaining above the ears and in the 
 occipital region only. Premature alopecia of this variety is much more 
 frequent in men than in women, indeed it is quite uncommon in the 
 latter, and when it does occur almost never reaches the proportions 
 frequently seen in men. 
 
 Alopecia Prematura Symptomatica, or that variety secondary to 
 local disease of the scalp, or to some general infection such as syphilis, 
 typhoid fever and the like, varies a good deal in its symptoms and course 
 according to its causation. As in the other forms of baldness it may 
 be partial or complete, and may involve other hairy regions as well as 
 the scalp. 
 
 By far the most common form of symptomatic alopecia is that 
 which follows seborrhceic dermatitis of the scalp (alopecia pityrodes, 
 alopecia furfuracea). The fall of the hair is preceded for a variable 
 period, usually considerable, by a more or less abundant scaling of 
 the scalp, which may be dry and bran-like or somewhat greasy, in the 
 latter case forming fatty crusts. After a time the hair-fall is increased 
 and the hair upon the anterior portion of the scalp and on the vertex 
 becomes increasingly thinner until partial or complete baldness results. 
 Exceptionally the loss of hair takes place with comparative rapidity. 
 
 More or less loss of hair frequently follows certain general diseases, 
 especially those attended by elevation of temperature for a consider- 
 able period, such as typhoid fever, pneumonia, erysipelas (defluvium 
 capillorum). With the appearance of convalescence the hair falls 
 out rapidly and abundantly, although complete baldness seldom occurs. 
 The loss of hair is commonly temporary and lasts but a comparatively 
 short time, although there are exceptions to this rule. 
 
 A temporary alopecia is a fairly common symptom of the secondary 
 42 
 
658 DISEASES OF THE SKIN 
 
 stage of syphilis (alopecia syphilitica). It occurs as a diffuse thin- 
 ning of the hair of the scalp or in ill-defined patches ; the loss of hair 
 is seldom sufficient to produce complete baldness. Areas of com- 
 plete and permanent baldness may result from the ulcerative lesions 
 of late syphilis when these are situated in the scalp. Alopecia con- 
 fined to the site of the eruptive lesions is common in lepra. Inflam- 
 matory diseases, such as eczema and psoriasis, when situated upon the 
 scalp, may be followed by a certain amount of thinning of the hair, 
 but actual baldness seldom results. Lupus erythematosus of the scalp, 
 folliculitis decalvans, and morphoea (localized scleroderma) are infre- 
 quent causes of patches of permanent baldness. 
 
 Disease of the scalp due to the vegetable parasites, such as ring- 
 worm and favus, are attended by partial or complete circumscribed 
 loss of hair. In the former the loss of hair is usually temporary, but 
 may be permanent after the inflammatory forms (kerion) ; in favus the 
 hair-follicles are often entirely destroyed with permanent loss of hair in 
 the affected areas. 
 
 Etiology and Pathology. — There is little or no doubt that a ten- 
 dency to early loss of hair is inherited and heredity is probably the 
 most active of the causes which predispose to premature alopecia. 
 The wearing of stiff hats, which interferes with the circulation of the 
 scalp and leads to a lessening of its nutrition, is regarded by some 
 authors (Jamison, King) as a predisposing factor ; and Ellinger thought 
 that the daily use of cold water upon the scalp interfered with the 
 proper growth of the hair. 
 
 In the symptomatic varieties of premature alopecia the most fre- 
 quent of all causes is seborrhcea or seborrhceic dermatitis of the scalp. 
 According to Elliot more than 90 per cent, are due to this cause ; Jack- 
 son found about 75 per cent, of his cases suffering from this affection, 
 while White noted it in 79 per cent. A considerable number of recent 
 investigators regard the seborrhceic affection as due to an invasion of 
 the follicles by a small bacillus, the mocrobacillus of Sabouraud, and 
 consequently transmissible. While there is some evidence for the 
 contagiousness of the malady this evidence is yet far from conclusive. 
 
 In those cases in which the alopecia has followed such diseases as 
 typhoid fever, pneumonia, erysipelas, the loss of hair is probably due 
 to some toxin rather than the high temperature, since many cases of 
 high temperature occur without loss of hair. The fall of hair which 
 occurs quite commonly after pregnancy is very probably a toxic effect. 
 
 Loss of hair may follow the internal administration of thallium ace- 
 tate, and is quite common after exposure of hairy parts to the X-ray. 
 
 In alopecia pityrodes there is a mild hyperkeratosis extending into 
 the mouths of the follicles which are filled with an accumulation of 
 horny epithelium in which are numerous microorganisms (micro- 
 bacilli). The rete is at first but little altered, but in the later stages 
 shows some atrophy. The vessels of the papillae are dilated and are 
 surrounded in places by a moderate cellular exudate in which are con- 
 
DISEASES OF THE APPENDAGES 659 
 
 siderable numbers of " mastzellen." The sebaceous glands in the 
 early stages show but little change, but in advanced cases are more 
 or less atrophied. 
 
 Prognosis. — The prognosis of all the varieties of alopecia depends 
 largely upon the causes. In the congenital, senile and idiopathic 
 premature forms the prognosis is most unfavorable, although in rare 
 instances hair does eventually appear in the congenital variety and 
 may be partially restored in the other forms. In alopecia pityrodes 
 the prognosis is fairly favorable if treatment is undertaken early and 
 carried out persistently and methodically. In cases of defluvium 
 capillorum following typhoid fever, pneumonia, erysipelas, and in 
 syphilitic alopecia the hair usually returns within a comparatively short 
 time. In the patchy baldness following local affections of the scalp, 
 like erythematous lupus and folliculitis decalvans, the loss of hair is 
 irreparable, as the follicles are destroyed. 
 
 Treatment. — When there is a hereditary tendency to early loss of 
 hair prophylactic measures are indicated. The scalp should be kept 
 clean by an occasional shampoo or by washing it with tincture of green 
 soap and warm water followed by cold, following the shampoo or the 
 washing by the application of a small quantity of some bland oil, such 
 as oil of sweet almond, oil of sesame or vaseline. Under ordinary 
 circumstances a shampoo every two or three weeks is quite often 
 enough; but for those who are much exposed to dust it may be neces- 
 sary to cleanse the scalp more frequently. Daily brushing the hair 
 with a stiff brush for a few minutes is also useful, as well as gentle 
 massage two or three times a week. Men should wear soft rather than 
 stiff hats and should not wear them in-doors. 
 
 While there are few if any remedies which exert a direct effect 
 upon the growth of the hair, internal treatment is frequently indicated 
 by the patient's general condition. Iron, arsenic, strychnia, cod-liver 
 oil and other remedies of a similar kind may be of use in certain cases, 
 owing to the presence of anaemia, or debility. In syphilitic alopecia 
 antisyphilitic remedies are, of course, indicated as in any other manifes- 
 tation of syphilis. As there is some evidence that pilocarpin stimu- 
 lates the growth of the hair small doses, from a one-twentieth to one- 
 fifteenth gr. (.003-004) three times a day, may be given for short 
 periods. 
 
 The chief reliance must be placed, however, upon local treatment, 
 and this consists for the most part in the application of stimulating 
 ointments and lotions and the use of such procedures as, by attracting 
 an increased blood-supply to the scalp, tend to increase the nutrition 
 of the hair-producing apparatus. Certain mechanical procedures, such 
 as vigorous brushing and massage to which reference has already been 
 made, are of decided use and should be employed methodically and 
 judiciously. The faradic brush and the high-frequency spark may also 
 be employed for the same purpose. The list of local remedies is a long 
 one and most of them have in common the property of producing 
 
660 DISEASES OF THE SKIN 
 
 more or less irritation and local hyperemia and many of them possess 
 parasiticide properties. Ammonia, acetic acid, carbolic acid, capsi- 
 cum, cantharides, sulphur, tar, are some of the drugs which are 
 employed locally, either as lotions or as ointments, with more or less 
 favorable effect. 
 
 Jackson speaks in laudatory terms of the following lotion contain- 
 ing pilocarpin, which, as already mentioned, probably exerts a directly 
 stimulating effect upon the growth of the hair : 
 
 Pilocarpin. muriat gr. xx (1.33) 
 
 Spt. odorati f3 iv (16.0) 
 
 Aq. rosse, 
 
 Alcoholis absolut. .aa partes sequales q. s. ad i% viij (250.0) 
 M. 
 Sig. Rub in well night and morning with the finger. 
 
 Quinine has long had a reputation as a " hair tonic," although it is 
 somewhat doubtful if it is deserved ; it is usually used as a lotion, 
 either alone or combined with some stimulating substance, as in the 
 following : 
 
 Spt. formicarum f3 ij (64.0) 
 
 Quinise sulphat gr. xvi (1.0) 
 
 Aq. Cologniens f3 i (32.0) 
 
 M. 
 
 Sig. Apply with gentle friction once a day. 
 
 Paschkis thinks the best results follow the use of the preparations of 
 the bark, probably because of the tannic acid which they contain. The 
 following lotion, containing acetic acid, a chemically incompatible mixture, 
 has been recommended by Cottle: 
 
 Acid, acetic f3 iv (16.0) 
 
 Pulv. boracis 3i (4.0) 
 
 Glycerini fSiii (12.0) 
 
 Alcoholis fSss ( 16.0) 
 
 Aq. rosse q. s. ad f3viii (250.0) 
 
 M. 
 
 The following is an old and useful stimulating lotion containing 
 cantharides in combination with capsicum : 
 
 Tr. cantharidis f3 i-f3 iv (3.40-16.0) 
 
 Tr. capsici f3 iv-fS i (16.0-32.0) 
 
 Ol. ricini f3ss (2.50) 
 
 M. 
 
 The treatment of alopecia pityrodes, or that which follows sebor- 
 rhcea or dermatitis seborrheica of the scalp, is essentially the treatment 
 of the seborrhceic affection. The scalp should first be freed of crusts 
 and scales by washing it with tincture of green soap and warm water, 
 after which the remedy chosen may be applied. Probably the most 
 effective of all the local remedies for seborrhcea is sulphur which, 
 owing to its insolubility, is usually employed as an ointment. The 
 
DISEASES OF THE APPENDAGES 661 
 
 sulphur " cream " devised by Jackson some years ago is a very agree- 
 able and effective preparation ; the formula is as follows : 
 
 Cerse alb 3 vij (28.0) 
 
 Ol. petrolati fS v (155.0) 
 
 Aq. rosas f3 ijss (75.0) 
 
 Sodii biborat gr. xxxvj (2.30) 
 
 Sulphur, prsecip 3 vij (28.0) 
 
 M. 
 
 This should be rubbed into the scalp every night ; after four days the 
 scalp should be washed with tar soap and water, dried, and the cream 
 reapplied. If more stimulation is thought desirable 2 or 3 per cent, of 
 salicylic acid may be added. An equally agreeable and effective ointment 
 is the following, in which the base is eucerin, a lanolin derivative : 
 
 Sulphur, praecip 3ss (2.0) 
 
 Eucerin Si (32.0) 
 
 The author has used this with very satisfactory results, occasionally 
 adding 1 per cent, pilocarpin muriate to it. 
 
 Resorcin is another useful agent, but less so than sulphur; it may 
 be used as an alcoholic lotion, 3 to 5 per cent., or as an ointment of the 
 same strength, applied once a day. Owing to the staining which it 
 causes it should not be used in those with white or light hair. Charles 
 J. White prefers a modification of resorcin, euresol, as more effective, 
 which he combines with mercuric bichloride in a lotion. 
 
 Hydrarg. bichlorid gr. iv (0.24) 
 
 Euresol 3 ij (8.0) 
 
 Spt. f ormicar i% i (32.0) 
 
 Ol. ricini f3 i-iij (4.0-12.0) 
 
 Alcohol, 70% q. s. ad f3 viij (250.0) 
 
 M. 
 
 A 4 to 5 per cent, solution of chloral hydrate in water or 70 per cent, 
 alcohol is a cleanly and agreeable application which is frequently effective 
 in mild cases ; if there is much oiliness of the scalp an equal quantity of 
 tannic acid may be added with advantage, but this addition should not 
 be made in the case of those with blonde or white hair, as it stains slightly. 
 The various preparations of tar are frequently serviceable, but their 
 strong odor and the staining which accompanies their use limits their 
 usefulness considerably. The following, which contains a deodorized 
 and decolorized tar, is used by Joseph: 
 
 Anthrasol HI xlv (3.0) 
 
 Ol. aurant. flor Til iv (0.25) 
 
 Spt. saponis kalin fS i (32.0) 
 
 Alcoholis 90% q. s. ad fS v (150) 
 
662 DISEASES OF THE SKIN 
 
 Sack recommends the following compound tar ointment: 
 
 Anthrasol f g S s-f 3 i (2.0-3.0) 
 
 Sulphur, praecip gr. lxxv-cl (5.0-10.0) 
 
 Resorcin gr. xv (1.0) 
 
 Tr. cantharidis f3 ss-f 3 i (2.0-5.0) 
 
 Ungt q. s. ad 3 iss (50.0) 
 
 M. 
 
 These may be rubbed in gently for some minutes once a day. 
 
 Lassar, who was fully convinced of the contagious character of 
 this form of alopecia, devised the following somewhat complicated 
 treatment which he found very efficacious in bringing about a return 
 of the hair. The scalp is to be washed daily with a strong tar soap, 
 rubbing in the lather for fifteen minutes. It is then rinsed off with 
 warm, followed by cold, water and a wash composed of equal parts of 
 a 1 : 300 solution of bichloride of mercury, spirits of Cologne and 
 glycerin is thoroughly applied. The scalp is then dried and an alco- 
 holic solution of naphthol, one to one and a half per cent, strength, is 
 rubbed in and finally a one and a half per cent, carbolized oil is applied. 
 
 For some years the author has used with considerable satisfaction 
 an ointment containing 10 to 15 per cent, of betanaphthol, usually 
 employing eucerin as a base ; this is decidedly stimulating and para- 
 siticide and rarely if ever produces undue reaction. 
 
 ALOPECIA AREATA 
 
 Synonyms. — Area Celsi ; Porrigo decalvans ; Alopecia circum- 
 scripta ; Fr., Pelade. 
 
 Definition. — Loss of hair occurring in circumscribed areas, usually 
 confined to the scalp and beard, but also affecting at times other parts 
 of, or exceptionally the entire, hairy system. 
 
 Symptoms. — In the great majority of cases the affection begins 
 without premonitory symptoms as one or more small circumscribed, 
 round or oval patches upon the scalp completely devoid of hair. In 
 a certain small proportion of cases, however, the patient experiences 
 some pains in the head or itching of the scalp for some little time before 
 the patches appear, but these symptoms are as a rule so vague and 
 indefinite as to have little or no significance. The hair often falls 
 quite suddenly, a patch occasionally appearing over night and spread- 
 ing rapidly for a time and then becoming stationary. When small 
 they are often discovered quite by accident, usually by some member 
 of the patient's household or by one of his associates. There may 
 be but a single area or there may be several, and occasionally there 
 are many which by peripheral spread produce extensive irregular bald 
 areas involving the greater part of the scalp (Fig. 231). The skin in 
 the patches is whitish or pinkish, soft and smooth ; in the early stages it 
 may be slightly cedematous, but later is apt to be somewhat depressed, 
 and the follicles less prominent than in the normal scalp. About the 
 
DISEASES OF THE APPENDAGES 
 
 663 
 
 borders of the spreading patches are usually a number of short hairs 
 which may be readily plucked out, the intrafollicular portion being 
 thinner than that which projects above the surface, the " exclamation- 
 point hairs" of Crocker. After a period of Variable duration lanugo 
 appears in the bald areas which is in time replaced by pigmented hair. 
 Not uncommonly, however, this new hair falls out one or more times 
 before permanent recovery takes place ; or the new hair may remain 
 thin and soft and without pigment for a considerable time. It not 
 infrequently happens that while new hair is growing in the early 
 patches new bald areas appear which pursue the same course as the 
 
 Fig. 231. — Alopecia areata (in brothers). 
 
 first and in this manner the disease may be prolonged for many months. 
 Instead of occurring in rounded or oval patches it may occur as irregu- 
 lar or serpiginous bands, especially about the borders of the scalp, the 
 ophiasis of Celsus. Sabouraud regards this form as peculiar to child- 
 hood, occurring only exceptionally in adults ; this does not accord, 
 however, with the experience of most other observers. 
 
 The bearded region in men is quite commonly attacked, usually 
 coincidently with the scalp, but occasionally alone. Exceptionally the 
 hair loses its pigment some weeks or months before it falls out 
 (Crocker). 
 
 In infrequent cases the loss of hair extends to the other parts of the 
 hairy system ; the brows and lashes may be lost wholly or in part and 
 
664 DISEASES OF THE SKIN 
 
 the hair in the pubic and axillary regions may fall. In rare cases all 
 the hair of the body may be lost, no vestige of it remaining on any part, 
 the so-called malignant alopecia. 
 
 Under the name alopecia seborrheica circinata Crocker has described 
 a form of circumscribed baldness in which the bald areas,, instead of 
 being smooth and without any alteration beyond the loss of hair, 
 present marked seborrhceic scaliness. 
 
 In a certain small proportion of cases alopecia areata is associated 
 with other cutaneous affections, such as vitiligo (Besnier, Feulard, 
 Dubreuilh Eddowes), scleroderma (Abrahams), and dystrophic affec- 
 tions of the nails (Le Sourd, Audry, Sabouraud, Wende). 
 
 The course of the affection is frequently quite erratic, the hair 
 may return in the course of a few months, either permanently or only 
 to fall out again one or more times ; as already mentioned, new patches 
 may appear while the old ones are disappearing, and in this manner 
 many months or one or two years may elapse before permanent 
 recovery. In the very extensive or universal cases it is usually some 
 years before recovery takes place even under the most favorable 
 circumstances. 
 
 Etiology. — Alopecia areata is most frequent between the ages of 
 ten and thirty, is decidedly uncommon before five years, and infrequent 
 after forty-five. Sex is without any definite influence upon its inci- 
 dence, although most authorities state that it is somewhat more fre- 
 quent in females than in males ; my own experience has been the 
 reverse of this. It is probable that heredity is an etiological factor in 
 a certain proportion of cases. Sabouraud believes that syphilis is an 
 occasional auxilliary cause, but never a primary one. 
 
 The direct cause is as yet undetermined. The chief theories con- 
 cerning its causation are, first, that it is a trophoneurosis; second, that 
 it is the result of an infection with some as yet undiscovered micro- 
 organism. In favor of the first theory are the well-authenticated cases 
 in which loss of hair has occurred in circumscribed areas supplied by 
 nerves which have been injured by accident or in surgical operations 
 (Pontoppidan, Schutz, Askanazy) ; the occurrence of loss of hair, at 
 times quite extensive or even universal, after severe mental shock, 
 fright, grief, and worry ; the association of the affection with other 
 maladies of known origin ; and, lastly, the experiments of Joseph, who 
 produced patches of baldness in cats by the excision of the second 
 cervical ganglia. Jacquet has advanced the theory that a common 
 cause is reflex irritation in the sphere of the fifth pair of nerves arising 
 from defective teeth, but satisfactory proof of the correctness of this 
 theory is still lacking. 
 
 The evidence in favor of the second or parasitic theory is almost 
 entirely clinical, but quite conclusive. Although a number of micro- 
 organisms have been described from time to time by various authors 
 (Bazin, Thin, von Sehlen, Robinson, Sabouraud) their etiological rela- 
 tionship to the affection has not been established. A considerable 
 
DISEASES OF THE APPENDAGES 665 
 
 number of epidemics, chiefly in schools and garrisons, have been re- 
 ported by Hillier, Crocker, Bowen, Feulard, and a number of others ; 
 and it is quite impossible to satisfactorily explain such occurrences 
 on any other theory than that of infection with some microorganism. 
 Hutchinson and Crocker regarded it as in some manner related to 
 ringworm, the former believing that alopecia in the adult was preceded 
 by ringworm in childhood. 
 
 The alopecia which has been observed to follow the internal adminis- 
 tration of thallium salts, the occurrence of which has been confirmed 
 by the experiments of Buschke, strongly suggests the probability that 
 certain cases, particularly those in which the loss of hair is extensive 
 and widespread, are due to some toxic substance formed within the 
 economy. 
 
 Pathology. — The histopathology has been studied by a number of 
 investigators, the most important studies being those of Robinson and 
 Giovannini, who in the main agree as to the changes present. In a 
 study of sections made from a patch of one week's duration Robinson 
 found the rete normal, but in the papillary layer there were slight signs 
 of inflammation which became more pronounced in the corium where 
 there was a considerable exudate of round cells about the vessels limited 
 to certain areas. Some of the lymph-vessels were dilated and in places 
 contained fibrous coagula. The sebaceous- and, sweat-glands were 
 normal. Some of the follicles were empty, others contained normal 
 or lanugo hair, and the hairs showed evidence of malnutrition, the 
 shaft being split or broken. In chronic cases there was thickening 
 of the vessel-walls with narrowing of the lumen. In a long-standing 
 case with permanent alopecia the hair-follicles and sebaceous glands 
 were destroyed. Unna does not find the cellular exudate composed of 
 leucocytes as Giovannini states, but of connective-tissue cells. Sabou- 
 raud observed a lack of pigment in the lower layers of the rete and 
 found considerable numbers of " mastzellen " in the cellular exudate. 
 
 The hairs show signs of disturbed nutrition ; the cells of the medulla 
 disappear and the medullary canal is in places obliterated, in others 
 dilated ; the cells of the cortex which contains a large amount of air are 
 dissociated, leading to splitting up and breaking off of the shaft. The 
 pigment disappears from the intrafollicular portion which resembles 
 lanugo while in the extrafollicular part it is normal or irregularly 
 distributed. 
 
 Diagnosis. — The suddenness of its appearance ; the completeness 
 of the hair loss ; the smoothness of the patches, and the complete 
 absence of all signs of inflammation and structural change differentiate 
 this form of alopecia from all other forms. It is most frequently mis- 
 taken for ringworm of the scalp, but in this affection the baldness, 
 with the exception presently to be noted, is rarely complete ; the 
 patches contain numerous stumps of broken hairs in which the ring- 
 worm fungus may be readily found with the microscope. In the 
 infrequent, so-called bald ringworm, however, the resemblance be- 
 
666 DISEASES OF THE SKIN 
 
 tween the two affections is very close and the differential diagnosis 
 can only be made by a careful microscopic examination of hairs from 
 the borders of the patches. Syphilitic alopecia rarely occurs in such 
 sharply circumscribed patches, but rather as a diffuse thinning, pro- 
 ducing a moth-eaten appearance. In the bald areas following lupus 
 erythematosus, folliculitis decalvans and in ulcerative affections of the 
 scalp well-marked symptoms of inflammation and scarring are always 
 present. 
 
 Prognosis. — The prognosis depends largely upon the age of the 
 patient, the type of the disease and its extent. Small patches in chil- 
 dren and young adults usually recover within a reasonable period, 
 although at times recovery may be delayed for some months, and 
 exceptionally, for a year or two. When a considerable part of the scalp 
 is denuded a guarded prognosis should be given, especially if the 
 patient is past forty and if the affection has lasted for some time. 
 In the cases in which a large part or the whole of the hair of the body 
 as well as of the scalp has been lost the prognosis is very unfavorable, 
 recovery being the exception ; although attempts at reproduction of 
 the hair in limited areas may occur from time to time, the new hair 
 usually falls out within a short time. In very exceptional cases is 
 the hair completely restored even after a number of years. Relapses 
 are common in all forms of the disease. 
 
 Treatment. — In case the patient is anaemic, ill-nourished, or presents 
 evidence of disturbance of the nervous system, functional or organic, 
 such internal remedies as iron, arsenic, strychnia and cod-liver oil are 
 indicated and such hygienic measures should be adopted as will tend to 
 improve in every way the general condition. In view of Jacquet's 
 contention that reflex irritation from diseased teeth is a common cause 
 of the disease the condition of the teeth should be carefully investi- 
 gated and defects corrected. 
 
 A number of authorities regard arsenic as exerting a favorable 
 influence upon the growth of the hair, but the evidence for this is, to 
 say the least, not very convincing, but it is useful, however, as a 
 general tonic. Small doses of pilocarpin, one-twentieth grain (0.003), 
 may be given three times a day for short periods, or it may be em- 
 ployed hypodermatically in the bald areas in doses of one-thirtieth grain 
 (0.002) (Crocker, Stelwagon). Although usually without influence the 
 author has in a few instances observed a favorable effect from thyroid 
 in long-standing and extensive cases. 
 
 Local treatment is usually indispensable and is decidedly more 
 effective than the general. It consists for the most part in the appli- 
 cation of ointments and lotions which, acting as local stimulants, produce 
 an increased afflux of blood to the affected regions. Among the most 
 useful local remedies are chrysarobin, sulphur, carbolic acid, acetic 
 acid, cantharides ammonia, and betanaphthol. Crocker and Stel- 
 wagon find chrysarobin one of the most effective remedies used in an 
 ointment containing from ten to sixty grains (0.65 to 4.0) to the ounce 
 
DISEASES OF THE APPENDAGES 667 
 
 (32.0), well rubbed in every night. It should be employed with some 
 care, as it occasionally produces a severe dermatitis of the face with 
 considerable swelling; another objection to its use is the decided 
 staining which it causes. Sack thinks nothing can take the place of 
 pure carbolic acid applied every eight days, and MacGow r an recom- 
 mends trikresol used in the same way, first cleansing the scalp with 
 benzine. These applications are usually quite painful and are fol- 
 lowed by free exfoliation. Acetic acid is a useful topical remedy and 
 may be used in the following mixture employed by Besnier : 
 
 Acid, acetic, glacial TTL viii-xxx (0.50-2.0) 
 
 Chlorof ormi fS ss (20.0) 
 
 M. 
 
 Sig. Rub on the scalp gently with a pledget of absorb- 
 ent cotton every day or every other day. 
 
 If this excites considerable irritation, as it may do, it should be omitted 
 until the irritation subsides. 
 
 The following lotion suggested by Erasmus Wilson is regarded by 
 Jamison as extremely useful : 
 
 Liq. amnion, fortior., 
 Chloroformi, 
 
 Ol. sesami aa f5ss (16.0) 
 
 Ol. limoni f3ss (1.90) 
 
 Spt. rosamarini q. s. ad fS iv (120) 
 
 M. 
 
 This should be gently rubbed in once or twice a day. 
 
 The author has frequently employed betanapthol with much satis- 
 faction in an ointment containing from 10 to 15 per cent., occasionally 
 combined with pilocarpin, as in the following: 
 
 R 
 
 Betanaphthol o i (4.0) 
 
 Pilocarpin. muriat gr. i (0.65) 
 
 Eucerin 3 i (3.20) 
 
 M. 
 
 Sig. Rub in thoroughly every night. 
 
 When used in the bearded region applications like the foregoing should 
 be reduced in strength at least one-half, otherwise a too severe reaction 
 is likely to be produced. 
 
 The high-frequency and static currents are recommended by Stel- 
 wagon as useful, making the applications long enough to produce 
 considerable reaction. The faradic brush may also be used with 
 excellent effect, each sitting being long enough to produce a well- 
 marked hyperemia. In recent years Finsen, Jersild, Sack, Kromayer, 
 Jackson, and others, have used phototherapy with favorable results in 
 many cases. The most useful form of light is that produced by the 
 iron electrode lamp. Exposures of from ten to thirty minutes are 
 given daily until there is a decided reaction, when the treatment should 
 be suspended until the reaction subsides. Jackson, who used the 
 Piffard lamp, thought this method of treatment superior to all others. 
 
668 DISEASES OF THE SKIN 
 
 FOLLICULITIS DECALVANS 
 
 Synonyms. — Alopecie innominee (Besnier) ; Acne decalvante 
 (Lailler) ; Lupoid sycosis; Ulerythema sycosiforme (Unna) ; Alopecia 
 orbicularis (Neumann); Alopecia cicatrisata (Crocker). 
 
 Definition. — A chronic inflammatory disease of the hair-follicles, 
 chiefly of the scalp, characterized by permanent loss of hair in patches 
 with atrophy and scarring of the scalp. 
 
 Symptoms. — The first symptom to attract the patient's attention is 
 usually one or more small patches of baldness in and about the borders 
 of which are scattered pin-head-sized pustules and small red points in 
 which are hairs. These patches spread slowly and new ones appear, 
 either in the neighborhood of the old ones or at some distance from 
 them, so that in course of time considerable irregularly shaped areas 
 more or less devoid of hair are formed. The baldness is seldom com- 
 plete, however, but here and there are small tufts of hair situated 
 in apparently normal scalp and single hairs twisted and bent. The 
 bare scalp usually shows some atrophy and scarring with here and 
 there small spines of horny epidermis filling the follicles. There is 
 usually some itching which may be at times quite annoying. The 
 course of the malady is a slowly progressive one ; and in the advanced 
 stages the pustules and other signs of inflammation of the follicles may 
 entirely disappear. Although seen for the most part in the scalp, a 
 similar affection may also occur in the beard (lupoid sycosis, q. v.) 
 or in other hairy regions, such as the axillae and the pubic region. 
 
 The affection described by Crocker under the name of alopecia 
 cicatrisata (the alopecia orbicularis earlier described by Neumann, the 
 pseudopelade of Brocq) differs from the foregoing malady chiefly by 
 the absence of well-defined inflammatory symptoms. There are no 
 pustules and only occasionally a slight redness around the hairs which, 
 although they show no signs of disease, are readily extracted. There 
 are usually a number of quite small bald patches which, as they increase 
 in numbers and size, form large hairless areas in which the scalp is 
 atrophied, depressed and smooth. Exceptionally after some time 
 pustules may appear just as in the epilating folliculitis described by 
 Quinquaud, and from which it is then quite indistinguishable. Indeed, 
 it is altogether likely that both these diseases represent variants of 
 the same affection. Brocq would include all the members of the 
 group under the name atrophying alopecia (alopecie atrophiante), 
 recognizing three forms, viz., pseudopelade ; folliculitis decalvans, and 
 lupoid sycosis. 
 
 Etiology and Pathology. — -The cause is as yet undetermined, 
 although, reasoning by analogy, there is but little doubt that it is a 
 follicular infection. Although it has been seen in infancy (Brocq) it 
 is for the most part a disease of adult life, most common between the 
 ages of twenty and forty-five. It is much more frequent in men than in 
 women, but one of the most marked cases ever under the author's obser- 
 vation occurred in a woman, beginning at the age of fifty. 
 
DISEASES OF THE APPENDAGES 669 
 
 Quinquaud found a collection of young cells in the derma situated 
 about the hair-follicles and, to a less degree, about the sebaceous glands. 
 Later atrophic changes appeared followed by disappearance of the 
 follicles and glands. In addition to the streptococcus he also found 
 a micrococcus, cultures of which when rubbed into rats, rabbits and 
 man produced a folliculitis with loss of hair, but other investigators 
 have not been able to confirm these findings. In the non-inflammatory 
 form, pseudopelade, Brocq found an enormous dilatation of the capil- 
 laries of the subpapillary and perifollicular network and a cellular 
 exudate composed chiefly of lymphocytes, but also containing plasma 
 cells, " mastzellen," eosinophiles and many large cells containing 
 granular pigment. The sebaceous glands underwent atrophy and dis- 
 appeared completely. 
 
 Diagnosis. — The various forms of the affection are to be distin- 
 guished from alopecia areata, from lupus erythematosus and from 
 favus. From the first they all differ by the presence of atrophy and 
 scarring, symptoms which are never present in uncomplicated alopecia 
 areata. Erythematous lupus is seldom confined to the scalp but usually 
 presents patches with characteristic distribution on the face and ears. 
 They differ from favus which they may at times resemble closely, espe- 
 cially when the latter is about terminating, by the absence of the 
 characteristic yellow crusts in which the Achorion may be readily 
 demonstrated microscopically. 
 
 Prognosis. — The prognosis as to the restoration of the hair is alto- 
 gether unfavorable ; the follicles have been destroyed and a regrowth of 
 hair is impossible. The duration of all the forms is usually prolonged 
 and they are but little amenable to treatment. 
 
 Treatment. — Brocq advises extraction of the loose hairs, although 
 not convinced of its necessity, and the use of the following lotion : 
 
 Acid, acetic, glacial Til lxxv (5.0) 
 
 Hydrarg. bichlorid. gr. vijss (0.50) 
 
 Glycerin f3 vi (25.0) 
 
 Alcoholis il ijss (75-o) 
 
 Aq. destil fS v (150.0) 
 
 M. 
 
 This should be rubbed in daily unless it produces irritation, and fol- 
 lowed by an ointment of yellow oxide of mercury, 15 to 30 grains 
 (1.0 to 2.0) to the ounce (32.0) of vaseline. He also recommends 
 sulphur ointment, 10 per cent., or the following: 
 
 Sulphur, prsecip gr. xxx (2.0) 
 
 Tr. cantharidis f 3 vi (25.0) 
 
 Bals. Peruvian HI x (0.75) 
 
 Medul. bovis Bijss (80.0) 
 
 Ol. ricin f 3 i (5.0) 
 
 M. 
 
 The author has had favorable results from the daily application 
 of an ointment of ammoniated mercury, 40 to 60 grains (3.0 to 4.0) to 
 
670 DISEASES OF THE SKIN 
 
 the ounce (32.0), using eucerin as a base. Crocker advised an ointment 
 of biniodide of mercury two grains (0.13) to the ounce (32.0), or one 
 containing 20 grains each (1.30) of sulphur and resorcin to the ounce 
 (32.0). Jackson apparently checked the progress of the affection by 
 the daily application of the following, containing colloidal sulphur: 
 
 Acid, salicylic gr. xv (1.0) 
 
 Sulphur, colloidal. . . 3 i (4.0) 
 
 Adipis lanae, 
 
 Adipis anserini partes aequales B i (32.0) 
 
 Ol. geranii TTJ, viij 
 
 M. 
 
 CANITIES 
 
 Synonjans. — Gray hair ; Hoariness ; Trichonosis discolor ; Poliosis ; 
 Poliothrix. 
 
 Definition. — Absence of pigment in the hair. 
 
 Symptoms. — Absence of pigment in the hair may exist as a con- 
 genital defect, or what is far more common, it occurs as a physiological 
 process, which usually begins about the fortieth or fiftieth year, but 
 often at an earlier period. It may exist in circumscribed regions or may 
 affect the greater part or the whole of the hairy system. 
 
 In the congenital form (canities congenita) which is uncommon, 
 it may occur as circumscribed patches situated most frequently upon 
 the scalp, but also at times upon other parts, such as the beard or the 
 brows. Such patches are not infrequently hereditary and may be 
 seen in several members of the same family and in successive genera- 
 tions, occupying the same region. Rizzoli and Strieker (quoted by 
 Sack in Mracek's Handbuch) record the occurrence of a white lock 
 of hair in six successive generations and Seligsohn observed it in four 
 sisters. Observations of a similar kind have been made by Godlee 
 and others. Congenital absence of pigment may also affect the entire 
 hairy system as one of the phenomena of albinism and is then associated 
 with other pigmentary defects, such as absence of pigment in the skin 
 and choroid. The hair in such cases is yellowish-white, differing from 
 the silvery-white usually characteristic of the canities of old age. 
 
 Acquired grayness of the hair is usually a physiological process 
 appearing about the fourth or fifth decennium (canities senilis), but 
 its occurrence at a much earlier period, at twenty to twenty-five years 
 of age or even earlier (canities prematura) is not at all uncommon. The 
 change in color usually first appears upon the temples (hence the name 
 of this region) and spreads slowly to other parts of the scalp. In the 
 beard, which usually becomes gray later than the scalp, although there 
 are numerous exceptions, it begins upon the chin and affects the mus- 
 tache last. In the great majority of cases the graying of the hair 
 takes place slowly, but it may occur quite suddenly. Although it has 
 been denied, chiefly on theoretical grounds, that sudden blanching of 
 the hair may occur there are too many well-authenticated instances on 
 record to doubt it, but it is also true that many of the published 
 
DISEASES OF THE APPENDAGES 671 
 
 cases are to be accepted with considerable hesitation. Landois 
 observed an instance in which the hair turned gray over night in a man 
 suffering from delirium tremens ; Brown-Sequard noted in his own 
 person that a few hairs became white daily, often in their whole length ; 
 and Raymond saw a case in which, during a severe attack of neuralgia 
 the hair turned from black to red in the course of five hours, and in the 
 following two days became white and fell out. Other instances in 
 which the hair became white in the course of some days or weeks have 
 been placed on record by reliable and competent observers. 
 
 When once begun the loss of pigment usually slowly continues 
 until it involves the entire scalp, the beard and finally the axillary 
 and pubic hair. Not very infrequently, however, certain regions, such 
 as the brows, for example, may retain their pigment long after the scalp 
 and beard have become perfectly white. As a rule the pigment first 
 disappears at the roots of the hair, but exceptionally the distal end is 
 the part first affected. With rare exceptions the depigmentation is 
 permanent, but in rare instances the hair has been known to resume its 
 original color. A remarkable example has been recorded by Jackson, 
 to whom it was communicated by Warner, in which the hair of the 
 scalp and beard changed from black to white and to black again three 
 
 Fig. 232. — Ringed hair. 
 
 times in thirty years. Richelot (quoted by Unna) observed that the 
 brown hair of a girl of seventeen turned white while she suffered from 
 chlorosis, but later was restored to its normal color. 
 
 As ringed hair (Fig. 232) (Pili annulati ; Fr., Canitie annelee ; Ger., 
 Ringelhaare) a very rare and peculiar form of graying of the hair has 
 been described, in which short sections of the hair-shaft are alternately 
 pigmented or white, giving the hair a ringed or banded appearance. 
 First described by Karsch, in 1846, other cases have been reported by 
 Simon, Spiess, Landois, Pincus, Brayton, Crocker, and a few others. 
 With but very few exceptions the hair showed no other alteration, but 
 in one instance the pigmentary change was associated with trichor- 
 rhexis nodosa (Crocker), and in another with monilethrix (Lesser). 
 The majority of the cases reported were observed in children, and with 
 the exception of the case observed by Crocker in which the mustache 
 was affected, it was confined to the scalp. 
 
 Etiology and Pathology. — The most important etiological factors 
 in the production of gray hair are age and heredity. Reference has 
 already been made to the hereditary character of the patchy grayness 
 and the absence of pigment in the hair which accompanies albinism ; 
 and the fact that the members of certain families become gray early is 
 a matter of common observation. The effect of prolonged mental 
 
672 DISEASES OF THE SKIN 
 
 effort and other mental stress such as worry, fear, shock in the produc- 
 tion of gray hair has long been known and generally admitted. Prema- 
 ture grayness may follow severe acute illnesses, such as the infectious 
 fevers, or chronic affections of various kinds. Local injuries to the 
 scalp may be followed by patches of gray hair, or less frequently, the 
 whole region may be affected. Patches of white hair may be a symp- 
 tom of vitiligo, the scalp at the same time being depigmented; they 
 also occur in the early stages of recovery in alopecia areata, the new 
 hair frequently remaining for some time without pigment. Senile 
 grayness is to be regarded as a physiological rather than a pathological 
 process, and is the result of alterations in the trophic processes con- 
 cerned in the growth of the hair about the details of which we know 
 little or nothing. 
 
 The white color of the hair may be due to disappearance of the 
 pigment, to accumulations of minute air-bubbles in the cortex, or to the 
 simultaneous occurrence of both these. When it is the result of the 
 disappearance of the pigment it is yellowish-white, and when air is 
 present in the shaft it is silvery-white, as in most cases of senile canities. 
 
 The manner in which the pigment disappears still lacks an alto- 
 gether satisfactory explanation. Ehrmann attributes the loss of pig- 
 ment to the failure of certain pigment-bearing cells (melanoblasts) to 
 convey pigment from the papillae to the hair cells, although pigment 
 may be still present in the former. Metchnikoff explains the loss of 
 the pigment by the phagocytic action of certain branched cells of the 
 medulla which absorb pigment from the cortex. In cases of sudden 
 whitening of the hair the change in color is probably due to accumu- 
 lation of air between the cells of the cortex which obscures the pig- 
 ment and which is still present to some degree. Wilson attributed 
 the occurrence of the white section in ringed hairs to accumulations 
 of gas in the hair which developed during the night or on alternate 
 days ; this is, however, pure speculation lacking confirmation. 
 
 Prognosis and Treatment. — The prognosis is most unfavorable — 
 hair which has become white remains so for the remainder of the 
 patient's life ; the cases in which there has been a restoration of the 
 normal color are to be regarded as clinical curiosities. In the senile 
 form loss of the pigment usually slowly increases and extends until all 
 the hair is affected ; very exceptionally its progress is arrested before 
 all the hair is involved. 
 
 In those cases in which the loss of pigment is attributable to some 
 general affection which lowers the patient's vitality, to mental stress 
 or other debilitating influence, hygienic measures, and abundance of 
 highly nutritious food and general tonics, such as iron, arsenic, strych- 
 nia, should be employed. The only method by which the color can be 
 restored is the use of some one of the many hair-dyes to be found in 
 the shops, but the use of these is not advisable. 
 
 Discoloration of the Hair. — Changes in the color of the hair may 
 follow diseases of various kinds, or may result from purely external 
 
DISEASES OF THE APPENDAGES 673 
 
 causes ; both are rare. Alibert, quoted by Rayer, twice observed a 
 change in the color of the hair following a severe illness ; in one in- 
 stance the blonde hair of a young woman which had fallen out after 
 an illness was replaced by black hair; in another, brown hair was 
 succeeded by red. Beigel has reported a case in which blonde hair 
 was replaced by black after an attack of typhus. Reinhard records the 
 case of an idiot boy with epilepsy in whom a change in the color of 
 the hair from a reddish blonde to yellow occurred during violent fits 
 of temper, the change beginning at the free ends and occupying about 
 two days ; after about a week the normal color was restored. Smyly 
 observed a change in the color of the hair from mouse color to yellow in 
 the right temporal region of an infant suffering from suppuration in the left 
 temporal bone. Mayer has reported the case of a boy with blonde 
 hair in whom a band of red hair about two fingers broad, appeared 
 at the occipital border on three separate occasions, the first during 
 convalescence from an illness. In a case reported by Squire there were 
 patches of auburn and brown hair on the side of the head of a youth, 
 sixteen years old, producing a coloration like that of a tortoise-shell cat ; 
 the condition was congenital. In the oft-quoted case reported by Prentiss 
 a change of color of the hair from blonde to black followed the hypo- 
 dermatic administration of pilocarpin for two months. The subject was 
 a young woman suffering from pyelonephritis and suppression of urine: 
 the hair was not only changed in color, but became coarser and grew 
 more vigorously than before. 
 
 Discoloration of the hair from external causes is occasionally 
 observed and may be an occupational affection. Green hair has been 
 observed in workers in copper ; blue in those who work in cobalt mines 
 and in indigo ; brown, in those who handle anilin. Discoloration of 
 the hair from various medicinal agents, such as chrysarobin and 
 resorcin, are not very uncommon. The former produces a brownish- 
 red stain, the latter a dirty yellow in those with white or blonde 
 hair. 
 
 Treatment. — The only treatment for discoloration of the hair aris- 
 ing from obscure internal causes is the use of a dye ; the treatment of 
 those due to external causes is sufficiently obvious — avoid the cause. 
 
 DERMATITIS PAPILLARIS CAPILLITII 
 
 Synonyms. — Acne keloid; Folliculitis nuchse sclerotisans (Ehrmann). 
 
 Definition. — A folliculitis situated on the occiput at the margin 
 of the hair characterized by firm, keloid-like nodules. This rare affec- 
 tion was first described by Kaposi in 1869, although it had been recog- 
 nized by earlier authors, the affection described by Alibert as pian 
 ruboid and by Rayer as sycosis capillitii being in all probability the 
 same disease. 
 
 Symptoms. — It is situated almost without exception on the nape 
 of the neck at the border of the hair (Fig. 233), whence it extends 
 upwards into the occipital region. It consists of a variable number of 
 
 43 
 
674 DISEASES OF THE SKIN 
 
 pin-head to pea-sized, red or pinkish, very firm nodules, which are 
 at first discrete, but later more or less confluent by the crowding- 
 together of the lesions, thus forming an elevated, nodular plaque. The 
 hair is lost in large part, although here and there small bunches of ill- 
 formed twisted hairs project between the nodules or from the centre 
 of the nodule itself and are usually quite firmly fixed in the follicle. 
 In the more advanced stages of the malady the surface of the diseased 
 area may become moist, covered with a foul-smelling sero-purulent 
 secretion, and scattered pustules and small abscesses are not uncom- 
 monly present. In the final stages there is marked atrophy with 
 sclerosis and more or less complete baldness of the affected area, only 
 a few scattered tufts of deformed hairs projecting from the distorted 
 follicles remaining. 
 
 Although in most cases limited to the nape of the neck, it may 
 
 Fig. 233. — Dermatitis papillaris capillitii (acne keloid). 
 
 extend some distance upwards over the occiput and cover a consider- 
 able area. Occasionally it extends laterally, forming a transverse band 
 across the back of the neck. 
 
 According to Ehrmann it begins with the appearance of discrete 
 or grouped pustules situated upon an infiltrated base each penetrated by 
 a hair, the nodules being a later manifestation of the disease. 
 
 The subjective symptoms as a rule are insignificant. 
 
 Etiology. — The direct cause is unknown. Sabouraud believes it 
 the result of invasion of the hair-follicles by the microbacillus of sebor- 
 rhoea. ' Ehrmann thinks it is caused by the staphylococcus aureus and 
 albus, its special clinical and histological features being due to the unusual 
 depth of the follicles and the mode of their arrangement in the affected 
 region. 
 
 Pathology. — The view of Bazin and some later observers that the 
 malady is simply a combination of acne and keloid, seems scarcely ten- 
 
DISEASES OF THE APPENDAGES 
 
 675 
 
 able in view of the fact that its subjects show no special predisposition 
 to keloidal growths elsewhere. There is apparently but little doubt 
 that it is a follicular infection, although there are differences of opinion 
 as to the nature of the infecting agent. 
 
 In the early stages the histology is that of a folliculitis and perifol- 
 liculitis which in the beginning at least affects the upper part of the 
 follicle. In and around the follicles there is an exudation of lympho- 
 pytes, polymorphonuclear leucocytes, some plasma cells and numerous 
 
 Fig. 234. — Dermatitis papillaris capillitii. Section from case shown in Fig. 233. A. Follicular abscesses; 
 E, exudate containing a considerable number of plasma cells and some lymphoid cells about follicles. 
 
 " mastzellen " (Fig. 234). Ledermann, Ehrmann, and some others 
 have observed giant cells in the exudate. ' The collaginous tissue is 
 increased and the elastin has disappeared. In advanced stages of the 
 disease there is complete atrophy of the follicles and sebaceous glands. 
 
 According to Unna, neither staphylococci nor the bacillus acnes is 
 present in the folliculitis with which the affection begins, and he there- 
 fore believes that the disease is a special one — neither acne nor keloid. 
 
 Diagnosis. — The clinical features of the malady are so charactristic 
 that the diagnosis rarely presents any difficulty. In its earliest stage it 
 may be mistaken for ordinary acne, but the presence of small solid 
 
676 DISEASES OF THE SKIN 
 
 keloidal elevations, which appear quite early in the disease, serves to 
 distinguish it from that affection. 
 
 Prognosis. — The disease is an extremely chronic one, lasting for 
 years and slowly extending in area; less frequently it becomes station- 
 ary after a time. 
 
 Treatment.— Ointments cf sulphur and ichthyol in moderate 
 strength are perhaps the best applications, and in mild and early cases 
 may suffice to bring about a cure. When the disease has lasted for 
 some time and there is much sclerosis, more vigorous methods of treat- 
 ment must be employed. Linear scarification, curettage, and excision 
 have all been advised. Abscesses when present should be thoroughly 
 evacuated after incision and the cavities cleansed frequently with hot 
 boric acid solution. According to Ehrmann the removal of the hairs 
 from the affected area by electrolysis is an absolutely certain method 
 
 of treatment. 
 
 The Rontgen ray has been employed with satisfactory results m 
 
 a few cases. 
 
 SYCOSIS VULGARIS 
 
 Synonyms.— Non-parasitic sycosis; Coccogenic sycosis; Folliculitis 
 barbse ; Fr., Sycosis non-parasitaire ; Ger., Bartfinne. 
 
 Definition.— A chronic inflammation of the hair follicles principally 
 of the beard, characterized by an eruption of papules, pustules and 
 nodules, each of which is perforated by a hair. 
 
 Symptoms.— The disease (Plate XXXVII) usually begins with a 
 few small discrete papules and pustules situated most commonly upon 
 the chin, cheek or upper lip and new lesions continue to appear, usually 
 in crops' at irregular intervals, until a patch of variable size is formed. 
 In time the entire upper lip, the greater portion of the cheek, or even 
 the entire bearded region may be covered by the eruption. In exten- 
 sive cases which have lasted for some time there is usually more or 
 less thickening and crusting of the affected region, especially when 
 the upper lip is the part involved. In rare cases when the crusts have 
 been allowed to accumulate the surface beneath is red, papillomatous 
 or vegetating, and covered with seropurulent discharge (Lang, 
 Neumann). Upon the upper lip, to which the disease is often limited, 
 the portion immediately beneath the nostrils is usually first affected 
 whence it spreads to other parts of the lip, or what is not at all infre- 
 quent, it may remain limited to the central portion, forming a flat, 
 sometimes tumor-like elevation covered with pustules and crusts. As 
 a rule the hairs are firmly retained in the follicles and attempts at 
 extraction are quite painful; exceptionally when the disease has lasted 
 for a considerable period and the inflammation has been deep-seated the 
 follicles may be completely destroyed with loss of hair and more or 
 less scarring (Fig. 235). The subjective symptoms vary from moder- 
 ate itching and occasional slight burning to severe itching or burning 
 or less frequently pain. Although limited in the vast majority of 
 
PLATE XXXVII 
 
 Sycosis vulgaris. 
 
DISEASES OF THE APPENDAGES 
 
 677 
 
 cases to the bearded region a similar affection may occur in other hairy 
 regions, such as the eyebrows, axillae and the pubic region. 
 
 The duration of the disease is quite indefinite. It usually lasts for 
 months and even years unless terminated by treatment. Spontaneous 
 recovery is a rare occurrence. 
 
 Some years ago Milton described a variety of folliculitis of the 
 beard in which the hair follicles were completely destroyed and exten- 
 sive scarring followed, to which he gave the name lupoid sycosis (Fig. 
 236) ; more recently Unna has proposed the name ulerythema sycosi- 
 
 Fig. 235.— Sycosis vulgaris. Many years' duration with scarring. 
 
 forme for it. The eruption, beginning as in the ordinary form with 
 small papules and pustules spreads from the place of its beginning 
 centrifugally, producing a smooth atrophic patch with red and slightly 
 elevated borders, from which the hairs have completely disappeared. 
 According to Unna it does not begin like the ordinary form, with 
 papules and pustules, but with erythematous spots upon which vesicles 
 appear. It is situated much more frequently upon the cheeks than 
 elsewhere in the beard, and is often limited to this region. It is 
 extremely chronic, lasting in most cases for many years with occasional 
 periods of remission of variable length. 
 
 Etiology.— The researches of Bockhardt, Unna, Sabouraud, and 
 
678 
 
 DISEASES OF THE SKIN 
 
 others have apparently demonstrated quite conclusively that the pri- 
 mary cause of sycosis is the Staphylococcus pyogenes, most frequently 
 the aureus, although the citreus and albus are likewise found in the 
 pustules. It would seem, however, that other organisms may also 
 occasionally produce a similar inflammation of the hair-follicle. Tom- 
 masoli has reported, under the name sycosis bacillogenes, a case of 
 sycosis in which he found a bacillus which was proven to be the active 
 cause by cultures and inoculations in the rabbit and his own skin. 
 
 Among predisposing causes are inflammations of the bearded region 
 
 Fig. 236. — Lupoid sycosis. 
 
 of various origin, either such as may result from local irritation, as from 
 shaving or from disease such as eczema, or seborrhceic dermatitis. In 
 sycosis of the upper lip there is quite commonly a nasal discharge which 
 leads to secondary infection of the follicles of the mustache, a fact of 
 great importance in connection with treatment of the disease in this 
 region. 
 
 Pathology. — Sycosis is a folliculitis and perifolliculitis in which, 
 according to Unna, four stages may be distinguished histologically. 
 The first stage is represented by a small pustule in the neck of the hair 
 follicle situated between the horny layer and the rete mucosum ; in the 
 second stage there is a nodular perifolliculitis in the neck of the follicle 
 
DISEASES OF THE APPENDAGES 679 
 
 and in the third a perifollicular abscess; from all of these there may be 
 complete recovery. In the fourth stage there is total suppuration of 
 the follicle followed by its complete destruction, loss of hair and scar- 
 ring. The walls of the follicle are infiltrated with numerous leucocytes 
 and contain great numbers of streptococci. 
 
 In lupoid sycosis (ulerythema sycosiforme) Sack, working in 
 Unna's laboratory, found extensive collections of plasma cells about 
 the follicles with complete disappearance of the elastic and rarefaction 
 of the collagenous tissues. There was also atrophy of the follicles, 
 sebaceous- and sweat-glands and muscles of the skin. The papillary 
 body contained large multinucleated chorio-plaques and numerous 
 " mastzellen." 
 
 Diagnosis. — Sycosis may be mistaken for pustular eczema of the 
 heard and for parasitic sycosis, trichophytosis (ringworm) of the beard. 
 In eczema the inflammation is rarely confined to the bearded region 
 alone, but spreads beyond it and is frequently present on other parts 
 of the face, such as the forehead or upon some part of the trunk or 
 extremities. The inflammation is not limited to the follicles as in 
 sycosis, but is diffuse and is accompanied by oozing and abundant 
 crusting with itching, frequently very pronounced. 
 
 Parasitic sycosis or ringworm of the beard usually begins much 
 more acutely than the non-parasitic variety and is usually much more 
 inflammatory. Sycosis vulgaris frequently attacks the upper lip ; the 
 parasitic variety only very rarely does so. In the latter the inflamed 
 area is often nodular or " lumpy " and elevations the size of a large 
 pea or hazel-nut occur in which the hairs are quite loose, so that they 
 may be readily and painlessly extracted, or fall out spontaneously. 
 Examination of these loose hairs reveals the presence of the 
 trichophyton. 
 
 Treatment. — It is extremely doubtful whether the course of sycosis 
 is influenced to any appreciable degree by internal remedies. If, how- 
 ever, the patient's general health is impaired in any way it is well 
 to employ such internal measures as will tend to repair it so that his 
 powers of resistance may be increased. If his nutrition is below the 
 normal cod-liver oil, moderate doses of arsenic, with some easily assim- 
 ilable form of iron if anaemia is present, may be found useful. The 
 sulphide of calcium or calx sulphurata which has been advised for its 
 supposed favorable effect upon suppuration is probably without effect; 
 certainly I have never seen it do any good. 
 
 When the inflammation is severe with much pain and burning and 
 frequent crops of pustules, mild lotions such as a saturated solution 
 of boric acid, or black wash, lotio nigra, applied three or four times 
 a day, will usually afford much relief, the beard first being closely 
 clipped and crusts, if present, removed by washing with hot water, 
 or the liberal application of some bland fat, such as vaseline, olive 
 oil, or cold cream. In the severest cases with swelling and pain, much 
 relief may be obtained by the use of a starch poultice made with a 
 
680 DISEASES OF THE SKIN 
 
 saturated solution of boric acid ; this serves not only as a soothing 
 application, but softens the crusts and facilitates their removal. Fre- 
 quent shaving, every day, or at least every other day, should be in- 
 sisted upon, as this is a most valuable auxiliary to the local treatment. 
 Depilation is advised by most authors, and is without doubt a valu- 
 able procedure, but done in the ordinary way with forceps it is fre- 
 quently so painful that the patient will not do it or permit it to be 
 done. Depilation by the X-ray, however, is frequently followed by 
 brilliant results ; with the falling of the hair the disease may com- 
 pletely disappear, leaving the skin quite smooth. Unfortunately the 
 eruption is likely to return with the hair, although occasionally the 
 cure is permanent. The exposures should be controlled by the Sabou- 
 raud-Noire pastile or Holzknecht meter, and should be just sufficient 
 to produce fall of the hair without dermatitis ; if this dose is exceeded 
 permanent loss of hair may result. 
 
 In the ordinary case with moderate inflammation which has 
 lasted for some time one of the most useful local remedies is sulphur, 
 used as an ointment or soft paste, in the strength of from twenty to 
 forty grains (1.30 to 2.60) to the ounce (32.0); this may be applied 
 once or twice a day with gentle friction. An ointment of ammoniated 
 mercury, twenty to thirty grains (1.30 to 2.0) to the ounce of cold 
 cream, or cold cream and lanolin is often of much service, and is little 
 inferior, if at all, to sulphur. 
 
 A very valuable remedy, although a rather disagreeable one on account 
 of its odor and color, is ichthyol. This may be used either as an aqueous 
 solution, 20 to 40 per cent., best applied with a brush, or as an ointment 
 containing 10 to 20 per cent. Occasionally it may be combined with 
 sulphur; a compound ointment of ichthyol, one to two drachms (4.0 to 
 8.0), and sulphur, one-half a drachm (2.0), does better than either 
 one alone. 
 
 In obstinate cases injections of a vaccine made from the patient's 
 own lesions may be tried; these are occasionally followed by brilliant 
 results, the eruption rapidly disappearing, but unfortunately quite as 
 often they are without effect. 
 
 DISEASES OF THE SEBACEOUS GLANDS 
 ASTEATOSIS 
 
 Synonym. — Asteatodes. 
 
 Definition. — A deficiency of fatty material in the skin. 
 
 Symptoms. — The skin is abnormally dry, inclined to superficial 
 fissuring, and is frequently finely desquamating. The deficiency of 
 fat is to be regarded as a symptom rather than as an independent affec- 
 tion ; it is frequently an accompaniment of other affections, such as 
 ichthyosis, prurigo, pityriasis rubra pilaris, extensive psoriasis. It is 
 frequently present in old age and in wasting diseases as a part of 
 
DISEASES OF THE APPENDAGES 681 
 
 the general failure of nutrition. As a local condition limited to cer- 
 tain regions, such as the hands and forearms, it is fairly common in 
 those whose occupation necessitates frequent and prolonged contact 
 with substances which remove the fatty material from the skin ; it 
 frequently occurs in washerwomen, whose hands and arms are im- 
 mersed for hours at a time in strongly soapy water, and in workers 
 in certain trades in which alcohol, ammonia, or other alkalis are 
 used. 
 
 Treatment. — The treatment is altogether symptomatic and consists 
 in the local use of such bland fats as vaseline, lanoline, oil of sweet 
 almond, or oil of sesame, either alone or in various combinations. 
 In the regional form contact with fat-dissolving substances should 
 be avoided when possible. 
 
 SEBORRHCEA 
 
 Synonyms. — Stearrhcea; Steatorrhoea ; Acne sebacea; Fr., Sebor- 
 rhee ; Ger., Schmeerflus. 
 
 Definition. — A disease of the fat-excreting glands of the skin char- 
 acterized by oiliness of the skin with or without the formation of fatty 
 crusts. 
 
 The present conception of seborrhcea differs in a number of important 
 particulars from Hebra's definition, which was almost universally accepted 
 for many years, the change being almost entirely due to the indefatigable 
 labors and numerous writings of Unna and Sabouraud. Many of the 
 most recent authors recognize but one form of seborrhcea, viz., the oily 
 form, the seborrhcea oleosa of Hebra, rejecting that author's seborrhcea 
 sicca altogether as belonging in another category. 
 
 As there is still considerable difference of opinion and uncertainty 
 as to the place of some of the forms of the latter, and as the author is not 
 yet fully convinced that some of them at least are not seborrhceic, two 
 forms are still recognized here for purposes of description, although it 
 is admitted that the pityriasis simplex of many authors, which Hebra 
 included among the dry forms of seborrhcea, is quite certainly not 
 seborrhcea. 
 
 Seborrhoea Oleosa. — Fluxus sebaceus ; Acne sebacee huileuse (Bes- 
 nier) ; Hyperidrosis oleosa (Unna) ; Hyperidrose huileuse (Brocq). 
 
 Symptoms. — This form of seborrhcea, which for a considerable 
 number of the most recent writers is the only true seborrhoea, is dis- 
 tinguished by a more or less marked greasiness of the skin. It ex- 
 hibits a very decided predilection for those regions in which the seba- 
 ceous glands are most numerous and active, such as the scalp, the 
 forehead, the nose and cheeks, the sternum and the interscapular 
 region. Much less commonly the entire cutaneous surface is abnor- 
 mally greasy. 
 
 Upon the scalp, which is one of the regions most frequently af- 
 fected, it varies from slight greasiness of the hair to extreme oiliness. 
 
682 DISEASES OF THE SKIN 
 
 In the most marked cases the hair is shining, and when long, as in 
 women, sticks together in greasy locks, looking as if oil had been 
 freely applied to it. 
 
 When the face is affected the forehead and nose are oily and 
 shining, and frequently grimy, owing to the readiness with which 
 floating dust and dirt adhere to the greasy skin. The mouths of the 
 ducts of the sebaceous glands are more or less dilated, giving an 
 appearance of coarseness to the skin, and from the dilated ducts slender 
 filaments of sebaceous material can be readily expressed, the "sebor- 
 rhceic filaments " of Sabouraud, which this author regards as an essen- 
 tial and characteristic feature of the malady. In many instances come- 
 dones and papules and pustules of acne are likewise present in vary- 
 ing numbers. 
 
 Seborrhcea sicca; Pityriasis simplex; Pityriasis steatodes; Eczema 
 seborrhceicum (Unna). 
 
 The so-called dry form of seborrhcea attains its most characteristic 
 development upon the scalp, to which region it is for the most part 
 confined. It is characterized by yellowish or grayish, friable or soft 
 greasy crusts, which glue the hair down to the scalp. Although ad- 
 herent, they may be readily removed and the scalp beneath is found 
 to be either normal in appearance or of a pale leaden color; occa- 
 sionally there is some hyperemia. 
 
 Occasionally there is an abnormal production and accumulation 
 of sebaceous material (smegma) beneath the prepuce in men and 
 about the clitoris in women, which may undergo decomposition and 
 give rise to balanitis in the former and vulvitis in the latter. 
 
 What may be regarded as a physiological seborrhcea exists to a 
 greater or less degree during the last months of intrauterine life and 
 in the new-born infant as the vernix caseosa. This quite commonly 
 persists for two or three months after birth upon the scalp as a 
 yellowish or greenish, quite adherent crust. The scalp beneath is often 
 normal in appearance, but may be more or less hypersemic, or even 
 inflamed, either as the result of decomposition of the fatty material 
 in the crust or from ill-directed efforts to remove it ; when inflam- 
 mation is present, it cannot properly be regarded as seborrhcea, but 
 as a seborrhceic dermatitis (eczema seborrhceicum). 
 
 Pityriasis simplex, pityriasis furfuracea, commonly known as dan- 
 druff, was regarded by Hebra as a form of dry seborrhcea, but there 
 is general agreement among writers of the present day that it is 
 not an affection of the sebaceous glands, but of the epidermis. It 
 is characterized by a more or less abundant dry bran-like scaling, con- 
 fined for the most part to the scalp, but not at all infrequent in the 
 beard and brows ; when at all marked, the patient's coat-collar and 
 shoulders are constantly covered with fine white scales, which sift 
 down from the scalp. The scalp is either normal in appearance or 
 slightly hypersemic and more or less itching, less frequently burning, 
 are present. Sooner or later the hair becomes dry, lustreless, and 
 
DISEASES OF THE APPENDAGES 683 
 
 thinned, and baldness (alopecia pityrodes) eventually appears. Occa- 
 sionally the smooth parts of the face present a similar desquamation, 
 and in those suffering from chronic wasting diseases the entire cutane- 
 ous surface may be affected (pityriasis tabescentium). 
 
 Etiology. — Seborrhcea is a disease of adolescence and early adult 
 life, beginning commonly about the time of puberty, when the sebace- 
 ous glands are undergoing rapid development. It occurs with about 
 the same frequency in both sexes, although it is stated by some authors 
 to be somewhat more frequent in women after middle age ; this, how- 
 ever, has not been the author's experience. It is more frequent in 
 those with dark complexions than in blonds. It is frequently asso- 
 ciated with that congeries of symptoms included under the some- 
 what vague term dyspepsia, and in a considerable proportion of cases 
 symptoms of anaemia, chlorosis, or tuberculosis are present. It occasion- 
 ally follows severe illnesses, such as the exanthemata, especially vari- 
 ola. All these, however, are nothing more than predisposing factors, 
 and any or several of them may be present in those who exhibit no 
 symptoms of seborrhcea. The present tendency is to regard it as 
 primarily due to some one of the microorganisms present in the gland- 
 ducts and the crusts. 
 
 According to Sabouraud, the cause is a microbacillus present in 
 enormous numbers in the seborrhoeic filament, which can be expressed 
 from the ducts of the sebaceous glands in the affected regions. 
 
 Pathology. — Largely as the result of the extensive studies of Unna 
 and Sabouraud, to which reference has already been made, many 
 authorities of the present day regard the infectious nature of the 
 malady as proven. As just observed, Sabouraud believes the infect- 
 ing agent in the oily variety to be his microbacillus. 
 
 The form characterized by fatty crusts is believed by this author 
 to be a secondary infection by a polymorphous coccus forming gray 
 cultures, probably identical with Unna's morococcus, engrafted upon 
 a scalp already affected by pityriasis. This last is not a seborrhoea 
 at all, but an epidermic affection due to the organism first described 
 some years ago by Malassez, which is probably the same organism 
 described later by Unna as the bottle-bacillus (Flaschenbacillus). 
 
 Unna does not believe the sebaceous glands are the source of 
 the fatty excretion, but the coil-glands, and calls the affection, not 
 seborrhoea, but hyperidrosis oleosa. Beatty's careful observations, 
 however, have confirmed the generally prevalent view that the sebace- 
 ous glands are the seat of the disease. They at the same time go 
 far to support Unna's contention that the dry forms are inflammatory 
 and should therefore be considered forms of seborrhoeic dermatitis 
 (eczema seborrhceicum). 
 
 Diagnosis. — The recognition of the oily form of seborrhcea is usually 
 easy; it cannot readily be mistaken for any other affection. When 
 fatty crusts are present it is to be distinguished from seborrhoeic 
 
684 DISEASES OF THE SKIN 
 
 dermatitis and from psoriasis. It is to be distinguished from the 
 former by the evident dilatation of the ducts of the sebaceous glands 
 from which vermicelli-like filaments can be readily expressed, and 
 the absence of inflammation. It must be admitted, however, that it 
 is sometimes difficult to draw the line between the two affections, as 
 the seborrhoea readily becomes inflammatory and is then no longer 
 a seborrhcea but a seborrhceic dermatitis. 
 
 In the author's experience no error is more common than to mis- 
 take a dry seborrhcea of the scalp for a psoriasis. A careful exami- 
 nation, however, will always prevent mistakes. The crusts of sebor- 
 rhcea are fatty or greasy, are diffuse instead of well-circumscribed, 
 and cover a scalp which is normal in appearance or paler than normal. 
 In psoriasis the crusts are dry and friable, circumscribed, and cover 
 areas of scalp which are red and inflamed, and in the great majority 
 of cases there are unmistakable patches on the smooth surfaces, par- 
 ticularly the elbows and knees. 
 
 Prognosis. — The prognosis as to a cure is only fairly favorable ; 
 improvement is likely to be slow, and relapses are common even with 
 the best-directed treatment. Sabouraud regards it as incurable, al- 
 though great improvement almost amounting to a cure can be brought 
 about by proper treatment. In the dry varieties baldness (alopecia 
 pityrodes) is an almost invariable sequel unless treatment is under- 
 taken early and continued perseveringly. 
 
 Treatment. — If the patient is anaemic or chlorotic, some readily 
 assimilable form of iron should be given either alone or in conjunc- 
 tion with small doses of arsenic. In those showing signs of tuber- 
 culosis, such as chronic adenitis, cod-liver oil may be administered 
 in small quantities with an abundance of easily digested and nutritious 
 food, and above all an abundance of fresh air and sunlight should be 
 insisted upon. If there are symptoms of faulty digestion and assimi- 
 lation, the diet should be carefully regulated and strychnia and hydro- 
 chloric acid given. Sabouraud is thoroughly convinced of the useful- 
 ness of the stronger sulphur waters taken internally. 
 
 However useful such general treatment as is briefly outlined above 
 may be, and there is no doubt that it is at times of use, it will ac- 
 complish little or nothing unless employed in conjunction with judi- 
 cious local treatment. 
 
 When the scalp is the seat of the disease, it should be washed at 
 first every five days, or once a week, with warm water and tar soap ; 
 or if there is considerable crusting the tincture of green soap may 
 be used instead. After washing, a small quantity of vaseline, or, bet- 
 ter, oil of sesame, should be rubbed in. As improvement takes place 
 the intervals between the washings may be lengthened to ten days 
 or two weeks. 
 
 The most useful external remedies are, in the order of their efficacy, 
 sulphur, resorcin, tar, and ammoniated mercury, and there is general 
 agreement among dermatologists that the first-named is much the 
 
DISEASES OF THE APPENDAGES 685 
 
 most efficacious. As a rule, ointments are more effective than washes, 
 although less agreeable to use. The following lotion containing sul- 
 phur in suspension is a useful one in the milder cases : 
 
 Sulphur, prascip., 
 
 Alcoholis, 90 per cent aa Sijss (io.o) 
 
 Aq. destil., 
 
 Aq. rosse aa fSiss (50.0) 
 
 M. 
 
 Sid. Apply once a day (Sabouraud). 
 
 The author has for some time used the following ointment of sulphur 
 with satisfactory results : 
 
 Sulphur, praecip gr. x-xx (0.65-1.30) 
 
 Eucerin 5i (32.0) 
 
 M. 
 
 Sig. Apply with friction every night upon retiring. 
 
 The preparations of tar are frequently of decided value, but are ob- 
 jectionable on account of their strong unmistakable odor and the 
 staining which follows their use. Sabouraud recommends the fol- 
 lowing tarry lotion : 
 
 Ol. cadini fSiij ( 100.0) 
 
 Decoct, quillaiae fSi (30.0) 
 
 Ovi vitel. No. i, 
 
 Aq. destil q. s. ad fBviij (250.0) 
 
 M. 
 
 The oil of cade and the quillaia are to be mixed first, the yolk of the 
 egg is to be gradually added in a mortar, stirring all the while, and 
 the water added last. One tablespoonful of this emulsion is to be 
 added to a quart of water and the mixture used as a lotion once or 
 twice a day. Anthrasol, a decolorized and deodorized tarry prepara- 
 tion, may be substituted for the oil of cade, making a more agreeable 
 application, although somewhat less effective, perhaps. 
 
 A lotion of resorcin, 2 to 5 per cent., in 70 per cent, alcohol, is 
 a useful application in many cases ; it should be gently rubbed in once 
 a day either with the fingers or with a pledget of cotton. Occasion- 
 ally the stronger lotions excite a considerable degree of inflamma- 
 tory reaction and should therefore be used at first with some care. 
 Should these lotions prove too drying, a few minims of glycerin, ten 
 to twenty to the ounce (32.0), may be added. Ointments of resorcin 
 are less effective than lotions and much less agreeable. Owing to 
 the staining which it produces, resorcin should not be used on the 
 scalp when the hair is fair or white. 
 
 A 4 to 6 per cent, ointment of ammoniated mercury is frequently 
 quite beneficial in seborrhoea of the scalp ; it is odorless and colorless, 
 and therefore much more agreeable than the preparations of tar and 
 sulphur. 
 
686 DISEASES OF THE SKIN 
 
 In seborrhoea of the face and other non-hairy parts, nothing in 
 the author's experience has been found superior to the sulphide of 
 zinc lotion. Beginning with one containing I per cent, each of the 
 sulphate of zinc and the sulphate of potash in water with ten to 
 fifteen minims of glycerin to each ounce (32.0) it may be gradually 
 increased to 2 or 3 per cent. 
 
 In seborrhcea of the genitalia, frequent ablutions with warm water 
 and castile soap and the application two or three times a day of a 
 saturated solution of boric acid or a lotion containing one-half to 
 one per cent, of resorcin, followed by a dusting powder of equal parts 
 of talc and boric acid, will be found effective. Ointments should not 
 be used in these regions, or if used should always be made up with 
 some one of the mineral fats, as those made with the animal and 
 vegetable fats speedily decompose and irritate. 
 
 COMEDO 
 
 Synonyms. — Blackhead ; Fr., Comedon ; Acne ponctuee ; Ger.,. 
 Comedon ; Mitesser. 
 
 Definition. — An affection of the ducts of the sebaceous glands dis- 
 tinguished by black or brownish dots which represent the outer end 
 of small plugs of sebum and epithelial debris filling the ducts. 
 
 Symptoms. — This very common affection is found for the most 
 part on those parts of the skin in which the sebaceous glands are most 
 abundant and best developed, such as the face, the upper portion of 
 the chest and back, the concha of the external ear; exceptionally it 
 occurs upon the abdomen, the shaft of the penis, in fact anywhere 
 where there are sebaceous glands. The small black point which 
 characterizes it may be level with the surrounding skin or slightly 
 elevated, forming small pin-head-sized papules with a black punctate 
 centre (acne punctata, acne ponctuee of the French). Upon the face, 
 which is one of the regions most frequently attacked, they may be 
 present as a few scattered black points, or exist in great numbers, 
 looking like grains of gunpowder imbedded in the skin, often pro- 
 ducing decided disfigurement. They vary in size from a mere point 
 to a pin-head or a hemp-seed, the larger lesions occurring upon the 
 nose and the cheeks adjoining. Upon the back and chest they are 
 often numerous and are usually larger than in the face ; in these 
 regions, the back especially, they frequently occur in pairs, represent- 
 ing double comedones, which communicate with each other beneath 
 the small bridge of skin which separates them. In the external ear 
 they may reach the size of a small hemp-seed and are frequently 
 bluish in color. By pressing on both sides of the mouth of the duct 
 the comedo may be expressed, and then appears as a yellowish cylinder, 
 the external end of which is quite firm and covered with a black top, 
 while the lower end is soft ; these are popularly known as "flesh- 
 worms." Lesions which have existed for some time may be quite 
 
DISEASES OF THE APPENDAGES 687 
 
 hard, and instead of being uniformly cylindrical may be somewhat pear- 
 shaped, the outer end being slightly smaller than the remainder. 
 
 Although comedones may exist independently of any other cutane- 
 ous affection, they are in most instances associated with some other 
 disease of the sebaceous glands, particularly with oily seborrhcea 
 and acne, the papules and pustules of the latter frequently arising in 
 the follicles already occupied by comedones. 
 
 Usually scattered about irregularly in the regions affected, they 
 may in rare cases occur in symmetrically placed groups, an observa- 
 tion first made by Thin and later confirmed by Crocker, Wetherill. 
 and others. In the cases observed by Crocker there were symmetrical 
 groups of closely crowded lesions on both sides of the face which 
 showed but little tendency to inflammation. In a case seen by the 
 author a few years ago they were confined exclusively to the upper 
 lids, each of which contained a dozen or more. The occurrence of 
 grouped comedones in quite young children and infants has been 
 noted in a few instances by Crocker, Caesar, Colcott Fox, and Harries, 
 the last-named having recently reported four examples. They were 
 usually present in large numbers upon the forehead, the occiput, the 
 cheeks, and occasionally in other regions. 
 
 The affection is a very chronic one, many of the lesions lasting- 
 with little or no change for years. In rare instances atrophic scars 
 at the mouths of the follicles have been noted as a sequel (Lang, 
 Neumann). 
 
 Etiology. — Comedo is most frequently seen in those between the 
 ages of fifteen and thirty, but may, as already noted, occur in child- 
 hood, and is not very uncommon in the elderly and old. In children 
 Crocker regarded heat and moisture, and perhaps local irritants, as 
 causal agents ; he also observed its simultaneous occurrence in several 
 members of a family, and quotes Haddon as having made a similar 
 observation, suggesting the possibility of its origin from contagion. 
 It frequently occurs in those who are anaemic or chlorotic, or in those 
 who suffer from some form of indigestion with constipation. In 
 women it is often associated with irregularity of the menstrual func- 
 tion or other evidences of disease of the generative apparatus. It 
 also occurs as an occupational disease in workers in tar and paraffin. 
 The author has seen numerous comedones occur upon the bald scalp 
 after inunctions of crude petroleum employed by the patient for the 
 purpose of promoting the growth of the hair. Dore observed them 
 follow inunctions of camphorated oil in a child. 
 
 Pathology. — According to the most recent views, comedo is not 
 to be regarded as an independent affection, but simply as a part of 
 certain pathological processes the result of an infection of the follicles, 
 which, beginning with seborrhcea, end with acne. Sabouraud regards 
 it as a degeneration of the "seborrhceic filament," which is always 
 present in seborrhcea. It begins with a hyperkeratosis of the mouth 
 of the follicle, which, interfering with the free escape of the sebum, 
 
688 
 
 DISEASES OF THE SKIN 
 
 leads to its accumulation in the duct, which sooner or later is dilated 
 in consequence. The retention of the sebum is a mechanical effect 
 and not the result of an alteration in its quality, as was formerly 
 believed. The comedo is composed of horny epithelial cells and sebum 
 and contains twisted or rolled-up lanugo hairs, pigment granules, espe- 
 cially in its outer end, and occasionally one or more samples of the 
 Acarus (demodex) folliculorum (Fig. 237). In the soft interior are 
 enormous numbers of a very small bacillus, the microbacillus of Sa- 
 
 Fig. 237. — Comedo. 
 
 bouraud, which that author believes to be the primary etiological factor 
 in its production. Unna has likewise described a small bacillus present 
 in the comedo, which is probably the same organism, which under 
 certain circumstances may be pyogenic and give rise to inflammation 
 and suppuration of the follicle (acne). The bottle-bacillus (Flaschen- 
 bacillus) is also to be found in its outer and firmer portion. The black 
 material found in the outer end of the comedo is not, as commonly 
 supposed, extraneous matter, but a pigment which Unna considers 
 is probably a degeneration product of keratin ; Sabouraud thinks it 
 likely that it is derived from the cortical cells of the hair. 
 
DISEASES OF THE APPENDAGES 689 
 
 Diagnosis. — The appearance of the comedo is usually so character- 
 istic that it is readily recognized ; the localities which it affects and 
 its frequent association with seborrhcea and acne are likewise more or 
 less characteristic. Occasionally small black dots resembling comedo 
 at a little distance are formed at the mouths of the follicles as the 
 result of a chemical decomposition when mercurial preparations are 
 followed shortly by sulphur, or vice versa. 
 
 Prognosis and Treatment. — With persevering treatment it is usually 
 possible to remove the affection and prevent its return. The treat- 
 ment, both general and local, is practically the same as that of acne. 
 In anaemic and chlorotic patients, iron and arsenic should be pre- 
 scribed; cod-liver oil is frequently of service, particularly in those 
 with thick, oily skins and enlarged glands. In the great majority of 
 cases laxatives, especially the salines, should be given. The diet should 
 be carefully looked after ; tea, coffee, and alcoholic beverages, par- 
 ticularly beer and sweet wines, should be forbidden, and plenty of out- 
 door exercise should be enjoined. 
 
 The face should be washed daily for a time with hot water and 
 tincture of green soap, or, if this proves too irritating, castile soap. 
 Two or three times a week the face should be steamed or thoroughly 
 bathed with warm water containing a small quantity of borax, and the 
 comedones gently expressed with the fingers or removed with one 
 of the "comedo extractors" to be obtained of the instrument makers. 
 One of the most useful local applications is the sulphide of zinc lotion, 
 ten to fifteen grains (0.65 to 1.0) each of sulphate of zinc and sul- 
 phide of potassium to the ounce (32.0) of water. This should be thor- 
 oughly shaken and mopped on every night before retiring. The fol- 
 lowing lotion of sulphur is especially useful in the cases in which there 
 is oily seborrhoea: 
 
 Sulphur, sublimat 3j (4.0) 
 
 Athens fBss (15.0) 
 
 Alcoholis f§iijss (90.0) 
 
 M. 
 
 Sig. Shake thoroughly and apply. 
 
 Van Harlingen recommends the following paste for the purpose of 
 loosening the comedones : 
 
 Aceti f 3ij (7.50) 
 
 Glycerini f3iij (12.0) 
 
 Kaolini Sss (15.0) 
 
 M. 
 
 This should be spread over the affected surface at night. 
 
 MILIUM 
 
 Synonyms. — Grutum ; Strophulus albidus : Acne albida; Acne mili- 
 aria; Tuberculum sebaceum. 
 44 
 
690 DISEASES OF THE SKIN 
 
 Definition. — Small, yellowish-white, cystic tumors having their 
 origin in the follicles of the lanugo hairs. 
 
 Symptoms. — Milium is distinguished by small to large pin-head- 
 sized nodules, which are opaque or faintly translucent, white, yellow- 
 ish-white, or pale yellow, situated most frequently on some portion 
 of the face. The most common sites are the malar eminences, the 
 lids, often at the inner canthus, the forehead, and the temples; less 
 frequently they are found on the shaft of the penis, the corona glandis, 
 the scrotum, where they may reach the size of a split pea, and the 
 inner surface of the labia in women. When the genitalia are affected 
 they may be the source of some uneasiness to the patient, who is apt 
 to regard them as of venereal origin. They are usually discrete and 
 without any special arrangement, although Crocker saw a case in 
 which they were arranged symmetrically on both cheeks. In most 
 cases they are present in moderate numbers, but occasionally they 
 are quite numerous, and two or more may unite to form a single lesion 
 as large as a pea. If incised a small white globular mass may be ex- 
 pressed with moderate pressure. In a few instances the contents 
 undergo calcareous degeneration, forming cutaneous calculi. 
 
 Etiology. — Milia occur at all periods of life from early infancy to 
 old age. Although most frequently seen in young adults, they are 
 quite common in early infancy {strophulus albidus), and are occasion- 
 ally present even at birth. They are sometimes observed to follow 
 pemphigus, dermatitis herpetiformis, and other bullous affections ; 
 they may be present in considerable numbers in the regions previously 
 occupied by the bullae ; they also occur in scars of varying origin. 
 
 Pathology. — Milia, which are situated in the upper portion of the 
 corium, are horny cysts, the product of a hyperkeratosis of the lanugo 
 hair- follicles, remnants of which Unna invariably found attached to 
 them. They contain small masses of horny epithelium arranged in con- 
 centric layers, forming so-called "pearls" ; true milia do not contain 
 fat. Virchow, who was the first to study their structure, although 
 recognizing their connection with the hair-follicle, regarded them as 
 retention cysts formed in a small sebaceous gland or in one of the 
 glandular acini. Robinson believes there are two forms, one arising 
 from aberrant embryonic epithelium of the rete, or of a hair-follicle 
 which is without duct, contains no fatty epithelium, and shows no 
 connection with the sebaceous gland ; the other contains fatty epi- 
 thelium and cholesterin and is provided with a duct, a deep-seated 
 comedo. According to Ehrmann, the place of origin of the cyst is 
 probably not the same in all cases, since he has been able in some 
 instances to demonstrate a connection with the excretory duct of the 
 sweat-gland. The discrepancies which exist between the earlier and 
 the more recent accounts of the histopathology of these small cysts is 
 probably due, as Unna suggests, to the failure of the earlier observers 
 to distinguish clinically with accuracy milium from comedo and small 
 sebaceous cysts. 
 
DISEASES OF THE APPENDAGES 691 
 
 Diagnosis. — When situated upon the lids they may be mistaken 
 for the nodules of xanthoma, but the latter are usually decidedly larger, 
 flat instead of hemispherical, often quite bright or orange-yellow, and 
 when incised do not give exit to the white material found in the 
 former. They differ from comedo, to which they may bear only a 
 very superficial resemblance, by their situation and the absence of 
 the small black dot which usually distinguishes the latter. The so- 
 called colloid milium, colloid degeneration of the skin, which occurs 
 in the same situation, is a very much deeper yellow and contains 
 a gelatinous substance quite unlike the white contents of ordinary 
 milium. 
 
 Prognosis and Treatment. — The affection is a trivial one, but when 
 the lesions are numerous they may produce considerable disfigure- 
 ment. It lasts for an indefinite period, but many of the individual 
 lesions eventually disappear spontaneously, leaving no trace. 
 
 In infants, washing with soap and warm water will frequently re- 
 move them ; in adults, the most satisfactory treatment is electrolysis, 
 by which they may be quickly and easily destroyed. A fine needle 
 connected with the negative pole of the battery should be inserted a 
 short distance into the little tumor and a current of one to two mil- 
 liamperes allowed to act for ten to fifteen seconds. The larger lesions 
 may be incised with a small scalpel and their contents expressed. 
 
 STEATOMA 
 
 Synonyms. — -Atheroma ; Sebaceous cyst ; Wen ; Fr., Steatome, 
 Kyste sebace, Loupe; Ger., Balggeschwulst, Griitzbeutel. 
 
 Definition. — A cystic tumor of the skin with soft, cheesy or semi- 
 fluid contents. 
 
 Symptoms. — Sebaceous cysts vary in size from a hemp-seed to a 
 walnut or an egg, and exceptionally may be as large as the fist. When 
 small they are round, somewhat flat, and button-like ; when larg-e 
 they are hemispherical or less frequently globular. They are usually 
 soft, elastic, and movable ; exceptionally they may be rather firm and 
 fixed. They are the color of the skin, pinkish, or, when large and 
 distended, whitish or slightly violaceous. In a certain number a small 
 opening exists, wdiich is at times closed by a small comedo-like plug, 
 from which the cheesy contents may be expressed, or from which 
 a milky, foul-smelling fluid escapes spontaneously from time to time ; 
 in many, if not most cases, however, no such opening can be discov- 
 ered. The most common site is the scalp, where in the early stages 
 they are covered with hair, but with increase in size they become 
 smooth and perfectly bald. They are infrequent upon the trunk and 
 rare upon the extremities ; they are occasionally seen upon the scrotum, 
 where they may exist in considerable numbers. They may be single 
 or multiple, and in rare cases are very numerous, scores or even hun- 
 dreds being present. It is quite likely, however, that most of the 
 
692 DISEASES OF THE SKIN 
 
 cases of so-called multiple sebaceous cyst were in fact dermoid cysts. 
 They usually grow very slowly, and after reaching the size of a 
 walnut may remain practically stationary for long periods. Occa- 
 sionally, either from over-distention or from injury, they may become 
 inflamed and suppurate or ulcerate ; in rare cases they may undergo 
 epitheliomatous change. At times they may become the seat of cu- 
 taneous horns, particularly those which have a patulous duct. They 
 are filled with a whitish, cheesy mass or an extremely fetid semifluid 
 material. Occasionally the contents undergo calcareous degeneration, 
 especially in the tumors of the scrotum, Joseph reporting an instance 
 in which there were forty such calcified tumors in this region. 
 
 Etiology and Pathology.— Sebaceous cyst is an affection chiefly of 
 adult life, rarely occurring before puberty. The direct cause is quite 
 
 unknown. 
 
 Virchow regarded the so-called atheroma or sebaceous cyst as a 
 retention cyst of the sebaceous gland, a view which was accepted by 
 the majority of pathologists and dermatologists for a considerable 
 time, but the more recent studies of Franke and Torok have appar- 
 ently proven its incorrectness, at least for a considerable number of 
 such tumors. The latter, in examining a number of atheromata from 
 various parts of the body, found papillae in all but two, a finding which 
 completely disproves the view that they originate in the sebaceous 
 glands. The contents of most of them were horny cells, cholesterm, 
 and in some instances chalky masses ; fat was very seldom present. 
 T6rok asserts that true atheromata are nothing but dermoid cysts. 
 Winiwarter was of the opinion that there was first a new formation 
 of gland tissue, which was later transformed into a cystic tumor. 
 According to Unna, true sebaceous cysts always have an external 
 opening ; those which have fatty contents are never true atheromata. 
 A survey of the literature leads to the conclusion that much of the 
 difference of opinion concerning the histopathology of this tumor is 
 due in large part to the failure to carefully distinguish clinically the 
 sebaceous cyst from other forms of cystic tumor of the skin. Joseph 
 agrees with Franke that under the name atheroma two forms of tumor 
 have been described— one a follicular cyst seated in the cutis, arising 
 in the sebaceous follicle ; the other, which Franke calls epidermoid, 
 situated in the subcutaneous tissue, arising from embryonic inclusions 
 
 of the epidermis. . . 
 
 The wall of the cyst is composed of fibrous connective tissue, and 
 it is lined by squamous epithelium. The contents, which may be 
 cheesy or semifluid, are horny epithelial cells, crystals of cholesterm, 
 fatty debris, and occasionally hairs. 
 
 Diagnosis.— Its situation in most instances upon the scalp; the 
 absence of hair from the larger ones ; the presence of an opening from 
 which whitish cheesy material can be expressed, or from which an 
 extremely offensive fluid escapes spontaneously from time to time, 
 are characteristic features of this form of tumor which readily dis- 
 
PLATE XXXVIII 
 
 Acne vulgaris 
 
PLATE XXXIX 
 
 Acne vulgaris. 
 
DISEASES OF THE APPENDAGES 693 
 
 tinguish it from other similar tumors. Those which are situated upon 
 the trunk or elsewhere than the scalp are to be distinguished from 
 fatty tumor (lipoma) and from fibroma. From the former they differ 
 by their smoothness, greater elasticity, and absence of lobulation; 
 from the latter by their greater softness. 
 
 Prognosis and Treatment. — Steatomata or sebaceous cysts are be- 
 nign tumors, as a rule unaccompanied by any painful or annoying sub- 
 jective symptoms ; when large or numerous they may produce decided 
 disfigurement. Occasionally, as already noted, they inflame and sup- 
 purate ; in rare instances they may become the seat of epithelioma. 
 
 The treatment is surgical. The overlying skin should be incised 
 and the cyst enucleated. If it is ruptured, or if its wall is adherent 
 to the skin, it should be carefully dissected out, taking care to leave 
 no portion of the wall behind, otherwise a recurrence is likely to take 
 place. Small cysts may sometimes be obliterated by injecting them 
 with tincture of iodine. 
 
 ACNE 
 
 Under the term "acne" are included a number of chronic inflam- 
 matory affections, for the most part pustular, having their seat in the 
 sebaceous glands and follicles, presenting more or less similarity in 
 their clinical symptoms, but varying considerably in their etiology. 
 The several diseases included under this title are : acne vulgaris, acne 
 rosacea, these two being the most closely related of the group ; acne 
 varioliformis, acne keratosa, acne urticata, and acne artificialis. The 
 first two of these are far more frequent than the others, and may be 
 regarded as types of this affection. They are closely related to one 
 another in their clinical symptoms, course, and etiology; while the 
 other members of the group are quite distinct etiologically, and prob- 
 ably have little or nothing in common with the first two but their 
 anatomical seat. 
 
 ACNE VULGARIS 
 
 Synonyms.— Acne simplex; Fr. Acne; Ger., Akne; Finnen. 
 
 Definition.— A chronic inflammatory disease of the sebaceous glands 
 characterized by an eruption of papules, pustules, nodules, and occa- 
 sionally abscesses, having its seat in the regions in which the glands 
 are most abundant and best developed, such as the face and the upper 
 portion of the chest and the back (Plates XXXVIII and XXXIX). 
 
 Symptoms.— There is considerable variation both in the number 
 and character of the lesions and in the extent of the eruption. 
 
 While the lesions, which may be small and superficial or large 
 and deep-seated, are for the most part pustular, or become so in the 
 course of their evolution, a certain number of them may remain papular 
 or nodular throughout the entire term of their existence. The erup- 
 tion is usually more or less multiform, being made up of papules and 
 pustules with comedones, and according to the predominance of one 
 or the other form of lesion and the course of the eruption, for conven- 
 
694 
 
 DISEASES OF THE SKIN 
 
 ience of description a number of clinical varieties are recognized, such 
 as acne punctata, acne pustuloses, acne indurata, acne cachecticorum. 
 In acne punctata the eruption consists of small red papules, frequently 
 not larger than a large pin-head, with a small black dot in the centre. 
 The eruption is usually quite abundant and has its favorite seat on 
 the forehead. Acne pustulosa presents two fairly distinct types ; one 
 in which the pustules, which are usually numerous, are quite small, 
 
 Fig. 238. — Acne vulgaris. 
 
 superficial, and only moderately inflammatory, the greater part of the 
 eruption being situated upon the forehead ; and a second type in which 
 the lesions are much larger, more inflammatory, occupying not only 
 the forehead, but the cheeks, the chin, the chest, and the back. In 
 acne indurata the eruption consists of large, deep-seated red or bluish- 
 red, firm nodules, which often remain without much change for weeks 
 or even a month or two, and then soften and discharge, or undergo 
 slow absorption, leaving well-defined and permanent scars. 
 
 In acne cachecticorum or scrofulosorum, the lesions are unusually 
 
DISEASES OF THE APPENDAGES 695 
 
 numerous and large, and extend over the face and trunk. They are 
 usually distinguished by an unusual lividity, and small abscesses are 
 common (Fig. 238). This variety of the malady is seen in tubercu- 
 lous or strumous subjects with pale, pasty skin, and in those whose 
 nutrition is much below the normal as the result of poor or improper 
 food or debilitating disease. 
 
 As a rule the subjective symptoms are trifling, or may be altogether 
 absent. There may be a moderate amount of itching, but rarely 
 enough to give the patient much annoyance, and occasionally some 
 of the larger and more inflammatory lesions are somewhat painful, 
 but this is decidedly the exception. 
 
 The number of lesions varies from a dozen or more upon the face 
 or back to hundreds, covering not only the face but the upper chest 
 and back and exceptionally extending in the last-named region to the 
 buttocks. In cases of moderate severity the forehead, cheeks, and the 
 angles of the jaws are the regions most affected. In almost all cases 
 more or less scarring follows the eruption, and in acne indurata the 
 cicatrices are apt to be large and deep, and when numerous may pro- 
 duce quite as much disfigurement as variola. The eruption is apt to 
 appear in crops coming out at irregular intervals, and shows no 
 tendency to any special arrangement, the lesions being scattered about 
 irregularly. In addition to the papules and pustules already described, 
 there are almost invariably evidences of disturbed function of the 
 sebaceous glands, such as comedones, seborrhoea, and small sebaceous 
 cysts. 
 
 Etiology.- — Among the predisposing causes of acne vulgaris a prom- 
 inent place must be assigned to youth. The disease almost invariably 
 begins at or about the time of puberty, and in the vast majority of 
 cases occurs in those between the ages of fifteen and twenty-five. Dis- 
 turbance of the gastro-intestinal tract is a common accompaniment 
 and plays a more or less important role in predisposing to the affection. 
 Disease of the generative organs, functional or organic, must also be 
 reckoned among the causes which predispose to it. The relationship 
 to disorders of these organs is especially noticeable in women, in 
 whom a more or less marked menstrual exacerbation is commonly 
 observed. 
 
 Unwholesome occupations, improper or insufficient food, and dis- 
 eases such as tuberculosis, by leading to malnutrition, favor the occur- 
 rence of the malady. The mechanical blocking up of the ducts of the 
 glands, which occurs in those whose occupation compels them to work 
 in an atmosphere charged with dust, predisposes to the disease. 
 
 The variety known as acne indurata, with large, livid, deep-seated, 
 sluggish lesions, is especially apt to be seen in seamstresses and factory 
 operatives, who, shut away from fresh air and sunlight for hours, 
 work in ill-ventilated and poorly lighted rooms. 
 
 As to the direct cause, the weight of evidence is greatly in favor 
 of a specific infection of the sebaceous glands. A number of micro- 
 
696 DISEASES OF THE SKIN 
 
 organisms have been found in the inflamed glands to which a causative 
 agency has been attributed, but definite proof of their etiological rela- 
 tionship has not yet been satisfactorily furnished. There is much, 
 however, in favor of the view that the organism described by Gilchrist 
 as the Bacillus acnes, which is similar to, if not identical with, the 
 microbacillus of Sabouraud, is the causative agent; but there is no 
 doubt that the infection is a mixed one in most cases, the Staphylo- 
 coccus albus and aureus taking a considerable part in the production 
 of the inflammation. 
 
 Pathology. — According to Unna, the first pathological change in 
 acne is a hyperkeratosis affecting the mouths of the sebaceous gland 
 ducts, which, by interfering with the discharge of the secretion of the 
 gland, leads to the formation of a comedo, a plug composed of horny 
 epithelial cells and sebum. The formation of the comedo is followed 
 in time by inflammation of the sebaceous gland, a folliculitis, and if the 
 inflammatory process extends to the parts about the gland by a peri- 
 folliculitis. 
 
 According to Leloir and Vidal, the inflammation begins in the peri- 
 follicular tissues and later extends to the follicle itself. The degree 
 of inflammation varies considerably; at times it is limited to the gland, 
 at others it extends to the parts around, with the frequent formation 
 of small abscesses (Fig. 239). In acne indurata the cellular exudate 
 about the gland is composed of connective-tissue cells, plasma cells, 
 an increased number of "mastzellen," and an occasional giant-cell. 
 The suppuration which is present is not the result of infection with 
 the staphylococci, according to Unna, but results from a bacillus found 
 in the comedo, and the severity and depth of the suppuration de- 
 pends upon the situation of these organisms, i.e., whether they 
 are situated in the upper or lower portion of the comedo. In those 
 cases in which the inflammation is severe and deep-seated, complete 
 destruction of the gland or of the entire follicle may take place, with 
 the formation of permanent scars. 
 
 Diagnosis. — The diagnosis of acne usually presents no difficulties. 
 The youth of the patient ; the inflammatory character of the eruption ; 
 its localization upon the face and upper portion of the trunk ; evidence 
 of disturbed function of the sebaceous glands, such as comedones and 
 unusual oiliness of the skin ; its chronic course ; and the usual absence 
 of any notable subjective symptoms, notwithstanding the frequently 
 considerable inflammation present, are features which sufficiently dis- 
 tinguish it from other eruptions. Errors are most likely to occur in 
 confounding it with some one of the acne-like eruptions which fre- 
 quently follow the internal use of the salts of iodine and bromine, but 
 these are usually distributed over a much more extensive surface, af- 
 fecting the trunk quite as much as the face, whereas acne vulgaris is 
 often confined to the face alone, and when it exists upon the trunk 
 is almost always limited to the shoulders and upper part of the chest. 
 
 Prognosis. — Untreated acne is commonly of long duration, lasting 
 
DISEASES OF THE APPENDAGES 
 
 697 
 
 for many months or several years. While there is frequently, per- 
 haps in most cases, a tendency to spontaneous disappearance as the 
 patient approaches the age of twenty-five or thirty, its continuance 
 after that period is by no means rare. The course and results of 
 the eruption are very materially influenced by the type of lesion 
 present. When these are small and superficial they usually run a com- 
 paratively rapid course and disappear without scarring ; if, on the 
 
 "^VJEfis** 
 
 Fig. 239. — Acne vulgaris. Section of a papulo-pustule. Follicle, /, is filled with cellular debris and 
 polymorphonuclear leucocytes, while about the follicle there is an abundant exudation of lymphoid, poly- 
 morphonuclear and plasma cells. 
 
 other hand, they are of the livid, deep-seated type, their course is 
 sluggish, they may last for six to eight weeks, and are followed 
 by deep and permanent scars. In most instances, however, even 
 in the severest cases, ultimate cure may be expected with judicious 
 treatment. 
 
 Treatment. — Since in the great majority of cases there is more or 
 less evidence of disturbance of the gastro-intestinal tract, such as 
 flatulence, discomfort after taking food, and constipation, the careful 
 regulation of the patient's diet and the use of laxatives are always 
 
698 DISEASES OF THE SKIN 
 
 matters of importance in the treatment of acne. Sweets, fried foods, 
 pork, pastry, tea and coffee, sweet wines and beer should be strictly 
 prohibited. Sound ripe fruit, fresh or cooked, should be taken freely. 
 In anaemic girls and young women the tartrate of iron and potash 
 in moderate doses, or Blaud's pill, should be given either alone or 
 with small doses of arsenic. In those cases in which the lesions are 
 large, livid, deep-seated, and sluggish, occurring in those with thick, 
 grayish skin, cod-liver oil is a remedy of decided value. The calx 
 sulphurata or calcium sulphide, which at one time enjoyed a consider- 
 able reputation in the treatment of pustular affections of various kinds, 
 has in the author's hands, as in that of others, proved of no value. In 
 the acne of women, uterine disease or menstrual irregularity should re- 
 ceive appropriate treatment. Among laxatives, the salines are as a rule 
 the most effective. The bitter mineral waters, such as Hunyadi, 
 Appenta, or Friederichschall, may be employed. Phosphate of soda 
 is likewise useful, although it is less efficient than sulphate of mag- 
 nesia. A slightly laxative mixture which the author has employed 
 for some years with much satisfaction in the treatment of acne is 
 the following : 
 
 Sodii hyposulphitis Bss (1.60) 
 
 Glycermi, 
 
 Aquae menthae piperita; aa f§iij (90.0) 
 
 M. 
 
 Sig. Two teaspoonfuls t.i.d. in water after meals. 
 
 This usually exerts a slightly laxative effect, which may be in- 
 creased if necessary by the addition of ten or fifteen minims of the 
 fluidextract of cascara to each dose. The compound licorice powder 
 in doses of one or two drachms (4.0-8.0) taken at bedtime is an espe- 
 cially useful laxative in acne. The mistura ferri acida is likewise 
 an efficient, but rather disagreeable, laxative mixture ; it is com- 
 posed as follows: 
 
 Magnesii sulphatis 3j (30.0) 
 
 Ferri sulphatis gr. viij (0.5) 
 
 Acidi sulphurici diluti f3jss (6.0) 
 
 Aquae menthae piperitae q. s. ad Sviij (250) 
 
 M. 
 
 Sig. One tablespoonful in a tumblerful of water be- 
 fore breakfast. 
 
 In recent years, following the studies of Wright on opsonins, the 
 hypodermatic injections of killed cultures of organisms such as the 
 staphylococcus and the Bacillus acnes, found in the lesions of acne, have 
 been employed with varying results. In a certain number of cases 
 the effect has been apparently most satisfactory, and it has been just 
 as disappointing in others. Even in those cases in which its use has 
 been followed by a rapid disappearance of the eruption, relapses have 
 
DISEASES OF THE APPENDAGES 699 
 
 occurred sooner or later. The use of autogenous rather than stock 
 vaccines is always to be advised ; indeed, most authors are agreed 
 that the latter are useless as a rule. With improved technic in 
 their preparation, and with more exact knowledge of the organ- 
 isms concerned, this will doubtless prove in time an effective 
 method of treatment, but it is yet on trial and can only be regarded 
 as promising. 
 
 The local treatment is quite as important as, if not more so than, 
 the internal treatment. 
 
 The pustules should be opened with a sterile needle and evacu- 
 ated by gentle pressure with the thumb and finger ; abscesses should 
 be incised with a small bistoury or tenotome and emptied ; comedones 
 should be expressed with a little instrument known as a comedo ex- 
 tractor, or with the thumb and finger, first thoroughly bathing the 
 skin with a hot, weak solution of borax or plain hot water. These 
 several little operations should be performed with gentleness, since 
 the violent squeezing of the lesion only increases the inflammation, 
 prolongs its course, and increases the liability to scarring. 
 
 In the somewhat exceptional cases in which the inflammation is 
 quite acute and the skin sensitive, the use of mild lotions should 
 precede for a time more stimulating applications. A saturated solu- 
 tion of boric acid in water, mopped on three or four times a day, will 
 often serve a useful purpose under such circumstances ; and this may 
 be replaced a little later by a saturated alcoholic solution which often 
 •answers admirably in the superficial types of pustular acne. 
 
 Sulphur and its compounds easily occupy the first place among 
 local remedies in the treatment of acne of all varieties ; it may be 
 used as a lotion or as an ointment, the latter usually being much more 
 effective than the former. The following cream-like mixture, known 
 as Kummerfeld's lotion, is a useful application in many cases : 
 
 Sulphur, praecip 3iv ( 16.0) 
 
 Pulv. camphorge . gr. x (0.65) 
 
 Pulv. tragacanth. .. gr. xx (1.30) 
 
 Liq. calcis, 
 
 Aq aa f Sij (60.0) 
 
 M. 
 
 Sig. Apply at bedtime. 
 
 When there are many comedones with much oily seborrhcea, the 
 following lotion, containing sublimed sulphur, will be found especially 
 useful : 
 
 Sulphur, sublimat 3j (4.0) 
 
 Alcoholis fSiijss (108.0) 
 
 Athens f3ss (15.0) 
 
 M. 
 
 Sig. Shake and apply at bedtime. 
 
700 DISEASES OF THE SKIN 
 
 The sulphide of zinc lotion, which is essentially a sulphur lotion, 
 may often be employed with good results in pustular acne when the 
 lesions are not very deeply seated. 
 
 Zinci sulphat., 
 
 Potas. sulphuret aa 3j (4.0) 
 
 Aquae giv (130.0) 
 
 M. 
 
 Sig. Apply night and morning. 
 
 Should this prove too drying, fifteen or twenty minims of glycerin 
 should be added to each ounce (32.0), or cold cream may be applied 
 after its use. In the sluggish, deep-seated types of the disease the 
 solution of the sulphuret of lime known as Vleminckx's solution is 
 a most effective application, but objectionable on account of the strong 
 odor of sulphureted hydrogen which it gives off. This is to be used 
 as a lotion in the strength of one part to three or six of water, mop- 
 ping it on twice a day. An ointment containing from thirty to sixty 
 grains (2.0 to 4.0) of precipitated sulphur to the ounce (32.0), the 
 strength depending upon the degree of inflammation and the depth 
 of lesions, is frequently most useful. When stimulation is desired, 
 as in acne indurata, salicylic acid, fifteen to twenty grains (1.0 to 1.50) 
 to the ounce (32.0), may be combined with the sulphur. The following 
 ointment of sulphur and green soap is often productive of marked 
 benefit in the cases in which the lesions are livid in color, deep-seated, 
 and sluggish : 
 
 Sulphur, prsecipitat., 
 
 Saponis virid aa 3ij (8.0) 
 
 Lanolini §ss (15.0) 
 
 M. 
 
 Sig. Apply at bedtime with friction, and wash off in 
 
 the morning with hot water. 
 
 The salts of mercury, such as the bichloride and ammoniated mer- 
 cury, are frequently effective local remedies. The bichloride may 
 be used as a lotion in the strength of 1 : 3000 to 1 : 2000, either in water 
 or 70 per cent, alcohol, or as an ointment containing 0.5 to 1 per cent., 
 the latter being reserved for cases with sluggish lesions. Ammoniated 
 mercury, which in the author's hands has often proved extremely useful, 
 may be used as a 10 to 12 per cent, ointment applied once a day. 
 
 Resorcin, although not so generally useful as sulphur, is neverthe- 
 less often efficacious, and may be used either as an ointment or lotion. 
 The ointment should contain from 10 to 12 per cent., and should be 
 well rubbed in at bedtime. If a more stimulating application seems 
 desirable, it may be used as a lotion containing from 3 to 5 per cent, 
 in 70 per cent, alcohol, which may be applied once or twice a day. 
 Occasionally, owing to unusual susceptibility, resorcin excites a con- 
 
DISEASES OF THE APPENDAGES 701 
 
 siderable dermatitis, and for this reason it should be used with some care 
 until it has been ascertained that no such unusual susceptibility exists. 
 
 In the severer forms with deep-seated pustular lesions, a 2 per cent, 
 solution of salicylic acid in 70 per cent, alcohol often produces admirable 
 results. It should be softly mopped on night and morning, and if it 
 produces more than a moderate amount of scaling it should be followed 
 by the application of cold cream, or, better, equal parts of lanolin and 
 cold cream. When used alone in an ointment it is far less effective, 
 although, as already observed, it is a useful addition to other ointments, 
 such as sulphur ointment. 
 
 In extensive, long-standing acne, with numerous large and deep- 
 seated lesions, the use of ointments, pastes, or washes containing beta- 
 naphthol, sulphur, or resorcin in sufficient strength to produce an 
 exfoliating dermatitis is frequently the speediest way to get rid of 
 the eruption. This method of treatment is, of course, to be employed 
 with care, and necessitates the patient remaining indoors for a short 
 time. A 15 to 20 per cent, solution of resorcin in alcohol applied twice 
 a day until desquamation occurs, or Vleminckx's solution one part, water 
 two parts, applied twice a day, until exfoliation occurs, may be employed 
 for this purpose. The following paste: 
 
 Betanaphthol 3j— 3ij (4.0-8.0) 
 
 Sulphur, prsecip 3ss (16.0) 
 
 Saponis viridi, 
 
 Unguent, aq. rosse aa 3ij (8.0) 
 
 may be used. This is to be applied to the face spread upon lint, and 
 allowed to remain from twenty minutes to one-half hour, after which 
 it is removed with vaseline or cold cream, the face washed with hot 
 water, and cold cream or other soothing ointment applied. This is 
 repeated every night until exfoliation begins. 
 
 The X-ray is an extremely valuable remedy in the treatment of 
 acne, but owing to its destructive effect upon the hair-follicles and 
 to certain untoward results which sometimes follow its use, even 
 in the hands of the most careful and experienced, it should be re- 
 served for the rebellious and more aggravated types of the malady, 
 and should always be used with caution. The exposure should sel- 
 dom exceed five to seven minutes in duration, given every five days, 
 stopping the treatment upon the appearance of the slightest erythema. 
 The treatment is best carried out with the aid of some one of the 
 various devices employed for the measurement of the ray. The Holz- 
 knecht meter and the Sabouraud and Noire pastille are convenient 
 and reliable instruments for this purpose. Care must of course be 
 taken to protect the brows and scalp. In certain cases a disfiguring 
 atrophy of the skin follows the use of the X-ray even when no decided 
 reaction has been produced. 
 
702 DISEASES OF THE SKIN 
 
 ACNE ROSACEA 
 
 Synonyms. — Rosacea ; Gutta rosea ; Fr., Acne rosacee, couperose ; 
 Ger., Kupferose ; Kupferfinne. 
 
 Definition. — A chronic affection of the skin characterized by hyper- 
 aemia, telangiectases, and increase in the number of the superficial 
 capillaries, with inflammatory lesions, such as papules, pustules, and 
 occasional hypertrophy of the fibrous tissue of the corium, particularly 
 of the nose "(Plate XL). 
 
 Symptoms. — The disease is limited to the face, occupying chiefly 
 and frequently in mild cases exclusively the central third, although in 
 advanced and neglected cases the whole face may be involved. 
 
 It usually begins as a transient redness of the forehead, nose, and 
 adjacent parts of the cheeks, which later becomes more pronounced 
 and more or less permanent. Sooner or later an eruption of pustules 
 and papules, the latter often of a bright red color, appears in the 
 reddened areas. Less frequently there is no precedent redness, but the 
 disease begins with small bright red papules scattered over the chin 
 and lower portion of the nose, often accompanied by slight scaling; 
 this variety is seen more particularly in women. As the disease 
 progresses the redness becomes more decided, the eruptive lesions in- 
 crease in number, and dilated vessels make their appearance upon 
 the nose and cheeks, especially upon the alse of the former. In the 
 later stages of the affection the nose enlarges, the enlargement being 
 usually confined to the lower portion, the mouths of the ducts of 
 the sebaceous glands are notably increased in size, and the entire 
 nose is oily and of a dull red or violaceous hue. In a small proportion 
 of cases the hypertrophy which occurs in the late stages of the dis- 
 ease gives rise to lobulated masses varying in size from a pea to a 
 small nut, resulting in marked disfigurement, a condition to which the 
 name rhinophyma is applied. 
 
 Notwithstanding the frequently marked inflammatory appearance 
 of the forehead, cheeks, and nose, the skin is cold to the touch and 
 subjective symptoms are as a rule entirely absent, although excep- 
 tionally itching and burning are present. The course of the affection 
 is markedly chronic, characterized by exacerbations during which 
 the redness is much increased and the number of papules and pustules 
 greatly multiplied. These exacerbations are frequently accompanied 
 by, or follow, symptoms of indigestion, and in women are especially apt 
 to occur at or about the time of the menstrual period; indeed, a men- 
 strual exacerbation is the rule. Unlike acne vulgaris, acne rosacea shows 
 no tendency to disappear spontaneously, but, on the contrary, grows 
 worse with advancing years. 
 
 Etiology.— It is decidedly infrequent before the age of thirty, al- 
 though exceptionally it may occur in much younger subjects. Women 
 are commonly said to be more frequently affected than men, but this 
 preponderance in the female sex is probably more apparent than real, 
 
PLATE XL 
 
 Acne rosacea. 
 
DISEASES OF THE APPENDAGES 703 
 
 since women are much more apt to seek advice on account of dis- 
 figurement than men. Disturbances of the alimentary canal from 
 errors in diet, inordinate indulgence in tea, coffee, and alcoholic liquors, 
 must all be reckoned among the causes which predispose more or less 
 to the affection. Exposure to the weather is likewise a factor in its 
 production. In women disease of the uterus or its adnexa is frequently 
 associated with the malady, and, as has already been noted, each men- 
 strual period is usually accompanied by a marked increase in the symp- 
 toms. Nasal disease, such as chronic catarrh, or other chronic affec- 
 tions of the interior of the nose, according to the observations of Seiler 
 and others, strongly predisposes to it. Folliculitis of the vibrissas by 
 producing repeated congestion of the overlying skin, may serve as 
 the starting point of the affection. 
 
 Pathology. — Authors are not quite in agreement as to its pathol- 
 ogy. Some, as Leloir and Vidal, regard it as an acne occurring upon 
 a skin chronically congested ; Unna believes it a variety of sebor- 
 rhcea, and would call it rosacea seborrheica. 
 
 The earliest changes consist in the dilatation of the branches of 
 both the superficial and deep network of vessels and especially of 
 those surrounding the pilo-sebaceous follicles, probably the result of 
 some toxic substance in the circulation of as yet undetermined char- 
 acter. This dilatation of the vessels, at first transient, later becomes 
 permanent, and is followed by inflammatory changes in their imme- 
 diate neighborhood and about the sebaceous glands, which are more 
 or less increased in size. In the papules and pustules the same patho- 
 logical changes are to be seen as in similar lesions of ordinary acne, 
 namely, a cellular exudate composed of polymorphonuclear and lym- 
 phoid cells in varying quantity situated in and about the sebaceous 
 glands. In the final stages of the malady, accompanied by an increase 
 in the size of the nose, glandular hypertrophy in some cases predomi- 
 nates, while in others there is a pronounced increase in the fibrous 
 connective tissue. Occasionally the blood and lymphatic vessels are 
 so greatly enlarged as to present the appearance of an angioma (Le- 
 loir and Vidal). 
 
 Diagnosis. — Acne rosacea when typical is not readily mistaken for 
 any other affection, but it is occasionally confounded with acne vul- 
 garis, erythematous eczema, erythematous lupus, and syphilis. 
 
 It differs from ordinary acne by its limitation to the face, where 
 it shows a pronounced predilection for the central portion, especially 
 the nose, and by the associated hyperemia and vascular dilatation 
 always present in cases of any duration. 
 
 In the early hypersemic stage, when papules are absent or small 
 and few, if itching is present, as is occasionally the case, it is some- 
 times mistaken for erythematous eczema, but it differs from that af- 
 fection by the mild type of the itching and the limitation of the red- 
 ness to the nose and chin. 
 
 It can only be mistaken for erythematous lupus when the latter 
 
704 DISEASES OF THE SKIN 
 
 is of the telangiectic type, but papules and pustules are never present 
 in that disease, which usually terminates in a peculiar atrophic scar- 
 ring. 
 
 Not very infrequently the hypertrophic stage is confounded with 
 late syphilis of the nose of the nodular type, but the absence of ulcera- 
 tion and scarring in the former and their almost invariable occurrence 
 sooner or later in the latter readily differentiate the two affections. 
 
 Prognosis. — Left to itself, the disease tends to grow more pro- 
 nounced with years. Under appropriate treatment, however, cases of 
 moderate severity are usually quite amenable, and even when the 
 disease is marked great improvement follows the use of well-directed 
 therapeutic measures and a careful regimen. When, however, there 
 is any considerable degree of hypertrophic change, the prognosis is 
 unfavorable as to cure, although the deformity which attends advanced 
 cases may be greatly lessened by the surgical removal of the lobulated 
 tumors. 
 
 Treatment. — In the general treatment of acne rosacea, careful reg- 
 ulation of the diet is of the first importance; and unless the patient 
 willingly and intelligently cooperates with the physician in this, but 
 little permanent improvement can be looked for. Plain, easily digested 
 food, taken at regular intervals, the avoidance of condiments, sweets, 
 pastry, rich soups and gravies, complete abstinence from tea, coffee, 
 and alcoholic beverages, the avoidance of hot soups or hot drinks, 
 or anything which tends to flush the face, all are a necessary part in 
 the treatment. Occupations which expose the face to heat or to 
 the wind should be avoided. When functional disorders of the uterus 
 or its adnexa are present, as is frequently the case, these should have 
 appropriate treatment if permanent improvement is to be obtained. 
 When constipation is present, as it usually is, laxatives, the salines 
 preferably, are to be given, and even in cases in which there is a daily 
 evacuation of the bowels an occasional short course of fractional doses 
 of calomel or five grains (0.32) of mercurial pill, followed by a saline, 
 will often be advantageous. When there are symptoms of atonic dys- 
 pepsia, nux vomica or strychnia and hydrochloric acid may be given 
 for a time. Fluidextract of ergot in doses of from twenty to sixty 
 minims three times a day, or ergotin in doses of three to five grains 
 (0.20 to 0.32) three or four times a day, has been advised for its 
 supposed effect upon the dilated vessels, but its usefulness is more 
 than doubtful. Unna advises ichthyol in three-grain (0.20) doses sev- 
 eral times a day for the same purpose, but there is very little reliable 
 evidence that it influences the vessels appreciably, and not infrequently 
 it disturbs the stomach. 
 
 The local treatment is much the same as that of acne vulgaris, 
 but as a rule lotions answer better than ointments. One of the most 
 useful local applications is the zinc sulphide lotion in the strength of 
 from five to ten grains (0.32 to 0.65) of each of the salts to the ounce 
 (32.0). Instead of water, it may be made up with 70 per cent, alcohol 
 
DISEASES OF THE APPENDAGES 705 
 
 when the hypersemia is marked; or two drachms (8.0) of the 1 : 1000 
 solution of adrenalin chloride may be added to each ounce (32.0) 
 for its effect upon the vessels. Occasionally, however, such a lotion 
 proves too irritating in any strength, especially in the cases charac- 
 terized by small, bright-red papules upon the nose and chin, 
 accompanied by itching. In such cases a saturated solution of boric 
 acid will often answer well for a time. A solution of bichloride of 
 mercury in 70 per cent, alcohol, 1 : 2000, is also a useful lotion. When 
 there is an abundant eruption of pustules and papules and beginning 
 thickening of the skin, Vleminckx's solution, one part to eight or 
 ten of water, may be applied with good effect. 
 
 Among useful ointments may be mentioned sulphur 20 to 40 grains 
 (1.30 to 2.60) to the ounce (32.0), resorcin 30 to 60 grains (2.0 to 4.0) 
 to the ounce (32.0), ichthyol 1 to 2 drachms (4.0 to 8.0) to the ounce 
 (32.0). Of these the sulphur ointment is the most generally useful. 
 Ichthyol is often a valuable remedy, but its disagreeable odor and color 
 limit its usefulness very much. One of the least disagreeable, and at 
 the same time one of the most effective, ways of using it is to apply 
 it as a varnish with a brush, using equal parts of ichthyol and water. 
 After a few minutes it dries, leaving a brown varnish-like covering, 
 which can be readily washed off with hot water. 
 
 As in acne vulgaris, the X-ray is a valuable method of treatment, 
 but it must be used with care and discrimination. 
 
 The dilated venules are best removed by electrolysis. The needle 
 attached to the negative pole is thrust into the vessels transversely 
 and a current of two or three milliamperes allowed to pass for twenty 
 or thirty seconds ; this is usually followed by the complete obliteration 
 of the lumen of the venule and its ultimate disappearance. 
 
 In the milder grades of hypertrophy, linear scarification, electro- 
 lytic puncture, or repeated puncture with the Pacquelin or galvano- 
 cautery, using a small point, may be tried. The lobulated fibrous 
 masses which occur upon the nose in advanced cases are to be dealt 
 with surgically, removal with the knife being the shortest and most 
 satisfactory way of dealing with them. 
 
 ACNE ARTIFICIALIS 
 
 An inflammation of the follicles resembling in many of its features 
 acne vulgaris ; may result from the ingestion of certain drugs, more 
 particularly the compounds of iodine and bromine. These, unlike 
 the eruption of true acne, are not limited to the face and shoulders, 
 but are usually much more extensively distributed. 
 
 The introduction of such substances as tar, paraffin, and chlorine 
 into the follicles from without, as happens in those employed in certain 
 occupations, frequently gives rise to blocking up of their mouths, with 
 the formation of large comedones and inflammation of the follicle. 
 Such artificial acnes are characterized by a widespread distribution 
 of large, black or brown comedones, and numerous acne-like pustules 
 45 
 
706 
 
 DISEASES OF THE SKIN 
 
 situated chiefly on the trunk and extremities, rather than the face. 
 These paraffin and tar acnes (Fig. 240), when of long duration, may 
 be followed by the formation of inflammatory wart-like lesions, which 
 not infrequently terminate in epithelioma, the so-called tar or paraffin 
 cancer. 
 
 Treatment.— The first and most important point in the treatment 
 of these artificial acnes is the removal of the cause. When they are due 
 to drugs, these should be suspended. In tar and paraffin acne the patient 
 should be informed of the cause of the eruption and should be advised 
 to bathe frequently and change his clothing often, since these, when 
 
 Fig. 240. — Paraffin acne. Patient worked in an oil refinery. 
 
 saturated with paraffin or tar, serve to convey these substances to the 
 follicles. If these precautions are observed, the disease may in large 
 measure be prevented. In the treatment of the eruption the same 
 remedies may be employed as in acne vulgaris. 
 
 ACNE VARIOLIFORMIS 
 
 Synonyms. — Acne necrotica ; Acne frontalis ; Acne atrophica ; Acne 
 rodens. 
 
 Definition. — A chronic acne-like inflammation of the skin character- 
 ized by pustules, situated about the margin of the scalp and over the 
 sternum, rarely in other regions, followed by pit-like cicatrices. 
 
DISEASES OF THE APPENDAGES 707 
 
 Symptoms. — Acne varioliformis, a name first given to the affection 
 by Hebra, is situated for the most part upon the forehead and tem- 
 ples, particularly at the border of the hair, in the scalp (Fig. 241), and 
 less frequently upon the hairy portion of the sternum; quite excep- 
 tionally it may occur upon the extremities. It is distinguished by an 
 eruption of small red papules upon which presently pustules appear,, 
 which dry into blackish depressed and adherent crusts. After ten 
 days to two weeks the crusts fall, leaving small pit-like indelible scars, 
 resembling those of variola, hence the name given the affection. The 
 number of lesions present at any one time is usually small and they are 
 commonly discrete without any special arrangement; occasionally 
 
 Fig. 241. — Acne varioliformis. 
 
 they are quite numerous and may show a tendency to occur in groups. 
 Beyond occasional slight itching and moderate tenderness when the 
 inflammation is at its height, the eruption is not accompanied by any 
 decided subjective symptoms. The affection is a chronic one, the 
 lesions coming and going for a number of years. 
 
 Etiology. — Sex seems to have but little, if any, influence upon the 
 incidence of the disease. Unlike ordinary acne, it is uncommon in 
 young adults, being seen most frequently between the ages of thirty 
 and fifty. 
 
 The weight of evidence is much in favor of its microbic origin. 
 Sabouraud believes it a mixed infection of the hair-follicle with the 
 micro-bacillus of seborrhcea and the staphylococcus, the latter being a 
 secondary invasion. Unna likewise thinks the infection a mixed one, 
 
708 
 
 DISEASES OF THE SKIN 
 
 the organisms being a small bacillus resembling the acne bacillus, and 
 a diplococcus. The latter organism, by destroying the former, even- 
 tually brings about the healing of the lesion. 
 
 In the early lesions taken from one of his cases, Fordyce found 
 great numbers of staphylococci, which he was inclined to regard as 
 the etiological factor, but in older lesions taken from a second case no 
 organisms at all were found. 
 
 Pathology. — There is apparently but little doubt that the disease 
 is an infection which has its seat in the pilo-sebaceous follicles. Some 
 authors are inclined to regard it as of tuberculous origin and would 
 place it among the so-called tuberculides (Stelwagon and others). 
 
 The histological studies of Leloir and Vidal, Fordyce, Sabouraud, 
 and Touton have shown that it is a folliculitis. About the upper por- 
 tion of the follicle, usually above the sebaceous gland, there is a dense 
 round cell exudate which, with the evolution of the lesion, extends 
 laterally and upward, occasionally downward, surrounding the seba- 
 ceous gland, involving the follicular wall, which is followed by necrosis 
 and complete or partial destruction of the follicle. 
 
 Diagnosis, — Acne varioliformis is distinguished from ordinary acne, 
 by its localization upon the scalp or other hairy region and the peculiar 
 pit-like scars which follow the eruption. It is frequently mistaken 
 for the pustular syphiloderm, but its localization about the margin of 
 the scalp and its frequent limitation to this region, the black, sunken 
 crusts which cover the lesions, and the absence of other symptoms of 
 syphilis are usually sufficient to distinguish it from that malady. 
 
 Treatment. — Crocker found the iodide of potassium produced im- 
 provement in most cases ; in others, chloride of iron was found more 
 useful. I have found Donovan's solution in five-minim doses, three 
 times a day, apparently influences the disease favorably. 
 
 Local treatment is much more effective than the internal. In the 
 author's experience one of the most effective local applications is the zinc 
 sulphide lotion, 15 grains (1.0) each of sulphate of zinc and sulphuret of 
 potash to the ounce (32.0) of water, mopped on twice a day. Stelwagon 
 advises a solution of resorcin in a saturated solution of boric acid. An 
 ointment of ammoniated mercury, 40 to 60 grains (2.60 to 4.0) to the 
 ounce (32.0), rubbed in gently twice a day, is often an effective remedy. 
 
 Prognosis. — Although lasting indefinitely, if left to itself, a cure 
 may usually be expected under judicious treatment, but relapses are 
 very likely to occur sooner or later unless the local treatment is con- 
 tinued for some time. 
 
 ACNITIS 
 
 Synonyms. — Disseminated follicular lupus (Tilbury Fox) ; Acne 
 
 telangiectodes (Kaposi) ; Hydradenitis destruens suppurativa (Pol- 
 litzer) ; Acne agminata (Crocker). 
 
 This infrequent malady, which was described by Barthelemy, in 
 
DISEASES OF THE APPENDAGES 709 
 
 1891, who gave it the name acnitis, is probably identical with the affec- 
 tion described by Tilbury Fox, in 1878, as disseminated follicular lupus. 
 Although Barthelemy regarded it as distinct from the disease which 
 he described under the name folliclis, the papulo-necrotic tuberculide 
 of other writers, most authors look upon it as simply a variant of that 
 affection. 
 
 Symptoms. — It usually begins rather suddenly with the appearance 
 upon the face of millet-seed-sized painless nodules deeply seated in 
 the skin, which at first produce little or no visible elevation, but which 
 gradually enlarge until at the end of eight to ten days they have reached 
 the size of a small pea. When fully developed they form brownish-red 
 papules, many of which show a waxy translucency, which usually suppu- 
 rate, discharging a drop or two of pus which dries into a crust. At the 
 end of three or four weeks the crust falls and the papule disappears, 
 leaving a small depressed pigmented scar. Not all of the lesions, 
 however, undergo suppuration ; some of them after three or four weeks 
 gradually disappear without any appearance of pus, with or without 
 scarring. The eruption usually appears in crops at intervals of a few 
 days, and is situated almost exclusively upon the face, where it tends to 
 form patches on the cheeks, chin, and forehead; isolated papules are 
 sometimes seen upon the neck and extremities. The numbr of lesions 
 is usually considerable, in some instances amounting to hundreds. The 
 disease reaches its acme in the course of three or four months, after 
 which each succeeding crop becomes smaller until at the end of six 
 months or a year recovery usually takes place. There is little or no 
 tendency to recurrence. 
 
 Etiology and Pathology. — All the cases thus far observed have been 
 in adults who have presented no special symptoms of disease outside 
 the cutaneous eruption. As has already been noted, most authors 
 regard it as simply a variety of the papulo-necrotic tuberculide, the fol- 
 liclis of Barthelemy, but efforts to find the tubercle bacillus and 
 attempts at animal inoculation have resulted almost without exception 
 in failure. Quite recently, however, Arndt has reported rinding the 
 organism in the lesions. As to its histopathology, it is a granuloma 
 presenting the features of tuberculosis. Darrier, who examined lesions 
 from one of Barthelemy's cases, found an accumulation of lymphoid, 
 epithelioid, and giant-cells about the pilosebaceous follicles, and Gallo- 
 way reported practically the same findings in one of Crocker's cases. 
 More recently Schamberg found an enormous cellular exudate extend- 
 ing through the entire thickness of the corium, consisting chiefly of 
 round cells with many giant cells, some of the Langhans type. The 
 exudation involved the hair-follicles and the sweat-glands, but he was 
 unable to decide whether the process originated in the latter as Pol- 
 litzer and Unna believe, or whether these were involved only 
 secondarily. 
 
 Diagnosis. — The diseases which it may resemble more or less at 
 times are acne, the papulo-necrotic tuberculide, and syphilis. From 
 
710 
 
 DISEASES OF THE SKIN 
 
 
 acne it may be distinguished by the grouping of the lesions, the 
 waxy lustre of many of them, and their comparatively sluggish course. 
 In the papulonecrotic tuberculide the eruption shows a decided predi- 
 lection for the hands and the neighborhood of the joints, avoiding the 
 face as a rule, while just the reverse is true in acnitis. The former is 
 almost invariably associated with chronic adenitis or other symptoms 
 of tuberculosis, while the latter exhibits no such association. Its 
 resemblance to syphilis is at times considerable, but it differs from 
 that disease in its usual limitation to the face, the uniform character 
 of the lesions, and the absence of general adenopathy. 
 
 Treatment.— It is very doubtful whether the course of the disease 
 is materially influenced by either general or local treatment. Besnier 
 believed he obtained beneficial effects from salol administered inter- 
 nally ; Schamberg thought his patient did better after taking biniodide 
 of mercury. One of the most useful local applications is the lotion 
 of sulphate of zinc and sulphuret of potash 15 or 20 grains (1.0 or 1.30) 
 of each to the ounce (32.0) of water. An ointment of ammoniated 
 mercury 30 to 40 grains (2.0 to 2.60) to the ounce (32.0), or one con- 
 taining 40 grains (2.30) of precipitated sulphur to the ounce (32.0), 
 may be used with good effect. 
 
 Prognosis. — Recovery usually takes place in the course of some 
 months, but more or less scarring follows the eruption. 
 
 ACNEFORM INFLAMMATIONS 
 ACNE URTICATA 
 
 Under the name acne urticata Kaposi first described an acne-like 
 eruption occurring in the regions affected by ordinary acne, such as 
 the face, the upper part of the trunk, and the arms. The primary lesion, 
 which is usually difficult to see as it is destroyed early by the patient's 
 nails, is a small, wheal-like papule upon the summit of which a vesicle 
 with turbid contents appears, which is soon scratched off and replaced 
 by a crust or superficial excoriation. The eruption comes out in crops, 
 is usually quite superficial, and is accompanied by marked itching, 
 which only disappears when the top has been torn off by scratching. 
 The affection, which is not a common one, runs a chronic course, 
 lasting for months and years. It is usually seen in young adults of 
 both sexes, but in the author's experience is much more frequent in young 
 women than in young men. 
 
 While the malady bears a certain superficial resemblance to ordinary 
 acne it is quite distinct from it, and is probably more nearly related 
 to the so-called acne varioliformis than to acne vulgaris. Lowenback, 
 who had the opportunity to carefully study clinically and histologi- 
 cally a case of the affection, believes it stands midway between acne 
 varioliformis and urticaria perstans. 
 
DISEASES OF THE APPENDAGES 711 
 
 ACNE KERATOSA 
 
 Under this title Crocker described some years ago an unusual form 
 of acne situated upon the face, principally about the angles of the 
 mouth, in which there were red, rather firm nodules on which pustules 
 formed, and in which were imbedded small conical plugs of horny 
 material. These plugs produced great irritation, and in order to obtain 
 relief the patient was impelled to squeeze them out. After extraction 
 of the plugs the lesion slowly healed, leaving a scar. The course of 
 the affection was a very chronic one, lasting in one case forty years. 
 
 DISEASES OF THE SWEAT-GLANDS 
 
 ANIDROSIS 
 
 Definition. — A functional disease of the sweat-glands characterized 
 by a diminution, or in rare instances total suppression, of the sweat. 
 
 Symptoms. — The skin is dry and harsh, frequently covered with 
 scanty furfuraceous scales, and is inclined to fissure in the normal lines 
 and about the smaller joints. Diminution of the perspiration is a symp- 
 tom of many diseases of the skin, particularly those of inflammatory 
 character; it accompanies ichthyosis, psoriasis, eczema, prurigo, ery- 
 sipelas, in the last of which it is, according to Aubert, suppressed for the 
 time altogether in the affected area. It is greatly diminished or altogether 
 suppressed in the patches of scleroderma and in the anaesthetic areas 
 of leprosy, injections of pilocarpin being usually without effect in 
 such areas. 
 
 In the majority of cases the lessened amount of sweat is due to the 
 inhibition of the activity of the sweat-glands ; in rare instances its total 
 absence is the result of a congenital absence of the glands, as in the 
 cases reported by Tandlau (quoted by T6r6k, Mracek's " Handbuch der 
 Hautkrankheiten "). In a small number of instances it has been noted 
 to follow disease or injury of the spinal cord, of peripheral nerves or 
 some portion of the sympathetic nervous system. 
 
 Treatment. — The treatment of the symptomatic form, which is by 
 far the more common, is quite secondary to the treatment of the diseases 
 of which it is a minor symptom; with the disappearance of these it also 
 disappears. Daily warm baths, the wearing of warm clothing, and the 
 taking of an abundance of fluids will serve to increase the excretion of 
 sweat. The cases of total absence of sweat due to congenital absence of 
 the sweat-glands are irremediable, of course. 
 
 HYPERIDROSIS 
 
 Synonyms. — Idrosis ; Polyidrosis ; Ephidrosis ; Sudatoria ; Fr., 
 Hyperidrose ; Ger., Schweissfluss. 
 
 Definition. — A functional disorder of the sweat-glands character- 
 ized by excessive sweating. 
 
 Excessive sweating may be general or local, symptomatic or idio- 
 
712 
 
 DISEASES OF THE SKIN 
 
 pathic. It is a frequent symptom in many general diseases, acute or 
 chronic, especially those accompanied by elevation of temperature, 
 such as pneumonia, typhoid fever, in both of which it frequently occurs 
 as a critical symptom, tuberculosis, particularly pulmonary tubercu- 
 losis, malaria, rhachitis, especially about the head, and in the rare 
 epidemic affection known as the " sweating sickness," sudor Anglicus. 
 The dermatologist, however, is especially concerned with the idiopathic 
 form, and more particularly with the regional varieties. 
 
 Symptoms. — Excessive general sweating occurring quite inde- 
 pendently of any other manifest disturbance -of health is not at all 
 uncommon, but it is not always easy to say when this is pathological, 
 since like other secretions what may be excessive for one individual 
 may be normal for another. 
 
 In the local forms which may present all degrees of severity, corre- 
 sponding regions are affected on both sides of the body, such as both 
 axillae, both palms, both soles ; much less frequently the sweating 
 occurs only upon one side. The regions most frequently affected are 
 the palms and soles and next to these the axillae ; all three may be 
 affected simultaneously or separately. The palms may be simply 
 damp or clammy, or the sweating may be so profuse that they drip with 
 moisture, saturating gloves in a very short time. The sweating may 
 be continuous or come on in paroxysms, sometimes as the consequence 
 of some emotional disturbance, often slight, or from some unknown 
 cause. The same variation in intensity occurs in hyperidrosis of the 
 soles ; they may be damp and cold, or the perspiration may be so 
 abundant that the socks are saturated, although changed several times 
 a day. In the milder cases the skin shows but little change, but in the 
 severe ones the horny layer, particularly on the heels and between 
 the toes, is white and sodden, and in the former region the macerated 
 areas are frequently surrounded by a hyperaemic border. The soles 
 may become sensitive so that walking is painful, and when the macera- 
 tion is extreme the entire horny layer of the epidermis may be stripped 
 off, leaving a red, raw-looking surface so sensitive that walking is 
 for a time impossible. As a sequel of chronic hyperidrosis a more 
 or less marked hyperkeratosis at times appears upon the palms and 
 soles, much more frequently in the latter than in the former region. 
 Owing to decomposition of the sweat and macerated epidermis a 
 particularly offensive odor commonly accompanies hyperidrosis of 
 the feet {bromidrosis, q. v.). 
 
 When hyperidrosis occurs in the axillary, genito-crural regions, or 
 between the buttocks, the consequent maceration of the epidermis and 
 friction frequently give rise to an intertrigo or to an eczema. 
 
 Unilateral sweating is rare and presents numerous variations in 
 its location and distribution. It occurs more frequently in the face 
 than in any other region, especially in the area of distribution of the 
 fifth pair of nerves. It may be limited to an extremity or to the lateral 
 half of the trunk. In very rare instances it has been observed to 
 
DISEASES OF THE APPENDAGES 713 
 
 occupy one-half of the face and the opposite half of the trunk, crossed 
 hyperidrosis ( Kaposi ) . 
 
 It is occasionally limited to very circumscribed areas, as in the case 
 recently reported by Sutton in which it was confined to the inner 
 extremity of the left eyebrow. 
 
 In the great majority of cases hyperidrosis pursues a very chronic 
 course, lasting for many months or years. Quite exceptionally it may 
 begin suddenly and last but a short time, as in a case under the author's 
 observation some years ago. A man without any signs of ill-health 
 suddenly began to sweat profusely upon the palms, the sweat trickling 
 from the finger-tips ; after eight to ten hours it ceased as suddenly as it had 
 begun and never returned. 
 
 Etiology and Pathology. — Excessive sweating occurs most fre- 
 quently between the ages of fifteen and forty-five, but is often seen 
 considerably before and after this period. Sex exerts no apparent in- 
 fluence upon its incidence. Exceptionally it seems to be hereditary. 
 As has already been noted, excessive general sweating is frequently 
 associated with symptoms of some constitutional disease; in the local 
 forms, however, the patient as a rule presents no signs of ill-health, 
 although there are at times symptoms of neurasthenia, especially in 
 those who suffer from hyperidrosis of the palms. A number of observ- 
 ers have noted the frequent association of flat-foot with hyperidrosis 
 of the soles (Lesser, Hardaway and Allison), and attribute a causal 
 influence to it. Palmar and plantar hyperidrosis occasionally follow 
 the administration of arsenic in considerable doses for considerable 
 periods, the excessive sweating preceding a characteristic hyperkera- 
 tosis of these regions. 
 
 Unilateral sweating is most commonly associated with injury to 
 or disease of the peripheral nervous system, or less frequently of the 
 brain and spinal cord. The classical experiments of Claude Bernard 
 demonstrated that unilateral sweating of the face could be produced 
 by injury to the cervical sympathetic; and localized sweating has been 
 noted to follow injury, such as gun-shot wounds (Weir Mitchell) of 
 the peripheral nerves. Less frequently unilateral hyperidrosis occurs 
 in individuals who present no discoverable signs of disease. It may 
 occur as an idiosyncrasy with regard to certain articles of food or drink. 
 Torok records a remarkable example of the former observed in the 
 person of a colleague who was perfectly healthy, in whom food contain- 
 ing red Cayenne pepper, vinegar, cheese, or mustard produced profuse 
 sweating of the left half of the face, neck, and chest, while heat, warm 
 drinks and exertion produced sweating on the right side onlv. Hutchin- 
 son noted an instance in which drinking tea caused sweating of the 
 feet. 
 
 There is but little room for doubt that unilateral or regional hyperi- 
 drosis is dependent upon some abnormality, inborn or acquired, of some 
 portion of the nervous system, although in many, if not most, instances 
 the nature of this abnormalitA r is not demonstrable. 
 
714 
 
 DISEASES OF THE SKIN 
 
 
 Virchow, who examined the sweat-glands of an individual dead 
 from pulmonary tuberculosis, found fatty degeneration of the epi- 
 thelium of the gland. Robinson was not able to find any alterations 
 in the glands in hyperidrosis of the palms. 
 
 Prognosis and Treatment. — Owing to the frequently erratic charac- 
 ter of the affection the prognosis is very uncertain. Occasionally after 
 a variable course it disappears spontaneously, but relapses are apt to 
 occur. The majority of cases of hyperidrosis of the palms and soles 
 last for months and are frequently very resistant to treatment. 
 
 In debilitated and neurasthenic subjects general tonics, such as 
 strychnia and iron, more especially the tincture of the chloride of iron, 
 or the mineral acids, such as aromatic sulphuric acid, are occasionally 
 of use. Drugs which directly diminish the secretion of sweat, such as 
 belladonna, or its alkaloid atropin, agaricin, and picrotoxin may be given 
 with temporary benefit, but seldom produce lasting improvement, the 
 sweating reappearing promptly with the suspension of the drug. 
 Crocker found sulphur, given in teaspoonful doses, twice a day, the 
 best of all internal remedies; he asserted that cases treated with this 
 remedy seldom required local treatment. If it acts too freely upon 
 the bowels its effect should be controlled by the administration of 
 astringents. 
 
 Local treatment is in most cases indispensable and is usually far 
 more effective than any constitutional treatment. 
 
 Astringent lotions containing sulphate of zinc, acetate of alumina or 
 tannic acid, in strengths varying from one-half to five per cent., are 
 frequently useful in the milder cases ; they should be mopped on two 
 or three times a day and followed by a dusting powder of equal parts 
 of oxide of zinc and talc, or, what is usually much more effective, 
 powdered boric acid, which should be liberally applied. Perhaps the 
 most effective of all the lotions is one containing from 10 to 20 per 
 cent, of formalin, a 40 per cent, solution of formaldehyde. Owing 
 to its irritating properties only the milder solutions are to be used 
 in regions in which the skin is sensitive such as the axillae and about 
 the genitalia ; upon the soles of the feet and the palms it may be 
 used much stronger. It should be applied with a brush or a small 
 mop of absorbent cotton once or twice a day and should be followed 
 by a dusting powder. In hyperidrosis of the feet the liberal use of pow- 
 dered boric acid to the inside of the stockings and the shoes and 
 between the toes, as recommended by Thin, will frequently suffice to 
 check the excessive sweating in mild cases. A dusting powder of talc 
 and oxide of zinc containing from 5 to 10 per cent, of salicylic acid 
 is likewise often most useful; it should be applied to the inside of 
 the stockings and between the toes twice a day. Frederique advised 
 the employment of finely pulverized tartaric acid in the stockings ; as 
 this sometimes proves quite irritating it should be used with some 
 care. Torok speaks well of tannoform, a condensation product of 
 formaldehyde, and tannic acid, used as a dusting powder in the stock- 
 
 
DISEASES OF THE APPENDAGES 715 
 
 ings, either pure or mixed, with an equal quantity of talcum. Paint- 
 ing the soles with a 5 per cent, aqueous solution of chromic acid 
 once a week frequently produces good results. Owing to the possi- 
 bility of toxic effects from absorption, it should not be used upon raw 
 surfaces. Legoux advises painting the soles with a mixture of the 
 solution of the sesquichloride of iron, 30, and glycerin, 10, as most 
 effective, occasionally bringing about a cure in a few days. 
 
 The treatment devised by Hebra has frequently afforded excellent 
 results, but is far too troublesome for the average patient. Diachylon 
 ointment spread upon strips of lint is closely bound upon the feet and 
 placed between the toes after carefully washing and drying them. 
 This application is renewed twelve hours later after thoroughly rub- 
 bing, not washing, off the old application with a dry cloth and a dust- 
 ing pow T der. This is repeated every day for ten days to two weeks, 
 at the end of which time the epidermis will have come off in brownish 
 flakes. When desquamation is complete the feet may be washed and 
 a dusting powder applied daily for some time longer. 
 
 The X-ray has recently been employed with good results in a num- 
 ber of instances (MacKee, Ormsby, and others). 
 
 CHROMIDROSIS 
 
 Synonyms. — Ephidrosis tincta; Ephidrosis discolor; Colored sweat- 
 ing; Stearrhcea nigricans; Seborrhcea nigricans; Pityriasis nigricans. 
 
 Definition. — A functional disorder of the sweat-glands characterized 
 by colored sweat. 
 
 Symptoms. — Although the earliest case to be found in literature 
 was published as early as 1709 by Yonge of England (Crocker), it was 
 not until much later that the publications of Le Roy de Mericourt 
 (1857-1864) called the attention of the profession to this rare and 
 remarkable affection. Although the conclusions of this author were 
 generally received with considerable scepticism and their correctness 
 denied by the French Academy of Medicine, and although a number of 
 the reported cases are not above suspicion, it is generally admitted 
 at the present time that genuine cases of colored sweating do occur. 
 
 The most frequent form of the affection is characterized by a black, 
 brownish-black, blue-black, or grayish discoloration situated in most 
 instances on the lids, especially the lower lids, and the region about 
 the eyes. While the orbital region is the one most frequently affected, 
 it may also occur on other parts of the face, such as the forehead, nose, 
 and around the mouth, to which parts it occasionally extends from 
 the lids, on the neck, the hands, the chest, the back, abdomen, groins 
 and scrotum. The discoloration is due to the presence on the skin of 
 a finely granular, in some instances flaky and slightly greasy, material 
 which is removed with difficulty by soap and water, but is readily 
 wiped off with oil ; when removed it is slowly reproduced. Besides 
 the various shades of black, brown, and blue, other colors have been in 
 rare instances observed. Dubreuilh has reported a case in which the 
 
716 
 
 DISEASES OF THE SKIN 
 
 
 
 thumb of both sides and one wrist were red. White, one in which the 
 underwear was stained a bright saffron yellow on one side of the trunk 
 only, the skin itself being of normal color. In rare cases the color 
 has changed from time to time or has varied in different situations 
 (Purdon). In a few cases discoloration of the hair has been associated 
 with the colored sweat. 
 
 Etiology and Pathology. — In the great majority of cases the sub- 
 jects of chromidrosis have been girls or women between the ages of 
 fifteen and fifty who have presented more or less marked and unmis- 
 takable symptoms of neurasthenia or hysteria; in a small minority 
 they have been men in apparently normal health. In some instances it 
 has followed strong emotional disturbance, as in one recorded by 
 Hyde, in which it appeared after the excitement produced by the 
 receipt of good news. Since a large number of the patients have 
 resided in the neighborhood of the sea, this has been supposed to bear 
 some causal relationship to the affection (de Mericourt, Mitchell), but 
 this is extremely hypothetical. Green sweat has been observed in 
 workers in copper (Clapton), and Hyde has recorded an example which 
 followed the application of a copper electrode to an abraded surface. 
 Collman and Scherer have reported a case in which a man while taking 
 iron had a light-blue discoloration of the scrotum which gave the 
 chemical reaction for iron. Blue sweat has been attributed to the 
 presence of indican in the excretion, many of the patients suffering 
 from obstinate constipation ; excreted in the colorless form it oxidizes 
 and turns blue when exposed to the air. Temple observed pink sweat 
 with simultaneous discoloration of the hair in an individual who was 
 taking iodide of potassium. The so-called red chromidrosis of the 
 axilla is not a true chromidrosis, as the sweat is colorless when ex- 
 creted, but it dissolves the pigment contained in small nodules attached 
 to the hair (lepothrix, q.v.) and thus produces staining of the underwear. 
 
 In all probability the sebaceous- as well as the sweat-glands are 
 involved in this disorder, this being especially the case when the 
 coloring material upon the skin is greasy. Under the microscope the 
 coloring substance presents a finely granular or occasionally crystalline 
 appearance. The chemical examinations made by a number of investi- 
 gators have given such varying results that no definite conclusions can 
 be drawn from them in most of the cases. 
 
 The affection is without doubt, in most instances, dependent upon 
 some functional disturbance of the nervous system, the nature of which 
 is quite unknown. 
 
 Diagnosis.— The appearance of the affection is usually so striking 
 and peculiar that it is readily recognized. It is necessary, however, to be 
 constantly on one's guard to escape being deceived by factitious cases. 
 
 Prognosis and Treatment. — The course of the malady is in most 
 instances a chronic one, but recovery usually takes place, occasionally 
 spontaneously. 
 
DISEASES OF THE APPENDAGES 717 
 
 Treatment is to be directed to improvement of the patient's general 
 condition and the removal of the underlying nervous affection which 
 causes it. Local treatment is of little or no avail ; removal of the 
 discoloration is always followed by its reproduction. 
 
 BROMIDROSIS 
 
 Synonyms. — Bromhidrosis ; Osmidrosis ; Stinking sweat ; Fr., 
 Bromidrose ; Ger., Stinkschweiss. 
 
 Definition. — A functional disorder of the sweat-glands distin- 
 guished by sweat of an offensive odor. 
 
 Symptoms. — The sweat generally may have a disagreeable odor, 
 as in certain individuals and in the members of certain races, as the 
 negro. A disagreeable odor of the sweat frequently accompanies a 
 number of febrile disorders, such as acute articular rheumatism, typhoid 
 fever, and the exanthemata in which the odor is frequently more or less 
 characteristic. In the great majority of cases, however, bromidrosis 
 is a regional affection, the regions especially affected being the axillae, 
 the genitalia particularly in women, and most frequently of all the feet. 
 The character and intensity of the odor vary greatly ; it may be simply 
 stale and disagreeable, or it may be an intolerable stench perceptible 
 some distance, making social intercourse impossible with the unfor- 
 tunate subject. In most instances there is an excessive production of 
 sweat, but the offensive odor may be present in sweat normal in 
 quantity. Gerber has recorded an instance, however, in which the 
 patient under ordinary conditions presented no trace of bromidrosis, 
 but when he perspired profusely, as after eating, drinking or exercising, 
 he gave off so disagreeable an order that he was compelled to forego 
 all social intercourse. Upon the feet when there is hyperidrosis 
 as well as bromidrosis redness, vesiculation and occasionally bullae 
 may appear, making walking painful or impossible. 
 
 In rare instances the sweat has a peculiar, but not disagreeable 
 odor, or even an agreeable odor. Hammond has reported an instance 
 in which it had an odor resembling violets and another in which it 
 was like pineapple. In diabetes mellitus it occasionally has the odor 
 of acetone. 
 
 Etiology and Pathology. — Bromidrosis occurs most frequently in 
 young adults, particularly in those who are for hours upon their feet 
 and who are anaemic or neurasthenic. Thin found a bacterium in the 
 sweat, the Bacterium fcctidiim, to which he attributed the production 
 of the offensive odor. Hebra long ago pointed out that in most in- 
 stances the sweat was devoid of disagreeable odor when first excreted 
 and only became offensive after it had been upon the skin for some 
 time. There is no doubt that the affection is the result of decomposi- 
 tion of the sweat and of epithelial debris and sebaceous material. 
 Abnormal odors may arise in the sweat after the ingestion of certain 
 articles of food, such as onions, garlic, or after taking certain drugs, 
 
718 
 
 DISEASES OF THE SKIN 
 
 such as copaiba, turpentine, asafoetida. In rare cases the odor may 
 accompany some nervous disorder, particularly hysteria and neuras- 
 thenia ; the genuineness of such cases, however, is to be accepted with 
 considerable reserve. 
 
 Treatment. — The treatment of bromidrosis is practically the same 
 as for hyperidrosis ; indeed, as already observed, the two are in most 
 instances associated. Especially useful are lotions and dusting pow- 
 ders containing substances which inhibit decomposition, such as lotions 
 of formalin, boric acid, or of permanganate of potash, and dusting pow- 
 ders containing tannoform and salicylic acid; these are to be employed in 
 the same manner as in hyperidrosis. Crocker regarded sulphur internally 
 and boric acid locally as the best treatment. The internal administration 
 of sodium salicylate has been credited with a cure in some instances 
 (Crocker). Frequent washing with soap and hot water and thoroughly 
 dusting the stockings and the shoes with a dusting powder containing 
 50 per cent, of tannoform is probably one of the least troublesome and 
 most effective methods of treatment. The X-ray has been employed with 
 benefit in a number of instances. 
 
 URIDROSIS 
 
 Synonyms. — Sudor urinosus ; Urinidrosis; Fr., Uridrose; Ger., 
 Harnschweiss. 
 
 Definition. — The excretion of some of the constituents of the urine, 
 particularly urea, in the sweat. 
 
 Symptoms. — The sweat normally contains traces of urea (Landois), 
 and this may be very sensibly increased in certain diseases of the 
 kidneys which interfere seriously with their excretory function. Urea 
 may also appear in the sweat in considerable quantities in other affec- 
 tions in which the urinary excretion is suppressed, as in cholera 
 (Drasche). It appears as a fine white crystalline deposit with a urinous 
 odor, most noticeable upon the exposed parts of the skin, such as the 
 face, hands, and forearms, which, when the excretion is considerable, 
 look as if lightly dusted with flour. 
 
 PHOSPHORIDROSIS 
 
 Synonym. — Photidrose ( Audry ) . 
 
 Definition. — Phosphorescent sweat. 
 
 As an extremely rare condition the sweat may be phosphorescent. 
 Panceri (quoted by Duhring) has reported the case of a physician who, 
 during an illness caused by eating phosphorescent fish, excreted sweat 
 which was luminous in the dark; Koster (Carpenter's Physiology) has 
 recorded an instance in which the sweat after violent exercise made 
 the underwear phosphorescent. Luminous sweat has also been observed 
 in phthisis and in miliaria. 
 
DISEASES OF THE APPENDAGES 719 
 
 H^MATIDROSIS 
 
 Synonyms. — Hsemathidrosis ; Hsemidrosis ; Sudor sanguineus ; 
 Ephidrosis cruenta; Fr., Hematidrose, sueurs sanglantes ; Ger., Blut- 
 schwitzen, Blutschweiss. 
 
 Definition. — Bloody sweat. 
 
 Symptoms. — This very rare affection, the existence of which was 
 long doubted until the observations of such competent observers as 
 Parrot, Hebra, Chambers, Erasmus Wilson, M'Call Anderson and 
 others had proven its occurrence, is distinguished by the appearance 
 of a pink or red fluid composed of blood pure or diluted upon the 
 unbroken skin. It usually appears without any premonitory symp- 
 toms, but in a small proportion of cases its appearance is preceded by 
 sensations of pricking, throbbing, or burning, or much less frequently 
 by hyperemia or an eruption of vesicles ; it is doubtful, however, 
 whether these last properly belong in the same category with the cases 
 in which no alteration of the skin precedes the hemorrhage. The 
 bleeding is usually limited to small areas which may be situated upon 
 any part of the cutaneous surface, but is more frequent upon the ends 
 of the fingers, in the face, upon the forehead, the nose, in the axillae, 
 upon the chest, the inner surface of the thighs, and the feet. The 
 quantity of blood is usually inconsiderable and the duration of its 
 discharge short, varying from a few minutes to several hours. It 
 usually oozes out slowly, almost imperceptibly, but may in exceptional 
 cases escape freely for a short time, as in the one observed by Hebra, 
 in which it was discharged as a small jet from the back of the hand. 
 
 Etiology and Pathology. — With but very few exceptions the dis- 
 ease is confined to females during the age of sexual activity who present 
 the stigmata of hysteria or suffer from derangement of the menstrual 
 function ; in a few instances it has been observed in those with sup- 
 pressed menstruation, appearing at the usual menstrual periods (vica- 
 rious menstruation). A few notable exceptions, however, have been 
 recorded; Hebra's case, already referred to, occurred in a young man 
 strong and well nourished. 
 
 The affection is not, accurately speaking, a secretion of bloody 
 sweat, as was pointed out long ago by Hebra, but a hemorrhage from 
 the skin in which the blood escapes from the mouths of the sweat- 
 ducts, as Crocker has expressed it, " a purpura of the sweat-glands." 
 Torok found red blood-cells in the lumen of the coils of the sweat- 
 gland, and Tittel could express blood from the sweat-pore in a case 
 under his observation (quoted by Torok, Mracek's " Handbuch der 
 Hautkrankheiten "). 
 
 Diagnosis. — The appearance of blood upon the skin without any 
 solution of continuity, which slowly reappears when wiped off, espe- 
 cially in an hysterical female, is so characteristic that the diagnosis 
 presents no difficulties ; but it is necessary to be on one's guard always 
 against fraud. 
 
 Prognosis and Treatment. — The amount of blood lost is so insig- 
 
720 
 
 DISEASES OF THE SKIN 
 
 nificant that it in no way impairs the patient's general condition, but 
 the affection is likely to run an irregular and indefinite course. 
 
 The treatment is essentially that of the nervous disorder upon which 
 it in most cases depends. 
 
 HIDROCYSTOMA 
 
 Synonyms. — Hydrocystoma ; Cyst of the coil-ducts. 
 
 Definition. — A non-inflammatory affection of the ducts of the 
 sweat-glands characterized by small vesicle-like cysts situated in the 
 face. 
 
 Symptoms. — This affection which was first described by Robinson, 
 
 
 '' \ 
 
 c i 
 
 'V 
 
 Fig. 242. — Hidrocystoma. Cysts, c, c, formed by dilated sweat-ducts. 
 
 in 1884, is distinguished by pin-head- to split-pea-sized tense vesicles 
 situated upon the cheeks, nose, forehead, and, less frequently, upon the 
 cutaneous surface of the upper and lower lips. They are translucent, 
 pearly, or, when large, bluish in color, and when deep-seated resemble 
 sago-grains embedded in the skin. Often limited in numbers there 
 may be as many as a hundred or more. After a time the contents of 
 
DISEASES OF THE APPENDAGES 721 
 
 some of them dry up, they become whitish, resembling milium, and 
 eventually disappear by absorption. In their early stages they are 
 always deep-seated, but as they grow larger they project more or less 
 decidedly above the surface. The lesions are usually symmetrically 
 distributed over the cheeks and nose, but in a case observed by Hutchin- 
 son they were limited very largely to one side. 
 
 Etiology and Pathology. — The disease has been observed almost 
 without exception in middle-aged women who, exposed to heat and 
 moisture, such as laundresses, sweat freely. It is usually worse in 
 summer, and may disappear wholly or in part in winter. In the uni- 
 lateral case reported by Hutchinson, referred to above, the patient 
 sweated only on the side occupied by the eruption. In a case observed 
 by Hallopeau an exacerbation occurred at the menstrual period. Hyde 
 and McEwen saw a typical case in a woman past the menopause who 
 suffered from exophthalmic goitre accompanied by sweating. 
 
 The affection is a cystic dilatation of the duct of the sweat-gland 
 (Fig. 242) situated in the deeper portion of the corium just above 
 the coil. Adam reports the finding of cysts in the gland itself, but this 
 finding has not been confirmed by other investigators. In the upper 
 part of the corium in the neighborhood of the larger and older lesions 
 a moderate exudation of leucocytes is present. The cysts are filled 
 with a fluid presenting the characters of normal sweat. 
 
 Diagnosis. — The affection is readily recognized; the non-inflamma- 
 tory character of the vesicles, their deep seat, their limitation to the 
 face, and their occurrence in middle-aged women exposed to heat 
 and moisture, are characteristic features. 
 
 Treatment. — Puncture of the lesions and evacuation of their con- 
 tents will cause them to disappear. Prolonged exposure to heat, par- 
 ticularly moist heat, and other causes of excessive sweating should 
 be avoided. 
 
 MILIARIA 
 
 Synonyms. — Miliaria rubra ; Miliaria alba ; Strophulus ; Red gum ; 
 Lichen tropicus; Prickly heat; Fr., Miliaire ; Ger., Frieselausschlag. 
 
 Definition. — An acute inflammatory affection associated with pro- 
 fuse perspiration, characterized by an eruption of small, bright-red 
 papules or minute papulo-vesicles. 
 
 Symptoms. — The eruption, which occupies the trunk chiefly, but 
 also occurs on the face and extremities, appears rather suddenly after 
 profuse sweating during hot w T eather, or in those who are exposed 
 for hours to heat and sweat profusely in consequence. It occurs as 
 innumerable minute bright-red papules (miliaria papulosa, lichen trop- 
 icus), or as very small, for the most part acuminate, papulo-vesicles 
 and vesicles with clear contents (miliaria rubra, miliaria vesiculosa), 
 which after some hours or a day become cloudy {miliaria alba). After 
 a few days the eruption, which is a very abundant one, the lesions 
 being closely placed but discrete, begins to fade ; the contents of the 
 
 46 
 
722 
 
 DISEASES OF THE SKIN 
 
 
 
 vesicles are absorbed or dry into minute yellow crusts, which cap the 
 lesions, and a moderate branny desquamation follows for a short 
 time. While the individual lesions are short-lived, the eruption as 
 a whole may continue for some weeks, new crops of vesicles appear- 
 ing more or less continuously. In poorly cared-for infants, in whom 
 it is very common during the hot summer months, it is frequently 
 accompanied by furunculosis and often terminates in eczema when 
 prolonged. In adults eczema may follow in regions where there is fric- 
 tion of opposed surfaces, such as the axillae, the groins, beneath the breasts 
 in women, and between the folds of skin in obese individuals. More 
 or less marked itching and burning accompany the eruption. 
 
 Etiology and Pathology. — Miliaria is most common in the hot 
 months of summer in children, and at any season in small infants 
 who are overclothed. The affection popularly known as " red gum," 
 or simply as "gum," strophulus, is a miliaria occurring in new-born 
 infants as the result of overclothing. It is also common in adults 
 who are exposed to high temperature and perspire excessively. The 
 eruption is a very common one among Europeans in tropical countries. 
 
 The vesicles are situated between the horny and granular layers 
 of the epidermis, or in the upper portion of the rete mucosum, and 
 contain granular material, leucocytes, and a few swollen epithelial 
 cells. The papillary vessels are dilated and are surrounded by a 
 moderate cellular exudate in which Torok found "mastzellen." Ac- 
 cording to Robinson, the affection is an inflammatory disease of the 
 epidermis, the lesions resulting from an exudation in the rete mu- 
 cosum around the orifice of the sweat-duct; he also believes they may 
 form independently of the sweat apparatus. Pollitzer regards the 
 vesicles as small retention cysts situated in the sweat-duct resulting 
 from a swelling of the epidermic cells in a skin insufficiently pro- 
 vided with fat. Torok was unable to demonstrate any connection of 
 the vesicles with the sweat-duct. 
 
 Prognosis. — Miliaria may be confounded with papular and vesicu- 
 lar eczema; it differs from these, however, by the suddenness of its 
 appearance, usually in hot weather or in those exposed to heat, by 
 its association with profuse sweating, by the diffuse character of the 
 eruption, the absence of oozing, and its usually very acute course. It 
 is to be remembered, however, that eczema is an occasional sequel 
 of miliaria. 
 
 Treatment. — Light clothing should be worn and woollen under- 
 wear should be avoided. The free use of a dusting powder, such as 
 equal parts of talc and oxide of zinc or subcarbonate of bismuth, 
 will usually suffice to afford relief in the average case. When the 
 inflammatory symptoms are more marked, the frequent application 
 of diluted alcohol or a saturated solution of boric acid in water, fol- 
 lowed by a dusting powder, will be found useful. Internal treat- 
 ment may in most cases be dispensed with ; occasionally a mild saline laxa- 
 tive and acidulated drinks may be given with some benefit. 
 
DISEASES OF THE APPENDAGES 723 
 
 MILIARIA CRYSTALLINA 
 
 Synonyms. — Sudamina ; Fr., Miliaire, Miliaire cristalline ; Ger., 
 Friesel. 
 
 Definition. — An acute non-inflammatory affection of the sweat- 
 gland ducts characterized by an eruption of small, transparent vesicles. 
 
 Symptoms. — The eruption appears suddenly after profuse sweating 
 as very small, pin-point to pin-head-sized, transparent, colorless vesi- 
 cles, which, owing to their extremely thin walls, look like drops of 
 dew sprinkled over the skin. It is usually most abundant upon the 
 anterior surface of the trunk, particularly the abdomen and lower 
 chest, but also occurs upon the neck and extremities. After a few 
 days' duration the contents of the vesicles are absorbed and a scanty 
 fine branny desquamation follows for a day or two. At no time are 
 there any signs of hyperemia or inflammation of the skin, or sub- 
 jective symptoms of any moment. 
 
 Etiology and Pathology. — As a rule, to which there are very few 
 exceptions, the eruption occurs in those suffering from some febrile 
 disorder attended by sweating, such as typhoid fever, pneumonia, 
 acute rheumatism, septic fever, pulmonary tuberculosis, and is fre- 
 quently seen after the so-called "critical sweats." 
 
 All those who have studied the affection microscopically agree in 
 placing the vesicles, which are in effect minute retention-cysts, in 
 the horny layer of the epidermis, at the mouth of the sweat-duct 
 (Robinson, Torok, Unna, Coats). In all the vesicles examined by 
 Torok a sweat-duct opened into the bottom of the lesion. The nature 
 of the obstruction leading to the retention of the sweat has not yet 
 been altogether satisfactorily explained, but Torok's explanation seems 
 to be the most plausible one ; he believes the mouth of the duct is 
 obstructed by an accumulation of horny epithelial cells during the 
 period of diminished or suppressed excretion of sweat during the febrile 
 period which frequently precedes the critical sweating. Coats thinks 
 it due to the formation of a plug of leucocytes of inflammatory origin, 
 but it is very evident that he does not accurately distinguish between 
 this affection and miliaria rubra, since he speaks of some of the vesi- 
 cles after a time containing leucocytes and becoming minute abscesses. 
 
 Diagnosis. — The exquisitely transparent character of the vesicles, 
 the complete absence of all symptoms of inflammation, and the inti- 
 mate association of the eruption with profuse sweating, are symptoms 
 so characteristic that an error in diagnosis is scarcely possible. 
 
 Prognosis and Treatment. — The affection is a trivial one, unaccom- 
 panied by any annoying symptoms, and usually terminates in a few 
 days. 
 
 In many cases no treatment is required beyond the use of a dusting 
 powder. If the affection is prolonged by repeated crops, a lotion of 
 dilute alcohol may be used several times a day in conjunction with 
 the dusting powder. 
 
724 
 
 DISEASES OF THE SKIN 
 
 MILIARY FEVER 
 
 Synonyms. — Sudor Anglicus ; Sweating sickness ; Suette de Pi- 
 cardie ; Suette miliaire ; Ger., Schweissfriesel. 
 
 Definition. — An epidemic disease characterized by fever, profuse 
 sweating, and an eruption resembling miliaria. 
 
 Symptoms. — This singular affection, about the history of which 
 there is a great deal of uncertainty, first appeared in England in 1485, 
 and remained limited to that country for more than half a century, 
 five epidemics occurring between that date and 1551. It then spread 
 to the Continent, where many epidemics of a similar, if not identical, 
 disease have since occurred, particularly in France, Italy, and Ger- 
 many, although it has never reappeared in England since the middle 
 of the sixteenth century. An attack may be precded by prodromal 
 symptoms, such as headache, weakness of the lower extremities, and 
 irritation of the skin, or it may appear suddenly without premonitory 
 symptoms with chilliness, headache, fever with profuse sweating and 
 a painful feeling of constriction of the chest and epigastrium, accom- 
 panied by dyspnoea, which in severe cases may be extreme and most 
 distressing. After three or four days, and sometimes later, an erythe- 
 matous eruption appears which may resemble the eruption of measles 
 upon which vesicles develop shortly with transparent contents, which 
 soon become turbid. Occasionally the eruption appears upon the 
 mucous membranes of the mouth. The duration of the affection varies 
 from two or three days in mild cases to eight or ten in the severe 
 ones, and terminates with a more or less marked desquamation. The 
 severity of the symptoms varies much in different epidemics ; occa- 
 sionally a fulminant form occurs, in which all the symptoms are 
 greatly aggravated, and death takes place in a short time. The mor- 
 tality varies from 8 or 9 per cent, to 20 or 30 per cent. 
 
 A remarkable feature of the disease is the very short duration 
 of the epidemics, which last, as a rule, only a few weeks, and in 
 some instances only a few days ; during this short period many hundreds 
 or thousands of cases may occur. 
 
 The cause is altogether unknown, but season exerts a very decided 
 influence upon its incidence, since the large majority of epidemics 
 have occurred during the summer and early autumn. 
 
 The treatment is to be conducted upon general principles, the 
 cutaneous symptoms being of secondary importance. 
 
 GRANULOSIS RUBRA NASI 
 
 Definition. — An inflammatory affection of the nose, occurring for 
 the most part in children, distinguished by redness, an eruption of 
 small papules, and localized hyperidrosis. 
 
 Symptoms. — This disease was first recognized by Luithlen, who 
 reported a case in 1900 as a peculiar form of acne accompanied by 
 changes in the sweat-glands. A year later Jadassohn reported seven 
 
DISEASES OF THE APPENDAGES 725 
 
 cases, together with the results of the histological study of four of 
 them, establishing its right to be regarded as a disease sui generis, 
 and proposing for it the name by which it has since been known, 
 granulosis rubra nasi. Other cases have since been reported by Herr- 
 mann, Pick, MacLeod, Little, and a few others. 
 
 It is confined to the lower portion of the nose, especially the tip 
 and alas, which is diffusely reddened and covered with a rather scanty 
 eruption of small dark-red or brown-red papules and an occasional 
 small pustule ; the end of the nose is constantly moist with perspira- 
 tion, which stands in small drops upon it. Occasionally hydrocystoma 
 is associated with it, as in the cases reported by Pinkus, Lebet, and 
 Jadassohn. It pursues a very chronic course, changing but little in 
 appearance when once established. With the exception of occasional 
 slight itching, there are no subjective symptoms. 
 
 Etiology and Pathology.— The affection is confined for the most 
 part to children, who are usually anaemic, ill-nourished, or nervous. 
 In a few instances it has been observed in adults ; Pinkus has re- 
 ported one in a man fifty-nine years old, Lebet one in an adult woman 
 over thirty years of age; and the author has notes of a case occurring 
 in a young woman twenty-two years of age. 
 
 The epidermis shows but little change, but characteristic alterations 
 are present in the corium. The vessels of the upper and middle portion 
 are dilated and surrounded in places by a cellular exudate composed 
 of leucocytes, connective-tissue cells, with a few plasma cells and 
 "mastzellen." The ducts of the sweat-glands are in places irregularly 
 dilated and surrounded by a cellular exudate. The collagen and elastic 
 tissue are but little altered. 
 
 Diagnosis. — The affection may be mistaken for acne rosacea, as 
 was done in several of the earlier reported cases, but the youth of 
 the patient and the presence of local hyperidrosis will serve to dis- 
 tinguish it from that affection. When the papules are well developed 
 and numerous it may bear some resemblance to lupus vulgaris, but 
 there are no intradermic nodules, and no tendency to infiltration 
 and ulceration. 
 
 Treatment. — The treatment is very unsatisfactory. Astringent lo- 
 tions and dusting powders afford some temporary relief. Among 
 dusting powders, one containing from 25 to 50 per cent, of tannoform 
 will be found one of the most useful. When the patient is ansemic or 
 ill-nourished, as is often the case, he should be given iron or cod-liver 
 oil, and should live outdoors as much as possible. 
 
INDEX 
 
 Absence of secondary lesions, 36 
 Acantholysis bullosa, 190 
 Acanthosis, 30 
 nigricans, 491 
 
 definition, 491 
 
 diagnosis, 492 
 
 etiology, 492 
 
 pathology, 492 
 
 prognosis, 492 
 
 symptoms, 491 
 
 treatment, 493 
 Acare des follicules, 458 
 Acarus f olliculorum, 458 
 
 scabiei, 446 
 Acetanilid, 41, 216 
 Achromia congenita, 537 
 Acne, 693 
 
 agminata, 708 
 albida, 689 
 artificialis, 705 
 
 treatment, 706 
 atrophica, 706 
 concrete, 472 
 frontalis, 706 
 keloid, 673 
 keratosa, 711 
 miliaria, 689 
 necrotica, 706 
 paraffin, 706 
 rodens, 706 
 rosacea, 702 
 
 definition, 702 
 
 diagnosis, 703 
 
 etiology, 702 
 
 pathology, 703 
 
 prognosis, 704 
 
 symptoms, 702 
 
 treatment, 704 
 rosacee, 702 
 sebacea, 681 
 sebacee, 472 
 simplex, 693 
 urticata, 710 
 varioliformis, 544, 706, 707 
 
 definition, 706 
 
 diagnosis, 708 
 
 etiology, 707 
 
 pathology, 708 
 
 prognosis, 708 
 
 symptoms, 707 
 
 treatment, 708 
 
 Acne vulgaris, 693, 694, 697 
 definition, 693 
 diagnosis, 696 
 etiology, 695 
 lotion for, 699, 700 
 mixture for, 698 
 ointment for, 700 
 paste for, 701 
 pathology, 696 
 prognosis, 696 
 symptoms, 693 
 treatment, 697 
 Acne decalvante, 668 
 ponctuee, 686 
 sebacee cornee, 477 
 Acneform inflammations, 710 
 Acnitis, 708 
 
 diagnosis, 709 
 etiology, 709 
 pathology, 709 
 prognosis, 710 
 symptoms, 709 
 treatment, 710 
 Acrodermatite suppurative, continue, 197 
 Acrodermatitis chronica atrophicans, 520 
 hiemalis, 210 
 perstans, 197 
 
 pustulosa hiemalis, 210, 254 
 urticarioides, 450 
 Acrodynia, 371 
 definition, 371 
 etiology, 372 
 symptoms, 371 
 treatment, 372 
 Actinomycose, 335 
 Actinomycosis, 335, 337 
 definition, 335 
 diagnosis, 337 
 etiology-, 336 
 pathology, 336 
 prognosis, 338 
 symptoms, 335 
 treatment, 338 
 Acute eczema, 138 
 
 circumscribed eczema, 65 
 arsenic in, 139 
 early stages of, 139 
 itching and burning, lotion for 
 
 140 
 lotions, 140 
 inflammations, 43 
 
 727 
 
728 
 
 INDEX 
 
 Acute inflammations, treatment of, 43 
 pemphigus, 179 
 
 duration of, 179 
 etiology, 180 
 symptoms, 179 
 Adenoma sebaceum, 557, 558 
 definition, 557 
 diagnosis, 558 
 etiology, 557 
 pathology, 558 
 prognosis, 559 
 symptoms, 557 
 treatment, 559 
 Adenomes sebaces, 557 
 Age, 25, 35 
 Agents, keratolytic, 47 
 
 keratoplastic, 47 
 Ainhum, 526 
 • definition, 526 
 etiology, 526 
 pathology, 526 
 prognosis, 527 
 symptoms, 526 
 treatment, 527 
 Akne, 693 
 Aktinomykose, 335 
 Albinism, 537 
 Albinismus, 537 
 definition, 537 
 etiology, 538 
 pathology, 538 
 symptoms, 537 
 Aleppo boil, 344 
 Algidite progressive, 510 
 Alopecia, 655 
 adnata, 655 
 areata, 662, 663 
 definition, 662 
 diagnosis, 665 
 etiology,. 664 
 lotion for, 667 
 ointment for, 667 
 pathology, 665 
 prognosis, 666 
 symptoms, 662 
 treatment, 666 
 cicatrisata, 668 
 circumscripta, 662 
 symptoms, 655 
 congenita, 655 
 definition, 655 
 etiology, 656 
 lotions for, 660, 661 
 orbicularis, 668 
 pathology, 656 
 prematura, 656 
 
 Alopecia prematuria idiopathica, 657 
 symptomatica, 657 
 etiology, 658 
 pathology, 658 
 prognosis, 659 
 treatment, 659 
 senilis, 656 
 
 symptomatology, 656 
 Alopecie, 655 
 
 congenitale, 655 
 innominee, 668 
 Alphos, 97 
 
 Alterations, objective, 17 
 qualitative, 33 
 quantitative, 33 
 Anaesthesia, 626 
 
 definition, 625 
 Anaesthetic leprosy, 316, 317 
 Anatomical wart, 249 
 Anatomy, 1 
 Angiokeratom, 489 
 Angiokeratoma, 29, 489 
 definition, 489 
 diagnosis, 490 
 etiology, 490 
 pathology, 490 
 prognosis, 490 
 symptoms, 489 
 treatment, 490 
 Angioma, 586 
 
 definition, 586 
 serpiginosum, 591 
 definition, 591 
 diagnosis, 592 
 etiology, 592 
 pathology, 592 
 prognosis, 593 
 symptoms, 591 
 treatment, 593 
 simplex, 587 
 Angioneurotic oedema, 65 
 Ani, eczema, 126 
 Anidrosis, 711 
 
 definition, 711 
 symptoms, 711 
 treatment, 711 
 Animal parasites, inflammations due to, 
 
 437 
 Ankylostomiasis cutis, 455 
 
 definition, 455 
 
 treatment, 456 
 Ankylostomum dermatitis, 455 
 Annulo-papular syphiloderm, 274 
 Anomaliae pigmentationis, 530 
 Anomalies of pigmentation, 530 
 Anthrax, 230, 338 
 definition, 338 
 
INDEX 
 
 729 
 
 Anthrax, diagnosis, 339 
 etiology, 339 
 pathology, 339 
 prognosis, 340 
 simplex, 230 
 symptoms, 338 
 treatment, 340 
 Antifebrin, 216 
 
 Antipruritics and sedatives, 47 
 Antiseptics and parasiticides, 47 
 Antitoxin and other sera, 217 
 Anus, eczema of, 126, 147 
 Aplasia pilorum intermittens, 648 
 Appendages, diseases of, 634 
 Area Celsi, 662 
 Argyria, 538 
 Arrectores pilorum, 7 
 Arsenic, 40, 217 
 Arsenical keratosis, 215 
 
 pigmentation, 33, 217 
 Arzneiexantheme, 215 
 Asphyxie locale et gangrene sym- 
 
 metrique des extremites, 204 
 AsteatodeSj 680 
 Asteatosis, 680 
 definition, 680 
 symptoms, 680 
 treatment, 681 
 Astringents, 47 
 Atheroma, 691 
 
 Atrophia cutis idiopathica, 520 
 senilis, 522 
 
 definition, 522 
 pathology, 523 
 symptoms, 522 
 treatment, 523 
 pilorium propria, 645 
 striata et maculosa, 523 
 unguium, 635 
 etiology, 636 
 symptoms, 635 
 treatment, 637 
 Atrophies, 520 
 
 Atrophoderma neuriticum, 529 
 pigmentosum, 612 
 senilis, 522 
 
 striatum et maculatum, 523 
 Atrophy of the nails, 635 
 Auftreibung und Bersten der Haare, 646 
 Aussatz, 307 
 
 Autogenous vaccines, 42 
 Axilla, ringworm of, 416 
 
 Bacillus leprae, 319 
 Baldness, 655 
 Balggeschwulst, 691 
 Barbae, eczema, 124 
 
 Barbae, trichophytosis, 410 
 Barbadoes leg, 514 
 Barley itch, 450 
 Bartfinne, 676 
 Bases, ointment, 144 
 Bastard measles, 391 
 Baths, 43 
 
 Bazin's disease, 257 
 Beard, eczema of, 124, 146 
 ringworm of, 410, 429 
 Beerschwam, 347 
 Benign cystic epithelioma, 551 
 miliary lupoid, 264 
 sarcoid, 572 
 Bird mite, 456 
 Biskra button, 344 
 Blackhead, 686 
 Blasenausschlag, 178 
 Blaschenrlechte, 154 
 Blastomycetic dermatitis, 328 
 Blastomycose cutanee, 328 
 Blastomycosis cutis, 328, 329, 330, 331 
 definition, 328 
 diagnosis, 332 
 prognosis, 332 
 symptoms, 328 
 treatment, 332 
 Blattern, 373 
 Blebs, 19, 31 
 Blood-vessels, 4 
 Blutfleckenkrankheit 461 
 Blutschwar, 227 
 Blutschweiss, 719 
 Blutschwitzen, 719 
 Bodies, molluscum, 550 
 Body, favus of, 399 
 
 ringworm of, 412, 414 
 Boil, 227 
 Bot-fly, 455 
 
 Botryomycose humaine, 234 
 Botryomycosis, 234 
 Boubas, 347 
 Bouton d'Alep, 344 
 Bowditch Island ringworm, 430 
 Brandschwar. 230 
 Breast, eczema of, 135 
 
 Paget's disease of, 611 
 Bromhidrosis, 717 
 Bromide eruption, 217, 218 
 Bromidrose, 717 
 Bromidrosis, 717 
 definition, 717 
 etiology, 717 
 pathology, 717 
 symptoms, 717 
 treatment, 718 
 Brown pigment, 4 
 
730 
 
 INDEX 
 
 Brown-tail moth dermatitis, 452 
 
 treatment, 452 
 Bucnemia tropica, 514 
 Bullous syphiloderm, 286 
 
 diagnosis, 286 
 Burrow of scabies, 447 
 Buttocks, Paget's disease of, 610 
 
 Cachexia thyropriva, 512 
 Cachexie pachydermique, 512 
 Callositas, 470 
 
 definition, 470 
 
 etiology, 470 
 
 pathology, 470 
 
 symptoms, 470 
 
 treatment, 470 
 Callosite, 470 
 Callosity, 470 
 Callus, 470 
 Calvities, 655 
 Cancer of the skin, 598 
 Cancroid, 598 
 Canities, 670 
 
 definition, 670 
 
 discoloration of the hair, 672 
 
 etiology, 671 
 
 pathology, 671 
 
 prognosis, 672 
 
 symptoms, 670 
 
 treatment, 672, 673 
 Caraate, 435 
 Carate, 435 
 Carboncle, 230 
 Carbuncle, 230 
 Carbunculus, 230 
 
 definition, 230 
 
 diagnosis, 231 
 
 etiology, 230 
 
 pathology, 231 
 
 prognosis, 231 
 
 symptoms, 230 
 
 treatment, 231 
 Carcinoma cutis, 598 
 
 lenticulare, 602 
 
 tuberosum, 603 
 diagnosis, 605 
 etiology, 603 
 pathology, 604 
 plaster for, 607 
 prognosis, 606 
 treatment, 606 
 Carrion's disease, 350 
 Cascadoe, 430 
 
 Cathartics and laxatives, 39 
 Causes of diseases of the skin, 27, 28 
 Caustics, 47 
 Cell, plasma, 32 
 
 Cells, giant, 32 
 
 mast, 32 
 
 prickle, 3 
 
 rete mucosum, 3 
 
 touch, 6 
 Cerumen, 13 
 Chalazodermia, 518 
 Chancre, Hunterian, 268 
 Charbon, 338 
 Cheiropompholyx, 167 
 Cheloid, 566 
 Cheloide, 566 
 Chicken louse, 456 
 Chickenpox, 393 
 Chigoe, 453 
 Chloasma, 531 
 
 definition, 531 
 
 diagnosis, 533 
 
 etiology, 532 
 
 pathology, 532 
 
 prognosis, 533 
 
 symptoms, 531 
 
 treatment, 533 
 Chloral, 219 
 Chromatophores, 7 
 Chromidrosis, 715 
 
 definition, 715 
 
 diagnosis, 716 
 
 etiology, 716 
 
 pathology, 716 
 
 prognosis, 716 
 
 symptoms, 715 
 
 treatment, 716 
 Chromophytosis, 540 
 Chronic eczema, 141 
 
 itching, lotion for, 141 
 liquor picis alkalinus, 143 
 ointments for, 142 
 palms and soles, 130 
 resorcin lotion for, 141 
 
 ointment for, 142 
 tar for, 142 
 
 leg ulcer, 148 
 
 ointment for, 149 
 
 pemphigus, 180, 181 
 symptoms, 180 
 Cicatrice, 570 
 Cicatrix, 570 
 
 definition, 570 
 
 etiology, 571 
 
 pathology, 571 
 
 symptoms, 570 
 
 treatment, 571 
 Cilia, 8 
 Cimex lectularius, 443 
 
 treatment, 443 
 Circinate papular syphiloderm, 273 
 
INDEX 
 
 731 
 
 Circinate squamous syphiloderm, 291 
 Circulation, lymphatic, 5 
 Circumscribed scleroderma, 506, 507 
 diagnosis, 509 
 etiology, 508 
 pathology, 508 
 prognosis, 509 
 symptoms, 506 
 treatment, 509 
 Clastothrix, 646 
 Clavus, 469 
 
 definition, 469 
 etiology, 469 
 pathology, 469 
 symptoms, 469 
 treatment, 469 
 Climate in relation to disease of skin, 24 
 Clothing and food, 25 
 Clou de Biskra, 344 
 
 de Gafsa, 344 
 Coccogenic sycosis, 676 
 Cochin-China leg, 514 
 Cod liver oil, 40 
 Coil-glands, 4 
 Cold, dermatitis form, 209 
 abscess of the skin, 259 
 -sore, 149 
 Colloid degeneration, 33 
 of skin, 584 
 
 definition, 584 
 diagnosis, 586 
 etiology, 585 
 pathology, 586 
 symptoms, 584 
 treatment, 586 
 milium, 584, 585 
 Colloidoma miliare, 584 
 Colored sweating, 715 
 Comedo, 686, 688 
 definition, 686 
 diagnosis, 689 
 etiology, 687 
 pathology, 687 
 prognosis, 689 
 symptoms, 686 
 treatment, 689 
 Comedon, 686 
 
 Condyloma acuminatum, 503 
 definition, 503 
 diagnosis, 504 
 etiology, 504 
 pathology, 504 
 prognosis, 504 
 symptoms, 503 
 treatment, 504 
 Condylomata, flat, 287 
 Condylome acumine, 503 
 
 Congelatio, 209 
 Congestions, 48 
 Copaiba, 219 
 Copra itch, 451 
 Cor, 469 
 Corium, 4 
 
 Corn, 469 • 
 
 Corne de la peau, 471 
 Corneum, stratum, 1 
 Cornification, 29 
 Cornu cutaneum, 471 
 definition, 471 
 etiology, 471 
 prognosis, 471 
 symptoms, 471 
 treatment, 471 
 
 humanum, 471 
 Corpuscles of Krause, 5 
 
 of Meissner and Wagner, 5 
 
 Pacinian, 4 
 
 tactile, 5, 6 
 
 of Vater, 5 
 Couperose, 702 
 Craw-craw, 460 
 
 treatment, 460 
 Creeping eruption, 458 
 Cretinoid oedema, 512 
 Crusts, 21 
 
 Cutaneous horn, 471 
 Cuticle of the hair, 8 
 Cuticula pili, 8 
 Cutis anserina, 7 
 
 blastomycosis, 328, 329, 330, 331 
 
 carcinoma, 598 
 
 cysticerus cellulose, 454 
 
 echinococcus, 458 
 
 endothelioma, 556 
 
 laxa, 518 
 
 leukaemia and pseudoleukemia, 622, 
 623 
 
 osteoma, 579 
 
 pendula, 518 
 
 sarcoma, 616 
 
 trypanosomiasis, 372 
 
 tuberculosis miliaris, 256 
 verrucosa, 249, 250, 252 
 
 verticis gyrata, 518, 519 
 Cyst of the coil-ducts, 720 
 Cysticercus cellulose cutis, 454 
 diagnosis, 455 
 
 Darier's disease, 477, 480 
 Das Sklerodem, 511 
 Deep trichophytosis, 424 
 Degeneration, colloid, 33 
 
 fatty, 32 
 
 hyaline, 33 
 
732 
 
 INDEX 
 
 
 Degeneration, myxomatous, 33 
 
 Delhi boil, 344 
 
 Demodex folliculorum, 458 
 
 Dermalgie, 631 
 
 Dermamyiasis linearis migrans oestrosa, 
 
 458 
 Dermanysse des oiseaux, 456 
 Dermanyssus avium et gallinse, 456 
 Dermatalgia, 631 
 diagnosis, 631 
 etiology, 631 
 prognosis, 631 
 symptoms, 631 
 treatment, 631 
 Dermatite exfoliatrice, 66 
 
 polymorphe douleureuse, 170 
 Dermatitis, 31, 207 
 a frigore, 209 
 artefacta, 221 
 atrophicans maculosa, 520 
 blastomycotica, 328 
 brown-tail moth, 452 
 bullosa hereditaria, 190 
 calorica, 208 
 
 chronica atrophicans, 520 
 definition, 520 
 diagnosis, 522 
 etiology, 522 
 pathology, 522 
 prognosis, 522 
 symptoms, 520 
 treatment, 522 
 congelationis, 209 
 contusiforme, 55 
 exfoliativa, 66, 68 
 definition, 66 
 diagnosis, 70 
 epidemica, 71 
 diagnosis, 73 
 etiology, 72 * 
 
 pathology, 72 >/::> 
 
 prognosis, 73 
 symptoms, 72 
 treatment, 73 
 etiology, 69 
 neonatorum, 76 
 definition, 76 
 diagnosis, 77 
 etiology, 76 
 pathology, 76 
 prognosis, 77 
 symptoms, 76 
 treatment, 77 
 pathology, 70 
 prognosis, 71 
 symptoms, 67 
 treatment, 71 
 
 Dermatitis factitia, 221, 222 
 definition, 221 
 diagnosis, 223 
 etiology, 223 
 symptoms, 221 
 treatment, 224 
 gangrenosa, 200 
 adultorum, 202 
 
 etiology, 203 
 
 pathology, 203 
 
 prognosis, 203 
 
 symptoms, 202 
 
 treatment, 203 
 diabeticorum, 203 
 infantum, 200 
 
 diagnosis, 201 
 
 etiology, 201 
 
 pathology, 201 
 
 prognosis, 201 
 
 symptoms, 200 
 
 treatment, 201 
 symmetrica, 204 
 
 definition, 204 
 
 diagnosis, 206 
 
 etiology, 205 
 
 pathology, 206 
 
 pre gnosis, 206 
 
 symptoms, 204 
 
 treatment, 206 
 herpetiformis, 170, 172, 173 
 definition, 170 
 diagnosis, 175 
 etiology, 174 
 
 pathological anatomy, 174 
 patholog}', 174 
 prognosis, 175 
 symptoms, 170 
 treatment, 176 
 medicamentosa, 215 
 papillaris capillitii, 673, 674, 675 
 
 definition, 673 
 
 diagnosis, 675 
 
 etiology, 674 
 
 pathology, 674 
 
 prognosis, 676 
 
 symptoms, 673 
 
 treatment, 676 
 pellagrous, 370 
 
 psoriasiformis nodularis, no 
 repens, 197, 198 
 definition, 197 
 diagnosis, 198 
 etiology, 197 
 pathology, 197 
 prognosis, 198 
 symptoms, 197 
 treatment, 198 
 
INDEX 
 
 733 
 
 Dermatitis scarlatiniformis recidivans, 73 
 seborrheica, 149 
 definitions, 149 
 diagnosis, 153 
 etiology, 152 
 lotion for, 154 
 pathology, 152 
 prognosis, 153 
 symptoms, 149 
 treatment, 154 
 traumatica, 207 
 vegetans, 199 
 venenata, 211, 213 
 definition, 211 
 diagnosis, 214 
 etiology, 212 
 pathology, 214 
 prognosis, 214 
 symptoms, 211 
 treatment, 214 
 Dermatolysis, 518 
 symptoms, 518 
 Dermatomycosis furfuracea, 540 
 Dermatomyoma, 577 
 definition, 577 
 diagnosis, 578 
 etiology, 578 
 pathology, 578 
 prognosis, 578 
 symptoms, 577 
 treatment, 578 
 Dermatophilus penetrans, 453 
 Dermatoses, drug, 215 
 Dermatosis Kaposi, 612 
 Desquamation, 74 
 Desquamative scarlatiniform erythema, 
 
 73 
 Diabetes, saccharine, 26 
 Diabetic gangrene, 203 
 etiology, 204 
 treatment, 204 
 Diagnosis, general, 35 
 Diet, 38 
 
 Diffuse idiopathic atrophy of the skin, 
 520 
 
 scleroderma, 505 
 Diphtheria of the skin, 206 
 Disease, Darier's, 480 
 
 of the ductless glands, 27 
 
 history of, 36 
 
 of the liver, 26 
 
 Paget's, 607, 608 
 
 Raynaud's, 204 
 Diseases of the appendages, 634 
 
 of the hair and hair follicles, 642 
 
 of the nails, 634 
 
 parasitic, 135 
 
 Diseases of the sebaceous glands, 680 
 
 of the sweat-glands, 711 
 Dracontiasis, 456 
 definition, 456 
 etiology, 457 
 pathology, 457 
 symptoms, 456 
 treatment, 457 
 Dracunculus medinesis, 456 
 Drug dermatoses, 215 
 definition, 215 
 diagnosis, 220 
 etiology, 220 
 pathology, 220 
 prognosis, 221 
 symptoms, 215 
 treatment, 221 
 eruptions, 215 
 .Ductless glands, 41 
 
 disease of, 27 
 Dusting powders, 44 
 Dysidrosis, 167 
 Dystrophic papillaire et pigmentaire, 491 
 
 Ears, eczema of, 124, 145 
 Echinococcus cutis, 458 
 Ecthyma, 226 
 
 definition, 226 
 
 diagnosis, 227 
 
 etiology, 226 
 
 pathology, 227 
 
 symptoms, 226 
 
 terebrant, 200 
 
 treatment, 227 
 Eczema, 116, 135 
 
 acute, 138 
 
 ani, 126 
 
 of the anus, 126, 147 
 lotion for, 148 
 
 aurium, 124 
 
 barbae, 124 
 
 of the beard. 146 
 
 of the breast, 125, 135 
 
 capitis, 123 
 
 chronic, 141, 142 
 
 craquile, 122 
 
 definition, 116 
 
 diagnosis, 132 
 
 of the ears, 124, 145 
 
 erythematosum, 119 
 
 erythematous, 119 
 
 etiology, 126 
 
 external causes, 128 
 
 of the face, infantile, 144 
 
 faciei, 123 
 
 fissum, 122 
 
 of the genitalia, 125, 147 
 
734 
 
 INDEX 
 
 
 
 Eczema, genitalium, 125 
 of the hands, 124, 146 
 legs, 148 
 of the lids, 145 
 mammarum, 125 
 manuum, 124 
 
 of the margin of the lids, 146 
 medicinal treatment of, 130 
 of the nails, 125 
 of the nipple and areola, 147 
 palpebrarum, 124 
 papular, 120 
 papulosum, 120 
 pathology, 129 
 pigmentation in, 131 
 prognosis, 136 
 pustular, 121, 133, 134 
 pustulosum, 121 
 regional forms of, 123 
 rubrum, 121, 126, 131 
 of the scalp, 144 
 
 ointment bases for, 144 
 scaly, 121, 134 
 sclerosum, 123, 132 
 of the scrotum, 147 
 seat of, 123 
 
 seborrhceicum, 149, 682 
 squamosum, 121 
 squamous, 134 
 subacute, 143 
 symptoms, 117 
 treatment, 136 
 unguium, 125 
 verrucosum, 123 
 vesicular, 119, 130, 133 
 vesiculosum, 119 
 Eczemas of infancy, 143 
 Ehrmann, melanoblasts of, 34 
 Eiterblase, 226 
 Ekthyma, 226 
 Ekzem, 116 
 Eleidin, 2 
 Elephant leg, 514 
 Elephantiasis, 514 
 arabum, 514 
 definition, 514 
 diagnosis, 517 
 etiology, 516 
 grsecorum, 307 
 pathology, 516 
 prognosis, 517 
 symptoms, 514 
 treatment, 517 
 Endothelioma capitis, 556 
 cutis, 556 
 
 etiology, 556 
 pathology, 556 
 
 Endothelioma cutis, symptoms, 556 
 
 treatment, 557 
 l'Endurcissement athrepsique, 510 
 Energy, radiant, 47 
 Entozoon folliculorum, 458 
 Ephelide, 530 
 Ephelis, 530 
 Ephidrosis, 711 
 cruenta, 719 
 discolor, 715 
 tincta, 715 
 Epidemic eczema, 71 
 Epidermis, 1, 29 
 
 spiral portion of sweat-gland in, 13 
 Epidermolysis bullosa hereditaria, 190 
 definition, 190 
 diagnosis, 191 
 etiology, 190 
 pathology, 190 
 prognosis, 191 
 symptoms, 190 
 treatment, 191 
 Epidermophyton inguinale, 422 
 Epithelial cancer, 598 
 Epithelioma, 29, 598, 599 
 adenoides cysticum, 551 
 baso-cellulare, 605 
 definition, 598 
 
 (molluscum) contagiosum, 544, 545, 
 546, 547, 548, 549, 55i 
 definition, 544 
 diagnosis, 549 
 etiology, 545 
 pathology, 547 
 prognosis, 550 
 symptoms, 544 
 treatment, 550 
 morphcea-like, 600, 601 
 Epitheliomatose pigmentaire, 612 
 Epitheliome kystique benin, 553 
 Eponychium, 13 
 Equinia, 340 
 
 definition, 340 
 diagnosis, 342 
 etiology, 341 
 pathology, 341 
 prognosis, 342 
 symptoms, 340 
 treatment, 342 
 Erbgrind, 398 
 Ergot, 219 
 Erntemilbe, 452 
 Eruptions, 17, 22 
 
 bromide, 217, 218 
 
 chronique circinee de la main, 572 
 
 medicamenteuses, 215 
 
INDEX 
 
 735 
 
 Eruptions, vaccinal, 381 
 Erysipelas, 231 
 
 definition, 231 
 diagnosis, 233 
 etiology, 232 
 pathology, 232 
 perstans faciei, 361 
 prognosis, 233 
 symptoms, 231 
 treatment, 233 
 Erysipeloid, 233 
 definition, 233 
 diagnosis, 234 
 etiology, 234 
 pathology, 234 
 prognosis, 234 
 symptoms, 234 
 treatment, 234 
 Erythema, 48 
 
 ab igne, 48, 49 
 caloricum, 48 
 contusiforme, 55 
 elevatum diutinum, 572 
 exsudativum multiforme, 51 
 induratum, 257, 258 
 
 definition, 257 
 
 diagnosis, 259 
 
 etiology, 258 
 
 pathology, 258 
 
 symptoms, 257 
 
 treatment, 259 
 intertrigo, 50 
 migrans, 233 
 multiforme, 51, 52 
 
 definition, 51 
 
 diagnosis, 54 
 
 erythema iris, 53 
 
 etiology, 53 
 
 pathology, 54 
 
 prognosis, 55 
 
 symptoms, 51 
 
 treatment, 55 
 nodosum, 55 
 
 definition, 55 
 
 diagnosis, 57 
 
 etiology, 56 
 
 pathology, 57 
 
 prognosis, 57 
 
 symptoms, 55 
 
 treatment, 57 
 pernio, 49 
 scarlatiniforme, 73 
 
 definition, 73 
 
 diagnosis, 75 
 
 etiology, 75 
 
 pathology, 75 
 
 symptoms, 73 
 
 Erythema scarlatiniforme, treatment, 75 
 
 scarlatinoides, 73 
 
 serpens, 233 
 
 simplex, 48 
 
 solare, 48 
 
 traumaticum, 49 
 
 venenatum, 49 
 Erythemata, idiopathic, 48 
 
 symptomatic, 48 
 Erythemato-sclerose du dos des mains, 
 
 572 
 Erythematous eczema, 119 
 
 syphiloderm, 270, 271 
 diagnosis, 271 
 Erytheme centrifuge, 357 
 
 endemique, 367 
 
 epidemique, 371 
 
 indure des scrofuleux, 257 ' 
 
 multiforme, 51 
 
 noueux, 55 
 Erythrasma, 434 
 
 definition, 434 
 
 diagnosis, 434 
 
 etiology, 434 
 
 pathology, 434 
 
 symptoms, 434 
 
 treatment, 435 
 Erythroderma exfoKante (Besnier), 66 
 Erythrodermie pityriasique en plaques 
 
 disseminees, no 
 Erythromelalgia, 632 
 
 definition, 632 
 
 diagnosis, 633 
 
 etiology, 632 
 
 pathology, 632 
 
 prognosis, 633 
 
 symptoms, 632 
 
 treatment, 633 
 Espundia, 346 
 Etiology, general, 24 
 Eucerin, 45 
 
 Examination of patient, 35 
 Exanthemata, 373 
 Excoriations, 21 
 External remedies, therapeutic effect of, 
 
 43 
 root-sheath, 9 
 treatment, 42 
 
 Exudationes, 51 
 
 Farcy, 340 
 
 Fat-lobules, 4 
 
 Fatty degeneration, 32 
 
 substances, 44 
 
 tumor, 575 
 Favus, 398, 400, 402, 403 
 
 body, 399 
 
736 
 
 INDEX 
 
 Favus, definition, 398 
 diagnosis, 404 
 
 etiology, 401 ^° v 
 
 prognosis, 406 
 scalp, 399 
 symptoms, 398 
 treatment, 405 
 Feigned eruptions, 221 
 Fettsclerem, 510 
 Feuermal, 587 
 Fever blister, 149 
 
 miliary, 724 
 Fibres, elastic, 32 
 Fibroma, 562 
 
 definition, 562 
 durum, 564 
 hard, 564 
 lipomatodes, 580 
 molluscum, 563 
 diagnosis, 565 
 etiology, 564 
 pathology, 565 
 prognosis, 565 
 symptoms, 563 
 treatment, 566 
 Filaria meddinensis, 456 
 Finnen, 693 
 
 Fischschuppenausschlag, 493 
 Fish-skin disease, 493 
 Fissura pilorum, 645 
 Fissures, 21 
 Flat condylomata, 287 
 Flea, 443 
 Fleckenmal, 593 
 Follicle, hair, 9 
 Folliclis, 254 
 
 Follicular vegetating psorospermosis, 30 
 Folliculitis barbae, 676 
 decalvans, 668 
 definition, 668 
 diagnosis, 669 
 etiology, 668 
 lotion for, 669 
 ointment for, 669 
 pathology, 668 
 prognosis, 669 
 symptoms, 668 
 treatment, 669 
 exulcerans, 254 
 nuchae sclerotisans, 673 
 Folliculorum, demodex, 458 
 Food and clothing in relation to diseases 
 
 of skin, 25 
 Foot, perforating ulcer of, 527 
 Foreign sera, 42 
 Fragilitas crinium, 645 
 definition, 645 
 
 236 
 
 342 
 542 
 
 Fragilitas crinium, etiology, 646 
 pathology, 646 
 symptoms, 645 
 treatment, 646 
 Frambcesia, 347 
 
 definition, 347 
 
 diagnosis, 349 
 
 etiology, 349 
 
 pathology, 349 
 
 prognosis, 350 
 
 symptoms, 347 
 
 treatment, 350 
 Freckles, 530 
 Fressende Flechte, 
 Friesel, 723 
 Frieselausschlag, 721 
 Fungus foot of India, 
 Furfur, microsporon, 
 Furoncle, 227 
 Furuncle, 227 
 Furunculus, 227 
 
 definition, 227 
 
 diagnosis, 229 
 
 etiology, 228 
 
 pathology, 228 
 
 prognosis, 229 
 
 symptoms, 227 
 
 treatment, 229 
 Furunkel, 227 
 
 Gad-fly, 455 
 Gale, 444 
 Gangosa, 352 
 
 definition, 352 
 diagnosis, 353 
 etiology, 353 
 pathology, 353 
 prognosis, 353 
 symptoms, 352 
 treatment, 353 
 Gangrene, 200 
 diabetic, 203 
 
 infectious, multiple, 202 
 Gastro-intestinal disease, relationship to 
 
 disease of the skin, 26 
 Gefassmal, 587 
 Gemeiner Floh, 443 
 General diagnosis, 35 
 etiology, 24 
 pathology, 29 
 symptomatology, 17 
 therapeutics, 38 
 acetanilid, 41 
 acute inflammations, treatment 
 
 of, 43 
 antimony, 41 
 antipyrin, 41 
 
INDEX 
 
 737 
 
 General therapeutics, antiseptics and 
 parasiticides, 47 
 
 arsenic, 40 
 
 astringents, 47 
 
 autogenous vaccines, 42 
 
 baths, 43 
 
 caustics, 47 
 
 cod liver oil, 40 
 
 diet, 38 
 
 ductless glands, 41 
 
 dusting powders, 44 
 
 eucerin, 45 
 
 external remedies, therapeutic 
 effect of, 43 
 treatment, 42 
 
 fatty substances, 44 
 
 foreign sera, 42 
 
 glycerin, 46 
 
 hypodermatic injections, 42 
 
 injections of serum, 42 
 
 internal remedies, 38 
 treatment, 39 
 
 iodides of sodium and potas- 
 sium, 40 
 
 iron, preparations of, 39 
 
 keratolytic agents, 47 
 
 keratoplastic agents, 47 
 
 laxatives and cathartics, 39 
 
 lotions or washes, 44 
 
 mercury, 40 
 
 occupation, 39 
 
 ointments and lotions, applica- 
 tion of, 43 
 soothing and protective, 45 
 
 paste, Lassar's, 45 
 
 pastes, 45, 46 
 
 patient's clothing, 39 
 occupation, 39 
 
 phenacetin, 41 
 
 phenol, 41 
 
 plasters, 46 
 
 protectives, 47 
 
 quinine, 40 
 
 radiant energy, 47 
 
 salves or ointments, 44 
 
 sedatives and antipruritics, 47 
 
 soaps, 46 
 
 sulphur, 4 
 
 vaccine treatment, 42 
 
 varnishes, 46 
 Genitalia, eczema of, 125, 147 
 Genitalium, eczema, 125 
 German measles, 391 
 Germinativum, stratum, 3 
 Giant-cell, blastomycetes in, 330 
 Giant-cells, 32 
 Giant urticaria, 65 
 47 
 
 Gland, sweat-, 12 
 Glanders, 340 
 Glands, 11 
 coil, 4 
 
 ductless, disease of, 27 
 of Moll, 12 
 sebaceous, 10, 14 
 sweat-, 4 
 Glossy fingers, 529 
 skin, 529 ^ _ 
 
 definition, 529 
 etiology, 529 
 pathology, 529 
 prognosis, 529 
 symptoms, 529 
 treatment, 529 
 Glycerin, 46 
 
 Gomme scrofulo-tuberculeuse, 259 
 Grain itch, 450 
 
 definition, 450 
 diagnosis, 451 
 etiology, 451 
 pathology, 451 
 symptoms, 450 
 treatment, 451 
 Granular layer, 2 
 Granules, pigment, 34 
 Granuloma annulare, 572, 573 
 definition, 572 
 diagnosis, 574 
 etiology, 574 
 pathology, 574 
 prognosis, 574 
 symptoms, 573 
 treatment, 574 
 fungoides, 323, 324 
 definition, 323 
 diagnosis, 327 
 etiology, 326 
 pathology, 326 
 prognosis, 327 
 treatment, 327 
 inguinale tropicum, 354 
 definition, 354 
 diagnosis, 354 
 etiology, 354 
 pathology, 354 
 prognosis, 355 
 symptoms, 354 
 treatment, 355 
 pediculatum, 234 
 pyogenicum, 234, 235 
 definition, 234 
 diagnosis, 235 
 etiology, 235 
 pathology, 235 
 prognosis, 235 
 
738 
 
 INDEX 
 
 Granuloma pyogenicum, symptoms, 234 
 treatment, 235 
 telangiectodes, 234 
 Granulomata, infectious, 236 
 Granulosis rubra nasi, 724 
 
 definition, 724 
 
 diagnosis, 725 
 
 etiology, 725 
 
 pathology, 725 
 
 symptoms, 724 
 
 treatment, 725 
 Gray hair, 670 
 Groin, ulceration of, 354 
 Ground itch, 455 
 Growths, new, 544 
 Grutum, 689 
 Griitzbeutel, 691 
 Guinea-worm, 456 
 Gumma, 293 
 
 diagnosis, 294 
 Gummatous syphiloderm, 293 
 Gune, 430 
 
 Gurtelausschlag, 158 
 Gtirtelrose, 158 
 Gutta rosea, 702 
 
 Haarbalgmilbe, 458 
 
 Habits in relation to diseases of skin, 36 
 Hemangioendothelioma tuberosum mul- 
 tiplex, 553 
 Hsemathidrosis, 719 
 Hsematidrosis, 719 
 
 definition, 719. 
 
 diagnosis, 719 
 
 etiology, 719 
 
 pathology, 719 
 
 prognosis, 720 
 
 symptoms, 719 
 
 treatment, 720 
 Hemidrosis, 719 
 Haemorrhcea petechialis, 461 
 Hemosiderin, 34 
 Hair, 8 
 
 bulb, 8 
 
 cuticle of, 8 
 
 discoloration of, 672 
 
 follicle, 9 
 
 follicles and smooth muscles of 
 scalp, 11 
 
 and hair follicles, diseases of, 642 
 
 ringed, 671 
 Hairy nevus, 594 
 Hands, eczema of, 124, 146 
 Harlequins foetus, 496 
 Harnschweiss, 718 
 Harvest bug, 452 
 
 Hautblastomykose, 328 
 
 Hauthorn, 471 
 
 Heat, dermatitis from, 208 
 
 Hef enmykose, 328 
 
 Helodermia simplex et annularis, 572 
 
 Hematidrose, 719 
 
 Hemorrhages, 461 
 
 Hemorrhagic, 461 
 
 Hemorrhagica, purpura, 462 
 
 Henle, layer of, 9 
 
 Hennoch's purpura, 462 
 
 Heredity, 24 
 
 Herpes, 133, 154 
 
 circinatus bullosus, 170 
 desquamans, 430 
 facial, 157 
 gestationis, 170 
 simplex, 154 
 
 definition, 154 
 diagnosis,- 157 
 etiology, 156 
 facialis, 155 
 herpes facialis, 154 
 herpes progenitalis, 155 
 pathology, 156 
 prognosis, 157 
 symptoms, 154 
 treatment, 157 
 tonsurans maculosus, 112 
 vulgaire, 149 
 zoster, 158, 161, 164 
 arsenicalis, 162 
 definition, 158 
 diagnosis, 164 
 etiology, 162 
 pathology, 163 
 prognosis, 164 
 symptoms, 158 
 treatment, 164 
 Herxheimer's spirals, 3 
 Hidrocystoma, 720 
 definition, 720 
 diagnosis, 721 
 etiology, 721 
 pathology, 721 
 symptoms, 720 
 treatment, 721 
 Hirsuties, 642 
 Hives, 58 
 Hoariness, 670 
 Holzbock, 454 
 Honeycomb ringworm, 398 
 Horny layer, 15 
 Hiihnerauge, 469 
 Hunterian chancre. 268 
 Huxley, layer of, 9 
 Hyaline degeneration, 33 
 
INDEX 
 
 739 
 
 Hyaloma, 584 
 
 Hydradenitis destruens suppurativa, 708 
 
 Hydradenomes eruptifs, 553 
 
 Hydroa aestivalis, 165 
 
 bulleux, 170 
 
 herpetiformis, 170 
 
 vacciniformis, 165 
 definition, 165 
 diagnosis, 166 
 etiology, 166 
 pathology, 166 
 prognosis, 166 
 symptoms, 165 
 treatment, 166 
 Hydrocystoma, 720 
 Hyperaemise, 48 
 Hyperesthesia, 625 
 
 definition, 625 
 Hyperidrose, 711 
 Hyperidrosis, 711 
 
 definition, 711 
 
 etiology, 713 
 
 pathology, 713 
 
 prognosis, 714 
 
 symptoms, 712 
 
 treatment, 714 
 Hyperkeratose figuree centrifuge atroph- 
 
 iante, 487 
 Hyperkeratosis, 29 
 
 excentrica, 487 
 Hyperpigmentation, 33 
 Hypertrichosis, 642 
 
 definition, 642 
 
 depilatory for, 644 
 
 etiology, 643 
 
 pathology, 643 
 
 symptoms, 642 
 
 treatment, 644 
 Hypertrophia pilorum, 642 
 Hypertrophise, 469 
 Hypertrophic scar, 568 
 Hypertrophies, 469 
 Hypertrophy, 29 
 Hypodermatic injections, 42 
 Hyponomoderma, 458 
 Hypotrichosis, 655 
 
 Ichthyose, 493 
 Ichthyosis, 493, 495 
 congenita, 496 
 
 diagnosis, 497 
 etiology, 496 
 pathology, 497 
 prognosis, 498 
 treatment, 498 
 definition, 493 
 f ollicularis, 496 
 
 Ichthyosis hystrix, 496 
 
 palmaris et plantaris, 482 
 sebacea, 496 
 simplex, 494 
 symptoms, 493 
 vera, 493 
 Idiosyncrasy, 25 
 Idrosis, 711 
 Impetigo, 194 
 
 Brockhart's, 194 
 contagiosa, 191, 192 
 circinata, 193 
 definition, 191 
 diagnosis, 196 
 etiology, 195 
 pathology, 195 
 prognosis, 196 
 symptoms, 191 
 treatment, 196 
 herpetiformis, 177 
 definition, 177 
 diagnosis, 178 
 etiology, 177 
 pathology, 177 
 prognosis, 178 
 symptoms, 177 
 treatment, 178 
 Induratio tela? cellulosae, 510 
 Infancy, eczema of, 143 
 Infantile eczema of the face, 144 
 paste for, 144 
 gangrenous ecthyma, 200 
 Infectious granulomata, 236 
 
 multiple gangrene, 202 
 Infective angioma, 591 
 Inflammations, 51 
 acneform, 710 
 
 due to animal parasites, 437 
 due to vegetable parasites, 398 
 Inflammatory fungoid neoplasm, t, 2 3 
 Injections, hypodermatic, 42 
 intracutaneous, 37 
 of sera, 42 
 Inner root-sheath, 9 
 Internal remedies, 38 
 
 treatment, 39 
 Intertrigo, 50 
 Intracellular oedema, 31 
 Intracutaneous injection, 37 
 Iodides and iodine, 219 
 
 of sodium and potassium, 40 
 Iodine, 427 
 
 and the iodides, 219 
 Iron, preparations of, 39 
 Itch, 444 
 
 copra, 451 
 grain, 450 
 
740 
 
 INDEX 
 
 
 
 
 Itching, 23, 626 
 Ixodes, 454 
 
 Jigger, 453 
 Juckblattern, yy 
 
 Kahlheit, 655 
 Karbunkel, 230 
 Keloid, 566, 567, 569 
 of Alibert, 566 
 definition, 566 
 diagnosis, 570 
 etiology, 568 
 pathology, 569 
 prognosis, 570 
 symptoms, 566 
 treatment, 570 
 Keratodermia blennorrhagica, 486 
 Keratodermie blennorrhagique, 486 
 palmaire et plantaire, 482 
 symmetrique hereditaire, 482 
 Keratohyalin, 2 
 Keratolysis neonatorum, 76 
 Keratolytic agents, 47 
 Keratoma, 470 
 senile, 472 
 Keratoplastic agents, 47 
 Keratose blennorrhagique, 486 
 Keratosis, arsenical, 215 
 blennorrhagica, 486 
 definition, 486 
 diagnosis, 487 
 etiology, 487 
 pathology, 487 
 prognosis, 487 
 symptoms, 486 
 treatment, 487 
 follicularis, 477, 478, 479 
 contagiosa, 481 
 diagnosis, 482 
 etiology, 482 
 pathology, 482 
 treatment, 482 
 definition, 477 
 diagnosis, 481 
 etiology, 479 
 pathology, 479 
 prognosis, 481 
 symptoms, 477 
 treatment, 481 
 nigricans, 491 
 palma? et plantse, 482 
 definition, 482 
 diagnosis, 485 
 etiology, 485 
 pathology, 485 
 prognosis, 486 
 
 Keratosis palmse et plantae, symptoms, 
 482 
 treatment, 486 
 of the palms and soles, 483 
 pilaris, 475 
 
 definition, 474 
 diagnosis, 476 
 etiology, 475 
 pathology, 476 
 symptoms, 474 
 treatment, 476 
 senilis, 472, 473 
 definition, 472 
 diagnosis, 474 
 etiology, 473 
 pathology, 474 
 prognosis, 474 
 symptoms, 472 
 treatment, 474 
 of the soles, 484 
 suprafollicularis, 474 
 vegetans, 477 
 Kleienflechte, 540 
 Knotenerythem, 55 
 Kratze, 444 
 Kraurosis vulvas, 525 
 definition, 525 
 etiology, 525 
 pathology, 525 
 prognosis, 526 
 symptoms, 525 
 treatment, 526 
 Krause, corpuscles of, 5 
 Kupferfinne, 702 
 Kupferose, 702 
 Kyste sebace, 691 
 
 La lepre, 307 
 rose, 231 
 Lanugo, 8 
 
 Larva migrans, 458, 459 
 definition, 458 
 etiology, 459 
 pathology, 459 
 symptoms, 459 
 treatment, 460 
 Lausesucht, 437 
 Laxatives and cathartics, 39 
 Layer of Henle, 9 
 horny, 15 
 of Huxley, 9 
 Leg ulcer, chronic, 148 
 Legs, eczema of, 148 
 Leichdorn, 469 
 Leiomyoma, 577 
 Lentigo, 530 
 
 definition, 530 
 
INDEX 
 
 741 
 
 Lentigo, etiology, 530 
 pathology, 530 
 symptoms, 530 
 treatment, 531 
 Lentille, 530 
 Lepothrix, 653, 654 
 definition, 653 
 symptoms, 653 
 treatment, 655 
 Lepra, 97. 307 
 
 anaesthetica, 312 
 definition, 307 
 
 maculo-anaesthetic, 313, 315 
 nervorum, 312 
 
 symptoms, 312 
 symptoms, 308, 309 
 tuberosa, 308 
 
 symptoms, 308 
 Leprae, bacillus, 319 
 Leprosy, 307 
 
 anaesthetic, 316 
 complete, 318 
 macular, 314 
 mixed, 318 
 Leptus, 453 
 Lesions, primary, 17 
 
 character of, 36 
 secondary, 20 
 
 absence of. 36 
 presence of, 36 
 Leukaemia and pseudoleukaemia cutis, 622, 
 623 
 diagnosis, 624 
 etiology, 624 
 pathology, 624 
 treatment, 624 
 Leukasmus acquisitus, 534 
 Leukoderma. 534 
 
 congenita, 337 
 Leukopathia. 534 
 congenita, 537 
 Lichen annularis, 83, 572 
 nitidus. 90 
 
 diagnosis, 90 
 etiology, 90 
 pathology, 90 
 symptoms, 90 
 treatment, 90 
 obtusus corneus, 80 
 pilaris. 474 
 
 spinulosus, 476 
 diagnosis, 477 
 etiology, 476 
 pathology, 476 
 treatment, 477 
 planus, 81. 82, 85, 86, 88 
 definition, 81 
 
 Lichen planus, diagnosis, 88 
 discoides, 84 
 etiology, 87 
 lotion for, 89 
 papules of, 133 
 pathology, 87 
 prognosis, 89 
 symptoms, 82 
 treatment, 89 
 psoriasis, 81 
 ruber, 93 
 
 acuminatus, 93 
 planus, 81 
 scrofulosorum, 261, 262 
 definition, 261 
 diagnosis, 263 
 etiology, 262 
 pathology, 262 
 symptoms, 261 
 treatment, 263 
 scrofulosus, 261 
 
 simplex chronicus, Vidal. 91. 92 
 definition. 91 
 diagnosis, 92 
 etiology, 91 
 pathology, 91 
 prognosis, 92 
 symptoms, 91 
 treatment, 92 
 tropicus, 721 
 variegatus, no 
 Lichenification, 91 
 Lids, eczema of, 145 
 
 the margin of, 146 
 Linsenflecke, 530 
 Linsenmal, 593 
 
 Liodermia essentialiscum melanosi et 
 telangiectasia, 612 
 neuritica, 529 
 Lipoma. 575, 576 
 definition, 575 
 diagnosis, 577 
 etiology, 576 
 pathology, 576 
 prognosis, 577 
 symptoms, 575 
 treatment, 577 
 Liver, disease of. in relation to diseases 
 of the skin, 26 
 spots, 531 
 Local asphyxia, 204 
 Lombardy leprosy, 367 
 Loose skin, 518 
 Lotion, Kummerfeld's, 699 
 Lotions, hair, 660, 661 
 
 or washes, 44 
 Loupe, 691 
 
742 
 
 INDEX 
 
 
 
 Lousiness, 437 
 Lucidum, stratum, 2 
 
 Lumpy jaw, 335 
 Lunula, 13 
 
 Lupoid sycosis, 668, 678 
 Lupus erythemateux, 357 
 
 dissemine, 254 
 erythematodes, 357 
 erythematosus, 357, 358, 359, 364 
 
 definition, 357 
 
 diagnosis, 363 
 
 etiology, 361 
 
 pathology, 362 
 
 prognosis, 364 
 
 scalp, 360 
 
 symptoms, 358 
 
 treatment, 365 
 exedens, 236 
 hypertrophicus, 240 
 lymphaticus, 559 
 sclerosus, 249 
 tuberculeux, 236 
 verrucosus, 249 
 vorax, 236 
 vulgaire, 236 
 vulgaris, 236, 237, 238, 239, 240, 242 
 
 complications, 241 
 
 Cosme's paste, form of, for, 247 
 
 definition, 236 
 
 diagnosis, 244 
 
 etiology, 241 
 
 local treatment, 246 
 
 pathology, 243 
 
 pyrogallol ointment for, 247 
 
 sequelae, 241 
 
 symptoms, 237 
 
 treatment, 245 
 Lymphadenie cutanee, 323 
 Lymphangiectasis, 489 
 Lymphangiectodes, 559 
 Lymphangioma, 559, 560 
 
 capillaire varicosum, 559 
 cavernosum, 559 
 circumscriptum, 559, 561 
 
 definition, 559 
 
 diagnosis, 561 
 
 etiology, 560 
 
 pathology, 561 
 
 prognosis, 562 
 
 symptoms, 559 
 
 treatment, 562 
 definition, 559 
 superficiale simplex, 559 
 tuberosum multiplex, 553 
 Lymphatic circulation, 5 
 Lymphomatose cutanee generalised, 323 
 
 Macular leprosy, 314 
 Macules, 17 
 
 Maculo-anaesthetic, lepra, 313, 315 
 Madura foot, 342 
 Madurafuss, 342 
 Mai de la rosa, 367 
 
 del pinto, 435 
 
 del sole, 367 
 
 des pieds et des mains, 571 
 
 perforant du pied, 527 
 Malignant papillary dermatitis, 607 
 Malum perforans pedis, 527 
 Masern, 388 
 Mast cells, 32 
 Matrix, 13 
 Mattress itch, 450 
 Measles, 388 
 
 definition, 388 
 
 diagnosis, 391 
 
 etiology, 390 
 
 pathology, 390 
 
 prognosis, 391 
 
 symptoms, 388 
 
 treatment, 391 
 Medulla of hair, 8 
 Meibomian glands, 11 
 Meissner and Wagner, corpuscles of, 5 
 Melanin, 4, 34 
 
 origin of, 7, 33 
 Melanoblasts of Ehrmann, 34 
 Melanoderma, 531 
 
 Melanosis lenticularis progressiva, 612 
 Melanotic sarcoma, 617 
 Melasma, 531 
 Membrana propria, 10 
 Meralgia paraesthetica, 633 
 
 definition, 633 
 Mercury, 40 
 
 ammoniated, 427 
 
 and its salts, 219 
 Microsporon dispar, 114 
 
 furfur, 542 
 Migrans, larva, 458, 459 
 Miliaire, 721 
 
 cristalline, 723 
 Miliaria, 721 
 
 alba, 721 
 
 crystallina, 723 
 definition, 723 
 diagnosis, 723 
 etiology, 723 
 pathology, 723 
 prognosis, 723 
 symptoms, 723 
 treatment, 723 
 
 definition, 721 
 
 etiology, 722 
 
INDEX 
 
 743 
 
 Miliaria, pathology, 722 
 
 prognosis, 722 
 
 rubra, 721 
 
 symptoms, 721 
 
 treatment, 722 
 Miliary fever, 724 
 
 definition, 724 
 symptoms, 724 
 
 papular syphiloderm, 276 
 
 pustular syphiloderm, 278, 279, 280, 
 281 
 Miliary tuberculosis of the skin, 256 
 Milium, 689 
 
 colloid, 585 
 
 definition, 690 
 
 diagnosis, C91 
 
 etiology, 690 
 
 pathology, 690 
 
 prognosis, 691 
 
 symptoms, 690 
 
 treatment, 691 
 Milzbrand, 338 
 Mistura ferri acida, 698 
 Mitesser, 686 
 Mixed leprosy, 318 
 
 diagnosis, 320 
 etiology, 318 
 pathology, 319 
 prognosis, 321 
 treatment, 322 
 Moist papules, 286 
 
 wart, 503 
 Mole, 593 
 
 Moll, glands of, 12 
 Molluscum bodies, 550 
 
 cholesterique, 580 
 
 contagiosum, 544 
 
 epitheliale, 544 
 
 fibrosum, 563 
 
 pendulum, 563 
 
 sebaceum, 544 
 
 simplex, 563 
 Monilethrix, 648, 649, 650 
 
 definition, 648 
 
 diagnosis, 651 
 
 etiology, 650 
 
 pathology, 650 
 
 prognosis, 651 
 
 symptoms, 649 
 
 treatment, 651 
 Morbi appendicium, 634 
 Morbilli, 388 
 Morbus pedicularis, 437 
 Morphine, opium and, 219 
 Morphcea-like epithelioma, 600, 601 
 Morve, 340 
 Multiforme, erythema, 51, 52, 53 
 
 Multiple benign sarcoid (Boeck), 264, 
 266 
 definition, 264 
 diagnosis, 267 
 epithelioma of the scalp, 556 
 etiology, 265 
 pathology, 265 
 prognosis, 267 
 symptoms, 264 
 treatment, 267 
 cachectic gangrene of the skin, 200 
 gangrene, infectious, 202 
 
 of the skin, 203 
 pigmented hemorrhagic sarcoma, 
 
 620 
 tumors of the skin, 80 
 ulcerating syphilitic gummata, 294 
 Muscles, 6 
 striped, 6 
 unstriped, 7 
 Mycetoma, 342 
 
 definition, 342 
 diagnosis, 344 
 etiology, 343 
 pathology, 343 
 prognosis, 344 
 symptoms, 343 
 treatment, 344 
 Mycetome, '342 
 Mycosis fungoides, 323 
 Myom, 577 
 Myoma, 577 
 
 levicellulare, 577 
 Myome, 577 
 Myxcedem, 512 
 Myxcedema, 512 
 definition, 512 
 diagnosis, 513 
 etiology, 513 
 pathology, 513 
 prognosis, 513 
 symptoms, 512 
 treatment, 514 
 Myxoedeme, 512 
 Myxomatous degeneration, 33 
 
 Naevi vasculaires et papillaires, 557 
 Naevocarcinoma, 602 
 Naevus cystepitheliomatosus, 553 
 flat, smooth pigmented, 596 
 hairy, 594 
 lupus, 591 
 pigmentaire, 593 
 pigmentosus, 593 
 definition, 593 
 diagnosis, 597 
 etiology, 595 
 
744 
 
 INDEX 
 
 
 Nsevus pigmentosus, pathology, 595 
 prognosis, 597 
 symptoms, 593 
 treatment, 597 
 
 sanguineus, 587 
 
 unius lateris, 595, 597 
 
 vasculaire, 587 
 
 vascularis, 587, 588 
 definition, 587 
 diagnosis, 589 
 etiology, 588 
 pathology, 588 
 prognosis, 589 
 treatment, 589 
 
 vasculosus, 587 
 Nail bed, 13 
 
 fold, 13 
 
 ringworm of, 640 
 
 substance, 14 
 Nails, 13 
 
 diseases of, 634 
 
 eczema of, 125 
 
 ringworm of, 641 
 
 syphilis of, 638 
 Narbe, 570 
 
 Nasi, granulosis rubra, 724 
 Nassende Flechte, 116 
 Neonatorum, oedema, 511 
 
 sclerema, 510 
 Neoplasie circinee et nodulaire, 572 
 Neoplasmata, 544 
 Nerve tumor, 578 
 Nerves, 5 
 
 Nervorum, lepra, 312 
 Nessel-ausschlag, 58 
 Nesselsucht, 58 
 Nettlerash, 58 
 Neuralgia of the skin, 631 
 Neurofibroma, 563 
 Neurom, 578 
 Neuroma, 578 
 
 definition, 578 
 
 diagnosis, 579 
 
 etiology, 579 
 
 pathology, 579 
 
 treatment, 579 
 Neuroses, 625 
 
 Nevrodermite circonscrite, 91 
 Nevrome, 578 
 New growths, 544 
 Nitrate, silver, 219 
 Nodosite des poils, 648 
 Nodular syphiloderm, 288, 290, 291 
 
 diagnosis, 290 
 Nodules, 20 
 Non-hairy parts, ringworm of, 429 
 
 Objective alterations, 17 
 
 symptoms, 17 
 Occupation in relation to diseases of 
 
 skin, 25, 30 
 (Edema angioneuroticum, 65 
 definition, 65 
 diagnosis, 66 
 etiology, 66 
 pathology, 66 
 prognosis., 66 
 symptoms, 65 
 treatment, 66 
 intracellular, 31 
 neonatorum, 511 
 definition, 511 
 diagnosis, 512 
 etiology, 511 
 pathology, 512 
 prognosis, 512 
 symptoms, 511 
 treatment, 512 
 of the newborn, 511 
 (Edeme des nouveaunes, 511 
 CEil de perdrix, 469 
 CEstrus, 455 
 
 treatment, 455 
 Oil, cod liver, 40 
 
 Ointment for eczema of the lids, 145 
 hair, 661, 662 
 
 or lotion, application of, 43 
 sulphur, 669 
 Ointments or salves, 44 
 
 soothing and protective, 45 
 Oligotrichosis, 655 
 Onychatrophia, 635 
 Onychauxis, 634 
 definition, 634 
 etiology, 635 
 symptoms, 634 
 treatment, 635 
 Onychia, 637 
 
 definition, 637 
 etiology, 638 
 symptoms, 637 
 treatment, 639 
 Onychitis, 637 
 Onychogryphosis, 635 
 Onychomycosis, 639, 640 
 definition, 639 
 diagnosis, 641 
 prognosis, 641 
 symptoms, 639 
 treatment, 641 
 Opium and morphine, 219 
 Oriental boil, 344 
 sore, 344, 345 
 
 definition, 344 
 
INDEX 
 
 745 
 
 Oriental sore, diagnosis, 346 
 
 etiology, 345 
 
 pathology, 346 
 
 symptoms, 344 
 
 treatment, 346 
 Orientbeule, 344 
 Origin of melanin, 7, 33 
 Oroya fever, 350 
 Osmidrosis, 717 
 Osteoma cutis, 579 
 Osteosis cutis, 579 
 Ovum pediculus capitus, 439 
 
 Pachydermatocele, 518 
 Pachydermia, 514 
 Pacinian corpuscles, 4 
 Paget's disease, 607, 608 
 of the breast, 611 
 of the buttocks, 610 
 definition, 607 
 diagnosis, 612 
 etiology, 610 
 pathology, 610 
 prognosis, 612 
 symptoms, 608 
 treatment, 612 
 Pain, 23 
 
 Palm, scaly eczema of, 146 
 Palmse et plantse, keratosis, 482 
 Palms and soles, keratosis of, 483 
 Panniculus adiposus, 4 
 Papilla of hair, 10 
 Papillae, 5 
 
 Papular eczema, 120 
 syphiloderm, 272 
 diagnosis, 277 
 Papules, 18 
 
 of lichen planus, 133 
 moist, 286 
 Papulo-necrotic tuberculide, 254 
 definition, 254 
 diagnosis, 255 
 etiology, 255 
 pathology, 255 
 prognosis, 256 
 symptoms, 254 
 treatment, 256 
 Papulo-pustular syphiloderm, 284 
 Paraffin acne, 706 
 Paraffinoma, 575 
 definition, 575 
 diagnosis, 575 
 pathology, 575 
 symptoms, 575 
 treatment, 575 
 Parakeratosis, 30 
 variegata, no 
 
 Paranghi, 347 
 Parapsoriasis, no 
 
 definition, no 
 
 diagnosis, 112 
 
 etiology, 11 1 
 
 pathology, 11 1 
 
 prognosis, 112 
 
 symptoms, in 
 
 treatment, 112 
 Parasitic diseases, 135 
 Parasiticides and antiseptics, 47 
 Pars papillaris, 4 
 
 reticularis, 4, 34 
 Paste, Lassar's, 45 
 
 for infantile eczema of the face, 144 
 Pastes, 45, 46 
 Pathology, general, 29 
 Patient's clothing in relation to diseases 
 of skin, 39 
 
 occupation in relation to diseases of 
 skin, 39 
 Pediculosis, 437 
 
 capitis, 437 
 
 corporis, 439, 440 
 diagnosis, 441 
 eruption of, 135 
 etiology, 441 
 treatment, 441 
 
 definition, 437 
 
 diagnosis, 439 
 
 etiology, 437 
 
 pubis, 442 
 
 diagnosis, 442 
 etiology, 442 
 treatment, 442 
 
 treatment, 439 
 Pediculus capitis, 437 
 
 corporis, 439 
 
 pubis, 442 
 Peitschenwurm, 456 
 Pelade, 662 
 Pellagra, 367, 368 
 
 definition, 367 
 
 diagnosis, 371 
 
 etiology, 369 
 
 pathology, 369 
 
 prognosis, 371 
 
 symptoms, 367 
 
 treatment, 371 
 Pellagre, 367 
 
 Pellagrous dermatitis, 370 
 Pemphigus, 178 
 
 acute, 179 
 
 bleb of, 186 
 
 chronic, 180, 181 
 
 circinatus, 170 
 
 definition, 178 
 
746 
 
 INDEX 
 
 
 Pemphigus foliaceus, 182 
 gangrsenosus, 200 
 vegetans, 183, 184 
 bleb of, 187 
 diagnosis, 185 
 pathology, 185 
 prognosis, 189 
 treatment, 188 
 vulgaris, 182 
 Pendje sore, 344 
 
 Penetration of skin by ointments, 45 
 Perforating ulcer of the foot, 527 
 definition, 527 
 diagnosis, 528 
 etiology, 528 
 pathology, 528 
 prognosis, 528 
 symptoms, 527 
 treatment, 528 
 Perforirendes Fussgeschwiir, 527 
 Pernio, 49 
 
 Persistent papular dermatosis, 80 
 Peruvian wart, 350 
 Petite verole, 273 
 Phenacetin, 41, 219 
 Phenol, 41 
 Phosphoridroses, 718 
 
 definition, 718 
 Photidrose, 718 
 Phthiriase, 437 
 Phthiriasis, 437 
 Physiology of skin, 14 
 
 and anatomy of the skin, 1 
 Pian, 347 
 
 Pied de madure, 342 
 Piedra, 652 
 
 definition, 652 
 diagnosis, 653 
 etiology, 652 
 nostras, 652 
 pathology, 652 
 symptoms, 652 
 treatment, 653 
 Pigment, 7, 14, 34 
 brown, 4 
 granules, 34 
 Pigmentary mole, 593 
 syphilide, 285 
 
 diagnosis, 285 
 Pigmentation, 1, 33, 34 
 anomalies of, 530 
 arsenical, 33, 2l 7 
 Pigmentationis anomalise, 530 
 Pilaris, keratosis, 474, 475 
 
 pityriasis rubra, 93, 94, 96 
 Pinta, 435 
 
 definition, 435 
 
 Pinta, diagnosis, 436 
 etiology, 436 
 pathology, 436 
 symptoms, 435 
 treatment, 436 
 Pityriasis maculata et circinata, 112 
 nigricans, 715 
 pilaris, 93, 474 
 rose, 112 
 
 rosea, 112, 114, 153 
 definition, 112 
 diagnosis, 115 
 etiology, 113 
 pathology, 115 
 pilaris, 93, 94, 96 
 definition, 93 
 diagnosis, 95 
 etiology, 94 
 ointment for, 97 
 pathology, 95 
 prognosis, 95 
 symptoms, 93 
 treatment, 95 
 prognosis, 116 
 treatment, 116 
 symptoms, 112 
 rubra, 66 
 simplex, 682 
 steatodes, 682 
 versicolor, 540 
 versicolore, 540 
 Plaques jaunatres des paupieres, 580 
 Plasma cell, 32 
 Plasters, 46 
 Plica, 651 
 
 definition, 651 
 etiology, 652 
 polonica, 651 
 symptoms, 651 
 treatment, 652 
 Plique polonaise, 651 
 Pocken, 373 
 Podelcoma, 342 
 Poils accidentels, 642 
 Poliosis, 670 
 Poliothrix, 670 
 Polyidrosis, 711 
 Polytrichia, 642 
 Pompholyx, 167, 168 
 definition, 167 
 diagnosis, 169 
 etiology, 168 
 pathology, 168 
 prognosis, 169 
 symptoms, 167 
 treatment, 169 
 
INDEX 
 
 747 
 
 Porrigo decalvans, 662 
 Postmortem wart, 249 
 Potassium and sodium, bromides of, 218 
 
 iodides of, 40 
 Pou de bois, 454 
 Powders, dusting, 44, 140 
 Prickle-cells, 3 
 Prickly heat, 721 
 Primary lesions, 17 
 
 character of, 36 
 Prokeratosis, 487 
 definition, 487 
 diagnosis, 489 
 etiology, 488 
 pathology, 488 
 prognosis, 489 
 symptoms, 487 
 treatment, 489 
 Protectives, 47 
 Prurigo, 77, 133 
 definition, 77 
 diagnosis, 79 
 etiology, 78 
 nodularis, 80, 81 
 definition, 80 
 diagnosis, 80 
 etiology, 80 
 pathology, 80 
 prognosis, 81 
 symptoms, 80 
 treatment, 81 
 pathology, 79 
 prognosis, 79 
 symptoms, 77 
 treatment, 79 
 Prurit circonscrit avec Hchenification, 91 
 Pruritus, 626 
 ani, 627 
 definition, 626 
 diagnosis, 628 
 etiology, 627 
 pathology, 627 
 localis, 627 
 lotion for, 630 
 oil for, 630 
 ointment for, 630 
 prognosis, 628 
 symptoms, 626 
 treatment, 628 
 universalis, 626 
 vulvae, 627 
 Pseudobotryomycose, 234 
 Pseudoleukemia cutis, 622 
 Pseudoxanthoma elasticum, 584 
 diagnosis, 584 
 pathology, 584 
 
 Pseudoxanthoma elasticum, treatment, 
 
 S84 
 Psoriasiform and lichenoid exanthem, 
 
 no 
 Psoriasis, 97, 100 
 anthrasol in, 109 
 chrysarobin paste in, 108 
 definition, 97 
 diagnosis, 103 
 etiology, 99 
 pathology, 101 
 prognosis, 105 
 pyrogallol in, no 
 symptoms, 97 
 tar in, 109 
 treatment, 105 
 X-ray for, no 
 Psorospermose folliculaire vegetante, 
 
 477 
 Pubis, pediculosis, 441 
 
 pediculus, 442 
 Puce commune, 443 
 
 de sable, 453 
 Pulex irritans, 443 
 penetrans, 453 
 treatment, 453 
 Purpura, 461 
 
 annularis telangiectodes, 465 
 diagnosis, 466 
 etiology, 466 
 pathology, 466 
 'prognosis, 466 
 symptoms, 465 
 treatment, 466 
 definition, 461 
 diagnosis, 464 
 etiology, 463 
 hemorrhagica, 462 
 Hennock's, 462 
 pathology, 463 
 prognosis, 464 
 rheumatica, 462 
 scorbutica, 466 
 simplex, 461 
 symptoms, 461 
 treatment, 465 
 Pustula maligna, 338 
 Pustular eczema, 121, 133, 134 
 syphiloderm, 278, 279, 283 
 Pustules, 19, 31 
 
 Qualitative alterations of pigment, 33 
 Quantitative alterations of pigment, 33 
 Quincke's disease, 65 
 Quinine, 40 
 Quirica, 435 
 
748 
 
 INDEX 
 
 
 Race, 24, 35 
 Radiant energy, 47 
 Radio-dermatitis, 224 
 pathology, 225 
 prognosis, 225 
 symptoms, 224 
 treatment, 225 
 Raynaud's disease, 204 
 Raynaud'sche krankheit, 204 
 Recklinghausen's disease, 563 
 Recurrent scarlatiniform erythema, 73 
 Recurring summer eruption, 165 
 Red gum, 721 
 Remedies, internal, 38 
 Repens, dermatitis, 197, 198 
 Resistant maculo-papular scaly erythro- 
 
 dermias, no 
 Rete mucosum, 3, 30 
 
 cells of, 3 
 Rheumatica, purpura, 462 
 Rheumatism and gout, 27 
 
 of the skin, 631 
 Rhinopharyngitis mutilans, 352 
 Rhinoscleroma, 355, 356 
 definition, 355 
 diagnosis, 357 
 etiology, 356 
 pathology, 356 
 prognosis, 357 
 symptoms, 355 
 treatment, 357 
 Rhynochoprion penetrans, 453 
 Ringed eruption, 572 
 
 hair, 671 
 Ringworm, 135, 153, 406, 412, 413 
 of the axilla, 416 
 of the beard, 410, 429 
 of the body, 412, 414 
 of the nails, 640, 641 
 of non-hairy parts, 429 
 of the scalp, 406, 407, 408, 418, 419 
 Ritter's disease, 76 
 Rodent ulcer, 598 
 Rontgen ray dermatitis, 224 
 Root-sheath, external, 9 
 
 inner, 9 
 Rosacea, 702 
 acne, 702 
 Rose, 231 
 
 Rosea, pityriasis, 112, 114, 153 
 Rotheln, 391 
 Rothlauf, 231 
 Rotz, 340 
 Rougeole, 388 
 fausse, 391 
 Rouget, 452 
 Rubella, 391 
 
 Rubella, definition, 391 
 
 diagnosis, 393 
 
 etiology, 392 
 
 pathology, 392 
 
 prognosis, 393 
 
 symptoms, 392 
 
 treatment, 393 
 Rubeola, 388, 391 
 
 Saccharine diabetes, carbuncles in, 26 
 
 furuncles in, 26 
 Saccharomycosis hominis, 328 
 Salicylate of soda, 219 
 Salicylic acid, 219 
 Salol, 219 
 Salt rheum, 116 
 Salts, mercury and its, 219 
 Salvarsan, 219 
 Salves or ointments, 44 
 Salzfluss, 116 
 Sand-flea, 453 
 Sandfloh, 453 
 Sarcoid, 264 
 
 multiple benign (Boeck), 264, 266 
 Sarcoma capitis, 556 
 
 cutis, 616 
 
 definition, 616 
 symptoms, 616 
 
 idiopathic multiple hemorrhagic 
 (Kaposi), 618, 619 
 
 melanotic, 617 
 
 multiple pigmented hemorrhagic, 620 
 
 non-pigmented, 616 
 
 of the skin, 616 
 Sarcomatosis cutis, 323 
 Sarcome cutane, 616 
 Savill's disease, 71 
 Scabiei, acarus, 446 
 Scabies, 444, 445 
 
 burrow of, 447 
 
 definition, 444 
 
 diagnosis, 448 
 
 etiology, 447 
 
 pathology, 447 
 
 prognosis, 450 
 
 symptoms, 444 
 
 treatment, 449 
 Scales, 20 
 Scalp, eczema of, 144 
 
 favus of, 399 
 
 lupus erythematosus of, 360 
 
 ringworm of, 406, 407, 408, 418, 419 
 
 smooth muscles and hair follicles of, 
 n 
 
 subacute eczema of, 144 
 Scaly eczema, 121, 134 
 
 of the palm, application for, 146 
 
INDEX 
 
 749 
 
 Scar, 570 
 
 hypertrophic, 568 
 Scarlatina, 382 
 
 definition, 382 
 
 diagnosis, 386 
 
 etiology, 385 
 
 pathology, 385 
 
 prognosis, 387 
 
 symptoms, 382 
 
 treatment, 388 
 Scarlatine, 382 
 Scarlet fever, 382 
 Scars, 22 ' 
 Scharlach, 382 
 Scharlachfieber, 382 
 Schmeerflus, 681 
 Schuppenflechte, 97 
 Schweissfluss, 711 
 Schweissfriesel, 724 
 Schwiele, 470 
 Scissura pilorum, 645 
 Sclerem der Neugeborenen, 510 
 Sclerema, 505 
 
 neonatorum, 510 
 definition, 510 
 diagnosis, 511 
 etiology, 510 
 pathology, 510 
 prognosis, 511 
 symptoms, 510 
 treatment, 511 
 Sclereme des adultes, 505 
 Scleriasis, 505 
 Scleroderma, 505 
 
 circumscribed, 506, 507 
 
 definition, 505 
 
 diffuse, 505 
 
 synonyms, 505 
 Sclerodermic, 505 
 Scleroma adultorum, 505 
 Scorbutus, 466 
 
 definition, 466 
 
 diagnosis, 467 
 
 etiology, 467 
 
 pathology, 467 
 
 prognosis, 468 
 
 symptoms, 466 
 
 treatment, 468 
 Scrofuloderma, 259 
 
 diagnosis, 260 
 
 etiology, 260 
 
 pathology, 260 
 
 symptoms, 259 
 
 treatment, 261 
 Scrofulosorum, lichen, 261, 262 
 Scrotum, eczema of, 147 
 Scurvy, 466 
 
 Season, 24 
 Sebaceous cyst, 691 
 
 glands, 10, 14 
 
 diseases of, 680 
 Sebaceum, adenoma, 557, 558 
 Seborrhee, 681 
 Seborrhoea, 681 
 
 congestiva, 357 
 
 corporis, 149 
 
 definition, 681 
 
 diagnosis, 683 
 
 etiology, 683 
 
 lotion for, 685 
 
 nigricans, 715 
 
 ointment, 685 
 
 oleosa, 681 
 
 pathology, 683 
 
 prognosis, 684 
 
 sicca, 149, 682 
 
 symptoms, 681 
 
 treatment, 684 
 Seborrhceic dermatitis, 149, 152 
 axilla, 151 
 sternum, 150 
 Sebum, 10, 14 
 Secondary lesions, 20 
 absence of, 36 
 presence of, 36 
 Sedatives and antipruritics, 47 
 Senile atrophy, 30 
 
 of the skin, 522 
 
 wart, 500 
 Senilis, alopecia, 656 
 
 atrophia cutis, 522 
 
 keratosis, 472, 473 
 
 verruca, 501 
 Serum, foreign, 42 
 
 injections of, 42 
 Sex in relation to diseases of skin, 25, 35 
 Shingles, 158, 160 
 Silver nitrate, 219 
 Skin, colloid degeneration of, 584 
 
 diphtheria of, 206 
 
 glossy, 529 
 
 multiple gangrene of, 203 
 Sklerodermie, 505 
 Sleeping sickness, 372 
 Small glands, 12 
 
 Small pustular scrofuloderm, 254 
 Smallpox, 373, 374 
 
 definition, 373 
 
 hemorrhagic, 376 
 
 symptoms, 373 
 Smooth muscles and hair follicles of the 
 
 scalp, 11 
 Soaps, 46 
 Soda, salicylate of, 219 
 
750 
 
 INDEX 
 
 
 Sodium, 218 
 
 benzoate, benzoic acid and, 218 
 
 biborate, boric acid and, 218 
 
 and potassium, iodides of, 40 
 Soft fibroma, 563 
 Soles, keratosis of, 484 
 Solution, Williams, 428 
 Sommersprosse, 530 
 Sore, oriental, 344, 345 
 Spargosis, 514 
 Spedalskhed, 307 
 Sphaceloderma, 200 
 Spindelhaare, 648 
 
 Spiral portion of sweat-duct in epider- 
 mis, 13 
 Spirals, Herxheimer's, 3 
 Spitzblattern, 393 
 Spitzencondylom, 503 
 Spitzenwartze, 503 
 Splenic fever, 338 
 Sporotrichosis, 333 
 
 definition, 333 
 
 diagnosis, 334 
 
 etiology, 334 
 
 pathology, 334 
 
 symptoms, 333 
 
 treatment, 335 
 Spotted sickness, 435 
 Squamous eczema, 134 
 
 palmar and plantar syphiloderm, 290 
 diagnosis, 293 
 
 syphiloderm, 292 
 St. Anthony's fire, 231 
 Stearrhcea, 681 
 
 nigricans, 715 
 Steatoma, 691 
 
 definition, 691 
 
 diagnosis, 692 
 
 etiology, 692 
 
 pathology, 692 
 
 prognosis, 693 
 
 symptoms, 691 
 
 treatment, 693 
 Steatome, 691 
 Steatorrhea, 681 
 Steatozoon folliculorum, 458 
 Stereo-phlogose nodulaire et circinee, 
 
 572 
 Stinking sweat, 717 
 Stinkschweiss, 717 
 Stratum corneum, 1 
 
 germinativum, 3 
 
 granulosum, 2 
 
 lucidum, 2 
 
 subcutaneum, 4 
 Straw dermatitis, 450 
 
 itch, 450 
 
 Striae et maculae atrophica^, 523 
 definition, 523 
 diagnosis, 525 
 etiology, 524 
 pathology, 524 
 symptoms, 524 
 Striped muscles, 6 
 Strophulus, 721 
 albidus, 689 
 prurigineux, 77 
 Subacute eczema, 143 
 
 remedies for, 143 
 of the scalp, 144 
 Subjective symptoms, 17, 23 
 Sudamina, 722, 
 Sudatoria, 711 
 Sudor Anglicus, 724 
 sanguineus, 719 
 urinosus, 718 
 Sudoriparous glands, 11, 14 
 Suette de Picardie, 724 
 
 miliaire, 724 
 Sueurs sanglantes, 719 
 Sulphonal, 220 
 Sulphur, 41, 427 
 Superfluous hair, 642 
 Sweat, 14 
 
 -duct in epidermis, spiral portion of, 
 
 13 
 -glands, 4, 11, 12 
 diseases of, 717 
 Sweating sickness, 724 
 Sycosiform syphiloderm, 275 
 Sycosis, lupoid, 678 
 non-parasitaire, 676 
 vulgaris, 676, 677 
 definition, 676 
 diagnosis, 679 
 etiology, 677 
 pathology, 678 
 symptoms, 676 
 treatment, 679 
 Symptomatic erythemata, 48 
 Symptomatica, alopecia prematura, 657 
 Symptoms, objective, 17 
 
 subjective, 17, 23 
 Syphilide, pigmentary, 285 
 Syphilis, 267 
 
 congenital, 295 
 cutanea congenita, 295 
 definition, 267 
 diagnosis, 269 
 initial lesion of, 268 
 of the nails, 638 
 Syphilitic gummata, multiple ulcerating, 
 294 
 
INDEX 
 
 751 
 
 Syphilitic papule, vegetating, 299 
 Syphiloderm, annulo-papular, 274 
 
 bullous, 286 
 
 circinate papular, 273 
 squamous, 291 
 
 erythematous, 270, 271 
 
 follicular, 276 
 
 gummatous, 293 
 
 large papulo-pustular, 284 
 
 miliary papular and pustular, 276 
 pustular, 280, 281 
 
 nodular, 288, 289, 290, 291 
 ulcerating, 289 
 
 papular, 272 
 
 pustular, 278, 279, 283 
 
 squamous, 292 
 
 palmar and plantar, 290 
 
 sycosiform, 275 
 
 varioliform, 282 
 
 vesicular, 277 
 Syphilodermata, 269 
 
 late or tertiary, 28S 
 Syringocystadenoma, 553 
 Syringocystoma, 553, 554, 555 
 
 diagnosis, 555 
 
 etiology, 554 
 
 pathology, 554 
 
 symptoms, 554 
 
 treatment, 556 
 
 Tache de feu, 587 
 
 de rousseur, 530 
 Tactile corpuscles, 6 
 Tartar emetic, 216 
 Tatouage, 539 
 Tatowierung, 539 
 Tattooing, 539 
 Teigne faveuse, 398 
 
 Telangiectasia follicularis annulata, 465 
 Telangiectasis, 590 
 definition, 590 
 etiology, 591 
 symptoms, 590 
 treatment, 591 
 Telangiectodes, purpura annularis. 465 
 Tetter, 116 
 
 Thallium acetate, 220 
 Therapeutics, general, 38 
 Tinea cruris, 415, 423 
 favosa, 398 
 
 imbricata, 430, 432, 433 
 definition, 430 
 diagnosis, 433 
 etiology, 431 
 prognosis, 433 
 symptoms, 431 
 treatment, 433 
 
 Tinea nodosa, 652 
 
 trichophytina, 406 
 versicolor, 540 
 definition, 540 
 diagnosis, 542 
 etiology, 541 
 pathology, 541 
 symptoms, 540 
 treatment, 543 
 Tokelau ringworm, 430 
 Touch-cells, 6 
 
 Traumatica, dermatitis, 207 
 Treatment, external, 42 
 internal, 39 
 vaccine, 42 
 Trichauxis, 642 
 Trichoclasia, 646 
 
 Tricho-epithelioma, 550, 552, 553 
 diagnosis, 552 
 etiology, 551 
 
 papulosum multiplex, 551 
 pathology, 552 
 symptoms, 551 
 treatment, 553 
 Trichomycose nodulaire, 652 
 Trichomycosis discolor, 670 
 nodosa, 653 
 palmellina, 653 
 Trichophytie, 406 
 Trichophytosis, 406, 423 
 barbae, 410 
 
 diagnosis, 411 
 symptoms, 410 
 capitis, 406 
 
 diagnosis, 409 
 symptoms, 406 
 corporis, 412 
 etiology, 416 
 
 pathological anatomy, 422 
 solution for, 428 
 symptoms, 412 
 treatment, 424 
 deep, 424 
 definition, 406 
 profunda, 417, 425 
 unguium, 640 
 Trichoptilose, 646 
 Trichoptilosis, 645 
 Trichorrhexis nodosa, 646, 647 
 definition, 646 
 etiology, 647 
 lotion for, 648 
 pathology, 647 
 prognosis, 648 
 symptoms, 647 
 treatment, 648 
 Trichosporie, 652 
 
752 
 
 INDEX 
 
 
 Trypanosomiasis cutis, 372 
 definition, 372 
 symptoms, 372 
 treatment, 372 
 Tuberculide, 254 
 
 papulo-necrotic, 254 
 Tuberculides, 253 
 Tuberculin, 220 
 
 employment of, 37 
 Tuberculosa gummosa, 259 
 Tuberculosis colliquativa cutanea, 259 
 cutis orificialis, 256 
 fungosa, 153 
 miliaris cutis, 256 
 
 diagnosis, 257 
 symptoms, 256 
 treatment, 257 
 propria cutis, 256 
 verruca necrogenica, 251 
 etiology, 251 
 pathology, 251 
 treatment, 252 
 verrucosa cutis, 249, 250, 252 
 diagnosis, 252 
 symptoms, 249 
 Tuberculum sebaceum, 689 
 Tumor formation with ulceration, 325 
 Tumors, 20 
 Tunica dartos, 7 
 Turban tumors, 556 
 Tyloma, 470 
 Tylosis, 470 
 
 palmar et plantse, 482 
 Tysonian glands, 11 
 
 Ulcerating granuloma of the pudenda, 
 354 
 
 nodular syphiloderm, 289 
 Ulceration, tumor formation with, 325 
 Ulcers, 22 
 Ulerythema centrifugum, 357 
 
 sycosiforme, 668 
 Uncinarial dermatitis, 455 
 Unguium, atrophia, 635 
 
 eczema, 125 
 
 trichophytosis, 640 
 Unstriped muscles, 7 
 Uridrose, 718 
 Uridrosis, 718 
 
 definition, 718 
 
 symptoms, 718 
 Urinidrosis, 718 
 Urticaire, 58 
 Urticaria, 58, 133 
 
 definition, 58 
 
 dermographism in, 59 
 
 diagnosis, 61 
 
 Urticaria, etiology, 60 
 pathology, 61 
 perstans, 80 
 pigmentosa, 63, 64 
 
 definition, 63 
 
 diagnosis, 65 
 
 etiology, 63 
 
 pathology, 63 
 
 prognosis, 65 
 
 symptoms, 63 
 
 treatment, 65 
 prognosis, 61 
 symptoms, 58 
 treatment, 61 
 
 Vaccinal eruptions, 381 
 Vaccine treatment, 42 
 Vaccines, autogenous, 42 
 Vaccinia, generalisata, 381 
 
 generalized, 381 
 Vaiuolo, 373 
 Varicella, 393, 395 
 
 definition, 393 
 
 diagnosis, 396 
 
 etiology, 396 
 
 gangrenosa, 200 
 
 pathology, 396 
 
 prognosis, 397 
 
 symptoms, 393 
 
 treatment, 397 
 Varicelle, 393 
 Varicellen, 393 
 Variola, 373 
 Variole, 373 
 
 Varioliform syphiloderm, 282 
 Varioloid, 377 
 
 diagnosis, 379 
 
 etiology, 378 
 
 pathology, 378 
 
 prognosis, 380 
 
 treatment, 380 
 Varnishes, 46 
 
 Vascularis, nsevus, 587, 588 
 Vater, corpuscles of, 5 
 Vegetable parasites, inflammations due 
 
 to, 398 
 Vegetating syphilitic papule, 299 
 Vegetations vasculaires, 557 
 Venereal wart, 503 
 Ver de Guinee, 456 
 Verolette, 393 
 Veronal, 220 
 Verruca, 498 
 
 acuminata, 503 
 
 definition, 498 
 
 necrogenica, 249 
 
 Peruana, 350 
 
INDEX 
 
 753 
 
 Verruca Peruana, definition, 350 
 diagnosis, 352 
 etiology, 351 
 pathology, 351 
 prognosis, 352 
 symptoms, 350 
 treatment, 352 
 plana juvenilis, 500 
 
 seniorum, 500 
 seborrheica, 500 
 Verrucae digitatae, 499 
 
 planae, 500 
 Verrue, 498 
 
 senilis, 501 
 
 diagnosis, 502 
 etiology, 501 
 pathology, 501 
 prognosis, 502 
 treatment, 502 
 symptoms, 498 
 Verrues telangiectasiques, 489 
 Versicolor, tinea, 540 
 Vesicles, 19, 31 
 
 situation of, 31 
 Vesicular eczema, 119, 130, 133 
 syphiloderm, 277 
 diagnosis, 278 
 Vesiculation, 31 
 Vibrissas, 8 
 Viruela, 37s 
 Vitiligo, 534, 536 
 definition, 534 
 diagnosis, 536 
 etiology, 535 
 pathology, 535 
 prognosis, 537 
 symptoms, 534 
 treatment, 537 
 Vitiligoidea, 580 
 Vitreous membrane, 9 
 Vogelmilbe, 450 
 Vulvae, kraurosis, 525 
 
 Wart, 498 
 Warze, 498 
 
 Washes or lotions, 54 
 Wasserpocken, 393 
 Water itch, 455 
 
 pox, 455 
 
 sores, 455 
 Weichselzopf, 651 
 Wen, 691 
 
 Wheals, 18 
 Wood-tick, 454 
 Wool-sorter's disease, 338 
 Wundrose, 231 
 
 Xanthelasma, 580 
 Xanthelasmoidea, 63 
 Xanthom, 580 
 Xanthoma, 580 
 definition, 580 
 diabeticorum, 581 
 diagnosis, 582 
 etiology, 581 
 pathology, 582 
 prognosis, 583 
 symptoms, 581 
 treatment, 583 
 elasticum, 584 
 palpebrarum, 580 
 planum, 580 
 
 symptoms, 580 
 tuberculatum, 580 
 tuberosum, 580, 583 
 multiplex, 580 
 symptoms, 580 
 Xanthome, 580 
 Xeroderma, 493 
 ichthyoide, 493 
 pigmentosum, 612 
 definition, 612 
 diagnosis, 615 
 etiology, 614 
 pathology, 614 
 prognosis, 615 
 symptoms, 613 
 treatment, 615 
 X-ray burn, 224 
 dermatitis, 224 
 
 Yaws, 347 
 
 Zona, 158 
 
 Zoster, 158, 160 
 
 arsenicalis, 162 
 brachialis, 160 
 facial, 160 
 femoral, 161 
 frontal, 159, 160 
 herpes, 158, 161, 164 
 lumbo-abdominal, 161 
 thoracic. 160 
 
1 ir