LIBRARY OF CONGRESS? 
 
 Ofoi. -^-Vl8»pFi# In 
 
 UNITED STATES OP AMERICA. 
 
A MANUAL 
 
 OF 
 
 DERMATOLOGY. 
 
 BY 
 
 A. R. ROBINSON, M.B., L.R.C. P. & S., Edin., 
 
 PROFESSOR OF DERMATOLOGY AT THE NEW YORK POLYCLINIC ; PROFESSOR OF HISTOLOGY 
 AND PATHOLOGICAL ANATOMY AT THE WOMAN'S MEDICAL COLLEGE OF THE NEW YORK 
 INFIRMARY ; ATTENDING PHYSICIAN TO THE DEMILT DISPENSARY, SKIN DEPART- 
 MENT ; PATHOLOGIST TO THE NEW YORK SKIN AND CANCER HOSPITAL; MEM- 
 BER OF THE AMERICAN DERMATOLOGICAL ASSOCIATION, OF THE NEW 
 YORK DERMATOLOGICAL SOCIETY, OF THE NEW YORK PATHOLOGICAL 
 SOCIETY ; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE, ETC. 
 
 
 WITH EIGHTY-EIGHT ILLUSTRATIONS. 
 
 MAR J4 1855/ 
 
 NEW YORK: ^V^«n 
 D. APPLETON AND COMPANY, 
 
 I, 3, AND 5 BOND STREET. 
 I88 5 . 
 

 Copyright, 1885, 
 By A. R. ROBINSON. 
 
PREFACE 
 
 This volume is intended to be the basis of a future much 
 larger, more pretentious, and more original work. In its present 
 form an effort has been made, not so much to write a distinct- 
 ively original work, as to present — in as concise a manner as 
 possible — the subject of Dermatology in its modern aspect. 
 
 The original intention was to give a concise and yet com- 
 plete description of the symptoms, histology, etiology, diagno- 
 sis, and treatment of the different diseases, in a work of about 
 three hundred to three hundred and fifty pages ; but it was 
 found that that was impossible, if any justice was to be done 
 to the subject. Even with the present size I have had to cur- 
 tail the matter much beyond my desire, and consequently the 
 histology and treatment are in many cases not so complete as 
 they might be. 
 
 Although I have done a great amount of work during the 
 last ten years on the histology of the lesions of many of the 
 skin-diseases, as may be perceived by a glance at the number 
 of original drawings accompanying the text, yet, on account of 
 the limited space at my disposal, I have not been able, as a rule, 
 to give more than a brief description of the result of these 
 studies. At some future time I expect to do this part of the 
 subject much more justice. 
 
 As regards the treatment of the different diseases, much more 
 could have been written, and the mode of application of many 
 of the local measures recommended rendered more intelligible, 
 perhaps, by a more lengthened description of the exact man- 
 ner in which they are to be employed ; but not only would space 
 not permit, but, furthermore, I believe that for the intelligent, 
 thinking physician, a statement of principles and indications is 
 of much more service than a long list of formulae. 
 
IV PREFACE. 
 
 As the object of the publication is to present the subject of 
 Dermatology in its modern aspect, and as the day is past when 
 one can write wholly original articles on the majority of skin or 
 other diseases, I have drawn freely from other writers, and am 
 especially indebted to the excellent works of Duhring, Hyde, 
 Wilson, Tilbury Fox, Hebra, Neumann, Kaposi, and " Hand- 
 buch der Haut-Krankheiten " edited by H. von Ziemssen. The 
 description of a number of the diseases is more or less copied 
 from one or other of these sources, as individual experience 
 alone would never enable one to write a complete original 
 work on diseases of the skin, owing to the fact that some forms 
 are very rare, and may never be observed by a dermatologist 
 with a very large practice, extending over many years. 
 
 Some diseases, as myxcedema, etc., which more properly 
 belong to internal medicine, have not been described in the 
 present volume. Miliaria (prickly heat) does not appear as a 
 separate disease, as histological studies have convinced me that 
 it is only a form of eczema. The same is true of lichen simplex. 
 Sixty-five of the illustrations are original, and are either 
 woodcuts or reproductions by the photo-engraving process. 
 
 This volume was announced to appear one year ago, but, 
 owing to illness and numerous professional engagements, both 
 public and private, it was impossible to complete the work 
 within the specified time, and it would not even yet have been 
 ready, had I not received great assistance from Dr. Gottheil, 
 my clinical assistant at the New York Polyclinic, who has 
 written the greater portion of a considerable number of arti- 
 cles. I am also indebted to Dr. S. M. Roberts and Dr. H. D. 
 Chapin for assistance in preparing the manuscript, and to Dr. 
 W. L. C. Forrester for proof-reading and preparation of the 
 contents and index. 
 
 With a full knowledge of the defects and incompleteness of 
 the volume, I hope it possesses sufficient merit, and contains 
 enough original work, to justify the publication. 
 
 356 West Forty-second Street, 
 January, 1885. 
 
CONTENTS. 
 
 PAGE. 
 
 Anatomy of the skin 9 
 
 Physiology of the skin 31 
 
 Symptomatology 35 
 
 Etiology of skin diseases 47 
 
 PAGE. 
 
 Diagnosis of skin disuses. .... 48 
 Treatment of skin diseases. ... 49 
 Classification of skin diseases. . 52 
 
 CLASS I. 
 
 ANOMALI.E SECRETIONIS ET EXCRETIONIS. 
 
 Seborrhcea 56 
 
 Asteatosis cutis 66 
 
 Comedo 67 
 
 Milium 71 
 
 Sebaceous cyst 74 
 
 Hyperidrosis 76 
 
 Anidrosis 80 
 
 Bromidrosis 81 
 
 Chromidrosis 83 
 
 Sudamina 84 
 
 Erythema traumaticum. 
 Erythema caloricum . . 
 
 CLASS II. 
 
 HYPER^EMI^. 
 
 91 I Erythema venenatum 92 
 
 ... 92 I Erythema symptomatica 92 
 
 CLASS III. 
 
 EXUDATIONES. 
 
 Morbilli 94 
 
 Rcetheln 97 
 
 Scarlatina 99 
 
 Variola 105 
 
 Varicella no 
 
 Vaccinia 112 
 
 Impetigo contagiosa. 116 
 
 Anthrax 118 
 
 Equinia 125 
 
 Erysipelas 130 
 
 Syphilis 142 
 
 Erythema multiforme 187 
 
 Erythema nodosum 193 
 
 Urticaria 196 
 
VI 
 
 CONTENTS. 
 
 EXUDATIONES.— Continued. 
 
 Lichen planus 202 
 
 Lichen scrofulosus 209 
 
 Prurigo 212 
 
 Herpes. 219 
 
 Herpes febrilis 219 
 
 Herpes iris 221 
 
 Herpes progenitalis 222 
 
 Herpes gestationis 223 
 
 Herpes zoster 224 
 
 Pemphigus 232 
 
 Hydroa 242 
 
 Pompholyx 246 
 
 Acne 256 
 
 Acne rosacea 265 
 
 Sycosis 269 
 
 Impetigo 280 
 
 Impetigo herpetiformis 282 
 
 Ecthyma 284 
 
 Pityriasis rubra 288 
 
 Furunculus 291 
 
 Carbuncle 296 
 
 Eczema 301 
 
 Dermatitis 336 
 
 Combustio 344 
 
 Congelatio ; . . . 352 
 
 Purpura. 
 
 CLASS IV. 
 
 HEMORRHAGIC. 
 
 359 J Hsematidrosis and Haemophilia 364 
 
 CLASS V. 
 
 HYPERTROPHIES. 
 
 Lentigo 366 
 
 Chloasma 367 
 
 Naevus pigmentosus 373 
 
 Keratosis 376 
 
 Callositas 376 
 
 Clavus 379 
 
 Cornu cutaneum 381 
 
 Keratosis pilaris 384 
 
 Psoriasis 385 
 
 Lichen ruber 403 
 
 Keratosis with papillary hyper- 
 trophy 410 
 
 Verruca 410 
 
 Ichthyosis 415 
 
 Scleroderma 421 
 
 Sclerema neonatorum 427 
 
 Morphcea 431 
 
 Elephantiasis 434 
 
 Dermatolysis 442 
 
 Hirsuties. ... 445 
 
 Onychogryphosis ...... 448 
 
 CLASS VI. 
 
 ATROPHIC 
 
 Albinismus 450 
 
 Vitiligo 452 
 
 Canities 455 
 
 Atrophia cut's propria 459 
 
 Alopecia 462 
 
 Alopecia areata 467 
 
 Atrophia pilorum propria 473 
 
 Onychatrophia 475 
 
CONTENTS. 
 
 Vll 
 
 CLASS VII. 
 
 NEOPLASMATA. 
 
 Rhinoscleroma 476 
 
 Lupus erythematosus 479 
 
 Lupus vulgaris 488 
 
 Scrofuloderma 502 
 
 Molluscum contagiosum 506 
 
 Lepra 512 
 
 Sarcoma 535 
 
 Carcinoma 536 
 
 Epithelioma 538 
 
 Keloid 549 
 
 Molluscum fibrosum 555 
 
 Xanthoma 558 
 
 Lipoma 561 
 
 Angioma 563 
 
 Lymphangioma 571 
 
 Neuroma 573 
 
 Myoma 573 
 
 Osteoma 574 
 
 Adenoma 574 
 
 CLASS VIII. 
 
 NEUROSES. 
 
 Hyperesthesia 576 I Dermatalgia 577 
 
 Anaesthesia 576 I Pruritus 578 
 
 CLASS IX. 
 
 PARASI1VE. 
 
 Tinea trichophytina 585 
 
 Tinea trichophytina capitis. . . 585 
 
 Tinea kerion 586 
 
 Tinea trichophytina barbae. . . 487 
 
 Tinea trichophytina corporis . . 5 S8 
 
 Tinea trichophytina cruris. . . 590 
 
 Tinea trichophytina unguium . 591 
 
 Favus 602 
 
 Tinea versicolor 610 
 
 Scabies 614 
 
 Pediculosis 624 
 
 Pediculus capitis 625 
 
 Pediculus corporis 627 
 
 Pediculus pubis 629 
 
MANUAL OF DERMATOLOGY. 
 
 ANATOMY. 
 
 A knowledge of the normal histology of the skin is abso- 
 lutely necessary for a due appreciation of its pathological con- 
 ditions, and although the proper place for its description is in 
 a work on histology, I will in the present case follow the cus- 
 tom of writers on dermatology and commence with a descrip- 
 tion of the structures which form the skin proper, includ- 
 ing its appendages, the hairs, nails, sweat and sebaceous glands. 
 
 General plan of arrangement — The integumentum commune 
 or skin, forms the external covering of the body, which it 
 mechanically protects, and at the same time is endowed with 
 certain physiological functions. The surface of the skin in 
 some parts of the body is smooth and soft ; in other parts it is 
 more or less uneven and rough. This latter condition depends 
 upon the presence of pores, hairs, furrows and ridges. The 
 pores correspond to the surface openings of the hair follicles, 
 sebaceous and sweat glands. The hairs vary in amount of de- 
 velopment according to their situation. In the so-called hairy 
 regions they are large ; other parts are provided only with very 
 fine hairs (lanugo hairs), and again, in certain regions they are 
 absent. There are no hairs on the palms of the hands and soles 
 of the feet, the dorsal surfaces of the terminal phalanges of the 
 fingers and toes, the glans penis, and inner surface of the prepuce. 
 The furrows are either long and deep, or short and superficial. 
 The former are found chiefly in the flexures of the joints, and 
 correspond to the folds in the derma produced by movements 
 of the joint. The latter run between the papillary elevations, 
 and by crossing each other, divide the surface into a number of 
 
IO 
 
 ANATOMY OF THE SKIN. 
 
 polygonal or lozenge-shaped fields. This division is well mar- 
 ked on the backs of the hands. These superficial furrows are 
 more developed on the extensor than on the flexor surfaces of 
 the extremities, and in the lumbar region more than on the 
 anterior surface of the abdomen. Their direction is dependent 
 on the degree of the tension of the skin. The ridges correspond 
 
 Fig. i. — Diagrammatic perpendicular section, through the normal skin : 
 (a), epidermis; (b), rete Malpighii ; (c), papillary layer ; (d), corium ; (<?), panni- 
 culus adiposus ; (/), spirally bent end of sweat duct; (g), straight portion of 
 duct; (//), sweat gland proper; (z), hair shaft; (/&), root of hair; (/), sebaceous 
 gland. After Neumann. 
 
 to the papillae, and are most developed on the palmar surfaces 
 of the last digital phalanges. 
 
 The color of the skin varies in individuals according to 
 race, and in the same individual according to the part of the 
 body. The dark skin of some races depends upon the presence 
 
ANATOMY OF THE SKIN. II 
 
 of blackish-brown pigment granules in the cell-body of the 
 columnar epithelia of the rete mucosum. In the Caucasian race, 
 pigment granules are usually present in greatest quantity in the 
 areolae of the nipples and in the scrotum and labia. 
 
 General structure. — The skin is composed of the following 
 tissues : epidermis, corium, subcutaneous connective tissue, 
 bloodvessels, nerves, lymphatics, sweat and sebaceous glands, 
 hairs and nails. 
 
 A perpendicular section through the skin shows (Fig. i.) three 
 well marked layers ; the most superficial is called the epidermis 
 proper, (a, b)\ the middle layer is the corium or cutis, (</); and 
 the deepest layer the subcutaneous connective tissue, (e). The 
 limit of the epidermis at its place of union with the corium is 
 sharply denned, but the corium and subcutaneous connective 
 tissue gradually merge into each other, the boundary between 
 them being only an artificial one. 
 
 Description of the different tissues. — The epidermis is sub- 
 divided from below upwards into the rete Malpighii, granular 
 layer, stratum lucidum and cor- 
 neous layer. This division is of 
 practical advantage, for whilst the 
 cells of all the layers are derived 
 primarily from the rete, and in their 
 movement toward the free surface 
 undergo the chemical changes which 
 give them their characteristic appear- 
 ance, and hence should be classed 
 
 Fig. 2. — Vertical section of 
 
 as One Structure, yet there is often a the epidermis: (a), rete cells; 
 j . , . c ^ • i • i • i iP)y granular layer; (c), stratum 
 
 deviation Of this physiological pro- lucidum ; (</), corneous layer ; 
 
 cess in one or other of its stages, £* is int Si£ piflbry "** ' ° ' 
 which demands a more exact defini- 
 tion than would be possible if the four layers were spoken 
 of as epidermis only. Thus ichthyosis is an affection of 
 the corneous layer and psoriasis of the rete Malpighii. In 
 some diseases the rete is diminished, in others increased and the 
 same holds true of all the layers. In Fig. 2 these different 
 layers are shown. 
 
12 ANATOMY OF THE SKIN. 
 
 The rete MalplgJiii consists of nucleated corpuscles, rich in 
 protoplasm, granular in appearance and disposed more or less in 
 parallel strata, the elements of the different layers differing 
 somewhat from each other as regards their size and shape. The 
 lowest layer consists of columnar-shaped bodies arranged 
 palisade-like, with their long axis more or less perpendicular 
 to the surface of the corium. Where the papillae are well 
 developed, this perpendicular arrangement is not so marked. 
 The base of some of these bodies terminates in a pointed 
 extremity, which passes a short distance into the corium. 
 
 Each cell body consists of granular protoplasm, and incloses 
 an oval nucleus. The next two or three strata consist of more 
 or less polygonal-shaped bodies, each with a spherical nucleus. 
 The cells are large, their contours sharply 
 defined, and they contain some pigment. 
 In the succeeding layers the cells in- 
 crease in size and are more granular in 
 appearance, the cells and nuclei become 
 flatter as they approach the granular 
 layer, and, finally, lie with their long axis 
 parallel to the general surface. 
 Fig. 3.—" Prickle " cells All the cells of the rete, except those 
 diaSete r rs. e magnified l6o ° of the first row, are united to each other 
 by filaments (Heitzmann), the so-called 
 prickles of Max Schultze (Fig. 3). 
 
 These filaments vary in length and size in different parts of 
 the body, they are most distinct where the rete is 
 well developed, and are thicker and longer in the 
 lower than in the upper layers. They are not ''i&m^ 
 
 found in the stratum lucidum. They are true con- „ M _ 
 
 . . Fig. 4. — Iso- 
 
 necting filaments between neighboring rete bodies, lated 'Prickle' 
 
 cell 01 rctG 
 
 and not prickles of adjoining cells. 
 
 The spaces between the filaments and cells are filled with an 
 intercellular albuminous substance, and may be regarded as 
 minute channels for the conveyance of nutriment to the cells, 
 and a path for peripheral nerve fibres. Variations in the num- 
 ber of the cellular layers in the rete are of normal occurrence, 
 
 '*£T 
 
ANATOMY OF THE SKIN. 13 
 
 but this part of the skin shows the least variation as regards its 
 thickness. The arrangement of the elements in the different 
 strata is the same in all parts of the body, and appears to be 
 independent of the thickness of the rete. The lower surface 
 of the rete adapts itself to the upper surface of the corium, 
 and between the papillae projects downward and forms the in- 
 terpapillary rete Malpighii. Wandering, lymphoid, or em- 
 bryonic cells are frequently present in this layer. 
 
 The granular layer (Fig. 2, b) consists of one or two strata of 
 flattened, granular-looking bodies, which, in perpendicular 
 section, appear spindle-shaped, with their long diameter parallel 
 to the free surface of the epidermis. They are united to each 
 other by very short filaments. The nuclei are very distinct and 
 flattened in the same direction as the cell bodies. The latter 
 are very coarsely granular in appearance, which is most 
 marked near the nucleus, and gradually diminishes in amount 
 as the periphery of the cell is approached. This granular 
 appearance depends upon the presence of round granules of a 
 peculiar substance, eleidin, (Ranvier), keratohyalin (Waldeyer), 
 a result of the chemical changes in the preparatory stage of the 
 horny process. They commence to form \\\ the rete, but do 
 not show distinctly by ordinary coloring. 
 
 The stratum lucidum (Fig. 2, e) is composed of at least three 
 layers. It presents a clear, homogeneous, or striated appear- 
 ance. The cells are flattened and have a staff-shaped nucleus. 
 They are formed from the cells of the granular layer by loss of 
 the granular substance and increase in transparency of the 
 intergranular material. 
 
 Corjieous layer. — In vertical section the corneous layer (Fig. 
 2, d) appears to be composed of wavy fibres and horny, trans- 
 parent cells of various sizes and shapes. This variation in bulk 
 and form depends in a great measure upon the thickness of 
 this layer- The nearer the stratum lucidum the more distinct 
 are the cells. If the layer is very thin the cells appear as 
 elongated, flat or curved bodies, giving to this part of the 
 epidermis a fibrous appearance (See the corneous layer in 
 many of the illustrations in this book). When the corneous 
 
14 ANATOMY OF THE SKIN. 
 
 stratum is thick the cells vary in size and form in different 
 parts of the layer. Those of the lowest layer color slightly in 
 carmine, are polygonal or spindle-shaped, and frequently con- 
 tain a shriveled nucleus. As the surface is approached they 
 become flatter and dryer and more bent upon themselves. 
 The most superficial layers are composed of elongated, flat, 
 dried up cells, the so-called epidermic scales. The corpuscles 
 of the stratum corneum are arranged in layers, but the elements 
 forming a layer are more closely united with each other than 
 with those of adjoining layers. Hence this stratum can be 
 
 HP 
 
 €V 
 
 Fig. 5. — Vertical section of the palm of the hand from a case of sudamina : 
 a, a, a, sweat ducts ; d, sweat vesicle ; c, rete Malpighii ; d, cutis. 
 
 divided into lamellae, as occurs in some pathological states of 
 the skin (pityriasis rubra, &c). This closer union between the 
 cells composing a layer than with the cells of adjoining layers 
 affords an explanation why, in the formation, for instance, of 
 sudamina vesicles (see Fig. 23) the liquid collects between the 
 layers instead of pushing towards the free surface. The corneous 
 layer participates in the elevations and depressions of the 
 underlying layers. This causes the undulating or wavy appear- 
 
ANATOMY OF THE SKIN. 15 
 
 ance of the lamellae, as observed in sections where the papillae 
 are well developed. The thickness of this layer varies greatly 
 in different parts of the body and reaches its greatest develop- 
 ment on the palms of the hands and soles of the feet (see Fig. 5). 
 
 Its thickness does not depend upon the rete Malpighii, as 
 it sometimes forms a thick layer where the rete is thin, and 
 vice versa. 
 
 The subcutaneous connective-tissue layer of the skin consists 
 principally of connective tissue bundles, which, coming from 
 the underlying fasciae of the muscles or from the periosteum, 
 pass in an oblique direction to the corium. These fasciculi are 
 generally cylindrical in form, and variable in size ; by their 
 anastamoses or division, they form networks with interfascicular 
 spaces. Generally the bundles are large, and hence a loose 
 connective tissue is formed. Adipose tissue in greater or less 
 quantity is found in this layer. The fat cells are collected into 
 masses or lobules of various size. Each lobule has an afferent 
 artery, a capillary plexus, and one or more efferent veins. 
 Several lobules are sometimes united in the form of an acinous 
 gland, and surrounded by a general sheath of connective tis- 
 sue. Owing to the amount of fat tissue so often found in this 
 layer, it has been called the panniculus adiposus. Fat lobules 
 are absent in the penis, scrotum, labia minora, eyelids, and 
 pinna. From this adipose tissue, fat columns, in some parts of 
 the body, pass upward in an oblique direction to the bases of 
 the hair follicles, especially to those of the fine ones. In cases 
 of starvation, in the so-called wasting diseases, and in all acute 
 diseases attended with excessive loss of tissue, the fat cells dis- 
 appear to a greater or less extent. The skin then becomes 
 correspondingly flaccid and wrinkled. Adipose tissue gives to 
 the skin its tension and fullness, and to the body its appearance 
 of roundness or plumpness. Obesity consists in an excessive 
 production of fat cells. Lymphoid corpuscles are present in 
 this layer, especially near the bloodvessels and glands. The 
 sweat gland coil, and the lower part of deep-seated hair folli- 
 cles lie in this layer. 
 
 Bloodvessels, lymphatics and nerves are present. The 
 
1 6 ANATOMY OF THE SKIN. 
 
 bloodvessels are large, and after giving off branches to the 
 hair follicles, sweat glands and fat globules, pass upward to the 
 corium. 
 
 The corium. — The principal part of the corium consists of 
 white fibrous and yellow elastic connective tissue, the latter 
 increasing in amount with advancing years. The white fibrous 
 tissue forms a much denser, firmer structure here than in the 
 subcutaneous layer. It consists of deep oblique and super- 
 ficial horizontal bundles. The latter comprise fine bundles of 
 fibrous connective tissue that run parallel with the surface of 
 the skin, and by their division and anastomoses, form a very 
 fine network, with small interfascicular lymph spaces. From 
 this layer bundles pass upward into the papillae, and there form 
 a still denser network. The deep, oblique layer is a continua- 
 tion upward of the subcutaneous connective tissue bundles. 
 When they reach the situation for the corium, they divide into 
 fasciculi, and these continue to divide and anastomose with each 
 other and with fibres from the superficial layer. The anasto- 
 moses are very close ; hence, the corium is formed of a dense 
 network of connective tissue, except where it is traversed by 
 bloodvessels, lymphatics, nerves, hair follicles, sebaceous and 
 sweat glands. From the greater size of the connective tissue 
 bundles in the lower part of the corium, and the consequent 
 looseness of the network formed by their anastomoses, this 
 part has been called the pars reticularis corii, and the upper 
 part, from the closeness of the network, the pars papillaris. 
 From the upper part of the corium fibres pass upward to form 
 the papillae. (See Fig. i, c. ; and fig. 5). The form and size of 
 the papillae vary in different parts of the body. Where they 
 are most developed, as on the inner surface of the terminal 
 phalanges of the fingers and toes, they are conical in shape. 
 In some other regions they are either absent, or form only 
 slight elevations on the corium, giving a wave-like appearance 
 to its upper surface. The corium is separated from the stratum 
 mucosum by a thin, transparent basement membrane, from 
 which prolongations pass upward between the cylindrical cells 
 of the rete. 
 
ANATOMY OF THE SKIN. 1 7 
 
 Elastic fibres are present in large numbers in the corium, 
 especially in its upper part, where they form a close network. 
 Numerous lymphoid bodies are also present, especially in the 
 vicinity of the bloodvessels and glands. Hair follicles, seba- 
 ceous glands, sweat ducts, nerves, lymphatics, and non-striated 
 muscles, are also present. 
 
 Bloodvessels. — Only the corium and subcutaneous tissue are 
 provided with bloodvessels. The arterial vessels supplying 
 the skin form two parallel horizontal layers, a superficial and a 
 deep one. The deep layer lies in the subcutaneous tissue, and 
 consists of large vessels running horizontally. From this 
 layer branches pass to the sweat glands and fat follicles of this 
 region. The principal branches pass perpendicularly or ob- 
 liquely upward through the corium to its upper part, and after 
 free branching and anastomoses, form a superficial horizontal 
 layer, the stratum subpapillare, directly beneath the papillae. 
 From the ascending vessels, branches are given off to the hair 
 follicles, sebaceous glands, and tissue of the corium. From 
 the subpapillary layer (see Fig. 6), small 
 branches pass upward into the papillae, 
 where they become capillary vessels, which 
 proceed to the summit of the papillae. Before 
 
 reaching the apex, they frequently divide 
 Fig. 6. — a, stratum . . , , ^i ... 
 
 subpapillare; b, papil- mto tw0 or nrore branches. ihose papillae 
 l* containing capillary j n wn ich tactile corpuscles are seated have 
 
 vessels. r 
 
 generally no bloodvessels. 
 
 The veins are arranged on the same plan as the arteries ; 
 they form a superficial and a deep layer, in corresponding situa- 
 tions. 
 
 Nerves. — Both medullated and non-medullated nerve fibres 
 are present in the skin. They are found in combination in the 
 nerve trunks situated in the corium and subcutaneous tissue ; 
 the medullated fibres being most numerous in those regions 
 where the Pacinian and tactile corpuscles are most abundant. 
 Both simple and compound bundles are met with. From these 
 bundles in the subcutaneous tissue ond lower part of the corium 
 nerve fibres pass to the glands, bloodvessels, and Pacinian 
 
1 8 ANATOMY OF THE SKIN. 
 
 corpuscles of these parts. In the corium some of the medulla- 
 ted fibres lose their medullary sheath and continue as non- 
 medullated fibres. The nerve bundles pass upward through 
 the corium to the subpapillary region, where many of them 
 change their course and run in a horizontal direction. Some 
 fibres before reaching this region return to the deeper parts of 
 the corium to re-ascend, forming a curve with the concavity to 
 the free surface. Some of the horizontally running fibres form 
 a plexus around the subpapillary vessels and capillaries of the 
 papillae. The subpapillary plexus is close and consists of fine 
 non-medullated fibres in close connection with the bloodves- 
 sels. Within the papillae, they form a dense plexus around the 
 capillaries, of thick or fine varicose fibres with many nuclei. 
 From this plexus, fibres pass toward the epidermis and either 
 enter it directly or after running a short distance parallel to its 
 under surface. Having entered the rete, they lie between the 
 epithelial bodies and form a plexus. According to some they 
 form a double plexus, a superficial and a deep one. They 
 have been described as ending in minute swellings, either be- 
 tween or within the cells, but if the view that the cells of the 
 rete afterwards become corneous cells be correct, this mode of 
 termination can hardly be possible. I believe they always form 
 a plexus. 
 
 Of the medullated fibres a. large number pass upward into the 
 papillae where they form loops and return to the subpapillary 
 region. (See Figs. 7, 8, 9, 10). From this situation they may 
 again pass upward into a neighboring papilla. (See Fig. 7). 
 Several of these looped medullated fibres are sometimes pres- 
 ent in a single papilla. (Fig. 8). Other medullated fibres pass 
 upward to form tactile corpuscles. In some situations, medul- 
 lated fibres pass in the subcutaneous tissue and corium from 
 the trunks to form Pacinian corpuscles. These corpuscles 
 generally occur in small groups, a nerve fibre sometimes divid- 
 ing to form two corpuscles. 
 
 The tactile corpuscles are generally round, oval, or longish 
 bodies situated almost always within a papilla, but occasionally 
 somewhat beneath it. When present they generally occupy 
 
ANATOMY OF THE SKIN. 
 
 19 
 
 the greater part of the papilla. Generally the papilla is devoid 
 of bloodvessels, but the latter are sometimes present, and may- 
 extend to the apex and be of the usual size or smaller than 
 those in the other vascular papillae. (See Fig. 9). A corpuscle 
 when examined microscopically, presents in vertical section a 
 transversely striated appearance, the lines running either di- 
 rectly transversely or obliquely, and giving to the corpuscle 
 (when previously hardened in chromic acid) a very irregular 
 exterior, as if formed by anastomosing bundles of white fibrous 
 tissue. (See Figs. 10, 11, 14). As shown by the action of a 
 
 Fig. 7. 
 
 Fig. 8 
 
 Fig. 7. — Two corpuscles in a single papilla ; the afferent nerve (b) coming 
 from an adjoining papilla. Fig. 8. — Looped medullated fibres. Fig. 9. — Papilla 
 with bloodvessel, corpuscle and looped fibre. 
 
 weak solution of potash in well colored gold specimens, the 
 striated appearance depends upon white fibrous connective 
 tissue and to a less extent upon nerve fibres. Each corpuscle 
 has an afferent and efferent nerve. The afferent nerve passes 
 more or less directly upward from the subpapillary region and 
 enters the corpuscle at or near its base. (See Figs. 7, 9, 10, 11, 
 12, 13, 14, 15). Some lose their medulla whilst in the corium 
 and enter the corpuscle as non-medullated fibres. Sometimes 
 
20 
 
 ANATOMY OF THE SKIN. 
 
 the afferent fibres come from a neighboring papilla. (See Fig. 
 7). Having entered the corpuscle, the nerve passes in a 
 spiral direction towards the apex and finally after a greater or 
 less number of windings leaves the corpuscle. The afferent 
 fibre sometimes loses its medulla before reaching the corpuscle, 
 and when within it, it frequently changes in thickness, from 
 changes in the amount of medullary substance present. The 
 fibre within a corpuscle frequently divides, and there may be 
 consequently two or more efferent fibres. 
 
 Pacinian Corpuscles. — The Pacinian or Vater's corpuscles are 
 
 elliptical or pointed, or occasion- 
 ally curved, or irregularly shaped 
 bodies found especially in the 
 
 Fig. 10. 
 
 Fig. i] 
 
 Fig. 12. 
 
 Fig. 10. — Corpuscle and looped medullated fibres. Figs, ii, 12, 13, 14, 15 
 show afferent and efferent fibres. Figs. 10, 11 show the stria? before the use of 
 potash. Fig. ii, corpuscle lies horizontally in the papilla. Figs. 7, 15 are two 
 corpuscles in a single papilla. 
 
 subcutaneous tissue of the volar side of the hand and plantar 
 side of the foot. Each corpuscle is connected with a medullated 
 nerve fibre which, with its thick sheath, represents the stalk of 
 the corpuscle. The corpuscle proper consists of a great num- 
 ber of capsules placed concentrically around a central elon- 
 
 * The reasons for the above view of the structure of the corpuscles were 
 given in a paper read before the American Dematological Association in 
 1882, of which a summary appeared in a September number of the Medical 
 News of Philadelphia. 
 
ANATOMY OF THE SKIN. 
 
 21 
 
 Fig. 13. 
 
 gated clear mass. It shows, therefore, a concentric striation, 
 each stria corresponding to a capsule seen in profile. The 
 capsules are thinner at the periphery than in the central por- 
 tions. Each capsule is composed of (a) a hyaline ground 
 membrane ; {b) in this membrane fine connective 
 tissue fibres arranged in a transverse manner either 
 regularly in one or two layers or irregularly are im- 
 bedded ; (c)on the inner surface of this membrane 
 is an endotheliod layer limiting the capsule. The 
 stalk of the corpuscle consists of an ordinary 
 medullated nerve fibre with fibrous connective 
 tissue ; outside of this a limiting membrane, and 
 most externally a number of lamellae like the cap- 
 sules. The medullary sheath and sheath of Schwann 
 cease at the entrance of the nerve into the central 
 clear mass. The central space contains the axis 
 cylinder and a transparent mat- 
 rix and limiting membrane. The 
 manner of termination of the 
 axis cylinder is not fully de- 
 cided. I believe that the nerve 
 forms a plexus or loop and leaves 
 the corpuscle at one of its ex- 
 tremities. Ranvier describes the 
 nerve as sometimes traversing 
 one corpuscle to terminate in a 
 second or even a third corpuscle. 
 In this case it loses successively 
 its envelopes, and its medullary 
 sheath completely disappears in 
 the central mass ; but at the oppo- 
 site pole all its membranes form 
 again before the nerve enters the 
 other corpuscles. 
 
 Sweat Glands. — The sweat glands — glandulcz sudorifercz — 
 are present in the skin of all parts of the body except that of 
 the glans penis and margin of the lips. They are most numer- 
 
 Fig. 15. 
 
 Fig. 14. 
 
22 
 
 ANATOMY OF THE SKIN. 
 
 ous in the palms of the hands and the soles of the feet, where 
 they number, according to Krause, 2,685 to 2,736 to the square 
 inch. A sweat gland is composed of two parts, viz : the 
 gland proper, or secreting part, and an excretory duct. The 
 gland proper lies in the subcutaneous tissue and consists of the 
 lower part of the sweat apparatus coiled upon itself into a 
 more or less globular form, the tube terminating in a cul-de-sac, 
 the blind extremity generally lying in the centre of the coil. 
 The diameter of the secreting part is greater than that of the 
 duct. The gland proper is formed of secreting cells, unstriped 
 muscle fibres and a basement membrane. The cells (glandular 
 
 B 
 
 Fig. 16. — A Pacinian corpuscle stained in gold chloride, a, proximal pole ; 
 6, distal pole. Two axis cylinders winding around each other are seen most 
 distinctly. At b the union is not seen, but the direction made it probable that a 
 loop was here present. 
 
 or secreting epithelial cells) are polygonal in form, and granular 
 in appearance. Oil globules are always present in the cell 
 body and in the lumen, and are the result of the normal physio- 
 logical action of the cells. The basement membrane is a thin, 
 transparent structure composed of flattened endothelial cells. 
 Between the secreting cells and the basement membrane un- 
 striped muscle fibres are present in small numbers. 
 
 In certain glands, especially those of the axilla, a layer of 
 unstriped muscle fibres is found external to the basement mem- 
 brane. 
 
 The sweat glands are surrounded by a somewhat loose, 
 
ANATOMY OF THE SKIN. 
 
 2 3 
 
 fibrous connective tissue, from which fibres pass inward and 
 form a denser tissue between the tube coils. A large num- 
 ber of lymphoid cells are always present in this intertubular 
 tissue. The gland is richly supplied with bloodvessels. 
 
 The excretory duct passes upward (see Figs, i and 17) from 
 the gland proper toward the free surface, where it opens with 
 a funnel-shaped orifice. In passing through the corium it 
 pursues a straight or slightly wavy course and enters at the 
 lowest part of an interpapillary portion. 
 The structure of the duct differs from 
 that of the gland proper in the shape of 
 the epithelial cells, the absence of mus- 
 cle fibres and the presence of acuticula. 
 This cuticula, a hyaline membrane, lines 
 the inner surface of the epithelial layer 
 and limits the lumen of the duct. As 
 the duct approaches the rete its epi- 
 thelial cells increase in number and form 
 two or more layers, and when it enters 
 the rete it loses the basement membrane 
 and is formed only of the cells of the 
 mucous layer, which have become more 
 or less flattened and spindle-shaped. 
 The direction of the tube through the 
 rete is either straight or spiral. In pass- 
 ing through the corneous layer the duct 
 pursues a spiral direction, the number of FlG< I?> _ Lower part of 
 spirals depending upon the thickness of a sweat g land : *, excretory 
 
 . duct ; b, coiled secreting; 
 
 the layer. I he largest number is present tube ; c, secreting tube cut 
 on the palms of the hands and soles of SfSKooi/ bl °° dves " 
 the feet. The wall of the duct is 
 
 formed of the cells of the corneous layer, and the duct opens 
 on the free surface at the summit of the ridges. 
 
 Sweat glands commence to form in the fifth month of foetal life; 
 in the seventh month a canal is formed and the lower end of the 
 tube becomes dilated and somewhat twisted. In the ninth month 
 the tube is coiled upon itself and the gland proper is formed. 
 
24 ANATOMY OF THE SKIN. 
 
 Sebaceous glands. — The sebaceous glands are seated in the 
 corium and are in close connection with the hair follicles. 
 When the hairs are large the glands appear as appendages to 
 the follicles into which their duct enters, but lanugo hairs may 
 be said to open into the ducts, as the diameter of the latter is 
 much greater than that of the former. 
 
 The sebaceous glands are almost, without exception, acinous 
 glands, the number of lobules forming a gland ranging from 
 two to twenty or more. The largest glands are seated in the 
 nose, cheeks, scrotum, about the anus and in the labia. 
 
 Every sebaceous gland consists of two parts, viz.: the secret- 
 ing portion or the gland proper, and the duct. The gland 
 proper consists of a basement membrane externally, and epi- 
 thelial cells or their product internally. (See Fig. 18.) The 
 basement membrane is a continuation of the basement mem- 
 brane of the skin, and is surrounded externally by dense con- 
 nective tissue containing bloodvessels, nerves and lymphatics. 
 The epithelial cells resemble in form those of the rete, those of 
 the outer layer are cylindrical in shape, further inward they 
 become larger, more or less polyhedral in form and contain fat, 
 the amount increasing as the centre of the gland is approached. 
 In the centre itself free fat, fat crystals, and remnants of epi- 
 thelial cells are found. 
 
 The duct is similar in structure to the gland proper. 
 
 Internal to the polyhedral cells are the cells of the corneous 
 layer of the epidermis, the number of which diminishes in pro- 
 portion to the distance from the free surface. In regions with 
 the large hairs the duct opens into the follicle at an acute angle 
 near its upper third, and the gland proper lies about on a level 
 with the middle third of the follicle. 
 
 The sebaceous glands commence to develop at the third 
 month of foetal life as a projection from the external root- 
 sheath of the hair, and consist at first of epithelial cells, which, 
 by subsequent multiplication and projection further downward, 
 form the gland. 
 
 Muscles. — Striated and non-striated muscles are present in the 
 skin. The former are found both in the smooth and bearded 
 
ANATOMY OF THE SKIN. 25 
 
 parts of the face, and also in the nose. They arise from the 
 deeply seated muscles, and passing upward between the glands 
 of the skin terminate in the corium. 
 
 The non-striated muscles are very numerous, and run either 
 in a parallel or in an oblique direction to the general surface. 
 Those lying parallel with the general surface run either in a 
 straight or circular direction. When they run in a straight 
 direction and anastomose with each other, they form a network, 
 as in the scrotum, prepuce, and perinaeum. Where they have a 
 circular course, as in the areola of the nipple, a continuous 
 ring muscle is formed. 
 
 The majority of the muscles running in an oblique direction 
 have a special relation to the hair follicles and sebaceous glands. 
 The muscle arises from the internal sheath of the hair follicle 
 and, passing obliquely upward, skirting the lower surface of the 
 sebaceous gland, terminates in the upper part of the corium, 
 (Fig, 18 n.) 
 
 Occasionally two muscles arise from opposite sides of the 
 same follicle sheath. A muscle in its course upward fre- 
 quently divides into two or more bundles, these secondary 
 bundles afterward pursuing different directions, or uniting 
 with fibres from other muscles, form a network in the corium. 
 Occasionally several secondary bundles run nearly parallel with 
 each other and terminate either separately or conjointly. 
 
 Some muscles have no relation to the follicles, but pass 
 more or less vertically upward to be inserted in the corium. 
 
 The number of muscles present in the skin varies in differ- 
 ent regions of the body. The order of frequency is as fol- 
 lows : Scrotum, penis, anterior part of the perinaeum, scalp, 
 forearm, thigh, arm, shoulder, forehead, abdominal wall, axilla, 
 leg, face, volar and dorsal surfaces of the hands and feet 
 (Neumann.) They are less developed on the flexor than on the 
 extensor surfaces. The size varies according to the person 
 and the region of the body. It is impossible, therefore, to 
 recognize with certainty a slight hypertrophy or atrophy of this 
 structure. The muscles are richly supplied with blood- 
 vessels. 
 
26 
 
 ANATOMY OF THE SKIN. 
 
 Fig. 18.— Hair from beard, a, canal of exit ; b, neck of hair follicle ; c, lower 
 part of hair follicle ; d, external sheath of hair follicle ; e, internal sheath of hair 
 follicle ; _/, external root-sheath of hair ; g, internal root-sheath of hair ; h, cortical 
 substance; k, medulla of hair; /, root of hair; m, fat cells; n, erector piii ; 
 o, papillae of skin ; fi, papilla of hair ; s, rete mucosum ; /, sebaceous gland ; 
 ep, stratum corneum which is continued into the follicle, (Biesiadecki.) 
 
ANATOMY OF THE SKIN. 27 
 
 The hair. — The parts to be studied in connection with the 
 hair proper are the hair follicle and the hair papilla. The hair 
 proper is a cylindrical structure seated within the hair follicle 
 and upon the hair papilla. 
 
 Its base lies either in the subcutaneous tissue or corium. 
 The portion of the hair proper within the follicle is called the 
 root of the hair, and the remainder the shaft of the hair. The 
 true hair follicle includes all that part of the hair-sac below 
 the place where the sebaceous duct enters the follicle. It is of 
 very variable size and consists of a blind extremity and a 
 funnel shaped orifice (a). The follicle is narrowed just below 
 the orifice, and forms the neck of the follicle {b). This is the 
 narrowest part of the follicle, and here the sebaceous duct 
 enters. From the neck downward the hair follicle increases in 
 size, being largest at its lower end, where it rests upon the papilla. 
 
 The hair follicle consists of three layers : the external, 
 middle, and internal hair-follicle sheaths. The middle and 
 external consist of connective tissue containing bloodvessels 
 and nerves. The internal sheath is a basement membrane. 
 
 The hair papilla is formed from the follicle sheaths, and has 
 the same structure. Within the papilla are one ormore arteries 
 and veins and non-medullated nerve fibres. The papilla is about 
 twice as long as broad, and the breadth is in direct proportion 
 to the length of the hair. 
 
 The follicles stand obliquely to the surface of the skin, and 
 the contents are the external and internal root sheaths and the 
 hair proper. 
 
 The external root-sheath consists of rete-like cells, the number 
 of which diminishes as the base is approached, and the sheath 
 generally ceases on a level with the apex of the papilia. 
 
 The internal root-sheath arises from the cylindrical cells cov- 
 ering the papilla which form the two layers, the sheath of 
 Henle and the sheath of Huxley. The hair is formed from 
 this sheath (Heitzman). Within the internal root-sheath lies 
 the hair proper, which consists of a knobbed extremity, the root 
 of the hair, and a cylindrical portion, the shaft. Between the 
 hair proper and Huxley's sheath lies the hair cuticula. 
 
28 
 
 ANATOMY OF THE SKIN. 
 
 The root of the hair consists of cells closely resembling those 
 of the rete. Those seated directly upon the basement mem- 
 brane are cylindrical, those above polyhedral and near the hair 
 shaft, spindle-shaped. The pigment of the root of the hair is 
 sharply limited externally by the cuticula. 
 
 The shaft of the hair consists of a central part or medulla and 
 a fibrous portion covered by the cuticula. The medulla con- 
 sists of polyhedral cells containing 
 fat and pigment. The fibrous por- 
 tion forms the principal part of the 
 shaft and consists of flattened fusi- 
 form cells with pigment. 
 
 A hair increases in length by the 
 formation of new elements in its root, 
 and they, by subsequent elongation 
 and movement upward, push the shaft 
 of the hair and its cuticula before 
 them. 
 
 The first development of hair takes 
 place at the end of the third or begin- 
 ning of the fourth month as a projec- 
 tion downward of the rete mucosum. 
 The papilla is formed later. The 
 first hairs are always of the lanugo 
 I variety— fine hairs with a very short 
 follicle. If a hair has reached its 
 proper term of existence, it falls out, 
 and is replaced by a new hair, which 
 grows from the old papilla. 
 
 The nails. — The nail is merely a 
 modification of the epidermis, and differs from the stratum 
 corneum only in being harder and firmer. It is a longish, four- 
 sided, hard, elastic, transparent, dense, flat body, situated in a 
 fold of the skin on the dorsal surface of the terminal phalanges 
 of the fingers and toes. It is slightly curved in its long diameter, 
 the convex surface being above and the concave below. The 
 fold of the skin in which the posterior and two lateral surfaces 
 
 Fig. 19. — Transverse section 
 of the hair beneath the neck of 
 the follicle : a 
 
 of follicle ; &, transversely cut 
 bloodvessels ; c, inner sheath of 
 follicle ; d, basement mem- 
 brane ; £, external root sheath ; 
 f y Henle's layer ; g, Huxley's 
 layer ; /i, cuticula ; /, hair shaft. 
 (Biesiadecki.) 
 
ANATOMY OF THE SKIN. 
 
 20 
 
 are imbedded increases in depth from before backward, and at 
 the posterior margin is continued forward for a short distance on 
 the surface of the nail. This fold is called the nail fold, and 
 the tissue upon which the nail is seated is termed the bed of the 
 nail. That part of the nail imbedded in the flesh posteriorly 
 is the root of the nail and the remainder its body. The flesh 
 underlying the root is called the matrix, and that underlying 
 the body of the nail the bed of the nail proper. The matrix 
 and bed of the nail proper are separated by a more or less 
 convex line, generally easily seen through the nail, and called 
 the lunula. The bed of the nail is formed of rete and corium. 
 
 Fig. 20. — Transverse section of the nail through the bed of the nail proper : 
 a, nail ; b, loose corneous layer beneath it ; <-, mucous layer ; d, transversely 
 divided nail ridges ; e, nail fold without papilla? ; _/, the horny layer of the nail 
 fold which has pushed forward on the nail ; g, papilla of the skin of the finger. 
 (Biesiadecki.) 
 
 There is no fat in its subcutaneous tissue. The papillae in the 
 matrix project forward, and are shorter and closer together 
 than in the bed of the nail proper. 
 
 In the bed of the nail proper the transition from rete to horny 
 cells is very rapid, whilst in the matrix it is gradual, conse- 
 quently this latter portion of the nail is softer than the other. 
 The nail is formed from the matrix, and thickened from the 
 corneous cells of the body of the nail. The nail is nourished 
 by blood from the nail-fold and from the bed of the nail. 
 They grow more rapidly in children than in adults, and more 
 rapidly in summer than in winter. The rapidity of growth 
 
30 ANATOMY OF THE SKIN. 
 
 depends upon the special nail and the individual. The nail 
 begins to form in the third month of intra-uterine life as a fold 
 covered with young epidermic cells. In the fourth month a 
 layer of new cells, which afterward become the horny cells of 
 the nail, appear between the rete and the young epidermic 
 cells. At the fifth month the epidermic covering disappears, and 
 the nail lies exposed. Between the sixth and eighth months the 
 nails are somewhat firm, but do not extend quite to the ends of 
 the fingers. At the eighth month the nails are well developed, 
 and extend to the ends of the fingers. 
 
PHYSIOLOGY. 
 
 The physiological functions of the skin are those of respira- 
 tion, secretion, regulation of the temperature of the body, sen- 
 sation and protection to the general surface of the body. 
 
 RESPIRATION. 
 
 The respiration performed by the skin is similar to that by 
 the lungs. Carbonic acid is given off, and oxygen, although in 
 very small quantity, is taken in. The amount of carbonic acid 
 given off as compared with that exhaled by the lungs is also 
 very slight. 
 
 SECRETIONS. 
 
 Sweat Secretion. — The sweat and sebaceous glands furnish 
 the secretory products of the skin. Probably all of the sweat 
 or watery liquid which reaches the free surface comes from the 
 gland proper portion of the sweat apparatus and none from the 
 papillary bloodvessels or duct of the sweat gland. Sweat is a 
 clear, watery secretion, with an acid reaction and saltish taste. 
 Sometimes, especially when the secretion is increased by such 
 diaphoretics as pilocarpine it is neutral or alkaline in reaction. 
 It contains water, volatile fats, acetic, butyric, propionic, 
 caproic, and caprylic acids, chloride of sodium, and urea. 
 Water forms about 99 per cent, of the whole secretion. Urea 
 is always present and is generally considerably increased in 
 amount in pathological conditions of the kidneys. The water 
 reaching the free surface of the skin usually escapes as vapor, 
 the so-called insensible perspiration, but if the sweat glands are 
 
32 PHYSIOLOGY OF THE SKIN. 
 
 very active it forms in drops — sensible perspiration. The 
 amount given off depends upon many conditions, and is conse- 
 quently, very variable, but is on an average about twice as 
 much as that given off by the lungs. One of the main condi- 
 tions which regulate the quantity of sweat formed is the 
 amount of blood passing through the capillaries of the skin, 
 and this depends on the quality, amount and temperature of 
 the food and drink taken ; on the temperature, moisture and 
 movement of the surrounding air ; on the nature of the cloth- 
 ing, the amount of muscular exercise, the mental condition of 
 the person and the condition as regards activity of the kidneys 
 and somewhat, also, of the intestinal tract. An increased 
 amount of blood in the capillaries causes an increase in the 
 discharge of water, consequently an increase in those condi- 
 tions above mentioned which regulate the amount of blood, in- 
 crease the quantity of sweat formed. Simple venous stasis with 
 normal oxydation of the blood and inflammatory hyperemia 
 do not increase the amount of water discharge. Also an 
 increase in the blood pressure in the aortic system from in- 
 crease in the amount of water taken does not excite sweat se- 
 cretion unless the blood is heated by the warmth of the liquid 
 taken, by the high temperature of the surrounding air, by re- 
 striction in the amount of heat and water given out, or by mus- 
 cular activity (Ziemssen.) 
 
 Atropia can cause diminution or cessation of sweat secre- 
 tion by paralysis of the nerves of the sweat glands. The se- 
 cretion of sweat depends upon a nervous influence ; the centres 
 for the sweat nerves are situated in the spinal cord and extend 
 as far as the medulla oblongata in which there is supposed to 
 be a general centre for all the spinal centres. The nerves in- 
 fluence the amount of sweating to a certain extent independent- 
 ly of the amount of blood in the cutaneous vessels, as shown by 
 the sweating in phthisis and in the crisis of some acute diseases. 
 
 In sweat secretion there are always some oil globules to be 
 detected. These no doubt assist in keeping the general sur- 
 face oiled ; though to a very small extent, as compared with the 
 secretion from the sebaceous glands. 
 
PHYSIOLOGY OF THE SKIN. 33 
 
 Sebaceous Secretion. — The sebaceous secretion consists of 
 free fat, epidermic cells, fat, sebaceous cells, cell debris and 
 cholesterine crystals. The free fat oils the hair and epidermis. 
 Chemically, sebaceous secretion consists of water, palmatin, 
 olein, palmitic and oleic acid, soap, cholesterine, a casein 
 like albuminoid body and inorganic salts. The amount of 
 secretion varies greatly in different persons, depending upon 
 the size and functional activity of the glands. From the 
 period of puberty until twenty-five or thirty, they are 
 most active. The secretion process is a continuous one 
 and consists in a filling of the sebaceous cells with fat, and 
 their subsequent rupture and expulsion of contents on the free 
 surface. The peripheral cells contain only a few fat globules, 
 and the amount of fat increases as the centre of the gland is 
 approached, until the whole cell is changed to a fat cell, when 
 it bursts, and the fat becomes free. 
 
 The secretion formed in the external auditory canal is a com- 
 bination of ordinary sebaceous and sweat secretion. 
 
 REGULATION OF THE TEMPERATURE OF THE BODY. 
 
 The skin regulates the amount of heat given out by the body 
 and thus controls the heat of the blood. Heat is given out 
 both by radiation and conduction. The corneous layer is a bad 
 conductor of heat and thus prevents too great loss of heat 
 by the body. It also exercises pressure upon the rete 
 mucosum and capillary bloodvessels preventing their over- 
 filling and loss of heat and fluid. Elevation or diminution 
 of the external temperature, produces, by reflex action 
 through the vaso-motor centres, either dilatation or contract- 
 ion of the capillaries, and relaxation or contraction of the mus- 
 cles of the skin. Cooling of the skin acts locally also by con- 
 tracting the bloodvessels and muscles, and thus diminishing the 
 amount of heat given off. To prevent the injurious effects of 
 too great heat of blood, sweat is secreted and heat carried off 
 by the water. In the evaporation of the sweat heat is con- 
 sumed. 
 
34 PHYSIOLOGY OF THE SKIN. 
 
 ORGANS OF SENSATION. 
 
 The organs of touch (the tactile corpuscles) are situated in 
 the skin, as also those of general sensation. We can thus 
 judge of space, feel of objects, temperature, ability to localize, 
 etc. 
 
 PROTECTION TO THE GENERAL SURFACE. 
 
 On account of the looseness of the subcutaneous tissue and 
 the elasticity and firmness of the cutis, the internal organs are 
 protected against injuries, blows, etc. From the insensibility 
 of the corneous layer and its great impermeability to liquids, 
 the deeper structures are protected from the effects of high or 
 low temperatures, and caustic or poisonous liquids. The hair 
 of the head, when in normal quantity, protects the brain from 
 the effects of heat and injuries. 
 
 As regards the faculty of the skin to absorb substances ap- 
 plied to it, the epidermis is almost impermeable to liquids, 
 gases and solid bodies. This resistance to absorption lies in 
 the corneous layer and is further assisted by the oiling which it 
 receives from the sebaceous gland secretion. If the epidermis 
 is removed, absorption can take place. Water, and substances 
 dissolved in water are not absorbed by the epidermis. The 
 corneous layer will, upon the application of water, swell up and 
 imbibe some of it, but it is not absorbed by the skin. If the 
 substances are dissolved or suspended in oils or fats and well 
 rubbed in, they are absorbed and taken into the system, as 
 shown by the effects of inunctions of mercurial ointment in the 
 treatment of syphilis. 
 
 The oleates are especially easily absorbed. 
 
 The mode of entrance in these cases is through the orifices 
 and ducts of the glands. Volatile substances, as turpentine and 
 camphor, may pass in, if the skin is previously washed with soap 
 or ether to remove the fat. 
 
 The question of the faculty of the skin for absorption is one 
 which requires further careful experiments and observation. 
 
GENERAL CONSIDERATIONS. 
 
 SYMPTOMATOLOGY. 
 
 The symptoms resulting from the nutritive or functional dis- 
 eases of the skin are either subjective or objective. Besides 
 these there are constitutional symptoms accompanying some 
 diseases, as fever, intestinal derangement, etc. 
 
 Subjective symptoms. — They consist in alterations in sensation, 
 either in increase or diminution, or change in quality. An in- 
 crease gives hyperaesthesia, a diminution anaesthesia, and a 
 change in quality, pain, itching, tickling, etc. For the presence 
 of these we must as a rule depend upon the statements of the 
 patient, but anaesthesia may be recognized by testing with 
 a needle, and when itching is present the skin will almost in- 
 variably be found excoriated, and in a manner suggestive of 
 the result of scratching with the finger nails ; that is, the ex- 
 coriations are in long lines. 
 
 Objective symptoms. — These are the most numerous and most 
 important. They are the result of the pathological process 
 occurring in the skin, and their careful study will enable us to 
 a great extent to judge of the nature of that process. They 
 are the lesions upon the skin which we are able to see and feel. 
 They are divided into primary and secondary lesions. This 
 division is of the greatest value, and in diagnosis we must 
 always seek for the nature of the primary lesion. The primary 
 lesions represent the pathological process up to the acme of its 
 development. The secondary lesions are the result of primary 
 lesions. Thus in scarlatina, the hyperasmic or slight inflamma- 
 tory condition is the primary lesion in the skin, and the subse- 
 quent scaling is secondary. In an ulcerating syphilide, the 
 syphilitic round cell infiltration is the primary lesion, and the 
 
$6 PRIMARY LESIONS. 
 
 breaking down and consequent ulceration is the secondary 
 lesion. 
 
 The primary lesions are i. Maculae, spots, macules ; 2. 
 Papulae, papules ; 3. Vesiculae, vesicles ; 4. Bullae, blebs ; 
 5. Pustulae, pustules ; 6. Pomphi, wheals ; 7. Tubercula, 
 tubercles ; 8. Phymata, tumors. 
 
 The secondary lessons are : 1. Squamae, scales ; 2. 
 Crustae, crusts ; 3. Rhagades, fissures ; 4. Excorationes, ex- 
 coriations ; 5. Ulcera, ulcers ; 6. Cicatrices, scars ; 7. Pigmen- 
 tation. 
 
 To appreciate the subsequent description of diseases, it is 
 necessary that we have a clear idea of the appearance and 
 nature of both the primary and secondary lesions. 
 
 PRIMARY LESIONS. 
 
 MACULAE ; SPOTS. 
 
 Definition. — Limited, variously sized, shaped and colored 
 spots of altered skin, unattended by special elevation or de- 
 pression. 
 
 As regards the color, they may be of all shades, but are gen- 
 erally red, brown, black, white or yellowish. If of bright red 
 color, they arise from hyperaemia of the papillary layer and 
 upper part of corium, and disappear upon pressure. If the 
 spots are from lentil to finger nail in size they are called 
 roseola, and if the redness is diffuse and extends over a consid- 
 erable area, it is called erythema. If there is exudation be- 
 sides hyperaemia, the spots will be darker in color, as in the 
 macular syphilide. Acquired hyperaemic spots, which with the 
 naked eye are seen to contain enlarged bloodvessels, are 
 called telangiectases, and when hereditary, are called naevi 
 vasculosi. The hyperaemic area around a skin lesion, for in- 
 stance, a boil, is called the areola. 
 
 If a macula is caused by haemorrhage into the skin, the dis- 
 ease is called purpura. The redness in this case does not dis- 
 appear upon pressure. If the haemorrhagic spots are pin point 
 in size, they are called petechiae ; if long, narrow, streak-like, 
 
PRIMARY LESIONS. 37 
 
 they are called vibices, and if of larger size and irregular shape, 
 are called ecchymoses. The blue, greenish-brown, or yellow- 
 color observed after haemorrhages have lasted a short time are 
 due to involution changes in the exudation. 
 
 If the maculae are white they arise from deficiency of pig- 
 ment either hereditary or acquired. As hereditary deficiency 
 it may be in spots (achroma) or general (albinismus). As ac- 
 quired it constitutes vitiligo. 
 
 An excess of pigment is frequently met with and produces 
 yellowish brown, dark brown or black maculae. The yellowish 
 brown spots, (chloasma), so frequently seen on the forehead and 
 face of women who have borne children or suffer from uterine 
 disease is due to an excess of pigment in the rete. Grouping of 
 pigment is seen in freckles, naevus pigmentosus, and naevus 
 spilus. If the change in color occupies a large part of the 
 body and is distributed in a uniform manner, it is called dis- 
 coloration. This condition is met with in icterus, chlorosis, the 
 last stages of carcinoma, lepra, and in the staining from the in- 
 ternal administration of nitrate of silver. 
 
 The macular patches show all variations as regards size and 
 form, but are usually circumscribed. They are the result of 
 various causes and represent various pathological conditions. 
 
 PAPULAE ; PAPULES. 
 
 Definition. — Millet to lentil sized, circumscribed, solid, ele- 
 vated pathological formations. 
 
 Pipules are of various shapes, round, conical, or flat, and 
 red, pale or normal in color. To the feel they are hard or 
 slightly compressible. They are met with in many diseases, 
 and owe their origin to many different pathological processes. 
 They may be formed by a simple collection of epidermic cells 
 on the general surface, as occurs in psoriasis, or from a collection 
 of similar cells in the mouths of hair follicles, as is the case in ker- 
 atosis pilaris. The most frequent cause is from exudation and 
 cell infiltration into the papillae and rete, as occurs in papular 
 eczema. This papule formation may represent the acme of the 
 
38 PRIMARY LESIONS. 
 
 process, or the inflammation may increase in intensity, accom- 
 panied by more exudation, and the papule become changed to 
 a vesicle ; or if with the exudation there is much cell emigra- 
 tion then a pustule will result. A collection of sebum in the 
 acini of the sebaceous glands produces a papule (milium) and 
 haemorrhage into the rete, papillae, or around glands, makes a pap- 
 ular eruption, purpura papulosa. Papules are also produced by 
 cell infiltration into the papilla and corium, as occurs in syphilis, 
 or from a new cell growth in the corium, as in lupus vulgaris. As 
 the nature of the pathological process is so different in the dif- 
 ferent cases, so the course of the eruption and its significance 
 differ according to the nature of the process. Itching may or 
 may not be present, according to the nature of the affection. 
 If acutely inflammatory, as in eczema, there will be itching, 
 but if depending on changes deep in corium, they will not itch 
 (lupus, milium). 
 
 VESICULiE ; VESICLES. 
 
 Definition. — Hemp to lentil sized, rounded or acuminated, 
 transparent, opaque or dark elevations of the epidermis, filled 
 with a serous, sero-purulent or bloody liquid. 
 
 The regular type of vesicle is transparent and contains clear, 
 serous or watery fluid. If opaque, it is from increased emigra- 
 tion of lymphoid corpuscles and their metamorphosis, and if 
 black, it is in consequence of haemorrhage into the vesicle. 
 In shape, vesicles are either round and acuminated, or have a 
 depressed centre on the summit, when they are called umbil- 
 icated. They may be fully or only partially distended by the 
 liquid contents. If only partially, then the walls will be 
 flaccid and have an uneven surface. The consistence of ves- 
 icles depends upon their situation. If deeply seated they are 
 firm, as the wall is thick ; but if superficially seated, the wall 
 is thin and the vesicle easily ruptured. Vesicles result 
 from exudation from the papillary vessels into the epidermis, 
 or from retention of sweat. As the exudation passes up- 
 ward the rete cells swell, the intercellular spaces enlarge, and 
 the liquid reaches the corneous layer, which it pushes before 
 
PRIMARY LESIONS. 39 
 
 it, and thus forms the vesicle. In sudamina the sweat collects 
 between the strata of the corneous cells, the rete remaining un- 
 affected. Vesicles are either simple, that is, have a single 
 chamber, as in sudamina ; or are compound, having two or 
 more chambers, as in variola. Vesicles are generally pres- 
 ent in considerable number on the body, and are either ir- 
 regularly distributed, as in eczema, or collected to groups, as 
 in herpes. Their course is generally brief, they either become 
 ruptured, or the contents dry up, or they become pustules by 
 increase in the number of lymphoid corpuscles. 
 
 BULLAE ; BLEBS. 
 
 Definition. — Irregularly shaped elevations of the epidermis, 
 varying in size from a bean to that of a goose egg, and con- 
 taining serous or sero-purulent contents. 
 
 Bullae correspond in all respects as regards mode of forma- 
 tion, appearance and nature of contents with vesicles. Their 
 only difference is that of size. Recent bullae are clear or pale 
 yellow in color. Later the contents change to a whitish or 
 yellowish color, or if blood is intermixed, the color is reddish 
 or brownish. Bullae vary greatly in size, ranging from that of 
 a bean to that of a goose egg, or even larger. Frequently 
 large and small bullae are found side by side. They are at first 
 generally fully distended from the rapid effusion of serum, but 
 soon the walls become flaccid if the bulla does not burst or 
 become ruptured. The wall generally rises abruptly from 
 normal skin, an inflammatory areola being rarely present. 
 Bullae are usually one-chambered, but sometimes are compound. 
 They have their seat in the epidermis the same as vesicles. 
 They usually have strong walls and do not readily burst, but in 
 some cases, as in pemphigus foliaceus, they tend to rupture 
 early. They are met with in a number of affections. 
 
 PUSTULE ; PUSTULES. 
 
 Definition. — Circumscribed, rounded, flat, acuminated or 
 umbilicated elevations of the epidermis caused by collections 
 of pus. 
 
40 PRIMARY LESIONS. 
 
 Pustules either originate as such, or result from the transition 
 of vesicles into pustules by continued increase in the number 
 of formed elements — emigrated corpuscles without a correspond- 
 ing increase in the amount of serum. Collections in which the 
 pustular stage has not been fully reached are called vesico-pus- 
 tules. Pustules may form in the mucous and horny layer, as in 
 variola ; or around sebaceous glands, as in acne ; or around hair 
 follicles, as in sycosis. They generally are surrounded by an 
 inflammatory areola, the extent of which differs in different 
 cases. They may consist of a single chamber, or be compound, 
 as in variola. Sometimes they contain blood as well as pus. In 
 disappearing they dry up and form variously sized yellowish, 
 brownish or blackish friable crusts. If the pus collection has 
 its seat in the epidermis only, the part will heal by new epider- 
 mis, but if a portion of the corium has been destroyed by the 
 inflammatory process its restitution can occur only by cica- 
 tricial tissue. Examples of destruction of limited areas of the 
 corium occur in acne and variola. The development of pustules 
 is usually attended by considerable subjective symptoms, as 
 burning and pain at the seat of the eruption. Their course 
 and significance depend upon their causation and not upon 
 their special anatomical structure, as pustules with similar ana- 
 tomical structure may represent widely different affections. 
 Pustules are present in acne, sycosis, impetigo, echthyma, im- 
 petigo contagiosum, eczema, variola, scabies and syphilis. 
 
 POMPHI, WHEALS, URTIC^E. 
 
 Definitioji. — Wheals are round, ovalish or elongated, firm 
 elevations of the skin of a pale or slightly reddish color, and 
 evanescent character and attended by much itching. 
 
 Wheals vary in size from a few lines to several inches in 
 diameter. They are round, ovalish, linear or band-like in 
 form. In children they are often very small, like the bite of 
 an insect, and may contain a little serum on the apex. Some- 
 times by peripheral spreading of the eruption and clearing up 
 of the central part rings are formed, and if neighboring rings 
 coalesce the erruption assumes a gyrate form. When the 
 
PRIMARY LESIONS. 4 1 
 
 wheals are very small they are usually pale in color, but if larger 
 the central part is pale and the periphery of a reddish or pink- 
 ish tinge. Sometimes their surface presents a glistening appear- 
 ance. They may exist singly, but there is generally a consid- 
 erable number of them, and when closely seated have a ten- 
 dency to coalesce and form large patches. They are always 
 attended by much itching, heat and tingling in the part. Scratch- 
 ing causes the existing ones to increase in size and new ones 
 to develop. They disappear rapidly and without desquama- 
 tion. They are closely related to simple erythema. They 
 consist in a serous exudation into the corium and rete. Occa- 
 sionally a little blood is mixed with the serum. The first part 
 of the pathological process seems to consist in an irritation and 
 contraction of the capillaries ; this contraction is very soon fol- 
 lowed by a dilatation of the capillaries and effusion of serum into 
 the tissues. At the periphery of the area of exudation the 
 capillaries are in a state of spasm, and when this spasm is past 
 the wheal disappears almost as suddenly as it arose. Some- 
 times the amount and rapidity of exudation is so great that the 
 epidermis is elevated in the form of a bulla, as occurs in urti- 
 caria bullosum. The well-known nettle rash shows typical 
 wheals. 
 
 TUBERCULA ; TUBERCLES. 
 
 Definition. — Circumscribed, pea to hazel-nut or larger sized, 
 firm, rounded, or acuminated, deeply-seated or elevated form- 
 ations in the skin. 
 
 The term tubercle is applied to any mass too large to be 
 called a papule, but not large enough for the designation of 
 tumor. There is no sharp line between the size of a papule 
 and a tubercle ; in fact, many of the tubercles we meet with 
 commenced as papules, as in the case of the tubercles in sec- 
 ondary syphilis. In many of these cases of syphilis one may 
 see all grades, from a small papule to a large tubercle, and in 
 other cases one is in doubt whether to describe the case as one 
 of papular or tubercular syphilis. 
 
 In shape, tubercles are generally circumscribed, and may be 
 
42 SECONDARY LESIONS. 
 
 roundish, flat, conical or irregular in outline. As they usually 
 owe their origin to an inflammatory cell-growth, they are gen- 
 erally reddish in color, but may be normal, as in molluscum con- 
 tagiosum, or black, as in purpura with considerable haemor- 
 rhage. They are firm in consistence and very similar in structure 
 to papules. They may have their seat deep in the skin, when they 
 can be recognized only by the feel, or they may be elevated above 
 the general surface. They are usually inflammatory or neoplastic 
 in origin, and are met with in syphilis, lepra, carcinoma, tinea 
 trichoplytina barbae and other affections. Their course de- 
 pends upon their nature ; usually they ulcerate, and are fol- 
 lowed by scars. 
 
 PHYMATA ; TUMORS. 
 
 Definition. — Variously shaped and sized tumor-like forma- 
 tions in the skin. 
 
 These growths vary in size from a walnut to that of a child's 
 head ; are usually semi-globular in shape, and have their origin 
 either in the subcutaneous tissue, or there and in the corium. 
 From the deep tissue they push upward, and form either eleva- 
 tions or pendulous tumors. Their color is usually that of the 
 skin. Their constitution differs according to the seat of origin 
 and nature of the pathological process. They may arise from 
 the sebaceous glands (milium), or as new growths in the 
 corium, subcutaneous tissue, bloodvessels or lymphatics. 
 
 SECONDARY LESIONS. 
 
 SQUAMAE ; SCALES. 
 
 Definition. — Collections on the cutaneous surface of loose, 
 dry, epidermic scales. 
 
 In normal conditions there is always some desquamation of 
 the uppermost corneous cells occurring, their place being sub- 
 sequently occupied by new cells from beneath. In pathologi- 
 cal conditions, it is the rapidity of the formation of epidermic 
 cells, or an interference with the normal horny transformation 
 process that gives rise to the collection of scales on the surface. 
 
SECONDARY LESIONS. 
 
 43 
 
 The desquamation occurs either in the form of thin, fine, bran- 
 like scales (furfuraceous desquamation), as occurs in squam- 
 ous eczema and tinea trichophytina corporis ; or as larger, 
 thin, shining, dry or fatty scales, as in psoriasis or seborrhcea 
 sicca ; or as large, thin lamellae, as in pityriasis rubra (mem- 
 branous desquamation); or as thick, plate-like masses, as in 
 ichthyosis ; or, finally, as large, adherent, parchment-like masses, 
 as occurs especially on the hands and feet in scarlatina des- 
 quamatio siliquosa. They are met with in all inflammatory 
 affections of the skin, and also in some anomalies of growth of 
 the epidermis. In pityriasis rubra, they are formed in immense 
 number. In psoriasis they form heaped up masses of a pearly 
 white color. In seborrhcea they have a shining, greasy appear- 
 ance from the collection of oil in the cells. In ichthyosis, and 
 in the later stages of lichen ruber, the amount of scaling is 
 very great. In color they are generally whitish or grayish ; 
 sometimes they are shining or glistening. They are generally 
 somewhat loosely attached to the epidermis beneath, but in 
 some cases, as in lupus erythematosus, they are very firmly ad- 
 herent. 
 
 CRUST^E ; CRUSTS. 
 
 Definition. — Masses of dried serous, or sero-purulent exuda- 
 tion on the free surface. 
 
 Crusts arise either from a drying up of the exudation de- 
 posited on the free surface from catarrhal inflammation of the 
 skin, as in ordinary or in impetiginous eczema ; or from a drying 
 up of the pus in the affections of the skin associated with the 
 formation of pustules ; or finally, from drying up of the exuda- 
 tion in ulcerative processes, as lupus and the ulcerating 
 syphilide. The color of the crust will depend upon the nature 
 of the exudation. If it is serous, the crust will be thin and 
 gummy or honey-like in appearance ; if it is dried up pus, it 
 will be yellowish or greenish ; if blood is mixed with the exu- 
 dation, it will be brown or black. Crusts vary in consistence 
 from the thin, friable crust of eczema to the thick, hard, dark 
 crust seated over syphilitic ulcers. The shape of the crust de- 
 
44 SECONDARY LESIONS. 
 
 pends upon the nature of the skin upon which it is seated, and 
 their size upon the amount of exudation and duration of the 
 disease. The oyster-shell shaped crust observed in syphilis 
 (rupia syphilitica) is caused by the peripheral spreading of 
 the ulcer at the same time that the central portion still continues 
 in a state of ulceration, and consequently furnishes continu- 
 ously fresh exudation to push the already formed crust more 
 and more outward. In some cases scales and crusts become 
 mixed together, and form what are called crustae lamellosae. 
 
 RHAGADES ; FISSURES. 
 
 Definition. — Linear fissures of the epidermis or epidermis 
 and corium. 
 
 Fissures arise from a rupture of the epidermis or corium of 
 a cutaneous or mucous surface. It is caused by the action of 
 the muscles on a skin which, from inflammation, has become 
 infiltrated and inelastic. It is consequently met with especially 
 on the flexures of joints, on the palms of hands and soles of 
 feet, upper eyelid, juncture of nose with upper lip, at the 
 back of the ear, at the angles of the mouth, and on the 
 tongue. It can also be caused by external applications which 
 produce too great dryness of the epidermis as occurs after the 
 use of strong soaps. In the latter case the fissure will extend 
 only through the epidermis, and not into the corium. Fissures 
 may be long or short, broad or narrow, superficial or deep, 
 straight or crooked. If deep they will have steep margins 
 and a bloody or purulent base. Fissures are met with espe- 
 cially in chronic eczema of the hands ; in lichen ruber, sclero- 
 derma and syphilis. 
 
 EXCORATIONES ; EXCORIATIONS. 
 
 Definition. — Greater or less loss of epidermis from traumatic 
 influences or chemical agents. 
 
 Excoriations are almost invariably caused by scratching on 
 account of itching in connection with some skin diseases. The 
 excoriation may consist in a loss of only a portion of the epi- 
 dermis, or it may extend to the corium, or even include some 
 
SECONDARY LESIONS. 45 
 
 loss of the papillary connective tissue, although if the corium 
 was affected to any appreciable extent it would be an ulcer. 
 The extent of the excoriations depends entirely upon the force 
 employed in scratching and the susceptibility of the skin. If 
 the epidermis is already injured by an inflammatory process, as 
 eczema, scratching will cause deeper excoriations than if it was 
 in a normal condition. Long-continued scratching of a part 
 leads to inflammation, infiltration and pigmentation of the 
 skin. Unless the corium is affected, excoriations heal by new 
 epidermis. The form and situation of excoriations often 
 assist in forming a diagnosis. In pediculosis corporis long ex- 
 coriations are found especially on the neck and shoulders. In 
 scabies they are small, round and found on the fore-arms, abdo- 
 men and thighs. 
 
 ULCERA ; ULCERS. 
 
 Definition. — Irregularly sized and shaped excavations in the 
 skin the result of a suppurative process. 
 
 A cutaneous ulcer is a suppurative process on the free sur- 
 face of the skin, accompanied by loss of substance of the 
 corium, and with a disposition to extend in size from molecu- 
 lar disintegration of the skin at the margin of the ulcer. A 
 laudable suppurating and granulating wound, or a loss of 
 substance which affects the epidermis alone, as occurs 
 in eczema, is not an ulcer. An ulcer is never a primary 
 formation, but is always the result of some other condi- 
 tion. Wherever an ulcer is to arise there must be at that 
 place either an inflammatory or neoplastic production formed 
 which has within itself the conditions of a molecular disinte- 
 gration and consequent ulcer formation, or the normal process 
 of recovery is interfered with by some local or general influ- 
 ences (Kaposi). Lupus, lepra, carcinoma and tubercular 
 syphilides are predestined from their nature to undergo ulcera- 
 tive degeneration. Local influences which produce ulceration 
 by increase of the inflammatory processes are local interfer- 
 ence with the circulation, varicose veins, tearing, bruising, 
 scratching, plasters, irritation of the granulations by saliva, 
 
46 SECONDARY LESIONS. 
 
 faeces, etc. Among distant causes of ulceration are diseases of 
 the heart, and dyscrasic conditions producing impoverished 
 blood. The inflammatory ulcers are those which are the result 
 of dermatitis of any kind, the best example being the so-called 
 varicose ulcer, scrofulous ulcers, and the syphilitic ulcers in- 
 cluding the chancroid. The ulcers arising from new growths are 
 those of lupus, epithelioma, carcinoma, and lepra. As objective 
 symptoms in every ulcer we should study the form and size of 
 the ulcer, the mode of spreading, nature of margin and base, 
 nature of secretion and condition of the surrounding tissues. 
 Small ulcers are generally round ; larger ulcers of irregular 
 form, deep, and unevenly pitted, or more superficial with 
 smooth base. In size they may vary from that of a bean to 
 that of the half or even whole of an extremity. The base is 
 usually of a grayish yellow color, infiltrated with pus and flat 
 or unevenly pitted. The margins are perpendicular, sloping 
 or undermined, movable or firmly attached, soft or hard. 
 The secretion is either copious or sparse, viscid, purulent or 
 sero-purulent and dries into crusts of different colors and 
 thickness, depending on the nature and amount of the secre- 
 tion. Outside the margin and base the skin in inflammatory 
 ulcers is usually inflamed ; in ulcers from new growths it is 
 generally normal. In every ulcer there is a stage of destruc- 
 tion corresponding to the period of extension ; and, if it heals, a 
 stage of reparation. In the chancroid ulcer the stage of de- 
 struction corresponds to the stage of contagiousness of the 
 secretion ; in the stage of reparation the secretion is no longer 
 contagious. Ulcers heal by the formation of cicatricial tissue, 
 leaving permanent scars. 
 
 CICATRICES ; SCARS. 
 
 Definition. — Variously sized and shaped, reddish, brownish 
 or whitish new formations of connective tissue occupying the 
 place of lost normal tissue. 
 
 In appearance scars are either smooth and soft, or uneven, 
 contracted, band-like, and freely movable or firmly attached 
 to the under-lying tissue. They are either on a level with the 
 
ETIOLOGY OF SKIN DISEASES. 47 
 
 surrounding skin (normal scar) or depressed (atrophic scar), 
 or elevated (hypertrophic scar) and are devoid of the furrows, 
 lines, pores and hairs of a normal skin. Recent scars are red- 
 dish in color, afterwards they gradually become paler, and fi- 
 nally white. Sometimes they are pigmented, especially at the 
 margin. The form of an ulcer depends upon the form of the 
 previous ulceration or wound of the part. There is no special 
 form of scar pathognomonic of any one disease; nevertheless, a 
 consideration of their number, situation, and form, often assists 
 in making a correct diagnosis. The kidney-shaped scar is gen- 
 erally the result of syphilis. So are also scars with sharply 
 limited margins and scalloped edges, as such a condition shows 
 that the preceding ulceration has commenced from two or 
 more closely-seated centres and has spread peripherically. 
 
 For the formation of a scar there must be previous loss of 
 corium ; loss of epidermis alone is not followed by cicatricial 
 formation. Scars are new formations of connective tissue with 
 a thin covering layer of epidermis. It contains in addition, 
 bloodvessels and lymphatics, but no nerves, sebaceous glands, 
 hair follicles or sweat glands. 
 
 PIGMENTATION. 
 
 Pigmentation is an increase in the color of the skin in con- 
 sequence of chronic hyperaemia, inflammation, new-growth for- 
 mation or trophic disturbance. It may be temporary or per- 
 manent. 
 
 The etiology, diagnosis and treatment of diseases of the skin 
 in general will be here but briefly alluded to, as they will re- 
 ceive full consideration when treating of the individual dis- 
 eases. The limits of the manual will not permit of unnecessary 
 repetition. 
 
 ETIOLOGY OF SKIN DISEASES. 
 
 Diseases of the skin are either idiopathic or symptomatic. 
 All of the acute contagious inflammatory diseases ; many of 
 the non-contagious inflammatory diseases, as urticaria, acne, 
 
48 DIAGNOSIS OF SKIN DISEASES. 
 
 herpes, pruritus, chloasma, etc., are symptomatic either 
 of a general blood condition, or dependent upon disorder 
 of a non-cutaneous organ or system. Among the idio- 
 pathic affections are to be included diseases of the sebaceous 
 glands ; most of the non-contagious inflammatory diseases ; 
 hypertrophies, atrophies (?), tumors and parasites. Many of 
 the idiopathic inflammatory affections are increased in intensity 
 or prolonged in duration by pathological non-cutaneous con- 
 ditions, such as intestinal disorders and an over-acid condition 
 of the system. Occupation, clothing, mode of living, contagion, 
 hereditary conditions, may all be factors in the production of 
 a cutaneous lesion. The different causes and the symptom- 
 atic or idiopathic nature of the lesions will be noted in con- 
 nection with each disease. 
 
 DIAGNOSIS OF SKIN DISEASES. 
 
 To be a successful diagnostician of diseases of the skin, the 
 physician must be acquainted with the anatomy of the skin, 
 with the pathological processes concerned in the formation of 
 both the primary and secondary lesions, and with the pathol- 
 ogy of inflammation, hypertrophy, atrophy and tumors. If he 
 understands these and has a classification to guide him and a 
 good text-book, the subject will not prove difficult to master. 
 For instance suppose he has to deal with a case of haemorrhage 
 into the skin, he can at once exclude by his knowledge of 
 pathological processes all the diseases included in the classifi- 
 cation except those under haemorrhages, and then by the aid of 
 a text-book can soon learn whether it is a case of purpura 
 simplex, rheumatica, haemorrhagica or a case of haematidrosis. 
 And so with all the other affections. If he finds that the les- 
 ion is an inflammatory one and not belonging to the acute 
 contagious inflammatory disease, he knows also whether it is a 
 papular, vesicular, pustular, etc., eruption, and can at once 
 place it as one of the diseases constituting that particular group, 
 and with the aid of his text-book complete the diagnosis. The 
 physician in learning to diagnose must not therefore rely en- 
 
TREATMENT OF SKIN DISEASES. 
 
 49 
 
 tirely upon objective symptoms, as color, shape of eruption, 
 etc., but must endeavor also to find out the cause of the ob- 
 jective and subjective symptoms and the nature of the patho- 
 logical process. 
 
 For examining a patient properly, daylight is necessary in 
 many cases, as artificial light changes the color of many of the 
 eruptions, and sometimes renders it impossible to make a posi- 
 tive diagnosis. The temperature of the room should not be 
 less than sixty-five degrees Fahrenheit ; except in the case of a 
 suspected macular syphilide which is made more prominent if 
 the temperature of the room is colder. The extent of the 
 eruption, its situation, color, form, mode of spreading, duration, 
 condition of the skin of the affected part, subjective symptoms, 
 age and history of patient, should be accurately learned and 
 noted. To determine the nature of the primary lesion, the 
 eruption is to be examined, and if there is but a single patch 
 on the body, the earliest lesion will be found generally at the 
 periphery. For instance, a squamous patch of eczema may re- 
 semble very closely a patch of psoriasis, but close examination 
 will almost invariably detect a few vesicles at the periphery 
 and thus settle the diagnosis. Examination of the whole body 
 is advisable, when permitted, as the person might have more 
 than one cutaneous disease ; and again it may be necessary for 
 diagnosis in a doubtful case. Inquiry should also be made as 
 to his occupation, mode of living, nature and place of habitation 
 and the kind of medicine, if any, which he is taking. 
 
 With all these observations properly carried out, it may still 
 be impossible to diagnose the eruption the first time it is seen ; 
 and a further study of its course and nature may be necessary 
 even with an experienced dermatologist. These very difficult 
 cases are rare and usually represent anomalous forms of erup- 
 tion. 
 
 TREATMENT OF SKIN DISEASES. 
 
 The treatment will be fully explained in connection with the 
 individual diseases. I only wish here to remark that a knowl- 
 edge of general medicine — a practical knowledge and not a 
 4 
 
50 TREATMENT OF SKIN DISEASES. 
 
 book one alone — is absolutely necessary for the successful 
 treatment of many skin diseases. Among all the specialties in 
 medicine and surgery, dermatology is the least independent of 
 general medicine and general pathology. 
 
 No cutaneous lesion can be cured too rapidly ; there is never 
 any danger of the general health or any organ suffering from 
 the removal of the skin disease ; but evil results may follow 
 the long continuance of even an ordinary eczema, as I have 
 observed many times in the case of young children. The con- 
 stant worriment from itching interferes with their appetites 
 and reduces their general nutrition, so that a bronchitis, acci- 
 dentally occurring, is liable to become chronic, and may lead to 
 a broncho-pneumonia and death. 
 
 The purely local diseases are to be treated by local measures 
 alone, but all others require local and general treatment. 
 Every case must be studied and treated according to its indi- 
 vidual peculiarities. Routine treatment will fail in many cases. 
 The local treatment will depend upon the form of eruption 
 and susceptibility of the skin. The internal treatment will con- 
 sist of special remedies for the eruption and such others as are 
 necessary to bring the general system to a normal physiological 
 -standard. Anaemic, chlorotic, or hydraemic persons must have 
 proper food, good air, and tonics, iron, quinine, cod-liver oil, 
 'etc., as the individual case requires. Plethoric or fleshy (fat) 
 persons require restricted diet, alkalies, as sulphate of magnesia 
 or Carlsbad water, exercise, and avoidance of beer or wine. 
 Rheumatic or gouty subjects must be treated for these con- 
 ditions even if they do not suffer specially from them at the 
 time of the eruption. I have seen a case of ulcer of the leg 
 from varkose veins resist all treatment until iodide of potas- 
 sium was given on account of a history of previous rheumatism, 
 upon which the wound healed very rapidly. 
 
CLASSIFICATION OF SKIN DISEASES. 
 
 For the study of skin diseases a classification is absolutely 
 necessary. A number of classifications have been proposed, 
 but that of Hebra's is the best for purposes of diagnosis. 
 With the exception of some few changes rendered necessary by 
 our increasing knowledge of the subject, the following classifi- 
 cation is that of Hebra. The classification proposed by 
 Auspitz, although to be commended for advanced dermatolo- 
 gists, is useless for teaching purposes. That adopted by the 
 American Dermatological Association was decided by ballot- 
 ing, and never should have seen the light. 
 
 LESIONS OF THE SKIN. 
 
 
 A. Primary Lesions. 
 
 
 B. Secondary Lesions. 
 
 I. 
 
 Maculae ; spots, macules. 
 
 I. 
 
 Squamae ; scales. 
 
 2. 
 
 Papula; ; papules. 
 
 o 
 
 Crustae ; crusts. 
 
 3- 
 
 Vesiculae ; vesicles. 
 
 3- 
 
 Rhagades ; fissures. 
 
 4- 
 
 Bullae ; blebs. 
 
 4- 
 
 Excoriationes ; excoriations, 
 
 5- 
 
 Pustulae ; pustules. 
 
 5- 
 
 Ulcera ; ulcers. 
 
 6. 
 
 Pomphi ; wheals. 
 
 6. 
 
 Cicatrices ; scars. 
 
 7- 
 
 Tubercula ; tubercles. 
 
 7- 
 
 Pigmentation. 
 
 S. 
 
 Phymata ; tumors. 
 
 
 
 CLASSIFICATION OF DISEASES OF THE SKIN. 
 
 Class I. Anomaliae Secretionis et Excretionis. 
 of Secretion and Excretion. 
 " II. Hypersemiae. Hyperaemias. 
 
 " III. Exudationes. Exudations. 
 
 Disorders 
 
52 
 
 CLASSIFICATION OF SKIN DISEASES. 
 
 Class IV. Hsemorrhagise. Hemorrhages. 
 
 V. Hypertrophic. Hypertrophies. 
 
 VI. Atrophic Atrophies. 
 
 VII. Neoplasmata. Tumors. 
 
 VIII. Neuroses. Neuroses. 
 
 IX. Parasitse. Parasites. 
 
 Class I. Anomalise Secretionis et Excretionis. Disorders of 
 
 Secretion and Excretion. 
 
 Sebaceous Glands. 
 
 Sweat Glands. 
 
 Seborrhea -j sicca ' 
 Asteatosis cutis. 
 
 ( Comedo. 
 Abnormal excretion < Milium. 
 
 ( Sebaceous cyst. 
 
 Of entity $%&£* 
 
 ~. ... { Bromidrosis. 
 
 Of quality - ( chromidrosis< 
 
 Of excretion -{ Sudamina. 
 
 Class II. Hypersemise. Hyperemias. 
 
 A. Active. 
 
 ■j Eryth 
 
 ema congestivum 
 
 t, -n , ( T . , ( mechanica. 
 
 B. Passive, -> Livedo j traumatica> 
 
 [ i traumaticum. 
 
 idiopathic < caloricum. 
 J ( venenatum. 
 
 ( simplex, 
 symptomatic i r , 
 (_ J r ( roseola. 
 
 Class III. Exudationes. Exudations. 
 
 Acute Contagious Inflammatory 
 Diseases. 
 
 f Rubeola . 
 
 Roetheln. 
 I Scarlatina. 
 
 Variola. 
 
 Varicella. 
 
 Vaccinia. 
 
 Impetigo contagiosum. 
 
 Anthrax. 
 
 Equinia. 
 
 Erysipelas. 
 L Syphilis. 
 
CLASSIFICATION OF SKIN DISEASES. 
 
 53 
 
 non contagious 
 
 Inflammatory 
 
 Diseases. 
 
 Erythematous. 
 Papular. 
 
 Vesicular. 
 
 Bullous. 
 Pustular 
 
 Erythema. 
 Urticaria. 
 
 J Lichen. 
 [ Prurigo. 
 
 Herpes. 
 
 {Pemphigus. 
 Hydroa. 
 Pompholyx. 
 
 r 
 
 Acne. 
 
 multiforme, 
 nodosum. 
 
 j planus. 
 
 ( scrofulosus. 
 
 ( febrilis. 
 
 iris. 
 \ progenitalis. 
 | gestationis. 
 ^zoster. 
 
 j vulgaris. 
 / foliaceus. 
 
 simplex, 
 indurata. 
 
 Sycosis. 
 Impetigo. 
 Ecthyma. 
 Squamous. •{ Pityriasis rubra. 
 
 ( Furunculus. 
 Phlegmonous. -] Anthrax. 
 ( Abscessus. 
 
 Erythematous, Eczema. 
 
 vesicular, J 
 
 papular, pustu- , ^ 
 K i i 11 Dermatitis, 
 
 lar, bullous. 
 
 calorica. 
 
 venenata. 
 
 traumatica. 
 
 Class IV. Haemorrhage. Hemorrhages. 
 
 Purpura. 
 Hoematidrosis. 
 
 fsimpl 
 rheun 
 hsemc 
 
 ex. 
 
 matica. 
 morrhagica. 
 
 Pigment. 
 
 Epidermis. 
 
 Class V. Hypertrophic. Hypertrophies. 
 
 Lentigo. 
 
 Chloasma. 
 
 Ephelis. 
 
 Naevus pigmentosus. 
 
 Callositas. 
 
 Clavas. 
 
 Cornu cutaneum. 
 
 Keratosis pilaris. 
 
 Psoriasis. 
 
 Lichen ruber. 
 
54 
 
 CLASSIFICATION OF SKIN DISEASES. 
 
 Epidermis and Papillae. 
 
 Connective Tissue. 
 
 Hair. 
 Nail. 
 
 ( Verruca. 
 ( Ichthyosis. 
 
 Scleroderma. 
 
 Sclerema. 
 
 Morphcea. 
 
 Elephantiasis. 
 __ Dermatolysis. 
 
 Hirsuties. 
 
 ■ Onychogiyphosis. 
 
 Pigment. 
 
 Class VI. AtrophiSB. Atrophies. 
 ( Albinismus. 
 
 CONNNECTIVE TISSUE. 
 
 Hair. 
 
 Nail. 
 
 -j Y ilili s°- 
 
 Canities. 
 j Atrophia cutis propria. 
 ( Atrophia senilis. 
 f Alopecia, 
 j Alopecia areata, 
 j Trichorexis nodosa. 
 (^Atrophia pilorum propria. 
 
 ■] Onychatrophia. 
 
 Class VII. Neoplasmata. Tumors. 
 
 ' Rhinoscleroma. 
 Lupus erythematosus. 
 Lupus vulgaris. 
 Scrofuloderma. 
 Cellular. ■{ Molluscum contagiosum. 
 
 I Lepra. 
 Sarcoma. 
 Carcinoma. 
 (^ Epithelioma. 
 ( Keloid. 
 
 I Molluscum fibrosum. 
 j Xanthoma. 
 (_ Lipoma. 
 
 j Naevus vasculosus. 
 I Angioma. 
 
 Fibrous Connective Tissue. 
 
 Bloodvessels. 
 
 Lymphatics. 
 
 Nerves. 
 
 ] Lymphangioma. 
 
 Neuroma. 
 
 Class VHI. Neuroses. Neuroses. 
 
 Hyperesthesia. 
 
 {Hyperesthesia. 
 Dermatalgia. 
 Pruritus. 
 
CLASSIFICATION OF SKIN DISEASES. 55 
 
 Class IX. Parasitae. Parasites. 
 
 f Tinea trichophylina f corporis (or tinea circinata). 
 
 I (parasite — Trichophyton J capitis (or tinea tonsurans), 
 tonsurans.) } barbae (or sycosis parasitica. 
 
 Vegetable. \ Tinea favosa (or favus). L cruris < or eczema ™ ar gi^tum). 
 (parasite — Achorion Schoenleinii) 
 
 I Tinea versicolor. 
 
 [ (parasite — Microsporon furfur). 
 
 f Scabies (parasite — Acarus scabiei). 
 J ( corporis. 
 
 J Pediculosis (parasite — Pediculus). < capitis. 
 [ ( pubis. 
 
 Animal. 
 
CLASS I. 
 ANOMALL^E SECRETIONIS ET EXCRETIONIS. 
 
 Disorders of Secretion and Excretion. 
 
 In this class are included all anomalies of secretion and ex- 
 cretion of the sebaceous and sweat glands. The secretion of 
 the sebaceous glands may be abnormally increased (seborrhoea) 
 or abnormally diminished (asteatosis cutis) in amount, or from 
 some cause or other it may not reach the surface in the usual 
 manner, but be retained in some part of the gland structure 
 (comedo, milium, sebaceous cyst.) The secretion of the 
 sweat glands may be abnormally increased (hyperidrosis) or 
 diminished (anidrosis) in amount or changed in quality (bromi- 
 drosis, chromidrosis), or not reach the surface, but be retained 
 within the epidermis or duct (sudamina.) 
 
 SEBOERHCEA. 
 
 Syn., Steatorrhoea ; Stearrhoea ; Seborrhagia ; Acne Sebacea ; 
 Ichthyosis Sebacea ; Cutis Unctuosa ; Dandruff. 
 
 Definition. — A functional disease of the sebaceous glands, 
 consisting in an increase in the amount and a change in the 
 quality of the sebaceous secretion, and characterized by the 
 formation of an oily coating or fatty scales on the skin. 
 
 Symptoms. — Under normal conditions the sebaceous glands 
 furnish a certain amount of secretion to the hairs and to the 
 general surface of the skin, to give them the necessary softness 
 and elasticity, and to protect the internal organs. This secre- 
 tion consists principally of free fat, fatty epithelial cells and 
 dry epithelial cell remnants from which the fat has escaped. 
 
SEBORRHCEA. 57 
 
 Seborrhoea consists in an abnormal excess in production of the 
 fat elements (seborrhoea oleosa) or of the dry, epidermic cells 
 (seborrhoea sicca) or of both combined. 
 
 Seborrhoea oleosa appears either in the form of drops of a yel- 
 lowish color, or as an oily covering to the cutaneous surface, or 
 as thicker or thinner fatty, friable crusts or scales. When 
 drops of oil form, their usual seat is the nose, but they may 
 form on other parts of the body. Crusts are met with prin- 
 cipally upon the scalp. 
 
 In seborrhoea sicca, which is the usual form encountered, 
 the secretion dries to fatty plates, or to thin bran-like scales, 
 or to a dry yellowish mass. 
 
 Seborrhoea is either general or local, that is, it occupies the 
 entire surface or is confined to parts of the body. The vernix 
 caseosa of newborn children is an example of general sebor- 
 rhoea. The secretion in this case usually dries to thin plates 
 and falls off in a few days. In some rare cases, however, it re- 
 mains, and drying, forms thick lamellae, which fix the skin be- 
 neath and lead to fissures on the fingers and flexures of the 
 joints. This form of eruption has been described as ichthyosis 
 congenita neonatorum. The eyes are fixed from the stretching 
 of the skin, the lips are also fixed, the gums exposed, and the 
 fingers, toes, and external portion of ears undeveloped. These 
 children die soon after birth. 
 
 On the scalp of children the sebaceous secretion usually con- 
 tinues to form in excess for one or two years, the amount 
 varying in different cases and forming collections varying 
 from thin scales to thick yellowish crusts or masses. It is often 
 complicated with eczema. 
 
 Universal seborrhoea in adults is rare. It appears either as 
 fine scales (seborrhoea tabescentium, pityriasis tabescentium), 
 or as large dry masses or plates overlying each other (ichthyosis 
 sebacea.) 
 
 Local seborrhoea is met with principally upon the scalp, 
 forehead, nose, cheeks, hairy part of skin over sternum, mons 
 veneris and genitals, and will be described under the local 
 forms. 
 
58 SEBORRHCEA. 
 
 Long continued seborrhcea in hairy regions may lead to 
 atrophy of the hair follicles and consequent alopecia. The 
 eruption is usually unaccompanied by inflammation, the skin 
 often presenting a pale or leaden hue. Itching is a prominent 
 symptom in the dry form. 
 
 Localized seborrhcea as it occurs upon the scalp, face, body 
 and genitals, requires separate consideration. 
 
 Seborrhcea capitis. — This is the most frequent and important 
 local seborrhcea, and appears generally in the dry form. In 
 children it is met with as a continuation of the vernix caseosa 
 condition, and may last a few months or one or two years. It 
 appears on the vertex first, in the form of isolated grayish or 
 yellowish scales and afterward, by an increased collection of 
 sebum, forms thick, yellowish, grayish-brown, cheesy-like, 
 friable, fatty or dry crusts or scabs which may become united 
 to each other and adherent to the scalp. After a short exist- 
 ence they become dark in color from admixture of dirt. These 
 crusts form especially over the anterior fontanelle region 
 where they may form adherent, hard, lamellar masses. If the 
 mass is removed artificially, it quickly re-forms, as the glands 
 are very active. The skin beneath is normal or slightly moist 
 in appearance,never inflamed or discharging unless complicated 
 by an eczema, the result of irritation from decomposition of 
 sebum situated beneath dry crusts. After a few months or 
 one or two years, the gland secretion gradually diminishes in 
 amount, the growing hairs remove the scales, and the part 
 heals spontaneously. In adults, seborrhcea capitis appears 
 either in the form of thin, or thick, yellowish white, adherent 
 lamellar scales from drying up of fatty matter, or, as is gener- 
 ally the case, it appears as thin, whitish, grayish, yellowish or 
 brownish dry loose scales. It generally extends over a con- 
 siderable part of the scalp, but especially affects the vertex. 
 The scales are always more or less friable and greasy to the 
 feel. The amount of scaling differs in different cases, there 
 may be only a few adherent scales around hairs, or they may 
 be thrown off in such amount as to require frequent brushing 
 from the person's clothes over the shoulders. The skin beneath 
 
SEBORRHCEA. 59 
 
 is normal in color, or paler, with a dull leaden hue ; especially 
 in chronic cases in elderly chlorotic females ; or slightly hyper- 
 aemic, especially- at the junction of the forehead with the 
 hairy scalp. Itching is a prominent symptom, and from the 
 irritation produced by scratching, small, localized spots of tem- 
 porary dermatitis often result. The hair follicles become more 
 or less affected, their nutrition is interfered with, the hair loses 
 its lustre, becomes loose in the follicle and falls out, producing 
 an alopecia. If the seborrhoea is chronic the alopecia may be 
 permanent, the hair follicles becoming destroyed. The course 
 of the disease is chronic, lasting months or years. 
 
 The eyebrows, mustache and beard are often affected in the 
 same manner as the scalp. 
 
 Seborrhea faciei. — This occurs especially upon the forehead, 
 nose, temples and chin, and appears either as the oily or dry 
 form, but generally as the former. It is met with principally 
 between the age of puberty and thirty, and is more frequent 
 in females than males. In the oily form the skin has a shining, 
 greasy look, which is easily removed by ether or alcohol, but 
 quickly reforms. Owing to the facility with which particles of 
 dust adhere to fat, the skin is difficult to keep clean, and if not 
 frequently washed has a dirty appearance from the dust col- 
 lected. The skin itself is normal in color or slightly reddish, 
 the mouths of the sebaceous follicles large, and comedones 
 plentiful. In the dry form the secretion dries to thin or thick 
 crusts or scales, which are firmly adherent and of a yellowish, 
 greenish-brown or blackish color. Removal of the scales with 
 the nails will show that plugs of sebaceous matter extended 
 from the scales into the ducts of the follicles. The skin 
 beneath is normal or hyperaemic. Itching is often present. 
 
 Seborrhoea is very frequent on the end of the nose (point 
 and alae) and adjoining skin. It forms either yellowish to 
 brownish crusts, which are firmly adherent, and provided 
 beneath with sebaceous plugs which dip down into the follicles ; 
 or their thin, dry, adherent scales with similar plugs. The skin 
 beneath is shining and often reddish, the follicle ducts are 
 large and the veins often dilated. Forcible removal of the 
 
60 SEBORRHCEA. 
 
 adherent crusts sometimes causes oozing of the blood. Eczema, 
 comedones, and acne spots are oceasional complications. 
 
 Seborrhea corporis. — On the non-hairy parts of the body 
 the disease differs considerably in appearance from seborrhcea 
 of the head and face. It occurs generally upon the back, be- 
 tween the scapulae and over the clavicle, and on the hairy part 
 of the skin over the sternum. It appears in the form of round- 
 ish or irregular shaped, more or less sharply limited, variously 
 sized patches, which remain isolated or afterward coalesce to 
 form larger patches. They are pale reddish in color, and covered 
 with yellowish or grayish-yellow fatty scales. The amount of 
 scaling varies, though it is rarely abundant, owing to their be- 
 coming detached by the friction of the clothing. The scales are 
 loose or semi-detached, and show under the microscope free 
 fat, fatty epithelium and horny epithelium. The entire gland 
 epithelium is sometimes thrown off without the contents alter- 
 ing their relative normal position in the gland — an exfolia- 
 tion more than a seborrhcea. A patch is sometimes made up 
 of pin-head sized, or larger, isolated spots corresponding to 
 separate sebaceous glands. If these are arranged in a circular 
 form, or if a larger patch clears up somewhat in the centre, the 
 eruption resembles considerably that of ringworm. Acne pa- 
 pules or pustules are often present around the margin of a 
 patch. Over the sternum the patches are usually circular in 
 form and, in my experience, have fewer scales than in patches 
 on the back. The skin is pale-reddish in color, and scraping 
 the patches often causes some oozing of blood. Itching is a 
 prominent symptom. They have a very chronic course. 
 
 Seborrhcea of the umbilicus is frequently observed. Here 
 the sebum collects, and, undergoing decomposition, irritates the 
 skin and produces an eczematous condition. 
 
 Seborrhcea gcnitalium. — In this region the condition described 
 as seborrhcea very frequently consists more in the retention of se- 
 creted sebaceous matter than in increased activity of the glands. 
 It is met with especially in persons with a narrow preputial ori- 
 fice. In males the sebaceous matter is found around the glans 
 penis and sulcus, and owing to the warmth and moisture present 
 
SEBORRHCEA, 6 1 
 
 readily decomposes and irritates the parts, producing a balanitis 
 or a balano-prostitis. The glans and prepuce become red, 
 swollen, excoriated and painful. There is considerable dis- 
 charge, and, as the urethral orifice often becomes affected by 
 the inflammation, the condition may resemble very closely a 
 gonorrhoea. In females the smegma collects between the 
 smaller labia and nymphae and around the clitoris, producing 
 sometimes a balanitis or vulvitis- 
 
 Anatomy. — Seborrhcea is a functional disease of the seba- 
 ceous glands ; there is increased secretion, but no inflammation. 
 If the process is chronic it leads to chronic degenerative 
 changes, and, in consequence, there is finally atrophy of the 
 sebaceous glands and hair follicles and more or less permanent 
 alopecia. In seborrhcea of the body there is, in some cases 
 slight nutrition changes in the peri-glandular tissue, as shown by 
 the redness of the skin and the few lymphoid corpuscles oc- 
 casionally present in the crusts. 
 
 Etiology — Vernix caseosa, and the continuation of this con- 
 dition, as observed on the heads of children for the first one or 
 two years of life, may be regarded as physiological. Sebor- 
 rhcea proper sometimes follows on a part which has been attacked 
 by an inflammatory process, as erysipelas, variola and eczema. 
 Seborrhcea of the scalp frequently follows conditions associated 
 with a depraved state of the general nutrition, as carcinoma, 
 tuberculosis, scrofulosis, acute exanthemata, and typhus ; or 
 occurs in consequence of an anaemic or chlorotic state of the 
 system. 
 
 It is more frequent in females than in males, and is especially 
 frequent about the period of puberty. Disorders of menstrua- 
 tion have been noted to be often present. Exposure to heat 
 assists in increasing the activity of the process in seborrhcea 
 faciei. Persons with light hair and complexion usually have the 
 dry form, and those with dark hair and complexion the oily 
 form. 
 
 Diagnosis. — Seborrhcea of the scalp may resemble eczema, 
 psoriasis, or ringworm. In eczema the eruption is not usually 
 confined to the scalp, but tends to invade the forehead, neck, 
 
62 SEBORRHCEA. 
 
 and back of the ears. The scales are usually more numerous, 
 are not greasy, but composed of inflammatory products and 
 epithelial cells ; there is great itching ; the glands of the 
 neck are frequently enlarged, which does not occur in 
 seborrhcea, and the skin is not pale, but red and inflamed. 
 In psoriasis the eruption rarely extends over the whole 
 scalp, occurring usually in patches, which are sharply limited 
 and covered by dry, shining scales seated upon a reddish 
 base. There is usually psoriasis patches on other parts of the 
 body. In both psoriasis and eczema the hair nutrition is un- 
 affected. In ringworm there is an eczematous condition present, 
 the patches are circular in shape, the hairs are broken off, and 
 the fungus is easily detected by means of the microscope. 
 
 Seborrhcea of the face resembles somewhat erythematous 
 lupus, eczema, psoriasis, or a commencing epithelioma of the 
 rodent form. In lupus the scales are fewer and more firmly 
 adherent, the patch is sharply limited, the growth is very slow 
 but continuous, except in the discoid form, there is new cica- 
 tricial tissue to be observed replacing the normal structure of 
 the part. The diagnosis between seborrhcea and eczema and 
 psoriasis has been given above. In that form of epithelioma 
 which supervenes upon a verrucca senilis, or commences like a 
 congestive seborrhcea, it is sometimes impossible, in the earliest 
 stage, to separate it from a seborrhcea sicca. Usually in epi- 
 thelioma the patch is sharply limited at the margin, and small 
 in extent, and there is a slight atrophy to be observed. If the 
 pin-head sized, dense, waxy-like nodules are present, then the 
 diagnosis is easily made. Seborrhcea of the body may resemble 
 any of the above diseases, or tinea versicolor and ichthyosis. 
 In ringworm the patches are circular in form, sharply limited, 
 spread rapidly, the centre soon heals, the peripheral part con- 
 tains indications of inflammatory papules or vesicles, the scaling 
 is slight, and consists of exudation and dry epithelium, and 
 the skin is in a more or less inflamed condition. Ichthyosis is 
 an hereditary affection ; the scaling is general and permanent, 
 the scales are dry, and the whole skin feels dry and harsh. 
 Seborrhcea is generally local, the scales are easily removed, are 
 
SEBORRHCEA. 63 
 
 greasy, the other parts of the patch are normal, and the 
 disease is curable. In ichthyosis, the skin, upon removal of the 
 scales, is pale and dry; in seborrhcea it is smooth, soft, and often 
 reddish. 
 
 Seborrhoea of the genitals may be mistaken for gonorrhoea. 
 The swollen condition of the glans, the excoriations in the 
 sulcus, the sero-mucus nature of the urethral discharge, and the 
 history of the case — the urethritis being secondary to the 
 balanitis, are sufficient for the diagnosis. 
 
 Prognosis. — Hereditary universal seborrhoea, apart from 
 vernix caseosa, is a fatal affection, the children dying soon after 
 birth. Seborrhcea of adults is a chronic, but also a curable 
 affection, unless the result of such diseases as carcinoma and 
 tuberculosis. Many cases undergo spontaneous cure. If 
 seborrhcea of the scalp continues any length of time it produces 
 temporary or permanent alopecia. In cases resulting from 
 chlorosis, scrofula and disorders of menstruation, it is difficult 
 to cure. 
 
 Treatment. — The treatment of seborrhoea is both constitu- 
 tional and local. The constitutional treatment depends upon 
 the special pathological condition present. If carcinoma or 
 tuberculosis is present no form of treatment will have a perman- 
 ent effect. If the person has a scrofulous or lymphatic constitu- 
 tion, tonics, with cod-liver oil and good hygienic conditions, are 
 necessary. If anaemic or chlorotic, iron, alone or in combination 
 with arsenic, together with good food, pure air and out-door ex- 
 ercise, are of marked benefit. If occurring at the age of puberty, 
 in persons otherwise healthy, a mixture containing sulphate of 
 magnesia, sulphate of iron, dilute sulphuric acid, and infusion 
 of quassia (the mistura ferri acidaof Startin) is of benefit. The 
 local treatment will depend upon the irritability of the affected 
 skin, the amount of crusting or scaling, and the duration of the 
 disease. In young children the crusts should be removed by 
 the use of oil (olive oil or sweet oil) in the following manner : 
 If only a small amount of crusting is present, the oil can be 
 thoroughly rubbed into the crusts, and in a few hours the part 
 can be washed clean by means of soap and warm water, and an 
 
64 SEBORRHCEA. 
 
 . astringent ointment, as oxide of zinc, applied. If the crusts 
 re-form to any exent, the same mode of treatment can be fol- 
 lowed every day until the part is normal ; but generally all that 
 is required is to use the soap and water, and ointment on the 
 subsequent days. The soap should be of good quality, such as 
 the elder-flower soap of Low, Son & Haydon, lest the skin 
 becomes irritated and eczema be produced. 
 
 If the crusts are very thick the oil should be well rubbed in 
 several times of an evening, and allowed to remain on the head 
 until the following morning ; a flannel cap and bandage pro- 
 tecting the bed clothes and preventing the oil from escaping. 
 The head is washed and treated in the morning in the manner 
 already described. The soaking in oil operation is to be re- 
 peated as often as necessary to keep the head free of crusts. In 
 adults the same plan of treatment is followed. The crusts 
 must always be removed before applying remedies to the scalp. 
 In males the hair should be cut short, although this is not ab- 
 solutely necessary and should not be recommended in the case 
 of females. If but a few scales are present, the oil can be ap- 
 plied with a stiff brush and the head washed soon afterward 
 with soft soap and warm water. After drying thoroughly, an 
 ointment or lotion should be applied for the cure of the disease. 
 If there is but slight seborrhcea, astringent ointments, as zinc 
 ointment with glycerine and bismuth, or a sulphur ointment, one 
 to two drachms to an ounce of lard, or the red oxide of mer- 
 cury, two grains, or calomel five to ten grains to an ounce of 
 vaseline are of benefit. Alkaline lotions, especially of borax 
 or ammonia, are of decided benefit by allaying itching and hin- 
 dering the formation of scales. Alcohol alone, or combined 
 with carbolic acid or glycerine or castor oil, or all combined, as 
 in the following formula, can be employed. 5. 01. ricin., 3 ss ; 
 acid, carbol., gtt. 20 ; alcohol 3 iss ; ol. amygdal. am. 3 ii. In 
 cases of dry seborrhcea of the scalp without much scaling, but 
 with itching and a tendency to the production of alopecia, I 
 have often used the following with good results : I£. Spir. am- 
 nion, aromat ; tinct. cantharid ; liq. potas. arsenitis, aa § ss ; 
 glycerini, 3 i ; aquae rosae, § vi. Sig. To be well rubbed into 
 
SEBORRHCEA. 65 
 
 the scalp once a day. If there is much itching, the head should 
 first be washed with borax or ammonia and water. Usually it 
 is only necessary to moisten the part sufficiently to enable one 
 to dress the hair. Occasionally oil of cade, one drachm to an 
 ounce of zinc ointment, acts well in these scaly cases attended 
 by unusual itching. Whenever the skin becomes tense, shining, 
 dry, an oil should be applied. I prefer fresh beef marrow or 
 pure salad oil. 
 
 In obstinate cases, with a tendency to an accumulation of a 
 large amount of secretion, it is generally necessary to follow the 
 plan of treatment laid down by Hebra. The crusts are to be 
 removed by first rubbing or soaking them thoroughly with oil 
 several times at short intervals, and then covering the scalp 
 with a flannel cap, and over that a bandage. This remains un- 
 til the following morning, when the scalp is washed with soap 
 and water. Ordinary soft soap is generally sufficient ; if not, 
 then use the spiritus saponis kalinus of Hebra, made by di- 
 gesting for twenty-four hours one part of green soap and two 
 parts of alcohol and flavoring with a few drops of an essential 
 oil. The soap or mixture is rubbed on the scalp, and the part 
 thoroughly washed and rubbed dry, using warm or cold water 
 applied with a flannel. The soap is then removed by clear 
 water, and the scalp dried. The skin is now red, dry, shining, 
 tense, so that it is necessary to apply an oil or pomade to re- 
 lieve the unpleasant feeling. After a few days, when the skin 
 is no longer tender, the lotions or salves previously recom- 
 mended can be employed. This operation of washing is to be 
 repeated as often as necessary to remove crusts. The active 
 friction with the flannel and the removal of the crusts removes 
 all the hairs which were loose in the follicles, or sticking only 
 in the crusts, and consequently the hair of the head appears 
 much thinner than before the washing. Patients must be in- 
 formed of this beforehand, otherwise they will regard it as a 
 result of the treatment. Whatever plan of treatment is fol- 
 lowed, it must be employed faithfully until the scalp has re- 
 turned to a normal condition. 
 
 Seborrhcea of the body and face requires the same treatment 
 5 
 
66 ASTEATOSIS CUTIS. 
 
 as that- described for the scalp, only the crusts are more easily 
 removed. 
 
 Seborrhcea of the genital region demands cleanliness, fre- 
 quent washing with water, retraction of the prepuce several 
 times a day, behind the sulcus for a few minutes, until the 
 part becomes dry by exposure to the air, and drying or as- 
 tringent powders, as bismuth, oxide of zinc, starch, lycopo- 
 dium. If there are excoriations, an ointment of zinc or dia- 
 chylon, spread on linen, should be used. In all cases, washing 
 of the inflamed part with the urine, by grasping the foreskin 
 and preventing the escape of urine until the prepuce has been 
 fully distended, is to be recommended. 
 
 ASTEATOSIS CUTIS. 
 
 Syn., Asperitudo cutis. 
 
 Definition. — An affection of the skin characterized by an 
 abnormal diminution in the amount of sebaceous matter 
 secreted. 
 
 Symptoms. — The affection is hereditary or acquired ; general 
 or partial. As an hereditary condition it is present in ichthy- 
 osis, and frequently in severe cases of hereditary syphilis. In 
 these cases the skin is dry, inelastic, and easily fissured ; the 
 hair is also dry, lusterless and falls out easily. Hereditary as- 
 teatosis is general in its distribution. Acquired asteatosis may 
 be general or partial. It is met with in chronic marasmic con- 
 ditions, as that of old age, or as is seen in some cases of can- 
 cer and in badly nourished subjects when it is general, or 
 associated with some forms of paralysis and anaesthetic lep- 
 rosy, when it is partial. An artificial asteatosis is produced by 
 the application of substances to the skin which remove fat, as 
 strong soaps, lye, and water containing lime salts or potash. In 
 these cases the skin is dry, inelastic, easily fissured, perhaps 
 finely scaly or hyperaemic, and, from the absence of the protec- 
 tive sebaceous matter, sometimes eczematous. The skin feels 
 dry in the scaly affections, as psoriasis and lichen ruber, but 
 the dryness is owing to the abnormal collection of dry epidermic 
 
COMEDO. 67 
 
 cells on the surface, and not to a deficiency in the activity of 
 the sebaceous glands. 
 
 Prognosis. — The prognosis depends upon the cause. If 
 this is removed the asteatosis will disappear. If from im- 
 perfect development of the glands, as in ichthyosis, it is 
 incurable. 
 
 Treatment. — The oil which keeps the skin soft and elastic is 
 derived mostly from the sebaceous glands, but a small quantity 
 is also furnished by the sweat glands. As we know of no drug 
 which increases the sebaceous gland secretion, and the diapho- 
 retic remedies, as pilocarpin, seem not to increase the oily part 
 of the sweat secretion, we are compelled in cases of asteatosis 
 to rely upon the external application of an animal or vegetable 
 oil, as almond oil, palm oil, vaseline, fresh fat to keep the skin 
 soft and pliable. If the condition depends upon some affec- 
 tion, as psoriasis, the latter must be treated at the same time. 
 For the dry, brittle hair the same treatment is required as for 
 the similar condition of the skin. 
 
 COMEDO. 
 
 Definition. — An affection of the sebaceous glands consisting 
 in dilatation of the duct with retention of sebaceous matter in 
 the lumen, and characterized by yellowish or blackish pin-point 
 to pin-head sized spots corresponding to the orifices of the 
 glands. 
 
 Symptoms. — Comedones are seated at the orifices of the 
 sebaceous glands and appear as pin-point to pin-head sized 
 yellowish, yellowish white or blackish points which correspond 
 to the orifice of a sebaceous gland. Unless there is retention of 
 a considerable amount of sebaceous matter in the glands they 
 are not elevated above the level of the skin. By lateral pressure 
 the sebum can be expelled in a thread-like form, and, as the end 
 has a black color from dirt the whole mass resembles somewhat 
 a worm in appearance. From this resemblance the laity fre- 
 quently speak of this eruption as " black worms in the skin." 
 In simple comedo there is no inflammation around the glands. 
 
68 COMEDO. 
 
 When this occurs the condition is called acne. The number of 
 points present varies greatly in different cases. There may be 
 only a few or the whole face or shoulders may be studded with 
 them. They are either disseminated or grouped, though usually 
 the former. They are met with especially upon the forehead, 
 nose, temples and shoulders ; situations where the sebaceous 
 glands are well developed and the hairs fine. The eruption is 
 generally combined with seborrhcea oleosa. The course of the 
 disease as a whole is variable. If untreated it may last several 
 years. With advancing age it tends to spontaneous cure. The 
 individual points disappear after a short duration to be 
 replaced by a new collection in the same duct ; or new points 
 form in other glands. Frequently the retained mass, either from 
 pressure or irritation from chemical changes in the se- 
 bum, produces a peri-follicular inflammation and consequent 
 acne. 
 
 Anatomy. — Comedo consists of dilatation of the lumen of a 
 sebaceous gland by a collection of retained sebum. The 
 dilatation may take place either in the duct or in the gland 
 portion proper. When occurring in the duct it may be 
 either at the external portion or deeper down, the orifice re- 
 maining normal. Usually there is some dilatation of both 
 duct and gland proper. The longer the comedo exists the 
 greater will be the dilatation in the gland. The retained 
 mass consists of a peripheral part made up of epidermic cells 
 of the duct and hair root sheath, and a central part consisting of 
 fatty epidermic cells of free fat, cholesterine crystals, detritus 
 and one or more lanugo hairs, either bent upon itself, curled up 
 inside the gland, or broken into two or more pieces. This 
 central mass, with the exception of the hair, comes from the 
 sebaceous gland. Occasionally the parasite, acarus folliculorum 
 is present, but has no part in the production of the pathological 
 condition. The black point is caused by dirt, not by natural 
 pigment, and the discoloration extends but a short distance on 
 the plug. In Fig. 21 is represented a section of a comedo in 
 which both the duct and gland proper is dilated. The con- 
 tents of the gland were much degenerated, the central part 
 
COMEDO. 
 
 69 
 
 consisting mostly of detritus. Three pieces of hair are seen 
 within the gland. The surrounding tissue was normal. 
 
 a 
 
 Fig. 21. — Vertical section of a large and small comedo : a, black point at 
 orifice of the sebaceous gland ; a', orifice of a sebaceous duct and hair follicle. 
 The orifice is somewhat dilated and the end of the plug discolored ; b, degenerated 
 epithelium and detritus in sebaceous gland ; c, collapsed wall of sebaceous gland. 
 
 Such a condition of the gland contents as is here observed 
 would lead to inflammation and destruction of the whole gland 
 structure. That this does not always occur is shown by the 
 frequency with which plugs form in succession in the same 
 orifice, perhaps a number of times. 
 
 Etiology. — Comedo is intimately associated with the period 
 of rapid development of the sebaceous glands and hairs. It is 
 most frequent at the period of puberty and lasts until the age 
 of twenty to thirty, ceasing as a rule earlier in females than 
 males. Disorders of digestion, constipation, chlorosis, scrofu- 
 lous conditions and disorders of menstruation are all to be 
 regarded as indirect causes of the eruption. The skin of the 
 part affected often seems to lack tone, it is muddy looking, 
 cedematous like, and oily from a seborrhcea oleosa. The un- 
 striped muscle bundles evidently contract sluggishly. The 
 lanugo hairs which grow very actively at the period of puberty, 
 and whose shaft in its upward course assists in bringing the 
 
70 COMEDO. 
 
 sebaceous gland secretion to the free surface, are often found 
 curled up within the gland, and in consequence, the means for 
 expulsion are probably often reduced below the necessary 
 amount. In persons with seborrhcea oleosa, the neglect of 
 washing the face sufficiently often with a strong enough soap 
 to remove the oil is often followed by comedo formation. 
 Cases of comedo resulting from working in an atmosphere of 
 tar or dirt are examples of mechanical obstruction to the exit 
 of the sebaceous matter. 
 
 Diagnosis. — Comedo may be confounded with acne punctata 
 or milium. In acne there is always a peri-glandular inflamma- 
 tion present, and in simple comedo it is absent. In milium 
 there is no black point or dilated duct and the sebaceous con- 
 tents cannot be squeezed out as in comedo. 
 
 Prog7iosis. — The prognosis is always favorable, the condition 
 can generally be removed in a few weeks, but it may last 
 months or years. 
 
 Treatment. — The treatment is constitutional and local. Dys- 
 pepsia, constipation, menstrual disorders, or a scrofulous con- 
 stitution, if present, must receive appropriate treatment. Easily 
 digested food, avoidance of acids or any thing that tends to 
 produce an acid dyspepsia, and proper outdoor exercise, with 
 frequent bathing, are to be ordered. If the bowels are consti- 
 pated and the patient robust, saline aperients, with a bitter in- 
 fusion should be given ; or, if they are chlorotic, or of a lymphatic 
 constitution, iron, cod-liver oil and saline aperients. A pill 
 composed of iron, aloes and nux vomica is also useful in the 
 latter case. Ergot internally, as for acne, is sometimes of advan- 
 tage. 
 
 Locally the comedo plug can be removed by perpendicular 
 pressure with a watch-key, or by lateral pressure between the 
 finger-nails, but as this is a troublesome procedure if there are 
 many comedoes present, it is best to wash the face well with 
 soft soap and warm water, using considerable friction. The 
 soap is to be put on a piece of flannel and this dipped in warm 
 water and then applied briskly to the face for a few minutes. 
 If necessary the soap can be combined with alcohol. The soap 
 
MILIUM. 71 
 
 is removed with warm water, the face then dried and a stimu- 
 lating application, as a sulphur ointment or alcohol, applied. If 
 a sulphur ointment is used it should be left on over night, 
 washed off in the morning and the skin powdered with starch 
 or bismuth. The ordinary sulphur ointment may be used, or 
 better, equal parts of sulphur, glycerine, alcohol, carbonate of 
 potash, sulphuric ether and peruvian balsam. If the skin is 
 irritated by treatment use should be made of alkaline lotions or 
 ointments of borax or bicarbonate of soda, or bismuth, or starch 
 powder used. If seborrhcea oleosa is present it must be treated in 
 the manner already recommended. For use in day time a solution 
 of corrosive sublimate in glycerine and alcohol is often of ben- 
 efit. I use the following : t>. Hydr. bi-chlor., gr. ii ; glycerine, 
 3 ii ; spir. vini rectif., 3 iv. This is used after washing the 
 face with soft soap and warm water and then drying it. It is 
 slightly stimulating and astringent. Sulphate of zinc, five 
 grains to the ounce, may be added to the solution if a more 
 astringent effect is desired. 
 
 MILIUM. 
 
 Syn., Grutum ; Acne Albida ; Strophulus Albidus ; Tuber- 
 culum Sebaceum. 
 
 Definition. — Milium consists in the formation of small, dense, 
 roundish, whitish, non-inflammatory elevations, situated in the 
 upper part of the corium. 
 
 Symptoms. — Probably a large number of the cases reported 
 as milium, have in reality been cases of comedo, in which the 
 retention of the sebaceous matter is retained in the secreting 
 portion of the gland. I would consider the milium or stroph- 
 ulus albidus of children, those white or yellowish collections of 
 sebaceous matter which occur especially on the nose and 
 cheeks, as cases of deep seated comedo. After superficial in- 
 flammation of the skin, as erysipelas and pemphigus, somewhat 
 similar collections have been observed and should be classed 
 with them. In these cases the whitish or yellowish substance 
 consists of very similar elements as normal sebaceous secretion, 
 and is clearly in connection with a sebaceous gland as shown 
 
72 
 
 MILIUM. 
 
 by the gland orifice. In true milium, a sebaceous gland orifice 
 is rarely to be found over the papule ; it seems to consist of 
 something imbedded in the skin like a new growth. As will be 
 seen afterward, their contents do not always resemble sebaceous 
 matter, but consist of cells which resemble more the corneous 
 cells of the epidermis. 
 
 They appear as pin-head to small pea sized, rounded, flat 
 or acuminated, elevated or non-elevated, hard, firm, whitish or 
 yellowish formations, situated generally just beneath the 
 epidermis. They are found especially on the upper eyelid, 
 cheeks and temples, penis and scrotum. There may be only 
 one or two, or they may be very numerous. They form slowly 
 and having attained a certain size, may remain unchanged for 
 years. 
 
 Anatomy. — The majority of authors consider them as resulting 
 from retention of sebaceous matter in one or more acini of the 
 
 d~ 
 
 Fig. 22. — Section of a milium, from the face : a } corneous layer ; b, rete ; 
 c, corium ; d, milium corpuscle ; e, sebaceous gland. 
 
 sebaceous gland. Virchow and Rindfleisch think they arise from 
 
MILIUM. 73 
 
 the hair follicles. My own view, based on the situation of the 
 formation, the nature of the contents in different cases, and the 
 presence or absence of connection with a gland duct, is, that 
 two different conditions have been described under the same 
 term. Where the formation is superficially seated, contains no 
 fatty epithelium, shows no connection with a sebaceous gland 
 when sections are examined by the microscope, and has no duct 
 in connection with it, I think it is a case of miscarried embryonic 
 epithelium from a hair follicle or from the rete. They may be 
 seated near a sebaceous gland without having any connection 
 with it, as in fig. 22. The formation in these cases, according 
 to my experience, consists of more or less lobulated collections 
 of corneous-like cells, the whole collection being surrounded 
 by a more or less perfectly formed capsule, from pressure ex- 
 ercised by the growing new formation, and provided with septa 
 of fibrous connective tissue. 
 
 In the cases following pemphigus, erysipelas, syphilis, lupus, 
 the contents consists of fatty epithelium and cholesterine, the 
 epithelium being often arranged in concentric layers around a 
 central fat nucleus. 
 
 Etiology. — Until our views on the anatomy of the subject are 
 more definite than at present, we cannot know the etiology. If 
 I am not correct in my view, then milium may follow superficial 
 inflammation of the skin as erysipelas and pemphigus, or result 
 from constriction of a portion of the gland by the cicatricial 
 tissue following the ulceration of lupus and syphilis. It is met 
 with at all ages, but is most frequent during the first two years 
 of life. 
 
 Diagnosis. — The affection may closely resemble xanthoma. 
 This eruption appears later in life, is never present in children, 
 the patches are symmetrical, of a yellow color and perfectly 
 soft and pliable, not dense and hard like milium. Milium can 
 be squeezed or easily dug out after cutting the epidermis 
 covering it ; in xanthoma this is impossible, the patch can only 
 be removed by the knife. 
 
 Prognosis. — The eruption has no influence on the skin in 
 general. It is easily removed by treatment. 
 
74 SEBACEOUS CYST. 
 
 Treatment. — In the case of children the spots disappear in a 
 few days, if the skin is washed with soap and water. In those 
 cases observed by Kaposi, occurring after pemphigus and 
 erysipelas, the application of soft soap to produce a slight 
 dermatitis caused them to be exfoliated in a few days. In 
 other cases the epidermis over the spots is to be cut and the 
 contents of the milium squeezed out or scraped out. If they 
 result from a closing of an acinus, the cavity can be subse- 
 quently touched with tincture of iodine to obliterate the acinus. 
 
 SEBACEOUS CYST. 
 
 Syn. — Atheroma ; Steatoma ; Sebaceous tumor ; Encysted 
 sebaceous tumor ; Follicular tumor. 
 
 Definition. — Variously-sized, elevated, roundish or semi-glob- 
 ular, sharply limited tumors in the corium or subcutaneous tissue. 
 
 Symptoms. — These tumors are cysts of the sebaceous glands, 
 and are found principally upon the scalp, forehead, eyebrows, 
 neck, back and scrotum. They may be single or multiple. 
 Their size and shape depend greatly upon their age. At first 
 they appear as small pea-sized roundish masses beneath the 
 epidermis, but as they grow in size they become more elevated, 
 roundish or semi-globular. They may attain the size of a hen 
 egg or larger. They are generally freely movable, and the skin 
 above them is normal or paler than usual from compression of 
 the vessels by the tumor, and more or less devoid of hair. In 
 old persons the surface generally presents a shining, greasy ap- 
 pearance. In some a gland duct orifice can be seen, and in 
 others it is absent. Their consistence varies from firmness to 
 fluctuation, depending upon the condition of the contents as 
 described in the anatomy. They grow very slowly, and having 
 attained a certain size, may remain stationary, or even break 
 down spontaneously and ulcerate, discharging a foetid, slimy or 
 sero-purulent matter. 
 
 Anatomy. — The tumor is a cyst of the sebaceous gland, and 
 is produced by retention of the gland secretion ; that is, it is a 
 retention cyst. It consists of a capsule and contents. The 
 
SEBACEOUS CYST. 75 
 
 capsule consists of fibrous connective tissue — the normal 
 capsule hypertrophied from irritation exerted upon the capsule 
 by pressure from distension. The contents vary in different 
 cysts. They may be hard and friable, or cheesy, soft, slimy, 
 or fluid. They are yellowish, grayish or whitish in color and 
 with or without a foetid odor. They consist of epidermic cells, 
 fat drops, cholesterine, detritus, and sometimes a lanugo hair. 
 Sometimes they undergo cheesy degeneration or even have 
 lime salts deposited in the mass. In young tumors the 
 epithelium is often arranged concentrically. They show no 
 tendency to produce acute peri-glandular inflammation like the 
 contents in comedo. 
 
 Diagnosis. — They resemble somewhat fatty tumors, osteo- 
 mata and gummata. Fatty tumors are rare upon the scalp, 
 are seldom multiple, have a doughy feel, are not so freely mov- 
 able, grow to large size, and have no connection with a 
 sebaceous gland duct. Osteomata are very hard and im- 
 movable. Gummata grow rapidly, are painful to the touch, 
 tend to break down and ulcerate, and are not movable like the 
 sebaceous cyst. 
 
 Prognosis. — The prognosis is favorable, except in the case of 
 very old, enfeebled persons, in whom they may suppurate and 
 produce serious results. 
 
 Treatment. — They may be removed by squeezing out the 
 contents through the duct and injecting the sack with iodine, 
 provided the contents are soft enough to be removed in this 
 manner ; or, the skin over the tumor may be destroyed by 
 caustic and the contents of the gland discharged by ulceration ; 
 or, the tumor may be excised. The last method is the best. 
 The contents may be removed and the capsule touched with 
 iodine, or better still, remove the capsule and contents and 
 treat the wound like any scalp wound ; that is, on antiseptic 
 principles. There is always some danger in removing them in 
 old and enfeebled subjects, but the danger is reduced to a min- 
 imum if antiseptics are employed for the wound, and tincture 
 of the chloride of iron given for two or three weeks previous 
 to the operation. 
 
76 HYPERIDROSIS. 
 
 HYPERIDROSIS. 
 
 Syn. — Idrosis ; Hydrosis ; Ephidrosis ; Sudatoria. 
 
 Definition. — A functional disorder of the sweat glands, con- 
 sisting in an increased secretion of sweat. 
 
 Symptoms. — The conditions which normally cause increased 
 activity of the sweat glands have been already noticed. An in- 
 crease in the sweat production from subjection to a high tem- 
 perature, exposure to the sun's rays, or excessive muscular ex- 
 ercise does not constitute a hyperidrosis. 
 
 Hyperidrosis may be either universal or local. In the course 
 of some general diseases, as rheumatism, phthisis, acute or 
 chronic fevers and cachectic conditions of the system, sweat is 
 often produced in excessive quantity either over the whole 
 body or in certain regions. Most fat persons sweat in conse- 
 quence of slight muscular exercise, or when laboring under ex- 
 citement or nervous irritation, or confined in warm rooms, and 
 in these cases the skin at first is congested and warm, and af- 
 terward cool from abstraction of heat by the sweat. Where 
 two surfaces come in contact, as in the groin, perineum, and 
 beneath the mamma, this constant production of sweat in uni- 
 versal hyperidrosis is liable to produce maceration of the epi- 
 dermis and intertrigo, which later tends to further changes 
 in the tissue and the production of an eczema. Sometimes a 
 papular or papulo-vesicular eruption like an eczema is ob- 
 served accompanying the hyperidrosis, but usually disappears 
 in a few days by desquamation. 
 
 General hyperidrosis may be continuous or temporary, lasting 
 many years, or only for a short period. 
 
 Local hyperidrosis occurs especially upon the face, scalp, 
 axillae, genitals, palms of the hands and soles of the feet. It 
 may be continuous or temporary, and symmetrical or non-sym- 
 metrical. Wilson reports a case where there was excessive 
 sweating on one side of the face, and the opposite side of the 
 chest, whilst the rest of the body was dry. It may soon 
 disappear or it may last a great number of years. Hyperi- 
 drosis of the axillary region is met with, especially in 
 
HYPERIDROSIS. 77 
 
 women, and is generally associated with increase in the se- 
 baceous gland secretion also. The excess in sweating may 
 be so great as to soak the clothes in that region in a short time. 
 From intermingling of the sweat and sebaceous secretion the 
 clothes are discolored and a most disagreeable odor emanates 
 from the arm-pits. Hyperidrosis of the genital region corre- 
 sponds in character with that of the axillae. In the palms of 
 the hands the affection is very frequent, and if severe is very 
 annoying from the inability of the person affected to keep the 
 hands dry. Usually the whole palm is affected. The sweat is 
 clear in color, and can be seen emerging from the orifices of the 
 sweat ducts. The skin acquires a whitish, sodden appearance, 
 and feels cold and clammy. It occurs in both sexes and mostly 
 in young persons. They are usually chlorotic, anaemic, and of 
 a " nervous " disposition, easily excited, etc., but may also be 
 apparently in excellent physical condition. Hyperidrosis of 
 the feet is similar to that of the hands, but owing to the neces- 
 sity of wearing hose and shoes, the secretion collects in these, 
 especially the former, and, decomposing, gives rise to a more 
 or less disagreeable odor, (" stinking feet " ; bromidrosis). The 
 skin is macerated, sodden in appearance, frequently painful to 
 pressure, and fissures form in the flexures of the toes. The 
 sweat at first is clear, but owing to the heat and moisture of 
 the part it quickly decomposes and produces the offensive odor. 
 It is met with in all classes and is generally worst in summer. 
 The hands may or may not be simultaneously affected. 
 
 Anatomy. — There are no anatomical changes to be observed 
 in the sweat glands or surrounding tissue. I have examined a 
 number of sections from the palm of the hand, and always 
 failed to detect any thing abnormal in the size of the glands or 
 in the appearance of the glandular epithelium. Virchow found 
 the glands enlarged and the epithelium in a state of fatty de- 
 generation in cases of hyperidrosis in connection with phthisis. 
 
 Etiology. — The indirect cause of the excessive sweating is 
 not well known. The direct cause depends on the nerves of 
 the part, and on the state of the circulation, although the latter 
 plays a secondary role in regulating the amount of sweat pro- 
 
78 HYPERIDROSIS. 
 
 duced. It is met with in persons suffering from some nervous 
 disorder, as migraine, paraplegia ; or, they are simply " nerv- 
 ous." It may arise from an irritation of the cerebro-spinal nerves, 
 or from a paralysis of the sympathetic. There is either a paraly- 
 sis of the vaso-motor nerves or an active capillary congestion. 
 If the sympathetic is cut in the neck, there will be hyperidosis 
 in the paralyzed part. In a reported case of unilateral hyperi- 
 drosis there was congestion and haemorrhage into the sympa- 
 thetic ganglion in the neck on the same side. Disease of the 
 lungs and of the right side of the heart, causing congestion of 
 the veins and capillaries, is a cause of excessive sweating. The 
 affection is sometimes hereditary. 
 
 Diagnosis. — Seborrhcea oleosa and prickly heat may resem- 
 ble somewhat hyperidrosis. In seborrhcea the secretion is oily 
 and the eruption itches. In prickly heat the little vesicles are 
 surrounded by an inflamed area, and consequently it is an in- 
 flammatory affection. In hyperidrosis there are no inflamma- 
 tory papules or vesicles formed. 
 
 Prognosis. — This will depend upon the cause. If dependent 
 upon debility or some functional derangement of the nervous 
 system, the prognosis is favorable. Hyperidrosis of the axilla, 
 hands, feet, etc., frequently ceases spontaneously. Most of the 
 cases, however, can only be relieved, and not cured. 
 
 Treatment — In universal hyperidrosis, besides the treatment 
 for the general condition, as obesity, etc., the local treatment con- 
 sists in sponging with alcohol or cologne water and using dust- 
 ing powders, as starch and~ lycopodium. Warm clothes, hot 
 drinks and inordinate muscular exercise are to be avoided. 
 Where cutaneous surfaces come in contact, as in the axilla, under 
 the mammary gland, etc., care should be taken to keep the 
 sweat from macerating the skin and producing intertrigo or 
 eczema, by the use of powders and absorbent antiseptic cotton. 
 Water for washing the parts should always be hot and medi- 
 cated. 
 
 In hyperidrosis of the axilla, hands, genitals, and mild 
 cases of the feet, the parts should be washed with astringents, 
 as solutions of tannic acid, acetate of lead, sulphate of zinc 
 
HYPERIDROSIS. 79 
 
 ( 3 i to aqua 3 j) ; corrosive sublimate, alcohol, tincture of 
 belladonna, full strength, tincture of aconite, chloral, 10 to 20 
 grains to the ounce of water, ammonia diluted in water, and 
 afterward powdered with starch, lycopodium, bismuth, oxide of 
 zinc, carbonate of lead, or salicylic acid with starch (1 to 40). 
 Dr. Thin recommends wearing cork soles, and soaking them and 
 the stockings in a solution of boracic acid and drying them 
 before using. This will assist in preventing decomposition of 
 the sweat and the formation of the disagreeable odor arising 
 therefrom. Lint or absorbent cotton, with the powder, should 
 be used between the toes and fingers, and under the breast. I 
 have seen cases of eczema of the perinaeum and axilla, depend- 
 ent upon irritation from excessive sweating entirely recover in 
 a short period by the use of borated absorbent cotton alone. 
 
 In severe cases of stinking feet, Hebra's treatment with dia- 
 chylon salve is the best. This salve is made by mixing equal 
 parts of lead plaster and olive oil or a petroleum extract (vas- 
 eline, cosmoline) together in a water bath over a slow fire. 
 This ointment will be spoken of in the remainder of this book 
 as diachylon ointment. A piece of linen, large enough to en- 
 velop the foot and cut to the right shape, is covered with the 
 ointment, care being taken to use plenty of the ointment, and 
 the foot placed upon it. Ointment is also spread on separate 
 pieces of linen and placed between the toes. The whole foot 
 is then enveloped with the linen upon which the salve has been 
 applied, bandaged, and the stockings and shoes put on. On 
 the following day the salve is removed by means of lint and 
 powder, not washed, and new salve applied as on the previous 
 day. This procedure is to be repeated from ten to fourteen 
 days, when powder only is to be applied. 
 
 In a few days the skin exfoliates as thick lamellae or crusts. 
 When this exfoliation is complete, the feet are to be washed 
 and powdered in the manner described for mild cases. If the 
 hyperidrosis is not cured with the first course of treatment, the 
 procedure must be repeated a second or third time if neces- 
 sary. 
 
 If there is any debility present, it should be treated by iron, 
 
80 ANIDROSIS. 
 
 quinine, strychnine, or the mineral acids. Anti-sweating rem- 
 edies, as aromatic sulphuric acid, belladonna, or ergot, may be 
 given. Of these belladonna or atropin is usually of most serv- 
 ice, but often has no effect whatever, either in small or large 
 doses. Pilocarpin, in small or large doses, has been recom- 
 mended ; as also faradization. In spite of the use of any or all 
 of the above remedies, many of the cases of local hyperidrosis 
 will not even show the slightest improvement from treatment. 
 
 ANIDROSIS. 
 
 Definition. — A functional disorder of the sweat glands, char- 
 acterized by diminution or cessation of the sweat secretion. 
 
 Symptoms. — Anidrosis is either idiopathic or symptomatic. 
 There are many persons in whom during th^ir'whole life the 
 sweat glands are very inactive under conditions which ordinar- 
 ily produce visible sweat. Exposure to great heat or active 
 physical exertion has little effect in these cases upon the 
 amount of sweat secreted. These cases may be considered as 
 cases of idiopathic anidrosis, and as constituting an independ- 
 ent functional disorder of the sweat glands. In them the skin 
 is dry and hard to the touch ; the palms of the hands and the 
 soles of the feet feel uncomfortably dry, and easily become 
 cracked and fissured. 
 
 As a symptomatic condition, in connection with certain 
 diseases of the skin, or disorders of the nervous system, 
 or of the general nutrition of the body, anidrosis may 
 be either local or general. A dry skin is present in cases 
 of ichthyosis wherever the eruption is present ; but in 
 places free of the scabs, as the palms of the hands and the 
 soles of the feet, axilla, etc., it is absent. In chronic eczema, 
 psoriasis, lichen ruber, the skin is dry where the eruption ex- 
 ists, and normal in other situations. Although it is maintained 
 that there is diminished secretion in these cases at the seat of 
 the eruption, the probability is that the amount is not 
 diminished, and that the skin feels drier than normal on ac- 
 count of the pathological condition of the epidermis. More 
 than the normal quantity of sweat secreted would be re- 
 
BROMIDROSIS. 8l 
 
 quired to keep the excessively produced scabs present in 
 those diseases as moist as the normal epidermis, hence the 
 dry feel of the skin in these places is no proof that the 
 sweat gland function is interfered with by the local nutrition 
 disorder. Moreover, the secreting portion of the sweat glands is 
 too deeply seated to be affected by any simple anomaly of growth 
 of the epidermis, as is the case in lichen ruber and psoriasis. 
 
 In certain forms of paralysis, in the anaesthetic form of 
 leprosy, in diabetes, in some neuralgias, anidrosis is present. 
 In diabetes it is general, and in the other conditions it is 
 local. In all, it lasts as long as the disease producing it. . 
 
 In disorders affecting the general nutrition of the body, the 
 so-called cachectic diseases, as -carcinoma, tuberculosis, and in 
 fevers, there is generally temporary anidrosis. From whatever 
 cause it arises, the skin in this affection is dry and rough, with 
 the subjective feeling of dryness, itching and tension. 
 
 Treatment. — If symptomatic, the producing disease or con- 
 dition must be treated, and in addition, sweat-producing reme- 
 dies, as water, hot baths and jaborandi, may be ordered, if there 
 are no contra- indications. In the idiopathic form, baths, with 
 friction to stimulate the glands, is all that can be done. If the 
 skin becomes fissured, emollient applications should be em- 
 ployed. 
 
 BROMIDROSIS. 
 
 Syn. — Osmidrosis ; Stinking sweat. 
 
 Definition. — A functional disorder of the sweat glands, 
 characterized by an offensive odor of the perspiration. 
 
 Symptoms. — The perspiration of every individual is more or 
 less characteristic as shown by the ability of a dog to track the 
 footsteps of his master. If the perspiration is offensive, the 
 condition is called bromidrosis or osmidrosis. It is physiological 
 in the colored race, and is most marked in warm weather when 
 they sweat more than in winter. This universal bromidrosis is 
 also met with in some white persons who bathe regularly, and 
 are otherwise cleanly in their habits. In these cases the odor 
 arises from the composition of the sweat secreted by the glands 
 6 
 
82 BROMIDROSIS. 
 
 and not upon chemical changes occurring after it has reached 
 the free surface. They are cases of genuine bromidrosis. The 
 stinking sweat may be secreted only from certain parts of the 
 body, as the axilla, groin, genital region, feet ; situations where 
 the sweat glands are well developed, and where the secretion 
 does not so rapidly evaporate. Jn the majority of the cases, 
 however, of localized " stinking sweat " the disagreeable odor 
 arises from decomposition of sweat and sebaceous matters after 
 they have reached the free surface. This is especially true of 
 many of the cases of bromidrosis of the feet which could with 
 propriety be regarded as examples of local hyperidrosis. Even 
 in these cases, however, the secretion decomposes sooner than 
 it should normally, and as the odor is the characteristic symptom, 
 they may properly be classed under bromidrosis, unless ordinary 
 cleanliness is sufficient to remove the odor. Bromidrosis of the 
 feet is generally symmetrical, is met with in both sexes, is most 
 common in middle age, but may exist from early childhood to 
 old age. The symptoms on the feet have already been des- 
 cribed under hyperidrosis. In both general and local hyperi- 
 drosis, the sweat secreted is usually, though not always, in- 
 creased in amount. 
 
 Some diseases, as small-pox, typhus fever, etc., are ac- 
 companied with a more or less characteristic odor which has 
 enabled physicians sometimes to diagnose the disease before 
 examining the patient. These are not properly cases of 
 bromidrosis, neither are those in which there is a peculiar odor 
 present after the eating of some kinds of food, or the taking of 
 certain medicines, as iodine, asafcetida, etc. 
 
 Etiology. — The local form depends on the decomposition of 
 the fatty acids present in the sweat and sebaceous glands. 
 The universal form is physiological in the negro race. Sex has 
 no influence in its production. It is most frequent in middle 
 life. The nervous system is sometimes at fault. 
 
 Diagnosis. — It is to be diagnosed from hyperidrosis. In the 
 latter, the smell depends on the decomposition of the fatty 
 acids retained in the clothes or on the skin, and is remedied by 
 ordinary cleanliness. 
 
CHROMIDROSIS. 83 
 
 Treatment. — If physiological, extra attention to cleanliness, 
 and the use of a pleasant perfume on the skin or clothes is all 
 that can be done. If the nervous system is at fault, it must be 
 strengthened by appropriate tonics, good air, and proper food. 
 The treatment for local bromidrosis consists in the means 
 already described for local hyperidrosis of the feet. 
 
 CHROMIDROSIS. 
 
 Syn — Colored sweat. 
 
 Definition. — An affection characterized by a change in the 
 color of the sweat secretion. 
 
 Symptoms. — This is a very rare affection, but cases have been 
 reported from time to time in which the sweat secretion has 
 been of a yellowish, greenish, bluish, reddish, brownish or 
 blackish color. Probably in many of these cases deception 
 has been practiced upon the physician, as they have been met 
 with chiefly in unmarried, nervous or hysterical females. Cases 
 of genuine chromidrosis, however, have been reported by care- 
 ful observers. It consists in the admixture of normal sweat 
 with coloring matter. The sweat secretion is usually, but not 
 always, increased in quantity. It is met with especially upon 
 the face, chest, abdomen, arms, hands and feet. It is not con- 
 stant in its presence, appearing and disappearing at irregular 
 periods. It is more frequent in females than males, and among 
 the former, more frequent in the unmarried. They have been 
 generally in a nervous or debilitated condition and afflicted 
 with some uterine disorder. The disease has been known to 
 follow great excitement or shock to the nervous system. The 
 color is supposed to generally depend upon the presence of Prus- 
 sian blue or indican. Scherer. in one case, found the bluish 
 color to depend upon protosulphate of iron. A bluish tinge has 
 been observed in the sweat of persons employed in copper works. 
 
 Treatment. — The treatment is to be conducted on general 
 principles. The system is to be brought to a normal physio- 
 logical condition. The chlorosis, debility, hysteria, and uterine 
 disorders require appropriate treatment. If the kind of em- 
 ployment is the cause, then it must be changed. 
 
84 SUDAMINA. 
 
 Uridrosis. — (Urinous sweat.) This consists in a union of 
 urine elements, especially urea, with the sweat secretion. Norm- 
 ally the sweat contains a small amount of urea, but in this con- 
 dition it is greatly increased. As the sweat glands can perform 
 some of the functions of the kidneys, uridrosis is met with especi- 
 ally in disorders of these latter organs. It has been observed 
 after the use of jaborandi, and in cases of cholera. The urea 
 may be present in such quantity as to form a colorless or 
 whitish crystalline deposit, like flour upon the skin. 
 
 Phosphoridrosis. — Phosphorescent sweat is rare, and has been 
 observed after eating certain fish, in malaria, and in phthisis. 
 In the dark the body appears luminous. 
 
 Black sweat, from the presence of blood which has passed 
 into the sweat apparatus, is not properly a chromidrosis, but 
 the result of a haemorrhage, and consequently is noticed under 
 class iv. 
 
 SUDAMINA. 
 
 Syn. — Miliaria Crystallina. 
 
 Definition. — A non-inflammatory affection of the sweat 
 glands, characterized by the formation of pin-point to pin-head 
 or larger, isolated, superficial, clear, dew-drop-like vesicles. 
 
 Symptoms. — Three forms of sudamina have been described : 
 (i) Sudamina rubra, consisting of pin-point to pin-head or 
 larger red papules, or vesicles with a reddish base caused by 
 excessive sweating. (2) Sudamina alba, an eruption in which 
 the epidermis forming the vesicle is macerated and the vesicu- 
 lar contents of a milky color. (3) Sudamina crystallina, in 
 which there are no signs of inflammation and the vesicle con- 
 tents are clear. The first two forms belong to the inflamma- 
 tory affections. In this place we have to deal only with the 
 third form which alone deserves the name of sudamina. 
 
 Sudamina occurs in connection with febrile diseases, as 
 puerperal fever, pneumonia, typhoid, scarlatina, rheumatism, 
 variola ; in disease leading to cachectic conditions, as tuber- 
 culous, phthisis, carcinoma, pyaemia, chronic diarrhoea and 
 pleurisy in children, etc. Active muscular exercise in fat or 
 
SUDAMINA. 85 
 
 feeble persons, the application of hot cloths to the skin under 
 febrile conditions, too much clothing, leading to profuse sweat- 
 ing, and vapor baths especially in warm weather often cause 
 sudamina. 
 
 As an example of the combined action of exercise and vapor 
 baths, we have the formation of sudamina on the face of 
 washer-women, which will be described further on. Any thing 
 that causes an excessive secretion of sweat is a cause of sudamina. 
 
 Sudamina appears especially on the face, chest, abdomen, axilla 
 and groin, but may occur on the extremities. In puerperal fever 
 it occurs on the neck, breast, abdomen and thighs ; in typhoid 
 fever, on the body and extremities ; in scarlatina, upon the 
 body especially ; in pneumonia, on the chest ; in rheumatism 
 and the cachectic conditions, on the neck, chest and abdomen. 
 It is most liable to occur where the epidermis is thin, but may 
 occur where it is thick, as on the palms of the hands. 
 
 The eruption appears as isolated, pin-point to pin head or 
 larger, elevated, tense, clear, pearly-like vesicles, which have 
 been properly compared to dew-drops. They form quickly, re- 
 main almost invariably isolated, although crowded together, and 
 disappear by evaporation of the contents, and desquamation of 
 the epidermic covering. Their course is variable ; fresh vesicles 
 may continue to form, and the eruption consequently be pro- 
 longed for a considerable time. The more superficially seated, the 
 more rapidly will the contents evaporate ; hence, vesicles on the 
 face last much longer than those on the body. On the latter 
 situation they may disappear in one, two or three days ; in the 
 former they may last two or three weeks. They are never red- 
 dish in color or surrounded by a red areola. Sudamina of the 
 face appears especially in women from 35 or 40 to 50 years of 
 age or more ; the vesicles are roundish or acuminated, and ap- 
 pear more deeply seated than sudamina vesicles on the body. 
 They form rapidly after active exercise as washing, in persons 
 who sweat considerably in the face ; they are situated upon the 
 nose, forehead or cheeks ; are isolated and disappear very 
 slowly, without becoming opaque, or leaving evidence of their 
 presence. Sudamina of the palms of the hands occurs in sum- 
 
86 SUDAMINA. 
 
 mer from excessive sweating caused by the high temperature, 
 but it occurs also as the result of debility of the nervous sys- 
 tem. I have observed sudamina arise in children a few hours 
 before death, in whom there was no febrile affection. 
 
 Anatomy. — The vesicles in sudamina are caused by the col- 
 lection of sweat in some portion of the epidermis or sweat 
 duct. The contents are neutral or acid and without odor. 
 Under the microscope they are seen to consist of clear 
 
 Fig. 23. — Vesicle of sudamina crystallina. a, sweat gland ; b, roof of vesicle, 
 formed of corneous lamellae, and showing at b the orifice of the sv/eat duct ; 
 c, hair follicle, cut obliquely ; d> rete ; e } corneous layer ; /, vesicle. 
 
 sweat. The statement of Cornil and Ranvier that the 
 vesicles contain a large number of lymphoid corpuscles 
 is not correct. In those cases where, as on the body, 
 the vesicles appear as elevated, dew-drop-like collections of wa- 
 ter, the vesicle is situated between the lamellae of the corneous 
 layer. The walls of the vesicle are formed entirely by the 
 corneous layer ; the roof consisting usually of more than half 
 of the thickness of this layer ; that is, the liquid lies between 
 
SUDAMINA. 
 
 87 
 
 the laminae of the deeper part of the corneous layer. In this 
 form, then, the vesicle is not caused by a distension of the 
 sweat duct, but by its obstruction, which prevents the sweat 
 reaching the surface ; and causes it to rupture the wall and col- 
 lect between the lamellae. As the union between the cells com- 
 posing a single lamella is greater than that between contiguous 
 lamellae, the sweat passing in the direction of least resistance 
 will collect between the lamellae instead of reaching the free 
 surface. That the vesicle contents come from a sweat gland, 
 and not from the papillary bloodvessels, is proven by the 
 
 fi- 
 
 Fig. 24. — Section of a sudamina vesicle of the palm of the hand. a y sweat 
 duct ; a', sweat duct ; a" y sweat duct ; b, sudamina vesicle ; c, rete ; i, corium. 
 
 chemical character of- the contents, and the invariable presence 
 of a sweat duct at its base, as shown in fig. 23. 
 
 In fig. 23 is represented the manner in which the corneous 
 layer is separated and the walls of the vesicle formed. 
 
 In the palm of the hand, where the corneous layer is thicker, 
 elevated vesicles do not form so readily, but the situation of 
 the sweat collection is the same. In the case from which figure 
 
88 SUDAMINA. 
 
 24 was taken there was a peculiar tingling, burning feeling in 
 the hands, and the case some ways resembled those described 
 by Dr. Tilbury Fox as cases of dysidrosis. There was marked 
 sweating of the hands and a general nervous condition, but the 
 vesicles showed no tendency to group. In this case the sweat 
 ducts were ruptured in places, and vesicles of all sizes were 
 numerous when the sections were examined by the microscope ; 
 but in every case they arose from retained sweat and not from 
 
 Fig. 25. — Section of a sudamina vesicle from the forehead. . a t vesicle ; 
 5, sweat gland ; c, fat tissue ; d, hair follicles cut obliquely ; e, epidermis ; 
 /, lining epithelial cells of duct ; g , cell emigration. [At g and c, and between 
 the upper part of the vesicle and the epidermis, there is a round cell collection, 
 the result of changes produced by pressure by the vesicle contents. 
 
 transuded serum. Neighboring vesicles also sometimes co- 
 alesced. 
 
 In connection with a and a small collections of sweat are 
 seen between the corneous cells. The vesicle b comes from 
 the sweat duct a". It is to be noted that not a single lymphoid 
 corpuscle, or round cell, is to be seen within the vesicles. 
 
 In those peculiar cases of sudamina of the nose, forehead 
 and cheeks of females especially, it has already been mentioned 
 that the vesicles appear to be deeply seated and have a longer 
 existence than sudamina vesicles of the body. In fig. 25 
 
SUDAMINA. 89 
 
 is represented a section of one of such vesicles. Here the 
 obstruction takes place, not in the corneous layer or in the rete, 
 but in the corium, and consists of a dilatation of the sweat 
 duct, and not in an escape of sweat into the neighboring tissue, 
 as in the two former instances. The deep seat and mode of 
 origin of the vesicle will explain its chemical characters. The 
 duct becomes enormously dilated, but still lined with epithe- 
 lium which has become flattened out, and the contents consist, 
 not of sweat and inflammatory products, but of sweat alone. 
 Thus in all three cases sweat, as sweat, does not irritate the 
 skin and produce inflammation, and the contents of pure sud- 
 amina vesicles do not become purulent. 
 
 Etiology. — The excessive sweating is caused in a few cases 
 by the increased activity of the glands from the elevated tem- 
 perature. In these cases the skin is very dry, and, as a conse- 
 quence, the corneous cells contract and narrow the duct of the 
 sweat gland, thus causing an obstruction to the excessively 
 formed sweat. The cause of the formation of the vesicle 
 within the corium I am unable to explain. 
 
 The conditions of the system favoring the development of 
 sudamina have been described under the head of symptoms. 
 
 Diagnosis. — The eruption might be mistaken for miliaria or 
 varicella. In miliaria the vesicles are of the same size as those 
 of sudamina, but they are reddish in aspect, whilst sudamina is 
 non-inflammatory. In varicella the vesicles are larger, some 
 are multilocular, they commence on the head and subsequently 
 appear over the whole body, and are inflammatory in character. 
 
 Prognosis. — The prognosis depends upon the cause. 
 
 Treatment. — Idiopathic sudamina is to be treated by dusting 
 powders, as starch, lycopodium, etc., and washing the skin with 
 alcohol. Symptomatic sudamina may be treated in the same 
 way. If the eruption depends upon sweating caused by 
 excessive muscular exercise, or vapor baths, these are to be 
 avoided. In cases associated with debility, anti-sudoriferous 
 remedies are indicated. 
 
CLASS II. 
 
 HYPEREMIA— HYPEREMIAS. 
 
 In the class of hyperemias are included those conditions 
 in which there is an excess of blood in the vessels of a particu- 
 lar part. Conditions characterized by general hyperemia 
 (plethora), in which there is an increase in the total quantity 
 of blood in the system, are not included in this class. An in- 
 crease in the quantity of blood in a part may result from an 
 abnormal amount of blood being admitted to the part by the 
 arteries, in which case the blood pressure will be higher and 
 the current more rapid ; or there may be interference with its 
 removal from the part by the veins, when the current will be 
 abnormally slow ; hence, hyperemia may be either active or 
 passive. This division in dermatology is somewhat arbitrary, 
 and is made after the prominent clinical symptoms. The two 
 forms may have the same cause, and they may be both present 
 at the same time, as in the case of collateral hyperemia, where 
 there is stasis at the centre and fluxion at the periphery ; 
 or an active hyperemia may subsequently become a pas- 
 sive one, from increasing atony of the walls of the bloodves- 
 sels, the result of the long-continued distension. The terms 
 atonic and arterial hyperemia and fluxion are synonymous with 
 the terms active hyperemia ; and venous hyperemia, or stasis 
 with passive hyperemia. 
 
 Cutaneous hyperemia consists in an abnormal amount 
 of blood in the vessels of the corium, and occasionally 
 in the subcutaneous tissue also, the extent of area affected 
 depending upon the cause of the hyperemia ; and the ap- 
 pearance presented, upon the quantity of arterial or venous 
 blood present. In active hyperemia, there is more blood in 
 the part, the current moves more rapidly, less oxygen is given 
 
HYPEREMIAS. 91 
 
 off to the tissues on account of this rapidity of circulation, 
 and from these factors the skin is redder in color, and warmer 
 than normal. In passive hyperaemia, there is more blood in the 
 part, the current moves slower, consequently more oxygen 
 is given off to the tissues than normally occurs, and the skin, 
 from these factors, is darker in color and colder than normal. 
 
 The color of the skin in hyperaemia varies from a pale to a 
 bright red, or dark-bluish red or cyanotic, the color disappear- 
 ing or paling upon pressure. The patches are either diffuse or 
 patchy, or crossed by dilated bloodvessels ; they are on a level 
 with the surrounding skin, or slightly elevated. The tempera- 
 ture of the part is normal, elevated or lowered. In size the 
 patches of eruption vary from a lentil to finger-nail, when it is 
 called roseola; or they are larger, more diffuse and irregular in 
 shape — erythema. They feel either smooth and normal, or 
 firm, and are frequently accompanied by a sensation of burn- 
 ing or itching. The rash arises rapidly, has an acute or chronic 
 course, lasting a few hours, or days or weeks, and disappears, 
 with or without pigmentation or desquamation. If it is long 
 continued, the skin may become oedematous or hypertrophied, 
 as the pressure overcomes the elasticity of the vessels and they 
 become dilated, changed, and allow exudation to occur. 
 
 Active hyperaemia is either idiopathic or symptomatic. Idio- 
 pathic hyperaemia arises from direct irritation or injury to the 
 part, acting directly by paralysis of the constrictors, or indi- 
 rectly by reflex action. The influences which cause this con- 
 dition are either of a traumatic, caloric, or chemical nature, 
 hence the division of idiopathic hyperaemia into erythema trau- 
 maticum, ca/oricum, and venenatum. 
 
 Erythema iraumaticii?n.— The hyperaemia of the skin result- 
 ing from mechanical action, as pressure from tightly fitting 
 clothes, corsets, suspenders, bandages ; from sitting or lying on 
 firm substances, as leaning the elbow upon a table; and the irri- 
 tation from scratching and rubbing, belong to this category. 
 The eruption is usually of short duration, disappearing without 
 scaling ; but if long continued, it can change to a dermatitis or 
 a passive hyperaemia. 
 
92 HYPEREMIAS. 
 
 Erythema caloricum. — This arises from the action of high or 
 low temperature of the air, light, and water upon the skin. If 
 the action is intense, it produces swelling of the skin, and more 
 or less exudation. The hyperaemia from the action of the sun 
 (erythema solare) appears only on the uncovered parts of the 
 body, and usually runs a rapid course. Very hot or very cold 
 baths frequently produce a temporary erythema. From what- 
 ever cause, the hyperemia is characterized by an eruption of a 
 bright red color, which later becomes of a darker brown ; the 
 skin is frequently pigmented, and there is slight desquamation. 
 
 Erythema venenatum. — Hyperaemia resulting from the action 
 of irritating chemical substances, the so-called rubefacients, as 
 turpentine, croton oil, pepper, various coloring substances, is 
 either temporary or long continued, depending upon the irri- 
 tating quality of the substance, and the duration of the appli- 
 cation. If the action is long continued, it leads to inflamma- 
 tion of the part. 
 
 Symptomatic active hyperemia — erythema symptomatica. — This 
 form of hyperaemia acts directly upon the bloodvessels, or in- 
 directly by reflex action from the central nervous system. It 
 frequently accompanies or follows febrile or non-febrile condi- 
 tions of the general system or of a special system, especially 
 that of the nervous. Hyperaemia frequently precedes or ac- 
 companies general diseases, as variola, cholera, typhoid fever, 
 vaccina ; the changed condition of the blood causing a reflex 
 erythema. Roseola cholerica appears in the asthenic, or recon- 
 valescent stage ; and roseola infantilis appears as a diffuse or 
 circumscribed redness, disappearing upon pressure, and accom- 
 panying febrile conditions, or an abnormal state of the intes- 
 tinal tract. 
 
 Symptomatic hyperaemia usually disappears without desqua- 
 mation, and there are no subjective symptoms ; but if the 
 hyperaemia recurs frequently, the bloodvessels become dilated, 
 oedema occurs, the gland secretion of the part may be in- 
 creased, and the tissue hypertrophied. 
 
 Passive hyperozmia. — In this form the circulation is slower 
 than normal, more oxygen is given off to the surrounding tis- 
 
HYPEREMIAS. 93 
 
 sues, consequently the skin is darker in color, varying from a 
 dark bluish red to black, which disappears upon pressure ; the 
 temperature of the part is normal or lowered ; there is some 
 swelling, and occasionally oedema and itching, and a feeling of 
 tension and creeping. The course is chronic, and may lead to 
 inflammation or even gangrene. Passive hyperaemia may re- 
 sult from changes in the heart or in the bloodvessels, causing a 
 diminution in the blood pressure, or an increased resistance to 
 the flow through the vessels. If the return of the blood from 
 a part is prevented by bandages, tight garters, tumors on the 
 extremities or in the abdominal cavity, etc., passive hyperaemia 
 will result. Varicose veins, low temperature and damp air, 
 sudden cooling of the body, removal of support of the vessels, 
 and diminution in the blood pressure, as occurs after tapping for 
 ascites, are all causes of stasis. In collateral hyperaemia, after 
 closure of a main vessel by a thrombus or embolus, there is first 
 an active and later a passive hyperaemia. Diminution in the 
 tonicity of the vessels from deficient innervation ; disease of the 
 bloodvessel walls ; interrupted return of blood, as in varicose 
 veins after long standing, or walking or lying ; weak heart after 
 disease, fatty degeneration or valvular lesions, are so many causes 
 of stasis. Long continued active hyperaemia, resulting from trau- 
 matic, caloric or chemical influences, results in becoming passive. 
 If the cause of a passive hyperaemia is in disease of the heart and 
 not in the bloodvessels, the stasis will be general — cyanosis; but 
 if from hinderance to the circulation at the periphery, the extent 
 of the stasis will depend upon the situation of the obstruction; 
 the nearer the periphery the smaller will be the area affected 
 (livedo). 
 
 Treatment. — The treatment for both active and passive 
 hyperaemia consists in the treatment of the cause. To alleviate 
 any itching or burning that may be present, washing with 
 alcohol or weak alkaline solutions (soda or borax), and dusting 
 the surface with starch, flour or lycopodium, is all that can be 
 accomplished. If the hyperaemia has passed to a dermatitis, 
 then antiphlogistic remedies, to be described later on when 
 treating of this subject, must be employed. 
 
CLASS III. 
 
 EXUDATIONES— EXUDATIONS. 
 
 In this class are included the acute, contagious, inflammatory- 
 diseases. As the exanthemata properly belong to general 
 medicine and not to dermatology, except in so far as it is neces- 
 sary for the dermatologist to be thoroughly acquainted with the 
 characters of the eruption present in the different diseases on 
 account of diagnosis ; so in treating of these subjects I will 
 confine myself to a description of the symptoms and diagnosis. 
 
 I have placed impetigo contagiosa in this class on theoretical 
 grounds, because, if it exists under the conditions described by 
 those who have written upon the subject, it must belong to the 
 acute, contagious, inflammatory diseases. 
 
 MORBILLI. 
 
 Syn. — Measles ; Rubeola. 
 
 Definition.— Morbilli is an acute, contagious, febrile affection, 
 characterized by a catarrhal inflammation of the mucous mem- 
 brane of the respiratory tract, and a papular rash over the sur- 
 face of the body. 
 
 Symptoms. — The period of incubation is from 12 to 14 days. 
 The stage of invasion lasts on an average about three days, and 
 presents the symptoms of a mild catarrh of the conjunctiva 
 and respiratory tract. There is at times a distinctly croupy 
 cough, or perhaps a well marked attack of catarrhal or false 
 croup may usher in the disease. The physical signs will be a 
 quickening of respiration, and at first sibilant and sonorous rales ; 
 a little later large mucous rales may be heard. The eyes present 
 at the same time an injected and watery appearance, with aver- 
 sion to light. There is frequent sneezing, due to marked coryza, 
 
MORBILLI. 95 
 
 and dull pain or a heavy sensation in the frontal sinuses. The 
 mucous membrane of the throat also shows an increased vascular- 
 ity without much swelling. There is more or less headache, 
 uneasiness at the epigastrium and constriction of the chest, due 
 to the bronchitis. A few hours after the beginning of the 
 symptoms a fever develops, which may rise as high as 102 ° or 
 1 03 °, with a corresponding rapidity of the pulse. The fever 
 occurring during the period of invasion of measles is remittent, 
 the lower temperature being in the early part of the day and 
 the exacerbation in the evening. Vomiting may take place at 
 any time before the eruption, but is not so characteristic as 
 in scarlatina. The stage of eruption may be delayed by expo- 
 sure to cold, or from internal complication (as a pneumonia) 
 preventing the determination of blood to the surface. The rash 
 first appears on the face and neck, and extends downward (in 
 rather orderly progression), covering the trunk and extremities 
 in from a day to a day and a half. It appears as small, red, flat 
 papules (very slightly elevated), which gradually increase in 
 size and become surrounded by little hyperaemic circles. The 
 papules are apt to unite and form little patches (of a mulberry 
 color) that sometimes take on a crescentic form, with clear skin 
 between. Although these patches are generally discrete, in 
 plethoric subjects with a high fever, several of them may co- 
 alesce and thus form a confluent rash. This is especially apt to 
 take place on the cheeks, back and nates. Where the hyperemia 
 is intense, there may occur capillary haemorrhages on the surface 
 of papules, but they do not indicate a malignant or dangerous 
 form, and are not true " hasmorrhagic measles " lesions. When 
 the rash first appears there is an increase in the local and general 
 symptoms. The face is slightly swollen, the conjunctiva much 
 injected and the cough more frequent, although there may be 
 little expectoration. The fever is also as high, as, during the 
 exacerbation of the remittent stage, it increases with the efflor- 
 escence of the eruption, so that the maximal temperature cor- 
 responds with the maximum of the exanthem. The symptoms 
 begin to decrease by the second day of the rash, which generally 
 disappears by the fourth to sixth day. The fever, in uncompli- 
 
g6 MORBILLI. 
 
 cated cases, then ceases, and all that remains is a slight staining 
 of the skin and a cough that continues for some days. When the 
 eruption disappears the stage of desquamation begins. It is not 
 so marked as in scarlatina, and sometimes it is so slight as hardly 
 to be observed. The exfoliation is furfuraceous and is most 
 marked where the rash has been thickest. 
 
 Occasionally an irregular form of measles has been noted. 
 Thus there may be no catarrhal inflammation of the respiratory 
 tract, and sometimes, though rarely, there is an entire absence 
 of the eruption. The latter condition may be caused by some 
 deep-seated internal inflammation which prevents the rash by 
 withdrawing the blood from the surface, or there may not be 
 sufficient blood-poisoning to cause changes in the skin. There 
 is a form of the disease called rubeola nigra, from the dark or 
 livid appearance of the eruption, which lasts a longer period of 
 time and does not fade on pressure. Petechias, or extensive 
 diffuse haemorrhages, may occur both in the skin and from mu- 
 cous membranes. This, the true haemorrhagic measles, is very 
 fatal. It is due to the malignant nature of the poison, and is 
 often accompanied by some internal inflammation, as pneumonia. 
 
 The most usual complications of measles are severe bronchitis 
 and broncho-pneumonia. The smaller bronchial tubes may be 
 involved, producing a capillary bronchitis. If this happen early 
 in the disease, the eruption may be delayed; or if it occur after 
 the development of the rash, it may cause its retrocession. 
 When pneumonia occurs, it results from the extension down- 
 ward of the inflammation, and hence is of the catarrhal variety, 
 with an exceedingly grave prognosis. 
 
 Entero-colitis not infrequently forms a serious complication 
 of measles. The brunt of the imflammation may be expended 
 upon the colon, producing mucous and bloody stools. In other 
 cases there may be a severe " non-inflammatory " diarrhoea. 
 Sometimes, in institutions, gangrene of the mouth or vulva may 
 develop in poorly nourished children as a sequel of measles. 
 
 Diagnosis. — Before the appearance of the eruption the diag- 
 nosis from simple coryza or tracheo-bronchitis may be sus- 
 pected by the character of the fever, which is generally higher 
 
RCETHELN. 97 
 
 than that caused by a mild catarrhal inflammation, (and from 
 the fact that it is not relieved by treatment). The character- 
 istic watery appearance of the eyes will assist in the diagnosis. 
 The diagnostic characteristics of measles are the sudden 
 onset of catarrhal symptoms, with considerable fever, lasting 
 generally 72 hours (the period of invasion thus being longer 
 than in the other febrile exanthems), followed by a mulberry- 
 colored, broadly papular rash, appearing first on the face, chin, 
 etc., and gradually extending over the trunk and extremities in 
 orderly extension without the development of either vesicles 
 or acuminated papules, the fever not subsiding on the appear- 
 ance of the rash, but rather increasing. These features, with 
 the absence of the peculiarities of the other exanthems will 
 furnish a diagnosis. The differential diagnosis of measles, 
 and the initial or true rash of variola and of varicella are given 
 under their respective headings. For the diagnosis from 
 scarlatina and from rcetheln, see page 98. 
 
 RCETHELN. 
 
 Syn. — Rubeola ; German measles. 
 
 Definition. — Rcetheln is a mild, feebly contagious disease, at- 
 tended by slight febrile movement and a roseolous rash. 
 
 Sympioins. — The period of incubation varies, but is probably 
 on an average about two weeks. The disease is sometimes ush- 
 ered in by feelings of slight malaise, and occasionally by some 
 nausea and vomiting. In a few hours, or sometimes a day, the 
 rash begins upon the face and scalp, and extends downward 
 upon the trunk and extremities. It commences as many close- 
 ly-set rosy points, very slightly elevated, generally arranged in 
 small circular areas, with clear skin between. The spots vary 
 in size from pin heads to two-fifths of an inch in diameter — the 
 size of a lentil. In general appearance the eruption bears more 
 resemblance to measles than to scarlatina. It usually covers at 
 least one half of the surface of the body and is sometimes ac- 
 companied by much itching. There is rarely any desquama- 
 tion of the epidermis, and the eruption completely disappears 
 
98 RCETHELN. 
 
 by about the fourth day. Accompanying the rash there is a 
 mild inflammation of the conjunctiva, with lachrymation and 
 some coryza. There is also slight injection of the fauces and 
 swelling of lymphatic glands of the neck. The larynx, trachea 
 and the bronchial tubes do not appear to become involved in 
 the inflammation, or if so, very slightly. The temperature is 
 not high, rarely beyond ioo°, and the whole duration of the 
 disease does not generally exceed five days. There is not any, 
 or, at most, only a very slight prodromal catarrhal stage in 
 rcetheln, and the little, if any, fever which occurs does not in- 
 crease to a maximum to correspond with the maximum of the 
 eruption, as in measles. In measles the prodromal stage is 
 about 72 hours. The spots in roetheln are rounder and more 
 regular in form, are more discrete, and also paler and more 
 rosy in color. In rcetheln the eruption may be fading from 
 the face and appearing on the legs, while in measles the erup- 
 tion on the face increases until the rash is fully out all over 
 the body, and then the whole rash begins to disappear. The 
 duration of rcetheln is shorter and the course milder. In 
 scarlatina the outset of the fever is severer, and is attended by 
 the characteristic initial vomiting and tjie especially rapid 
 pulse. The attendant pharyngitis will probably be severer and 
 parenchymatous, the anterior surface of the soft palate appear- 
 ing pale by comparison with the intense injection of the 
 rest of the fauces. The tongue may have the characteristic 
 vivid red papillae on a white ground at first, and soon become 
 red and glazed from shedding of its epithelium. 
 
 The rash appears first in scarlatina on the neck and breast, 
 is comparatively scanty on the face, and when present leaves a 
 relative pallor around the mouth and on the region of the chin 
 and nose. In rcetheln the rash is abundant in the face. The 
 scarlatinal rash spreads more rapidly over the body, is more 
 like a diffuse erythema, though it can be seen to be made up 
 of innumerable fine, distinct points, and when the blotches are 
 more discrete, the size of the separate punctae are not as large 
 as the rosy spots of rcetheln. The sequelae of scarlatina, ne- 
 phritis, synovitis, etc., would later on confirm the diagnosis. 
 
SCARLATINA. 
 
 SCARLATINA. 
 
 99 
 
 Syn. — Scarlet fever ; Scarlet Rash ; Febris Anginosa. 
 
 Definition. — Scarlatina is an acute, contagious, febrile disease, 
 attended by a more or less severe inflammation of the throat, 
 and the development of a scarlet rash over the whole or part 
 of the body. 
 
 Symptoms. — The period of incubation varies from one to 
 seven days, although the disease may sometimes begin as early 
 as a few hours after exposure. The symptoms usually be- 
 gin abruptly, without a prodromal stage like measles. Fre- 
 quently there is a distinct rigor, but sometimes only a feeling 
 of chilliness through the body is experienced. (In children a 
 convulsion may occur instead of a chill.) Following this there 
 is a quick rise of temperature, which generally reaches as high 
 a point at this time as at any period in the disease. The fever 
 reaches usually 103 or 104 , and in bad cases as high as 106 
 or 107 , with the pulse more frequent than in other fevers of 
 the same temperature. The occurrence of vomiting at this 
 time is an important and characteristic symptom, and is prob- 
 ably due to the irritating effect of the scarlatinous poison upon 
 the medulla. If there is simple nausea, there will probably be 
 a mild grade of fever, while if the irritation of the stomach is 
 extreme and persistent, a severe form of the disease will prob- 
 ably follow. One of the earliest symptoms is a reddening of 
 the mucous membrane of the mouth and throat. The tongue 
 is at first covered with fur and has a reddening of the tip and 
 edges with the papillae enlarged and elevated, giving the famil- 
 iar strawberry appearance. Swallowing is difficult and painful, 
 and the follicles of the tonsil are frequently plugged by a slight 
 fibrinous exudation. The inflammation often spreads up to 
 the mucous membrane of the nose, giving rise to an irritating 
 muco-purulent discharge. Although there is not so much ten- 
 dency for the morbid process to extend downward into the 
 trachea and bronchial tubes, yet there may be a slight cough 
 from the collection of mucus in the back of the throat, or, 
 rarely, from mild bronchitis. 
 
IOO SCARLATINA. 
 
 The rash appears from six hours to a day following the ini- 
 tial symptoms. It first appears about the neck and chest and 
 flexures of the joints, where the surface is apt to be warmest. 
 At the beginning there may be only indistinct patches here and 
 there, but these soon coalesce and extend, until in a few hours 
 the trunk and extremities are covered by a diffuse and continu- 
 ous erythema. The character of the rash may differ somewhat 
 in different cases. Thus it frequently presents a smooth, boiled- 
 lobster appearance ; or it may consist of minute, distinct, punc- 
 tate points very closely set and separated from one another by 
 small and paler areas of skin. These points are due to en- 
 gorgement of the cutaneous papillae, and when they occur about 
 a hair follicle impart rather a rough sensation to the finger. The 
 reddening disappears on pressure but quickly returns when the 
 circulation is good ; if on the other hand it is slow on return- 
 ing it shows a feeble circulation and a serious form of the dis- 
 ease. In cases where the dermatitis is severe, small whitish 
 vesicles may make their appearance either in patches or almost 
 over the entire surface of the body. Occasionally vesicles may 
 appear larger, as in herpes or varicella, as the result of sweating 
 during defervescence, or as complications and sequelae. In 
 rare cases, on account of the intensity of the exanthem, mi- 
 nute violet haemorrhagic points may appear on the skin without 
 very serious import. Also exudations of blood may take place 
 into the superficial layers of the skin in larger points, or in broad 
 patches, or even into the subcutaneous cellular tissue, indicating 
 a severe blood poisoning and an unfavorable prognosis. 
 The throat affection, fever and prostration continue with un- 
 abated severity for from four to six days, when the symptoms 
 become less urgent and a gradual decline of the disease begins. 
 Convalescence is generally well established by the beginning of 
 the second week. The inflammation of the buccal and faucial 
 mucous membrane becomes greatly lessened, and the tongue 
 resumes more its natural appearance. The rash is much less 
 distinct and soon fades away altogether. Following this there 
 is a desquamation of the epidermis over the body, usually be- 
 ginning on the face and neck. On the palms of the hands or 
 
SCARLATINA. 101 
 
 any place where the epidermis is thickened it may be detached 
 en masse forming a sort of cast of the part ; in other places 
 where the skin is thin, there is a furfuraceous desquamation. 
 The exfoliation of the epidermis occupies from several days to 
 several weeks and is usually accompanied by a general improve- 
 ment in the condition of the patient. 
 
 There is no disease that presents such varying degrees of 
 severity as scarlatina. Thus there is an exceedingly mild form 
 of the disease in which there is little fever and acceleration of 
 pulse. The pharyngitis is slight, and the rash instead of being 
 continuous over the whole body appears in different patches 
 and has not the deep scarlet hue so often seen in this disease 
 (Scarlatina Variegata). The patient does not appear or feel 
 very sick, and the mild symptoms begin to disappear in from 
 two to four days. In cases of this kind it is often difficult or 
 impossible to make a positive diagnosis, but they should be 
 watched with great care, as not infrequently there follows a 
 severe or fatal nephritis. 
 
 Another form of the disease is known as scarlatina anginosa, 
 which is marked by unusually severe inflammation of the mu- 
 cous membrane of the throat and tonsils. There is much 
 swelling from sub-mucous infiltration and extensive inflamma- 
 tion of the lymphatic glands and connective tissue of the neck. 
 This affection produces an increase in the severity of the fever 
 and constitutional symptoms, which continue after the rash has 
 subsided. The inflammation may disappear after one or two 
 weeks by resolution, or go on to suppuration and the formation 
 of abscesses. 
 
 In certain epidemics scarlatina takes on a malignant 
 form. The invasion is severe with a very high temperature 
 and quick pulse. The eruption assumes a dusky color and 
 slowly returns after pressure, showing feebleness of the capillary 
 circulation. The cerebro-spinal system is early and markedly 
 affected by the poison. An intense headache may be one of 
 the first symptoms of the malignant form, quickly followed by 
 delirium ; or convulsions may occur early. In some cases the 
 patient will become rapidly comatose and remain in that condi- 
 
102 SCARLATINA. 
 
 tion until death ; the nervous system being overcome by the 
 virus at the very commencement of the disease, the period in 
 which it is usually most active. There is a condition of great 
 restlessness in those cases in which the nervous system is not 
 so quickly overpowered. 
 
 Scarlatina may at times take on an irregular form due to the 
 existence of some other disease or to a disordered condition of 
 the system. Thus it is reported that an enteritis has postponed 
 the appearance of the rash for almost a week after the initial 
 symptoms had appeared. In any case in which there is acute 
 or chronic disease of any of the viscera, with a consequent con- 
 gestion of the parts, the eruption may be slow in developing, or 
 not appear at all. In rare cases the disease may pursue an ir- 
 regular course in a person apparently in perfect health and 
 without any known cause. The occurrence of diphtheria may 
 be observed early in the disease, or not until the fever is begin- 
 ning to abate. 
 
 A thick false membrane forms upon the mucous mem- 
 brane, usually of the tonsils, penetrating into its substance. The 
 pseudo-membrane may spread from the fauces up to the nares. 
 It not infrequently happens that inflammation of the synovial 
 membrane of certain joints occurs with scarlatina. The red- 
 ness and swelling are so slight as often to be overlooked, es- 
 pecially as the pain is of a very mild grade. The wrist joint is 
 frequently affected. Pleuritis and pericarditis occasionally oc- 
 cur during the period of desquamation and cause a very un- 
 certain prognosis. A most frequent complication or sequel of 
 scarlatina is nephritis. A slight albuminuria due to congestion 
 of the kidneys is of common occurrence during the existence 
 of the fever, but actual inflammation of these organs usually 
 takes place after the second week, when the rash has disap- 
 peared, although it sometimes happens before. The urine is 
 diminished, contains albumen and casts, and soon all the typi- 
 cal symptoms of uraemia may manifest themselves. At times 
 in the declining period of the fever or during convalescence, 
 the inflammation in the throat may spread up the Eustachian 
 tube to the middle ear, causing a severe otitis media. Pus col- 
 
SCARLATINA. 103 
 
 lects in the cavity of the tympanum, and after several days 
 pressure ruptures the drum-head and escapes through the ex- 
 ternal meatus. If the aperture in the drum closes by granula- 
 tion hearing will not be impaired, but if this do not occur, or 
 if there be caries of the surrounding bone, with destruction of 
 the ossicles, hearing will be lost. 
 
 The differential diagnosis of scarlatina from variola, varicella, 
 and rcetheln has been given in the chapters devoted to those 
 subjects. In the early stages of the eruption, scarlatina may 
 be mistaken for measles, but they differ in the following re- 
 spects : In scarlatina the prodromal period is very brief, be- 
 ginning rather suddenly with high fever, which speedily may 
 reach 104° or more. Vomiting is much more frequent at the 
 outset, and also convulsions in children ; the pulse more 
 rapid, and in severe cases the nervous system more profoundly 
 affected. In about twelve hours appears the rash on the skin 
 and the redness of the fauces. In measles there is a prodromal 
 period of about seventy-two hours, marked by catarrhal symptoms 
 of conjunctivae and respiratory tract, the fever being of only 
 moderate severity. The fever in both cases continues or in- 
 creases after the eruption appears. The redness of the throat 
 in measles is diffused without sharp limits over the mucous mem- 
 brane of the mouth, palate, and pharynx, and may be spotted, 
 and the swelling is only moderate. In scarlatina the anterior 
 surface of the soft palate is comparatively free, the pharyngitis 
 being limited at the free margin, and in most cases accom- 
 panied with greater swelling and deeper seated inflammation. 
 The tongue also will assume the " strawberry " appearance. 
 In measles the eruption appears first on the face as a rule, 
 and is there especially abundant on the cheeks and chin, while 
 in scarlatina the rash is more likely to appear first on the neck 
 and breast, and to leave the face relatively free. Even when pres- 
 ent on the face there is a characteristic pallor about the mouth. 
 
 The eruption in scarlatina spreads more rapidly, often cover- 
 ing the most of the body in twenty-four hours, when extensive ; 
 while in measles it is slower and more orderly in its progress in 
 normal cases, requiring two days or more for its full develop- 
 
104 SCARLATINA. 
 
 ment, and the rash first appearing on the face increases in 
 severity till the full development on the legs, etc. 
 
 The individual spots in measles rapidly become more papu- 
 lar and broader, coalescing into irregular blotches of crescentic 
 shape, with indented margins, with decidedly clear patches of 
 skin between, unless in very confluent cases. In scarlatina, 
 however extensive and uniform the exanthem, it can nearly 
 always be seen to be made up of innumerable fine points, with 
 minute white lines or circles about them, and, when the con- 
 gestion is marked about the hair follicles, gives a roughened 
 feeling to the touch. 
 
 The desquamation in measles is furfuraceous, in scarla- 
 tina in scales and flakes. 
 
 In cases where the diagnosis is doubtful from the scantiness 
 of the eruption, the sequelae will afford indications for diagnosis, 
 being, after measles, bronchitis, and catarrhal pneumonia ; 
 after scarlatina, necrotic or diphtheritic pharyngitis, nephritis 
 and inflammations of synovial and serous membranes. 
 
 In the beginning of certain febrile diseases, as for instance, 
 acute pneumonia, a very general erythema may appear on the 
 skin of plethoric children, particularly on the trunk, which for 
 a few hours can scarcely be distinguished from the eruption of 
 scarlatina, but generally the lips and face are very red at the 
 same time, and the blush of the skin will not be made up of 
 fine punctse ; moreover, the flexures of the joints may be rela- 
 tively unaffected. In such a case, twelve to twenty-four hours 
 would suffice to develop the peculiar pharyngitis and tongue 
 in the one case, or in the other the rash will disappear with the 
 advent of symptoms peculiar to that disease. 
 
 In the roseolas and erythema arising from gastric disorders, 
 etc., the individual spots are larger, more rosy, and coalesce 
 into irregular blotches, and are distributed in masses and 
 patches irregularly over the trunk, etc. They are fugacious, 
 coming and going without the orderly evolution and distribu- 
 tion seen in the specific exanthem. They are also without 
 prodromal symptoms and those arising from the localization of 
 the poison in the pharynx, etc. 
 
VARIOLA. 105 
 
 VARIOLA. 
 
 Syn. — Small-pox ; pocken ; Blattern ; variole. 
 
 Definition. — Variola is a specific, contagious, febrile affec- 
 tion, running a definite course and characterized by a papular, 
 vesicular and pustular eruption on the skin. 
 
 The incubative period, when the infection is received through 
 the air, is from twelve to fourteen days ; if inoculation has been 
 practiced, it is from eight to eleven days. 
 
 Symptoms. — A statement of the principal symptoms will be 
 given as an indispensable aid to the correct diagnosis of the 
 skin lesion. 
 
 Stage of Invasion. — The disease begins abruptly with either 
 repeated chills or a severe rigor marked by a severity peculiar 
 to variola. Following upon this is the primary fever which is 
 apt to run high, sometimes reaching 104 or 105 . The tongue 
 is coated, and gastric irritation, shown by nausea and vomiting, 
 may be a very prominent feature at this time. There is usually 
 a marked frontal headache, and in some cases delirium more or 
 less violent, and muscular tremors, with an aching feeling in 
 the limbs and intense lumbar pain. When unusual severity of 
 these preliminary symptoms is present, the confluent variety of 
 the eruption may generally be predicted. There may occur 
 during this stage a general erythema of the skin, not unlike 
 scarlatina, or the redness may be in isolated patches, looking 
 more like measles (erythema variolosa), but the patches never 
 become papular. These prodromal rashes appear most fre- 
 quently on the second day, and last usually twelve or twenty- 
 four hours, though the duration may be much prolonged. 
 There is also occasionally noticed in benign cases a greater or 
 less number of minute petechias upon the surface both of the 
 trunk and extremities, especially on the lower part of the ab- 
 domen or the inside of the thighs, which leave brownish-green 
 stains. The period of invasion generally lasts from forty-eight 
 hours to three days. In this initial stage is also observed 
 the fatal condition known as true haemorrhagic small-pox, 
 
106 VARIOLA. 
 
 variola nigra, purpura variolosa. About the second day of the 
 fever, which is not very high, appears a general, intense scarla- 
 tinaform, seldom measley rash, on the trunk and extremities, 
 leaving the face nearly always exempt. The redness disappears 
 on pressure, but in this erythema petechias and more diffuse 
 cutaneous haemorrhages soon appear, varying in size from a 
 pinhead to an inch in diameter. They are generally discrete 
 on the extremities, but confluent on the breast and ab- 
 domen. The conjunctivae are bloodshot, and large, dark rings 
 are formed about the eyes by haemorrhage into the orbital cel- 
 lular tissue. Haemorrhage also takes place from the various 
 mucous membranes, causing bloody stools and vomit, with some 
 precordial pain and metrorrhagia. Albumen in considerable 
 quantity generally precedes a haematuria. These symptoms 
 are accompanied by a feeble pulse and great prostration, but 
 the intellect generally remains clear. This variety of small-pox 
 is uniformly fatal, and it is exceptional for a patient to survive 
 the sixth day. 
 
 Local haemorrhages sometimes occur later on into the formed 
 pock or even papule, but this condition, although probably of 
 the same nature, is somewhat distinct from the one above des- 
 cribed ; it is very much less fatal. 
 
 Stage of eruption. — The rash usually begins on the third day, 
 when there is a marked remission in the primary fever in mild 
 cases and in varioloid ; twelve to eighteen hours later in severe 
 cases, which may reach almost complete apyrexia. The erup- 
 tion commences as minute red spots, appearing first on the face 
 about the lips and chin, and sometimes almost simultaneously 
 on the neck and wrists. It then covers the rest of the face and 
 scalp, and gradually extends over the chest, arms, abdomen and 
 legs, occupying from one to three days in its diffusion over the 
 whole surface. In young children, the rash sometimes first ap- 
 pears in the folds of the skin about the genitals. The centre 
 of each macule soon becomes indurated and raised, until a 
 small, round, hard papule is formed, which is tender and feels 
 like shot under the finger. In about twenty-four hours after 
 the first appearance of the eruption, some clear liquid begins 
 
VARIOLA. I07 
 
 to collect in the top of the papules, which are thus converted 
 into vesicles. The vesicles attain their full size about the fifth 
 day of the eruption. They are umbilicated, with a circular, 
 indurated base and a surrounding area of redness and tender- 
 ness. Not only the skin, but some of the mucous membranes, are 
 at the same time affected by the eruption. The lining membrane 
 of the mouth and throat is most frequently involved, although the 
 larynx, trachea and bronchi, and even the conjunctiva, may be at- 
 tacked. The eruption on the mucous membranes presents an 
 altered appearance, as the absence of the horny layer of the 
 skin prevents the formation of typical vesicles and pustules, 
 but in their place are seen little erosions and ulcerations. About 
 the fifth day of the eruption the contents of the vesicles be- 
 gin to grow turbid, the reticulated structure is lost, and the um- 
 bilication disappears. 
 
 Stage of suppuration. — This begins about the fifth day of the 
 eruption and is accompanied by the development of a well- 
 marked secondary fever. The temperature is generally higher 
 in the evening, and is accompanied by a quick pulse and dry- 
 ness of the skin. Redness and oedema is more or less marked 
 between the pustules. The swelling is often extensive in the 
 face and eyelids, and is accompanied by a burning sensation. 
 At times the contents of the distended pustules may rupture 
 from friction of the clothing, and add to the irritation of the 
 skin. If the suppuration is very extensive this stage may be 
 accompanied by marked ataxia, delirium or coma. The dura- 
 tion of the period of suppuration is from four to five days. 
 
 Stage of desiccation. — The drying begins upon the full develop- 
 ment of the pustules, which is about the twelfth day of the dis- 
 ease. The inflammatory oedema of the skin begins to subside, 
 while the more fluid portion of the ruptured pustule evaporates, 
 leaving a crust behind. If there is no rupture of the pustule, 
 the liquid portion will be absorbed and a dried scab result. In 
 places where the eruption is confluent, a continuous crust will 
 be formed, and at this period an unpleasant odor from the skin, 
 at once peculiar and characteristic, is noticed. The crusts form 
 first upon the face, then upon the trunk and upper extremities. 
 
108 VARIOLA. 
 
 and finally, on the lower extremities, according to the order in 
 which the eruption first appeared. More or less fever may be 
 present at this time, although the symptoms generally abate as 
 desiccation progresses. 
 
 Stage of desquamation. — Finally, the scabs and crusts are 
 thrown off. This usually occupies several days, but sometimes 
 a much longer time will elapse before all the crusts are de- 
 tached. If the inflammation of the skin has been mild, noth- 
 ing but a reddening will be left, which soon disappears. Gen- 
 erally, however, more or less of the corium has been involved, 
 and hence the production of permanent cicatrices, which may 
 be linear or circular. This is the so-called pitting. The dis- 
 ease at times runs a somewhat irregular course. Thus there 
 may be a severe pharyngitis, laryngitis or bronchitis from the 
 presence of the eruption in these situations. Erysipelas may 
 appear upon various parts of the body. The eruption may 
 commence as early as the second day, in which case it is said 
 by some and denied by others that it will usually be confluent ; 
 or its appearance may be delayed until the fifth or sixth day, 
 thus forecasting a mild grade of the disease. 
 
 Diagnosis. — While it is impossible to make a certain diag- 
 nosis before the appearance of the eruption, the following 
 symptoms are significant : Severe chill, repeated vomiting, 
 headache, intense pain in the small of the back, with a high fever. 
 Even as late as the first appearance of the eruption, it is 
 somewhat difficult to make a positive diagnosis, but the appear- 
 ance of vesicles seated on papules, and which become umbili- 
 cated, may be considered pathognomonic. Ash colored spots on 
 the mucous membrane of the mouth may be present at an early 
 stage of the disease, showing a beginning of the variolous 
 eruption in this situation before the skin has become involved 
 hence a careful inspection of the buccal and faucial surfaces 
 may assist in the diagnosis in doubtful cases. For the stage of 
 invasion the petechial exanthem located principally in the 
 crural triangle, the base of which is a horizontal line near the 
 umbilicus, with the apex extending over the os pubis and be- 
 tween the thighs, is pathognomonic of variola. The diffuse 
 
VARIOLA. I09 
 
 erythema sometimes present, especially in the initial stage of 
 varioloid, may resemble that of scarlatina, but it is less diffused 
 over the skin, is bright, more rosy, more mottled, and not such 
 a finely punctated rash. Even if haemorrhages begin to ap- 
 pear, ahaemorrhagic scarlatina might be suspected, but ecchy- 
 moses in the conjunctiva only take place in variola. Again, 
 this diffuse erythema, as well as the beginning true small pox 
 eruption, may be distinguished from that of scarlatina by the 
 following characters : Scarlatina begins suddenly with vomit- 
 ing, an unusually rapid pulse, and a sore throat, the redness 
 being limited to the tonsils and pharynx, the posterior wall of 
 the palate and velum, while the anterior wall is unaffected. 
 The initial fever is about twelve hours and increases with the 
 spread of the eruption. In small pox the initial fever lasts forty- 
 eight hours, and remits soon after the eruption appears. 
 
 In scarlatina the rash first appears on the neck and chest, 
 and speedily extends to the trunk and extremities. The face 
 remains often nearly free, and even when much affected, the 
 skin about the mouth and nose is quite white by contrast. In 
 small pox the forehead, lips, chin and wrists are earliest affected, 
 the eruption proceeds in orderly course during two days over 
 the trunk and extremities. Very soon the maculae become 
 hard, papular and shot-like to the touch and, in about twenty- 
 four hours, a little serum appears on the summit of the papules, 
 when the diagnosis is beyond doubt. The general symptoms 
 of variola have been previously detailed and will assist in the 
 diagnosis. 
 
 In measles there is an initial stage of seventy-two hours 
 marked by catarrhs of the respiratory tract and conjunctiva, 
 producing cough, coryza, sneezing and lachrymation ; the fever 
 is moderate during this stage, but increases with the appear- 
 ance of the eruption until its maximum is attained, thus 
 strongly contrasting with the high initial fever and violent on- 
 set of variola, and the rapid remission of fever after the full 
 eruption appears. The papules of measles are also larger, 
 irregular in shape, flat, broad, with indented margins, only 
 slightly elevated, feel more superficial, with healthy skin between 
 
IIO VARICELLA. 
 
 them, and appear on the back, and head, and face almost simul- 
 taneously. They never become vesicular or pustular. 
 
 In varicella the maculae appear simultaneously with the first 
 febrile symptoms, which are usually very slight, or within twelve 
 to twenty-four hours after. They rapidly became clear vesicles 
 within a few hours, seated on a level surface of skin, without any 
 indurated base or surrounding inflamed areola, unless irritated. 
 They appear first on the face, scalp and upper half of the 
 body. Very early two or three broad, fully formed vesicles are 
 often found between the scapulae, further advanced even than 
 on the face. The vesicles come out in successive crops, so 
 that recent ones appear between others one or two days older, 
 and already nearly dried up, an occurrence never observed in 
 variola. They do not develop into pustules, unless irritated, 
 but speedily desiccate and do not leave permanent scars. They 
 are rarely umbilicated, but may be, though to a less extent than 
 in variola. 
 
 VARICELLA. 
 
 Syn. — Chicken-pox ; swine-pox. 
 
 Definition. — Varicella is a mild, contagious fever, accom- 
 panied by the formation of vesicles over the surface of the 
 body. 
 
 Symptoms. — Varicella occurs rarely after the age of ten years. 
 The period of incubation is the longest of all the eruptive 
 fevers, being from thirteen to seventeen days. The disease be- 
 gins with slight headache, malaise, and sometimes a general 
 chilly feeling. The fever is mild and the pulse not much 
 quickened, so that patients are generally not confined to bed 
 and may be ignorant of any special ailment before the appear- 
 ance of the eruption. In a few hours or simultaneously with 
 the onset of the fever, the rash appears, first on the trunk and 
 head and spreads rapidly to the extremities. There is first a forma- 
 tion of small hyperaemic maculae that are disseminated, are not so 
 close or large as in measles, and are entirely without the hard, 
 shot-like feeling of the commencing papules observed in variola. 
 
VARICELLA. Ill 
 
 In a few hours clear vesicles, like blisters made by small drops 
 of boiling water, have formed over the maculae and are sur- 
 rounded by a narrow circle of hyperemia, but with an entire 
 absence of the indurated, inflamed base that is found under- 
 neath the variolous vesicles. There is very rarely any umbili- 
 cation of the vesicles, unless irritated, and they exhibit no 
 uniformity of shape. They vary in size from that of a pin- 
 head to that of a pea and rarely become fuller ; some are large 
 and oval, others acuminated and hemispherical. They appear 
 in successive crops, new red spots appearing close by fully 
 formed vesicles. The inflammation does not extend down to 
 the corium, but only involves the superficial layer of the skin. 
 The vesicles cause some itching and the individual ones reach 
 their full development by the second day, when their contents 
 are almost transparent. This liquid soon becomes turbid and 
 desiccation commences, and is often quite marked within twenty- 
 four hours. By the fifth day small, thin scales have formed, 
 which are soon detached. A little reddening is left, but no 
 pitting, except in rare cases in which the upper part of the 
 corium has been involved. This may happen from continuous 
 irritation of the vesicle by scratching. The vesicles may be 
 abundant, but are rarely confluent, and often occur on the 
 mucous membrane of the mouth, throat, and, exceptionally on 
 the conjunctiva, nasal and genital mucous membranes of girls 
 and prepuce of boys. 
 
 Diagnosis. — It is extremely important to differentiate this 
 disease from variola. In the latter affection the invasion is 
 severe and lasts two or three days. The maculae speedily be- 
 come small, hard papules and go on to the development of the 
 characteristic vesicles and pustules. The first appearance of 
 varicella vesicles is usually on the head and trunk, between the 
 scapulae, and they spread to the extremities rapidly. In variola 
 papules appear first on the forehead, chin and wrists and re- 
 quire a day before the top of the hard papule begins to be 
 vesicular. (See variola, page 1 06). The appearance of freshly 
 developing maculae in the midst of or in the neighborhood of 
 mature vesicles, the exanthema thus cominsr out in successive 
 
112 VACCINIA. 
 
 crops, is characteristic of varicella. The exanthema of measles 
 appears after seventy-two hours of catarrhal symptoms, with 
 generally higher fever, which increases as the eruption develops, 
 and the spots are larger, more diffused, darker colored and do 
 not vesiculate. 
 
 In scarlatina the generally severer onset of the symptoms, the 
 early and characteristic sore throat ; the fine punctate rash, the 
 points of which are much closer ; the rapid diffusion of uniform 
 redness over larger surfaces, on which no vesiculation occurs 
 within a few hours, will readily distinguish it from the first 
 stages of varicella. Varicella generally appears first on the 
 face and the hairy scalp, where it is usually abundant ; in scar- 
 latina the neck and flexures of the joints are the early spots of 
 predilection and the face is comparatively free. The presence 
 of vesicles in the buccal and palatal mucous membranes will 
 early distinguish varicella from scarlatina. 
 
 VACCINIA. 
 
 Syn. — Cow-pox. 
 
 Definition. — Vaccinia is an eruptive disease of the cow, with 
 a lesion resembling variola, that has been induced in man by 
 inoculation to prevent susceptibility to variola. 
 
 Symptoms. — After a period of three or four days' incubation 
 the specific inflammation begins. At first a few small red, 
 indurated papules form at the seat of inoculation ; these increase 
 in size, and by the fifth day there begins to be a collection of 
 lymph at the inflamed spot which, raising the cuticle, forms a 
 few vesicles. At the sixth day the diameter and size of the 
 vesicles are increased and they become umbilicated. The 
 vesicles reach their full development by the eighth day. They 
 are multilocular, like those of variola, and there is now formed 
 around them an inflammatory areola to the extent of one or 
 two inches. By the ninth day the lymph begins to become dis- 
 tinctly purulent, the areola becomes larger and more marked 
 and a slight fever usually develops, with local discomfort and 
 itching. The constitutional symptoms are of a very mild grade. 
 
VACCINIA. II3 
 
 The pustule generally reaches its full development by the tenth 
 day, when the lymphatics leading from it may be painful and 
 somewhat swollen, with enlargement of the corresponding 
 lymphatic glands. At the eleventh day the inflammation begins 
 to decline ; the areola narrows, the fever subsides, and the local 
 induration and tenderness abate. Desiccation begins in the 
 centre of the pustule by absorption of its liquid contents, and 
 gradually extends over the whole of the pock, producing a 
 hard, dark-colored scab that usually falls off some time before 
 the twenty-fifth day. A reddish cicatrix is left which eventually 
 becomes whiter than the surrounding integument and presents 
 several minute, but well-marked depressions. 
 
 When bovine virus has been used the pock is of larger size 
 and usually takes a longer time for its full development. Some- 
 times the papules may not be produced until the tenth or 
 twelfth day, and the vesicles and pustules will then be deferred 
 to a corresponding period, and the crusts may not be cast off 
 before the fourth or fifth week. The bovine lymph also pro- 
 duces some increase in severity of the constitutional symp- 
 toms. 
 
 Certain general eruptions have occasionally been noted in 
 connection with vaccinia that are undoubtedly caused in some 
 way by the constitutional effects of the virus. The rash may 
 appear within two days after vaccination or not until the pustule 
 is fully matured, by the ninth or tenth day. The first variety 
 of eruption to be considered is roseola vaccinia, which usually 
 appears from the eighth to the tenth day, remains well marked 
 for about two days and then gradually disappears, leaving be- 
 hind a slight pigmentation. There may also occasionally be 
 slight desquamation. Evidences of a slight constitutional dis- 
 turbance, such as malaise, with a mild febrile movement, may 
 accompany this eruption. The rash may appear like scarlatina 
 or measles ; in the former case consisting of a diffuse and bright 
 red coloring of the skin ; in the latter, of patches of dusky red 
 mottling. It has been said to resemble German measles. At 
 times, after beginning as a macular form it afterwards spreads 
 
 over the whole body as a uniform and diffuse efflorescence. 
 8 
 
114 VACCINIA. 
 
 Many small vesicles sometimes dot over the patches, but they 
 soon dry up without becoming pustular. 
 
 Another eruption that sometimes appears by the second day, 
 but more frequently not until the ninth day after vaccination, 
 bears a close resemblance to erythema multiforme. It appears 
 more frequently on the extremities, although not excluded 
 from other parts of the body. The patches may be unusually 
 large and undergo the typical slow changes in form and 
 color. 
 
 It is not at all unusual for a vesicular eruption to develop 
 with vaccinia. The vesicles are small and are either confined 
 to one region or generally diffused over the body. They 
 may either develop in successive crops or synchronously with 
 the vaccine vesicle. The contents soon dry up and do not at 
 any time contain the virus ; neither is there any umbilication 
 of the vesicles. Cases of true generalized vaccinia have occa- 
 sionally been reported, accompanied by the development over 
 the body of vesicles and pustules which resemble the typical 
 lesion upon the point of vaccination and that contain an in- 
 oculable fluid. It is still a disputed question, however, whether 
 the vaccine virus is able to act upon the whole system in the 
 same manner as the poison of variola. 
 
 An urticaria occurring upon the skin and mucous membranes 
 sometimes appears a day or more after vaccination. It is ac- 
 companied by the usual burning sensations and does not differ 
 from urticaria produced in other ways. 
 
 An eruption resembling that of impetigo contagiosa has 
 sometimes been observed to follow vaccination, but it probably 
 does not depend upon the same cause. 
 
 The appearance of bullae by the second day, or more frequently 
 by the eighth or ninth day after vaccination has occasionally 
 been noted. The bullae are isolated and have thin walls that 
 soon rupture, forming a light scab. Sometimes the contents 
 become turbid and desiccate without undergoing rupture of the 
 walls. The bullae are rarely so closely grouped as to become 
 confluent. A number of cases have been reported in which 
 this eruption bore a close resemblance to varicella. 
 
VACCINIA. 115 
 
 In a very rare number of cases that have been observed the 
 cow pox has taken on a hemorrhagic form. Numerous 
 petechiae have appeared on the body a few days after vaccina- 
 tion, and have not begun to fade until about the sixteenth day. 
 In one of these cases that has been reported the purpuric 
 eruption appeared in a child that had apparently been pre- 
 viously in perfect health. 
 
 It is well recognized that there may occasionally be a con- 
 nection between vaccination and certain of the well marked 
 skin diseases. There have recently been not a few cases of 
 eczema and pustular eruptions reported as being associated 
 with vaccination. In these cases the constitutional impress of 
 the vaccine virus has been strong enough to indirectly cause the 
 development of skin diseases in persons predisposed to them. 
 The cause of this phenomenon is not found in any specific 
 action of the virus, as cases have been reported of psoriasis 
 developing after scarlatina, and the latter disease cannot be 
 considered as a specific cause of the former. 
 
 Considering all the cases of vaccinia, eruptions occur in 
 comparatively few instances. They have probably occurred 
 more frequently of late, because the more active bovine virus 
 now used is able to induce severer constitutional effects than 
 the long humanized virus. 
 
 Before leaving the subject of vaccinia it may be well to 
 notice certain irregular forms it occasionally assumes. Thus a 
 papulo-vesicle may be formed that is conoidal or pointed in 
 shape instead of having the central umbilication ; it develops 
 quickly and leaves behind a feebly marked cicatrix. In other 
 cases a vesicle, irregular in shape, appears by the second day, 
 which soon dries up, leaving a pigmented base when the scab 
 is thrown off. Sometimes a vesicle will run its regular course, 
 but after a crust forms, a deep ulceration begins under it that 
 may cause much local and general disturbance. The so-called 
 " raspberry sore " is usually produced by the coalescence of a 
 few small papules forming a pigmented tubercle. It itches a 
 great deal and may grow as large as a pea. It slowly disap- 
 pears after a few weeks, leaving behind some pigmentation. 
 
Il6 IMPETIGO CONTAGIOSA. 
 
 These irregular manifestations must not be regarded as pro- 
 tective after a primary vaccination. 
 
 Erysipelas sometimes develops after vaccination in persons 
 whose systems are in a condition favorable for its occurrence. 
 It may occur early after the operation or during the pustular 
 stage or be delayed until the separation of the scab. It is 
 always caused by absorption of some septic matter from the 
 seat of vaccination. 
 
 IMPETIGO CONTAGIOSA. 
 
 Definition. — An acute, inflammatory, contagious disease, 
 characterized by the formation of isolated, superficial, flat or 
 raised vesicles or blebs which quickly pustulate, and afterwards 
 dry to thin, yellow and very slightly adherent crusts. 
 
 Symptoms. — This form of eruption was first described as a 
 separate disease by the late Dr. Tilbury Fox and is admitted as 
 such in this work in deference to the views of many able der- 
 matologists, although in nearly all the cases I have seen with a 
 corresponding form of eruption, the condition was secondary 
 to other diseases and especially associated with the presence of 
 pediculi. The eruption is frequently preceded by febrile 
 symptoms and commences as small, isolated, flat or raised ves- 
 icles, or small bullae, which rapidly become vesico-pustules. 
 The vesicles afterward increase in size, are round or oval in 
 form, and, if large, are sometimes umbilicated. In some 
 anomalous cases the vesicles are few, ill defined and irreg- 
 ular in shape. An individual vesico-pustule is about the size 
 of a large split pea and the number present is always small, rare- 
 ly exceeding ten or twelve. They areat first isolated, but if closely 
 seated may subsequently coalesce and form a patch. In a few 
 days, they dry to flat, yellow or straw-colored, granular looking, 
 very slightly adherent crusts, beneath which, especially in 
 strumous subjects there is slight excoriation. In the severer 
 forms of the eruption there is a slight areola around the spots, 
 which is absent in mild cases. When the crusts fall off the 
 skin beneath appears erythematous, which condition afterward 
 
IMPETIGO CONTAGIOSA. 117 
 
 disappears. The vesicles appear simultaneously or successively, 
 and have a definite duration, lasting from seven to ten days. 
 The eruption does not pain and itches very little. Its most 
 frequent seat is the face and hands, but it may appear on other 
 parts of the body, and it has been reported as even occurring 
 upon the mucous membrane of the eyes and mouth. On the 
 scalp the patches are circular, isolated, dry to a flat scab and 
 produce matting of the hair. 
 
 Etiology. — The eruption is met with especially in ill nourished 
 or uncleanly persons and generally in children. It is conta- 
 gious and auto-inoculable. It has been observed to follow 
 vaccination. As already stated I have frequently met with a 
 similarly appearing eruption, which has almost invariably had 
 its origin from persons with pediculosis capitis, and the pus from 
 ill nourished persons being especially contagious and auto- 
 inoculable, a number of persons have become affected, and in 
 this manner the eruption appeared to be epidemic in character ; 
 hence for the exclusion of pediculi, as the cause of the erup- 
 tion in a given case, it is not sufficient to prove their absence in 
 the case of the person under observation, but also in the indi- 
 vidual first attacked. 
 
 Pathology. — Differently formed vegetable organisms discov- 
 ered in the crusts have been described by different observers as 
 the cause of the eruption, whilst others, including Tilbury Fox, 
 have been unable to demonstrate the presence of any special 
 fungus in the vesicle, and regard those organisms which have 
 been occasionally found in the crust as occurring accidentally. 
 As yet there has been nothing found in the vesicles or crusts 
 except the pus to account for the inflammation. 
 
 Diagnosis. — The eruption may be confounded with impetigo, 
 eczema pustulosum, varicella, pemphigus and ecthyma. The 
 quasi-epidemic character, the contagiousness of the eruption, 
 the antecedent pyrexial symptoms, its occurrence in children 
 especially, the seat, the yellow or straw-colored, flat, slightly 
 adherent " stuck on " crusts are sufficient points for the diagnosis. 
 In impetigo the eruption is pustular, the pustules are raised, the 
 patches large and the crusts thicker than in the contagious form. 
 
Ij8 ANTHRAX. 
 
 In eczema pustulosum there are no antecedent febrile symp- 
 toms, the pustules are not isolated, there is itching and infiltra- 
 tion of the skin, and the crusts are thicker. The duration of 
 existence of a patch is also indefinite. In those cases, however, 
 in which the eruption is seated on the scalp it is frequently- 
 impossible to make a positive diagnosis. In varicella the 
 smallness of the vesicles and their distribution over the whole 
 body make the diagnosis easy. 
 
 Prognosis. — With appropriate treatment the eruption rapidly 
 disappears. 
 
 Treatment, — The treatment is general and local. Good 
 food, pure air and cleanliness should be insisted upon. Tonics 
 are to be given if the general condition of the system indicates 
 their use. Locally, zinc salve, or still better, white precipitate 
 ointment should be applied to the patches of eruption, and 
 any pediculi or nits present destroyed by kerosene or some 
 other anti-parasitic remedy. 
 
 ANTHRAX. 
 
 Syn. — Malignant pustule. 
 
 Definition. — A spreading, grangrenous inflammation of the 
 skin, the result of inoculation with the specific poison derived 
 from animals suffering from anthrax and associated with the 
 development in the blood of the bacillus anthracis. It com- 
 mences as a vesicle on the exposed skin ; the gangrenous pro- 
 cess rapidly invades neighboring tissues — and may ultimately 
 cause death by septic infection. 
 
 History. — Malignant pustule is a disease usually communi- 
 cated to man from the lower animals ; it being one of the 
 manifestations in the human subject of infection by the virus 
 of the disease known to veterinaries under the various names 
 of anthrax, charbon, splenic apoplexy or fever, Texan fever 
 and braxy. 
 
 Anthrax has been known to occur as an an epizootic disease 
 among solipeds, horned cattle, and birds, from the earliest times, 
 and every outbreak has been signalized by a large human 
 
ANTHRAX. 
 
 II 9 
 
 mortality among those who handled the diseased cattle, or par- 
 took of their flesh. Thus, in 17 16, near Naples, 60,000 persons 
 perished from eating the flesh of animals dead of anthrax. 
 In 1756 and 1785 it prevailed among the cattle on 
 the islands of Minorca and Granada, respectively ; and both 
 the Balearic herdsmen and the West Indian negroes succumbed 
 in great numbers to the fatal malady. At about the same time 
 it prevailed extensively in France, and it has been endemic 
 there and in many other parts of Europe ever since. In Ameri- 
 ca it is a disease rather less commonly seen, but just as fatal 
 as in Europe. 
 
 AV 
 
 m to 
 
 Fig. 26. — Capillaries in a villus of intestine, containing- the bacillus anthracis. 
 The bacilli are visible as definite rods. Multiplied 700 diameters. (Koch.) 
 
 Anthrax in cattle is probably due to the reception into the 
 system and the development in the blood of an organism termed 
 bacillus anthracis. Inoculation of the blood or tissue of a 
 
120 ANTHRAX. 
 
 charbonous animal causes in the human being the same disease, 
 most commonly in the form of malignant pustule ; and the in- 
 oculation of animals with the material from malignant pustule 
 causes anthracoid disease. The bacillus is present in all forms. 
 
 The bacillus anthracis (Cohn) is a small, rod-shaped body 
 whose length equals about twice the diameter of a human red- 
 blood corpuscle. The rods exhibit power of motion in a suit- 
 able habitat and multiply rapidly — either by fission or by spore- 
 production. That it is the essential element of charbonous 
 disease has been strenuously maintained by Cossar Ewart, 
 Pasteur, and Koch. It is but fair to state, however, that other 
 observers, equally trustworthy, have found the virus to persist 
 under conditions such as treatment with absolute alcohol, and 
 compressed oxygen, and filtration through porous porcelain ; 
 conditions incompatible with organic life even of the lowest 
 kind. Panum long ago pointed out that probably some body 
 of the nature of a ferment was the active agent. In a recent 
 elaborate review of the whole subject, Burdon-Sanderson 
 reaches no positive conclusion ; and while admitting the con- 
 stant presence of the bacillus, inclines to the belief that the 
 contagium of the disease belongs to the class of " unformed 
 ferments." 
 
 Three varieties of anthrax are distinguished by veterinarians ; 
 all occur in the human subject — but in one only are we at pres- 
 ent interested. These varieties are : 
 
 i. Charbonous or anthrax fever. — A rapidly fatal general dis- 
 ease with hardly any external manifestations. The patients 
 sink in a few hours with symptoms of profound septicaemia. 
 
 2. Symptomatic charbon. — When the animal lives long enough 
 to permit the development of the characteristic flat subcutane- 
 ous tumors, and the intestinal and pulmonary inflammations. 
 
 3. Essentia/ charbon. — Resulting from inoculation and unpre- 
 ceded by fever — being that form of anthrax so well studied by 
 Dr. William Budd, and by him called malignant pistule. 
 
 Etiology. — Malignant pustule is the result of the implanting 
 of the charbonous poison upon any part of the body. As 
 might be expected, it occurs almost invariably upon those un- 
 
ANTHRAX. 121 
 
 covered parts of the body which are exposed to inoculation. 
 Handling the carcasses and bones of animals dead of the disease 
 is the usual mode of infection ; and butchers, tanners, etc., 
 chiefly suffer. Eating of the meat, or using the butter or milk 
 of diseased animals will cause anthrax. A well recognized 
 mode of contagion is through the medium of various insects, 
 those with piercing probosces, like gad-flies, are most often car- 
 riers of the disease ; but even flies can bring the poison from 
 animals to man on their soiled wings and feet. The flies them- 
 selves, though the bacillus has been found in them in abund- 
 ance — seem to be incommoded by the disease. 
 
 The hair and wool of plague-stricken animals long retain the 
 virus, and many instances are on record where wool-sorters, 
 furriers and tanners have contracted charbonous disease either 
 by local inoculation or by the inhalation of the dust containing 
 it. The tenacity to life of the virus is remarkable; and it is 
 probable that it is carried to the surface from the carcasses of 
 buried animals by the earthworms — and then, through the vege- 
 tation, produces the disease anew among the cattle. 
 
 Symptoms and course. — Twelve to fifteen hours after in- 
 oculation a sensation of burning or itching draws the patient's 
 attention to a small spot looking like a flea-bite. This spot is 
 soon elevated into a papule — and the papule shortly becomes 
 a vesicle ; underneath this is a small, hard, well-defined 
 nucleus — the "parent nucleus" of Virchow, the "Maetka" of 
 the Russians. The vesicle is filled with a bloody serum, and 
 is ruptured by the patient, or dries up. In thirty-six hours a 
 dark-brown or black scab is left, surrounded by a dark-red 
 brawny induration — covered perhaps with secondary vesicles 
 like the primitive one. This eschar may extend until it attains 
 the size of a silver half dollar. The entire affected tissue be- 
 comes gangrenous ; sensibility is lost, and it may be cut or 
 burned with impunity. The termination of the process varies. 
 If the patient is to recover, the disease ceases to advance — 
 and the gangrenous mass is cast off by the inflammation and 
 ulceration of the neighboring healthy parts ; to be replaced 
 by new connective tissue and cicatrices. If the process con- 
 
122 ANTHRAX. 
 
 tinues — extension of the cedematous infiltration and the gan- 
 grene, together with the symptoms of constitutional septic in- 
 fection end the scene. 
 
 Meantime, the general symptoms are sometimes marked, but 
 may be absent even in severe forms of the disease. There 
 may be high febrile movement, 105 F., with violent delirium 
 and other brain symptoms ; or there may be hardly any fever, 
 but great mental depression and physical exhaustion, with low 
 muttering delirium, and coma. In fatal cases, syncope, the 
 brown, dry tongue, the shrunken features and glassy eyes, or 
 cyanosis and embarrassed respiration, foretell the end. Lym- 
 phangoitis, and suppurative axillary adenitis are common. If 
 recovery is to take place, the pulse revives, the " crisis " of the 
 fever occurs, perspiration sets in, and the healing process com- 
 mences in the local lesion. 
 
 The pustule itself is almost invariably situated on the hands, 
 arms, or face, most commonly on the back of the hand. But 
 the poison may be carried to any external part of the 
 body — and even, according to the latest investigations, be 
 conveyed with food and drink into the gastro-intestinal, or 
 with the inhaled air into the broncho -pulmonary tract, and 
 there cause the characteristic lesion. With these latter forms of 
 malignant pustule, as well as with the more general kinds of 
 charbonous infection, we have here no concern. 
 
 The entire absence of marked pain, and the manifest local 
 anaesthesia are peculiar and perhaps characteristic symptoms 
 in so severe a process. 
 
 Pathology and Morbid Anatomy. — Post-mortem, we find the 
 subcutaneous cellular tissue infiltrated with gas, the product of 
 a putrefaction that sets in with extreme rapidity. The blood 
 is profoundly altered, chemically and physically ; the white 
 cells are in excess ; the red cells are deformed, the haemoglo- 
 bin leaves them ; bacilli and their spores, and granular de- 
 tritus, found in abundance ; the fluid is black, tarry and viscid. 
 Haemorrhages, varying from petechial spots to large ecchy- 
 moses are present in numbers, under the skin, in all the serous 
 and mucous membranes, and in all the internal organs and 
 
ANTHRAX. 123 
 
 muscles ; all the organs are intensely congested and softened. 
 Purulent effusions into the serous cavities are common. 
 Locally, the gangrene at the site of the pustule has extended 
 deeply into the subcutaneous parts ; the surrounding tissues 
 contain blood extravasations — and the meshes of the connective 
 tissue are infitrated with a semi-gelatinous, blood-stained fluid. 
 A noteworthy point is the. absence of inflammation and of 
 pus, which only appear when separation of the gangrenous 
 part is about to occur. Lesions in every respect analagous to 
 the external pustule are found in the bronchial mucous mem- 
 brane, and also, though rarely, in the gastro-intestinal. 
 
 Diagnosis is very difficult in the early stages of malignant 
 pustule, and it is unfortunately in those stages only that we 
 can expect much from treatment. A very evident history of 
 contagion — or a special prevalence of anthracoid disease at the 
 time, may be of assistance. Later, recognition is easy ; in 
 carbuncle, the only disease with which malignant pustule is 
 liable to be confounded, the numerous openings in the skin, 
 the pain, the site, together with the absence of the above-men- 
 tioned characters of the pustule, will enable us to avoid error. 
 An abundance of the peculiar bacilli may be found in the 
 bloody serum of the vesicle, and in the fluids of the gangre- 
 nous parts. Inoculation of mice or other animals may be resor- 
 ted to for confirmation. 
 
 Prognosis is decidedly unfavorable. A large proportion of 
 cases of the milder, primarily cutaneous forms of charbonous 
 disease succumb. The fatality of malignant pustule varies in 
 different epidemics — but t>Z per cent, of deaths is, if any thing, 
 an understatement of the mortality. 
 
 Treatment. — The local treatment is of much importance, and 
 an early recognition of the disease renders it of most avail. 
 Free cauterization, or excision, or both, of any suspicious 
 vesicle or papule in one exposed to the disease, is imperative. 
 The best results have been obtained by crucial incisions, cau- 
 terization by pure carbolic or fuming nitric acid, or the actual 
 cautery, followed by a dressing of carbolized oil, or carbolized 
 lint. Lately, complete excision of the pustule has been advised, 
 
124 ANTHRAX. 
 
 and I am inclined to think if the disease is recognized early, 
 that it offers the greatest chances of success. 
 
 The constitutional treatment is mainly that proper for all 
 adynamic, typhoid conditions. Nutrition should be sustained 
 to the greatest possible extent ; the cardiac and respiratory 
 stimulants, alcohol, ammonia, ether and atropia should be 
 used as necessary. Quinine in large doses, and the in- 
 halation of the vapor of carbolic acid have been favor- 
 ably reported on. Later, if the patient survive, tonics, in the 
 widest sense of the word, are indicated. The treatment of 
 the other forms of charbonous disease belongs to the province 
 of general surgery. 
 
 Compulsory destruction by fire of the carcasses of animals 
 dead of anthrax ; the prohibition of the importation of hides, 
 bones, etc., from localities where the disease is known to be 
 epidemic, or even, if possible, the adoption of some general 
 method of disinfection of these raw goods ; these form the 
 basis of the more important, the prophylactic, treatment of the 
 disease. 
 
 It is, perhaps, proper to mention here another form in 
 which charbonous disease manifests itself upon the external 
 integument, though its rare occurrence makes it of less import- 
 ance than malignant pustule. It is known as malignant oedema 
 of the eyelids, and consists of a more or less extensive swelling 
 of the skin, with subcutaneous infiltration. No external lesion 
 is visible ; there is simply a hard, indolent, pale swelling, the 
 skin over which is tense and smooth. It usually affects the 
 eyelids, and spreads thence to the nose, cheeks, and ears, but 
 occasionally also it appears on other parts. The constitutional 
 symptoms are grave, and a fatal termination in from two days 
 to a week is the rule. Treatment is the same as for malignant 
 pustule ; the cauterization of the cedematous parts must be 
 very thorough indeed if any good is to be done by it. 
 
EQUINIA. 125 
 
 EQUINIA. 
 
 Syn. — Glanders and Farcy. 
 
 Definition. — A specific contagious disease, due to the intro» 
 duction into the system of the peculiar virus derived from 
 solipeds or human beings suffering from glanders and farcy. 
 It is a febrile affection of a malignant type, characterized by 
 specific inflammatory lesions of the nasal and respiratory 
 mucous membranes, of the lymphatic system, and of the 
 skin. 
 
 History. — Glanders and farcy are two varieties of a disease 
 which has long been known to occur amongst horses, asses, 
 and mules, but which has only within the last century been 
 recognized and described in the human subject. Other animals 
 are also liable to the disease, but cattle, pigs and fowls resist 
 contagion, even when inoculated. 
 
 Formerly looked upon as two distinct diseases of frequent 
 occurrence amongst horses, glanders and farcy are now known 
 to be but different manifestations of one disorder, which, in 
 consequence of the somewhat close analogy between it and 
 vaccinia, has been designated equinia. Glanders is that form 
 of equinia in which the nasal passages show the chief local 
 lesions, whilst in farcy the lymphatic system is prominently 
 affected. 
 
 In 182 1 the attention of physicians was first called to the fact 
 that a number of cases of a peculiar, severe and even fatal dis- 
 ease had occurred in persons whose occupations were such as to 
 bring them in close contact with glandered and farcied horses. 
 At that time Muscroft published an account of a case in 
 which the whipper-in of a hunt wounded himself while cutting 
 up a glandered horse for the kennel, and died in two weeks of 
 undoubted glanders. Other cases were soon recognized, and 
 in 1828 Coleman proved by recorded cases that the disease 
 was communicable from the horse to man, and from man to 
 the ass. Somewhat later Rayer, in an exhaustive paper, col- 
 lected all that was then known of the disease ; and finally, in 
 
126 EQUINIA. 
 
 1862, Zimmermann proved its transmissibility from one human 
 subject to another. 
 
 Equinia is a rather rare disease ; yet in the city of Paris 
 alone three or four deaths are due to it every year. In America 
 it is not very uncommon ; some four or five cases have occurred 
 in as many years among veterinary surgeons in New York city 
 alone — veterinarians, cavalry-men, stablemen, etc., are naturally 
 most often exposed ; and wherever horses are collected and 
 confined in large numbers, as in camps and on shipboard, it is 
 almost certain to appear and infect human beings. 
 
 Etiology. — Equinia is due to inoculation by a specific conta- 
 gious poison, always derived, in man at least, from one already 
 suffering from the disease — almost invariably from a glandered 
 or farcied horse. In the human subject it never originates, 
 and whilst most cases of equinia in animals are directly trace- 
 able to contagion, many veterinarians believe that, under 
 certain circumstances, the disease originates de novo in horses. 
 (Williams). What these circumstances are supposed to be is 
 not very clear. Bad air, over-crowding, telluric conditions, 
 etc., are mentioned ; but they hardly agree with our ideas of a 
 specific virus such as this is. So far as we are concerned, 
 equinia, in man, is always traceable to direct or mediate con- 
 tagion. 
 
 Nothing is known as to the exact nature of the virus, which 
 is present in the blood and urine, but especially in the 
 " jetage " from the ulcerated nasal mucous membrane, and in 
 the contents of the farcy buttons. Horses are very liable to 
 spread the disease by their snorting to get rid of the viscid 
 mucus that clogs the air passages, thus scattering the virus in 
 small particles through the air and upon all neighboring objects, 
 where it may long remain and retain its virulence. It is prob- 
 able that an abrasion of the skin or mucous membrane is 
 necessary for the reception of the contagion, certain cases to 
 the contrary notwithstanding. 
 
 Symptoms and course. — After a period of incubation of two or 
 three days, if infection is due to direct inoculation, or of several 
 weeks, if the virus has been received on the unbroken mucous 
 
EQUINIA. 127 
 
 membranes, the symptoms of constitutional infection appear. 
 Acute and chronic forms of both the glanders and the farcy 
 variety of the disease are described ; but no clear distinctions 
 between them can be drawn clinically. 
 
 The first general symptoms are those that may mark the ad- 
 vent of any acute febrile disease — headache, malaise, costive- 
 ness, anorexia, slight chills, etc. Soon the temperature rises, 
 •and the fever may be continued, or irregularly remittent. 
 Pains and even swellings of the joints are so constant and 
 severe that all authorities warn us against mistaking the dis- 
 ease for rheumatism. 
 
 Meantime the wound, or the place where the virus was inoc- 
 ulated, has inflamed ; an erysipelatous redness appears around 
 it ; destruction of tissue goes on rapidly, and we soon have an 
 unhealthy, chancroidal-looking ulcer, with undermined edges, 
 and discharging an offensive sanies. 
 
 The characteristic affection of the mucous membrane ap- 
 pears early, and usually affects first the naso-pharyngeal sur- 
 face, spreading from thence to contiguous membranes, and to 
 the skin. Small whitish, tubercular-looking masses appear 
 deep in the membrane ; and the resultant diffuse inflammation 
 causes a discharge, which, at first yellowish and muco-puru- 
 lent, soon becomes foul, ichorous, and bloody. The granular 
 masses soon break down, and the unhealthy ulceration spreads 
 rapidly, until the whole surface looks worm-eaten. Necrosis of 
 the turbinated and ethmoid bones commonly occurs. The in- 
 flammation spreads from the mouth and anterior nares to the 
 skin of the face, and blebs filled with a bloody serum and 
 large ulcerations appear ; the larynx is affected, and oedema of 
 the glottis may suddenly end the disease. 
 
 The lymphatic vessels, meanwhile, in the neighborhood of 
 the lesion, are swollen, and present a knotted, cord-like ap- 
 pearance ; the lymphatic glands are acutely inflamed, and 
 form the so-called farcy-buds or buttons. The lymphatic in- 
 volvement spreads through the body, the glands suppurate, and 
 large abscesses form. 
 
 In accordance with the greater involvement of the mucous 
 
128 EQUINIA. 
 
 membrane or of the lymphatics, the disease is designated 
 glanders or farcy. 
 
 By about the twelfth day the skin eruption manifests itself, and 
 is preceded or accompanied by profuse foetid sweats. The ex- 
 anthem is characteristic, and consists at first of little red spots, 
 like flea-bites, scattered over the body ; later they become ap- 
 parently papular. There are, however, no real elevations ; they 
 seem to be small, circumscribed collections of neoplastic mat-, 
 ter deep down in the corium, situated on an inflamed, livid base. 
 As the collection breaks down, the lesion apparently becomes 
 first vesicular, then pustular. Eventually the surface is de- 
 stroyed, and unhealthy circular ulcers, spreading and discharg- 
 ing a brown sanious fluid, are left. Similar cell-collections in 
 the subcutaneous tissue lead to the formation of large, painful, 
 indurated masses, which ultimately cause extensive ulceration 
 and sloughing. Large black bullae are observed on various 
 parts of the body, especially on the fingers, toes, and genitals, 
 and are followed by gangrene of the parts. 
 
 Meanwhile the general symptoms increase in severity, and the 
 patient falls into a typhoid condition ; a foul, bloody discharge 
 wells from the nostrils ; the face is livid, swollen and ulcerated ; 
 extensive pus collections and spreading gangrene occur in va- 
 rious parts of the body, especially in the lungs and large joints. 
 Death by exhaustion occurs in two-thirds of the more acute 
 class of cases before the seventeenth day ; but the disease in 
 other cases may last one to twelve months. Not all the symp- 
 toms recorded are present in any one case, and in accordance 
 with the general rapidity of the processes, we get acute and 
 chronic glanders, acute and chronic farcy. 
 
 Pathology and Morbid Anatomy. — The growth of the pecu- 
 liar nodules above mentioned are the cause of most of the 
 lesions of the mucous membranes, skin, lymphatics, muscles, 
 lungs, etc. They consist of a closely packed collection of 
 lymphoid cells, with numerous free nuclei. The nodules they 
 form are about the size of a small pea, and are at first hard ; 
 but they soon undergo fatty degeneration, and the mass 
 breaks down. At first discrete, they soon coalesce, and the re- 
 
EQUINIA. I29 
 
 suiting ulceration lays bare large tracts of surface and pene- 
 trates deeply, denuding cartilage and bone, and causing necro- 
 sis. This same small-celled mass infiltrates the lymphatic glands 
 and causes the farcy " buds ; " it appears in the skin, and causes 
 the peculiar eruption. 
 
 The apparent pustules are found after death to be white, 
 surrounded by a livid areola, and containing a puriform liquid 
 consisting of the broken down and fattily degenerated round 
 cells in their interior. If the softened matter has been evacu- 
 ated during life, as sometimes occurs, we find small circular 
 ulcerations in the skin in their stead. 
 
 Larger collections of pus in the subcutaneous cellular tissue 
 are not uncommon. 
 
 Abcesses of the joints, acute pneumonia and gangrene of the 
 lung are frequently seen. 
 
 The close analogy which equinia bears to tuberculosis, es- 
 pecially as regards its pathology, has led Villemin to suspect 
 a relationship between the two diseases. 
 
 Diagnosis. — The peculiar naso-pharyngeal lesions,, the dis- 
 charge from the nostrils, the cutaneous eruption, the marked 
 involvement of the lymphatic system, sufficiently distinguish 
 the fully developed disease. In the early stages) and in the 
 absence of a history of infection, it may, as above stated, be 
 mistaken for rheumatism, and even for pyaemia or typhoid 
 fever ; but the subsequent course of the disease soon clears up 
 the diagnosis. The more chronic forms have often undoubt- 
 edly been confounded with syphilis. 
 
 Prognosis. — Equinia is a malignant disease in every sense of 
 the word, and the prognosis is extremely unfavorable. The 
 more acute forms are very rarely recovered from, though there 
 happens to be living in New York city at present a person who 
 has survived it. In the more chronic forms the prognosis is 
 slightly better, the mortality being about 5.0 per cent. 
 
 Treatment is of little avail. The cauterization by potassa- 
 
 fusa, or better, the excision of any suspicious wound, is to be 
 
 practiced. All those engaged in the care of cases of equinia 
 
 should wear rubber gloves when they handle the patient. Stim-u- 
 9 
 
I^O ERYSIPELAS. 
 
 lation and general support must be relied on. Quinine and 
 tincture of the chloride of iron may be freely given. Many 
 other drugs are recommended, but experience has not sanc- 
 tioned their use. Abscesses should be opened early, and the 
 resulting cavities should be kept as clean as possible with 
 antiseptic injections, and perhaps poulticed. In the glanders 
 form of the disease the nose should be thoroughly syringed out 
 several times a day with carbolic acid or thymol solutions. 
 
 ERYSIPELAS. 
 
 Syn. — Rose ; St. Anthony's fire. 
 
 Definition. — A specific asthenic febrile disease, accompanied 
 by an inflammation of the integument or mucous membranes, 
 which tends to spread indefinitely, and may involve the under- 
 lying connective tissue and deeper structures. 
 
 Symptoms. — Under the name erysipelas are usually described 
 several affections which have for their chief local manifestation 
 a peculiar inflammation of the skin and subcutaneous cellular 
 tissue. At least three varieties are recognized, in accordance 
 with the severity of the disease as shown by the extent of the 
 superficial process. 
 
 These varieties are : 
 
 i. Cutaneous Erysipelas. — Where the skin only is at- 
 tacked. 
 
 2. Cellular Erysipelas — Or diffuse cellulitis, where the in- 
 flammation is limited to the subcutaneous connective tissue, 
 the fascia., and the inter-muscular areolar places. 
 
 3. >Cellulo-Cuta?ieous Erysipelas or phlegmonous erysipelas, 
 where both the skin and the subcutaneous tissue are involved. 
 
 Besides these there is described erysipelas of mucous mem- 
 branes, and of the lining membranes of veins and lymphatics. 
 
 All these affections belong rather to the province of surgery 
 than to that of dermatology ; but in certain cases the manifes- 
 tations upon the skin form the most important part of their 
 symptomatology, and they are generally included in systematic 
 works upon the diseases of that organ. Only the first-men- 
 
ERYSIPELAS. I3I 
 
 tioned form, simple cutaneous erysipelas, properly belongs 
 here, and to that we will confine our attention, referring the 
 reader to the works on general surgery for the other varie- 
 ties. 
 
 In simple cutaneous erysipelas there is usually a period of 
 from twelve to twenty-four hours, during which — as with the 
 eruptive fevers — certain prodromal symptoms are manifested. 
 These consist of slight recurring chills, followed by feverish- 
 ness, nausea, anorexia, costiveness, headache, pains in the 
 limbs, etc., etc. But the attention of the patient is not directed 
 to the true cause till the local symptoms become prominent. 
 As is usual, convulsions may in children replace the mild rigors. 
 The invasion may, however, be sudden, and a rise of tempera- 
 ture to 103 F. may occur within twenty-four hours after the 
 first general symptoms. 
 
 It is stated that swelling and tenderness of the lymphatic 
 glands of the neck, together with pyrexia, are almost certain 
 signs of the advent of facial erysipelas. 
 
 Within two days at most from the occurrence of the first 
 feelings of malaise, the patient's attention is drawn to some 
 part of the integument by itching and a feeling of tension, 
 combined with a moderate amount of pain ; and he finds an 
 irregular, but sharply defined, raised, rose-colored spot, the 
 surface of which is smooth and shining. It is sensitive to the 
 touch, and pressure, dispelling the redness, leaves a yellowish 
 stain behind. If the process has begun at a wound, the red- 
 ness starts at its border, and spreads thence to the neighboring 
 integument ; if there is none visible, some unnoticed abrasion 
 or acne-spot has formed the nidus. 
 
 Gradually the inflammation extends over the skin, advancing 
 most rapidly along the lymphatic vessels, which stand out as 
 red streaks radiating from the hyperaemic centre. In two or 
 three days it has attained the size of a man's hand, or more ; 
 by four to six it has usually reached its greatest extent. The 
 advancing margin is irregular and raised ; and the general 
 swelling varies with the amount of the subcutaneous connec- 
 tive tissue and its implication in the inflammatory process, : 
 
132 ERYSIPELAS. 
 
 being often very great where, as in the eyelids and scrotum, it 
 is abundant and lax. Small vesicles, or blebs, may form on 
 the inflamed surface ; they are filled with a serum that is usually 
 clear, but in bad cases may be dark and bloodstained ; these 
 may rupture, and their dried contents form scabs, but there is 
 no true ulceration. 
 
 After the eruption has attained its full size, it remains station- 
 ary for a period varying from three days to two weeks or more, 
 and then the retrogressive changes begin. The vivid red 
 gradually fades into a pale brownish-red, the sharp border be- 
 comes lost, the turgescence of the vessels and the hardness of 
 the skin remit, and a small-scaled desquamation of the epi- 
 dermis leaves the normal though somewhat discolored skin 
 behind. The wound, if there was one, in which the secretions 
 had become dried up, the edges swollen, and healthy repair 
 ceased, begins to look better ; laudable pus is poured out, and 
 granulation begins. 
 
 Meanwhile the general symptoms have varied much, in ac- 
 cordance with the severity of the inflammation, and the im- 
 portance of the part involved. The primary fever rises with 
 the appearance of the eruption, and may attain a height of 106 
 or even 107° ; it is usually remittent in type, with moderate 
 evening exacerbations. The pulse is hard and quick — in bad 
 cases feeble ; its character is our best guide for prognosis. In 
 severe cases delirium is common ; the lips and teeth are cov- 
 ered with sordes ; there is constipation or a foetid diarrhoea ; 
 and, as in other acute fevers, there may be a small amount of 
 albumen in the urine. These symptoms all remit when the 
 local process begins to retrogress. The fever ceases, often 
 suddenly ; the tongue clears, and sleep and appetite return 
 whilst desquamation is going on. But the patient often remains 
 weak and anaemic for a long time. 
 
 Not all cases of cutaneous erysipelas end in so favorable a 
 manner. The delirium present in the bad cases may, even 
 without extension of the inflammation to the brain, deepen into 
 coma, and the patient may succumb to the extent of the blood 
 changes, or die simply of exhaustion. Complications, such as 
 
ERYSIPELAS. 133 
 
 pleurisy, pneumonia, meningitis, septicaemia or pyaemia, may 
 determine an unfavorable issue. Even in mild cases relapses 
 are very liable to occur. 
 
 It remains for us to describe several varieties of simple ery- 
 sipelas which from their location, or their peculiar course, 
 merit special enumeration. 
 
 I. Varieties as to intensity. — If the infiltration of the epi- 
 dermis goes on to the extent of forming vesicles or bullae, we 
 have what is termed E. Vesiculosum or E. Builosum. Some- 
 times the vesicles contain a purulent fluid, E. Pustulosum, and 
 eventually we get E. Crustosum. The infiltration may even be 
 so intense as to cause death of the skin from compression of 
 the vessels, giving us E. Gangrenosum. This latter is espe- 
 cially liable to occur on the eyelids, penis, and scrotum. 
 
 II. Varieties as to location. — It occasionally happens that 
 instead of the inflammation remaining localized to one spot, 
 and then running its course, it is ambulatory ; the process ad- 
 vancing at one edge whilst retrogressive changes are going on 
 at another. It is then spoken of as E. Migrans, and may 
 cover large tracts of surface, or even the entire body (E. U?ii- 
 versatis) ; nay, the disease may complete the cycle, and go 
 again over the ground where it began. In the migratory form 
 lymphangoitis plays an important part ; the disease may last four 
 weeks, or more, and the patient is much reduced by the amount 
 of the exudation and the fever. As might be supposed, the 
 danger of the occurrence of complications is greatly increased 
 in these cases ; oedema of the brain, of the lungs, of the glottis, 
 inflammation of the meninges, of the pleura, of the lungs, of 
 the endo- and pericardium, of the joints, pyaemic processes, etc., 
 are common. E. faciei is the most common form of cutaneous 
 erysipelas that comes under our notice. It usually begins at the 
 angle of the mouth or at the external nares or at the corner of 
 the eye, near the point of junction of the skin and mucous 
 membranes ; scrofulous or specific rhinitis, caries of the nasal 
 bones or teeth, chronic conjunctivitis, etc., can usually be de- 
 tected at its point of origin. The amount of exudation into 
 the loose connective tissue of the part is often enormous ; the 
 
134 ERYSIPELAS. 
 
 face is dreadfully deformed — the nose, ears, eyelids, and lips 
 stiff, swollen and shining — and the cedematous skin of the face 
 perhaps covered with blebs. Saliva wells from the mouth, the 
 tongue is brown, dry, and cracked. The temperature is often 
 high, the pulse rapid and feeble ; much constitutional depres- 
 sion and brain symptoms are not uncommon. The process, 
 nevertheless, usually terminates favorably. 
 
 If erysipelas occurs on the scalp, we have E. capillitii. The 
 hairs hide the process to some extent, but the continuous head- 
 ache and the local sensitiveness soon draw our attention to it. 
 Sleeplessness, delirium, etc., are prominent symptoms in this 
 form of the disease even when the fever is not high. A general 
 falling out of the hair from exudation in the follicles follows its 
 subsidence, and an obstinate seborrhcea is often left. The 
 occurrence of meningeal or brain complications in these forms 
 of erysipelas is shown by the retarded pulse, the sluggish 
 pupils, jactitation, psychic depression, stupor or coma, or low 
 muttering delirium. Though rare, the possibility of their oc- 
 currence renders E. capillitii a grave form of the disease. 
 
 E. Genitalium occurs in both sexes after operations or inju- 
 ries of the genital organs. Fistulae, strictures, and peri-urethral 
 abscesses, ulcerative processes, specific or otherwise, or simple 
 decomposition of the secretions of the parts in those of unclean 
 habits, all these may start the inflammatory process. The 
 cedema is very great, and the pain causes still further neglect, 
 and extensive gangrene is by no means uncommon. 
 
 One of the commonest forms of erysipelas is E. extremitalium. 
 It presents nothing peculiar. E. vaccinate has been quite fre- 
 quently noticed of late years. 
 
 E. Umbilici is the erysipelas that occurs in new-born 
 children, and usually starts from the navel. Its history is 
 that of an ordinary erysipelas — and is to be carefully dis- 
 tinguished from the erysipelas of the new-born which is 
 due to infection, and often occurs epidemically during the 
 prevalence of puerperal fever and other septic diseases in 
 our public institutions. This latter form is called by Bohn 
 E. neonatorum puerperale j it is very dangerous from the 
 
ERYSIPELAS. 135 
 
 fever — the local gangrene — haemorrhage from the navel — 
 enteritis — peritonitis — and pneumonia. It usually comes 
 to a fatal issue ; the mortality is certainly over 95 per cent. 
 Inasmuch as the general constitutional infection forms by 
 far the most important part of its history, the reader is re- 
 ferred for its history to the special text books on the dis- 
 eases of children. 
 
 Complications. — Abscesses seldom occur in simple cutaneous 
 erysipelas. Gangrene, as I have already said, is not very rare 
 in certain forms of the disease. It is usually circumscribed, 
 and leads to great deformities. In adynamic cases a typhoid 
 state often sets in ; the pulse is rapid, feeble, or dicrotic ; the 
 tongue is dry and cracked ; the abdomen swollen ; and the skin 
 covered with a clammy sweat. The patient usually succumbs 
 by the second week. 
 
 Various inflammations of internal organs, especially of those 
 lying near the seat of the disease, are liable to occur. In the 
 erysipelas of the trunk, peritonitis and enteritis ; in that of the 
 chest, pericarditis, endocarditis, pleurisy and pneumonia ; in 
 that of the face, meningitis — are noticed. 
 
 Pathology and Morbid Anatomy. — The redness and swelling 
 which were so characteristic in the earlier stages during life 
 fade away after death, leaving perhaps a faint yellowish tinge 
 and slight cedema of the subcutaneous connective tissue. 
 Blebs, pustules, and crusts remain, of course, post mortem. In 
 the worst cases we find the ordinary visceral alterations of the 
 malignant fevers — blood-changes and post mortem stainings ; 
 petechias are seen on the various membranes ; the blood is 
 dark, tarry, and imperfectly coagulable ; there is softening and 
 cloudy swelling of the various internal organs. Any inter- 
 current affection gives us, of course, the lesions appropriate to 
 it — pneumonia, pleurisy, myocarditis, pericarditis, endocardi- 
 tis, parenchymatous nephritis, myositis, etc.; but they present 
 no specific characters and are just like the same affections 
 when they occur from other causes. 
 
 Even the morbid anatomy of the erysipelatous process itself 
 shows nothing specific, for the changes are those of an ord- 
 
136 * ERYSIPELAS. 
 
 inary dermatitis, more or less superficial as the case may be. 
 The exudation that infiltrates the epidermis, corium, and sub- 
 cutaneous connective tissue is mainly a serous one, though 
 cell-forms are not wanting in it ; they are the ordinary round 
 cells, but degenerated, and containing highly refracting gran- 
 ules (fat). The cells of the rete are swollen, cloudy, and de- 
 formed ; their nuclei are often divided, and they are evidently 
 in a state of active proliferation. The connective tissue 
 fibrillar of the corium are swelled and indistinct. The amount 
 of the round-celled infiltration varies, of course, in different 
 cases ; but it is only in the phlegmonous form of the disease 
 that it is abundant enough to form pus. The cells infiltrate 
 the sebaceous glands and hair follicles also ; hence the falling 
 of the hair from loosening of the root-sheath, and the excess- 
 ive cell-proliferation, which, in the form of a seborrhcea, so 
 often persists after the original disease has gone. 
 
 The neighboring vessels may have their walls infiltrated with 
 pus, and suppurative lymphangoitis may be present. The 
 neighboring lymphatic glands are swollen, red and ecchymosed. 
 
 As above mentioned, a variety of opinions prevail as to the 
 presence of a specific organism, of an erysipelas micrococcus. 
 Orth and Koch state that they invariably find them in the ad- 
 vancing margin of the disease ; Billroth, Lukowsky and Coats 
 find them sometimes, and sometimes do not ; Hiller denies 
 their existence altogether. They are said to be found in 
 abundance in the lymphatic vessels at the latest points of in- 
 vasion. 
 
 A peculiar condition of the skin is observed in persons who 
 have been the subject of frequent attacks of erysipelas. Some 
 of the round-celled exudation remains, and probably becomes 
 organized (Virchow), and new connective tissue and thickening 
 of the skin or pachydermia result. It is chiefly seen in the 
 cheeks and legs, where this recurrent erysipelas most frequently 
 happens. 
 
 Etiology. — Erysipelas is an infectious and contagious disease ; 
 it shows in many respects a marked analogy to the other blood 
 poisons (eruptive fevers, etc.), though the activity of the virus 
 
ERYSIPELAS. 1 37 
 
 is not so great as in the case of these latter. It is undoubtedly 
 closely related to the contagium of such diseases as scarlet 
 fever, puerperal fever and septicaemia, for they seem in certain 
 cases to be convertible. 
 
 The epidemics of erysipelas which have occurred from time 
 to time in all the larger hospitals have afforded abundant 
 opportunity for the study of the etiological relations of the dis- 
 ease. Outbreaks in St. George's Hospital, London, and in the 
 Edinburgh Hospital have been carefully described by Drs. Baillie 
 and Cullen ; and Mr. Erichsen's cases in the University College 
 Hospital are well known. In this last instance, where no case 
 of the disease had been seen for some time, an erysipelatous 
 patient was accidentally kept for two hours in Brundrett (surg- 
 ical) Ward, and in spite of the most careful disinfection, the 
 disease attacked one after another of the inmates, and proved 
 fatal to several of them. Pujos, Reynaud, and many others 
 recount epidemics that followed the importation of a single case. 
 
 It is a well recognized fact that the disease spreads not only 
 by direct, but also by mediate contagion, by fomites. Even the 
 walls and floors of hospital wards and sick bays occasionally 
 become so infiltrated with the poison that the thorough disin- 
 fection of the places becomes necessary. In the Charity 
 Hospital of this city the surgical wards, in 1882, were so in- 
 fected that almost every case contracted the disease ; nor did 
 the most radical measures for disinfection possible suffice to 
 stop its ravages. Dry-rubbing and whitewashing of floors, 
 ceilings and walls, with prolonged ventilation, seem to be the 
 best means of destroying the contagium ; but they are some- 
 times insufficient, and, therefore, to-day separate pavilions or 
 light structures, which can be destroyed, are preferred to more 
 permanent edifices for hospital purposes. 
 
 An interesting and as yet incompletely answered question is 
 in regard to the relationship between erysipelas and puerperal 
 fever. Erysipelas, as well as the various forms of septic pois- 
 oning are undoubtedly capable of producing the disease; and 
 it is almost as certain that the poison of puerperal septicaemia 
 will, in suitable cases, produce erysipelas. 
 
I38 ERYSIPELAS. 
 
 The exciting cause in the form of a contagium is always 
 present ; but besides this, various predisposing or contributing 
 causes are usually spoken of. These are : 1. Constitutional 
 predisposition — some patients being much more liable to the 
 disease than others. 2. Previous attacks — which undoubtedly 
 render the patient more susceptible than otherwise. 3. The 
 presence of a lesion — a punctured or incised wound, or one 
 from chemical or mechanical injuries, or an erosion, or acne 
 pustule, an eczema, in fact any thing that causes retention of 
 pus and decomposition of secretion, etc. This is a prominent 
 factor in the so-called surgical erysipelas. In the new-born 
 child the disease may start from the navel. 4. Mal-nutrition 
 — bad hygiene and i?iteniperance are of undoubted effect. 5. 
 Epidemic influences — during which numbers of persons not usu- 
 ally susceptible, contract the disease. 6. Special Causes — af- 
 fecting certain cases. The same articles of diet, such as mus- 
 sels or periwinkles, will cause it in some cases, and instances 
 have been recorded where women have attacks every month. 
 Any definite knowledge of the exact nature of the poison of 
 erysipelas is as yet wanting. Many (Hebra, Kaposi, etc.,) 
 hold that the constitutional symptoms are the expression of the 
 infection of the system by the secondary chemical products of 
 the local inflammation, while Cohnheim regards it as a mias- 
 matic contagious disease. 
 
 Inoculation experiments have often been made by various 
 observers to determine the nature of the contagious principle, 
 but the results have hardly been of much value. A distinct 
 erysipelas micrococcus has been described by Billroth, and 
 also by Koch, Fehleisen, Huter and Lukowsky, which obtains 
 access through a wound to the lymphatic vessels of the skin and 
 subcutaneous tissue, and spreads along their course. Never- 
 theless, its presence in many cases cannot be demonstrated, 
 and it is looked upon by very competent observers as a con- 
 comitant, not a causative phenomenon. (Geber — Bohn.) One 
 thing only has been proved — that the contagium is a specific 
 substance which obtains access to the body from without. 
 
 Some lesion of the skin is therefore a necessary occurrence 
 
ERYSIPELAS. 139 
 
 in every case of erysipelas, whether it be an open wound, or an 
 insignificant erosion, or even an acne pustule. In this way is 
 to be explained the occurrence of the so-called medical or idi- 
 opathic erysipelas ; the poison having obtained access to the 
 lymphatics through a lesion so small as to have escaped the 
 patient's notice. Dental caries, eczema, scrofulous or spe- 
 cific rhinitis, etc., all may occasionally form the nidus for the 
 disease germs. 
 
 Diagnosis. — Erysipelas is not a disease likely to be mistaken 
 for any thing else. The presence of a wound, the peculiar in- 
 filtration and advancing redness of the skin, the sharp limita- 
 tion, conjoined with the constitutional symptoms, well distin- 
 guish it. Before the rash appears it cannot be diagnosed. 
 Nevertheless, there are some affections which might possibly, 
 under certain circumstances, be mistaken for it. 
 
 Erythema simplex and urticaria itch severely, do not pro- 
 gress by contiguity, are not usually single, and do not have the 
 distinct border and the general inflammatory symptoms. The 
 limited extent of erysipelas, and its usual connection with an 
 injury, will serve to differentiate it from the exanthemata. 
 
 It is said that malignant small-pox may at first be mistaken 
 for it, but the greater severity of all the constitutional symp- 
 toms, and the extent of the eruption in small-pox, must suffice 
 to prevent error. 
 
 A periostitis of the tibia especially, may closely resemble 
 an erysipelas, but the history of the case, the pain, the shining 
 skin and the kind of margin will generally enable one to make 
 the diagnosis. 
 
 Prognosis. — The prognosis varies much in accordance with 
 the severity of the disease and the constitution of the patient. 
 In general, it is good ; in persons whose health has not been 
 undermined by excesses, who are not alcoholics or the subjects 
 of chronic Bright's disease, the chances of recovery from sim- 
 ple cutaneous erysipelas are very good indeed. Yet it is " a 
 dangerous and deceitful disease," especially when affecting 
 persons at the extremes of life, or in the puerperal state, or 
 when suffering from extensive injuries. 
 
140 ERYSIPELAS. 
 
 The mortality is usually set down at from ten to fifteen per 
 cent. Sometimes it is considerably greater, especially when it 
 occurs in epidemic form. Thus Billroth records an invasion 
 of the disease wherein he lost nearly twenty per cent, of his 
 cases. On the other hand, Alvan Beck records a set of cases 
 from the University College Hospital with a mortality of only 
 four per cent. The amount of the fever, delirium and diar- 
 rhoea ; the occurrence of prostration and the so-called typhoid 
 symptoms, and especially the appearance of complications, 
 these, rather than the extent or location of the eruption will 
 afford us the materials for prognosis. If the disease affects 
 the pharynx, the possibility of the occurrence of oedema glot- 
 tidis is to be borne in mind. 
 
 E. faciei is, it is true, liable to meningeal complications ; but 
 in most cases the prognosis is food. 
 
 Where there is contracted kidney, the prognosis is almost 
 hopeless. 
 
 In children it is a very fatal disease if occurring during the 
 first few weeks or even months of life, and many of these cases 
 die very quickly when to all appearance the eruption is rapidly 
 subsiding. 
 
 Treatment. — Must be both constitutional and local. 
 
 i. Constitutional treatment. — Being essentially a disease of 
 depression, no one nowadays recommends for erysipelas the 
 antiphlogistic modes of treatment — bloodletting and blistering 
 — formerly in vogue. (Sydenham). On the contrary, every 
 means of sustaining the patient's strength should be employed, 
 nourishing diet — beef tea, eggs, milk, wines, etc. The bowels 
 are to be kept free, perhaps best by a full dose of calomel, fol- 
 lowed by salines. Sleep must be procured, if necessary, by 
 opiates ; chloral is less liable to disagree than opium itself, 
 though Bryant warns us to be cautious in our use of hypnotics 
 in this disease. If the temperature is high, quinia, or salicylic 
 acid must be used, though ice-bags may be preferable if the 
 stomach is irritable. Tincture of the chloride of iron is 
 very generally employed, and does seem, as Dr. Reynolds 
 claims, to have something of a specific action. It must be 
 
ERYSIPELAS. 141 
 
 given freely, from twenty to sixty minims every two to three 
 hours. 
 
 2. Local treatment. — A great variety of local remedies have 
 been recommended at various times, but they have hardly 
 stood the test of experience. Cold, in the form of ice-bags, 
 may be employed, but, since it does not affect the course of the 
 disease, it is only to be used in so far as it is agreeable to the 
 patient's feelings. It lessens the local heat and tension, but, if 
 there is much infiltration, it may, by still further interfering with 
 the circulation, tend to produce gangrene. It should, there- 
 fore, not be used continuously. Dry heat, by means of 
 cotton, wool, etc., is often very grateful ; poultices 
 are too irritating. The various indifferent applications, 
 simple ointments, flour and starch, are not to be recom- 
 mended ; they retain the secretions, and act as irritants. The 
 use of tincture of iodine or collodion, as well as the attempt to 
 hinder the progress of the disease by drawing a line around 
 it with nitrate of silver or blistering fluid is not to be recom- 
 mended. 
 
 A simple lead-water, or better, the ordinary lead and opium 
 wash, used hot, lukewarm or cold, as most agreeable to the 
 patient, are the commonest and best of our local applications. 
 Belladonna, equal parts of the extract and glycerine, form a 
 very useful topical sedative. 
 
 In accordance with our later ideas of the probable depend- 
 ence of erysipelas on a living contagium, various applications 
 destined to destroy it have been recommended, as tar or oil of 
 turpentine, the subcutaneous injection of a one-half per cent. 
 of carbolic acid, salicylic acid. None of them have justified 
 the hopes at first entertained. 
 
 Probably the best results are to be obtained by a rational 
 general treatment, (good food and pure air) with tincture of 
 the chloride of iron internally, and lead and opium, or a lead 
 wash, or the belladonna paint locally. 
 
 If erysipelas invades the pharynx, the possibility of a sudden 
 necessity for scarification or tracheotomy must be borne in 
 mind. 
 
142 SYPHILIS. 
 
 Above all, the various measures to prevent the recurrence 
 and spread of the disease must not be lost sight of. Free drain- 
 age must be secured for wounds ; local collections of pus must 
 be well opened. E. faciei occurs often from dental caries, or 
 from imprisonment of pus under the crusts of a chronic 
 rhinitis, or from acne pustules. Future attacks of the disease 
 may be prevented by due attention to these points. 
 
 Patients suffering from erysipelas should be isolated, and 
 especially separated from surgical cases or puerperal women. 
 It is hardly needful to recall the importance of thorough disinfec- 
 tion of hands and instruments to the attendants. It is im- 
 proper to attend midwifery cases whilst in charge of a patient 
 with erysipelas. 
 
 SYPHILIS. 
 
 I have placed syphilis among the acute contagious inflamma- 
 tory diseases, on account of its similarity in many respects to 
 the ordinary exanthematous affections. In the majority of 
 works on dermatology it is classed with the new growths, but a 
 study of the tissue changes, in syphilis show that the process is 
 inflammatory in nature. This is not the place to describe the 
 various forms of chancre, or to discuss the unity or duality theory 
 in reference to them. The conditions in this disease which 
 especially interest the dermatologist, are its cutaneous manifes- 
 tations, the so-called syphilides or syphilodermata. As regards 
 form the syphilides do not differ from forms met with in other 
 cutaneous diseases, and may appear as macules, papules, vesicles, 
 blebs, pustules or tubercles. In any given case they take their 
 name from the form of the primary cutaneous lesion, thus, if 
 the syphilitic eruption makes its appearance as a macule, it is 
 called a macular syphilide, and if it appears as a papule it is 
 called a papular syphilide, and so on. The character of the 
 general syphilis which follows a chancre, depends greatly upon 
 the constitution and state of general nutrition of the person 
 affected, and upon the surrounding hygienic conditions. 
 
 Scrofulous and badly nourished persons suffer more than 
 
SYPHILIS. 143 
 
 those who are robust and well nourished. Bad hygienic sur- 
 roundings aggravate the disease and interfere with treatment. If 
 the first cutaneous manifestations appear at a period much later 
 than usual after the first formation of the primary sore, the proba- 
 bilities are that the disease will be mild, provided the nutrition 
 and hygienic conditions are good. So also, if the first syphi- 
 lide is macular or papular in form, the case will be milder than 
 if it was vesicular or bullous. Either a mild or severe case of 
 syphilis may follow both an ulcerating and non-ulcerating 
 chancre. The potency of syphilitic virus is the same whether 
 derived from a primary or from a secondary lesion. 
 
 Before describing the different forms of cutaneous syphilis, 
 we will notice certain general characteristics peculiar to all of 
 them, and which are of service in forming a diagnosis. 
 
 1. Seat of the eruption. — The earlier eruptions generally 
 occur over the whole body ; they are superficial in character, 
 and tend to symmetrical arrangement, that is, to be distributed 
 in a similar manner on both sides of the body. The cause of 
 this general distribution and symmetrical arrangement is, that 
 
 v at this stage the virus exists every where in the body ; in other 
 words it is a disease of the general system : a blood and tissue 
 disease. Remote secondary eruptions, and those of the ter- 
 tiary period may be more or general, but are not symmetrical 
 in arrangement, the lesions are deeper seated in the skin, and 
 they cause destruction of the tissue, as shown by the atrophy 
 or ulceration produced. The conditions which usually cause 
 ulceration of the skin are epithelioma, lupus, lepra, simple non- 
 contagious inflammation, as in the so-called varicose ulcer, and 
 syphilis. All except the last one have rather special seats for 
 development, whereas syphilis may appear upon any part of the 
 body. If, therefore, we find cicatrices, especially with rounded 
 margins upon the body or arms in a case without a history of 
 injury, the probabilities are that syphilis was the cause. 
 
 2. Color. — The color varies with the form of eruption, its 
 age and the rapidity of development of the lesion. The large 
 papular syphilide is darker in color than the small papular or 
 the macular form. All of the lesions become darker with age.- 
 
144 SYPHILIS. 
 
 The more acute the development the brighter the color. 
 Usually the color is not the bright red of ordinary dermatitis, 
 but is of a dull brown or raw-ham appearance. The raw-ham- 
 like color is supposed to be characteristic of the syphilides, but 
 it is not always present, and is met with also in other eruptions, 
 as rosaceous acne and lichen planus. In the macular form 
 this coppery color is not present. In the small papular form 
 it is also generally absent, but is well marked in the large papu- 
 lar and tubercular forms. When present, this coppery color is 
 always significant. The surrounding skin may show increased 
 pigmentation. 
 
 3. Polymorphism. — The tendency to exhibit several forms of 
 eruption at the same time is especially characteristic of the 
 earlier syphilides, but is met with in the later eruptions also. 
 Macules, large and small papules and vesicles, are often seen 
 in the same case. So also papules, tubercles, pustules, vesico- 
 pustulesand ulcers may be present at the same time. Thus it 
 happens that one portion of a syphilitic eruption may so far re- 
 semble other cutaneous affections as to render the diagnosis diffi- 
 cult, whilst another part will exhibit characteristic lesions. This 
 fact should never be forgotten in obscure cases. The different 
 forms of lesion also show a tendency in their course to become 
 changed into other forms. The small papule may assume the 
 large papular form, and the latter in turn may become pus- 
 tular. 
 
 4. Configuration. — The earliest lesions are generally rounded 
 in form, whilst the later eruptions have a great tendency to 
 assume a linear, circular, semi-circular, crescentic, or ser- 
 piginous form. In the ulcerating syphilide the ulcer is at first 
 round, but afterward serpiginous or horse-shoe in shape. The 
 cause of this will be stated further on. The base is always 
 irregular and ashen-gray in color, the edges are sharply cut or 
 undermined, the margin invariably infiltrated by sharply limited 
 syphilitic tissue and the surrounding skin usually normal in 
 appearance. The crusts are thick, greenish, or black in color, 
 adherent, and, if the ulcer is deep, laminated. 
 
 5. Scales. — The scales are always few and firmly adherent. 
 
SYPHILIS. 145 
 
 They are most abundant in the papulosquamous form. In the 
 later eruptions they are present only after the lesion has existed 
 some time. 
 
 6. Subjective Symptoms. — Itching and burning are rarely 
 present. In the maculo-papular form ; in pustules situated on 
 the scalp or hairy part of face, and in papules on the scrotum, 
 itching is often present. Friction, sweat, and heat will cause 
 itching. Tubercles, just before undergoing ulceration, and 
 ulcers, especially on the extremities, or in connection with bones 
 and nodes, are accompanied by pain. 
 
 7. Course. — The syphilides develop slowly and run a pro- 
 tracted course. They show a great tendency to recur after 
 removal. An ulcerative syphilide spreads more rapidly than 
 lupus or epithelioma, but slower, as a rule, than the simple 
 inflammatory ulcer (varicose ulcer). 
 
 Although not one of the above described characteristics can 
 be regarded as peculiar to the syphilides, since all are found in 
 other cutaneous affections, yet, taken together, they are of 
 great value in forming a diagnosis. In all doubtful cases, 
 however, our reliance must be upon a knowledge of the pecul- 
 iarities of the syphilides as resulting from the pathologico- 
 anatomical course of a single lesion. Syphilitic productions in 
 the skin have three characteristic features : 
 
 First — They consist, in every case, except in the macular 
 form, of a dense, sharply limited round cell infiltration into 
 the upper part of the corium and corresponding papillae. 
 
 Second — The cells comprising the infiltration are not capable 
 of higher organization, as, for instance, the formation of con- 
 nective tissue ; but always, after a longer or shorter period, 
 undergo retrograde changes and disappear either by fatty de- 
 generation and absorption, or by ulcerative degeneration. 
 
 Third — The extension of the infiltration and the retrograde 
 changes always take place in a centrifugal manner. The peri- 
 pheral portion of a syphilitic eruption is therefore always the 
 youngest, and possesses the character of a recent infiltration, 
 as described above, while the central part is the oldest, and is 
 the first to undergo retrograde changes. 
 10 
 
146 SYPHILIS. 
 
 Upon these three features depend all the symptoms of the 
 syphilides. Take, as an example, a syphilitic papule as the 
 representative lesion. 
 
 First — A perpendicular section of a papule shows that it is 
 composed of a dense cell infiltration of the upper part of 
 corium and papillae above, and that this infiltration is sharply 
 limited at the sides — that is, ceases abruptly against normal 
 tissue. On this account the papule is elevated ; it has sharply 
 limited margins ; it is firm to the feel from the density of 
 the infiltration ; the surface shines because the epidermis is 
 stretched over the infiltration ; it is dark red, from transudation 
 of haemoglobin from the compressed bloodvessels. If all of the 
 above symptoms are not present, then the lesion is not syphi- 
 litic — at least, is not a recent syphilitic papule. 
 
 After a time, retrograde changes occur in the infiltration, and 
 it finally disappears by absorption, the oldest portion, that is, 
 the most central part, disappearing first. The central part be- 
 comes depressed, the epidermis sinks in and becomes first 
 wrinkled and afterward scaly, whilst the peripheral part of the 
 papule still retains its original character. If the eruption 
 spreads peripherically there will always be a retrograding por- 
 tion occurring in the spreading infiltration, but as the cells 
 retain their vitality for some time, there will always be an ex- 
 ternal zone of dense, shining, dark red, sharply limited infil- 
 tration. 
 
 Instead of disappearing by fatty degeneration and subse- 
 quent absorption the infiltration may undergo purulent degen- 
 eration, and ulceration occur. The purulent secretion then 
 dries to crusts, the size of which will depend upon the extent 
 of the ulceration. The situation of the crusts will correspond 
 with that of the fatty degenerated part in the previous mode of 
 degeneration. They are always surrounded by a zone of un- 
 changed infiltration like an ordinary papule. After the syphil- 
 itic infiltration has acquired a certain size by peripheral growth 
 it no longer continues to spread further equally in all directions, 
 but ceases to extend at one part of the ring, whilst at the re- 
 maining portion it continues to spread. As the degeneration 
 
SYPHILIS. 147 
 
 and subsequent atrophy or circatrization process continues to 
 follow the infiltration, the eruption or ulceration gradually 
 changes from the rounded to a horse-shoe form. If the exten- 
 sion takes place from only one-third or one-quarter of the 
 ring, the ulcer will after a time assume the horse-shoe shape. 
 
 The laminated character of the crusts of rupia syphilitica 
 arise in the following manner. The centre of a tubercle 
 breaks down, ulcerates and the secretion dries to a crust. The 
 infiltration upon which the crust sits also breaks down in its 
 turn, and dries to a second and larger crust beneath the first, 
 which thus becomes elevated. As the ulcerative process con- 
 tinues to spread peripherically, as in other syphilitic forms, 
 new crusts continue to be formed beneath and around the pre- 
 vious crusts. In this manner the oyster shell form of crust is 
 formed. (See Fig. 27). Outside the crust there is always a 
 zone of recent undegenerated infiltration, that is, there is a 
 zone of sharply limited, dense, dark red infiltration. 
 
 I am indebted to the above described mode of arriving at a 
 clear idea of the syphilitic lesions to Kaposi, from whose 
 clinics I first learned the mode of making the diagnosis. 
 
 We will now describe the different forms of syphilides. 
 
 MACULAR SYPHILIDE. 
 
 Syn. — Erythematous Syphilide ; Roseola Syphilitica ; Exan- 
 thematous Syphilide. 
 
 Syniptoms. — This is the first eruption which arises after the 
 syphilitic virus has entered the system, and shows itself usually 
 in from six to eight weeks after the first appearance of the 
 primary lesion, although it may not appear for several months 
 or even more than one year. It consists of a more or less gen- 
 eral eruption of macules of various sizes and shapes. They 
 are from a lentil to finger-nail in size, of irregular, round or 
 oval shape, with a rather ill-defined outline, and either on a level 
 or very slightly elevated above the general surface. Sometimes 
 the spots are so indistinct that they only give a mottling appear- 
 ance to the part. If the individual is stripped and exposed to 
 a low temperature, the maculae become much more distinct and 
 
148 SYPHILIS. 
 
 more sharply defined. Sometimes a small papular elevation is 
 present in the centre of a macule — erythema syphiliticum pap- 
 ulatum. The color depends upon the condition of the individual, 
 the extent of hyperemia present, and the age of the eruption. 
 "The darker the person, the darker red will be the eruption. So 
 also, the greater the hyperemia and the older the patch, the 
 darker will be the color. At first it is of a pale red, which 
 disappears upon pressure ; but later becomes darker 
 and does not disappear upon pressure. As it fades away it 
 assumes a dirty-yellow, coppery, or grayish brown color. The 
 number present varies in different cases ; they may be few or 
 very numerous. They appear usually first around the umbilicus, 
 and afterward extend to the trunk, and the rest of the body. 
 They are most numerous on the trunk and flexor surfaces of 
 the extremities, and are rare on the back of the hands and 
 face. The eruption is sometimes ushered in by fever and a 
 feeling of malaise, but may arise without any fever symp- 
 toms. Itching is rarely present, except the macules form 
 rapidly and are elevated. It is often accompanied by 
 pains in the joints and tibia, or sternal region ; by loss of 
 hair and an erythematous condition of the fauces. The 
 course of the eruption is usually very slow ; a patch re- 
 quires usually about a week to arrive at its height, and then it 
 remains unchanged as regards extent for weeks or months, de- 
 pending on the intensity of the case and the mode of treat- 
 ment. The spots do not coalesce unless the eruption is very 
 profuse. They have no tendency to form rings like the papu- 
 lar syphilide. They disappear usually without desquamation, 
 leaving behind pigmented places which afterward become nor- 
 mal. If the macules are elevated, or are of the papular form, 
 there will be slight desquamation. Relapses of this form of 
 syphilide may occur during the first year, and then as large 
 macular or annular patches, and often mixed with papules. 
 
 Diagnosis. — The macular syphilide may be confounded with 
 measles, roseola, simple erythema, urticaria, tinea versicolor or 
 with some medicinal eruptions. In measles, the catarrhal con- 
 dition, the fever, the form of eruption, its situation and the ef- 
 
SYPHILIS. 149 
 
 fects of cold in making it more indistinct, are sufficient for the 
 diagnosis. In roseola, the patches form quickly and change 
 form rapidly. In urticaria, there are wheals ; they arise quickly, 
 are of short duration and itch greatly. In tinea versicolor, the 
 patches increase by peripheral growth ; they may be from a 
 pin-head to several inches in diameter, and, upon scratching with 
 the finger-nail, abundant scales are raised which contain numer- 
 ous fungous elements. Medicinal rashes are diagnosed by the 
 history of the case, the fever, the form and duration of the 
 eruption. 
 
 PIGMENTARY SYPHILIDE. 
 
 This is a rare condition, and consists of rounded or irregu- 
 larly-shaped and ill-defined macules of a pale grayish or dirty 
 brown color, not elevated above the level of the skin, and 
 not disappearing upon pressure. They are either discrete 
 or confluent, and are found almost exclusively upon the 
 neck on one or both sides, but may arise also upon the trunk 
 or extremities. They appear during the first or second year of 
 the disease, and are met with generally in women, the eruption 
 being very rare in men. The course of the disease is very 
 slow, lasting several months or two or three years, and is said 
 to be not amenable to anti-syphilitic treatment. In the only 
 well-marked case which I have observed, the eruption rapidly 
 disappeared during the use of a mercurial internally. The erup- 
 tion resembles considerably chloasma and tinea versicolor. 
 Chloasma occurs as large patches of increased pigmentation, 
 and not as small maculae. It is rarely symmetrical, and is 
 usually present on the forehead or temples, and not upon the 
 neck. In tinea versicolor the fawn-colored patches with their 
 abundance of scales as shown by scratching the surface, and 
 the situation as a rule upon the anterior surface of the thorax, 
 is sufficient for the diagnosis. 
 
 PAPULAR SYPHILIDE. 
 
 The papular syphilide appears as a more or less general 
 eruption of small or large acuminated or flat papules. The 
 
150 SYPHILIS. 
 
 small and large papular eruption require a separate descrip- 
 tion. 
 
 SMALL PAPULAR SYPHILIDE. 
 
 Syn. — Miliary papular syphilide ; Lichen syphiliticus. 
 
 This eruption usually makes its appearance in from two to 
 three months after the commencement of the primary lesion, 
 and may be the first manifestation of general syphilis, or may 
 develop from or after the macular form. It is more or less 
 general over the body, and the papules show a great inclina- 
 tion to arrange themselves in groups or lines, a dozen or more 
 papules forming a group. It commences as small red points, 
 which soon become pin-head sized, elevated, firm papules ; or if 
 they form rapidly, as especially if seated in a hair follicle, there 
 may be a small collection of serum in the apex, which afterward 
 may become opaque and form a miliary pustule. In shape they 
 are round and acuminated, and are covered by a very few scales, 
 or, in the case of the miliary vesicles or pustules, by a little 
 crust. In color they are at first of a bright red, and later be- 
 come of a dark or brown red. The eruption is generally sym- 
 metrical, and situated especially upon the face, shoulders and 
 arms. It is either an early or late manifestation, although gen- 
 erally the former. It is very chronic in its course, and is liable 
 to recur. When it does recur, the eruption is less profuse, and 
 occurs more on the flexures of the joints and about the angles 
 of the mouth. The first outbreak is usually accompanied by 
 fever. Itching is usually absent. The papule disappears by 
 fatty degeneration, leaving behind pigmentation and slight 
 atrophy of the part. 
 
 The eruption is to be diagnosed from lichen ruber, psoriasis 
 punctata, papular eczema, keratosis pilaris and lichen scrofu- 
 losus. The extent of the eruption, the color, the grouping and 
 the pathologico-anatomical course of the papules render the 
 diagnosis easy. In keratosis pilaris the papules are pale in 
 color, are not so firm, are not grouped, and the scaling is much 
 greater. The papules in lichen scrofulosus are small, have a 
 tendency to group and are situated around hair follicles, but 
 
SYPHILIS. 151 
 
 they are found especially upon the trunk ; are reddish or yel- 
 lowish in color, flat, and scale considerably. They are met 
 with only in scrofulous persons, and in these especially about 
 the age of puberty. Psoriasis is known by the amount of scal- 
 ing, the oozing upon scratching and the presence of patches, 
 which are extending by peripheral growth. Lichen ruber is 
 known by the definite size of the papules and the mode of 
 spreading of the eruption. Papular eczema itches, the eruption 
 is not general, the papules are not grouped, and generally soon 
 become vesicles. There is also exudation on the free surface, 
 a coalescence of the papules or vesicles, and the formation of 
 crusts or scales. 
 
 LARGE PAPULAR SYPHILIDE. 
 
 The lesions of this eruption differ in size, shape and color 
 from those of the small papular syphilide. They vary in size 
 from that of a split pea to that of a finger-nail, are circular or 
 oval in shape, elevated above the level of the skin, sharply 
 limited externally, firm in consistence, and with a flat, non- 
 scaling, smooth, shining surface. The color at first may be 
 pale red, but soon becomes dark or brownish red, and often is 
 of the raw-ham appearance. It is in this and the tubercular 
 form that the coppery color has been seen. The number of 
 papules present in a given case depends, as a rule, upon the 
 length of time that has elapsed since the first appearance of the 
 primary lesion ; that is, whether the eruption is a recent or a 
 late manifestation of the syphilis. As the extent of the blood 
 poisoning diminishes with the age of syphilis infection, so the 
 more recent the manifestation the more general and more sym- 
 metrical will be the eruption, and the later it appears the less 
 general and the more regional, that is, confined to certain 
 regions or parts of the body. As it is a later manifestation as 
 a rule than the small papular eruption, so also the number of 
 lesions is generally less. It may appear upon any part of the 
 body and the papules may be either disseminated or grouped. 
 In recent eruptions they are more disseminated, and in later 
 outbreaks they tend to arrange themselves in groups to form 
 
152 SYPHILIS. 
 
 patches. They are met with especially upon the forehead and 
 the angles of the mouth, on the back, the flexor surface of the 
 extremities, the scrotum, groin, genitalia and around the anus. 
 The papules arise slowly, may increase in size by peripheral 
 growth in the manner previously described, remain weeks or 
 months as fully developed papules and finally disappear by 
 fatty degeneration and subsequent absorption of the infiltration, 
 leaving behind an atrophied spot which at first is pigmented 
 and afterwards white ; or during their degeneration there may 
 be excoriation and slight ulceration. The eruption is very 
 liable to recur again and again, each subsequent outbreak 
 showing a tendency to regional distribution and grouping of the 
 lesions. 
 
 As modifications of the large papular syphilide we have to 
 consider the moist papule and the papulo-squamous form of 
 eruption. 
 
 Moist Papule. — (Mucous patches, condylomata). The moist 
 papule is peculiar to syphilis. It is derived from the ordinary 
 papule and is met with about all mucous orifices, as the mouth, 
 throat, anus ; or where opposing surfaces of skin come in con- 
 tact, as in the axilla, beneath the mammae in women with large 
 breasts, in the perinaeum, groins,on the scrotum,genitalia, between 
 the toes and at the umbilicus. They arise especially easily on 
 the tender skin of infants in the regions named. In size they 
 vary from a pinhead to a finger-nail or even larger by co- 
 alescence of two or more papules. They are generally elevated, 
 but may be flat or even depressed. Their outline is not so well 
 defined as the dry papule, and they are softer in consistence. 
 Their surface is moist and covered with a mucoid secretion 
 which may dry to a thin scab. The surface may take on hyper- 
 trophic action and form a vegetating, warty or papillary growth, 
 the so-called vegetating syphilide. These are always elevated, 
 circumscribed, and present a warty appearance. They are met 
 with especially on the scalp and genitalia, and grow very rapidly. 
 If the parts which are the seat of moist papules, especially 
 the perineal and genital, are not kept cleanly the secretion be- 
 comes decomposed, has an offensive odor and irritates the 
 
SYPHILIS. 153 
 
 surrounding skin, producing dermatitis, which in its turn may 
 give rise to more or less simple inflammatory, warty growths. 
 The patches themselves may ulcerate and become painful. 
 
 Mucous patches of the mouth are more irregular in shape, 
 are flat, perhaps depressed, and may vegetate or ulcerate. At 
 the angles of the lips they are generally deeply fissured, the 
 fissure being single and horizontal in direction. The secretion 
 from mucous patches is as contagious as that from the primary 
 lesion. The moist papule may develop upon a primary chancre, 
 hence may represent either a primary or a secondary lesion. If 
 situated at the angle of the mouth or on the nipple of a nurse 
 it may be impossible to say whether it is a primary or secondary 
 lesion. 
 
 Papulosquamous Syphilide. — Both the small and large papular 
 syphilitic lesions show slight desquamation during the absorp- 
 tion stage, but in the papulo-squamous lesion the scaling is 
 much greater and is a prominent symptom. The eruption is 
 rarely extensive, being generally more regional, and the lesions 
 are either disseminated or grouped. In size they correspond 
 to the large papular syphilide above described, are elevated, 
 with flattened surface, which is covered with a greater or less 
 number of grayish, dry, fine, non-imbricated, somewhat adherent 
 scales. They extend by peripheral growth and show a tendency 
 to form lines or circles, or patches of considerable size. The 
 eruption is usually symmetrical, and although it may occur 
 upon any part of the body it is most frequently met with upon 
 the palms of the hands and soles of the feet, forming the so- 
 called palmar and plantar syphilide. Here, on account of the 
 great thickness of the corneous layer, we miss the marked eleva- 
 tion of the papule as occurs on parts with a thin epidermis. If 
 the papule has attained the ordinary size close inspection will 
 show some elevation and a sharp outline. They tend to co- 
 alesce, and by peripheral growth form roundish, serpiginous or 
 irregular patches. At the margin of these patches there is 
 always to be seen a seam of dark red infiltration. If the patch 
 is small it is covered by thin, grayish, adherent scales. If it 
 has acquired some extent the scales are generally present only 
 
154 SYPHILIS. 
 
 at the margin, and here they are semi-detached, the inner part 
 being free. Sometimes a large patch is covered with scales, 
 presenting an appearance much like that seen in some cases of 
 squamous eczema in this region. Removal of the scales shows 
 a dark red skin beneath. Fissures sometimes form. The 
 eruption rarely spreads to the wrists or to the back of the 
 hands, or upper surface of the feet. It is very chronic in its 
 course, lasting months or years, and is a symptom of either 
 recent or late syphilis. It is frequently combined with other 
 forms of the syphilides. As it disappears the color fades, the 
 scaling becomes less, and finally the part becomes normal. 
 Itching is rarely present. 
 
 Diagnosis. — The large papular syphilide may be confounded 
 with acne, lichen planus, and psoriasis. In acne the eruption 
 is confined to the face and throat, the papules form rapidly, are 
 brighter red in color,the redness disappearing greatly upon pres- 
 sure, they are acuminated, are not arranged in groups, fre- 
 quently become pustular in a few days and finally disappear 
 after a short existence. The history of the case and the pres- 
 ence of comedones will also assist in the diagnosis. Lichen 
 planus occurs especially upon the forearms and legs, the pa- 
 pules are angular in outline, rise abruptly from the normal skin, 
 are but slightly elevated above the general surface, and have a 
 smooth shining surface which is frequently depressed in the 
 centre — umbilicated. The umbilicated appearance and angu- 
 lar outline are of most value in the diagnosis, as in the size of 
 the papules, their color and the tendency to form groups they 
 resemble the papular syphilide. In psoriasis the papule is 
 made up of scales and not of an infiltration in the corium ; the 
 scales are numerous, laminated, of a bright white or mother-of- 
 pearl color, easily removed, and scratching of the rete beneath 
 is followed by oozing of blood. In syphilis the papule consists 
 of an infiltration; at first there is no scaling, subsequently a few 
 grayish, firmly adherent scales are present, and scratching of the 
 skin beneath is not followed by oozing of blood. In psoriasis 
 the color is pale or rose red and mostly disappears upon pres- 
 sure ; in syphilis the color is soon dark red and persistent, not 
 
SYPHILIS. 155 
 
 disappearing upon pressure. The other points will be consid- 
 ered in the diagnosis of the palmar syphilide. 
 
 Mucous patches or moist papules are to be diagnosed from 
 the simple inflammatory or non-venereal papillary new-forma- 
 tions called vegetations. These owe their origin to irritation of 
 the skin from acrid secretions and uncleanliness, and are found 
 especially just behind the corona glandis but also at the orifice 
 of the urethra, on the scrotum and around the ar.us. They are pa- 
 pillomatous growths, are very vascular, warty in appearance and 
 composed chiefly of epithelium. They are usually peduncula- 
 ted and generally multiply. 
 
 The palmar and plantar squamous syphilide is often con- 
 founded with squamous eczema of the palms and perhaps also 
 with psoriasis. In eczema there is generally a history of heat, 
 burning and discharge which is absent in syphilis. Eczema 
 does not consist of papules arranged in circles and spreading 
 peripherally with a sharply limited margin as frequently occurs 
 in syphilis. In eczema the patches are irregular in shape, the 
 margin gradually passes into healthy skin beyond, there is an 
 entire absence of the sharply limited, dark red infiltrated seam 
 at the periphery as in syphilis; the patch itself shows evidence of 
 present or past vesicles as a rule ; there is more or less general 
 infiltration of the affected skin; fissures are generally present 
 from loss of elasticity of the skin due to this inflammatory 
 infiltration, and the eruption shows great tendency to extend to 
 the sides or backs of the fingers in the form of a vesicular or 
 papular eczema. Finally eczema itches very much and syphilis 
 none. Psoriasis of the palms is a very rare affection at all times 
 and probably never occurs on the palms or soles without being 
 present on other parts of the body ; hence the diagnosis cannot 
 be difficult. When seated on the palms the spots or patches 
 could be diagnosed by the following characters. In psoriasis 
 the spots are made up of scales, which are easily detached 
 and upon removal show a bright red rete beneath. In syphilis 
 the spots are formed by an infiltration in the corium and re- 
 moval of the scales shows a dark red infiltrated base. The scales 
 in psoriasis are numerous, in lamellar arrangement, easily de- 
 
156 SYPHILIS. 
 
 tached; in syphilis they are few, are fine, not imbricated and 
 semi-detached on spreading patches. Psoriasis patches form 
 rapidly, syphilitic form slowly. Besides these local differences 
 psoriasis is seen especially on the elbows and knees and syphilis 
 rarely there. Psoriasis maintains its characteristic form wherever 
 situated, syphilis is polymorphous, and a palmar syphilide is 
 usually associated with other symptoms of syphilis on other 
 parts of the body. 
 
 VESICULAR SYPHILIDE. 
 
 This is a very rare manifestation of syphilis and occurs within 
 six months of the primary infection. The vesicles may be small 
 and grouped like in eczema, hence the term syphilitic eczema 
 as sometimes employed ; or large and isolated as in varicella, 
 (syphilitic varicella). In the first form the vesicles are pin-head 
 sized, acuminated, elevated, and usually grouped, being situated 
 upon a dark red base, or, if isolated surrounded by a dark areola. 
 They are situated especially around hair follicles. The vesicles 
 may become pustules, or the contents may dry up and desqua- 
 mation occur, or the vesicles may break down and dry to thin 
 scabs which slowly separate, leaving pigmentation but not scars. 
 They are met with on the face, extremities and body, and are 
 liable to recur. The large vesicular syphilide consists of vesi- 
 cles the size of a split pea, elevated, roundish, somewhat umbili- 
 cated, with a red areola and clear or cloudy contents. The 
 vesicles are either grouped or disseminated and either become 
 pustules or dry up and be succeeded by greenish brown crusts 
 which are slowly cast off and leave no scars. Sometimes the 
 vesicles are arranged in circles like in herpes. The eruption is 
 rarely extensive or the lesions numerous and it is usually asso- 
 ciated with other forms of the syphilides. 
 
 Diagnosis. — The small vesicular syphilide may be mistaken 
 for eczema. In the latter the vesicles form quickly, are ephem- 
 eral, soon bursting, are not seated upon a dark red base, itch 
 very much and cause general or confluent crusting. The large 
 syphilide may resemble the eruption of varioloid, but the slow 
 formation of the vesico-pustules, their chronic course, the 
 
SYPHILIS. 157 
 
 absence, as a rule, of fever, the dark areola and the concomitant 
 syphilitic lesions are sufficient for the diagnosis. 
 
 The pustular syphilide is a rarer manifestation of syphilis 
 than either the macular or papular form. It may appear either 
 early or late in the disease, and is usually met with in persons 
 suffering from improper nourishment or with " broken down " 
 constitutions. The lesions may be few or numerous, general 
 or localized, disseminated or grouped, and situated around hair 
 follicles and sebaceous glands or beneath the epidermis. They 
 may arise rapidly or slowly and proceed from papules or ves- 
 icles, or arise primarily as pustules. In size they vary from a 
 millet seed to an inch or more in diameter, and are acuminated 
 or rounded, or flat, on the surface ; circular, ovalish or irregu- 
 lar in outline, and seated upon an indurated or slightly red- 
 dened base, and surrounded by a larger or smaller areola. The 
 large pustules have a tendency to crust early. The crusts are 
 acuminated, flat or raised, thick or thin, soft and friable ; or 
 hard, laminated, more or less adherent, and from a yellow 
 brown to black. An ulcer is always present beneath the crusts. 
 The ulcer is superficial or deep ; the base uneven and covered 
 with a grayish, yellowish, or greenish purulent secretion ; the 
 edges are sharply defined and surrounded by more or less 
 dark-red infiltrated tissue. Cicatrices always result, their 
 character depending upon the extent and depth of the ulcera- 
 tion. Pustular syphilides are often associated with syphilitic 
 lesions of the eyes, bones, testicles and matrix of the nails. 
 
 The pustular syphilides may be divided into the small 
 acuminated, the large acuminated, the small flat and the large 
 flat pustular syphilide. 
 
 The small acuminated pustular syphilide. — This form has its 
 seat at the hair follicles, and consists of pin-head sized, acumi- 
 nated, raised papules with a reddish base and a small amount 
 of pus in the apex. A hair is frequently present in the centre 
 of the pustule. The pus soon dries to a scab, which afterward 
 desquamates, leaving a slight depression and some pigmenta- 
 tion. The lesions are generally numerous and spread over 
 large areas or confined to certain regions. They are most 
 
158 SYPHILIS. 
 
 frequently met with on the extremities, chest and back. They 
 are either isolated or confluent and grouped or irregularly dis- 
 tributed. It is either an early or a late symptom, and may 
 recur a number of times. Other syphilitic lesions, as papules 
 or miliary vesicles, are generally present at the same time. 
 
 Large Acuminated Pustular Syphilide. — This form has the 
 same seat as the small acuminated lesion, that is it is seated 
 around a hair follicle or sebaceous gland, and consists of split 
 pea-sized, acuminated pustules seated on a red or copper-colored 
 base. The lesions may form rapidly or slowly, pus collecting 
 on the papules to its full development in twenty-four or forty- 
 eight hours, or not before one or two weeks. The base is at 
 first red and afterward dark-brownish or copper colored. The 
 pus dries to yellowish or brownish, thick or thin, adherent 
 crusts, beneath which there is ulceration. The crusts disap- 
 pear by desquamation and the ulcers heal by cicatricial tissue. 
 A single pustule lasts about two weeks. The lesions are gen- 
 erally few in number and are disseminated or grouped. The 
 more chronic the course of the pustule formation the fewer are 
 the lesions present. They are seated especially upon the scalp, 
 face and shoulders, but may appear on other parts of the body. 
 It is an early manifestation, but seldom occurs before the sixth 
 month after infection, and lasts about three or four months ; 
 but may be prolonged by the successive formation of new pus- 
 tules. Other lesions, as papules, are generally present at the 
 same time. If many pustules form simultaneously there may 
 be considerable general symptoms, as fever, etc., but usually 
 these are absent. 
 
 Diagnosis. — The eruption may resemble acne or variola. 
 In acne the eruption is usually confined to the face and 
 shoulders, the lesions are not grouped, they form more rapidly, 
 they have no copper-colored base or areola, the eruption is 
 chronic in its course and the concomitant symptoms of syphilis 
 are wanting. In variola the intensity of the general symptoms, 
 the situation and extent of the eruption, the umbilicated pus- 
 tules, and the definite duration of the disease are sufficient for 
 the diagnosis. 
 
SYPHILIS. 159 
 
 Small Flat Pustular Syphilids (Impetigo syphilitica). — This 
 form of eruption consists in the formation of small, flat pus- 
 tules, situated on a reddish base, the pus drying and forming 
 crusts of various colors and thickness. The pustules are either 
 superficial or deep. In the superficial form, which is an early 
 manifestation of syphilis, the pustules are grouped into an 
 irregularly shaped patch which soon crusts. The crusts are 
 yellowish or brownish in color, dry, laminated, friable, and 
 somewhat adherent. They are surrounded or not by a red 
 areola, and beneath them is a superficial ulceration which heals 
 by cicatrization. 
 
 In the deep form, which is a late symptom of syphilis and 
 occurs especially in cachectic persons, the pustules are situated 
 on an elevated reddened patch, and they dry to dark green or 
 brownish, thick, uneven crusts, beneath which is a deep ulcer 
 with a grayish, dirty secretion, sharp cut edges and an indu- 
 rated base. After a time the crust falls off and the ulcer heals 
 by cicatrization, or the ulceration may spread and form large 
 irregular ulcers. 
 
 The small flat pustular syphilide is usually met with on the 
 face, scalp, genitals and extremities. It is often accompanied 
 by fever and associated with periosteal pains, and headache, 
 which are most severe at night. 
 
 Diagnosis. — It is to be diagnosed from pustular eczema. In 
 the latter there is no ulceration, no hard infiltration, the crusts 
 are lighter colored and seated on a discharging, non-ulcerated 
 base. 
 
 Large flat pustular syphilide (Ecthyma syphiliticum.) 
 
 This form consists of large, flat, isolated pustules, situated 
 upon a red base, and containing purulent or even bloody con- 
 tents, which dry to form adherent crusts or scales of various 
 color and thickness. They are always seated upon ulcers. 
 
 The eruption is generally a late manifestation and the pus- 
 tules are few in number, isolated and unsymmetrical. It is 
 met with in cachectic and badly nourished subjects. There 
 are two forms, the superficial and deep, according to the kind 
 of ulceration present. The superficial form of the lesion 
 
l6o SYPHILIS. 
 
 arises upon a small reddened patch ; they are from a pea to an 
 inch in diameter, rounded, disseminated or grouped, often urn- 
 bilicated and are surrounded by a red areola. The pustules 
 burst and dry to an uneven, thick, brownish or blackish crust 
 beneath which there is supeficial ulceration. In the deep form, 
 pus forms on dark red elevated nodules which dries to thick, 
 uneven brownish or blackish crusts often formed like oyster 
 shells (rupia.) Beneath the crusts there are deep ulcers with 
 a grayish, dirty, indurated base, steep edges, and a red areola. 
 The ulceration may heal by cicatrization or spread peripherally 
 and produce serpiginous or kidney shaped ulcers. Upon heal- 
 ing there is generally pigmentation around the cicatrix. 
 
 The cicatrix in this form of syphilis depends on the depth 
 and extent of the ulceration. The eruption appears especially 
 upon the scalp and lower extremities. The mucous mem- 
 branes are also frequently affected, there are deep ulcers on 
 the tonsils and soft palate, and small aphthous ulcers in the 
 mouth and gummata in the skin. The eruption is frequently 
 associated with fever resulting from inflammatory processes in 
 the bones. 
 
 Diagnosis. — From ordinary inflammatory ecthyma the erup- 
 tion is diagnosed by the history of the case, the presence of 
 other syphilitic lesions, the red, copper-colored areola, the deep 
 ulcer, the kind of crust present, and the increase in size of 
 the ulcer by peripheral spreading. 
 
 Bullous Syphilide (Pemphigus Syphiliticus.) — This form con- 
 sists in the formation of pea to walnut size, rounded or ovalish, 
 more or less tense blebs containing an opaque liquid which soon 
 becomes purulent or bloody. Sometimes the eruption resembles 
 pustules more than blebs. The blebs are situated upon an infil- 
 trated base and surrounded by a red areola which deepens in color 
 with the duration of the lesion. They rupture early and the con- 
 tents dry to dark brown, deep green or blackish crusts. The 
 latter vary in character according to the depth and breadth of the 
 ulcer which produces them. They may be small, flat and thin ; 
 or large, conical and thick ; and are usually very adherent. 
 Beneath the crusts there are ulcers with a greenish-yellow, 
 
SYPHILIS. 
 
 161 
 
 dirty grayish secretion, sharp edges and an infiltrated base. 
 These ulcers have a great tendency to spread peripherically and 
 form round or serpiginous ulcers like a tubercular syphilide. 
 If the ulcer spreads at the periphery crusts will constantly be 
 formed corresponding in circumference with the extent of 
 the ulceration ; and as the successively 
 formed crusts will consequently be be- 
 neath and at the same time larger than the 
 previously formed ones they will, when 
 united, form a conical mass arranged in 
 layers and resembling an oyster shell in 
 appearance. As the ulceration does not 
 as a rule spread equally in all directions, 
 the first formed crust, representing the 
 apex of the mass, will be gradually re- 
 moved from the centre towards the mar- 
 gin. If, however, the ulcer spreads 
 equally in all directions, the crust will 
 be conical in form and the crust first 
 formed and constituting the apex will be 
 over the centre of the whole mass, as is 
 
 Fig. 27.— Rupia syphilitica showing the mode of formation of the oyster- 
 shell-like crusts ; near the wrists the early stage of the disease is observed. 
 
 seen in Fig. 27, which is diagrammatic and partly copied from 
 plate XL of the Sydenham Society Atlas. 
 
 These rupia or oyster-shell-like crusts may arise in con- 
 11 
 
l62 SYPHILIS. 
 
 nection with a small or large pustular, a bullous or a tubercular 
 syphilide, the real mode of formation being the same in all 
 cases. The ulcers heal by cicatricial tissue, the scar being gen- 
 erally smooth, at first red and afterwards white, and sometimes 
 crossed by bloodvessels. 
 
 The eruption is either an early or a late lesion, and hence ap- 
 pears either symmetrically or non-symmetrically upon the body. 
 Its favorite situation is on the extremities, especially the lower, 
 but it appears on the back, head or breast. In its course it is 
 either acute or chronic, depending upon the condition of the 
 individual affected. It is most frequent in ill-nourished and 
 cachectic persons. If the eruption is acute and the number 
 of blebs considerable, it will be accompanied by fever, etc., but 
 in chronic cases this is absent. Other syphilitic lesions of the 
 bones, mucous membranes, or skin are usually present at the 
 same time. 
 
 Diagnosis. — The eruption may resemble pemphigus vulgaris 
 or lupus vulgaris.' In pemphigus vulgaris the history of the 
 case, the thin crusts, and the absence of ulceration serve to 
 diagnose the disease from syphilis. In lupus the easily bleeding 
 granulating base, the undermined edges, the soft papules 
 outside the ulcerating patch, the slow course of the eruption, 
 and the absence of concomitant syphilitic lesions render the 
 diagnosis usually not difficult. 
 
 Tubercular Syphilide. — This form of eruption is characterized 
 by the formation of tubercles varying in size from a pea to a 
 bean, or larger, and correspond in every respect, except in the 
 size and numbers, to the large papular syphilide already de- 
 scribed. They are elevated, rounded in outline, semi-globular 
 in shape, firm, dense, with a glistening surface, and of a dark 
 red or brownish-red or coppery color. They are seated deep 
 in the corium, and may extend into the subcutaneous tissue. 
 They are single or multiple, generally the latter, but are never 
 present in great numbers. As a rule, the smaller the papules 
 the more numerous they are. The longer the period since the 
 primary infection the larger, as a rule, will be the papule. They 
 are either disseminated or grouped, and, if at all numerous, 
 
SYPHILIS. 163 
 
 show a marked tendency to an arrangement in clusters, circles, 
 semi-circles, or lines. If neighboring circles unite, the eruption 
 has a serpiginous form. They are not attended by pain or 
 itching. They are situated especially upon the face, back, and 
 around joints, but may appear on other parts of the body. The 
 lesions have a very chronic course, and the infiltration consti- 
 tuting them may continue to spread peripherically, so as to 
 cover large areas, as observed in the serpiginous form. This 
 peripheral extension may occur in isolated or grouped tubercles. 
 Im the former case the patch is circular in shape, until it 
 reaches say one or two inches in diameter, when it ceases to 
 spread at one part of the patch and continues at the remainder, 
 thus producing the horse-shoe or kidney-shaped eruption. 
 When the tubercles are grouped they soon coalesce, but the 
 resulting patch never acquires the even circular outline of the 
 one resulting from a single tubercle. The margin has a scolloped 
 form, the number of curves corresponding to the number of 
 tubercles present before they coalesced. 
 
 The tubercles may disappear either by fatty degeneration 
 and subsequent absorption, or by ulceration. If they disappear 
 by absorption, the skin appears atrophied and pigmented, the 
 amount of atrophy depending on the size of the tubercle. The 
 ulceration may be superficial or deep, depending on the depth 
 in the skin of the tubercle. If seated in the upper part of the 
 corium it will be superficial, but if it has extended into the sub- 
 cutaneous tissue there will be deep ulceration, as the latter 
 consists simply in a breaking down of the syphilitic infiltration. 
 When ulceration occurs scabs form, the extent and thickness 
 depending upon the extent and depth of the ulcerative process. 
 They are always dark in color, firmly adherent, and may have 
 the oyster-shell arrangement as already described. Beneath 
 the scales an ulcer is always present. The base is covered with 
 a grayish or sero-purulent pultaceous mass, the edges are 
 sharply cut, the margin consists of a dense, dark red, sharply 
 limited infiltration, external to the spreading, degenerated, 
 broken down tissue. If the eruption has assumed the ser- 
 piginous or kidney shape in the manner already described, the 
 
164 SYPHILIS. 
 
 ulceration will also assume that same form. The ulcers heal 
 by new tissue from the surrounding skin and from the con- 
 nective tissue at the base, the round cells constituting the 
 syphilitic infiltration being incapable of forming a higher 
 tissue. Papillary formations sometimes arise from the base of 
 the ulcers ; they are met with especially on the scalp, are cov- 
 ered with a puriform, offensive secretion, and form the so- 
 called syphilis cutanea papillomata. 
 
 Tubercle formations are usually a late manifestation of 
 syphilis ; they are very rare before the second year, are most 
 frequent from the second to fourth, but may occur as late as 
 ten or twenty years after the acquisition of the primary 
 chancre. 
 
 Diagnosis. — The eruption may resemble lupus vulgaris, lepra, 
 epithelioma, psoriasis, and simple inflammatory ulcer. In 
 lupus vulgaris the tubercles are soft, the base of the ulcers are 
 red, granular, and bleed easily ; the margins flabby, and there 
 are almost always tubercles to be found external to the general 
 ulcerating patch. It commences generally in young persons, 
 and its progress is many times slower than that of syphilis. 
 The resulting scars produce more deformity, and do not show 
 the scolloped edge of the serpiginous form of syphilis. The 
 absence of syphilitic lesions (papules, gummata, etc.) on other 
 parts of the body would assist to exclude syphilis. In lepra 
 the history of the case, the slow growth of the tubercles, their 
 varnished look, the absence of the raw ham color, and the con- 
 comitant lesions on other parts of the body, are sufficient for 
 diagnosis. In epithelioma, the age of the patient, the situation 
 of the ulcer, the single lesion, its slow growth, the red, easily 
 bleeding base and raised, hard, waxy edge with or without 
 "cancroid corpuscles," will always prevent confounding such a 
 process with that of syphilis. In psoriasis, the manner of 
 spreading and the character of the crusts may, though rarely, 
 closely resemble that of tubercular syphilis, but the absence of 
 ulceration or atrophy of the skin excludes syphilis. 
 
 Simple idiopathic non-contagious inflammatory ulcers of the 
 lower extremities, resulting from a varicose condition of the 
 
SYPHILIS. 165 
 
 veins, and usually called varicose ulcers, are very frequently 
 diagnosed as syphilitic by those not versed in the nature of the 
 processes at work in the two diseases. How ulceration occurs 
 and under what conditions, has been already described. It is 
 always to be remembered that the ulcer in syphilis arises from a 
 breaking down of the sharply limited, dense, dark red syphilitic 
 infiltration present in the corium, and that this infiltration always 
 exists as such for some time before undergoing the retrograde 
 process. As the eruption is constantly extending by peripheral 
 growth, it follows that, external to the ulcerated part, there 
 will always be a zone of sharply limited, undegenerated infil- 
 tration. Outside of this infiltration the skin is unaffected by 
 the syphilitic disease. In "varicose ulcers" the ulceration is 
 the result of an ordinary inflammatory dermatitis, consequently 
 the ulcer will probably not be so deep, the base redder, more 
 granulation like, the edges sloping or perpendicular, rarely 
 undermined, the margin may be red, firm, and elevated, but 
 the redness mostly disappears upon pressure, and the elevation 
 is not sharply limited, but a gradual sloping from the healthy 
 tissue to the edge of the ulcer. This inflammatory area around 
 the ulcer is always considerable in extent, and is the main 
 guide in the diagnosis, for it shows that the ulcer is an inflam- 
 matory one. The shape of a varicose ulcer may be exactly the 
 same as that of a syphilitic ulcer, and consequently can not be 
 relied upon for making a diagnosis. 
 
 Giwunatous Syphilide. — This is a late lesion, and consists in 
 the formation of pea to walnut sized, round nodules seated in 
 the subcutaneous tissue. They commence as pea sized, mov- 
 able, circumscribed, rounded, firm, indolent nodules in the 
 subcutaneous tissue, which afterward increase in size, from ad- 
 hesions to the surrounding skin, and finally, when fully devel- 
 oped, represent walnut sized or larger, elevated, rounded, firm, 
 nodules. Later they become softer, somewhat doughy to the 
 feel, the overlying cutis becomes adherent, and later dark red 
 or livid in color. The nodules may be single or multiple ; are 
 very slow in reaching their full development, and finally disap- 
 pear either by absorption or ulceration. If they break down 
 
1 66 SYPHILIS. 
 
 and ulcerate, the resulting ulcer is fistulous, or roundish, or 
 oval in shape, with clear cut edges and a base covered with 
 a gummatous or a purulent material. The ulcer extends into 
 the subcutaneous tissue, and may attack the periosteum, carti- 
 lage or bone beneath. The margin of the ulcer is infiltrated 
 and the secretion drying, forms thick, dark scabs. The ulcera- 
 tion may increase in width, and even assume the serpiginous 
 form of some of the earlier lesions. The ulcer heals by 
 granulation, and the resulting cicatrix is smooth, whitish in 
 the centre, and pignented towards the peripheral part. 
 
 Gummata are usually seated upon the scalp, forehead, 
 shoulders, or in the skin over the anterior part of the tibia. 
 They are frequently associated with marked nocturnal pains. 
 
 Diagnosis. — Gummata may resemble in shape, size, feel, and 
 situation, fibrous or fatty tumors, but the history of the case, 
 the presence of scars, or other signs of syphilis, on other parts 
 of the body, the rapidity of growth, the nocturnal pains, and 
 the situation, especially when below the knees, will enable one 
 to make a correct diagnosis. The ulcers from gummata may 
 resemble epitheliomatous or simple inflammatory ulcers. In 
 epithelioma the red, easily bleeding base, the waxy margins, the 
 slow growth, the density of the base, and the situation are 
 characteristic features. In inflammatory ulcers — the so-called 
 varicose ulcer, the points for diagnosis are those already given 
 under diagnosis from a tubercular syphilide. 
 
 Cutaneous syphilides are often associated with syphilis of 
 the mucous membranes, nails, bones, and internal organs. 
 Visceral syphilis and syphilis of the nervous system, bloodves- 
 sels, bones, etc., belong to internal medicine or surgery, and 
 will not here be described. 
 
 Paronychia syphilitica. — Syphilitic paronychia is character- 
 ized by a reddened, swollen infiltration of the skin on the root 
 and side of the nails of the fingers and toes. The infiltration 
 disappears by absorption or ulceration, and the nail is cast off. 
 It is frequent in the hereditary bullous syphilide in children. 
 If the nail is affected independently, it loses its original color, 
 the margin becomes brittle, " broken off," and irregular. This 
 
SYPHILIS. 167 
 
 condition is most common in connection with syphilis of the 
 palm. 
 
 Erythema, mucous patches, ulcers, opacity of epithelium, and 
 gummata occur on the mucous surfaces, and in case of doubt- 
 ful diagnosis, the mouth, pharnyx and nose should always be 
 carefully examined. 
 
 Anatomy. — As far as can be judged by the microscope, the 
 pathological elements forming the syphilitic lesions do not dif- 
 fer histologically from the elements observed in some other in- 
 flammatory conditions. It is the cause of the lesion which is 
 specific and probably depends on a special organism, as the 
 cause of syphilis is a fixed contagium. The special character- 
 istics of the syphilitic infiltrations have been already referred 
 to ; they are, the density of infiltration, its sharp limitation and 
 inability of the cellular elements to produce a higher or- 
 ganized tissue ; they, after a period, always undergoing a fatty 
 degeneration, and disappearing by absorption or ulceration. The 
 earlier syphilides are situated in the papillae and upper part of 
 the corium, and the later lesions in the corium and subcutane- 
 ous tissue. 
 
 In the macular syphilide there is round cell infiltration 
 along the capillaries of the papillae and upper part of the 
 corium, and in the adventitia of the larger vessels, besides pig- 
 ment deposits. 
 
 The papular lesions consist of a dense, sharply limited cell 
 infiltration in the papillae and upper part of the corium, and in 
 the case of the larger papules in the subcutaneous tissue also. 
 
 The deeply lying tubercles, and gummata, have an outer por- 
 tion of round cells and granulation-like tissue, and a central 
 portion of gummous material consisting of degenerated cells. 
 
 In the broad condylomata there is granular degeneration of 
 the epidermic cells, the cells of the interpapillary rete are 
 swollen or absent, the rete is infiltrated with cells, and the 
 papillae and the papillary bloodvessels enlarged. 
 
 The vesicular and pustular lesions resemble the papular as 
 regards the changes in the corium, but in the epidermis there 
 is more exudation and round cell collection. 
 
l68 SYPHILIS. 
 
 For a description of the changes occurring in internal organs, 
 the bloodvessels, nerves, bones, etc., the reader is referred to 
 works on syphilis. 
 
 Prognosis. — As regards the removal of the cutaneous mani- 
 festations in syphilis the prognosis is always very favorable. 
 The length of time required for their removal differs in differ- 
 ent cases, depending upon the form of the eruption, the con- 
 dition of the patient's nutrition, and his ability to use the 
 proper remedies. The macular is the easiest, and the pustular 
 syphilide the most difficult to cure. If the person is debili- 
 tated, or the hygienic surroundings not good, or he is easily 
 salivated, the prognosis is not so good. Syphilis, in old per- 
 sons with a broken down constitution, and especially if intem- 
 perate, is often fatal either directly, or indirectly from pneu- 
 monia, or from erysipelas originating from an ulcer. In chil- 
 dren, the prognosis is often unfavorable, the intensity of the 
 process in their case being as dangerous as the slowness in old 
 persons. In gouty and scrofulous persons, the disease is usually 
 obstinate to treatment. The prognosis is greatly influenced 
 by the kind of organ or system affected. Thus, when the lesions 
 are in the cutaneous system the prognosis is much more favor- 
 able than when seated in the bones, iris, or brain. Syphilis of 
 the nervous system is always a grave affection, although 
 epilepsy or paralysis, the result of this disease, is more man- 
 ageable than when occurring from other causes. Visceral 
 syphilis is especially fatal. 
 
 Can syphilis be cured ? That the disease can be cured is 
 shown by well authenticated cases of a second infection. That 
 the system may become free of any constitutional syphilis is 
 further shown by the 'birth of healthy children from parents 
 previously syphilitic. 
 
 Unfortunately we are unable to judge when in any given 
 case the system is free of the poison. Tertiary lesions may 
 form in a person who has for many years shown no trace of 
 syphilis. The ability to beget healthy children is also no proof 
 that tertiary lesions will not occur at some future time. Ter- 
 tiary lesions, however, are but local pathological conditions and 
 
SYPHILIS. 169 
 
 their secretions are not infectious ; hence reinfection may occur 
 during their presence in the system. When a patient has been 
 properly treated for three years, and no lesions have formed for 
 more than one year, it is generally considered that he can 
 marry without danger to his wife or fear of begetting syphilitic 
 children. 
 
 Treatment. — The treatment of the cutaneous syphilide is 
 that of the treatment of syphilis in general, and is hygienic, 
 constitutional and local. As already noted the severity of the 
 cutaneous lesions depends in a marked degree upon the state 
 of the nutrition of the body of the person affected. Thus the 
 vesicular, pustular and ulcerative syphilides are met with es- 
 pecially in badly nourished individuals, and in those living under 
 unfavorable hygienic conditions. This being the case it is 
 always necessary in treating cases of syphilis to keep the per- 
 son in as good physical condition as possible. Lesions which 
 in well nourished subjects rapidly disappear under anti- 
 syphilitic remedies will, in badly nourished subjects and broken 
 down constitutions, often resist the same remedies until the 
 general nutrition is improved, and the individual placed under 
 favorable hygienic conditions. Persons with syphilis should 
 not be kept in doors, but allowed to exercise in the open air or 
 follow their usual vocation, provided it does not overtax their 
 muscular power or expose them to inflammatory conditions. 
 Their food should be liberal and nourishing, and wine and 
 beer can be partaken in moderate quantities. Brandy, whisky, 
 gin, etc., should, I believe, be avoided. Iron or other tonics 
 should be given according to the special indications in any 
 given case. 
 
 The constitutional treatment consists in the administration 
 of mercury and iodide of potassium according to the indica- 
 tions of the case. Mercury is the antidote to the syphilitic 
 poison, and consequently is indicated in all stages of the 
 disease. Iodide of potassium causes the disappearance of 
 gummatous formations, but does not prevent their formation, 
 hence it is especially useful in the later stages of the disease, 
 and in syphilis of internal organs. 
 
I70 SYPHILIS. 
 
 The administration of mercury should be commenced as 
 soon as a positive diagnosis of syphilis is made, and should be 
 continued for at least two years or for one year after disappear- 
 ance of all lesions. Whether the drug should be used con- 
 tinuously or with intervals of no, treatment is still an undecided 
 question. I believe it is better, instead of discontinuing the 
 remedy, to change the form of the drug and give continuous 
 treatment, so as to oppose the virus unremittingly during its 
 active period. If the same form of mercury is always used it 
 is often necessary to stop its administration for a short 
 time, especially when it seems to lose its power over the 
 lesions. 
 
 The drug can be used in all forms and stages of the disease, 
 but where gummatous formations are present iodide of potas- 
 sium should also be given either separately or in combination 
 with the mercurial. I prefer to give them separately at differ- 
 ent periods of the day, or give the iodide of potassium internally 
 and the mercury by inunction. Anaemia, especially when 
 caused by the syphilis, is no contra-indication to the use of 
 mercury. In these cases, however, iron, good food and favor- 
 able hygienic surroundings assist very much as already men- 
 tioned. If the person is pregnant, treatment should be given 
 until the seventh month, and preferably by inunction. Some 
 physicians consider mercury contra-indicated in cases of 
 chronic nephritis not dependent upon syphilis. 
 
 If a certain preparation fails to exert the desired effect upon 
 the syphilitic lesions ; or having been given for some time 
 loses its action more or less, some other preparation should be 
 employed, or the mode of administration changed. That the 
 proto-iodide or the bi-chloride in a given case does not cause a 
 rapid disappearance of the cutaneous lesions is no proof that 
 calomel or inunctions of mercurial ointment or oleate of mer- 
 cury will not do so, and vice versa, hence, in cases of slow 
 recovery it is well to try more than one preparation to find out 
 which works most actively. As long as lesions are visible the 
 drug should be given in doses strong enough to just escape 
 salivation, and after their disappearance, small doses, about one- 
 
SYPHILIS. 171 
 
 third of the previous quantity, should be administered, for 
 about a year longer. 
 
 It is difficult to persuade patients to take medicine for a 
 long period when no rash or other symptoms of syphilis are 
 present ; but if the physician explains to the person affected, 
 the true nature of the disease, and the ultimate dangers to 
 their internal organs and bloodvessels, as well as future chil- 
 dren from the virus, many of them will follow directions and 
 endeavor to be cured if possible of the disease. 
 
 Mercury can be administered by inunction, fumigation, hypo- 
 dermically, or by the mouth. 
 
 By inunction the system is brought more quickly under the 
 influence of the drug than by any other means, and hence is 
 specially indicated in all cases where a rapid effect is desired, 
 as in syphilis of the eye, brain, nervous system, soft palate or 
 larynx. In severe hereditary syphilis it is also preferable to 
 treatment by the mouth. It is also to be employed in all cases 
 where mercury is not well borne by the stomach, and in many 
 cases of anaemia or syphilis in persons with chronic pulmonary 
 disease. Finally, it can be employed against any form of 
 syphilis that can be affected by any mercurial preparation 
 given in other ways. The objections to its use in general in 
 preference to other modes of administration are, that it is not 
 so cleanly, that patients will not persist in its use, and that it 
 frequently irritates the skin and produces an eczema, especial- 
 ly in children and persons with tender skin. The fact that 
 patients object to employing this mode of treatment will in 
 private practice always restrict its use to the special cases 
 above mentioned. 
 
 The preparations employed for inunction are the blue oint- 
 ment and the oleate of mercury. The latter is cleanlier to use, 
 and is much more readily taken up by the skin, but I think it 
 is a question if it acts as favorably against the syphilitic virus 
 as the blue ointment does. If blue ointment is used, half a 
 drachm to a drachm is sufficient for one inunction, and it 
 should be rubbed in gently but firmly for ten or fifteen min- 
 utes with the palm of the hand moved in a circular manner 
 
3 72 SYPHILIS. 
 
 over an area several inches in diameter. The inunction should 
 be made in a warm room, and the skin previously washed with 
 soap and warm water. Inunctions can usually be continued 
 weeks or months without producing salivation, but if this 
 should occur, the applications should be stopped for a few 
 days. If the skin becomes irritated, the oleate should be em- 
 ployed or the strength of the ointment reduced. If an oleate 
 is employed, the twenty per cent, solution should be diluted 
 with one or two parts of vaseline, and one drachm used for a 
 single inunction. 
 
 Inunctions are to be made daily, and to avoid too much irri- 
 tation of the skin from the mercurial, different parts of the 
 body should be chosen for succeeding days. Hairy parts of 
 the body are to be avoided lest peri-folliculitis be produced. 
 Sigmund advised the following order as to the places for in- 
 unction : First day, one, or both inner and posterior surface 
 of the calves ; second day, both thighs, inner surface ; third 
 day, abdomen and sides of thorax, excluding the axilla and 
 nipple region ; fourth day, back ; fifth day, both arms. Sixth 
 day, commence to repeat, as before. 
 
 If an oleate is employed, it can be rubbed into the soles of 
 the feet, especially in children ; or in adults, where the skin is 
 thinnest, as in the flexures and over the ribs. 
 
 Fumigation is too troublesome and difficult to carry out prop- 
 erly ever to become much employed in the treatment of 
 syphilis. In cities and hospitals, with the necessary apparatus 
 and attendants on hand, it can be used with advantage in some 
 cases. It may be employed for any stage of syphilis, but more 
 especially for the late ulcerating syphilides. The small pap- 
 ulo-vesicular eruption sometimes disappears rapidly by this 
 mode of treatment. Calomel or the black oxide of mercury 
 are the preparations sublimed. From ten to thirty grains is 
 sufficient for one bath, and the sitting should last from fifteen 
 to twenty minutes. The baths should be employed as long as 
 the eruption is present. The action of the drug should not go 
 beyond a slight touching of the gums. 
 
 The treatment of syphilis by hypodermic injections of calo- 
 
SYPHILIS. 173 
 
 mel, or other mercurial preparations, is not to be recommended, 
 as the method is troublesome, painful, often produces ab- 
 scesses, does not act, unless locally, as favorably as inunc- 
 tions, etc., and is too expensive. 
 
 Mercury is given internally, as blue pill, gray powder, calo- 
 mel, corrosive sublimate, or proto-iodide. 
 
 Blue pill in the dose of two to five grains daily can often 
 be taken for a long time without producing gastric dis- 
 turbance. 
 
 The gray powder is rather slow in its action, but is non-irri- 
 tating to the stomach, and is very useful in syphilis in children, 
 either acquired or hereditary, especially in the latter form. If 
 it gripes, a small amount of opium should be mixed with it. 
 The dose for adults is two to five grains three times a day, 
 and for children half a grain twice a day. It should not be 
 given, except in mild cases, when a rapid, active effect on the 
 lesions is not required. 
 
 Calomel is more active than the gray powder, but is liable to 
 irritate the intestinal tract. If it irritates, small doses of opium 
 or Dover's powder should be combined with it. The dose is 
 from one to three or four grains twice a day. It is a very use- 
 ful preparation for hereditary syphilis in children, and is to be 
 given in doses of one-eighth to half a grain twice a day. In 
 nearly all cases in children, it should be combined with an 
 iron preparation, of which the best is the saccharated carbonate 
 given in doses of from one to two grains. If not well borne 
 by the stomach, the gray powder can be given, or what is 
 usually better, inunctions of blue ointment, or of the oleate, as 
 already described. The effects of calomel can be very rap- 
 idly obtained by giving small doses; say one fiftieth to one- 
 twentieth of a grain every hour. Thus administered, it is very 
 useful in the severe headaches of syphilis. It may also be 
 given in cases of iritis, in conjunction with inunctions of blue 
 ointment in the skin around the eye, and atropin for dilatation 
 of the pupil. 
 
 The bi-chloride of mercury, although perhaps the most fre- 
 quently prescribed of all the mercurial preparations, is one of 
 
174 SYPHILIS. 
 
 the least useful ones. It is slow in its action, and is very liable 
 to irritate the stomach. 
 
 The dose should at first be small and afterwards gradually- 
 increased if necessary. One-thirtieth to one-fifteenth, or one- 
 tenth of a grain may be given two or three times a day. It 
 may be given in pill form or with vegetable tinctures or syrups. 
 It should always be taken after meals. It is frequently com 
 bined with iodide of potash for the late stages of syphilis, but 
 I believe it is usually better to give the iodide and the mercur- 
 ial separately at different times of the day and select as the 
 mercurial that form best suited for the individual case. This 
 form will probably be the proto-iodide, or the blue ointment. 
 Tincture of the chloride of iron can be combined with corro- 
 sive sublimate in anaemic or "broken down" constitution 
 cases. 
 
 The proto-iodide is the best mercurial preparation for inter- 
 nal administration. If pure, it may be given for a long period 
 without causing gastric disturbance. As usually found in the 
 market it sometimes causes griping or even diarrhoea, and to 
 avoid this it is necessary to combine opium and hyoscyamus 
 with it. It is to be given in pill form, the dose depending upon 
 the effect desired. If the syphilitic eruption is extensive, or a 
 rapid action of the drug is required on account of the situation 
 of the lesions or danger to vital organs, it may be given in doses 
 of a grain or a grain and a half three times a day until the 
 gums become affected. In ordinary cases of secondary erup- 
 tion, I give half a grain three times a day, or twice a day, ac- 
 cording to the ability of the patient to take the drug as judged 
 by the effect upon the mouth. If one and a half grains a day 
 do not produce salivation that quantity is given until the 
 eruption has subsided, and then the dose is reduced to a grain 
 a day for a few weeks, and afterwards to half or a third of a 
 grain for a year or longer, taking care to increase the dose or 
 change the preparation for a time if there are any symptoms 
 that the virus is not being controlled by the course followed. I 
 prefer to give the daily dose two or three times in the day in- 
 stead of at one time, as it seems to me that its action on the 
 
SYPHILIS. 175 
 
 disease is more energetic, and less griping results, when thus 
 administered. The granules made by Gamier and Lamoureux 
 are on this account very convenient and at the same time re- 
 liable. 
 
 The proto-iodide is useful for all the forms and stages of 
 syphilis for which a mercurial is indicated, but is not as re- 
 liable as inunctions when a rapid effect is required. 
 
 Iodide of potash is given in the late secondary eruptions for 
 gummatous formations, for tertiary lesions, and in affections of 
 the bones, nervous system and internal organs. Even in these 
 cases its use should not be long continued without giving a 
 mercurial also, for, as already stated, though it may, and gener- 
 ally does cause certain lesions to disappear, it does not prevent 
 their formation. Gummata of the subcutaneous and sub-mu- 
 cous tissues, ulcers of the pharynx and larynx with rapid de- 
 struction of tissue, periosteal pains and late effects of syphilis, 
 as occurring in internal organs, muscles, nervous system, blood- 
 vessels, etc., should be treated by iodide of potash, and the use 
 of the drug continued for two or three weeks after disappear- 
 ance of the lesions. In the macular and early papular syphil- 
 ides it is of no service unless the mucous membrane becomes 
 affected, when it may be given for a few days in addition to the 
 mercurial treatment. If a rapid effect is not obtained in any 
 given case from the iodide, its use should be discontinued and 
 mercurials employed. I have seen iodide of potash in large 
 doses given for several months for a severe ulcerating syphilide 
 without exerting a particle of power over the disease, when 
 subsequent treatment by mercury both internally and locally 
 caused the ulcers to heal in a few days. These cases teach the 
 lesson never to continue giving a certain drug for any length of 
 time in syphilis, unless you observe improvement in the symp- 
 toms from its use. If the disease does not yield, the drug, or 
 the preparation, or mode of administration must be changed. 
 
 The iodide should be given after meals and in large quan- 
 tities of water. It can be made fairly palatable by dissolving 
 it in an aromatic water and adding the compound tincture of 
 cardamoms or the syrup of orange. Many prefer to have the 
 
176 SYPHILIS. 
 
 taste disguised by a vegetable bitter, as the compound tincture 
 of gentian. If it causes irritation of the nose and eyes it should 
 be combined with carbonate of ammonia or the aromatic 
 spirits of ammonia. In syphilitic affections of the brain asso- 
 ciated with convulsions, epilepsy, etc., the bromide should be 
 given with the iodide. Unless the symptoms are urgent as in 
 cases of syphilis of internal organs and especially of the nerv- 
 ous system it is best to commence with small doses and after- 
 ward gradually increase the amount to be taken daily. Com- 
 mencing with a scruple a day in divided doses it is rarely nec- 
 essary to increase the amount to more than one drachm, al- 
 though in brain syphilis, especially if associated with convul- 
 sions, two, three or more drachms may be required to exert the 
 desired effect. 
 
 These large doses should be employed only as long as urgent 
 symptoms are present ; upon their subsidence the drug should 
 be continued in the ordinary amount, for the necessary length 
 of time. The iodide may be given in combination with a mer- 
 cury preparation, as the biniodide or the bichloride, but I be- 
 lieve it is better to give them separately, at different periods of 
 the day. If the stomach is irritable the mercurial can be em- 
 ployed by inunction, and the iodide of potash, or, what is some- 
 times better borne by the stomach,the iodide of soda, given in- 
 ternally. Whilst taking the iodide the hygienic surroundings 
 should be as good as possible, and the food abundant and 
 nourishing. 
 
 Local treatment. — Syphilitic lesions of the cutaneous and 
 mucous surfaces can be more rapidly removed by a combina- 
 tion of local and general treatment than by constitutional 
 treatment alone. This combined treatment is to be employed 
 when the lesions, no matter of what form, are situated upon 
 exposed parts of the body ; in cases of condylomata, in lesions 
 upon the mucous membranes, and in the ulcerative syphilides, 
 calomel, blue ointment, the acid nitrate of mercury, iodoform, 
 oleate of mercury and nitrate of silver, are the substances us- 
 ually employed for local treatment. The nitrate of silver is 
 used against tertiary lesions of the mucous membrane of the 
 
SYPHILIS. 177 
 
 mouth, and the others are used against lesions accompanying 
 constitutional syphilis — the secondary lesions. Calomel is to 
 be used only upon absorbent surfaces, as in the condylomata 
 and ulcerating lesions. Blue ointment can be used in all cases. 
 It is to be spread upon strips of linen and bound firmly to the 
 affected part. The acid nitrate of mercury is used as a caus- 
 tic in obstinate cases of mucous patches. Iodoform is sprinkled 
 upon ulcerating surfaces. It sometimes causes pain and very 
 often exerts no beneficial action upon the lesion. Its value, I 
 think, has been over-estimated. The oleate can be employed 
 in the same cases as the blue ointment, and is preferable to it if 
 the lesions are deeply seated, as in the late secondary lesions. 
 
 In syphilitic lesions of the face, local treatment is always to 
 be employed to prevent disfiguration and allow the patient to 
 pursue his usual occupation, or take out door exercise without 
 feeling that persons will recognize his disease, whilst at the 
 same time he is being radically treated by constitutional means. 
 Papules and tubuerles are treated by the blue ointment, and in 
 an ulcerating syphilide, calomel is sprinkled upon the ulcerated 
 surface, and an oleate or blue ointment applied. The blue 
 ointment should be changed once a day, and the calomel 
 applied about twice a day. In cases of iritis the pupil must be 
 quickly and well dilated with atropin ; and blue ointment, or 
 an oleate, rubbed into the temple once or twice a day. In 
 condylomata, calomel sprinkled upon the papules, and isolation 
 with charpie, or burning with a solution of corrosive sublimate 
 in alcohol, is all that is necessary. I prefer the use of the cal- 
 omel and charpie. If the condyloma is dry it should be first 
 moistened with a solution of common salt, and the calomel 
 then applied. Cleanliness in all cases is necessary to success 
 in their removal. They can also be removed by touching them 
 two or three times a day with a two to five grain solution to 
 the ounce of nitrate of silver. In papular and ulcerative affec- 
 tions of the mouth, astringents will suffice for mild cases, but 
 in severe cases, more active agents are required. Opaque 
 patches are to be touched occasionally with nitrate of silver, 
 or in more obstinate cases, with acid nitrate of mercury, al- 
 12 
 
178 HEREDITARY SYPHILIS. 
 
 though this latter is not always necessary. If there is ulcera- 
 tion of the softer tissues of the mouth, thorough cauterization, 
 combined with energetic internal treatment, is necessary to pre- 
 vent irreparable loss of tissue. Syphilis of the general surface is 
 to be treated in the manner already described for that of the face. 
 Gummata are to be opened only when the skin over them is 
 red and tense. An apparent fluctuation in gummata is no in- 
 dication for the use of the knife, and the internal administra- 
 tion of iodide of potash will soon cause the absorption of the 
 mucoid contents. 
 
 For further information on the treatment of syphilis, the 
 reader is referred to works devoted exclusively to this disease. 
 
 HEREDITARY SYPHILIS. 
 
 This term is to be restricted to cases where the child is in- 
 fected i?iutero through one or both parents. Syphilis acquired 
 after birth runs essentially the same course as in adults. 
 
 Syphilis may be transmitted from parent to offspring, from 
 (a) a mother infected either before conception or up to about 
 the seventh month of pregnancy ; (b) from a father, the mother 
 being healthy — (according to most authorities, or only appar- 
 ently so according to others) ; and (c) when both parents are 
 syphilitic; in which latter case the disease appears in an intens- 
 ified form. 
 
 The foetus may be diseased at an early stage of intrauter- 
 ine life, and consequently die and be cast off, abortion taking 
 place ; or it may be born alive prematurely ; or be still-born 
 at full term ; or it may be born alive at full term and present 
 some of the characteristic lesions of syphilis ; or, as most 
 frequently happens, appear perfectly healthy at birth and later 
 give evidences of its syphilitic taint. 
 
 Recurring abortions are among the most characteristic 
 symptoms of syphilis in pregnant women, and the more recent 
 the general syphilis in the parents at the time of conception 
 the greater will be the liability to abortion; hence after 
 many abortions and still-births a child may finally be carried to 
 
HEREDITARY SYPHILIS. 1 79 
 
 full term and appear quite healthy at birth. The intensity of 
 the inherited disease varies in degree, according as the trans- 
 mission is from one or both parents, and according to the 
 length of time which has elapsed from the date of the original 
 infection of the parent. 
 
 Children born alive with an eruption already present, are 
 usually small and undeveloped, with a thin, wrinkled skin and 
 an aged appearance. Beside any of the usual forms of 
 eruption which may not yet have appeared, tubercles, like boils 
 may develop in the subcutaneous connective tissue, which 
 break down and discharge ; pemphigus bullae also may appear 
 more or less extensively over the body, but especially on the 
 hands and feet. These children usually are marastic and per- 
 ish early from diarrhoea and other digestive disorders, com- 
 plicated perhaps with visceral syphilis or suppuration of the 
 epiphyses. 
 
 The bullous syphiloderm known as pemphigus neonatorum 
 syphilitica consists of flabby bullae from the size of a pea to 
 that of a hazel-nut, usually flat and disseminated, but may be- 
 come confluent. They may be flaccid or distended, and their 
 contents clear, cloudy, sanious, or contain a thin greenish pus. 
 The favorite seat of the eruption is on the soles of the feet and 
 palms of the hands, and the bullae are also disposed to appear 
 on the fingers and toes and lower limbs. The epidermis is apt 
 to be ruptured, laying bare the very red papillae beneath, or 
 showing an excoriated, ulcerated base which is very slow in 
 healing. These ulcers are not unfrequently seen on the joints 
 of the fingers and toes. Sometimes almost the entire body, 
 especially the face, is covered with these bullae, which, on dry- 
 ing, form crusts which spread at the edges and become conflu- 
 ent. A very similar eruption occurs in cachectic children who 
 are not syphilitic. The distinction is made generally by at- 
 tention to the concominant symptoms, though, according to 
 Zeissl, the bullae of the non-syphilitic form are distinguished 
 by the rapidity with which they dry up. 
 
 According to Lancereaux, the syphilitic pemphigus appears 
 within a few days after birth and is located especially upon the 
 
l8o HEREDITARY SYPHILIS. 
 
 palms of the hands and soles of the feet, while the bullae in the 
 non-syphilitic variety are more generally distributed over the 
 body. 
 
 As stated above, the majority of children are born appar- 
 ently healthy, the first symptoms of syphilis appearing at a 
 later period; in almost all cases, however, within three months. 
 According to Diday's table of reported cases — 158 in number 
 — the first symptoms appeared during the first month in S6 
 cases ; during the second month in 45, during the third in 15, 
 and at the fourth month in 7. Thus in the great majority of 
 cases the disease makes its appearance during the first six 
 weeks or two months, and that after the fourth month the 
 probability is that the child has escaped infection. Symptoms 
 appearing later and said to be present for the first time are to 
 be very doubtfully attributed to hereditary syphilis. In many 
 cases of disease in children of three, four or five years of age, 
 the lesions of acquired syphilis have been erroneously attrib- 
 uted to hereditary taint because no discovery of an initial 
 lesion could be made. 
 
 Some children born with hereditary syphilis are at first 
 plump and well nourished, and for a few weeks continue their 
 normal development, but afterward gradually become delicate, 
 anaemic, and begin to waste, and frequently to suffer from indi- 
 gestion and diarrhoea. The skin assumes a dingy, muddy hue, 
 the subcutaneous fat disappears, and the skin hangs in loose 
 wrinkles and folds on the extremities, and exhibits many 
 creases and furrows. The face has a pinched and weazened 
 expression like that of an old man, the so-called senile counte- 
 nance. One of the earliest specific symptoms is coryza. The 
 child " snuffles " and the discharge from the nostrils is at first 
 thin, but becomes thicker and more tenacious, gradually drying, 
 and accumulating and blocking up the nasal passages, so as to 
 interfere with or entirely prevent the act of nursing, whereby 
 the infant is still further reduced in strength from deprivation 
 of its nourishment. The discharge irritates the nasal orifices 
 and the upper lip, and crusting takes place. Later on, if the 
 process is not arrested, ulceration of the nasal mucous mem- 
 
HEREDITARY SYPHILIS. l8l 
 
 brane results, and the nasal bones may become carious and 
 come away in fragments, the discharge becoming sanious, 
 purulent and very foetid. 
 
 At this time, too, the mouth and throat are affected by erythe- 
 ma and mucous patches, and the coryza is accompanied by 
 more or less hoarseness and even aphonia. The hoarse, 
 squeaking cry at this stage is peculiar to hereditary syphilis. 
 
 Lesions of the skin usually appear about the same time as 
 the coryza. The eruption may take the form of erythema, 
 maculo-papules, papules, etc., or a combination of these lesions. 
 Blebs or bullae generally appear with the severer syphilis 
 present in bad cases at birth. Most frequently a mixture 
 of both macules and papules are observed. Sometimes the 
 whole body, especially the face, is covered with large, flat 
 copper-colored papules, more or less coalescent in places. 
 Again, the eruption is confined to a few bright red papules 
 upon the buttocks which, when moistened by the discharges, 
 assume soon the characteristics of mucous patches and may 
 even result in tolerably marked ulcerations. At the angles 
 of the mouth and the eyes, in the creases of the neck, be- 
 hind the ears, in the inguinal folds, and at the sides of the 
 scrotum, or wherever there are opposing surfaces moistened 
 by perspiration or discharges, the papules frequently take 
 the form of mucous patches and rapidly increase in size by 
 coalescing, etc. 
 
 In the earliest stage of the maculo-papular eruption the 
 color may have a more yellowish or fawn-colored tinge which 
 afterward deepens to brownish red. Sometimes, before any 
 general eruption has appeared, the attention will be attracted 
 to the shiny, glistening appearance of the epithelium 
 on the palms of the hands and soles of the feet, while there 
 may be a brownish discoloration of the skin of the eye-brows 
 alone or this be accompanied by a dingy, smoky tint of the 
 prominent surfaces of the face, while the hollow of the inner 
 canthus and of the cheeks and under the lower lip may be 
 paler and clearer in comparison. Aside from this discoloration, 
 there may be no general eruption or even snuffles for a time, 
 
182 HEREDITARY SYPHILIS. 
 
 to assist one in making a diagnosis. The papules about the 
 buttock very much resemble the excoriated and moist, or the 
 dried and crusted flat papules of an eczema, or eczema-inter- 
 trigo, often observed in children who have diarrhoea with acid 
 passages and urine, when great cleanliness is not practiced. 
 In the latter case, however, the papules will not be observed at 
 the margin of the anal mucous membrane and skin, as is the 
 case with mucous patches, and also the eruption will be dis- 
 tributed pretty symmetrically about the buttocks and confined 
 to the region usually covered with a soiled diaper. The syphi- 
 litic erythematous patches (which are often quite extensive 
 about the thighs and lower part of the trunk) in a few weeks 
 usually become broad, flat papules of the size of a finger nail, 
 or run together into extensive patches of infiltration. They may 
 be dry, or squamous, or moist, according to the situation, etc. 
 
 These broad papules and mucous patches are the common 
 syphiloderm of children. At the same time as the appearance 
 of these eruptions on the skin, signs of stomatitis and pharyn- 
 gitis are observed, and mucous patches appear on the mucous 
 membrane of the mouth, palate and throat. 
 
 Children with hereditary syphilis, who have passed through 
 the acute stage, may afterwards develop normally and remain 
 free from any subsequent effects of the poison, developing in 
 normal manner, or remain delicate and feeble, and bear traces 
 of the disease for life. During the latent stage, subsequent to 
 about the first year, relapse may occur, mostly in the form of 
 condylomata, but rarely, if ever, is there a return of the char- 
 acteristic rashes of the acute stage. In general, however, these 
 children may enjoy continuously their usual good health. 
 About the age of second dentition or puberty, following this 
 so-called latent stage, new symptoms are frequently developed, 
 mostly the so-called tertiary lesions of the bones, subcutaneous 
 connective tissues, viscera and nervous system. There occur 
 serpiginous ulceration of the skin or eruptions resembling 
 rupia, the character of the individual lesions not differing from 
 those of the variety in acquired syphilis which have already 
 been described. 
 
HEREDITARY SYPHILIS. 
 
 183 
 
 A somewhat peculiar affection of the bones of the fingers 
 and toes occurs in syphilitic children, during even the earlier 
 stages of the disease, known as dactylitis syphilitica. It con- 
 sists of a gummy periostitis or ostitis, affecting chiefly the 
 posterior surfaces of the phalanges, and most frequently the 
 proximal phalanx. It may, however, involve the carpal or tar- 
 sal bones. It usually is a painless and insensitive swelling at 
 first, and is confined at the outset to 
 the shaft of the phalanx, not involving 
 the joint. (See cut 28.) This form of 
 bone- lesion also occurs in the later ter- 
 tiary stage, but, different from the usual 
 course in acquired syphilis, it not infre- 
 quently is met with in the first months 
 of the disease. If not cured it runs the 
 course of other syphilitic bone affec- 
 tions, and with the usual results of 
 caries and necrosis. 
 
 These deep seated lesions require 
 notice here only for the purposes of 
 diagnosis, and to enable us to recognize 
 the subjects of hereditary syphilis. 
 
 For the purpose of diagnosis we can, 
 with Mr. Hutchinson, divide the course 
 of the disease into three stages : 1st, in- 
 fantile period ; 2d, the stage of latency ; Fig. 28. — Syphilitic dacty- 
 
 , , r • litis. (Berg.) 
 
 3d, that of tertiary symptoms. 
 
 Some of the peculiarities of the first and second stages have 
 been described already. In addition to the senile facies, the 
 shiny palms of the hands and soles of the feet, the discolored 
 eyebrows and peculiar eruptions described above, these chil- 
 dren may bear evidences of a fcetal arachnitis, as shown by the 
 prominent forehead, and occasionally by a general hydro- 
 cephalus. This hydrocephalus, however, in contra-distinction to 
 one dependent upon anon-specific cause, is capable of much im- 
 provement from specific treatment. In the third period we recog- 
 nize hereditary syphilis from the marks left by previous lesions. 
 
184 HEREDITARY SYPHILIS. 
 
 Genital atrophy and general arrest of development (infant- 
 ilism) are important results of previous syphilis. The stature 
 may be dwarfed, virility retarded, the development of the tes- 
 ticles or ovaries and mammae delayed or arrested, and the hair of 
 the beard and pubis scanty, thin or absent. Deformities of 
 the cranium may be present as the result of early hydrocepha- 
 lus, giving a protuberant forehead, prominent bosses on the 
 cranial bones from hyperostoses, sometimes asymmetry of the 
 cranium or a keel-shaped forehead, (Fournier.) 
 
 The nose may be retracted at the end from loss of the carti- 
 lages, or broadened and flattened at the base from thickening 
 of the periosteum of the nasal bones during the existence of 
 the coryza, or the bridge may be flattened from loss by caries 
 of the nasal bones. Bony tumefactions may be found on the 
 shaft, or at the extremities of the long bones, especially of the 
 tibia ; also deformities of the joints, as a result of syphilitic ar- 
 thritis, either dry or suppurative. 
 
 Gummy infiltration with rapid destruction of the soft palate, 
 is observed not infrequently in the early part of the third 
 period, and leaves a gap resembling, superficially, ordinary cleft 
 palate. 
 
 Cicatrices on the skin, especially characteristic, may be found 
 in the fine lines at the angle of the mouth and nostrils, the 
 result of mucous patches in infancy, also in the lumbo-gluteal 
 and posterior-crural regions- These are often very slightly 
 marked and faint. 
 
 Interstitial keratitis and iritis are not uncommon incidents of 
 inherited syphilis which leave permanent traces. A milky 
 cloudiness, like that of ground glass, involving the cornea, may 
 appear, and afterwards very much clear up, but nearly always 
 one can detect a faint haze in the substance of the cornea, there 
 being no scars on its surface, as in ordinary leucoma. The 
 sclerotic in the ciliary region is somewhat dusky and thin. 
 
 Nervous deafness, or deafness from purulent otitis, has also 
 been observed. These two series of symptoms, with peculiar 
 alterations of the teeth, constitute the so-called " triad of 
 Hutchinson." The teeth maybe dwarfed, or undeveloped, or 
 
HEREDITARY SYPHILIS. 1 85 
 
 easily decay, as the result of syphilis, without presenting any 
 special diagnostic peculiarities. Either deciduous or perma- 
 nent teeth may suffer much in their nutrition and development, 
 but it is the second dentition which is characteristically 
 affected, and especially the upper central incisors. " The 
 characteristic malformation of the upper central incisors con- 
 sists in the dwarfing of the tooth, which is usually both narrow 
 and short and in the atrophy of its middle lobe. This atrophy 
 leaves a single broad notch (vertical in the edge of the tooth, 
 and sometimes from this notch a shallow furrow passes up- 
 wards on both anterior and posterior surfaces nearly to the 
 gum. This notching is usually symmetrical." (In a few cases 
 only one incisor is affected.) " Sometimes these teeth diverge, 
 and at others they slant toward one another." (See cut.) 
 
 Figs. 29.— Syphilitic teeth. (Hutchinson.) 
 
 These teeth are spoken of as u screw-driver " teeth. Often the 
 canines are affected, being dwarfed to small pig-points, and 
 carious. 
 
 Many of the erosions and furrows seen are not characteristic 
 of hereditary syphilis, and the notched teeth are not absolutely 
 pathognomonic of it, but constitute a strong presumption. 
 
 Irregularity of implantation and arrangement of the teeth, 
 the spaces separating the teeth being much augmented, are 
 especially observable in hereditary syphilitics. 
 
 The tertiary lesions in this period are often symmetrical (as 
 double keratitis, etc.) in contrast with what occurs in this stage 
 in the acquired disease. 
 
 The fact of the polymortality of syphilitic families, and the 
 direct examination of the brothers and sisters, will often aid 
 greatly in forming a diagnosis. 
 
 The prognosis in inherited syphilis is favorable or unfavor- 
 
l86 HEREDITARY SYPHILIS. 
 
 able, in proportion to the date of the appearance of the eruption, 
 its intensity, and the general physical condition of the child. 
 
 Children born covered with a profuse rash, and marastic, are 
 generally also affected with visceral syphilis, and die very soon. 
 
 Nasal catarrh, if severe, may block the nasal passages and 
 prevent nursing, and so fatally interfere with nutrition. Dis- 
 order of the stomach and bowels, with vomiting or diarrhoea or 
 both, is a very unfavorable complication. 
 
 When the child is born plump and remains in good condition 
 for a few weeks, and then breaks out with a moderately exten- 
 sive eruption, proper treatment is very effective and speedy 
 cure generally the result. 
 
 The treatment of hereditary syphilis, in the early forms at 
 least, consists in bringing the system speedily and fully under 
 the influence of a mercurial. For general systemic effect in- 
 unction is one of the best, and, perhaps, the best method of 
 employing the remedy. One or two drachms of mercurial 
 ointment may be rubbed up with an equal amount of vaseline, 
 and rubbed partly into the skin of the abdomen and partly 
 smeared on a broad flannel bandage, covering the abdomen 
 and chest of the child ; this to be renewed every two or three 
 days without washing the skin. In this way any irritation of 
 the stomach by the drug is avoided. But there are cases in 
 which the indigestion, vomiting and diarrhoea, with ill-smelling 
 passages resulting in general marasmus, will be much benefited 
 by the local anti-fermentative effect of calomel in minute doses, 
 in addition to its specific action on the syphilitic lesion. One- 
 tenth to one-third of a grain of calomel, mixed with one-half 
 grain of ferri carb. saccharat. and given three times a day, often 
 acts very favorably : or hydrarg. cum creta can be substituted 
 in doses of one-third of a grain. Where any visceral lesions are 
 suspected, there is an advantage to be gained by giving the 
 mercurial internally. A pretty general and profuse rash can be 
 made to disappear very rapidly, with equally good effect upon 
 the general nutritive condition, by rubbing in daily over the 
 affected surface an ointment of ung. hydrarg. ammoniat. and 
 vaseline in the proportion of one to four. Oleate of mercury is 
 
ERYTHEMA MULTIFORME. 1 87 
 
 a very effective local application to a limited lesion. The moist 
 condylomata on the nates, scrotum, etc., should be dusted with 
 calomel, which will cause their rapid disappearance. 
 
 Baths and fumigations are, practically, not very available. 
 Medication through the medium of the nurse's milk is, at pres- 
 ent, pretty much given up as of little practical merit. 
 
 Iodide of potassium should be used for the removal of the 
 late lesions of hereditary syphilis, such as periosteal nodes and 
 gummy tumors, etc., and in doses, and according to the methods 
 proper in the acquired form ; but a long course of mercurials 
 is needed to confirm the cure or prevent the return of the 
 symptoms. Usually the medication will require to be continued 
 for two or three months to produce entire removal of the les- 
 ions, and it should be continued for probably at least six months 
 longer to confirm the cure, and be renewed again if any mani- 
 festations should ever subsequently return. 
 
 The management of the child's diet and hygiene and the 
 regulation of his digestive functions is of the greatest import- 
 ance, and upon their proper management almost as much de- 
 pends for success as upon the mere administration of the spe- 
 cific remedies. 
 
 ERYTHEMA MULTIFORME. 
 
 Definition. — An acute inflammatory disease, usually symme- 
 trical ; appearing especially upon the dorsum of the hands and 
 feet, and characterized by the formation of variously sized and 
 shaped spots of an erythematous character. 
 
 Symptoms. — The eruption is almost invariably symmetrical, 
 and appears usually upon the dorsum of the hands and feet 
 and adjoining part of the forearm and leg, but may appear 
 first on other parts of the body. The lesions are of an erythe- 
 matous type, associated with more or less exudation from the 
 bloodvessels, and are remarkable for the variety of forms they 
 may assume within a few hours of their existence ; commencing 
 as macules, they may soon appear as papules, tubercles, vesicles 
 or bullae, according to the amount of exudation present. 
 
l88 ERYTHEMA MULTIFORME. 
 
 The eruption commences as pin-head sized or larger, flat, red 
 macules, which spread rapidly by peripheral growth ; or as ele- 
 vated, sharply limited, reddish papules of a firm, cedematous, or 
 normal feel. In a few hours the spots enlarge by peripheral 
 growth to finger-nail or larger sized erythematous patches ; or 
 from increase in the amount of exudation form papules, tuber- 
 cles, vesicles or bullae. The central portion of the erythematous 
 patch, that is, the oldest portion of the lesion, soon commences 
 to disappear ; it sinks in and becomes cyanotic from stasis in 
 the venous capillaries, whilst the peripheral part still maintains 
 its red color. If the erythematous patch continues to increase 
 to finger-nail or larger in size, the lesion will acquire a ring 
 form, from this spreading at the periphery and disappearing of 
 the older central exudation. When the lesion has this form it 
 is called erythema annulare, and consists of circular, spreading 
 patches and a fading centre. If two or more neighboring 
 rings coalesce, with disappearance of the exudation at the place 
 of union, serpentine lines or bands will result. This form is 
 called erythema gyratum. If a new patch forms within an exist- 
 ing ring and undergoes the same changes of form and color it 
 is called erythema iris. Sometimes two or more rings will form 
 in succession within an existing ring, and as each undergoes 
 the usual changes in color the patch will present a variegated 
 appearance from the red, blue, yellow and greenish colors 
 present. If a patch acquires a considerable size and has a 
 clear, well defined spreading margin, occupying but a part of a 
 circle and an almost normal older part, it is called erythema 
 marginatum. 
 
 From the number of lesions usually present and the changes 
 they undergo, the part affected in a few days becomes dark- 
 bluish in color, cold to the feel, and upon pressure shows pig- 
 mentation to exist. Even haemorrhage occasionally occurs ; the 
 result of the stasis in the venous capillaries. If new patches 
 continue to form there will be a combination ot bright red 
 from the new spots, and of dark blue from the older ones. 
 
 The lesion is frequently papular, the papules being discrete 
 or aggregated, flat, elevated above the general surface, of vari- 
 
ERYTHEMA MULTIFORME. 189 
 
 able size and shape, and of a bright red or violaceous color 
 which disappears upon pressure — erythema papulation. They 
 last about a week and disappear with or without desquamation. 
 If the lesion is large it is called an erythema tuberculatum. 
 They may increase by peripheral growth, as in the case of the 
 macules. Occasionally there is sufficient exudation present to 
 form a vesicle upon the summit of the papule, forming an 
 erythema vesieulosum, and as the papule spreads peripherally 
 whilst the central part subsides and becomes cyanosed, elevated 
 rings are formed, with a vesicular periphery and a cyanosed 
 centre, representing herpes circinatus. 
 
 If similar new rings form within the existing ring it is called 
 herpes iris. 
 
 The exudation may be sufficient to form bullae, forming an 
 erythema bullosum. 
 
 These vesicles or bullae may arise upon the summit of either 
 macules, papules or tubercles, and rarely rupture. Macules, 
 papules, tubercles, vesicles and bullae may all be 
 present at the same time, as also the forms annulare, gyratum, 
 marginatum, circinatus and iris ; all being symptoms of the 
 same disease ; the differences in character depending upon the 
 mode of spreading and the amount of exudation present ; hence 
 the appropriateness of the term erythema multiforme. 
 
 The individual lesions last only a few days, and the whole 
 eruption usually disappears in from two to four weeks, although 
 it may be prolonged several weeks by new lesions appearing, 
 either on the same region or on other parts of the body. When 
 disappearing, it leaves a bluish tint, or slight pigmentation and 
 desquamation. Itching is usually absent. 
 
 The eruption is sometimes accompanied by fever, pains in 
 the joints, gastro-intestinal disorders and mental depression. 
 Endocarditis, pleurisy, haemorrhage from the kidneys have also 
 been observed. As erythema multiforme is a symptomatic 
 eruption, these conditions are usually either the cause of the 
 eruption or have a similar origin. 
 
 Erythe?na Diphtheriticum. — In some cases of diphtheria a rash 
 similar to the above appears upon the skin. The skin becomes 
 
I90 ERYTHEMA MULTIFORME. 
 
 affected either in the early stages of the disease or at a later 
 stage when there is severe blood poisoning. 
 
 Early Eruption. — Sometimes at the commencement of the 
 disease, sometimes as late as the second or third day, a diffuse 
 erythematous rash of variable extent appears. When limited 
 in extent it is generally present upon the anterior surface of the 
 thorax or abdomen, though it is generally present also upon the 
 extremities. In some cases it is not a diffused erythema, but 
 presents a mottled, punctated appearance, like in many cases 
 of scarlatina, normally-colored skin alternating with pin-head 
 sized red spots. The rash is from bright red to pale red in 
 color and disappears upon pressure. It is not perceptibly 
 elevated above the general surface. It does not itch or burn, 
 and is not accompanied by marked elevation of temperature. 
 After lasting twenty-four to forty-eight hours it disappears 
 without desquamation. It occurs both in mild and severe cases 
 of diphtheria. 
 
 Rash of Septic Diphtheria. — This eruption, which differs con- 
 siderably from the earlier appearing rash, appears only after the 
 diphtheria has lasted several days and the system is more or less 
 profoundly affected by the diphtheritic septicaemia. It occurs 
 especially in connection with nasal diphtheria, and appears most 
 frequently upon the extremities. It is usually limited in extent, 
 but may be general over the whole body. It commences as 
 pin-head sized, or larger, elevated, erythematous spots, the red- 
 ness disappearing upon pressure. A large number of spots 
 may appear simultaneously or within a few hours, on the same, 
 or on different portions of the body. Each spot soon com- 
 mences to spread peripherically, and generally after they have 
 reached the size of a one-cent piece, become depressed and 
 cyanosed, or paler in the centre. They continue to increase in 
 size by peripheral extension at the same time that the central 
 part continues to return to a normal condition. In this manner 
 rings are formed, and if it has attained any considerable size it 
 will show a red, elevated periphery, more internal a cyanosed 
 part, and a normal centre — an erythema annulare. These rings 
 may increase in size until they reach several inches in diameter, 
 
ERYTHEMA MULTIFORME. 
 
 I 9 I 
 
 the red, elevated periphery being generally not more than one- 
 third of an inch in diameter and sharply limited externally. At 
 the same time that these spots are spreading new ones continue 
 to arise and a multiform erythematous eruption results. The 
 rapidity with which the erythema spreads varies greatly in dif- 
 ferent cases and in different spots on the same person. Some- 
 times they require two or three days to attain any considerable 
 size, and again I have seen a ring three inches in diameter form 
 in fifteen minutes. Neighboring rings often coalesce, producing 
 the forms gyratum and figuratum. On dependent parts of the 
 body the spots do not clear up as much in the centre as they do 
 on other regions, so that instead of rings there are large patches 
 with bright red margins and a somewhat cyanotic centre. The 
 eruption does not itch or burn, disappears without desquamation 
 and occasionally leaves a slight pigmentation. 
 
 Sometimes the eruption does not clear in the centre, but 
 forms large, irregular raised patches, or in other cases it resem- 
 bles that of measles. 
 
 In fatal cases, the eruption continues until death ; new spots 
 arising on the old ones, and after reaching a certain size, 
 remaining as elevated, reddish patches or rings. 
 
 Anatomy. — The eruption consists in a vaso-motor disturb- 
 ance. There is at first capillary hyperemia and afterwards 
 passive venous capillary distension. The amount of exudation 
 varies from the small amount present in the macular form to 
 the considerable amount occurring in the bullous form. 
 There may also be haemorrhage into the lesions. 
 
 Etiology. — From its symmetrical character and definite course 
 the eruption is to be regarded as symptomatic of some special 
 blood condition which acts through the nervous system upon the 
 peripheral bloodvessels. The special conditions producing it are 
 not as yet well-known. We have seen that the poison of diph- 
 theria can produce the eruption. It may arise from gastroin- 
 testinal disorders, genito-urinary diseases and the rheumatic 
 condition. It is most frequent in spring and autumn, and 
 occurs generally in young persons. It is more frequent in fe- 
 males than in males. 
 
I92 ERYTHEMA MULTIFORME. 
 
 Diagnosis. — The symmetrical character, rapid course, variety 
 of form, change in color, situation and absence of burning are 
 sufficently characteristic to enable the diagnosis to be easily 
 made. It might be confounded with bruises, erysipelas, urtica- 
 ria, erythema nodosum, and papular eczema. In bruises there 
 is an absence of symmetry and multiformity of lesions as well 
 as the peculiarity of the situation and number of spots ob- 
 served in erythema. In erysipelas the skin is hot, burning, 
 shining, and the lesion is more deeply seated. In urticaria 
 there are wheals which form and disappear rapidly, the skin is 
 irritable and shows wheals after scratching with the ringer nail, 
 the lesions burn or sting and are not so red in color, as those of 
 erythema multiforme. In lichen urticatus, which is probably 
 closely related to erythema multiforme, the papules are seated 
 upon wheals which itch very much. In erythema nodosum the 
 nodules are raised, oval or rounded in shape, firm, painful, 
 deep seated and situated especially along the ridge of the tibia. 
 In papular eczema the papules are small, conical in shape, 
 itch greatly, do not form rings, and do not become cyanosed. 
 
 Prognosis. — The prognosis depends upon the nature of the 
 disease of which the erythema is symptomatic. Usually it is 
 favorable, the eruption disappearing in from two to four weeks. 
 Relapses may occur, but are not frequent. 
 
 Treatment. — If there is heat or burning, cold water, alcohol 
 and water, a lotion of acetate of lead, or a protecting powder 
 as starch, oxide of zinc, etc., may be used. The internal treat- 
 ment is the most important. At present we know too little of 
 the cause of the eruption and are consequently obliged to treat 
 it on general principles. Generally tonics, as iron, quinine, 
 strychnine are indicated. Any intestinal derangement should 
 be corrected. If rheumatism is present, or rheumatic pains in 
 the joints, alkalies should be given. The diet should be of an 
 easily digested kind, and alkaline mineral water can be ordered 
 for thirst. If septicaemia is present, as in the case of diphtheria, 
 stimulants, tincture of the chloride of iron, carbonate of am- 
 monia, quinine in small but frequently repeated doses, and a 
 nourishing diet are to be given. 
 
ERYTHEMA NODOSUM. 193 
 
 ERYTHEMA NODOSUM. 
 
 Syn. — Dermatitis contusiformis ; Urticaria tuberosa. 
 
 Definition. — An acute inflammatory affection characterized 
 by the formation of variously sized, elevated, roundish or oval- 
 ish, erythematous looking nodules, situated usually upon the 
 lower extremities, over the tibia. 
 
 Symptoms. — The disease is generally ushered in with fever, 
 gastric disturbance, malaise, and pain in the joints. The 
 eruption forms rapidly and consists in the formation of hazel- 
 nut to hen egg sized or larger nodules which are elevated, 
 roundish, ovalish or semi-globular in shape, firm, painful to 
 pressure and with a smooth erythematous or rose like surface. 
 They are either single or multiple, though generally there are 
 a number present and are frequently symmetrical in their distri- 
 bution. Their usual situation is the lower extremities, as the 
 skin over the tibia, but they are also frequently met with on 
 the forearms, especially over the ulna, and may appear on other 
 parts of the body, as the face, shoulders and thighs. The first 
 nodules frequently appear over the tibia and after a few days 
 others appear on the thigh or forearm, etc. The number pres- 
 ent may range from one to twenty or even more, and are 
 usually disseminated ; but no matter how closely they may be 
 grouped they never coalesce. They are rarely so small as not 
 to form elevated nodules and have abnormally colored skin over 
 them. Occasionally the inflammatory process is so intense 
 as to cause haemorrhage in the central part of the nodular area. 
 
 After existing one, two, or three days, they begin to change 
 color and consistence, the infiltration becomes less and less,, and 
 in five to ten days they completely disappear, leaving behind 
 them, except in the case of the very small nodules, a dark 
 brown discoloration. During the stage of disappearance the 
 color, which at first was bright red or of a rosy tinge, becomes 
 later, brown-red, green, and yellow, like the color changes in 
 ordinary contusions of the skin. If haemorrhage has occurred 
 the changes take place slower than usual. The consistence,, 
 13 
 
194 ERYTHEMA NODOSUM. 
 
 which was at first firm, becomes softer, more boggy-like, and 
 the pain diminishes with the diminution in the infiltration. 
 The fever subsides as soon as new nodules cease to form. The 
 nodules never suppurate. 
 
 Very rarely vesicles or bullae form on the surface of the nod- 
 ules. Lymphangitis has also been observed arising from 
 the nodules. 
 
 The duration of an individual nodule is from five to ten or 
 fourteen days, but as new nodules continue to form for some 
 time, the eruption usually lasts from three to four or five weeks, 
 and may even be prolonged for several months. 
 
 The eruption may be associated with pain in the joints, de- 
 rangement of the stomach, colic, diarrhoea, painful nodules 
 in the tongue, mouth and pharynx. 
 
 Anatomy. — The local process consists in an inflammatory 
 oedema, with a large amount of serous transudation, some 
 blood corpuscles and occasionally a haemorrhage. 
 
 Etiology. — The cause of the disease is not well known. It 
 may appear as a distinct disease or only as part of an erythema 
 multiforme. Usually ordinary erythematous patches are pres- 
 ent in cases of erythema nodosum ; it has a marked tendency 
 to occur on the same parts of the body ; it occurs about the 
 same time of the year and has an acute and typical course. 
 The above facts justify the view that the two diseases are 
 closely related. 
 
 Erythema nodosum is met with generally in children and 
 young persons, especially weakly females, but may also occur 
 in older, well-nourished and otherwise healthy subjects. It 
 occurs most frequently in spring and autumn. It has been 
 observed as a complication in cases of disease of the heart, blood- 
 vessels, lungs and pleura conditions, which interfere with normal 
 circulation and respiration. Rheumatism, endocarditis, tuber- 
 culosis and chlorosis have been regarded as frequent causes, 
 but probably do not bear such a close relation to the disease as 
 has been supposed. Lewin regards it as an angio-neurosis, the 
 dilatation of the bloodvessels and the consecutive exudation 
 resulting from a change in the tone of the vaso-motor nerves. 
 
ERYTHEMA NODOSUM. I95 
 
 A more probable explanation is that which refers the local 
 changes to the presence of a noxious substance in the blood 
 which causes the prodromal fever — an irritation in the walls of 
 the blood vessels,coagulation of blood within them at the seat 
 of the lesions, and secondary peripheral inflammation. I have 
 observed a case of erythema nodosum associated with herpes 
 of the external ear both eruptions dating from the same day, 
 and apparently, at least, depending upon the same condition. 
 
 Diagnosis. — The nodules may resemble bruises of the skin, 
 abscesses and syphilitic gummata. Bruises never present the 
 rosy hue of erythema nodosum. In addition the number of 
 the lesions, their situation, and when multiple the different 
 stages to be observed in the different nodules render the diag- 
 nosis easy. In abscesses the previous history, the number and 
 course of the lesions are different. The lesions in erythema 
 nodosum never suppurate. Non-ulcerating syphilitic gummata 
 are sharply limited, grow slowly, have no rosy skin over them, 
 are non-symmetrical, unaccompanied by fever, few in number 
 and generally met with in adults. 
 
 Prognosis. — The prognosis is good, as the disease tends to 
 spontaneous cure. In weakly infants or children the pain and 
 loss of appetite may interfere so much with the general nutri- 
 tion as to lead to serious complications of the intestinal tract 
 or pulmonary organs. If haemorrhages occur, especially from 
 the kidney, the case may terminate fatally. Relapses are 
 rare. 
 
 Treatment. — The treatment is local and constitutional. 
 Local treatment consists in rest in the recumbent position, cold 
 water applications, with or without the addition of lead and 
 opium. The kind of internal treatment to be given will de- 
 pend upon the condition in individual cases. In children 
 easily digested food and correction of any intestinal derange- 
 ment is required. In all cases the complications, chlorosis, 
 rheumatism, pleurisy, etc., are to receive appropriate treat- 
 ment. If fever is present quinine or salicylate of soda, may 
 be given. In well-nourished persons with but slight fever, a 
 low diet and mineral saline waters are all that is requisite. 
 
I96 URTICARIA. 
 
 URTICARIA. 
 
 Syn. — Hives ; Nettlerash ; Febris Urticata. 
 
 Definition.— -Urticaria is an affection of the skin accompanied 
 by the rapid development of ephemeral wheals of a whitish, 
 pinkish or reddish color, or equivalent erythematous spots or 
 patches, accompanied by sensations of stinging, pricking, itch- 
 ing or burning. 
 
 Sympto7tis. — The affection generally runs an acute course. 
 Sometimes in the beginning there is a mild fever, slight head- 
 ache and coated tongue with some gastric disturbance. These 
 evidences of mild constitutional disturbance are, however, 
 often absent, the disease beginning by the sudden appearance 
 of wheals or their equivalent lesion. The size of these varies 
 within very wide limits, but they are generally not larger than 
 a finger-nail. Sometimes patches of various size will form 
 from a coalescence of the individual lesions. In appearance a 
 wheal consists of a circumscribed efflorescence with a slightly 
 elevated, whitish centre and a surrounding red areola. They 
 may have a pinkish color and occasionally present a variegated 
 appearance. Their shape is generally oval, but an irregular or 
 band-like form maybe assumed. The eruption may consist 
 only of elevated or non-elevated erythematous bands, or 
 patches of cedematous tissue. A common variety is known as 
 papular urticaria or lichen urticatus. Papules that are flat or 
 pointed, of a bright red color, with their central projecting 
 part whitish, suddenly appear and act in the same manner as 
 wheals. They are situated around follicles and occur over 
 the surface of the body, especially on the extremities. They 
 are most frequently observed in children who are ill nour- 
 ished or have an acid dyspepsia. Owing to the great amount 
 of itching that accompanies them the children scratch the 
 skin vigorously, tearing off the apices of the papules, causing 
 haemorrhage and leaving a blood-crust that remains after the 
 urticaria has disappeared. Such spots are frequently seen 
 over the bodies of poorly nourished children and always 
 
URTICARIA. I97 
 
 show that an urticaria has existed previously. It also some- 
 times happens in children, that, partly due to the oedema of the 
 tissues, and partly to irritation from scratching, various crops of 
 papulo-vesicles will form, presenting somewhat the appearance 
 of herpes when the hyperemia has left the tissues and the 
 vesicles remain. Another variety is that in which, after ordin- 
 ary wheals have formed they are replaced by bullae from 
 excessive exudation from the bloodvessels. This is called 
 urticaria bullosa and is of rare occurrence. At times the blebs 
 may be so large as to simulate the appearance of pemphigus. 
 Still rarer is the form known as urticaria nodosa, or tuberosa, 
 in which the wheals appear as tubercles, varying in size from 
 a walnut to an egg ; situated in the skin and subcutaneous 
 tissue and scattered over the body. This form bears some re- 
 semblance to erythema nodosum. The nodules usually disap- 
 pear in a few hours. In whatever of these different forms the 
 wheals may appear certain symptoms generally accompany 
 their development. There is a sensation resembling the sting 
 of a nettle, namely, a hot tingling or stinging of the skin. The 
 scratching that this involuntarily induces is apt to cause still 
 further irritation. The eruption occurs suddenly and may as 
 quickly disappear. Sometimes the wheals after remaining for 
 a few hours on one part of the surface of the body suddenly 
 disappear and others show themselves on some distant part. 
 From the first the whole surface of the body may be attacked ; 
 again, at times, only certain regions are invaded. The mucous 
 membranes are not exempt from attack. 
 
 Individual wheals are very evanescent in character, disappear- 
 ing usually in a few hours. They are often accompanied by con- 
 siderable oedema, or occur as cedematous erythematous patches 
 alone, especially on the face ; they may produce much swelling, 
 causing closure of the eyes and considerable disfigurement 
 (urticaria cedematosa) ; at times neighboring wheals coalesce, pro- 
 ducing a deep, burning pain, which, with the accompanying 
 swelling, presents an appearance somewhat suggestive of ery- 
 sipelas. Within a few hours or days an attack terminates by 
 the disappearance of the wheals together with the subjective 
 
I98 URTICARIA. 
 
 sensations of itching and burning. There is always a liability to 
 a return of the disease. Urticaria sometimes occurs in connec- 
 tion with other diseases, such as measles, pertussis or scarlatina. 
 It is sometimes secondary to scabies. It also occurs occasion- 
 ally in connection with purpura, presenting the appearance of 
 wheals with petechise. Whenever, for any reason, the cause of 
 the disease persists, it assumes a chronic character. This con- 
 dition is particularly seen in weak children placed in unfavorable 
 hygienic surroundings. They are rarely free from the eruption, 
 as evanescent wheals continue to appear for an indefinite period. 
 The persistent scratching of the patient also keeps irritating 
 the eruption and may to a certain extent modify its nature. 
 Urticaria perstans is a form of the disease that has been des- 
 scribed, in which the wheals and the accompanying hyperemia 
 persist for a longer period than usual. Reddish macules also 
 remain for some days after the wheals have disappeared. 
 
 Anatomy. — The vaso-motor nervous system and the muscular 
 fibres of the skin are probably the principal factors in the produc- 
 tion of the wheals. The cause of the disease acts by irritating the 
 sensitive nerves of the skin and producing a spasm of the ves- 
 sels ; this is rapidly followed by their paralytic dilatation with 
 effusion of serum. This inflammatory exudation takes place 
 particularly into the papillary layer of the corium. There is 
 hyperemia and dilatation of both the superficial and deep ves- 
 sels of the corium. In consequence of the exudation, the cir- 
 culation of the blood in the overfilled vessels of the wheal is 
 interfered with ; the blood is pressed outward to the periphery, 
 forming the surrounding red areola and leaving the pale anaemic 
 cedematous centre. 
 
 Etiology. — The disease is neurotic in character and the vaso- 
 motor disturbance may be the result of either direct irritation 
 or reflex action. Although particularly apt to develop in sub- 
 jects affected by uncleanliness and poor hygienic surroundings, 
 it may occur in persons living under the most favorable con- 
 ditions, but possessing a delicate and sensitive skin. Among 
 the external sources of the disease may be mentioned the bites 
 of certain insects, as mosquitoes and bed-bugs, the sting of the 
 
URTICARIA. I99 
 
 nettle and jelly fish, excessive and irritating clothing, and very 
 hot weather. 
 
 The internal cause that is most frequently found is some dis- 
 turbance of the gastro-intestinal tract. Excess in any rich va- 
 riety of food or wine may bring out the eruption, while almost 
 any article of diet may by individual idiosyncrasy develop the 
 rash. Shell fish, oysters, crabs, lobsters, pork, porridge and 
 strawberries may be especially mentioned in this connection. 
 Certain medicinal substances not infrequently case urticaria, as 
 turpentine, copaiba, iodide of potassium, quinine, hydrate of 
 chloral, salicylic acid and salicylate of soda. Intestinal worms 
 occasionally cause the affection in children, although even 
 when worms are present the rash is probably generally depen- 
 dent on the catarrhal condition of the intestinal tract so fre- 
 quently existing at the same time. Lastly, uterine disturban- 
 ces and mental emotions occurring in nervous and excitable in- 
 dividuals may bring out the eruption. 
 
 Diagnosis. — The recognition of the disease depends on the 
 subjective sensations of burning and itching, the rapidity of 
 formation, the characteristic evanescent appearance of the 
 wheals and their disappearance without desquamation. The 
 principal affections to be differentiated from urticaria are 
 erythema simplex and erythema multiforme. In the former 
 disorder the patches of hyperaemia are larger and more diffuse 
 than occur in urticaria, while the entire absence of any spots 
 of elevation with a whitish centre marks a constant distinction 
 between the two diseases. By bearing in mind the pathologi- 
 cal difference between erythema simplex and urticaria, the for- 
 mer being a simple hyperaemia while the latter consists of an 
 inflammatory exudation, the distinction between the two affec- 
 tions will not usually be difficult. Erythema multiforme sometimes 
 bears a close resemblance to urticaria. The rash of the former 
 affection, however, is more stable in character, the patches of 
 inflammation lasting longer and being more compact inform and 
 color. While there are never any wheals in erythema multiforme 
 the eruption may take the form of variously sized flat papules,of a 
 violaceous or bright, red color. These, however, are not so evan- 
 
200 URTICARIA. 
 
 eseent as the wheals of urticaria, usually lasting from one to two 
 weeks, and are not accompanied by much itching and burning. 
 
 Again, the patches of erythema multiforme assume a great 
 variety of shapes, as erythema annulare, iris and marginatum, 
 all of which assist in the diagnosis. Urticaria tuberosa some- 
 times resembles erythema nodosum, but the nodules in the lat- 
 ter affection are not usually accompanied by itching, are very 
 painful to the touch, and have a longer duration. Sometimes 
 when several wheals coalesce, especially on the face, causing 
 much swelling and burning, urticaria may be mistaken for 
 erysipelas, but the evanescent character of the eruption, its rapid 
 formation, the absence of a starting point, the intolerable itch- 
 ing and absence of the constitutional symptoms of erysipelas 
 should prevent such a mistake in diagnosis. 
 
 Prognosis. — While urticaria is at times quite distressing to 
 the patient it is never accompanied by danger to life. In fact 
 most of the constitutional effects are due to the accompanying 
 gastro-intestinal disturbances. The acute variety rarely lasts 
 more than a few days, but is liable to relapses, if the previous 
 exciting condition should again exist. The chronic form per- 
 sists until its exciting cause is removed. 
 
 Treatment. — In conducting a case of urticaria reference must 
 be had to general and local remedies. The general treatment 
 of any case must depend upon the nature of the attack and its 
 cause. If by the idiosyncrasy of the patient any particular 
 article of food causes the eruption, an emetic should be given 
 before it leaves the stomach. In cases in which the patient is 
 not seen sufficiently early for this, a saline laxatine, such as 
 epsom or rochelle salts, should be administered. In all cases 
 a very careful inquiry into the diet must be instituted. There 
 is often an undue condition of acidity present in the gastro- 
 intestinal tract which is to be counteracted by alkalies. The 
 bicarbonate of sodium or potassium in ten to thirty grain doses, 
 the subnitrate of bismuth and the alkaline mineral waters are 
 here of service. The salicylate of sodium in five grain doses 
 repeated every few hours will often give speedy relief. The 
 sulphate of atropine has been recommended in order to pro- 
 
URTICARIA. 20 1 
 
 duce a paralysis of the vaso-motor centres. If prescribed, it 
 should be administered until the eruption disappears or its 
 physiological effect is produced. All stimulating articles of 
 diet should be avoided, and food of the simplest kind taken. 
 When the disease assumes a chronic form a careful investiga- 
 tion into the condition of the system that permits the continu- 
 ance of the attack should be made. If the rheumatic or gouty 
 diathesis exists alkalies and colchicum must be given. The 
 dietary of the patient must be rigidly inspected and any irritat- 
 ing article of food excluded. In females the condition of the 
 uterus and ovaries should be ascertained. Frequently a very 
 slight cause will be found sufficient to keep up this (an urtica- 
 rial) condition. Among the drugs that have been recom- 
 mended for their more or less specific action may be mentioned 
 muriate of ammonia, arsenic, belladonna, chloral and bromide 
 of potassium. Much may be done by local treatment to relieve 
 the unpleasant sensations produced by this affection. Alkaline 
 baths made with the bicarbonate of potassium, the carbonate 
 of sodium and borate of sodium often give relief. From one 
 to four ounces of these salts may be added to an ordinary bath 
 containing about thirty gallons of water. Bran baths at times 
 may do good service. In some cases acid lotions give satis- 
 factory results. The itching surface may be sponged with a 
 solution of citric or acetic acid, or with ordinary vinegar and 
 water. I have seen excellent results from the use of lemon 
 juice in cases where internal treatment by alkalies, belladonna 
 and bromide of potash was of no service. If a bath is desired 
 about half an ounce of nitric and muriatic acids may be added 
 to thirty gallons of water. Carbolic acid is sometimes used 
 with good results in relieving the itching, from one to three 
 drachms being added to a pint of alcohol and water. A serv- 
 iceable ointment is made by adding a drachm of camphor and 
 chloral to an ounce of the ordinary rose ointment. In connec- 
 tion with local treatment all irritating articles of apparel worn 
 next to the skin must be removed. The patient should sleep 
 upon a hard mattress, with light bed coverings, and in a well 
 ventilated room. 
 
202 LICHEN PLANUS. 
 
 Urticaria pigmentosa. — In connection with urticaria mention 
 is to be made of a rare form of eruption which has been desig- 
 nated urticaria pigmentosa and xanthelasmoidea. It makes its 
 first appearance (in the cases so far reported) before the third 
 year of life, and is characterized by the presence of papules, 
 tubercles or wheals of a pinkish, reddish or yellowish brown 
 color, which last a few days or weeks, and are followed by buff- 
 colored, brownish, yellowish or greenish pigmented spots. The 
 spots may be few or numerous and scattered over the whole 
 body, or limited to certain parts. They do not desquamate. 
 The skin of the whole body is very sensitive and wheals are 
 easily produced by scratching the skin over the spots or in 
 other situations. The pigmented spots are always elevated and 
 there is thickening of the skin of the part. The eruption is 
 most frequent in warm weather. 
 
 The pathology of the disease is not known. By some it is 
 regarded as a special disease, and by others as a chronic urti- 
 caria, the chronicity of the vascular changes accounting for the 
 pigmentation and thickening of the skin. The proper mode of 
 treatment is not yet settled. 
 
 LICHEN PLANUS. 
 
 Definition. — A chronic circumscribed inflammatory affection 
 of the skin characterized by the formation of discrete or aggre- 
 gated, dull red, roundish or angular, elevated, smooth, shining 
 umbilicated papules generally seated upon the anterior surface 
 of the forearms just above the wrists. 
 
 Symptoms. — This form of eruption was first described by 
 Erasmus Wilson, and consists of papules remarkable for their 
 color, shape, tendency to arrangement in groups, situation, 
 local and chronic character, and the pigmentation they leave 
 when they subside. 
 
 Color. — The color of the papule is a dull red, more or less 
 vivid and suffused with a lilac tinge, which is most character- 
 istic in recently formed and discrete papules ; while in aggre- 
 gated papules and in those of long standing it is of a duskier 
 
LICHEN PLANUS. 
 
 203 
 
 hue. A slight hyperaemic areola is present at the base of 
 recent papules. 
 
 Shape. — When very small the papules are roundish in shape, 
 but when fully developed they are generally angular in outline 
 and rise abruptly from the normal skin. They range in size 
 from one to three or four lines in diameter, are but slightly 
 elevated above the general level of the skin, and have a flat, 
 smooth, shining surface, which is frequently depressed in the 
 centre — umbilicated. The papules are covered on their sur- 
 face by a thin layer of horny, transparent cuticle, which is not 
 a scale, and neither separates nor exfoliates (Wilson). When 
 the papule subsides this layer disappears without exfoliation. 
 If the eruption is diffuse and aggregated there is some desqua- 
 mation and scaling, especially if the part has been irritated, and 
 appearances somewhat resembling a small diffuse patch of 
 lichen ruber or of chronic, dry, scaly eczema or psoriasis. 
 Upon the removal of the thick adherent scales in these cases 
 the skin beneath may present an excoriated surface. 
 
 Arrangement of the papules. — The papules are either discrete 
 or aggregated, but generally show a tendency to form larger or 
 smaller groups. Occasionally they are arranged as broader or 
 narrower, longer or shorter bands. In the discrete form of 
 eruption the papules arise successively, and after a time 
 variously sized patches are formed, consisting of aggregated and 
 discrete papules united by an inflamed and infiltrated base. 
 The inflammation and infiltration cause a blending of the 
 papules and interpapular skin, and the formation of a raised, 
 thickened, scaling patch. The eruption spreads peripherically 
 by the formation of new papules at the same time that the 
 older papules disappear, leaving behind a dark pigmentation. 
 A single papule may spread by peripheral growth until it has 
 reached, say, the size of a split pea ; but a large patch is never 
 formed by peripheral growth of a single papule, as occurs, for 
 instance, in psoriasis. Sometimes a patch is large enough to 
 show a raised border and depressed centre, or a ring is formed 
 by the formation of a chain of papules at the periphery of a 
 patch. If neighboring rings coalesce the eruption at that place 
 
204 LICHEN PLANUS. 
 
 will assume a gyrate form. A patch may consist of a depressed 
 and pigmented centre ; external to this large, well-developed 
 papules, and a periphery formed of small developing papules. 
 
 Situation. — The eruption is generally symmetrical, and ap- 
 pears especially upon the anterior surface of the fore-arms, 
 just above the wrists ; it may, however, appear upon any other 
 part of the body, and especially upon the lower part of the 
 abdomen, the calves of the legs, and around the knee. It has 
 even been observed upon the palms of the hands and soles of 
 the feet, upon the penis, and on the mucous membrane of the 
 mouth and fauces. 
 
 Course. — The course of the eruption is very chronic, and 
 the individual papules may remain unchanged for many months 
 before undergoing a retrograde process. When they disappear 
 they leave behind deep pigmentation and occasionally a slight 
 atrophy. When removed by treatment, it has been observed 
 that old papules leave behind more pigmentation than recent 
 ones. The eruption never appears in the form of vesicles or 
 pustules. The hairs and nails remain unaffected in this dis- 
 ease. There is generally very little itching attending the erup- 
 tion, but sometimes it is intense. The general nutrition of the 
 body is never affected ; no matter how long the eruption lasts, 
 it does not produce any of the grave conditions observed in 
 lichen ruber, owing probably to its not becoming general over 
 the whole body. 
 
 Anatomy. — In fig. 30 is represented a vertical section of a 
 recent papule of lichen planus, together with normal skin at 
 both sides. The papule corresponds to the region occupied by 
 the dense round cell collection in the papillary region and 
 upper part of the corium (d). The corneous layer in the 
 region of the papule is almost entirely absent, consisting only 
 of one or two layers of dried, flat, horny cells. The absence 
 of the corneous layer in this situation was observed in all the 
 sections of both recent and old papules examined, and conse- 
 quently was not an artificial condition from cutting or manipu- 
 lation of the sections. Outside the papule region the corneous 
 layer is of normal appearance and thickness, as seen in fig. 
 
LICHEN PLANUS. 
 
 205 
 
 30 a. The rete mucosum is thickened in some places, 
 especially in the central portion of the papule area. Pa- 
 pillae are not recognizable in the central part of the papule. 
 The papillae and upper part of the corium are occupied by a 
 sharply limited dense collection of round cells (d). At the 
 periphery of this collection the bloodvessels are dilated and 
 crowded with corpuscles, while a considerable number of emi- 
 grated white blood-corpuscles are present directly around the 
 vessels. The deeper portion of the corium appears normal, 
 except that some of the bloodvessels are dilated and sur- 
 rounded by a few emigrated corpuscles. Examining such a 
 
 Fig. 30. — Complete section of a recent papule of lichen planus under a low 
 magnifying power. The section includes normal skin at both sides, but most at 
 left side : a, corneous layer ; b, rete mucosum ; c , orifice of sweat duct ; d, round 
 cell infiltration ; e, bloodvessel ; /, corium. 
 
 section with higher powers, the rete is found to be hypertro- 
 phied in the central portion of the papule, and especially in 
 the region of the sweat-ducts. The cells of all the layers 
 over the dense round cell collection in the corium are flattened 
 in a horizontal direction, the amount depending upon the 
 amount of pressure from below, as shown by the almost nor- 
 mal condition of the cells toward the periphery of the papule. 
 The granular layer is much thicker than usual, consisting some- 
 times of five or more layers of cells where the rete is thickest. 
 This hypertrophy of the rete is very variable as to situation 
 and extent. Generally it is greatest in the centre of the 
 
206 LICHEN PLANUS. 
 
 papule and in the region of the sweat-duct orifices, but may- 
 occur in the latter situation only. In many places within the 
 area of the papule there is no appreciable hypertrophy, and in 
 the earliest stage of the eruption it is entirely absent. 
 
 The cutis papillae in the central portion of the papule are so 
 infiltrated with cells and the rete so flattened that in some 
 cases the line of separation between the rete and cutis is not 
 recognizable, as is the case in figs. 30 and 31. If the cell col- 
 
 FiG. 31. — Vertical section of the central portion of a recent papule of lichen 
 planus : a, orifice of sweat-duct ; b, round cell collection ; c, region of a blood- 
 vessel. 
 
 lection is not very dense the papillae will be observed to con- 
 tain dilated bloodvessels. At the outer portions of the papule 
 the papillae contain a more or less dense collection of round 
 cells and dilated bloodvessels. The cell infiltration into the 
 papillae and upper part of the corium consists of embryonic 
 corpuscles (white blood-corpuscles) which take the place of 
 the connective tissue to a greater or less extent. At the outer 
 portions of the papule connective-tissue bundles are still pres- 
 ent, but in the central part, when the collection is very dense, 
 all trace of connective tissue is lost. In the deeper parts of 
 the corium there is nothing abnormal except the presence of a 
 few dilated bloodvessels, some of which are surrounded by 
 emigrated corpuscles. 
 
LICHEN PLANUS. • 207 
 
 The hair-follicles and sweat-glands are normal, except that 
 around the sweat-ducts the cell infiltration generally extends 
 deeper than in other parts. In all of the papules examined a 
 sweat-duct was found near its centre, and seemed to be the 
 principal cause of the umbilicated appearance of the papules, 
 as its presence prevented the pushing upward of the epidermis 
 by the round-cell collection. This umbilical appearance was 
 also partly owing to the absence of so much of the corneous 
 layer from the central portion of the papule. The hair-follicles 
 had no influence in determining the situation of the papules. 
 
 From the foregoing observations the papules of lichen planus 
 examined by me owed their origin to an inflammatory process 
 occurring in the papillae and upper part of the corium, as shown 
 by the round-cell infiltration and the changes in the tissues 
 of the part. The changes observed in the rete and corneous 
 layer are variable in amount and extent, and can be regarded 
 as secondary conditions depending upon the changed nutrition 
 condition in the cutis. If the papule is of long standing there 
 may be considerable hypertrophy of the rete and corneous 
 layer, as shown by the observations of Dr. Crocker, and 
 further substantiated by the scaly appearance of some patches 
 of the eruption. The dense cell infiltration, by its pressure 
 upon the papillary bloodvessels and interference with their 
 circulation and nutrition, allows of the passing out of red 
 blood-corpuscles, as occurs in the dense cell infiltration in con- 
 nection with syphilitic papules. As a result of this extravasa- 
 tion we have the dark red color, and pigmentation remaining 
 after disappearance of the papules. In the return to the nor- 
 mal condition the changes are such as usually occur in inflam- 
 matory states, the round-cell collection disappears by fatty 
 degeneration of the corpuscles and the epidermis regains its 
 normal activity. 
 
 According to the above description, lichen planus papules 
 are the result of a circumscribed inflammation of the papillae 
 and upper part of the corium, and any changes in the epidermis 
 are secondary to the changed nutrition, the result of this local- 
 ized inflammation. 
 
2o8 LICHEN PLANUS. 
 
 Etiology. — The cause of the affection is obscure. According 
 to Wilson it is generally associated with constitutional disturb- 
 ance depending upon digestive disorders. In many of the cases 
 there is general debility from improper nourishment or over- 
 work. T. C. Fox believes it is neurotic in origin, as shown by 
 the symptoms of nervous debility and disturbance of the sym- 
 pathetic system of nerves present in many cases. It is met with 
 at all ages, but is most frequent during middle life. 
 
 Diagnosis. — It may be confounded with eczema papulosum, 
 or with the papular syphilide. In some cases of papular or 
 follicular eczema, especially when seated on the forearms and 
 legs, there is the greatest resemblance to lichen planus. Many 
 of the papules are dark colored, elevated, shining, and have a 
 depressed centre. They, however, itch considerably, are very 
 variable in size, ranging from that of a pin-point to a pin-head, 
 or larger, are roundish, and some have a little serum at the 
 apex. They also appear and disappear much more rapidly 
 than the papules of lichen planus, and do not leave such deep 
 pigmentation behind. The papular syphilide is diagnosed by 
 the pointed shape of the papules, their round form, the absence 
 of the perpendicular margin, the general distribution, and the 
 polymorphous character of the eruption. 
 
 Prognosis. — The prognosis, as regards the ultimate result, 
 is always favorable, the disease, although very chronic in its 
 course, having a tendency finally to spontaneous disappear- 
 ance. 
 
 Treat7nent. — The treatment is both general and local. Many 
 of the cases of lichen planus are in persons with the symptoms 
 of so-called nervous debility, the result of derangement of the 
 digestive organs, or from over-work, improper food, impure air, 
 or mental anxiety, and this condition of general nutrition must 
 be remedied by appropriate treatment. The mineral acids, 
 alkalies, quinine, iron, cod-liver oil, etc., and proper nourish- 
 ment should be ordered according to the special indications in 
 individual cases. With special reference to the skin affection, 
 if the eruption is general and the hyperaemic factor consider- 
 able, alkaline diuretics are indicated. Of these, acetate of 
 
LICHEN SCROFULOSUS. 209 
 
 potash, with sweet spirits of nitre, given after meals and well 
 diluted with water, is the best. Mercurials are of benefit in the 
 more chronic forms. Arsenic should not be given in this dis- 
 ease, as it frequently aggravates the eruption. Chlorate of 
 potash, given in the dose of twenty grains dissolved in four 
 ounces of water, given fifteen minutes after meals and followed 
 fifteen minutes later by twenty drops of dilute nitric acid in a 
 wineglassful of water, has caused rapid improvement in some 
 cases (Taylor). The local treatment consists in endeavoring to 
 allay irritation and to promote absorption of the inflammatory 
 products. To allay itching the same means are to be employed 
 as for this condition in other diseases. Alkaline baths with 
 bran, and subsequent rubbing of the body with vaseline or zinc 
 salve containing carbolic acid, or vapor baths, may be em- 
 ployed. Generally local applications have no influence upon 
 the course of the eruption, consequently our chief reliance is 
 upon the internal treatment, so conducted as to bring the whole 
 system into a normal physiological condition. 
 
 LICHEN SCROFULOSUS. 
 
 Definition. — A chronic inflammatory disease, limited to the 
 hair follicles and perifollicular papillae, occurring in scrofulous 
 individuals, and characterized by the formation of millet to 
 pin-head sized, pale, red, yellow, or reddish-brown, somewhat 
 elevated, slightly desquamating, non-itching papules. 
 
 Symptoms. — The eruption is most frequently seated upon the 
 abdomen, breast, or back, but may occur also in the inguinal 
 region and upon the extremities, and, in the case of children, 
 also upon the face and scalp. The papules composing the 
 eruption may develop gradually and successively, or more or 
 less simultaneously ; they reach their acme of development 
 quickly, remain in this fully developed condition a long time, 
 and finally disappear, leaving the skin normal, pigmented or 
 atrophied. Generally the papules at the commencement of 
 the eruption form variously sized groups, which later may 
 coalesce and give the skin a dirty brown, reddish color and 
 14 
 
2IO LICHEN SCROFULOSUS. 
 
 scaly surface. Instead of forming groups, the papules are 
 sometimes arranged in circular lines, or are irregularly distrib- 
 uted over the surface. The individual papules are very uni- 
 form in size, ranging from that of a millet to a pin-head, are 
 never much elevated above the general surface, and are of the 
 normal color of the skin, or of a reddish, yellowish, or reddish- 
 brown color. They are not very firm to the feel, and their 
 apex is covered with a thin, slightly adherent scale, or more 
 rarely contains a little pus. The papules disappear by absorp- 
 tion, the lesion becoming gradually paler, and flatter and flatter, 
 accompanied by scaling. The disease is slow in its develop- 
 ment and chronic in its course, being prolonged for years by 
 the successive development of new papules, which in turn 
 undergo absorption. When they no longer continue to form, 
 the eruption soon disappears. 
 
 The eruption is sometimes combined with acne pustules situ- 
 ated between the papules or on other parts of the body, and 
 in severe cases, eczema of the genital region is a frequent com- 
 plication. Brown pigmentation of the skin of the face resem- 
 bling ordinary chloasma, and appearing and disappearing at 
 the same time as the lichen, has been observed in some cases. 
 
 Persons with lichen scrofulosus are always of a scrofulous 
 constitution and the eruption is generally accompanied by some 
 of the usual manifestations of this disease, as enlarged lym- 
 phatic glands, especially those of the sub-maxillary, cervical 
 and axillary regions, or periostitis, caries, necrosis, cutaneous 
 ulceration and a condition of general mal-nutrition. 
 
 Anatomy. — Each papule corresponds to a follicular orifice and 
 the immediately surrounding papilla?. The papule is formed 
 by cell infiltration and cedematous swelling of the peri-follicular 
 papillae and the central scales or pustule in or upon the apex 
 of the papillae arises from the collection of hyperplastic epi- 
 dermic cells or exudate in the orifice of the follicle. The cell 
 infiltration takes place first around the bloodvessels and into 
 the connective tissue at the base of the hair follicles and 
 sebaceous glands, and later they collect in large numbers around 
 and within the glands. The number collected within the glands 
 
LICHEN SCROFULOSUS. 211 
 
 may be so great that in the sebaceous glands the epithelial cells 
 of this structure become pushed out from the orifice of the 
 duct, and in the hair follicles the root sheaths become separated 
 from the follicle sheaths. Later the glands become dilated and 
 all infiltration occurs in the peri-glandular papillae. The exu- 
 dation cells subsequently either degenerate and become ab- 
 sorbed, leaving the part in a normal condition, or they break 
 down in the centre of the mass and form an abscess, in which 
 case the follicle sheath becomes separated from the hair shaft, 
 the hair falls out, the surrounding connective tissue undergoes 
 mucoid degeneration, the follicle is destroyed, the peri-glandu- 
 lar papillae partly atrophy, and finally flat cicatrices, similar to 
 those in acne, result (Kaposi). 
 
 Etiology. — The disease is very rare in this country. It is 
 more frequent in children than in adults. It may appear as 
 early as the second year of life. Hebra never observed it in per- 
 sons over twenty-five, but Neumann saw one case in a person 
 thirty-three years of age. Persons with this eruption are never 
 otherwise perfectly healthy but always show other signs of a 
 scrofulous constitution, and the eruption itself is to be regarded 
 as a scrofulide. 
 
 Diagnosis. — The eruption may be confounded with papular 
 eczema ; a small papular syphilide ; lichen ruber or keratosis 
 pilaris. In papular eczema the papules are often arranged in 
 groups or lines as in lichen scrofulosus ; but they develop rap- 
 idly, are very irregular in size, are more elevated, are of a 
 bright red color, itch intensely, dry to small scales on the sum- 
 mit, and, if numerous, some vesicles will be present. 
 
 In the small papular syphilide the papules are of a dark red 
 color, are distributed over a large area, have a more rapid 
 course and are accompanied by other symptoms of syphilis. 
 They are hard, shining, elevated, grouped or arranged in cir- 
 cles or lines and vary in size from a pin-head to that of a lentil, 
 a variation not met with in lichen scrofulosus. 
 
 In lichen ruber the dark red color, the elevation, the absence 
 of grouping, and the gradual extension over a large area make 
 the diagnosis easy. 
 
212 PRURIGO. 
 
 In keratosis pilaris the papules are not grouped, they are not 
 so firm, have more scaling, and are situated especially upon the 
 extensor surfaces of the extremities. 
 
 Prognosis. — The prognosis is very favorable, the eruption 
 can always be removed and relapses prevented. If untreated 
 the lesions remain a long time stationary without affecting the 
 general system, and finally disappear spontaneously. When it 
 is complicated with acne cachectorum it is more difficult to 
 cure, and cicatrices will result from destruction of some of the 
 follicles. 
 
 Treatment. — The treatment is that for scrofula in general 
 and consequently need not here be fully described. Cod-liver 
 oil in large doses with or without iron, hypophosphites or other 
 anti-scrofula remedies in addition will always effect a cure. 
 The external application of cod-liver oil, rubbing it well into 
 the skin twice a day, the patient wearing closely fitting flannel 
 underclothes during the course of external treatment, to pro- 
 tect the outer clothing, will hasten the cure. The general nu- 
 trition must be attended to ; plenty of good food, especially 
 meat, pure air, moderate exercise and so on ; that is, those 
 things which tend to improve the general nutrition of the body. 
 
 PRURIGO. 
 
 Fr. Eq. — Strophulus prurigineux. (Hardy). 
 
 Defijiition. — Prurigo is a chronic affection characterized by 
 small pin-head sized, pale or slightly red, solid papules situated 
 in the skin, and accompanied by a most intense pruritus ; the 
 integument itself in time becoming thickened and pigmented. 
 
 The itching of the skin observed in old age, that due to 
 dyspepsia, albuminuria, icterus, amenorrhcea, is not prurigo ; 
 but a neurosis without preceding pathological change in the 
 skin, and will be described under the head of pruritus cuta- 
 neus. 
 
 History. — Prurigo was not recognized as a distinct disease un- 
 til the 1 6th century. It was confounded with eczema, scabies, 
 and urticaria, even by such observers as Sauvages and Lorry. 
 
PRURIGO. 213 
 
 Willan and his followers, and Cazenave, Alibert, and Bazin, all 
 correctly depicted it ; but by all of them pruritus due to 
 phtheiriasis was included with genuine prurigo. To Hebra be- 
 longs the credit of giving the disease a definite place and an 
 accurate history. 
 
 Prurigo has its home in Austria, and exists to a slight ex- 
 tent in other parts of the world. In Vienna, Hans Hebra met 
 recently forty cases during a single year, whilst in France it is 
 extremely rare, and in England and America is practically un- 
 known. 
 
 The disease possesses not only a well-defined clinical history 
 — but a perfectly clear pathological anatomy — and is to be 
 sharply distinguished from the other two itchy affections, 
 pruritus and pediculosis, with which it is even to the present 
 day confounded. 
 
 Sympto7?is. — Although prurigo is not a congenital disease, its 
 manifestations almost invariably begin very early in life. Even 
 during the first year it is noticed that there are times when the 
 child is very irritable and restless, and scratches itself violently ; 
 in fact, suffers from the symptoms of a recurrent urticaria. 
 
 It is probably well on into the second year before the 
 symptoms of the disease begin fully to develop themselves 
 and the characteristic eruption appears. This is seen as very 
 small and but slightly prominent papules, which may be evi- 
 dent to the touch before they become visible to the eyes. In 
 size they vary from a pin's head to a hemp seed ; in color they 
 usually do not differ at all from the normal skin, though they 
 may be slightly pinkish or reddish. They are found upon the 
 outer surfaces of the lower limbs, and especially upon the legs, 
 the lumbar and gluteal regions, and the exterior surfaces of 
 the upper extremities are also affected. The rest of the 
 body is sometimes involved, but the axillary and popliteal 
 spaces always remain free, and present in advanced cases, a 
 marked difference from the surrounding skin. The little pa- 
 pules may be comparatively few, or they may be so numerous 
 as to give the affected skin the feeling of a nutmeg-grater. 
 They are never grouped — and many of them are sur- 
 
214 PRURIGO. 
 
 rounded by a few minute dried epidermic scales or pierced by 
 a hair. 
 
 This papular eruption constitutes the essential objective 
 symptom of the disease ; for the other skin lesions, extensive 
 and varied as they may be, are merely secondary. 
 
 The intense itching associated with the eruption soon causes 
 the head of the little papule to be scratched off, and a minute 
 drop of serum or of blood exudes, and dries up into a small 
 crust. Extensive excoriations, blood crusts, and pustules soon 
 result from the continuous use of the finger nails. 
 
 By the third year the disease may be fully developed. The 
 secondary lesions almost entirely obscure the original eruption. 
 Irregular excoriations and crusts of blood or pus cover various 
 parts of the body ; the hair is torn out ; the inguinal lympha- 
 tic glands are swollen. In the course of time the skin be- 
 comes streaked or diffusely colored with a brown pigmentation 
 of varying intensity ; a melasma exactly similar to that which 
 occurs from scratching in any itchy skin disease of long stand- 
 ing. The skin is dry, rough, and grater-like ; it is thickened, 
 and the natural lines and furrows are increased in depth. 
 Eczematous processes are usually present to a greater or less 
 extent in various places. 
 
 It is a curious fact that the inner surfaces of the joints — the 
 axilla and front of the elbow — the groin and popliteal space — 
 and the palms and soles, are always free ; their skin is white 
 and soft — and there are never any papules upon them. 
 
 Two forms of the disease are recognized ; prurigo agria 
 seu p. ferox, and prurigo mitis. They vary only in degree ; 
 in p. mitis the original papular eruption, the itching, and the 
 secondary lesions are far less marked than they are in the other 
 form. Nor does the one degree change into the other ; a case 
 of p. mitis always remains such to the end of the disease, 
 and vice versa. 
 
 Most of these patients are much better in summer, when the 
 free perspiration greatly lessens the pruritus. 
 
 Besides the above-mentioned complications, buboes and 
 lymphangoitis may occur. 
 
PRURIGO. 215 
 
 Once established, the disease lasts with but slight change, 
 for life. From time to time the secondary lesions vary in their 
 intensity, or change their seat ; but in the original malady but 
 little change is wrought by time — or, by therapeutic effort. 
 
 Pathology. — No very characteristic anatomical changes have 
 been found to explain the marked and persistent local symp- 
 toms of prurigo. 
 
 On section through the papule of the eruption we see appear- 
 ances exactly similar to those of an ordinary papular eczema. 
 In the papillae and rete there is a moderate collection of young 
 cells and serous fluid. In chronic cases the ordinary secondary 
 results of long standing chronic dermatitis are present, as thick- 
 ening, proliferation of the rete, cell-infiltration and pigmenta- 
 tion of the corium, dilated lymph spaces, deformed or atrophied 
 sweat and sebaceous glands with fatty degenerated epithelium, 
 etc. 
 
 The appearances hardly explain the intense pruritus. Hebra 
 supposes that pressure on the papillary nerves from the sudden 
 appearance of a small quantity of serum in the papilla causes it 
 at first ; but why should this symptom last for years, after the 
 changes of chronic inflammation have come on, and not be 
 present in cases like herpes, where far more fluid is exuded ? 
 The question is still unanswered. The disease is certainly not 
 a neurosis as is pruritus, for a definite anatomical change 
 always accompanies or even precedes its advent. 
 
 Etiology. — We possess no very definite knowledge upon this 
 head. We do not know the cause of the disease, nor why it 
 should be common in one country and almost unknown in other 
 and neighboring ones. It occurs often in the poorer classes, 
 among those who are exposed to hardships and are insufficient- 
 ly nourished ; but it is occasionally seen among wealthier peo- 
 ple. It is oftenest noticed in weakly, scrofulous children ; but 
 sometimes in those that appear to enjoy the best of physical 
 health. It occurs oftener among males than among females. 
 Hebra remarks that cases of it are oftenest seen in foundlings 
 and among the children of beggars, etc., and he believes that 
 in a large proportion of cases the mothers were sufferers from 
 
2l6 PRURIGO. 
 
 chronic tubercular lung troubles at the time of the child's birth. 
 But the disease is never hereditary in the ordinary sense ; 
 though several members of a family are sometimes found 
 affected. 
 
 No external influences of any kind, as clothing, food, baths 
 etc., have, so far as we know, any direct influence upon its 
 production, nor is it directly due to any general diseas ; like 
 scrofula or tubercle. It is in no sense contagious. So far as 
 our present knowledge extends, prurigo is an idiopathic disease 
 of the skin. 
 
 Diagnosis. — Prurigo presents the picture of a distinct and 
 well-defined disease, and ought not to be mistaken for any 
 other affection. Perhaps the malady with which it is most 
 liable to be confounded is pruritus ; but the points of distinc- 
 tion are manifold. Prurigo is extremely rare — almost unknown, 
 in this country ; pruritus is common. Prurigo is preceded by 
 a characteristic eruption ; pruritus may show papules, pustules, 
 blood crusts, etc., but they are all secondary lesions. In prurigo 
 the skin is harsh, thickened, and roughened ; in pruritus 
 it is, save when irritated, normal. Prurigo occurs upon 
 the exterior surfaces of the limbs especially ; pruritus 
 over the whole body. Prurigo begins in infancy, is pri- 
 mary, and lasts for life ; pruritus may occur at any time, is 
 usually secondary to some well marked visceral condition, and 
 is transient. Again, prurigo occurs in the lower and more badly 
 nourished classes ; pruritus in all classes. Finally, the buboes 
 and characteristic whiteness and non-involvement of the flexor 
 surfaces of the joints mark the more serious disease. 
 
 From urticaria it may be quite difficult to distinguish the 
 affection, especially during its early stages in childhood. When 
 the peculiar eruption appears, however, with its persistent 
 papules and the cause of the disease becomes evident, no diffi- 
 culty should be experienced. 
 
 In scabies, phtheiriasis, etc., there is much itching and there 
 may be papules, excoriations, blood crusts, etc., but they are all 
 purely secondary lesions. 
 
 Scabies is located on the trunk and around the genitals and in 
 
PRURIGO. 
 
 217 
 
 the finger clefts ; pediculosis on the trunk, especially where lie 
 the folds of the clothing ; prurigo upon the limbs. In both 
 the itch and phtheiriasis the peculiar living cause or its 
 remains will be round if carefully sought for. 
 
 Eczema may, and in severe cases usually does, exist in con- 
 junction with prurigo, and in those cases the diagnosis may be 
 very difficult. Of course the scratching, from the prurigo, tends 
 to keep up the eczema in spite of all we may do for it. The 
 situation of the eruption, the color of the papules, the presence 
 of vesicles and of exudation on the free surface are sufficient for 
 the diagnosis of an eczema. 
 
 Prognosis. — Hebra regards prurigo in general as an entirely 
 incurable disease, and all authors agree that this is the case in 
 p. agria, and even in p. mitis in adults. But Kaposi claims 
 that the milder form actively treated in early childhood can be 
 cured. 
 
 Hebra draws a very vivid picture of the lamentable fate of a 
 man condemned from infancy to suffer from this most annoy- 
 ing disease ; how in childhood he is constantly reproached and 
 punished by his parents and teachers for his incessant scratch- 
 ing ; in youth, ostracized from school and workshop ; as an 
 adult, compelled to renounce society and marriage. He cannot 
 even enlist as a soldier. The malady has been known to cause 
 its victim to commit suicide. 
 
 Treatment. — Although we cannot cure prurigo, we can do 
 much to mitigate its symptoms. We may reject the internal 
 medication formerly in vogue as absolutely useless, viz : calo- 
 mel, tartar emetic, arsenic, colchicum, bleeding. Nor are there 
 any valid grounds for believing that any special kind of food 
 or the excessive use of salt meats, condiments or coffee, exer- 
 cise any influence whatsoever upon it. External remedies only 
 are to be relied on, and especially such as tend to soften the 
 skin and remove the upper layer of the epidermis. 
 
 The most important of the agents is water, which may be 
 used as shower, or vapor, or the ordinary hot bath. This, used 
 daily and thoroughly, and especially used in conjunction with 
 soft soap, is perhaps our most effective mode of treating the 
 
2l8 PRURIGO. 
 
 symptoms of prurigo. Sulphur baths, either natural or artificial, 
 are also sometimes very serviceable. 
 
 The tars ; ol. cadini, ol. rusci, either alone or in conjunction 
 with olive or cod-liver oil, are useful in many cases ; they may 
 be employed after the warm baths. 
 
 In the early, urticarial-like stages, the thorough use of sul- 
 phur or tar soap — or immersion for an hour or more occa- 
 sionally in a bath of strong soapsuds — followed by the inunction 
 of any bland oil, usually suffices. 
 
 Hebra very strongly recommends Wilkinson's ointment : 
 
 5- — Sulphuris Sublimati, 
 Olei Cadini, aa 3 ii. 
 Cretse Preparata, 3 iiss 
 Saponis Viridis, 
 Adipis, aa § i. 
 M. Ft. Mist. 
 
 It is to be applied every night for six to ten days, the patient 
 sleeping between blankets ; at the end of that time a warm bath 
 is to be taken. 
 
 Corrosive sublimate baths, 3 i. to a large bath-tub ; ordinary 
 alum, one pound to the bath, have also occasionally been suc- 
 cessfully employed. 
 
 Kaposi has obtained excellent results from the use of naph- 
 thol — so excellent indeed as to render it perhaps the first in the 
 list of palliative agents which we can employ. It is to be used 
 as a five per cent, ointment for adults ; a one-half per cent, 
 ointment for children. 
 
 Complications, among which eczema stands pre-eminent, 
 must be treated by the recognized methods. 
 
 Finally, ol. morrhuse, alone or with one-tenth per cent, of 
 sodium in scrofulous patients, and the best of nourishment and 
 general hygiene in all, are to be employed. 
 
 In this way we may greatly mitigate the sufferings of patients 
 with prurigo, and even render the disease quiescent for months 
 at a time ; but we may be very sure that sooner or later its 
 symptoms will return. 
 
HERPES. 219 
 
 HERPES. 
 
 Definition. — An acute, non-contagious inflammatory eruption 
 of definite course, and characterized by the formation of pin- 
 head to pea-sized vesicles arranged in groups upon an erythem- 
 atous base, and situated on regions having a direct relation to 
 the peripheral termination of certain cerebro-spinal nerves. 
 
 Symptoms. — The outbreak of the eruption is generally pre- 
 ceded for a longer or shorter period by a burning or stinging 
 pain, which is sometimes intense in the part to be attacked. 
 This pain continues long after the eruption has disappeared, or 
 as is usually the case, diminishes in intensity or subsides after 
 the eruption has lasted a few days. The disease makes its 
 appearance in the form of one or more groups of small elevated 
 papules situated upon an erythematous base. In a few hours 
 the papules become vesicles, and these afterward become pus- 
 tules. The lesions of a group are usually of the same age and 
 in the same stage of transformation to vesicles or pustules, but 
 the lesions of all the groups are not necessarily, in fact are 
 rarely, of the same age and appearance. The vesicles or pus- 
 tules rarely burst, and the contents drying to yellowish, or dark 
 crusts, which afterward fall off, leaving the skin beneath at 
 first reddish and subsequently normal. Cicatrices rarely result, 
 except in those cases in which the lesions are haemorrhagic in 
 character. 
 
 According to the situation, arrangement and cause of the 
 eruption, the disease is divided into herpes febrilis, h. iris, h. 
 progenitalis, h. gestationis, h. zoster. They require separate 
 consideration. 
 
 HERPES FEBRILIS. 
 
 Syn. — H. labialis ; h. facialis ; hydroa febrilis ; fever sores. 
 
 Definition. — An acute eruption of one or more herpetic 
 groups of vesicles situated upon the face, and accompanying 
 febrile conditions of the system. 
 
 Symptoms. — The eruption is most frequently met with upon 
 the lips at the junction of the cutaneous and mucous surfaces, and 
 
2 20 HERPES FEBRILIS. 
 
 upon the alse nasi, but may occur upon other parts of the face, 
 as forehead, lids, cornea, ears, chin, cheeks and mucous mem- 
 brane of the mouth and tongue. It commences in the manner 
 already described as peculiar to herpes in general, and consists 
 of one or more groups of vesicles varying from a pin-head to a 
 pea in size, which, after becoming pustules dry up in from two 
 to four days and form crusts which soon fall off, leaving a red 
 skin beneath, which soon becomes normal. The vesicles of a 
 group are of the same age and rarely rupture unless the erup- 
 tion is seated on a mucous membrane, when the covering be- 
 comes detached and the spot presents an excoriated surface, 
 covered with more or less purulent exudation. The vesicles of 
 a patch may remain discrete or may coalesce, forming small 
 bullae. The eruption is sometimes symmetrical and is met 
 with in acute catarrhal conditions of the upper air passages and 
 in some other febrile conditions, as pneumonia, typhus fever, 
 etc. It is met with in affections which are ushered in with a 
 chill, and this chill process is supposed to have some close 
 connection with its cause. The eruption itself has no prognostic 
 significance, as it occurs in both mild and grave conditions. 
 Relapses are very frequent. 
 
 Pathology. — According to Baerensprung it is to be regarded 
 as a mild form of zoster, and as resulting from irritation of 
 peripheral sympathetic ganglia. According to Gerhardt it is 
 caused by dilated small arteries pressing upon the trigem- 
 inus and sympathetic fibres as they pass through the bone 
 canals. 
 
 Diagnosis. — It resembles in many respects an acute eczema, 
 but the grouping of the lesions, their similarity in age of the 
 vesicles of a group, and the definite course of the eruption 
 sufficiently distinguish the eruption. 
 
 Treatment. — Treatment is generally not necessary. The 
 burning may be relieved by the application of zinc ointment, 
 rose ointment, or cold cream. 
 
HERPES IRIS. 221 
 
 HERPES IRIS. 
 
 Definition. — An acute inflammatory eruption consisting of 
 vesicles or bullae arranged as a single, or as several concentric 
 circles. 
 
 Symptoms. — This eruption is perhaps identical with erythema 
 multiforme, and occurs usually upon the backs of the hands 
 and feet. It is symmetrical in distribution, and arises as a 
 single vesicle which, after one or two days, sinks in, and new 
 vesicles form in a circle at its periphery. If the central vesicle 
 has undergone involution, the eruption will consist of a ring of 
 discrete or confluent vesicles and a central pigmented spot — 
 herpes circinatus. New rings of vesicles may again form at 
 the periphery, and the patch finally consist of three or more 
 rings of discrete or confluent vesicles, and be several inches in 
 diameter. In this case the rings, on account of the difference 
 in age, will exhibit differences in color — herpes iris. The 
 vesicles of a ring are about the same size and contain yellowish 
 or puriform liquid, which soon dries to crusts. The vesicles 
 rarely rupture, hence the patch does not present a discharging 
 surface. Sometimes the vesicles coalesce to form bullae. The 
 skin between them is raised and of a pinkish or reddish color. 
 There may be only two or three patches, or there may be several. 
 They disappear after one or two weeks, leaving the skin pig- 
 mented, but rarely desquamating. New patches continue to 
 form during the first two or three weeks of the disease. It is 
 liable to relapse. 
 
 It is met with in adults of both sexes, but is most frequent 
 in young persons, and occurs chiefly in spring and autumn. 
 
 Diagnosis. — It may resemble tinea tonsurans, but the location, 
 its symmetrical arrangement, and absence of fungi make the 
 diagnosis positive. From herpes zoster it is distinguished by 
 the symmetrical distribution, the arrangement of the vesicles, 
 the absence of pain and the location of the eruption. In pem- 
 phigus the size of the bullae, their mode of formation, their 
 color and the course of the lesions are different. 
 
 Prognosis. — The prognosis is favorable, the eruption dis- 
 
2 22 HERPES PROGENITALIS. 
 
 appearing after two or three weeks, though relapses may 
 occur. 
 
 Treatment. — The general condition should be attended to. 
 Tonics, especially quinine, are of advantage. Local applica- 
 tions are unnecessary unless the intensity of the inflammation 
 should render antiphlogistics, as cold water applications, etc., 
 necessary. 
 
 HERPES PROGENITALIS. 
 
 Syn. — Herpes praeputialis. 
 
 Definition. — An acute inflammatory eruption of vesicles of 
 herpetic character situated upon the male or female genitals. 
 
 Symptoms. — The mode of origin and arrangement of the 
 vesicles correspond to that already described in herpes febrilis. 
 The eruption, in the male, appears upon the prepuce, espec- 
 ially its inner surfaces, upon the meatus, in the sulcus, upon 
 the margin of the prepuce and the adjoining integument. 
 
 In the female it occurs upon the prseputium clitoridis, the 
 labia minora, and adjoining portion of the labia majora. It 
 commences with itching and burning, and consists of one or 
 more groups of pin-head sized vesicles, seated upon an erythem- 
 atous base. Usually only one group is present. The ac- 
 companying inflammation may be sufficient to cause consider- 
 able swelling and oedema of the part. Unless seated upon a 
 cutaneous surface the vesicles frequently burst and serum is 
 exuded upon the free surface. Excoriations frequently result 
 from bursting of the vesicles, and the inflammation may extend 
 to the urethra in the male, or the vagina in the female, pro- 
 ducing a urethritis or a vaginitis. In a few days the vesicles dry 
 to small crusts and the part heals. The contents of the vesicles 
 may be pustular in character, or contain blood from haemor- 
 rhage ; in both these cases the lesions last a number of days, 
 ulceration occurs and they heal by cicatricial tissue. Super- 
 ficial ulceration is not infrequent when the lesions are seated 
 on the inner surface of the prepuce, or in the sulcus, or on the 
 posterior part of the glans. 
 
 The vesicles remain discrete, or coalesce, forming a patch 
 
HERPES GESTATIONIS. 223 
 
 covered with a crust. The eruption may appear on one or 
 both sides of the genitals at the same time. 
 
 Pathology. — Probably the eruption depends upon an inflam- 
 mation or irritation of peripheral sympathetic ganglia. Some 
 persons are attacked after every act of coition. All of the 
 persons I have known to be so affected have been of an excit- 
 able or nervous temperament. 
 
 Prognosis. — The prognosis is favorable, although relapses 
 are to be expected. 
 
 Treatment. — The part may be dusted with starch, bismuth 
 or other drying powder, or borated absorbent cotton be applied 
 to reduce irritation and prevent rupture of the vesicles. If 
 they have ruptured the same means may be employed, or 
 astringent applications, as a solution of tannic acid or acetate 
 of lead, or an ointment of vaseline or oxide of zinc, be ap- 
 plied. For excoriations, calomel and bismuth, or iodoform and 
 bismuth are useful. The part should be kept clean either by 
 washing or allowing the urine to bathe it by grasping the 
 prepuce and momentarily keeping the urine around the glans 
 penis. After the disease has disappeared, the general condi- 
 tion should be attended to and the genital, cutaneous, or 
 mucous surface hardened by the use of astringent solutions, as 
 acetate of lead or tannic acid. 
 
 HERPES GESTATIONIS. 
 
 Syn. — Pemphigus hystericus. 
 
 Symptoms. — This form of eruption, which may be regarded 
 as belonging to the herpetic or the pemphigus group of cuta- 
 neous diseases, is met with among pregnant women, and arises 
 either before or after parturition. 
 
 I have seen two cases, in one the eruption always occurred 
 after delivery, and in the other it occurred during pregnancy. 
 It appears especially upon the extremities and commences by 
 excessive itching which is soon followed by the formation of 
 papules, or vesicles, or small bullae. They are attended by 
 considerable itching and burning sensations. The vesicles 
 and bullae are variously sized, ranging from that of a pea to 
 
224 HERPES ZOSTER. 
 
 that of a walnut. Urticaria, neuralgia, general nervous pros- 
 tration may accompany the eruption. Relapses are liable to 
 occur at subsequent pregnancies. It seems to me to be more 
 closely related to pemphigus than to herpes. It does not fol- 
 low nerve tracks, and the vesicles are not grouped as in 
 herpes. 
 
 HERPES ZOSTER. 
 
 Syn. — Zona ; ignis sacer ; zoster ; shingles. 
 
 Definition. — Herpes zoster is an acute inflammatory disease 
 of definite duration and special course, characterized by the 
 appearance of groups of vesicles situated upon inflamed bases, 
 corresponding in location to the course of one or more of the 
 cranial or spinal nerves, and accompanied by more or less neu- 
 ralgic pain. 
 
 Symptoms. — The outbreak of an attack of zoster is usually 
 preceded by certain prodromal symptoms. These consist of 
 more or less febrile disturbance, with its accompaniments, 
 together with neuralgic pains of varrying intensity in the skin- 
 territory shortly to be attacked. The pains usually precede 
 the eruption only a few hours or days ; but occasionally they 
 are felt a month or more beforehand. They may occupy the 
 whole area of the subsequent vesiculation — or they may be 
 confined to a few points ; these being the well-known painful 
 points of Romberg — so commonly seen in ordinary neuralgias; 
 and corresponding to the origins of the cutaneous branches 
 given off by the nerves. In many cases, however, the eruption 
 itself is the first symptom of the disease. 
 
 The herpes begins with a localized reddening of the skin, 
 upon which there soon appear groups of lentil-sized, brilliant 
 red papules — which in the space of from a few hours to two 
 days develop into vesicles varying in size from a pin-head to 
 a split-pea. A marked sensation of burning accompanies the 
 outbreak. The vesicles are usually discrete ; but if very numer- 
 ous they may coalesce and form large irregular bulla?; they con- 
 tinue to appear in successive crops for from one-half to one 
 week ; but those of each crop are of the same age. 
 
HERPES ZOSTER. 225 
 
 After each group of vesicles has existed some three or four 
 days, the clear watery serum becomes opaque, then puru- 
 lent ; and in from eight to ten days after the time of their ap- 
 pearance they have dried up into yellowish-brown crusts. 
 
 By the end of the first week the eruption has reached its 
 height ; by the end of the second week most of the crops have 
 run their course and have become desiccated. In a short time 
 the brownish crusts drop off, leaving a normal but slightly 
 pigmented skin behind. 
 
 The number of herpetic groups corresponds to the severity 
 of the disease. In mild cases there may be only one ; in the 
 severer ones the groups may crowd one another, and large 
 skin territories be covered by confluent vesicles or pustules. 
 The vesicles do not tend to burst as in eczema ; they are sit- 
 uated deep in the skin, and unless interfered with, remain in- 
 tact until they dry up. 
 
 As a usual thing the neuralgic pains and burning which 
 were so marked in the beginning, subside when the eruption 
 comes out. But sometimes they may persist; or even become 
 worse, and remain for days, weeks or even years after the 
 vesicles are entirely gone. The papules may on the other 
 hand, never run their full course and become vesicles ; they 
 may disappear gradually, to be followed by a moderate 
 desquamation. This last has been designated the abortive form 
 of the disease ; and in many cases the latest crops of the erup- 
 tion will run their course in this manner. 
 
 Of rather rare occurrence is the hemorrhagic form of the mal- 
 ady — Herpes Zoster Hcemorrhagicas. — In every severe zoster 
 individual vesicles will have their serum stained reddish from 
 haemorrhage into them, but in this form of zoster the haem- 
 orrhagic vesicle is the prevailing type. Such an eruption may 
 terminate in the usual way — by desiccation; but more often the 
 bloody vesicles burst, and the rete is exposed. As there is here 
 always more or less destruction of the papillae, by the haemor- 
 rhages, the ulcerating surface heals by granulation and cicat- 
 rization. Such attacks are usually very severe, and it may be 
 two or three months before healing is complete. This is the 
 
226 HERPES ZOSTER. 
 
 only form of herpes zoster which causes scarring. Certain 
 occasional sequelae of zoster must be mentioned. They con- 
 sist in persistent neuralgias of the part — or anaesthesias — or 
 local paralyses — atrophy of the muscles — falling of the hair and 
 teeth even. They are especially to be feared when the disease 
 attacks old or debilitated individuals. Nevertheless, in the 
 vast majority of cases the disease is a benign one, and runs a 
 definite course. 
 
 Herpes zoster occurs but once in a lifetime. Few cases 
 only have been reported in which it has attacked the same 
 individual twice ; and Kaposi's unique case has had up to 1882, 
 eleven attacks. But these are the exceptions that prove the 
 rule, and do not invalidate the general statement. It occurs at 
 all ages. It is almost always confined to one lateral half of the 
 body ; but a number of cases of bilateral zoster are on record, 
 especially upon the face and neck. Zoster is a fairly common 
 disease, and occurs in both sexes and at all ages. It is seen 
 oftener in winter than in summer. 
 
 In accordance with its location, or with the affected nervous 
 tract, a number of varieties of herpes are described. Thus Z. 
 frontalis occurs in the territory of the supraorbital nerve — the 
 upper eyelid and forehead and scalp. It is very often haemor- 
 rhagic. Z. ophthalmicus is one of the most painful and serious 
 of all ; conjunctivitis, keratitis, iritis, even panophthalmitis 
 and destruction of the eyeball, with eventual phlebitis, pyaemia 
 and death have been recorded. Z. auricularis affects the skin 
 of the ear and the back part of the head. Z. faciei affects the 
 lower lid, the side of the face, cheeks, and lips. When the 
 skin of the lower jaw and neck are involved, difficulty of de- 
 glutition and violent toothache are common. Atrophy of the 
 alveolar processes and falling out of the teeth have been ob- 
 served. In all these cases the affection may be confined to the 
 most limited nerve-distribution, and but a single limited group 
 of vesicles appear : or on the other hand, several contiguous 
 nerve tracts be involved, and the whole surface of the face 
 and neck be covered by the eruption. 
 
 Z. occipito-collaris occurs in the region of distribution of the 
 
HERPES ZOSTER. 227 
 
 occipitalis major and minor, the auricularis magnus and the 
 subcutaneus colli, appearing on the posterior surface of the 
 ear, the side of the neck and head, and the under surface of the 
 chin. Z. cervico-subclavicularis corresponds to the region of 
 the subclavicular nerves, and is seen upon the lateral portion of 
 the neck and the shoulder. Z. cervico-brachialis is one of the 
 commoner varieties ; the branches of the brachial plexus are 
 affected, and the eruption occurs upon the shoulder, over the 
 whole upper extremity — even at times to the tips of the fingers 
 — and over the first and second ribs to the sternum. Z. pec- 
 toralis is the most frequent form of all ; the eruption then ex- 
 tends from the spinal column behind to the sternum in front 
 over half the body, and including two, three or more intercos- 
 tal spaces. In some cases, only the territory of individual cu- 
 taneous branches are affected. Pain and difficulty in respiration 
 are often present, even before the vesicles appear, and may be 
 mistaken for the signs of an incipient pleurisy ; in point of 
 fact, pleurisy, as a complication or a cause, has been noted in 
 this variety of herpes zoster. 
 
 Z. lumbo-femoralis corresponds to the first to fourth sacral 
 nerves, and appears very much as the preceding variety does. 
 It is seen upon the lumbar and sacral regions, upon the sides 
 of the abdomen, the anterior and inner surface of the thigh 
 to the knee, the scrotum, labia majora, etc. Finally, in Z. 
 sacro ischiadicus and Z. sacro genitalis the disease affects 
 the district animated by the last branches of the lumbar and 
 by the sacral plexus, and is seen on the gluteal region, the per- 
 ineum and the posterior surface of the scrotum, the anal 
 region, labia, the lower part of the leg and foot. The labia 
 minora and vestibule of the vagina may be affected, and upon 
 the penis the disease is often strictly unilateral from the scro- 
 tum to the glans. 
 
 Anatomy. — Baerensprung was the first to connect zoster with 
 disease of the nervous system. In a case observed by him, he 
 found the spinal ganglia and intercostal nerve bundles corre- 
 sponding to the seat of the eruption, swollen and reddened 
 from inflammatory changes. Wyss, in a case of zoster facialis, 
 
228 HERPES ZOSTER. 
 
 found the Gasserian ganglion softer, larger, of a bright red 
 color, the nerve between the brain and ganglion surrounded 
 by extravasated blood, and new soft tissue between the 
 peripheral nerve fibres. Wagner found swelling and enlarge- 
 ment of the intervertebral ganglia, and fatty degeneration, and 
 destruction of the nerve cells from inflammation, and new 
 tissue formation in the part. Danielssen found only neuritis of 
 two intercostal nerves, with cell infiltration of the neurilemma 
 in a case examined by him. Kaposi found the bloodvessels of 
 the ganglia distended with blood, a haemorrhage around the 
 ganglion, and destruction of some of the ganglion cells from 
 the blood extravasation. He considers the disease may be of 
 cerebral, spinal, ganglionic or peripheral nerve origin, as the 
 eruption may be bi-lateral, semi-lateral, or limited to one or 
 two groups of vesicles, which latter could only correspond to 
 the peripheral distribution of a branch of a nerve trunk. 
 
 From the foregoing observations the eruption clearly depends 
 upon a pathological condition of sensitive nerves or ganglia, 
 either spinal, Gasserian or peripheral. 
 
 As regards the anatomical changes occurring in the skin at 
 the seat of the lesion, Baerensprung found the papillae enlarged, 
 their bloodvessels dilated, and the tissue of the part infiltrated 
 with new cells. This new cell infiltration extended to the cor- 
 ium and subcutaneous tissue. Spindle-shaped corpuscles were 
 observed extending from the papillae into the rete, separating 
 the cells of the latter, and giving them an elongated form. A 
 peri-neuritis with cell infiltration in and round the neurilemma 
 was also observed. 
 
 In Fig. 32 is represented a perpendicular section of a young 
 herpes vesicle from a case of zoster pectoralis. 
 
 In the earliest stage the exudation occurs in the rete, the 
 epithelial cells of which are separated, and many of them 
 drawn out to form bands, as observed at the margin of the ves- 
 icle in Fig. 32. The lacunae formed by the elongated rete 
 cells are filled with serum, and a few round cells. The vesicles 
 frequently form around hair follicles. As the exudation within 
 the vesicle area increases in amount, the rete cells become 
 
HERPES ZOSTER. 
 
 229 
 
 more and more separated from each other, and finally are found 
 in considerable number as isolated bodies in the exuded liquid. 
 In the upper part of the vesicle many of the cells still retain 
 their connection with each other, although their form has often 
 
 Fig. 32. — Vertical section of a vesicle of herpes zoster : a, corneous layer ; 
 6, rete mucosum ; c, hair follicle orifices ; d, base of vesicle ; e, connective tissue 
 of corium ; _/j muscle bundle ; g, cell infiltration extending to base of vesicle. 
 
 been greatly changed. The corneous layer is elevated, but re- 
 mains usually intact as the vesicles rarely rupture. The rete 
 and corneous layer, except at the margin of the vesicles, become 
 separated from each other by the action of the exuded liquid 
 upon the rete cells. The vesicle itself is at first chambered by 
 the elongated rete cells, but afterward becomes a single vesicle 
 
230 
 
 HERPES ZOSTER. 
 
 containing rete cells, pus corpuscles and serum. At first there 
 are but few pus cells, but their number gradually increases 
 until the vesicle becomes a pustule. The base of the vesicle is 
 at first formed by the lower strata of rete cells, but afterward 
 is formed by the corium. All signs of papillae in the vesicle 
 area are absent. The surrounding corium and papillae are in- 
 filtrated with round cells, and the papillary bloodvessels dilated. 
 This inflammatory condition extends a considerable distance 
 
 Fig. 33. — Section of subcutaneous tissue in a case of herpes zoster : a, nerve 
 bundle ; a', a", branches of the nerve bundle a ; £, bloodvessel ; c, surrounding 
 loose connective tissue. 
 
 in the papillary region, but not far in the corium or subcutan- 
 eous tissue. Passing upward from the subcutaneous tissue, 
 there is a columnar-shaped area of tissue which is greatly in- 
 filtrated with round cells. In my specimens this area has cor- 
 responded to a hair follicle region. By observation of Fig. 32, 
 especially of its base, it is seen that the mode of formation and 
 results of the exudation differ considerably from that occurring 
 in eczema. 
 
HERPES ZOSTER. 23 1 
 
 Deep in the subcutaneous tissue, deeper than the inflamma- 
 tion producing the vesicles reaches, a round cell infiltration is 
 observed within and around the neurilemma ; that is, there is a 
 peri-neuritis. This cell infiltration can be observed to follow 
 the course of the nerve bundles, as shown in Fig. 33. This 
 drawing was made from the deep subcutaneous tissue, and the 
 neighboring tissue was perfectly normal. 
 
 Etiology. — As already noted herpes depends on a pathologi- 
 cal condition of the sensitive nerves or ganglia ; hence any thing 
 that will cause irritation and inflammation of these structures 
 may lead to the production of the disease. Atmospheric 
 changes, sudden cold, sudden checking of excessive perspira- 
 tion, direct injuries to the nerves, as from blows, etc., new 
 growths, collections of pus, periostitis, pleuritis or inflammatory 
 exudations, by pressing upon nerve trunks and irritating them 
 may cause the eruption. The internal use of arsenic has been 
 known to produce an herpetic eruption. The same has been 
 observed from poisoning by carbonic oxide gas. 
 
 Diagnosis. — The diagnosis is to be made upon the history of 
 the case, the pain, absence of itching, the grouping of the 
 vesicles, and their tendency to dry up without rupturing. From 
 the other forms of herpes it is known by its unilateral distri- 
 bution, presence of a number of groups, the location, and the 
 absence of relapses. 
 
 If the affected person has had within a few days a suspicious 
 connection a guarded diagnosis should be made. 
 
 Prognosis. — The prognosis is favorable ; occasionally neuralgic 
 pains, sometimes very intense in character, persist for weeks, 
 months or years after the disappearance of the eruption. A 
 second attack is not to be expected. 
 
 Treatment. — The treatment consists in protecting the inflamed 
 skin, in subduing the pain, and if possible preventing subsequent 
 neuralgia. If the vesicles have not burst the part can be pro- 
 tected by non-irritating powders, as lycopodium, starch, etc., by 
 the use of absorbent cotton or by wearing cotton, linen or silk 
 underclothing. If the vesicles burst antiseptic absorbent cotton 
 should be used. For the relief of pain, anodyne lotions or 
 
232 PEMPHIGUS. 
 
 hypodermic injections of morphine, or the local application of a 
 two to ten per cent, solution of oleate of morphine should be 
 used. The ten per cent, solution of morphine should not be 
 applied too freely to a raw surface, as it is easily absorbed. The 
 use of the constant current is sometimes of service. 
 
 Internally, phosphide of zinc in the dose of a third of a grain 
 every three hours has been recommended for the relief of the 
 pain. Morphine may also be given internally. I have found 
 the bromide of potash, and arsenic of decided value in quiet- 
 ing the patients and relieving the pain. Rest is of advantage, 
 and should be recommended when possible, and they should 
 lie on the side opposite to that affected in order to avoid in- 
 creasing the inflammation. 
 
 PEMPHIGUS. 
 
 Definition. — Pemphigus is an acute or chronic disease of the 
 skin, characterized by the successive formation of variously 
 sized bullae containing a clear or yellowish serous liquid and 
 seated upon a slightly inflamed base. 
 
 Symptoms. — There are two varieties of pemphigus, viz. : pem- 
 phigus vulgaris and pemphigus foliaceus. The former, which is 
 the variety usually met with, is either an acute or chronic disease, 
 but the latter, which is very rare, is always a chronic affection. 
 
 Pemphigus vulgaris. — The symptoms, course of the eruption, 
 the number of bullae present, their situation and arrangement, 
 vary in different cases. The disease is generally ushered in by 
 a feeling of chilliness, headache, fever, etc., but it may appear 
 without prodromal symptoms. The fever, when present, gener- 
 ally disappears with the abatement of the eruption, to reappear 
 at the next outbreak of bullae. In the majority of cases bright 
 erythematous spots or wheals make their appearance at the 
 commencement and during the course of the disease, and the 
 bullae arise on such places or upon previously normal skin. The 
 eruption may appear upon the different parts of the body or 
 upon the mucous membranes, but is most frequently found upon 
 
PEMPHIGUS. 233 
 
 the lower extremities, and is rare upon the palms of the hands, 
 soles of the feet and scalp. The eruption may appear as out- 
 breaks at regular or irregular intervals, or continuously. When 
 successive bullae are being rapidly and continuously formed the 
 eruption is called a pemphigus diutinus. 
 
 The eruption consists of blebs varying in size from a lentil 
 to a hen's egg, or even larger ; they are hemispherical or ovalish 
 in form, and with tense walls from distension by their liquid 
 contents. They are irregularly localized, isolated or arranged 
 in groups {p. confertus). Occasionally new bullae are ar- 
 ranged in a circular manner around an older bulla (p. circina- 
 tus). They are seated upon a slightly inflamed base and are 
 surrounded by normal or somewhat hyperaemic skin. They 
 form either slowly or rapidly, often attaining their full devel- 
 opment in a few hours, and continue as blebs during their 
 whole existence. Each bulla runs its course in from two to 
 six or eight days. They retain their original size or increase 
 either by coalescing with neighboring bullae, or by spreading 
 peripherically. They may be limited to certain regions or ex- 
 tend over a considerable portion of the body. The outbreak 
 of the eruption is accompanied by a feeling of burning or itch- 
 ing. There may be only a few isolated bull&e, or the number 
 may be considerable. The walls of the blebs are at first tense 
 from the exuded fluid, but afterward, in consequence of 
 absorption or evaporation of this fluid, the epidermis compos- 
 ing them becomes wrinkled and shriveled up. The contents 
 of the bullae are at first clear or slightly opaque, but afterward 
 become sero-purulent, from an increase in the number of pus 
 corpuscles present. Occasionally they are dark colored from 
 admixture of blood. The contents usually disappear by absorp- 
 tion or evaporation without rupture of the wall ; or if rupture 
 occurs they dry and form a thin scab. If sero-purulent mat- 
 ter becomes confined beneath the scab, considerable inflamma- 
 tion may result or a lymphangoitis arise. 
 
 The base of a bulla is formed by one or two layers of rete 
 cells or by the naked corium, and the covering, by the corneous 
 layer alone or by rete cells in addition. After the scab has 
 
234 PEMPHIGUS. 
 
 fallen off, the skin which has been the seat of the eruption, 
 shows a brown pigmentation, which lasts some time. Scars are 
 never produced. 
 
 Acute Pemphigus Vulgaris is most frequently met with in chil- 
 dren, being very rare in adults. Its existence in any case has been 
 doubted by Hebra and others, but a sufficient number of cases 
 have been seen by different competent observers to prove that it 
 undoubtedly exists, although it is a rare affection. I saw a well- 
 marked case last winter occur in a child just after recovery from 
 measles. It is usually ushered in by chills, fever, etc., and the 
 eruption arises either upon an erythematous or a previously 
 normal skin. The bullae may appear upon different parts of 
 the body, but are met with especially upon the backs of the 
 hands and corresponding part of the feet. The disease runs a 
 favorable course, the bullae disappearing in two or three weeks, 
 except in the case of ill-nourished or sickly children, in whom 
 a fatal termination may occur. If the disease is malignant in 
 character, the bullae will have sero-purulent or bloody contents. 
 A pemphigus haemorrhagicus occurring over the whole body has 
 been described. 
 
 Chro7iic Peitiphigus Vulgaris is characterized by the successive 
 development of variously sized bullae of the character already 
 described. The eruption is rarely general over the whole body, 
 and the number of bullae present is generally limited. The 
 contents of the bullae disappear either by absorption or evap- 
 oration without rupture of the covering, or the wall bursts, and 
 the contents dry to a scab, beneath which the skin is red and 
 secretes a sero-purulent exudation. The disease is chronic in 
 its course, the duration of the eruption being prolonged by suc- 
 cessive outbreaks of new blebs. Its course may be favorable or 
 unfavorable, depending upon the general condition of nutrition of 
 the individual affected. It is usually benign, when it runs its 
 course in from two to six months. There may be only one attack, 
 but relapses generally occur after intervals of months or years. 
 In the malignant form, which is rare, the number of bullae is con- 
 siderable ; they form rapidly, coalesce and the contents dry up 
 without rupture ; or, bursting, dry into thick crusts, and leave 
 
PEMPHIGUS. 
 
 2 35 
 
 the base covered with a puriform or sanguinolent exudation. 
 Successive bullae rapidly form involving a considerable area of 
 the skin and death finally results after a few weeks, or perhaps 
 years, from general prostration or consecutive disease of the 
 lungs or kidneys. 
 
 Some cases of pemphigus are attended by intense itching, 
 which causes the patient to scratch and rupture the bullae or 
 even cause haemorrhage. This form is called pemphigus pruri- 
 ginosus. These cases have often an unfavorable termination, 
 as the scratching causes excoriations or ulcerations, and the 
 patient's health becomes gradually undermined. 
 
 In children bullae often appear without any symptoms of 
 general systemic disturbance ; in these cases the number of 
 bullae is limited, and the disease is prolonged by the successive 
 formation of a few isolated blebs. 
 
 Pemphigus Foliaceus. — In this form the bullae are small and 
 the walls are not tense, but flabby, as the exuded liquid is not 
 in sufficient quantity to fully distend them. The contents are 
 of a milky, opaque or yellowish-red color. The eruption 
 generally commences on the front of the chest as a single bulla 
 seated upon a slightly infiltrated skin. Wherever situated, new 
 bullae generally form around a primary bleb and afterward 
 unite with it, or the latter spreads by peripheral extension. 
 The contents of the bullae show little tendency to drying up, 
 but the bullae bursting, the liquid oozes out upon the free sur- 
 face and- the epidermic wall hangs in shreds from the excoriated 
 areas. 
 
 New epidermis rarely forms upon the affected part, and as the 
 eruption extends the corium soon forms the base over a greater 
 or less extent of area, the skin presenting a red and weeping 
 surface, and the secretion drying to thin varnish-like friable 
 crusts. Sometimes new epidermis forms, but it is speedily re- 
 moved, either mechanically or from new exudation occurring. 
 If the contents dry to a scab, the under surface of the latter has 
 numerous villous-like processes composed of sebaceous matter, 
 which is derived from the ducts of the sebaceous glands, and 
 with which they are directly united. 
 
236 PEMPHIGUS. 
 
 When the eruption extends over a large area it resembles 
 the condition in cases of burning in the second degree. In 
 this condition there are no bullae present, as the epidermis is 
 not capable of forming a covering. The surface of the affected 
 area is crossed by irregular curved fissures, and partly covered 
 with crusts of a moist or dry, dark-red, parchment-like char- 
 acter. When the eruption becomes general, as it almost always 
 does sooner or later, the hairs become sparse and thin or fall 
 out, the eyelids ectropic, the nails thin and brittle, there is 
 loss of appetite, restlessness, severe pain from lying or turning, 
 fever attacks, at first slight and intermittent, later continuous ; 
 diarrhoea, and finally death. The general system suffers in 
 this manner only after the disease has lasted a considerable 
 period and a large extent of surface is affected. 
 
 When the eruption has lasted a long time the whole surface 
 of the body becomes affected and the condition of the patient 
 is one of extreme misery. After healing, millet-sized milia in 
 groups are sometimes found over the whole surface. 
 
 The eruption may appear on the lips, mouth, nose, pharynx, 
 tonsils, external auditory canal, bronchi, stomach, intestinal 
 canal and vaginal mucous membrane. In these cases the epi- 
 thelial covering is soon softened and thrown off, leaving bright 
 red or grayish, sharply limited spots. It has also been observed 
 on the conjunctiva bulbi. Sometimes it appears first on the 
 mucous membrane and afterwards on the skin. 
 
 Anatomy. — The liquid in recent bullae is serous, with few 
 corpuscles, but soon pus, fatty acid crystals, blood corpuscles 
 and epithelial cells are present ; uric acid crystals and free 
 ammonia have been found by some but not by others. The 
 reaction is alkaline, and the older the fluid the more alkaline it 
 becomes. 
 
 The bulla has been described as one-chambered, the lower 
 cells of the rete being separated by the exuded liquid, and the 
 cells elongated, whilst the upper layers are flattened and have 
 their long axis parallel with the surface of the corium. The 
 lengthened rete cells are soon thrown off and suspended in the 
 bullous liquid. The papillae are swollen and broader, and the 
 
PEMPHIGUS. 
 
 237 
 
 tissue penetrated by fine spaces and infiltrated with serum. 
 The bloodvessels are enlarged ; hyperemia of the skin may 
 exist before the bullae are formed. The bullae are more super- 
 ficially seated than in herpes or eczema, the covering being 
 formed from the corneous layer and upper part of the rete and 
 the base by the lengthened rete cells or corium. From their 
 superficial situation there is, even after a long duration of the 
 eruption, no loss of substance and consequently no cicatrices, 
 but restitution with temporary pigmentation. 
 
 MjSX 
 
 Fig. 34. — Vertical section of half a recent bulla of chronic pemphigus : 
 a, corneous layer ; b, rete ; c, bulla ; d, upper part of corium ; e, chambers at 
 peripheral part of bulla; g, deep part of corium. Cavity of bulla contains a 
 fibrinous material. 
 
 Post mortem examination has shown anaemia of the muscles, 
 flabbiness of the heart and lungs, oedema of the brain, general 
 anaemia, and occasionally amyloid degeneration of the liver and 
 spleen, all of which are to be regarded as a result of the 
 cachexia. 
 
 I have made a considerable number of sections of bullae 
 from a case of chronic pemphigus and found the bullae con- 
 tents to lie between the rete cells and the corium. The lower 
 
238 PEMPHIGUS. 
 
 rows of rete cells were generally destroyed by the process and 
 seemed to have undergone a fibrinous degeneration, a coagula- 
 tion necrosis. At the margin of the bulla these changed cells 
 divided the bulla into a number of compartments. Through- 
 out the entire bulla bands of fibrinous material were observed, 
 as shown in fig. 34. In some of the bullae examined the lower 
 row of rete cells remained unchanged and the bullae was 
 formed between the lower and upper rete cells. The corneous 
 layer was unaffected. The papillae, corium and subcutaneous 
 tissue were infiltrated with round cells and their bloodvessels 
 dilated. 
 
 Etiology. — Pemphigus is a rare disease. It is much more 
 frequent in children than in adults. I have met with it most 
 frequently in the first year of life. Atmospheric changes do 
 not influence its production. Generally there is a depraved 
 condition of the body, especially of the nervous system. Uter- 
 ine disorders sometimes cause it, if we regard herpes gestatio- 
 nis as a pemphigus. It is not contagious. Syphilis is not a 
 cause ; the so-called syphilitic pemphigus being not a true 
 pemphigus but a bullous syphiloderm. 
 
 Different views are held as to the causes of pemphigus ; by 
 some it is regarded as a disease of the blood, by others as 
 produced by a deficient excretion of urine in cases of nephritis. 
 Pemphigus foliaceus is more frequent in women than in men, 
 but pemphigus vulgaris occurs equally in both sexes. Some 
 cases seem to be hereditary. According to Steiner it is often 
 of pyaemic origin in children. In 7,000 cases of sick children 
 at the Out-door Department of Bellevue Hospital I have seen 
 but two cases. In the Nursery and Child's Hospital cases of 
 acute pemphigus were occasionally observed. 
 
 Hebra observed a case of pemphigus vulgaris of the skin and 
 mucous membrane on a man affected with prurigo ; the 
 prurigo eruption disappearing during the existence of the 
 pemphigus and reappearing upon its subsidence. 
 
 Diagfiosis. — Pemphigus can be confounded with herpes iris, 
 urticaria, pustular syphilide, bullous syphilide, scabies, impet- 
 igo, eczema rubrum, and erysipelas. In herpes iris the bullae are 
 
PEMPHIGUS. 239 
 
 sometimes of similar constitution and may easily be confounded 
 with pemphigus. They disappear rapidly and do not return ; 
 whereas in pemphigus new bullae always return and relapses of 
 the eruption occur. Herpes arises always on an erythematous 
 base, pemphigus only occasionally. Herpes is generally situ- 
 ated on the back of hands and feet, and later, on other parts of 
 skin ; pemphigus has no special situations. In pemphigus the 
 general constitution is much more affected than in herpes iris. 
 
 Herpes iris is always acute, lasting a few weeks ; the vesicles 
 and blebs are of varied colors throughout their course ; the sur- 
 rounding skin is inflamed, the vesicles are arranged concentric- 
 ally and increase in this manner. Pemphigus is a chronic af- 
 fection, the varied colors of herpes iris are absent, and the 
 surrounding skin is generally normal. The bullae are seldom 
 arranged concentrically. 
 
 In syphilis, bullae sometimes form that rapidly — become pus- 
 tular and ulcerate. 
 
 Bullous syphilide is distinguished from pemphigus by other 
 signs of congenital syphilis and by the character of the crusts, 
 which are thick and firm, while those of pemphigus are thin 
 and brittle. In syphilis there is also generally some form of 
 ulceration present. 
 
 The bullous syphiloderm dries into thick, bulky, greenish 
 crusts, and beneath the crusts there is excoriation or ulceration, 
 conditions absent in pemphigus. 
 
 In scabies bullae are often present in children, but the gen- 
 eral symptoms and course of the eruption present in scabies 
 make the diagnosis easy. 
 
 Pemphigus can only be confounded with impetigo when the 
 contents of the bullae dry to crusts. The frequent appearance 
 of impetigo on the lower extremities, the slow development of 
 the pustules, their course, and absence of any general constitu- 
 tional symptoms enable the diagnosis to be made. 
 
 Pemphigus foliaceus resembles eczema rubrum and squa- 
 mosum in the color of the skin and presence of scales. The 
 depressed constitution and the successive development of 
 bullae, the slight amount of discharge, itching or infiltration of 
 
240 PEMPHIGUS. 
 
 the skin, the loss of flesh and dark pigmentation point to pem- 
 phigus. 
 
 In erysipelas the general character of the eruption, its 
 spreading, etc., soon show the character of the disease. 
 
 Blebs are often produced by artificial means, as strong 
 acids and chloroform, for the purpose of feigning disease. 
 
 Artificial bullae can be produced by mechanical influences on 
 the soles of the feet and ankles from too much traveling, or in 
 fleshy persons on the buttock. 
 
 Bullae sometimes develop on wheals, but in these cases there 
 are always some ordinary wheals also present. 
 
 For the diagnosis of pemphigus not only the presence of 
 blebs, but their manner of appearance, their course, and the 
 successive development is necessary for the diagnosis. 
 
 Prognosis. — The prognosis depends on the special form of 
 the disease. In pemphigus vulgaris it is in general favorable, 
 while in pemphigus foliaceus and pruriginosus it is unfavor- 
 able as a rule, as they generally lead to death. 
 
 In pemphigus vulgaris the duration of an attack can not be 
 prognosticated and the final result is indefinite. Cases with 
 tense walls, few bullae, slow production without fever, in well 
 nourished young persons and children are favorable ; while 
 numerous bullae, successive development of new ones, flabby 
 walls, continuous fever, loss of strength, and marasmus are un- 
 favorable symptoms. 
 
 Those cases in which a few bullae relapse after a day's 
 duration are never dangerous. Numerous bullae, by the 
 rapid decomposition of their contents, may produce a 
 lymphangoitis, adenitis, loss of strength, or purulent pneumonia, 
 pyelitis and death. 
 
 In children the prognosis is unfavorable when the disease is 
 complicated with bronchial or intestinal catarrh, kidney trouble, 
 or haematuria. 
 
 Treatment. — The treatment is both local and internal. The 
 local treatment consists in the administration of baths either 
 simple or medicated, and the use of ointments or dusting pow- 
 ders. At the commencement of the eruption, and when only a 
 
PEMPHIGUS. 241 
 
 few bullae are present, any non-irritating dusting powder may 
 be employed. If the bullae are tense they may be pricked. If 
 crusts are present, salves, as zinc, or diachylon ointment may 
 be employed for their removal. 
 
 If the eruption is limited in extent, the use of these salves 
 may be continued. If the skin is much inflamed, douches, or 
 wet-packs, or baths may be employed. If the eruption is ex- 
 tensive and the skin irritable, use may be made of the con- 
 tinuous bath ; this bath may consist of water alone at a temper- 
 ature of 95 , or it may be medicated by the addition of corrosive 
 sublimate, or the carbonate of soda. From 2 to 3 drachms of 
 the bichloride are sufficient for a bath. 
 
 Tar baths are especially useful in pruriginous pemphigus. 
 The patient may remain days or weeks in these baths if neces- 
 sary. If the baths are not well borne, the surface may be pro- 
 tected by non-irritating powders or ointments. Antiseptic ab- 
 sorbent cotton applied to the surface lessens the suppuration, 
 and the disagreeable smell from decomposing pus. When the 
 mucous membrane of the mouth is affected, it should be gargled 
 with a solution of chlorate of potash or the permanganate of 
 potash. 
 
 Internal treatment. — The general condition of the system 
 must receive careful attention, good food, animal diet, milk, 
 wine or ale, freedom from mental excitement, tonics, and 
 mineral acids should be administered. 
 
 Among medicinal substances arsenic is the only one which 
 exerts a specially curative effect ; this remedy when given in 
 sufficiently large doses, acts almost as a specific against pem- 
 phigus vulgaris, as first shown by Mr. Hutchinson. If neces- 
 sary the dose must by increased until the physiological action 
 has been reached, and its use persisted in for some time. In 
 pemphigus foliaceus its action is not so beneficial ; for these 
 cases the treatment recommended by Dr. Sherwell, of Brooklyn, 
 seems to give the best results. His plan consists in the free 
 administration of linseed oil both internally and externally. 
 For internal use either the pure oil should be taken, or the 
 seeds may be eaten in large quantities. Externally the oil is. 
 16 
 
242 HYDROA. 
 
 applied by inunction, or by wrapping the patients up in cloths 
 soaked in the oil. 
 
 HYDROA. 
 
 Syn. — Pemphigus Prurigineuse. 
 
 Definition. — Hydroa is an acute or chronic disease of the 
 skin, probably the result of a trophic change, due to some as 
 yet undetermined lesion of the central nervous system, and 
 appears as solid groups of vesicles or small bullae situated 
 upon reddened, infiltrated, papular bases, attended by an in- 
 tense degree of pruritus and much constitutional depression. 
 
 History. — Hydroa is a disease as yet not at all well defined ; 
 our ideas about it are very indefinite and uncrystallized, and in 
 most of the text books on dermatology it is either not men- 
 tioned at all, or inextricably confounded with other affections, 
 herpes iris, pemphigus, etc. Nevertheless the term represents 
 a definite disease entity and a more complete definition of it 
 lies undoubtedly in the near future. 
 
 Bazin first used the word hydroa, intending to designate 
 thereby a set of vesicular or semi-bullous eruptions which 
 could not be classified under the head of erythema, herpes or 
 pemphigus, even in their more unusual manifestations. He 
 described three varieties ; one acute, and two chronic ; and 
 named them hydroa vesiculeux, hydroa vacciniforme, and hy- 
 droa bulleux. He evidently included the herpes iris of Wil- 
 lan and Bateman, which certainly does not belong here. 
 Hydroa vacciniforme, also, is simply a variety of hydroa ves- 
 iculeux. 
 
 The French dermatologists of to-day in the main follow 
 Bazin's classification, though some of them, notably Diday and 
 Doyen, regard hydroa bulleux as a " pemphigus a petite bulles." 
 
 By the German writers the disease as an entity is entirely 
 passed over. In 1880 there appeared in the Archives of Der- 
 matology an article by T. Colcott Fox, compiled from the 
 papers of the late Tilbury Fox, of London, which is quite ex- 
 haustive and gives clinical studies of a number of recorded 
 
HYDROA. 243 
 
 cases. To that paper I am indebted for most of the informa- 
 tion concerning the disease here embodied. 
 
 Symptoms. — Hydroa is probably a neurotic disease, in which 
 vaso-motor disturbances, permanent inflammatory changes and 
 disturbances of sensation play an important part. Its features, 
 as a whole disease, are always present ; but it is worse in parox- 
 ysms, as are so many nervous diseases. 
 
 There is a variable period of general ill-health before the 
 disease comes on. There is probably for a long time more or 
 less constitutional depression, general weakness, etc. The 
 immediate attack is preceded by a slight pyrexia, with malaise, 
 insomnia, gastric disturbance, etc. Then there appears a small 
 bulla — pin-head to split-pea in size — very itchy, and developed 
 upon a small itchy papule. The lesions are arranged in groups, 
 with normal intervening skin, and the groups are usually seen 
 upon the exterior aspect of the limbs, upon the genitals, the 
 face, or even upon the mucous membrane of the mouth. They 
 may disappear in a few days, or become purulent, and lead to 
 the formation of crusts, etc. The pruritus is very intense. Suc- 
 cessive paroxysmal eruptions may occur. Acute cases last one 
 to two months ; chronic ones for months or years. 
 
 Three varieties are to be distinguished : 
 
 1. H. simplex. These are the slight or vesicular cases. The 
 lesions form scattered patches of small vesicles upon various 
 parts of the body ; they are slightly itchy, and do not recur ; 
 or if they do recur, it is after a long interval of time, and in the 
 same slight form. 
 
 2. H. herpetiforme. Here the lesions are severer, and the 
 disease more extensive. Herpetiform groups of vesicles, larger 
 than in the simple form, and more numerous, are found over 
 various parts of the body. They are more apt to be chronic, 
 and to run into the third form. 
 
 3. H. bulleux s. pruriginosum. Here small bullae are 
 found widely scattered over the surface of the body, which soon 
 rupture and leave infiltrated, red, pruriginous spots. This is 
 the chronic form of the disease, and successive crops follow 
 one another continuously. The itching is most intense. 
 
244 HYDROA. 
 
 Etiology. — General ill-health, exposure, overwork, worry, ex- 
 cessive wear and tear of mind and body, nervous shocks : 
 these are the causes that bring about the lesion of the nervous 
 system which shows itself as hydroa ; for there is little reason 
 to doubt that the disease is due to some neurosis ; probably 
 the spinal cord is in some way injured, and hence its symmet- 
 rical occurrence. When death occurs from it, which sometimes 
 happens, it is not due to the intensity of the eruption, but rather 
 to depravity of the general system and nervous exhaustion. 
 
 Diagnosis. — In a disease not yet thoroughly distinguished from 
 the conditions that resemble it, the differential diagnosis as- 
 sumes great importance. We will therefore consider at some 
 length its relations to the maladies for which it may be taken. 
 
 H. Simplex may be mistaken for varicella. But varicella oc- 
 curs almost invariably in children ; hydroa usually in those of 
 mature age. Moderate hydroa also has no febricula, and its 
 vesicles are few in number, and grouped. In the severer and 
 more general forms the eruption is bullous, and not at all like 
 varicella. 
 
 In pemphigus the blebs are always larger than in H. sim- 
 plex. 
 
 Erythema multiforme, and especially that variety of it called 
 E. papulatum, may become vesicular like hydroa ; and in fact 
 many of the cases called vesicular erythema, have really been 
 cases of hydroa. Erythema papulatum itself is only very ex- 
 ceptionally vesicular. The pruritus, and the herpetiform dis- 
 tribution will also distinguish hydroa. Indeed, both diseases 
 run a short course, and their treatment is very much the same. 
 More advanced and chronic hydroa is pruriginous and bullous, 
 and not to be mistaken for erythema. 
 
 Herper iris at first looks very like hydroa ; indeed Duhring 
 and others look upon them as identical. But the secondary 
 rings of vesicles soon form in herpes iris, and the dull purplish 
 color indicates the hemorrhagic tendency. 
 
 In so far as herpes itself is concerned, it is so like the hydroa 
 herpetiforme that no real distinction can be drawn between 
 them. They are virtually the same thing. 
 
HYDROA. 245 
 
 The remains of an herpetiform or bullous hydroa are hardly- 
 likely to be mistaken for eczema. 
 
 H. Bullosa and the pruriginous pemphigus of some of the 
 French writers are one and the same thing. 
 
 Any case of scabies in which the eruption is abundant enough 
 to make it look anything like a hydroa will be one in which the 
 acari and their burrows will be readily found. 
 
 From urticaria, hydroa may be distinguished by the invasion, 
 manifest cause and original wheals of the former disease. 
 
 Two forms of acne might be taken for hydroa. The first is 
 iodine acne which may resemble it very closely ; the small size 
 of the iodide pustules, the localization upon the face, and the 
 etiology, may help the diagnosis. The acne which occurs in 
 debilitated individuals, the so-called acne cachecticorum is in- 
 dolent, painless, and non-pruritic ; hydroa is very itchy, is 
 paroxysmally recurrent in its attacks, and is found where there 
 are no sebaceous glands at all, as upon the palms of the hands. 
 
 The last and one of the most important of the diseases to be 
 differentiated from hydroa bullosa is pemp/iigus. The bullae 
 of hydroa are smaller than those of pemphigus ; they are not 
 spread over the whole body, as those of pemphigus usually 
 are, but are clustered in irregular groups. Hydroa is intensely 
 itchy ; pemphigus is not. Nevertheless, it must be admitted 
 that there are a number of cases which seem to be on the 
 border line between the two diseases ; in which it is impossible, 
 with our present knowledge, to say whether they belong to 
 hydroa or pemphigus. 
 
 Prognosis. — Mild cases usually terminate in recovery. 
 Chronic ones are very obstinate ; but the patient succumbs to 
 the general marasmus rather than to the extent or severity of 
 the eruption. 
 
 Treatment. — Hydroa, when chronic, is a very stubborn dis- 
 ease. The milder cases run a definite and short course ; for 
 them general treatment — quinine and iron — and local soothing 
 applications will suffice. In any case a most important ele- 
 ment in the therapy is the treatment of the threatened nervous 
 debility by hygienic and medicinal means of all kinds. 
 
246 POMPHOLYX. 
 
 For the severer cases a variety of measures may be employed. 
 Nerve tonics — arsenic, iron, quinine, strychnia — or best of all, 
 especially when there is struma present — cod-liver oil. When 
 there is congestion of any of the internal organs, when excre- 
 tion is not properly performed by the skin, and there is ten- 
 dency to an erythematous congestion, diuretics are useful. Fox 
 recommends acetate of potash, nitre, and taraxacum. The 
 gastric functions must be carefully seen to, and all abnormali- 
 ties corrected. Dyspeptic troubles and costiveness especially 
 increase the severity of hydroa. Good plain diet, with but 
 little meat, much milk and vegetables must be enjoined. Car- 
 bonate of magnesia and nux vomica is useful in these cases here. 
 Besides all these, careful avoidance of overwork of any kind, 
 of mental excitement, or chilling of the surface or exposure to 
 the sun's heat must be observed. 
 
 For that most annoying symptom, the pruritus, which wears 
 the patient out by preventing rest, and thus directly con- 
 tributes to a lethal result, various local applications may be 
 used. As good as any are lead or calamine lotions ; oil inunc- 
 tions are also recommended. Bran or alkaline baths are useful ; 
 but special stress is laid by Fox upon the value of the tar 
 preparations for this symptom. 
 
 POMPHOLYX. 
 
 Syn. — Cheiro-pompholyx ; dysidrosis. 
 
 Definition.- — An acute inflammatory affection characterized 
 by the symmetrical development upon the palms of the hands, 
 and generally also upon the soles of the feet, of deep seated, 
 clear vesicles, usually grouped, which afterward become opaque, 
 and in a few days disappear by rupture or absorption, leaving 
 a non-inflammatory skin behind. 
 
 Symptoms. — I have placed this affection among the non-con- 
 tagious inflammatory affections, as I believe it to be closely re- 
 lated to herpes, but a considerable number of dermatologists 
 regard it as an affection of the sweat glands, hence the name 
 dysidrosis as originally proposed by the late Dr. Tilbury Fox. 
 
POMPHOLYX. 247 
 
 The eruption has been especially described by English derma- 
 tologists, especially Dr. Fox and Mr. Hutchinson. I will quote 
 their description of the affection, and add a history of a case 
 which was under my observation in New York, as that will 
 give the reader the best idea of the subject. 
 
 Mr. Hutchinson's description of the affection is briefly as 
 follows : " The more severe forms which I have seen have 
 always been in women, and usually in association with a highly 
 nervous temperament. • The disease appears to be characterized 
 by rapid and symmetrical development, by tendency to spon- 
 taneous cure, and by the liability to recur over and over again 
 in the same individual. The hands are the parts first affected ; 
 the feet come next ; and in a few instances a rash appears over 
 the rest of the body. In the majority of cases the hands alone 
 suffer, and in all they are the parts most severely affected. A 
 tendency to spontaneous absorption of the fluid contained in 
 the vesicles or bullae, even when the latter are very large, is a 
 very remarkable feature. It is not connected with any local 
 cause nor is it influenced by local treatment. The eruption 
 begins with intense burning and itching on some part of the 
 hand, usually between the fingers. After a short time — a few 
 hours or a day or two — there are seen, deeply placed in the 
 skin, small accumulations of clear serum, looking like sago- 
 grains. These are perfectly transparent and not unfrequently 
 resemble the vesicles of scabies sufficiently to excite suspicion. 
 They differ, however, from those of scabies in being much 
 more deeply placed, having flatter tops, in being usually closer 
 grouped together instead of scattered, and in the entire absence 
 of burrows. In some it occurs during hot weather, but in most 
 instances no cause can be given for its occurrence. Those who 
 have had it once will very probably have it again, and several 
 of the facts in its clinical history coincide pretty nearly with 
 what is true of herpes of the lips and of the prepuce. I do 
 not recollect even to have seen a well-marked example of it in 
 a patient under the age of puberty, nor in a very old patient. 
 The tendency to speedy and spontaneous disappearance, leav- 
 ing the skin quite sound, supplies a feature of positive differ- 
 
248 POMPHOLYX. 
 
 ence from eczema, of which the indefinite duration and the 
 tendency to persist and become aggravated are such marked 
 characters. Symmetry, spontaneous cure and liability to re- 
 lapse are its clinical characteristics. In minor degrees the 
 affection is tolerably common. Many, indeed perhaps most of 
 us, are liable at times in connection with slight derangements 
 of health, or possibly with exposure to the sun, to the occur- 
 rence of a very irritable sago-grain eruption on the sides of the 
 fingers. The so-called sago-grains are deeply placed effusions 
 of serum, but in a large majority of cases they undergo 
 spontaneous absorption after a few days, and not even peeling 
 of the epidermis results. They never by any chance result in 
 eczema. In those liable to this slight affection the disease is 
 prone to recur repeatedly at intervals perhaps of a few years. 
 More severe cases, in which the vesicles coalesce and develop 
 into bullae, are not very uncommon, their subjects being, so far 
 as my experience has gone, almost invariably young women. 
 In several of the most severe cases which I have witnessed the 
 eruption was attended by extreme depression of spirits. Al- 
 though the eruption always shows a tendency to spontaneous 
 disappearance, yet, in some instances, it may last a couple of 
 months and require treatment. In one case under my care the 
 liability to attacks had extended over thirty years. In this 
 case the vesicles always broke, and a state much resembling 
 that known as psoriasis palmaris resulted in the palms, whilst 
 on the sides of the fingers it looked more like eczema." 
 
 Dr. Fox who has very carefully studied the clinical charac- 
 ters of the disease in a great number of patients, says : " The 
 disease in its slightest form, is confined to the hands, occurring 
 in the interdigits, over the palm and along the sides of the 
 fingers, and on the palmar surfaces. It makes its appearance 
 in those who habitually perspire freely, and the patients feel 
 weak and depressed. The eruption consists of minute vesicles 
 deeply imbedded in the skin, and are at first isolated. They 
 do not readily burst, and when a few days old look like sago- 
 grains imbedded in the skin. The vesicles afterward become 
 more distended and raised. They are not pointed, but oval, 
 
POMPHOLYX. 249 
 
 'eventually become faintly yellow in color, and run together and 
 form bullae. The hand is then stiff and painful. If the erup- 
 tion is left undisturbed, the fluid is partly absorbed, partly 
 evaporated, the cuticle then peels off, leaving a non-discharg- 
 ing, reddened, exposed derma. In some of the milder cases 
 only vesicles are formed. When disappearing altogether from 
 the hand the palm is left harsh and slightly scaling. In some 
 cases a red, dry, slightly scurfy, painful surface is left behind 
 and becomes chronic. No patient is well who has this disease. 
 In severe cases there is great nervous debility." 
 
 History of my patient. — L. S., born 1846, is of medium 
 height, light complexion and weak muscular development. In 
 1849, one of his thighs was fractured twice, after which time 
 mother says he was sickly and nervous for a number of years. 
 In 1866 was married, and six children have been born to him 
 since that time, three of whom are dead and three living. Two 
 children (boy aged 5 months and girl aged 2 years) died of 
 spinal meningitis, and one (a female child) died of pemphigus. 
 In February, 187 1, he received an appointment in the New York 
 fire department, since which time he has always been connected 
 with this service. Previous to his marriage a few vesicles 
 would appear occasionally on his hands, but the first 
 severe attack was in July, 187 1. This attack lasted about 
 two months, appearing both on the hands and feet, but 
 commencing on the hands. The feet were not attacked 
 until about one month after the hands. The eruption 
 occupied the entire palms of the hands, the palmar aspects 
 and sides of the fingers, and a portion of the plantar surfaces 
 of the ungual phalanges. On the feet it appeared only on the 
 soles, from which it removed the entire corneous layer of the 
 epidermis. According to the patient's statement, the eruption 
 during this attack consisted of vesicles, at first deeply placed 
 and isolated, but afterwards frequently uniting and forming 
 bullae. The vesicles almost always dried up, their contents 
 being absorbed without a rupture of the walls taking place. 
 Even the large bullae generally dried up without rupturing. If 
 large areas of the skin were bereft of all that part of the epi- 
 
250 POMPHOLYX. 
 
 dermis above the vesicles or bullae, i. ^., the corneous layer of 
 the skin, all that was observed beneath was a reddish, smooth 
 surface. Various applications were made to the hands in the 
 treatment of the disease (it having been regarded as an 
 eczema), but no benefit was derived from their use. He then 
 ceased treatment and the disease disappeared spontaneously, 
 having lasted about two months. In 1872 he was bitten in the 
 right hand by a dog, and the dread of hydrophobia made him 
 very nervous and depressed in spirits. In February, 1877, the 
 second severe attack occurred, though isolated vesicles ap- 
 peared every now and then during this interval of nearly six 
 years. During this last attack, which still continues (June 
 14th), he has been under my care. The eruption had lasted 
 about three weeks when I first saw him. It had commenced 
 on the palms of the hands near the wrist, and spread over 
 the entire palms, and between the sides and on the palmar 
 surfaces of the fingers. When I saw him the majority 
 were seated between the fingers. The eruption had changed 
 but little in its mode of appearing and in its course since 
 I first saw him. An outbreak is always preceded by a ting- 
 ling, burning sensation in the parts, and the patient is more 
 than usually depressed and nervous. The eruption appears 
 as small clear vesicles, deeply placed in the skin. They may 
 be single or collected in groups of two, four or more. Very 
 frequently the vesicles forming a group are all of the same age 
 and size. The eruption always was symmetrical, and I have 
 very often observed that exactly corresponding parts of the 
 hands or feet became affected at the same time. If but a single 
 vesicle existed it almost invariably dried up. Where there was 
 an aggregation of vesicles they were at first isolated, but after- 
 ward frequently united and formed a bulla. If then the 
 liquid was absorbed, the skin covering them became very hard 
 and dry. I stated that the vesicles appeared to contain a per- 
 fectly clear liquid, but this afterward generally became more 
 or less opaque, though scarcely ever yellowish in color. This 
 latter occurred only when large bullae were formed and the 
 liquid slowly absorbed, *. e., in other words, it was observed 
 
POMPHOLYX. 251 
 
 only when the bullae were of several days' standing, and, as 
 will be seen afterward, was owing to the number of pus cells 
 present in the liquid. The vesicles were never seen to have a 
 red base. The walls of the vesicles appeared of a darker 
 color (from compressed cells) than the surrounding skin or the 
 contained liquid. This really made the vesicles look like sago- 
 grains imbedded in the skin. The vesicles gradually become 
 larger, and raised. Isolated vesicles in the palms of the hands 
 seldom became raised above the level of the skin previous to 
 absorption. Where they appeared in groups they always 
 became raised above the general surface, as also most of the 
 isolated vesicles between the fingers. They were never pointed, 
 but always had a more or less flattened top. After the absorp- 
 tion of the contents or rupture of the vesicles or bullae, a red- 
 dened surface (on account of the thinness of the epidermis) 
 was left behind. At no time was there a cracked or discharg- 
 ing surface or any appearance resembling that of eczema in 
 this region. Occasionally the eruption spread peripherically, 
 especially in the palms of the hands. There has been no 
 change in the appearance of the vesicles since I first saw him, 
 but at present the disease is not so severe, the eruption con- 
 sisting principally of isolated vesicles and but very few bullae. 
 Occasionally, however, an " outbreak " occurs lasting two or 
 three days. Then the eruption presents more of the character 
 it had in an earlier period of the disease. The feet are also 
 affected, but only in a slight degree, a group of vesicles ap- 
 pearing occasionally here and there. Their appearance 
 is always preceded by a tingling in the part. They appear 
 symmetrically, and often on exactly corresponding parts. 
 There has never been any accompanying eruption on the other 
 parts of the body. I have tried various local applications with- 
 out any benefit except keeping the parts soft. 
 
 The patient is exceedingly nervous and depressed in spirits. 
 He was so nervous that he hesitated several weeks before al- 
 lowing me to remove a second portion of the skin from his 
 finger. Even then I was obliged to benumb the part with ether 
 spray before using the knife. He says his forearms and hands 
 
252 POMPHOLYX. 
 
 feel benumbed and " sleepy," especially in the morning, if he 
 keeps them elevated above the bedclothes. He sweats a great 
 deal, yet the hottest day in summer is not too hot for him. 
 
 The above description was written in 1877, and since that 
 time the disease has recurred many times, in fact just as often 
 as he is subjected to great excitement and exertion consequent 
 upon his duties as a fireman. I have seen a few other cases, 
 but none so marked as this one is. 
 
 Anatomy. — According to Tilbury Fox, Tweedy, and some 
 others, the vesicles are caused by retained sweat, the obstacle 
 to the escape of the sweat being situated somewhere in the 
 rete. As Hoggan failed to find any connection in the early 
 stage of the vesicle formation between the sweat duct and the 
 vesicle in the sections prepared by Dr. Fox, although he more 
 than wished to do so, we may regard the sweat duct theory as 
 certainly not proven. My own view is that the disease is a 
 neurosis, and the vesicles have a similar origin as those of 
 herpes, especially herpes progenitalis. In the earliest stage the 
 vesicle contains clear serum, and no formed elements, but after- 
 ward pus cells appear and increase in number with the duration 
 of existence of the vesicle. The fluid is either alkaline or 
 neutral, never acid. The liquid comes from the papillary ves- 
 sels, and passing through and between the lower cells of the 
 rete, collects in different situations in different vesicles. 
 Usually it collects in the upper Malpighian layer at a distance 
 of two or three layers of cells from the stratum corneum. The 
 liquid at the place of collection presses the cells apart in every 
 direction, and changes their form. They are gradually flattened 
 and drawn out, more especially those cells which line the wall 
 of a vesicle. The more the vesicle increases in size the more 
 the cells are flattened out, until at last they appear as fibres in 
 which a nucleus is no longer visible. The cells forming the 
 summit of the vesicle are not so much flattened, and even when 
 the vesicle bursts and the liquid escapes to the free surface, 
 this occurs, not so much by a flattening out of the cells form- 
 ing the covering, as by a rupture and separation of these struc- 
 tures. The cells of the corneous layer at an early stage of the 
 
POMPHOLYX. 
 
 253 
 
 vesicle are affected, and in different places over the vesicle be- 
 come detached from each other, leaving spaces filled with a 
 
 Fig. 35 shows the formation of vesicles from adjoining papillae. The bands 
 separating the vesicle correspond to the inter-papillary spaces. Between A and B 
 the separating band has become very narrow, whilst that between B and C is still 
 broad. The stretching and flattening out of the cells of the Malpighian layer is 
 well shown in this drawing. In B pus cells have appeared, and some are present 
 in the papillae and in that part of the Malpighian layer lying between the corium 
 and the vesicles. On the right is to be seen the apex of a papilla cut across. 
 
254 POMPHOLYX. 
 
 watery fluid. On this account a portion of the corneous layer 
 is frequently removed even when the vesicles do not burst. 
 The bloodvessels in the papillae are at first but slightly 
 changed, and but few round cells are found outside of their 
 walls ; but in the later stages they become more dilated ; 
 though they seldom become what one would call widely dilated. 
 In these later stages also out-wandered round cells appear in 
 greater number in the papilla, and passing in the same direc- 
 tion as the effused serum, they are found also in the Malpighian 
 layer and within the vesicle. Sometimes the collection of 
 these round cells is so great in the Malpighian layer that it is 
 impossible to distinguish the form and outlines of the cells 
 forming the lower two or three cell-layers of this structure. 
 The serum in passing from the papilla to the place of col- 
 lection causes marked changes in the form and appearance 
 of the cells between which it passes. They become drawn 
 out, paler in color, and less granular in appearance from the 
 imbibition of serum. Generally the change of form and ap- 
 pearance is so great that their outline becomes indistinct, 
 and only occasionally is the nucleus to be seen. Sometimes 
 they appear to reach from the corium to near the corneous 
 layer. It is, however, frequently impossible to see where they 
 terminate, as the Malpighian layer has more the appearance of 
 being commposed of long bands of fibres than of cells. 
 
 The change in the parts depends upon the age of the vesicle 
 and the amount of fluid effused. In the earliest stage only the 
 cells of the lower Malpighian layer are drawn out, and those 
 cells surrounding the liquid slightly flattened. But few round 
 cells are seen, and the bloodvessels of the papilla are scarcely 
 changed. The number of layers of cells from the upper Mal- 
 pighian layer lying between the vesicle and the corneous layer 
 are greater than in a later stage. This of course is not true of 
 those cases in which the liquid at the commencement is situated 
 between the Malpighian and the corneous layers. 
 
 In the later stages, the vesicle is larger, the cells more 
 flattened, their margins more indistinct, the bloodvessels 
 more enlarged, and a greater number of round cells 
 
POMPHOLYX. 255 
 
 present in the papillae, Malpighian layer and vesicles. 
 The liquid lies nearer the corneous layer and the corium 
 (as the vesicle increases in size in all directions), and 
 the corneous layer is more broken up. If neighboring vesicles 
 join, the separating bands composed of elongated rete cells 
 rupture, and in this way bullae may form. 
 
 In this case the vesicles are originally separated from each 
 other by a greater or less distance, according to the number of 
 papillae lying between them. When coalescence occurs the ves- 
 icles spread in the usual manner, and the liquid extending hori- 
 zontally between the cell layers, the vesicles unite before the 
 summit is ruptured. By this union of the effused liquid bullae 
 are formed, corresponding in size to the amount of liquid con- 
 tained in the coalesced vesicles. The liquid passes horizontally 
 either between the corneous and Malphigian layer, or between 
 the cells of the latter, and the intervening band is ruptured in 
 the same manner, and its cells become changed in the same 
 way as when the vesicles arise from adjoining papillae, as 
 already described. This union of separated vesicles and con- 
 sequent formation of bullae is accidental, depending upon the 
 amount of resistance offered to the escape of the liquid to the 
 free surface by the structures forming its covering, and upon 
 the distance between the separate vesicles. 
 
 In the later stages of the disease, in which several adjoining 
 papillae are affected, the cell infiltration is greater comparatively 
 than when a single papilla is affected. Instead of being re- 
 stricted to the papillae there is considerable round-cell infiltra- 
 tion along the course of the bloodvessels close to the mucous 
 layer, between the papillae. On account of the amount of cell 
 infiltration into the latter their cells are no longer to be distin- 
 guished. This out-wandering of round cells accounts for the 
 occasional opacity of the vesicles in the later stages, as they 
 appear also in the liquid, as I have already written. No change 
 whatever was to be found in the subcutaneous tissue beneath 
 any of the vesicles. The sweat glands were found to be 
 perfectly normal, and there was no distension whatever of 
 their ducts with sweat. In one case the sweat duct was the 
 
256 ACNE. 
 
 principal structure separating two vesicles and delaying their 
 union. 
 
 Etiology. — The eruption occurs in persons of a nervous 
 temperament, or whose nutrition is below normal. Many of 
 these persons sweat greatly, especially upon the hands and 
 feet. The disease is a neurosis and not a catarrhal inflamma- 
 tion like eczema, as maintained by Kaposi, who has probably 
 never seen a case of the affection, and his statement that it 
 does not exist, is on a par with the denial of the existence of 
 a varicella or tinea trichophytina barbse. 
 
 Prognosis. — The eruption is easily cured, but relapses are 
 very liable to occur. 
 
 Treatment. — Locally there is no application which is of any 
 service in removing the eruption or hastening its course. 
 Ointment of zinc or vaseline, combined with anodynes, may 
 be employed when the part pains or burns. Internally the 
 majority of the patients require tonics of iron, quinine, 
 strychnine and hypophosphites to improve their general nutri- 
 tion and strengthen the nervous system. All causes of ex- 
 citement should be avoided as much as possible. Stimulants 
 and tea and coffee are probably injurious. Belladonna in my 
 hands has not been of any service. Arsenic is the only remedy 
 I have found that has a special effect in this disease, and, 
 when given in the proper dose, will almost invariably cut 
 short the eruption. It acts as promptly as it does in pemphigus 
 and this action makes it the more probable that the affection is 
 a neurosis. Fowler's solution or arsenious acid may be given 
 in full doses until the eruption has disappeared, and then small 
 doses should be continued for a considerable length of time 
 longer, together with appropriate tonics and food. 
 
 ACNE. 
 
 Syn. — Acne vulgaris ; Acne dissemimata ; Whelk. 
 
 Definition. — Acne is a chronic inflammatory disease of the 
 sebaceous glands, and the immediately surrounding tissue ; it 
 is characterized by the appearance of red papules, or tubercles 
 
ACNE. 257 
 
 or pustules upon various parts of the body, but especially 
 upon the face and back. 
 
 Symptoms.— Acne is one of the commonest forms of skin dis- 
 ease with which we have to deal ; it is a malady principally of 
 the sebaceous glands, and, as we might expect, often occurs in 
 conjunction with the other affections of those glands, sebor- 
 rhcea and comedo. It consists of papules or tubercles varying 
 in size from that of a pin-head to that of a pea, many of which 
 subsequently develop into pustules. The lesions are usually 
 of a reddish or violaceous color, with a suppurating point or a 
 comedo in their centre. They are generally purely inflamma- 
 tory, and the peri-glandular connective tissue is almost always 
 involved. They naturally occur with greater frequency in 
 those localities where the sebaceous glands are most numerous 
 and most highly developed ; they are oftenest seen upon the 
 face, and next most frequently upon the back between the 
 shoulders. They rarely occur in other localities, and are, of 
 course, never seen upon the palms of the hands and the soles 
 of the feet, where no sebaceous glands exist. Subjective sen- 
 sations are not present except at the commencement of their 
 formation. 
 
 The acne papules or pustules may occur in large numbers 
 over the face and back, or only a few, perhaps only one or two, 
 may be present. The individual lesions generally run an 
 acute course ; in a day or two the papule becomes a pustule 
 and bursts ; but the disease itself is essentially a chronic one, 
 and may last for years. In a well-marked case we will see 
 lesions in all stages of development, from the painful subcu- 
 taneous peri-glandular induration at the very beginning, to the 
 circular punched out scars left by the deep pustular form. 
 Between these two extremes every variety of papule, tubercle, 
 and pustule may be met with upon one and the same patient. 
 
 The amount of involvement of the connective tissue and 
 the intensity of the inflammation vary much in different cases. 
 In the superficial form, only the gland itself is involved. A 
 small papule forms, which becomes a pustule, with perhaps a 
 comedo in its centre marking the obstructed orifice of the in- 
 17 
 
258 ACNE. 
 
 flamed gland. The pustule is ruptured or bursts, and the 
 inflammation quickly subsides, leaving no trace behind. But 
 in bad cases a large amount of the surrounding tissue is impli- 
 cated ; large inflammatory tubercles appear, and considerable 
 tissue destruction with much pus formation results. In many 
 of these cases dermic abscess rather than pustules are found. 
 The neighboring lymphatic glands may become swollen and 
 tender, and disfiguring cicatrices are left when the process 
 terminates. 
 
 The eruption of acne is a symmetrical one, though there is 
 no regularity in its distribution. The forehead, cheeks and 
 chin are most commonly attacked. The superficial forms con- 
 stitute a slight disorder ; the severe ones a serious evil, and 
 lead to much disfigurement. It is pre-eminently a disease of 
 early youth ; it seldom comes on before puberty, and usually 
 disappears as mature age comes on. It occurs in both sexes, 
 but is commoner in men than in women. It is a local affection, 
 and is in no way prejudicial to the general health. Although 
 almost always a multiform eruption, in most cases there is some 
 special prevailing type. Thus we speak of acne punctata, in 
 which a whitish or blackish point (comedo) marks the centre 
 of the small papule, and of acne papulosa, when the lesion con- 
 sists principally of more or less acuminated papules, usually 
 small in size. This latter variety is usually found upon the face, 
 and especially upon the forehead. Most of the papules never 
 go on to form pustules. Then there is acne pustulosa, the fully 
 developed type and commonest form of the disease. The pus- 
 tules are rounded or acuminated, and, as before stated, the 
 amount of surrounding inflammation varies much in different 
 cases. They are formed rapidly, and are usually soon rup- 
 tured artificially ; when this does not occur they undergo a 
 slower desiccation. If the amount of perifollicular inflamma- 
 tion is great, the pustule is situated on a hard, sensitive and in- 
 flamed base, and the disease is called acne indurata. 
 
 Loss of tissue and subsequent scaring occur as a rule only 
 in the pustular form of the affection ; but occasionally we see 
 cases of papular acne in which pus never forms, but in which 
 
ACNE. 259 
 
 the papules, when they disappear, show a distinct loss of tissue 
 and leave a small depressed scar behind. This variety of the 
 disease is known as acne atrophica, and is usually very obstinate. 
 In acne hypertrophica the leucocytes in the perifollicular in- 
 flamed mass become organized, instead of forming pus ; new 
 connective tissue is formed, and a permanent hypertrophy re- 
 mains at the site of the papule. 
 
 Other varieties of acne are described. Thus there is 
 acne cachccticorum, which occurs in scrofulous and marasmic 
 individuals ; it appears as small, flat, livid red papules, or pus- 
 tules, not usually affecting the face. It has been seen in well- 
 nourished individuals suffering from psychic depression. It 
 usually lasts until the cause is removed. Again, irritations of 
 the sebaceous glands by medicinal substances, which reach the 
 follicles from without, being applied to the skin, or taken 
 internally and excreted through the sebaceous glands ; 
 as applications of tar, or any of its congeners, oil of cade, 
 ol. rusci, benzine, creosote, etc., cause an acne called a.picealis, 
 which is composed of pea-sized reddish-brown papules, with 
 a characteristic black point in their centre, a plug of tar oc- 
 cluding the mouth of the gland. Pustules and furuncles are 
 also present. It is seen most commonly upon the exterior sur- 
 faces of the limbs. The mere presence in a space impregnated 
 with the particles of these substances, or the breathing of their 
 vapor, is often sufficient to cause the eruption. The iodine 
 acne occurs from the use of the iodides, and is seen upon the 
 face as conical pustules upon a vivid red base. The presence 
 of iodine has been proved in the pus by Adam Kiewicz. The 
 bromine acne is sometimes very intense, besides the ordinary 
 pustules and papules there occurs a deep seated inflammatory 
 infiltration of the cutis, with destruction of the glands and fol- 
 licles. Thus there are seen diffuse infiltrations composed of 
 multitudes of closely packed acne pustules, after the opening 
 of which the whole surface presents a honey-combed appear- 
 ance, and goes on to unhealthy ulcerations ; also dark-brown 
 diffuse infiltrations, as large as a silver dollar, or even the palm 
 of the hand, etc. They leave scars in many cases. Bromine 
 
260 ACNE. 
 
 has been demonstrated by Gutman in the contents of the pus- 
 tules. 
 
 For further information upon the subject of these medicinal 
 eruptions, the reader is referred to the chapter on dermatitis. 
 
 Anatomy. — In the majority of cases of acne the inflamma- 
 tion is due to the retention of sebum within the sebaceous follicle 
 and its subsequent decomposition, which irritates the surround- 
 ing bloodvessels and sets up a perifolliculitis. If the inflamma- 
 tion is extensive, the gland is destroyed and perhaps also the hair 
 follicle. In the earliest stage of the disease there is bloodves- 
 
 FlG. 36. — Section of an acne pustule : a, cavity of sebaceous gland ; b, acinus 
 of the gland in a normal condition ; c, round cell infiltration ; d, hair follicle ; 
 e, subcutaneous tissue. 
 
 sel dilatation with exudation of serum and emigration of cor- 
 puscles. If the inflammation continues to increase the exuda- 
 tion will be purulent in character. In some cases the follicle 
 becomes destroyed by the serous exudation alone, as I have 
 observed in a case of atrophic acne. The sebaceous gland may 
 also be destroyed from changes occurring within the gland with- 
 out much perifolliculitis occurring, as seen in Fig. 36. 
 
 The hair follicles are not always affected in cases of acne, 
 but hairs are often found curled up within the dilated seba- 
 ceous gland cavity. As the first changes occur within the gland, 
 
ACNE. 26l 
 
 acne is therefore to be regarded as a folliculitis and in this re- 
 spect differs from a sycosis, which is primarily a perifolliculitis. 
 
 Etiology. — It is met with in both sexes and most frequently 
 at the age of puberty. Dyspepsia and other derangement of 
 the digestive and intestinal tract, and disorders of menstruation 
 or of the uterus are the principal causes of acne. Scrofula, 
 general debility, chlorosis, comedones and masturbation are un- 
 doubtedly frequent causes. Retention of sebaceous matter, 
 either from weakness of the muscle fibres of the skin, or from 
 inflammatory swelling from a neighboring follicle, is probably 
 an occasional cause. 
 
 Diagnosis. — The eruption may resemble a papular or pustu- 
 lar syphilide, or an acne rosacea. In syphilis the history of the 
 case ; the situation of the disease, the eruption being as a rule 
 general over the whole body, whilst acne is confined to the 
 face and shoulders ; the grouping of the papules or pustules, 
 and the duration of the individual lesions, the lesions in syph- 
 ilis being very chronic in their course, will generally enable one 
 to make a correct diagnosis. 
 
 The diagnosis from acne rosacea is given when discussing 
 the latter disease. 
 
 Prognosis. — The prognosis depends upon our ability to re- 
 move the cause. Generally the eruption is quickly removed, 
 but relapses are very liable to occur. 
 
 Treatment. — As we have learned, acne almost invariably 
 depends upon some abnormal condition of the intestinal canal 
 or of the uterus, and, consequently, as long as these conditions 
 exist, the eruption is liable to continue. The treatment of 
 acne, therefore, must be directed not only to the existing 
 eruption, but also to the cause, in order to prevent relapses 
 occurring. In fact, if we can remove the cause, the eruption 
 soon disappears, as the life of an individual papule or pustule 
 is very short, and the lesion disappears spontaneously in a 
 few days. The habits and constitution of the patient must be 
 carefully studied, and the cause of the eruption, if possible, 
 discovered. The digestive organs must be kept in a normal 
 condition by regulation of the diet and treatment of any 
 
262 ACNE. 
 
 abnormal condition. The manner in which this should be 
 done belongs to the domain of internal medicine, and need not 
 be dwelt upon here. Dyspepsia, of whatever kind, must be 
 cured, and the bowels regulated. In plethoric individuals, 
 Hunyadi Janos water, or a mixture of sulphate of magnesia in 
 a vegetable infusion, answers well. If the person is not 
 plethoric, and an acid dyspepsia is also present, the ordinary 
 rhubarb and soda mixture, combined or not with nux vomica, 
 or a vegetable bitter and an aromatic, as the compound tinc- 
 ture of cardamoms, together with regulation of diet, especially 
 as regards acids, tea, or coffee, and foods which give rise to 
 flatulence, is perhaps the best treatment. If anaemic or chlorotic, 
 iron and aloes may be prescribed. 
 
 If there is any uterine trouble, as inflammation or displace- 
 ment, these should unquestionably be treated if the acne 
 proves obstinate. As many of the cases of acne occur in young 
 unmarried females, the uterus can not, as a rule, receive local 
 treatment, and hence we are obliged to rely upon keeping the 
 intestinal tract normal, and prescribing such remedies as will 
 reduce the congestion of the uterus, if any be present. Vaginal 
 injections of hot or cold water, as the individual case requires, 
 and the internal administration of ergot, as first suggested for 
 this disease by Dr. Denslow, will generally prove effective. I 
 believe the benefit derived from ergot depends upon its action 
 on the uterus much more than upon the unstriped muscle fibres 
 of the skin, but whatever its action, it is certainly a valuable 
 remedy in the acne of females. I have not had any thing like 
 the same benefit from it in the case of males. The average 
 dose of the fluid extract is about half a drachm three times a 
 day, but it may be necessary to slightly increase or consider- 
 ably reduce this amount in many cases. Sulphide of lime in 
 small doses until its physiological effect has been produced, as 
 shown by hyperaemia and perhaps the formation of pustules, 
 is recommended by Piffard. Arsenic is sometimes of advan- 
 tage, but is not be relied upon. Glycerine, in doses of one 
 tablespoonful three times a day, is beneficial in some cases. 
 In acne indurata in anaemic, chlorotic, or scrofulous persons, 
 
ACNE. 263 
 
 there is nothing of so much advantage as cod-liver oil. It may- 
 be employed both externally and internally, and given alone 
 or with iron, as indicated in individual cases. These latter 
 cases also are benefited by good diet, pure air, etc. 
 
 Local Treatment. — Local treatment can remove the eruption, 
 but generally will not prevent relapses. It is to be regulated 
 according to to the pathological condition present. In acute 
 cases with considerable hyperemia, heat, redness, etc., sooth- 
 ing applications, as hot water, dusting powders, etc., should be 
 employed. In the subacute papular and pustular form the 
 eruption is generally treated by slightly stimulating applica- 
 tions, producing hyperaemia and the removal of the superficial 
 layers of the horny cells, and assisting the circulation of the 
 part. For this purpose green soap may be used in the follow- 
 ing manner. Wash the face thoroughly with green soap, or 
 green soap and alcohol in the proportion of two of soap to one 
 of alcohol (spiritus saponis kalinus, Hebra), using considerable 
 friction; then remove the soap with warm water and apply a 
 dusting powder, as bismuth or starch, or a non-irritating oint- 
 ment, as rose ointment. The strength of the soap solution 
 and the amount of friction to be employed are to be regulated 
 by the special irritability of the skin. Instead of green soap, 
 Vleminck's solution (calcis § iv., sulphur, sublim. § i., aqua 
 § x, boil to J vi., and filter) may be used. If there is much 
 induration the green soap may be spread upon a flannel and 
 applied over night, and washed off in the morning. This use 
 of green soap and emollient applications will remove the erup- 
 tion of a papular, pustular or indurated acne. The substance 
 most used for its stimulating effect and assistance in the excre- 
 tion of the sebaceous matter by removal of the upper layer of 
 horny cells is probably sublimed sulphur used as a powder, 
 lotion, or ointment. The sulphur can be used alone or 
 mixed with some inert powder, and dusted on the face. Kum- 
 merfeld's lotion (sulphur, precip. 3 xiv., pulv. camph. gr. x, 
 pulv. tragacanth. 3 i., aq. calcis, aq. rosse, aa f ii.), or Vlem- 
 inck's solution, 1 to 4 or 6 of water, may be used as a lotion, 
 or precipitated sulphur, 3 ss. to 3 ii. to the ounce of lard, as an 
 
264 ACNE. 
 
 ointment, to be well rubbed in at night. The iodide of 
 sulphur, 2 to 3 grains to the ounce of lard, or the hypochloride 
 of sulphur (sulphur, hypochloridi, 3 iss., potass carb., gr. x.; 
 adipis benz. J i., ol. amygdal., gtt. v.) ointment, as recommended 
 by Erasmus Wilson, may also be used. All these prepara- 
 tions have very similar action, and should be tried in cases of 
 chronic acne. Washing with green soap and, after drying, 
 using a i to 2 gr. solution of corrosive sublimate in alcohol is 
 useful in ordinary papular acne. If it is desired to make the 
 solution more astringent, sulphate of zinc, five grains to the 
 ounce, can be added. If there is much induration, the mer- 
 curial plaster or white precipitate ointment, spread on cloth, 
 should be applied every night. In cases of papular and pus- 
 tular acne without much induration, I use the following oint- 
 ment : Ung. zinci benz. § i., bismuthi. subnitratis 3 i., glycerini 
 3 i. If marked induration is present, the white precipitate 
 ointment, in the strength of 1 to 2 drachms to the ounce of the 
 ointment, or calomel 5 to 10 grains to the ounce, should be 
 added. Oleate of mercury applied to papules or tubercles 
 causes them to rapidly become pustules, and may be used on 
 indurated nodules. 
 
 Iodized glycerine (iodine, potass, iod., aa 1 part, glycerine 
 2 parts) applied twice a day and then waiting until the irrita- 
 tion subsides, to be again re-applied, is recommended by Ka- 
 posi. 
 
 By means of the dermal curette, applied with some force, the 
 top of papules and pustules may be torn off and the orifices of 
 the sebaceous glands opened. This opening of the orifices of 
 the ducts and the bleeding accompanying the operation pro- 
 duces in some cases markedly beneficial effects on the erup- 
 tion. It is indicated in chronic cases and it should be repeated 
 every three or four days, oil being applied after each scraping. 
 
 The eruption having been removed by any of the above 
 modes of treatment, relapses should be guarded against as 
 much as possible by attention to the diet, etc., and always 
 washing the face with hot water and a good soap. An oc- 
 casional solitary acne papule can not be prevented and re- 
 
ACNE ROSACEA. 265 
 
 quires no treatment beyond the prophylactic measures already 
 mentioned. 
 
 ACNE ROSACEA. 
 
 Syn. — Rosacea ; gutta rosea ; wine-nose ; brandy-nose. 
 
 Definition. — Acne rosacea is a chronic hyperasmic or inflam- 
 matory disease of the skin of the face, especially of the nose 
 and cheeks, characterized by a diffuse redness, by dilated 
 bloodvessels, by soft reddish acne-formed papules, and event- 
 ually by hypertrophy of the integument of the part. 
 
 Symptoms. — Rosacea is a very common affection of the skin 
 of the nose, chin, cheeks, and forehead, and occurs in three 
 forms, or rather three stages, which merge into one an- 
 other. 
 
 In the first and earliest stage there is noticed a diffuse 
 redness of the nose, perhaps also of the forehead, cheeks, and 
 even ears. There occurs a passive hyperemia of the parts ; 
 the blood circulates slowly through the capillaries and is in- 
 clined to stasis. The surface is cold, the circulation is slug- 
 gish, and more or less seborrhcea is often present at the same 
 time. The redness fades off into the normal skin ; it is not 
 permanent ; it becomes deeper and even purplish in hue dur- 
 ing winter, or when exposed to sudden changes of temperature ; 
 it is also more marked after eating or drinking, and in women 
 during the menstrual period. When thus exacerbated some 
 heat and burning may be felt in the part. At times it may 
 fade away entirely, leaving the skin in an apparently normal 
 condition. It may remain for months or years in this state, 
 and then disappear entirely, or it may become worse and 
 develop into the next stage. 
 
 After a variable period the redness becomes permanent, and 
 the second stage begins. Dilatation of the cutaneous bloodvessels 
 appears and they are to be seen as delicate red lines branching 
 in various directions through the superficial layers. Individual 
 vessels may become greatly developed, so as to be visible at 
 some distance ; they are usually largest and most numerous on 
 the alae, nose, and cheeks. Eventually acne papules and pus- 
 
266 ACNE ROSACEA. 
 
 tules appear over the affected area. They show themselves as 
 vivid red, painless, elastic elevations of the size, perhaps, of a 
 small pea, and situated upon the erythematous surface. They 
 are usually only few in number, but there may be many of 
 them closely crowded in exceptional cases. Over their tops 
 the hypertrophied radicles of the cutaneous vessels ramify. 
 Pustules also are occasionally present. In this permanent 
 condition the part may remain for years, varying, as in the 
 first stage, from time to time, but never spontaneously dis- 
 appearing. At length the third and last stage sets in. 
 
 The third or highest degree of acne rosacea is much less 
 common than the other two. The passive hypersemia continues ; 
 the bloodvessels become larger and probably more numerous ; 
 the glands are enlarged, and hypertrophy of the connective 
 tissue of the affected skin sets in. Round or irregular 
 elastic outgrowths gradually appear upon the part, covered 
 with a plexus of dilated bloodvessels, and studded with 
 comedones and acne pustules. The nose is almost exclu- 
 sively the part affected, and the gradual hypertrophy may 
 cause it in the course of years to attain monstrous propor- 
 tions. The alae may project downward till they touch the 
 upper lip, and the lip become irregularly lobulated and pen- 
 dulous until it overhangs the mouth. At first the hyper- 
 trophied part is of a dark red or livid color, but eventually, in 
 old age, it again becomes white. It forms the well known 
 " brandy nose," or rhinophyma, occasionally seen here, but 
 commoner in other parts of the world, especially in wine grow- 
 ing districts. 
 
 Acne rosacea is always a chronic disease and may last for 
 many years. It occurs in both sexes, but is commoner, se- 
 verer, and more extensive among men than among women. It 
 may remain permanently in any one of its stages. Its limit- 
 ation to the centre of the face, forehead, nose, cheeks, and 
 chin is very characteristic, though some cases have been seen 
 in which it spread from the side of the face on to the neck. In 
 the early stages, where the passive hyperaemia is the marked 
 feature, the part is colder than normal ; but when the acne 
 
ACNE ROSACEA. 267 
 
 lesions are abundantly present, it feels warm to the touch. 
 Subjective symptoms are almost always absent. 
 
 Anatomy. — In the first stage there is hyperaemic stasis of the 
 bloodvessels. In the second stage there is hypertrophy of the 
 bloodvessels and of the sebaceous glands. In the third stage 
 there is, in addition to the above changes, also hypertrophy of 
 the connective tissue of the corium. Whether there is a new 
 formation of bloodvessels or only a dilatation and hypertrophy 
 of the existing ones is not known. The epidermis does not 
 take part in the hypertrophy. 
 
 Etiology. — Acne rosacea is met with in both sexes, but is 
 more frequent in men than in women. In men it arises from 
 digestive disorders, as dyspepsia, constipation, etc.; the habit- 
 ual use of spirituous liquors; exposure to wind and weather, 
 and, occasionally, from the excessive use of cold baths. In 
 women it is met with in early life and during the climacteric 
 period and is almost invariably associated with disorders of the 
 intestinal tract or of the uterus. When occurring at the early 
 period of life it is frequently associated with seborrhoea. 
 
 Diagnosis. — The disease may be confounded with a tuber- 
 cular syphilide, acne vulgaris, lupus erythematosus or lupus 
 vulgaris. In syphilis the tubercles are generally of a darker 
 brown color, they are not symmetrical but often grouped, the 
 sebaceous glands do not became inflamed, the bloodvessels are 
 not enlarged, ulceration and crusting occurs, and the mucous 
 membrane or cartilages of the nose are frequently affected. In 
 acne rosacea the process is a slower one, but the color of the 
 tubercles is usually not so dark brown, the course of the erup- 
 tion is very slow, the sebaceous glands are frequently inflamed, 
 there is never any ulceration-, the cartilages are not destroyed, 
 and the eruption is more or less symmetrical. The history of 
 the case and the condition of the skin on the rest of the body 
 will assist in the diagnosis. 
 
 In acne vulgaris there is no permanent dilatation of the 
 bloodvessels, the eruption is more acute in its course, and there 
 is generally a considerable number of comedones, papules and 
 pustules present, whereas in acne rosacea the tubercles or pus- 
 
268 ACNE ROSACEA. 
 
 tules are few in number, slow in formation and much larger in 
 size. In erythematous lupus there are no pustules, the disease 
 is very slow in its course, there are a few firmly adherent thin 
 scales with sebaceous plugs attached to their under surface pres- 
 ent, and cicatricial tissue formation invariably occurs ; in acne 
 rosacea there are pustules and no firmly adherent thin scales or 
 cicatricial tissue present. In lupus vulgaris the soft non- 
 elevated papules, the tendency of the eruption to spread at the 
 periphery, the absence of dilated or hypertrophied blood- 
 vessels, the degeneration, ulceration and cicatricial tissue for- 
 mation are sufficient for the diagnosis. 
 
 Prognosis. — If the disease has passed to the third stage the 
 prognosis is not very favorable, but if in the first stage and the 
 cause can be removed, the eruption will disappear. 
 
 Treatment. — The constitutional treatment is the same as that 
 for acne vulgaris. Any digestive or intestinal trouble or displace- 
 ment of the uterus should receive proper treatment. It is impos- 
 sible to cure the disease unless these organs are in a fairly normal 
 condition. Proper food, the avoidance of every thing indigestible, 
 and pure air are necessary. Tea or coffee should only be taken 
 in moderation or not at all, and spirituous liquors, wine or beer 
 should be avoided. Ergot internally is often of decided 
 benefit. 
 
 The local treatment depends upon the stage of the disease. 
 In the early stage it is the same as that for acne vulgaris and 
 need not be repeated. Later the object is to reduce the 
 hypersemia, and remove the tubercles and dilated bloodvessels. 
 The tubercles are to be removed by a mercurial plaster, or in 
 the manner recommended for acne vulgaris. If there are a few 
 dilated bloodvessels they may be cut with a bistoury, and warm 
 water afterward applied to promote bleeding. It may be neces- 
 sary to perform the operation a great number of times, as new 
 vessels generally appear every few days. If there is a diffuse 
 redness from dilatation of a great number of vessels, the part 
 may be scarified by making a number of parallel superficial 
 cuts with a fine bistoury, or the bloodvessels may be torn with 
 a dermal curette and the bleeding stopped by compression with 
 
SYCOSIS. 269 
 
 charpie. Destruction of the vessels by electrolysis has been 
 recommended. Redundant tissue may require removal by the 
 knife or scissors. 
 
 SYCOSIS. 
 
 Syn. — Sycosis barbae (Celsus); mentagra (Plenck); dartre 
 pustuleuse mentagre, herpes pustolosus mentagra (Alibert); 
 folliculitis barbae (Kobner); acne mentagra ; lichen menti. 
 
 Definition. — Sycosis is a chronic non-contagious perifollicular 
 inflammation involving the hair follicle in its course, appearing 
 chiefly upon the bearded part of the face, and characterized by 
 papules, tubercles and pustules which are invariably perforated 
 by hairs. 
 
 Symptoms. — Sycosis appears only on those parts of the body 
 which are supplied with hair, and is almost always confined to 
 the bearded part of the face. Sometimes it is limited to the 
 upper lip, or to the side of the chin, or to a part only of the 
 submaxillary region. It has been observed, though rarely, 
 upon other parts of the body. The parts most frequently 
 attacked after the bearded part of the face are the eyebrows, 
 then the scalp, and, lastly, the other hairy parts of the body, 
 especially the axillae and pubis. 
 
 The eruption in the majority of cases is preceded by a 
 chronic moist or dry eczema ; sometimes only a chronic 
 hyperaemia is present, or an over-irritability of the cutaneous 
 tissue. When it appears primarily on the upper lip, it is 
 usually preceded by a nasal catarrh, the discharge from the 
 nose irritating the skin, and producing a congestion or an 
 eczema, which, in its turn, is followed or accompanied by 
 sycosis. Here it generally remains limited in area, rarely ex- 
 tending to the cheeks. 
 
 Sycosis of the beard is generally ushered in with some- 
 what severe local symptoms. It is preceded or accompan- 
 ied by a feeling of heat, smarting, and a painful, pricking 
 sensation, with swelling or intumescence of the part. Some- 
 times the attack is so severe, and the local inflammation so 
 
270 SYCOSIS. 
 
 great, as to produce swelling of the lymphatic glands in the 
 neck. The eruption makes its appearance in the form of 
 papules and tubercles of greater or less size, ranging from 
 that of a millet seed to that of a pea, isolated or collected 
 in groups. 
 
 In acute cases, and with the first outbreak of the eruption, 
 the tubercles are generally seated near each other ; but in 
 chronic cases the local symptoms are not so severe, and the 
 papules and tubercles are oftener isolated and fewer in number. 
 In subsequent outbreaks new papules and tubercles appear, 
 and, if seated in the same locality, may unite with the former 
 ones and form connected infiltrations. This occurs only 
 where the eruption is seated on parts thickly studded with 
 hairs, and a considerable number of the follicles are affected 
 by the inflammation. The eruption from a single outbreak 
 rarely appears over a large surface, and subsequent attacks are 
 not necessarily confined to the same location. The papules 
 and tubercles are of a red color, somewhat conical in shape, 
 and generally elevated. They afterward increase in size and 
 the majority become converted into pustules. In scrofulous 
 individuals the pus formation proceeds slower and is not so 
 abundant as in the robust ; in chronic cases it also forms 
 slower than in acute attacks ; and, lastly, it collects usually 
 more rapidly in the perifollicular region of stiff hairs than in 
 that of fine ones. Each papule, tubercle, or pustule, whether 
 raised above the level of the skin or not, is perforated through 
 its centre by a hair. This perforation is characteristic of the 
 disease and is our principal aid in forming a diagnosis. If the 
 hairs are not shaven, the pus dries into crusts ; these crusts are 
 generally thin and isolated, seldom forming thick crusts like 
 those of impetiginous eczema. Upon their removal, a circular 
 funnel-shaped excavation is observed, with a hair in the centre 
 and the base formed of pus. From the inflamed condition of 
 the tissue surrounding the hair during the papular stage great 
 pain is caused by epilation ; but in the late pustular stage the 
 hairs lie loosely in the follicle and are easily extracted. If not 
 removed the ever increasing accumulation of pus around and 
 
SYCOSIS. 271 
 
 within the follicle, and its subsequent movement to the surface 
 through the space previously occupied by the hair-sheaths, or 
 the immediate surrounding tissue, finally expels the hairs, and 
 the part heals with or without cicatricial tissue formation. If 
 the hair follicle is completely destroyed by the inflammatory 
 process, permanent alopecia will result. Sometimes the inflam- 
 mation is such that there is complete destruction of the cutis, 
 hair follicles and sebaceous glands, and healing by cicatricial 
 tissue. This, however, rarely occurs, and the only evil result 
 generally of even a long continued chronic sycosis is destruc- 
 tion of the hair follicles and sebaceous glands, with consequent 
 permanent alopecia. Even this, to any considerable extent, 
 is not a frequent occurrence ; yet a limited number of follicles 
 are usually destroyed, if the suppuration has been at all ex- 
 tensive, and epilation not performed at the proper time. 
 
 The papules, tubercles, and pustules are generally isolated ; 
 but sometimes they are collected, and accompanied by infiltra- 
 tion in the intervening skin and subcutaneous tissue. This 
 occurs only when the affected part is provided with numerous 
 hairs, or in acute attacks accompanied with considerable local 
 inflammation. When they are thus united by infiltrations, 
 papules or tubercles no longer arise in that region as long as 
 the infiltration exists to any considerable extent ; but new 
 pustules arise in the infiltrated tissue, and the pus, passing to 
 the surface, becomes dried up, forming brownish or yellowish 
 scabs, perforated with hairs. On removal of these scabs, 
 we find underneath, as in the case of the scabs formed on 
 isolated pustules, circular, funnel-shaped excavations, cor- 
 responding in number to that of the follicles, and each 
 excavation is perforated by a hair unless this has been ex- 
 tracted in the removal of the crust. 
 
 In no case does the peri-folliculitis occur around all the 
 follicles of an affected area, but only around a few, and those 
 often the more deeply seated ones. The disease is usually a 
 chronic one, lasting weeks or even years, and is prolonged by 
 successive outbreaks occurring at irregular periods, each out- 
 break, after having completed the pustular stage, to be sue- 
 
272 SYCOSIS. 
 
 ceeded by a similar eruption upon the same or some other 
 region, and so on. Upon the termination of the disease the 
 part regains its normal character, or there may be more or less 
 permanent alopecia or scars. 
 
 Etiology. — The disease usually occurs between the ages of 
 twenty-five and fifty ; generally it is preceded by eczema or 
 chronic hyperemia, or the skin is in irritable condition from 
 internal or external causes. The stiffer the hair the more 
 easily do they produce a perifolliculitis. Any thing that pro- 
 duces deranged circulation, or increased irritability of the skin 
 can cause the disease ; thus, shaving, especially with a dull 
 razor, eczema, exposure to strong rays of heat, dusty sub- 
 stances, irritating powders, cosmetics, etc., etc. These all act 
 in the same way, producing an irritable condition of the skin, 
 and the stiff hairs acting upon' this irritable skin produce an 
 inflammation in their immediate neighborhood — a perifollicu- 
 litis. The stiffer the hair the more liable is it to produce an 
 inflammation. 
 
 Pathology. — Sycosis is primarily a peri-follicular inflammation 
 of the skin. The first changes which take place occur around 
 the follicle in the peri-follicular region, and are those which are 
 usually observed in vascular connective tissue inflammations. 
 The transuded serum penetrates the hair follicle, and, as the 
 inflammation proceeds and the pus and serum increases in 
 quantity, the follicle becomes more and more affected. Its 
 sheaths become softened and more or less destroyed, and a 
 portion of the pus may enter the follicle through the rup- 
 tured sheaths. The cells of the external root sheath become 
 swollen and soon begin to break down, similar changes 
 occur in the cells of the hair root ; they swell, the proto- 
 plasm becomes more granular in appearance, and there is 
 evidence of commencing destruction. After the rupture of 
 the follicle sheaths, or even before, the cells of the hair root 
 and of the root sheaths rapidly become broken up and changed 
 by the transuded serum entering the follicle. If pus corpuscles 
 have also entered the follicle the hair root is infiltrated with a 
 sero-purulent matter ; it does not, however, in every case enter it 
 
SYCOSIS. 273 
 
 in large amount. In the pustular stage the principal changes 
 take place within the follicle ; the hair root and its sheaths 
 are broken down and separated from the follicle sheaths, so 
 that the hair lies loosely within the follicle, and can be easily 
 extracted. 
 
 Explanation of Fig. 37. — Early appearance of the pustular stage. Round 
 bodies — pus corpuscles — are present in great number around the fundus of the 
 follicle, and the follicle-sheaths and external root-sheath are partly broken down 
 and separated. Toward the neck of the follicle the changes are less and less. 
 
 As the inflammation progresses the connective tissue around 
 the follicle becomes crowded with pus cells as far as the sur- 
 face of the skin. If the hair is allowed to remain within the 
 follicle until expelled by the accumulating pus, the root-sheaths 
 and soft parts of the hair are destroyed, and only the hard part 
 remains. The follicle-sheath, and the peri-follicular tissue are 
 more or less destroyed, and the Malpighian layer becomes rup- 
 18 
 
2 74 sycosis. 
 
 tured at the neck of the follicle. The pus reaches the surface by 
 breaking through the epidermis near the hair. Some occasionally 
 passes to the surface between the hair-shaft and the follicle- 
 sheath. The cells from which the hair grows seem to resist 
 the inflammatory process more than the other cells of the 
 bulb, which accounts for the slight amount of permanent 
 alopecia generally occuring in sycosis. The cavity left after 
 the extraction of a hair whose follicle is not completely de- 
 
 Explanation of fig. 38 — Shows the nature of the cavity, when permanent alopecia 
 results. The entire follicle is destroyed. 
 
 stroyed, contains pus along its entire walls and base. The 
 follicle-sheaths are more or less destroyed, but the papilla re- 
 mains from which a new hair will grow. When permanent 
 alopecia results, both the follicle-sheaths and the base of the 
 follicle are completely destroyed as shown in figure 38. 
 
 Such a cavity becomes obliterated by cicatricial tissue. 
 
 Such are the pathological changes occurring in simple un- 
 
SYCOSIS 275 
 
 complicated sycosis ; if eczema is present the changes are the 
 same, but the root-sheaths, and follicle-sheaths are acted upon 
 in their entire length at the same time. 
 
 The sebaceous glands may also become affected, though not 
 at so early a stage of the disease as the fundus of the hair, and 
 the whole gland may be destroyed by a process of molecular 
 retrograde degeneration. The sweat glands generally escape, 
 but the epithelial cells may become detached or the gland 
 even destroyed. In the most severe form of sycosis, there is 
 more or less destruction of the hair- follicles, sebaceous, and 
 sweat glands, and of the other tissues of the part, and substitu- 
 tion by cicitrical tissue. 
 
 Diagnosis. — There are few diseases of the skin whose 
 characters are more sharply defined than those of sycosis, yet 
 some other diseases are frequently regarded as sycosis merely 
 because they are located on the bearded part of the face. It 
 is not a frequent disease, and hence the chances are that an 
 eruption, when seated on the face, is not sycosis, but one of the 
 more frequent diseases of this region, as eczema or acne. The 
 diseases with which it is generally confounded are tinea tricho- 
 phytina barbae (sycosis parasitica), acne, eczema and syphilis. 
 
 Tinea trichophytina barbae is a parasitic affection, the fungus 
 being that of ordinary ringworm, the characteristics of the 
 eruption depending upon the anatomical characters of its seat. 
 The fungus passes down into the hair follicle, then into the 
 shaft of the hair, and even outside the follicle. It is easily de- 
 tected in recently altered hairs, but generally absent where 
 much pus is present. It is generally preceded by a red, itch- 
 ing, or scaly spot of ringworm. The tubercles present arise 
 without the pricking, burning sensation present in sycosis, and 
 are produced continuously and not by " outbreaks." The 
 hairs are early affected, becoming opaque, brittle, loose and 
 easily extracted. The part is much indurated, and the tuber- 
 cles are larger than in sycosis. In the majority of the cases I 
 have seen, the tubercles were large, prominent and studded 
 with hairs which lay loose in the indurated mass. It begins 
 imperceptibly, proceeds slowly and steadily ; whilst sycosis 
 
276 SYCOSIS. 
 
 begins with severe local symptoms, pain and swelling of the 
 part, which soon subside, but reappear in a few days accom- 
 panied by a new outbreak of the eruption. When several 
 tubercles of the parasitic disease lie closely together they form 
 a circular mass, their margins are sharply limited, the surface 
 is uneven, fissured and studded with loose hairs ; the base is 
 broad, firm and lies deep in the subcutaneous tissue. Patches 
 of ringworm are also generally present on some other part of 
 the body or among the patient's companions. If any doubt 
 still remains, a microscopical examination of the proper hairs 
 will decide the point. 
 
 Acne is not confined to the bearded part of the face, but 
 appears on the forehead, nose, shoulders, etc. It is met with 
 generally in young persons, and the papules and pustules are 
 seldom perforated by hairs. 
 
 Syphilis is known by its concomitants, the arrangement of 
 the papules in rows, their dark color, slow development, ab- 
 sence of pain, and presence of the eruption on other parts of 
 the body. In an ulcerative syphilide, the loss of substance, 
 the shape of the ulcers, and the absence of pustules perforated 
 by hairs suffice for the diagnosis. 
 
 In eczema there is either a moist, red surface with itching 
 and exudation which dries to scabs, or there is only a harsh, 
 dry skin with furfuraceous desquamation. The eruption is not 
 limited to the parts provided with thick hairs, but is also 
 generally present on other parts of the face. If papules or 
 pustules are present they are not as a rule perforated by hairs, 
 though frequently a few such pustules are to be observed. In 
 uncomplicated sycosis all pustules are perforated by hairs. 
 
 Prognosis. — The natural duration of the disease varies greatly 
 in different persons ; sometimes it lasts only a few weeks whilst 
 in other cases it may continue months or even years. In 
 syphilitic and strumous subjects it is very obstinate. The 
 patient's occupation often controls the prognosis. The greater 
 the amount of pustulation, the greater is the liability of the 
 follicles to be destroyed, and permanent alopecia produced. 
 Relapses are very liable to occur ; though they may not, if the 
 
SYCOSIS. 277 
 
 exciting and predisposing causes be avoided. If the disease 
 depends upon the occupation of the person, a relapse is certain 
 to occur unless this be changed. 
 
 Treatment. — Though sycosis is a local disease, yet certain 
 conditions of the general system predispose to its development, 
 aggravate the disease when present, and prolong its duration. 
 These conditions must receive due attention if a rapid cure is 
 desired or relapses prevented. The general nutrition of the 
 patient must be attended to, and any morbid condition, as rheu- 
 matism, intestinal disorders, syphilis, struma requires its ap- 
 propriate treatment. A strumous condition of the system 
 especially aggravates the disease, and causes an unusual 
 amount of pus to be produced. Eczema, if present in the same 
 locality, must be treated simultaneously with the sycosis, as the 
 latter can not be cured without the removal of the former also. 
 In sycosis of the upper lip the disease is generally produced 
 and kept up by a nasal catarrh, and it is almost impossible 
 to cure the former so long as the discharge from the 
 latter continues to irritate the part. Relapses may 
 often be prevented by attention to the special predis- 
 posing cause at work in a given case. If the patient's 
 occupation plays an important part in producing the eruption, 
 it should, if possible, be changed. Exposure to excessive heat 
 or cold should be avoided, also the use of cosmetics, snuff, 
 and other irritating substances. Cleanliness is an excellent 
 prophylactic in this affection. When the disease is present, the 
 local treatment depends upon the condition of the part af- 
 fected. In the acute stage the treatment is that for acute 
 inflammation of the skin in general. Lead and opium solu- 
 tions, warm or cold water applications, as may be most agree- 
 able to the patient, or poultices should be applied, and this 
 antiphlogistic and soothing treatment continued until the 
 acute symptoms subside. Afterward we must still continue 
 to allay irritation of the skin, as this is the principal pre- 
 disposing cause of the eruption. We may use simple rose 
 ointment, which protects and prevents irritation from external 
 agents, or if the skin is not very irritable, combine with it 
 
278 SYCOSIS. 
 
 oxide of zinc in the strength of about twenty to forty grains to 
 the ounce of ointment. If the disease has lasted some time, 
 astringent ointments should be employed. Diachylon ointment, 
 either alone or in combination with zinc ointment, should be 
 used. The greater the irritability of the skin, the greater 
 should be the proportion of the zinc to the diachylon oint- 
 ment. In the more chronic stage our object should be to 
 reduce irritation, produce absorption of effused products, and 
 remove the existing inflammation. If scabs are present they 
 must be removed by poultices or oily applications before com- 
 mencing other treatment. If the patient has a long beard, and 
 will not permit its being removed, the sycosis will be much 
 more difficult to cure than if the beard is short, though its 
 presence is not an insuperable object to successful treatment. 
 Diachylon ointment is a most excellent remedy in this stage 
 also, and can be used alone or in combination with zinc oint- 
 ment, or if there is much inflammatory thickening present it is 
 better to add in addition the white precipitate ointment. We 
 frequently employ the following : 
 
 3- Ung. Diachylon (Hebra), 
 
 " Zinci Oxidi aa 3 iss 
 
 " Hydr. Ammon. Chlor. . . . 3 ill 
 
 Bismuthi Sub-Nit 3 iss 
 
 M. 
 
 Whether the part affected should be shaven or not before 
 applying the ointment, depends upon the individual case. If 
 shaving does not irritate the skin too much, it should be per- 
 formed. With many persons it is such a painful operation, 
 however, that it is much better to clip the hairs as short as pos- 
 sible with scissors. The ointment should be spread thickly 
 on cloth and bound on the part, as it then acts more powerfully 
 and efficiently than when simply rubbed in. 
 
 Ointments containing sublimed sulphur or the iodide of sul- 
 phur, in varying proportions, according to the amount of indu- 
 ration and irritability of the skin, are of service in some 
 chronic cases ; but must not be made too strong. 
 
SYCOSIS. 279 
 
 In strumous subjects the local application of cod liver oil, 
 often acts more beneficially than ointment of lead, sulphur or 
 mercury. The internal administration of sulphide of lime in 
 small doses, frequently repeated has been very strongly recom- 
 mended by some dermatologists (Piffard). 
 
 After the acute stage is passed epilation is not only very use- 
 ful in reducing inflammation, but is absolutely necessary in the 
 treatment if permanent alopecia is to be prevented. Some 
 authors say they derive but little benefit from it, but I believe, 
 if it is performed at the proper time, the result is most benefi- 
 cial. To remove the hairs during the papular stage while they 
 are still firmly seated in the follicle, increases temporarily the 
 irritation, as their extraction causes great pain ; but during the 
 pustular stage they are generally easily extracted, and when the 
 operation is performed not only has the pus a free exit but the 
 follicle is thereby frequently saved, and permanent alopecia 
 prevented. Though extraction during the papular stage causes 
 pain and temporarily increases the irritation, yet I believe the 
 evil resulting from the additional irritation thus produced is 
 more than counterbalanced by the good resulting from the free 
 exit allowed to the pent-up pus and the removal of the irrita- 
 ting hairs in the chronic stage. Fomenting the part with hot 
 water lessens the pain produced by the operation. In epila- 
 ting, but a single hair should be seized by the forceps at one 
 time, and traction made in the direction of the long axis of the 
 hair follicle. In cases of chronic circumscribed sycosis, it is 
 better to remove all the hairs from such a spot, even if the 
 operation causes considerable pain. 
 
 This removal of the hairs is a much better procedure than 
 opening the pustules with a knife. In the acute stage the hairs 
 should be extracted from the pustules only, and not from 
 the papules. After epilation has been performed the appropri- 
 ate ointment should then be applied twice in every twenty-four 
 hours, and kept constantly on the part. After the disease has 
 disappeared, the skin, if dry, or harsh or scaly, should be kept 
 soft by a mixture of glycerine, alcohol and water. We use the 
 following proportions : 
 
280 IMPETIGO. 
 
 5 . Glycerini '. . 3 ii. 
 
 Spir. vin. rect 3 vj. 
 
 Aqua Rosas \ hi. 
 
 Sig. To be applied two or three times a day. M. 
 
 This treatment, by sooothing applications in the acute stage 
 and epilation and astringent ointments, with or without the ad- 
 dition of a mercurial preparation, according to the amount of 
 infiltration present, and appropriate internal treatment, will cure 
 the majority of cases ; except the destructive form, in a short 
 time, provided the predisposing cause is removed. 
 
 IMPETIGO. 
 
 Definition. — An acute inflammatory affection of the skin, 
 characterized by the formation of isolated, rounded, elevated 
 pustules from the size of a split pea to half an inch or more in 
 diameter, seated upon a slightly inflamed, non-ulcerating base, 
 and healing without resulting pigmentation or scar. 
 
 Symptoms. — Most dermatologists regard impetigo as a variety 
 or complication of some other skin disease, but with 
 some others, I prefer to describe it as a separate affec- 
 tion. The eruption is sometimes preceded by slight febrile 
 symptoms, though they are never well marked. The lesion 
 commences as a vesico-pustule, and when fully formed is of the 
 size of a small split pea to that of half an inch or more, seated 
 upon a slightly inflamed base and surrounded by a slight areola. 
 The number present varies from one to twenty, thirty, or more 
 and they appear either simultaneously or successively. The 
 vesico-pustules soon become pustules, roundish in shape, eleva- 
 ted, well distended by the contents, somewhat acuminated, and 
 never umbilicated. Even when closely seated together they do 
 not tend to coalesce. The contents are at first sero purulent, 
 afterward purulent, or occasionally bloody, and yellow in color, 
 except when blood is present. The pustules have no tendency 
 to rupture, and the contents are either more or less absorbed, or 
 dry to thin yellowish crusts. Removal of the crust shows an 
 inflammatory non-ulcerating surface, secreting a thin puriform 
 
IMPETIGO. 281 
 
 liquid. When the dried crusts fall off there is an erythematous 
 base, which afterwards disappears without leaving pigmentation 
 or scar. Itching is generally very slight. The parts most fre- 
 quently attacked are the face, hands, feet and lower extremi- 
 ties, but the eruption may appear on any part of the body. 
 
 Anatomy. — Impetigo is a circumscribed superficial inflamma- 
 tion of the skin, the nutrition changes being limited to the 
 upper and papillary portion of the corium. It is especially a 
 corpuscular inflammation, the embryonic or pus corpuscles being 
 present in great numbers in comparison to the amount of serum. 
 The origin of these corpuscles is from the circulation and from 
 the tissue of the inflamed region, and not, as stated by Hyde, from 
 the corneous layer of the epidermis, as it is the latter which 
 forms the covering of the pustule. 
 
 Etiology. — The disease is met with almost exclusively in chil- 
 dren, and especially among those who are uncleanly and improp- 
 erly fed. I have noticed that the children frequently have an 
 acid dyspepsia or other digestive trouble. In a number of cases 
 it accompanied convalescence from some other disease. 
 
 Diagnosis. — The description I have given of impetigo cor- 
 responds with that given by Dr. Duhring, and is to be distin- 
 guished from impetigo contagiosa, ecthyma, pemphigus and 
 pustular eczema. 
 
 Impetigo contagiosa is primarily vesicular, the pustules are 
 flat, often umbilicated, and when closely seated tend to coalesce. 
 The pus is also auto-inoculable and contagious, and the eruption 
 is frequently present on several children in the same family or 
 society. 
 
 In ecthyma the pustules are flat, with a hard inflammatory 
 base and considerable areola. The crusts are flat, thick and 
 dark in color, and the skin beneath excoriated. 
 
 In eczema pustulosum the eruption is generally of long dura- 
 tion, and there is more or less infiltration of the skin, the pustules 
 are small, numerous, itch greatly, and tend to coalesce. 
 
 Prognosis. — The prognosis is favorable, as, with appropriate 
 treatment, the eruption soon disappears. 
 
 Treatment — The treatment is local and general. If the pus- 
 
282 IMPETIGO HERPETIFORMIS. 
 
 tules are distended they should be opened, the surface cleaned 
 with a disinfecting solution and an astringent, and protecting 
 salve, as zinc salve, with or without carbolic acid, applied. 
 Pure air, cleanliness and proper food should be ordered. 
 Special attention should be given to the condition of the intes- 
 tinal tract and any acid dyspepsia removed by proper food 
 and antacids. 
 
 IMPETIGO HERPETIFORMIS. 
 
 Definition. — An eruption characterized by the formation of 
 small yellow pustules, arranged in groups or rings, forming 
 patches which increase in size by new pustules forming about 
 the periphery ; the pustules dry to yellow flat scabs ; the skin 
 beneath being red, moist, and excoriated, but not ulcerating, 
 and the whole process accompanied by considerable constitu- 
 tional disturbance. 
 
 Symptoms.— This disease which is very rare — eight cases only 
 have been observed in the Vienna clinic — is met with almost 
 exclusively among pregnant women, and is characterized by the 
 development of pin-head sized opaque, later yellow, pustules, 
 which are arranged in groups or rings, to form small patches. 
 The pustules dry to dark brown scabs, whilst new pustules of 
 similar character arise and form one or more rings around the 
 periphery. These pustules also dry to scabs and unite with the 
 central scab. This arrangement of the pustules in the annular 
 form gives the eruption somewhat the appearance of a herpes 
 iris or circinatus. The skin beneath the crusts is covered with 
 new epidermis or is red, moist, infiltrated, excoriated, like in 
 eczema rubrum, smooth or papillary, but not ulcerating. 
 From the primary seats of eruption the disease spreads by the 
 formation of new pustules at the periphery of the constantly 
 enlarging patch. From this peripheral spreading neighboring 
 patches coalesce, and finally the eruption in three or four 
 months may cover a large area, and the cutaneous surface be 
 then swollen, hot. covered with crusts and having fissures or 
 excoriations. After several weeks' duration there may be spon- 
 
IMPETIGO HERPETIFORMIS. 283 
 
 taneous cure of the parts first attacked, with an outbreak on 
 previously healthy places. 
 
 The eruption appears especially on the anterior surface of the 
 abdomen and inner surface of the thigh, but may appear on 
 other situations, and has been observed on the mucous mem- 
 brane of the tongue, forming a circumscribed gray patch with 
 depressed centre. In Hebra's cases, there was a continuous 
 remitting fever, with intercurrent rigors, and high fever and dry 
 tongue, preceding a new outbreak of pustules. 
 
 Dr. Duhring describes several cases of a milder form of this 
 disease, the eruption being vesicular and bullous, or pustular, 
 or pustular and bullous combined, or these lesions alternating. 
 The pustules showed a tendency to group and the patch to 
 extend by peripheral new formation of pustules. The amount 
 of constitutional disturbance was variable, the itching was 
 intense, there was a tendency to recurrence of the eruption, 
 and the cases were in non-pregnant women. I have lately 
 observed a well-marked case of this eruption in a boy ten years 
 of age, in whom the eruption consisted of papules, vesicles, 
 pustules and bullae. The spots spread by the formation of 
 vesicles in a ring form around the central papule, vesicle or 
 bulla, or spread as in cases of ringworm. The vesicles or bullae 
 contained at first clear liquid, which afterward became purulent 
 and finally dried to crusts. The eruption was general over the 
 whole body except the palms of the hands and soles of the 
 feet, and the bullous form was much more marked on the ante- 
 rior than on the posterior surface of the body. 
 
 Dr. Heitzman has described a case occurring in a woman at 
 the climacteric period, in whom, during the first ten weeks of the 
 disease the eruption was that of impetigo herpetiformis, and 
 afterward resembled that of an ordinary pemphigus. The case 
 proceeded to a fatal termination. 
 
 Anatomy. — Newman found in one case dilatation of the veins 
 and lymphatics, round cell infiltration in the cutis, and the cells 
 of the sweat glands increased. 
 
 Etiology. — As it occurs almost exclusively in pregnant women, 
 it probably has some relation to the condition of the nervous 
 
284 ECTHYMA. 
 
 system. Heitzman s case would show a close relationship with 
 the causes of pemphigus. 
 
 Diagnosis. — The eruption is to be diagnosed from herpes, 
 eczema and pemphigus. 
 
 In herpes the eruption consists of groups of vesicles, and not 
 pustules, with a typical course and localized on certain parts 
 of the body. 
 
 Eczema is a papular or vesicular eruption, and the disease 
 never spreads by annularly arranged pustules. There is also no 
 constitutional disturbance. 
 
 In pemphigus the size of the bullae, their manner of origin 
 their location and the history of the case are sufficient for the 
 diagnosis. 
 
 Prognosis. — Nearly all of Hebra's cases died within a period 
 of from one to three months. The foetus was prematurely ex- 
 pelled, but that did not have any effect upon the course of the 
 disease. 
 
 Treatment. — The treatment must be conducted upon general 
 principles, until we know more of the etiology of the disease. 
 The uterus should probably be emptied as soon as possible, and 
 the general nutrition maintained to resist the effects of the 
 remittent fever. Hebra's treatment consisted in cold applica- 
 tions, continuous baths, salves and general measures, but it did 
 not have any favorable effect upon the disease. 
 
 ECTHYMA. 
 
 Definition. — An inflammatory affection, cnaracterized by the 
 formation of a variable number of generally large, isolated, flat 
 pustules, seated upon a hard, deep-seated inflammatory base ; 
 the pus drying to hard, dark colored, firmly adherent scabs, 
 beneath which there is superficial ulceration, followed generally 
 by pigmentation and slight cicatrices. 
 
 Symptoms.— Many dermatologists deny the existence of 
 ecthyma as a special cutaneous disease, preferring to regard 
 it as an accidental and secondary condition to other affections. 
 The pustules possess, however, sufficiently defined characters to 
 
ECTHYMA. 285 
 
 entitle them to a separate description and name even if they 
 were always, which they are not, the consequence of some other 
 skin disorder. 
 
 The eruption may appear on any part of the body, but it is 
 most frequently observed upon the extremities, and especially 
 upon the lower ones. In children it is often seen upon the chest 
 and back. 
 
 Its course is either acute or chronic. In acute ecthyma the 
 eruption is sometimes ushered in by febrile symptoms, together 
 with heat, itching and pain at the seat where the pustules will 
 arise. These places are at first reddish raised spots, from the 
 size of a pea to an inch or more in diameter, or even larger, 
 which quickly pustulate and in a few days discharge, the pus 
 drying to a hard, thick, firmly adherent scab. The pustules are 
 few or numerous, isolated, roundish in form,' sharply limited, and 
 the scab varies in color from yellow to a very dark brown, depend- 
 ing upon the amount of blood intermixed with the pus, and is 
 firmly adherent to the inflamed skin beneath. Upon removal of 
 the scab there is seen to be superficial ulceration of the skin 
 present ; the secretion is generally of a yellowish, purulent, 
 tenacious character, upon the removal of which the base of the 
 ulcer presents an inflammatory granulating surface. When the 
 scab is cast off in the healing process a slight cicatrix and pig- 
 mented spot remain, which afterward disappear. 
 
 The pustule is seated upon a hard, inflammatory base, and 
 the surrounding areola is generally of considerable extent, of a 
 bright reddish color and tender to the touch. The lesions ap- 
 pear either simultaneously or successively, and the whole pro- 
 cess may last two or three weeks or longer. In cachectic per- 
 sons the pustules are large, the areola broad, and dark red in 
 color, the scabs dark-colored, and the secretion beneath of a sa- 
 nious character. 
 
 In chronic ecthyma the pustules are of the same character 
 and occur in the same situations as in the acute form, and is 
 the condition generally met with, acute ecthyma being rarely 
 observed. It is nearly always the consequence of some other 
 pathological condition of the skin ; the exciting cause being 
 
286 ECTHYMA. 
 
 generally direct irritation from scratching in persons badly- 
 nourished or affected with scabies, pediculi, etc. The pustules 
 are developed successively and the disease may last as long as 
 the original predisposing affection. When seated on the lower 
 extremities of old and badly nourished subjects, chronic ulcers 
 may result. 
 
 Anatomy. — Ecthyma consists in an acute intense inflamma- 
 tion of the upper layers of the derma, attended by slight loss of 
 sub-epidermal tissue, an inflammation more intense and destruc- 
 tive than that of impetigo, and not so deep as in furunculus. 
 It is a pustular inflammation from the commencement, with the 
 ordinary nutrition changes occurring in vascular connective tis- 
 sue inflammation, the amount of pus production depending upon 
 the intensity of the inflammation, and the condition of general 
 nutrition of the individual. The affected part heals by cica- 
 trization, and the spot is often temporarily darkly pigmented. 
 
 Etiology. — The causes are predisposing and exciting. The 
 predisposing causes are all those which lead to mal-nutrition, 
 as insufficient or improper food, bad air, uncleanliness, 
 etc. I have seen a number of cases in children's hospitals 
 from bad air and improper food with consequent deranged di- 
 gestive system. The exciting causes are those of dermatitis in 
 general, as heat, scratching, pediculi ; irritation, in grocers from 
 sugar, and in bricklayers from lime. It is often met with in 
 scabies, especially upon the buttocks, and rarely in eczema. 
 
 Diagnosis. — Ecthyma can be confounded with impetigo, 
 impetigo contagiosa, impetigo herpetiformis, eczema pustulo- 
 sum, furunculus and flat pustular syphiloderm. 
 
 In impetigo the inflammation is more superficial, the pustules 
 are sero-purulent, rounded, elevated ; the discharge yellowish, 
 viscid ; the scabs light colored, softer and not firmly adherent 
 to the skin beneath. There is no loss of derma, no hard indu- 
 rated base and only a slight areola. The pustules are gener- 
 ally numerous, and often confluent. 
 
 In impetigo contagiosa, the lesion is a vesico-pustule, with a 
 slight areola, the crust is superficial, flat, roundish, yellowish, or 
 straw-colored, and but slightly adherent. 
 
ECTHYMA. 287 
 
 In impetigo herpetiformis the arrangement of the lesions in 
 groups, or in an annular form, their mode of spreading peri- 
 pherically, their tendency to become confluent and the superfi- 
 cial character of the process make the diagnosis between the 
 two diseases easy. 
 
 In furunculus the inflammation is deeper, there is more loss 
 of tissue, there is a central core, the course is slower, and there 
 is little or no scab formed. 
 
 In the flat pustular syphiloderm, the inflammatory symptoms 
 are much less intense, pus forms much slower and dries to 
 thicker scabs, often arranged as superimposed layers, like an 
 oyster shell, the ulceration is deeper, the base dirty-looking 
 and covered by a thick puriform secretion. Other symptoms 
 of syphilis are also always present on other parts of the body. 
 
 Pi'Ggnosis. — The prognosis is favorable, the cause being gen- 
 erally removable. When occurring in cachectic persons, and 
 not the result of uncleanliness or pediculi, the disease may last 
 a considerable time. 
 
 Treatment. — The treatment is general and local, the former 
 being of more importance than the latter. The general treat- 
 ment has for its object the removal of the predisposing causes 
 and the improvement of the general nutrition of the body. The 
 etiology of the disease is to be our guide. Pure air, change of 
 climate, large, well ventilated rooms, bathing, recreation, cleanli- 
 ness, good diet, especially easily digested animal food, and in 
 some chronic cases in old persons claret wine, are requisite. In 
 children special attention must be directed to the intestinal 
 tract and food of the proper quality and quantity given. Acid 
 dyspepsia or indigestion must be removed. 
 
 In chronic cases especially, in addition to the hygienic means 
 enumerated above, medicines of the tonic class are to be given. 
 Iron, quinine, strychnine, hypophosphites, the bitter vegetable 
 tonics or mineral acids are to be prescribed according to the 
 special indications in individual cases. All the organs of vege- 
 table life should perform their physiological functions normal- 
 ly, digestion should be easy and the bowels act regularly. If the 
 patient's occupation is the exciting cause, as in the case of 
 
288 PITYRIASIS RUBRA. 
 
 grocers and bricklayers, it may be necessary for a time to relin- 
 quish it. 
 
 The local treatment depends upon the cause and upon the 
 condition of the part. If the disease is the result of scabies or 
 pediculi in an ill-nourished subject they must be removed, upon 
 which pustules will probably cease to form. In the acute 
 stage, alkaline baths, emollients, anodyne applications, as a so- 
 lution of lead and opium may be employed. When crusts 
 have formed they should be removed, the base of the ulcer dis- 
 infected with a solution of carbolic acid or with iodoform, and 
 an ointment of oxide of zinc applied. Generally zinc oint- 
 ment, with ten drops of carbolic acid to the ounce of ointment 
 is the only application necessary. The ointment should be 
 changed two or three times a day. Plasters should not be 
 applied. 
 
 PITYRIASIS RUBRA. 
 
 Syn. — Dermatitis exfoliativa. (Wilson.) 
 
 Definition* — An inflammatory disease, involving in its course 
 generally the whole surface, and characterized by its deep red 
 color, absence of papules, vesicles or moist exudation, and by 
 an abundant exfoliation of thin whitish scales. 
 
 Symptoms. — This is a rare disease, appearing first generally 
 on the body, and begins as red, scaly, rather circumscribed 
 patches and spreads rapidly over the greater part or whole of 
 the body. When fully developed the skin appears of a uni- 
 form deep red color, disappearing partly upon pressure, leaving 
 behind a yellowish tinge. The affected part is covered by 
 very thin, whitish scales, which are rapidly and continuously 
 formed and exfoliated. The scales in many cases are very 
 large, some being an inch or more in diameter and attached to 
 the skin by the central part only. In other cases they are 
 branny in character. The skin of the palms of hands and 
 soles of feet is pale or injected and covered with a layer of 
 shining epidermis. If removed, the skin beneath has a shining 
 aspect, without any signs of moist exudation. In severe cases 
 
PITYRIASIS RUBRA. 289 
 
 the amount of scales exfoliated in 24 hours may amount to 
 two or three handfuls. The amount, however, varies very 
 greatly in different cases and at different times in the same case. 
 The skin is not thickened except in some chronic cases, though 
 there is probably always some exudation present. Sometimes 
 oedema of the lower extremities occurs, which perhaps 
 depends upon the condition of the kidneys or general system. 
 The nails are frequently attacked and become uneven and 
 opaque and even softened. Itching in many cases is very 
 slight, but the patients complain of tenderness of the skin and 
 suffer from cold or chilliness. The temperature is elevated. 
 The disease may be acute or chronic, lasting months or 
 years. 
 
 In the severe cases it proceeds after a few years to atrophic 
 changes in the skin, rendering it too small for the body. In 
 consequence of the tension of the skin the mouth can be only 
 imperfectly opened, the lower eyelids become ectropic, the fin- 
 gers half bent ; on the extensor surfaces of the knee and 
 elbow the skin is smooth, shining, thinned and difficult to raise 
 in a fold, also the skin of the soles of the feet, preventing walk- 
 ing on account of the pain. The hair of the whole body 
 becomes thin and falls out, the nails become thin and brittle, 
 or thickened and caseous degenerated. (Kaposi). These cases 
 die of marasmus, with or without complicating pneumonia, 
 diarrhoea or tuberculosis. In mild cases the constitutional 
 symptoms may be absent. 
 
 Pathology. — According to Hans Hebra, who examined micro- 
 scopically sections of skin in two severe and fatal cases, appear- 
 ances of a chronic inflammatory infiltration of the skin were 
 present. In one case there was a rich cell infiltration in all the 
 layers of the skin. The cells filled all the tissues in great 
 numbers, being most abundant immediately beneath the epi- 
 dermis. In the other, in some parts nothing so marked was 
 found ; immediately under the thickened corneous layer there 
 was a thin layer of mostly distorted rete cells richly filled with 
 infiltration cells. Then followed a flat, thick, connective tissue 
 
 layer with fewer cells, and underneath this a layer of thick 
 19 
 
290 PITYRIASIS RUBRA. 
 
 elastic tissue Often twice the thickness of the three layers com- 
 bined. Here the infiltration was less, but there was a rich pro- 
 duction of a yellowish brown granular pigment. Generally all 
 signs of papillary structure were absent ; the different layers 
 above described lying directly upon one another, either 
 straight or wavy. In some places an elevation of the epider- 
 mis and thickening of the rete was present without possessing 
 the characteristic structure of a papilla. 
 
 The bloodvessels in the sub-epidermal tissues were surround- 
 ed by an abundant cell infiltration. The sweat glands were 
 entirely absent, and only occasionally a sebaceous gland was 
 seen, hence the great dryness of the skin during life. The 
 hairs were very scanty and the sheaths above the papillae, in- 
 filtrated with cells. In the milder cases the cell infiltration 
 was less, the mucous layer more normal, the papillary body in- 
 tact, and the glands and hair had their normal appearance. 
 There was absence of pigment collection and elastic fibre pro- 
 ductions. 
 
 In long standing pityriasis rubra the normal structure of the 
 skin is entirely changed from atrophy. 
 
 Diagnosis. — The disease is to be diagnosed from lichen 
 ruber, eczema squamosum universale, psoriasis universalis 
 and pemphigus foliaceus. 
 
 Lichen ruber is a papular affection, and can be confounded with 
 pityriasis rubra only after it has existed for some time, and the 
 papules have coalesced, and are associated with a production 
 of a large quantity of desquamating epidermis. In the peri- 
 phery, however, isolated, firm red papules will be found, which 
 never appear in pityriasis rubra. In lichen ruber there is 
 thickening of the skin. 
 
 From eczema it differs by the absence of thickening of the 
 skin, vesicles, -papules, weeping or scabs, in the forma- 
 tion and character of the scales, and in its universality ; 
 eczema rarely occupying the whole surface of the body. Ec- 
 zema, without treatment, or by treatment, always disappears. 
 
 Pityriasis rubra as a rule does not disappear, and the un- 
 pleasant symptom of tension. at first felt continues to increase 
 
FURUNCULUS. 29 I 
 
 until immobility results, and great pain is produced from the 
 resulting fissures. 
 
 Psoriasis is very rarely universal in its extent, and begins 
 as isolated elevated epidermic papules, which spread peri- 
 pherically, healing in the centre and are sharply limited in the 
 periphery, whilst pityriasis rubra becomes general without the 
 production of papules or these circular or gyrate forms of erup- 
 tion. In psoriasis the scales are bright, thicker, more in 
 layers, and seated upon an elevated base. There is also more 
 or less thickening of the skin beneath the scaling patch of 
 psoriasis. 
 
 In pemphigus foliaceus the distribution and the exfoliation 
 may be similar in appearance to that of pityriasis rubra, but 
 bullae are always formed in this affection. 
 
 Prognosis. — According to German authors, the disease is in- 
 variably fatal. The more severe and universal form may be 
 regarded as invariably fatal. In some of the milder cases, in 
 which the eruption appears in patches, a more favorable prog- 
 nosis may be given. 
 
 Treatment. — Treatment seems to have but little effect upon 
 the disease. The internal treatment is to be conducted upon 
 general principles, and will vary with the individual case. 
 Many of the patients are of a depraved constitution, with 
 lowered nutrition, and die with pulmonary disease or under 
 symptoms of general marasmus. Iron, quinine, cod liver oil, 
 arsenic, carbolic acid and linseed oil may be given according 
 to the indications in individual cases. Linseed oil and carbolic 
 acid have occasionally been of some benefit. Externally 
 benefit has been observed from continuous envelopment in 
 linseed oil or cod liver oil. 
 
 FURUNCULUS. 
 
 Definition. — An acute inflammatory affection of the skin, 
 characterized by the formation of one or more pea to egg-sized, 
 circumscribed, sharply limited, elevated, indurated inflamma- 
 tory tumors, situated in the corium and subcutaneous tissues, 
 
292 FURUNCULUS. 
 
 and rapidly passing to suppuration and with expulsion of the 
 central necrosed part as a core. 
 
 Symptoms. — The first symptoms are those of pain in the part, 
 and if the finger be passed over it a hard, deep-seated infiltra- 
 tion can be felt. Soon there appears a small, rounded, reddish 
 spot, painful to pressure and slightly elevated above the general 
 surface, and in three or four days this increases to the size of a 
 hazel-nut or larger, forming an elevated, hard, circumscribed in- 
 flammatory tumor with a small pustule on the apex. The small 
 pustule corresponds frequently to the seat of the opening of a 
 follicle, and is occasionally penetrated by a hair. 
 
 The inflammation having reached this extent the tumor may 
 disappear by the point of the apex drying up and the inflamma- 
 tory infiltration disappearing, producing what is termed a blind 
 boil. 
 
 Blind boils occur in those cases in which the inflammatory 
 process is not very intense, and especially in old, weakly persons. 
 Usually however the inflammation does not terminate in this 
 manner, but passes on to suppuration, with necrosis of the cen- 
 tral portion of the tumor ; or probably, more properly, necrosis 
 of a gland occurs first, and this necrosed tissue sets up the sur- 
 rounding inflammation, which generally rapidly passes on to 
 suppuration. 
 
 With this increase in the inflammatory process the tumor in- 
 creases in size, becomes of a dark-red color, circumscribed, 
 with great induration, pus forming in the centre of the apex and 
 a few pustules or vesicles on the apex. It is very painful upon 
 pressure, pulsates strongly, and is accompanied by febrile symp- 
 toms. 
 
 The tumor gradually becomes purulent and in seven or eight 
 days opens and discharges a bloody serous liquid. The central 
 core is not expelled until a day or two later, when the opening is 
 larger and the core itself smaller, unless pressure be made and 
 it be forcibly expelled. It is of a yellowish-green color, tough 
 and infiltrated with pus. 
 
 After expulsion of the core the walls fall together, and after 
 discharging for a few days the part heals by cicatricial tissue, 
 
FURUNCULUS. 293 
 
 leaving a small cicatrix in the centre of a pigmented spot. 
 This gradually disappears and nothing remains unless a trace 
 of the cicatrix. 
 
 The pain in furuncles continues to increase in severity until 
 the abscess opens. The cpmparative amount of pain in differ- 
 ent cases depends greatly on the seat of the affection ; a furun- 
 cle of the perinaeum producing more pain than one in the gluteal 
 region. The pain can be so great as to sensibly undermine the 
 constitution of young children and old, weakly persons. 
 
 There may be but a solitary furuncle or there may be a num- 
 ber, and they may appear simultanously or successively. When 
 appearing successively for some time the disease is called 
 furunculosis. 
 
 A?iatomy. — Furunculus is a circumscribed phlegmon, having 
 its origin around a sebaceous or sweat gland or a hair follicle, 
 or even in the subcutaneous tissue (Kochmann). An embolus 
 or a thrombus probably occurs in the capillaries surrounding 
 the glands, leading to necrosis of the gland, and this necrosed 
 tissue in its turn causing consecutive inflammation and plastic 
 infiltration around the necrosed tissue, and the elimination 
 of this latter by suppuration, makes up the furuncular process. 
 
 The inflammation has no tendency to become diffuse, but re- 
 mains circumscribed and of limited extent. The plastic infiltra- 
 tion is succeeded by a purulent infiltration, which finds its way to 
 the free surface and is discharged, carrying with it the core. 
 After the discharge of the core a cavity is left, with hardened 
 walls, which heals by granulation. 
 
 Etiology. — The causes are either local or general ; the inflam- 
 mation very frequently depends upon local irritation of the skin, 
 and accompanies those diseases attended by itching, as prurigo, 
 eczema, and pediculosis ; long continued irritation from clothes, 
 salves, vesicatories in old persons, irritating effects of cold baths, 
 especially shower baths, are frequent causes. When symptom- 
 atic, they occur in connection with derangements of the intes- 
 tinal tract, as chronic dyspepsia, diabetes, retained urea, Bright's 
 disease, tuberculosis, scrofulosis, gout, poor nutrition and in 
 convalesehce from severe febrile conditions. 
 
294 FURUNCULUS. 
 
 Diagnosis. — Furuncles may resemble ecthyma, pustular 
 syphiloderm and carbuncle. 
 
 In ecthyma the inflammation is not so deep, there is no cen- 
 tral core, and there is a considerable areola of inflamed tissue 
 surrounding the ulcerated area. 
 
 In syphilis the history of the case, the absence of the core, 
 the slow course, the infiltrated narrow margin, the tendency 
 to continuous ulceration, and the presence of tubercles or pap- 
 ules on other parts of the body, render the diagnosis easy. 
 
 As compared with carbuncle, furuncle is smaller, of a roundish 
 shape, and has a single point of suppuration. Carbuncle is al- 
 most always solitary and has two or more points of suppuration, 
 is flatter, may be several inches in diameter, and is not so sen- 
 sitive as a furuncle. 
 
 Treatment. — The treatment is local and general. 
 
 The local treatment consists in endeavoring to allay the pain, 
 reduce the inflammation, and promote the early expulsion of the 
 central necrosed tissue. For the relief of the pain cold or warm 
 applications for the diminution of the inflammatory process, and 
 anodynes for their direct effect in reducing pain, maybe em- 
 ployed. Whether cold or warm applications should be used de- 
 pends on the special effect in individual cases. Whichever is 
 most agreeable to the person should be employed, although, as 
 a rule, cold in the early stages and warmth in the later stages are 
 indicated. Cold reduces pain, relieves tension, and prevents, to 
 an extent, the inflammatory process by interfering with the life 
 movements of the living matter of the white blood corpuscles, 
 emigration, and tissue change. If applied early and properly, 
 boils can often be made to abort by its use. After suppuration 
 is well established and when the furuncle feels doughy to the 
 touch, cold should no longer be employed. Warm applications, 
 as warm water or linseed poultices, should be used, as the moist 
 heat favors suppuration, assists in softening the central mass 
 and the tissue over the boil area, and thus, in several ways, aids 
 in the early opening of the furuncle and the expulsion of its 
 contents. 
 
 The objection to hot poultices is that they frequently cause 
 
FURUNCULUS. 295 
 
 new boils to arise in the place of the existing one. After the 
 boil has opened, the warm application should be continued two 
 or three days longer or until all pain, hardness and swelling 
 have disappeared. 
 
 Whether a boil should be opened by an early incision or not 
 is still an undecided question. An early incision reduces ten- 
 sion and lessens obstruction to the expulsion of the core, but it 
 lessens the suppurative process without stopping it, and this 
 process more than incision hastens the expulsion of the dead 
 tissue. The incision reduces the severity of the inflammation ; 
 but unless the overlying tissue has been freely incised, it will 
 resist the pressure from the core longer than if it had not been 
 cut on account of this very lessened inflammatory condition. 
 On theoretical as well as practical grounds then, it is generally 
 better to use warm applications and wait until it opens sponta- 
 neously, or until the covering has become very thin. 
 
 Injecting two or three drops of a five per cent, solution of 
 carbolic acid into the apex of a recent boil is said to fre- 
 quently cause it to abort. 
 
 The general treatment consists inattention to the general 
 health and in the administration of substances supposed to be 
 specially useful in suppurative processes. If the person is in a 
 sthenic condition, saline aperients should be given and the diet 
 restricted. Acids, all indigestible foods, wine, beer, etc., should 
 be avoided. If the urine is acid or high colored, depositing 
 urates upon cooling, alkaline diuretics, as acetate or citrate of 
 potash dissolved in large quantities of water, are useful. If the 
 person is gouty, alkalies and colchicum are required. In weakly 
 individuals, pure air, good food, stimulants, as wine or beer, 
 tonics, exercise and frequent washing are required. For atonic 
 dyspepsia, strychnia and the mineral acids are the best. In 
 every case we should endeavor to find the special condition 
 causing the furuncles. Arsenic and phosphorus have been 
 found sometimes useful. Sulphite and hyposulphite of sodium, 
 in doses of 15 to 30 grains every 2 or 3 hours, is recommended 
 by Dr. Duhring. Sulphide of lime in small doses — one-sixth 
 to one-tenth of a grain, frequently repeated is one of the best 
 
296 CARBUNCLE. 
 
 remedies to prevent the formation or to hasten the suppurative 
 process in furunculosis. It is especially useful in boils in 
 children. 
 
 CARBUNCLE. 
 
 Carbuncle is commonly called anthrax both in our own and 
 in foreign manuals of Dermatology. The term is a misnomer, 
 leading only to confusion, and should be abandoned. Anthrax 
 is a specific disease affecting animals and men, and due to a 
 specific organism, the bacillus anthracis ; the special skin 
 lesion caused by it is known to us as malignant pustule, and to 
 that disease alone the term anthrax should be applied. 
 
 Definition. — A circumscribed inflammation of the skin and 
 of the subcutaneous connective tissue, often involving deeper 
 parts. It terminates in gangrene of the affected area, and may 
 prove fatal by septic infection. 
 
 Symptoms. — Carbuncle occurs by preference in those situa- 
 tions where the subcutaneous connective tissue and fat are 
 abundant — on the buttocks, back, and neck — though it may 
 appear on any other part of the body. A peculiarly malignant 
 form is that which appears on the face. 
 
 After a variable period of general malaise, marked by slight 
 fever, headache, anorexia, etc., the local trouble begins as a 
 deep-seated, painful, circumscribed swelling, of a bright-red or 
 livid color. Soon a small vesicle appears on its summit, filled 
 with a bloody serum ; it breaks, or is ruptured by the patient. 
 The swelling increases in size, and usually reaches its full ex- 
 tent in two weeks, and forms a firm, brawny infiltration of a 
 dusky red or violaceous hue. Itching, throbbing, and burning 
 sensations, and a very considerable amount of pain are present. 
 The ruptured vesicle discloses a number of small apertures 
 going deep down into the subjacent tissues ; a thin sanious pus 
 oozes from them as through a sieve. Each opening marks a 
 centre of suppuration — and from each eventually there comes 
 away a " core " — a plug of necrotic tissue. 
 
 At the end of from ten days to three weeks, in accordance 
 with its size, the tumor, still hard at its periphery, begins to 
 
CARBUNCLE. 297 
 
 soften in the centre ; the ridges of dusky skin between the 
 numerous openings break down, and the whole mass forms an 
 ashen, shiny slough, which comes away eventually either piece- 
 meal or en masse, as suppuration proceeds. 
 
 The process may be very extensive, varying in size from that 
 of a child's fist to that of an ordinary dinner plate ; and whilst 
 it is commencing to heal by suppuration and casting-off of dead 
 tissue in the centre, it may be progressing at the periphery. 
 Lesions may thus be formed which cover half the back, 
 forming immense infiltrated plates with yellow or black necrotic 
 masses in various places — and between them bands of dusky 
 or violaceous skin. In the worst cases the whole integument 
 of the part dies, and not only the connective tissue and fat, 
 but the muscles and even the periosteum may be involved. 
 
 Ultimately a cavity of varying size is left, with uneven base 
 and undermined edges ; it heals very slowly, and leaves a 
 large, deforming cicatrix, often pigmented. 
 
 In the meantime the constitutional symptoms vary much, in 
 accordance with the extent of the inflammation and the general 
 condition of the patient. In the earlier stages, fever, slight 
 jaundice, nausea, foetid diarrhoea are common ; even delirium, 
 etc., may occur. In moderate cases these symptoms soon sub- 
 side, and are gone by the time that the process of separation of 
 the slough begins. In bad cases the general symptoms are 
 marked, and a sudden increase of the fever, together with 
 severe chills, announce the occurrence of septic infection. 
 When the carbuncle is very large, or when it invades the 
 scalp — especially if the patients suffer also from diabetes, 
 Bright's disease or gout — pyaemia in its worst forms is apt to 
 occur. Pleurisy, peritonitis, spinal or cerebral meningitis may 
 occur from the direct extension of the disease ; if situated on 
 the neck, the pressure of the carbuncle on the trachea and 
 oesophagus may impede respiration and deglutition — and hasten 
 a fatal issue. Occasionally the disease runs an indolent course, 
 and the absence of pain is considered by Follin as of very bad 
 omen. The whole duration of the process is usually two to six 
 weeks. 
 
298 CARBUNCLE. 
 
 Anatomy. — The inflammation begins simultaneously at a 
 number of points in the inflamed part, probably starting from 
 the sweat and sebaceous glands. Thence it extends downward 
 into the subcutaneous connective tissue — and then horizontally 
 — and, eventually, gangrene of the whole mass occurs. The 
 fascia and muscles are often involved ; and even the periosteum 
 and bone may be attacked. Serous membranes and deeper 
 organs are invaded sometimes as the disease extends. The pus 
 collects, and points in as many places as there are primary 
 inflammatory centres ; hence the characteristic sieve-like 
 appearance, and in each opening there is a plug composed of 
 necrosed connective tissue and skin. 
 
 The carbuncle is cured by the occurrence of healthy inflam- 
 mation in the surrounding uninvolved parts, and in the casting 
 off of the entire dead tissue. 
 
 Etiology. — The causes of carbuncle are very much the same 
 as those designated for furunculosis. In many cases they are 
 absolutely unknown to us ; but in a general way improper food 
 and bad hygiene, especially if conjoined to some local irrita- 
 tion of the skin, may be mentioned. It occurs more commonly 
 in summer than in winter ; and is rarely seen in young per- 
 sons, attacking those who are debilitated either by years or by 
 excesses. It is more frequent in men than in women, and 
 attacks with impartiality persons in all stations of life. It is 
 prone to occur in gouty subjects and in those suffering from 
 chronic Bright's disease. The interesting point in its etiology 
 is in regard to its relationship to diabetes mellitus. It is well 
 known that abscess, gangrene, furuncle, and carbuncle, are 
 more common amongst diabetic patients than amongst others, 
 and in a number of cases these troubles have led to the ex- 
 amination of the urine and the subsequent discovery of sugar. 
 Acute attacks of saccharine diabetes sometimes occur in the 
 course of carbuncle, and A. Wagner has reported several cases 
 of the disease in which the urine had a specific gravity of 1029, 
 and contained 5 per cent, of sugar. Prout has recorded a number 
 of similar observations, but Follin did not succeed in demon- 
 strating the presence of sugar in the urine even in the most ex- 
 
CARBUNCLE. 299 
 
 tensive cases of carbuncular disease. No etiological relation- 
 ship has as yet been established between the two affections ; 
 but the subject is an interesting one, and the urine should be 
 examined in every case. 
 
 Diagnosis. — It is hardly likely that a carbuncle will be con- 
 founded with a simple boil or a phlegmon. The large extent of 
 tissue affected, the livid tint, the multiple points of suppuration, 
 all distinguish the graver disease. Its hardness, painfulness and 
 circumscription distinguish it from erysipelas. Malignant pus- 
 tule may be differentiated from carbuncle by the history, situa- 
 tion, absence of pain, and other signs of acute inflammation 
 which distinguish the former disease, or by the presence of the 
 characteristic organism in the fluids of the charbonous part. 
 
 Prognosis. — The prognosis varies with the age of the patient, 
 the extent of the disease, and the presence of complications. It 
 is bad if the patient is over fifty years of age, or if the carbuncle 
 becomes very large — 5 to 6 inches in diameter ; or if the patient 
 is a diabetic or albuminuric subject, or is otherwise broken down 
 in health. There is danger of extension to more important 
 structures in any case that affects the scalp. With all this, the 
 disease is not so often fatal as is commonly supposed. 
 
 Auspitz does not believe that either the extent or the depth 
 of the carbuncle has much to do with the prognosis, holding 
 that small ones often cause fatal septic poisoning when they 
 occur in marasmic subjects. 
 
 Treatment must be both local and general. As regards the 
 former, a considerable change has occurred in the opinions of 
 many surgeons as to the advisability of free crucial incisions 
 through the inflamed tissues. That was the rule formerly pre- 
 scribed in every case, but it has been claimed, especially by 
 Paget and Agnew, that the extent of the necrotic process is not 
 thereby affected, and that the loss of blood, which is often 
 severe, is a positive injury to the patient. Nevertheless it 
 does, especially in the earlier stages, greatly relieve the tension 
 and the throbbing pain ; and the opening up of the various 
 inflammatory foci probably tends to prevent septic absorption. 
 Kaposi even recommends the removal of the necrotic tissue by 
 
300 CARBUNCLE. 
 
 the knife or curette, with a subsequent dressing of carbolized 
 oil. 
 
 A very excellent method of treatment is the one* so ably- 
 advocated by Dr. Physick. It consists of the insertion into 
 the carbuncle, either at the orifices already formed, or into a 
 special opening made with the knife, of small lumps of caustic 
 potash, which are allowed to melt in situ. Pieces of the size of 
 a pea may be used, in number varying according to the extent 
 of the disease. Bryant lauds this as the most effective treat- 
 ment, and claims that it markedly helps the separation of the 
 slough and diminishes the danger of pyaemia. It causes no 
 bleeding, and but little pain, and soon transforms the carbuncle 
 into a healthy, granulating wound. Poultices, carbolic or 
 opium lotions may be used in conjunction with this treatment. 
 
 Various other applications may be used. Hebra favored 
 cold ice-bags. Blistering in a broad band around the part, 
 or tincture of iodine has been used, but is not of special 
 benefit. Better results have been obtained by the hypodermic 
 injection of 5-10 <f solutions of carbolic acid into various parts 
 of the tumor, or by the free use of the Vienna paste. 
 
 Perhaps warm applications, as hot flax-seed poultices, fre- 
 quently changed, do as much good as any method of treat- 
 ment. They certainly relieve the throbbing pain better than 
 any thing else, and they tend to promote the suppuration by 
 which the necrosed mass is to be cast off. Whatever the pre- 
 vious treatment may have been, they should be used whenever 
 the reactive inflammation sets in. 
 
 The carbuncle should be carefully dressed twice a day, and 
 the removal of the necrotic tissue is to be recommended. Dry 
 cupping is said by Leitner to hasten the separation of the 
 slough and to afford much relief. 
 
 The resulting ulcer may be dressed in any of the ordinary 
 ways — cold water, carbolized oil, balsam of Peru, etc. ? — but 
 perhaps best by a watery 1-10 carbolic acid dressing. 
 
 As far as the general treatment is concerned, it consists 
 mainly in hygiene — generous diet and moderate alcoholic 
 stimulation. In slight cases, when the patient's health and the 
 
ECZEMA. 30I 
 
 situation of the carbuncle permit it, exercise in the open air 
 may be freely taken. Tinct. ferri chlor. in doses of twenty 
 drops every two hours, or quinine, fifteen grains, three times 
 a day are recommended by Duhring. Ringer has urged the 
 use of the calcium sulphide in this as in the kindred affec- 
 tion of furunculosis. The mineral acids and the various 
 digestive tonics should be given. Opium is often necessary 
 to allay pain and to procure rest, especially in the early stages. 
 
 ECZEMA. 
 
 Syn. — Tetter ; salt rheum ; milk crust. 
 
 Definition. — An acute or chronic catarrhal inflammation of 
 the skin characterized by diffuse redness and exudation, or by 
 the formation of isolated or closely seated papules, vesicles or 
 pustules, followed by weeping or scaling, and attended generally 
 by much itching. 
 
 Sy??ipto?7is. — Eczema is the skin disease for which the physi- 
 cian is consulted more frequently than any other, although acne 
 and pediculi capitis are more frequent conditions. It is essen- 
 tially a catarrhal inflammation of the skin, and the polymor- 
 phous character of the eruption depends upon the intensity and 
 duration of the inflammation present, which intensity of inflam- 
 mation depends upon the nature and amount of the noxious 
 agent causing the tissue changes and the special degree of irri- 
 tability of the skin affected. As shown by Hebra, all the symp- 
 toms and anatomical changes occurring in ordinary eczema 
 can be produced at will upon the skin by the application of 
 certain irritating agents, and especially croton oil. If a slight 
 amount of croton oil be gently rubbed into the skin in different 
 regions of the body, a superficial inflammatory condition will be 
 produced, which will vary in degree according to the irritability 
 of the different parts to which it has been applied. If the part 
 is easily irritated, as is the case in the flexures or in the skin of 
 infants and children, the resulting inflammation will be diffuse ; 
 that is, of an erythematous type. On the extensor surfaces the 
 skin is less irritable and the inflammation will not be diffuse, 
 
302 ECZEMA. 
 
 but be limited to the hair follicle region especially, and conse- 
 quently consist of isolated papules, that is, be of a papular form 
 of eruption. 
 
 Upon cessation of the irritation both these conditions of the 
 skin subside, and the part returns to a normal condition after 
 undergoing more or less desquamation. If more croton oil be 
 rubbed in, or the rubbing be longer continued, or repeated the 
 following day upon the same parts, there will be an increase in 
 the intensity of the inflammation and in the amount of exuda- 
 tion and nutritive changes. The erythematous inflammation 
 will extend deeper in the skin, the heat and swelling of the part 
 will be increased, and the amount of exudation may be so great 
 that it may remove the upper part of the epidermis and appear 
 on the free surface, giving a dermatitis with a weeping surface — a 
 moist form of dermatitis. If the part be not further irritated 
 by additional applications of the oil, the inflammation 
 will gradually subside, the exudation upon the free surface 
 will dry to crusts and the epidermis beneath afterward 
 desquamate, and finally regain its normal condition. 
 
 In the desquamating stage is represented a squamous derma- 
 titis. 
 
 In the papular form an increase in the intensity of the inflam- 
 mation will cause new papules to arise and the existing ones to 
 become vesicles or vesico-papules, according to the amount of 
 increase of serous exudation from the bloodvessels ; giving a 
 superficial papular, papulo-vesicular or vesicular eruption. If 
 the vesicles do not rupture and the irritation ceases, the exuda- 
 tion is absorbed and the eruption disappears by desquamation. 
 If the amount of exudation, however, be sufficient to 
 rupture the vesicle walls, the discharge reaches the free 
 surface, and, as in the case of the erythematous form, 
 dries to crusts or scabs. The part finally returns to a normal 
 condition after passing through the scaling stage. 
 
 A more intense inflammation, or one of longer duration, which 
 can be produced by repeating the croton oil application, or an 
 inflammation occurring in scrofulous constitutions, will be asso- 
 ciated with an increase in the number of formed elements pres- 
 
ECZEMA. 303 
 
 ent in the exudation, and consequently the vesicles will become 
 pustules ; or if the discharge is poured out upon the free surface, 
 the exudation will be first serous, and later sero-purulent, the 
 extent of the purulent character depending upon the constitu- 
 tion of the individual and the intensity and duration of the 
 inflammatory process. When these changes take place the 
 dermatitis is purulent in character ; it represents a pustular 
 form of eruption. As in the previous form, the exudation dries 
 to crusts, and later, the skin returns to a normal condition 
 through a scaling stage. 
 
 In the above experiment, we observe a simple dermatitis, 
 producing a polymorphous eruption, the polymorphous charac- 
 ter depending upon the intensity of the inflammation and the 
 special condition as regards irritability and pus-formative 
 power of the tissues affected. From a single application of the 
 oil to different parts of the body, all the forms may be pro- 
 duced at the same time, the irritability of the skin being differ- 
 ent in different parts of the cutaneous surface. It is to be 
 noted further, that the erythematous, papular, vesicular and 
 pustular forms of the eruption represent an active inflamma- 
 tory process, whilst the desquamative or scaling condition repre- 
 sents a healing stage. The pustular or vesicular form must com- 
 mence as an erythematous or papular eruption, but the papules 
 do not necessarily proceed to become vesicles or pustules. 
 
 Eczema, as ordinarily observed and produced, presents the 
 same polymorphous character as the dermatitis from croton 
 oil. The eruption may be of an erythematous, papular, ves- 
 icular, pustular, weeping or squamous character, or all may be 
 present on a single individual at the same time. As in the 
 other case, so here also, the erythematous or papular form is 
 the primary form of the lesion, and may remain the only one, 
 or the eruption may become vesicular, pustular or weeping in 
 character. According to the form or appearance of the lesion 
 present we may consequently have an erythematous, a papular, 
 a pustular, a weeping or a squamous eczema. A pustular 
 eczema, in which the pus collects upon the free surface, is 
 often called an impetiginous eczema ; and a weeping eczema, 
 
304 ECZEMA. 
 
 in which there is much discharge, an eczema madidans ; or if 
 the rete is exposed and is very red, an eczema rubrum. These 
 differences in form depend upon the intensity of the inflam- 
 mation, and this in its turn upon the character of the agent 
 producing it and upon the degree of irritability of the tissues 
 affected. In persons with tender skin, and especially in chil- 
 dren and scrofulous individuals, the eruption will be frequently 
 of a weeping or pustular or intense erythematous form, whilst 
 in adults, especially on the extensor surfaces of the extremi- 
 ties, the papular or vesicular form is often observed. In old 
 persons and in gouty and rheumatic subjects, the squamous 
 form is very frequent. 
 
 Although, as already stated, all the forms of lesion may be 
 present at the same time, and the disease in such cases be per- 
 haps properly and sufficiently described by the term eczema, 
 yet is it advisable to define more minutely the form of the 
 lesions present, as they represent, as we have already observed, 
 degrees of inflammation and consequently special manner of 
 treatment. 
 
 All of the forms may be acute or chronic, and the longer 
 the duration of the disease the greater and deeper are the 
 nutrition changes in the skin. 
 
 We will first describe in general the symptoms and appear- 
 ance of the different forms of eczema, and afterward the erup- 
 tion, as it appears upon different parts of the body ; as not only 
 the form of the lesion but also the situation of the disease 
 regulates the course of treatment to be employed. 
 
 Erythematous Eczema. — In this form the skin is red, swollen, 
 somewhat elevated, hot and accompanied by more or less 
 itching. If the inflammatory process is acute, the exudation 
 will soon pass on to form papules or vesicles ; but if subacute, 
 the inflammatory symptoms soon begin to subside and the 
 part returns to a normal condition after undergoing desquama- 
 tion. This form is met with especially on the face, neck, 
 genitals, palms of the hands and soles of the feet. When 
 acute and seated on the face it resembles in many respects an 
 erysipelas. 
 
ECZEMA. 305 
 
 Papular Eczema. — In this form all the usual symptoms of 
 a superficial inflammation are present, and upon the surface 
 of the skin are to be seen a greater or less number of millet- 
 sized papules, either isolated or closely seated, of a pale red 
 color, acuminated, and the apex at first smooth, but afterward 
 covered with a firm thin crust. They give rise to much itching. 
 They either afterward become vesicles or remain as papules 
 for a length of time. As a persistent papular eruption they are 
 often observed on the extensor surfaces of the extremities, and 
 form what was previously called a lichen simplex. In these 
 cases the inflammation is seated especially around hair folli- 
 cles. It is also frequent upon the scrotum and posterior sur- 
 face of the body. 
 
 Localized patches of papular eczema are found on other sit- 
 uations, and from their arrangement in circular patches may 
 bear a close resemblance to the eruption caused by the fungus 
 of ringworm. In all cases of eczema, whether vesicular, pus- 
 tular or squamous, a greater or less number of papules are 
 generally to be found at the periphery of the patch, and in all 
 cases of doubtful diagnosis between psoriasis, ringworm and 
 eczema, they should be sought for. A papular eczema consist- 
 ing of isolated papules situated around hair follicles is often 
 very persistent, as local remedies are of little avail to remove 
 the lesions and prevent new ones forming. When removed, the 
 eruption is very liable to return. 
 
 Vesicular Eczema. — This form is always papular first, but the 
 liquid may form so rapidly in the papules that the primary 
 stage is not observed. It consists of millet to pin-head sized 
 vesicles seated upon an inflamed and cedematous base. The 
 vesicles are isolated, or closely seated, or may coalesce to form 
 larger vesicles or blebs, and contain sticky contents which af- 
 terward become opaque from the presence of pus corpuscles. 
 The vesicles burst very readily and discharge their contents 
 upon the free surface. If the epidermis is thick, as upon the 
 palms of the hands and soles of the feet, the vesicles may 
 remain unruptured for a long time. In these situations they 
 are not elevated above the general surface but appear as 
 20 
 
306 ECZEMA. 
 
 a deep seated collection resembling a boiled sago grain in ap- 
 pearance. When the exudation is discharged upon the free 
 surface it is of a sticky consistence and dries to thin light-yel- 
 lowish crusts. The skin upon which the vesicles are situated 
 is tender and the part itches very much. The greater the 
 number of vesicles present, the more intense is the cedematous 
 swelling of the part. The color of the affected area depends 
 upon the intensity and stage of the inflammatory process. The 
 extent of surface affected varies in different cases, and the mar- 
 gins of the eruption are always ill defined. 
 
 The eruption may continue vesicular in character for a long 
 period ; or, by removal of the upper layer of the epidermis, the 
 formation of vesicles will be prevented, and if the process con- 
 tinues very active, there will be a free discharge of exudation 
 upon the general surface. When this occurs, the disease has 
 received the name of eczema madidans. 
 
 Sooner or later the inflammatory process begins to subside, 
 the amount of discharge diminishes, the crusts become thinner 
 and looser, the skin appears red, desquamation takes place 
 instead of exudation on the free surface, and the part finally 
 returns to a normal condition. 
 
 This form is met with on all parts of the cutaneous surface, 
 and during its active stage represents a more intense inflamma- 
 tion than the preceding forms. 
 
 Pustular Eczema. — This form is met with especially in young 
 or scrofulous persons. It is very frequent upon the scalp and 
 face of children. It arises from the erythematous, papular, or 
 vesicular forms ; or when seated on the hairy scalp may be 
 pustular almost from the commencement of the inflammation. 
 
 The exudation, which is abundant and is discharged upon 
 the free surface, contains a large number of formed elements — 
 pus-corpuscles, and dries to yellowish, greenish, or dark crusts. 
 The skin beneath the crusts is red, and shows a surface dis- 
 charging asero-purulent material. This condition is called an 
 impetiginous eczema. Formerly it was called impetigo, but this 
 term is now used to denote a different condition. 
 
 In pustular eczema there is considerable infiltration of the 
 
ECZEMA. 307 
 
 skin, and itching is a prominent symptom. The disease disap- 
 pears in the same manner as the vesicular form. 
 
 Squajnous Eczema. — This form usually represents a stage of 
 the preceding forms, but it may occur primarily, in that scaling 
 takes place directly upon a reddened skin, as is often observed 
 upon the face from the effects of heat, or upon the hands from 
 the action of chemical substances (Neumann.) I prefer to re- 
 gard this condition as belonging to the erythematous form, and 
 all scaling to be a secondary condition. 
 
 In this form the inflammation is less intense, the exudation 
 less in amount, the crusts thinner, harder, more adherent, and 
 the skin beneath red and scaling. This form may last a long 
 time and then it is associated with more or less marked infil- 
 tration of the corium or sub-cutaneous tissue. 
 
 When from the eczematous process the corneous layer be- 
 comes removed by the exudation from beneath, leaving a dark 
 red, naked rete Malpighii and presenting a surface discharging 
 a thin liquid, the condition is sometimes called eczema, ru- 
 brum. 
 
 On the lower extremities a long continued eczema in persons 
 of middle age or advanced life, gives rise to a warty like condi- 
 tion of the skin, from hypertrophy of the papillae consequent 
 upon the chronic inflammation. These papillomatous forma- 
 tions are usually very closely seated and covered with very thin 
 crusts or scales. This condition is called eczema vermcosum. 
 
 Whatever form of eczema is present it heals without ulcera- 
 tion, and with or without pigmentation following. 
 
 Eczema may be either acute or chronic, although it is gener- 
 ally chronic. 
 
 Acute eczema may appear on any part of the body, but it is 
 most frequently met with on the face, hands, feet and 
 genitals. • It commences as one or more patches, and may in- 
 crease in extent either by spreading at the periphery or by new 
 spots arising in distant parts. It commences with symptoms 
 of general disturbance, as chills, fever, restlessness, wakeful- 
 ness, and general malaise. In twenty-four to forty-eight hours 
 the skin becomes red, swollen, and covered with papules, 
 
308 ECZEMA. 
 
 vesicles or pustules ; the vesicles burst quickly, and a clear, 
 gummy-like, sticky exudation is poured upon the surface, 
 which afterward dries to crusts, beneath which a red, dis- 
 charging surface is seen. Afterward the discharge gradually 
 diminishes in quantity, the skin commences to desquamate, 
 and later heals without scars. The eruption is always ac- 
 companied by burning and itching. 
 
 Acute general eczema is a rare disease, and arises from the 
 union of a large number of localized patches. It is ushered 
 in and accompanied by the symptoms described above, only 
 that the general symptoms are more marked. It lasts two or 
 three months, and usually leaves localized spots behind, es- 
 pecially on the flexures of the joints. These spots are often 
 the starting points for relapses of the general eruption. 
 
 Chronic eczema results from exacerbations and remissions 
 occuring on the same place, or from the continuous formation 
 of new spots on other parts of the body, prolonging the dura- 
 tion of the disease. In chronic eczema all the forms of erup- 
 tion may be present. If the disease has lasted for a long 
 period on any spot, the skin becomes thickened, red and scaly, 
 and if seated at the junction of a mucous and cutaneous sur- 
 face, or over the joints, or on the palms of the hands, fissures 
 are liable to form. In chronic eczema of the whole body, the 
 skin appears red, scaly or moist, fissures form, the hair falls 
 out, the nails degenerate, and there is much itching and a fre- 
 quent slight shivering feeling. The duration of the disease is 
 indefinite. 
 
 We will now proceed to describe the eruption as it occurs on 
 different parts of the body. 
 
 Eczema of the Scalp. — In this situation the eczema is either 
 acute or chronic. Acute eczema is most frequently of the im- 
 petiginous or squamous forms. It is most frequently met with 
 in children. In this situation the exudation from the blood- 
 vessels becomes mixed with fatty matter from the sebaceous 
 glands, and the discharge in consequence has a disagreeable 
 odor. The amount of secretion is usually considerable in 
 quantity, and produces matting of the hairs. The exudation 
 
ECZEMA. 309 
 
 dries to crusts, beneath which the skin is red, and discharges 
 a sero-purulent liquid. Usually a considerable area of the 
 scalp is affected. If the eruption is limited, it is generally due 
 to local irritants, as lice. Eczema of the scalp frequently 
 passes to the forehead, ears and cheeks. 
 
 Chronic eczema of the scalp is most frequently met with in 
 children. It occurs most generally upon the vertex, occipital 
 region and nape of the neck, and exists alone, or in combina- 
 tion with eczema of the face. The part is covered with crusts 
 or scales, and the skin beneath is red, shining, with many white, 
 fatty scabs ; or there is some discharge. Acute outbreaks oc- 
 casionally occur, or the inflammation may extend deeper 
 around the hair follicles and produce appearances similar to 
 sycosis. Eczema of the scalp, caused by lice, is usually of the 
 impetiginous form, and appears as isolated patches from the 
 size of a finger nail to one or two inches in diameter, covered 
 with thick, dry, yellowish or dark colored, bad smelling crusts, 
 beneath which the skin is red, smooth and shining, or moist, 
 and discharging a sero-purulent liquid. These patches occur 
 especially in the occipital region, and are generally associated 
 with a papular or vesicular eczema of the nape of the neck. 
 The glands of the neck are usually swollen, chronically and 
 inflamed, but rarely suppurate. 
 
 Pityriasis of the scalp ; that form of dandruff in which the 
 greater part of the scalp is red, and covered with fine, branny 
 scales, is a chronic squamous eczema. In this form the hairs 
 fall out to a greater or less extent if the disease lasts a long 
 period. 
 
 Eczema of the Face and Head. — Eczema of face and head may 
 be acute or chronic. Acute general eczema of the face may 
 be erythematous, vesicular or pustular in character, and usually 
 commences with symptoms resembling an erysipelas. There is 
 redness, swelling, burning, and oedema, especially of the forehead 
 and eyelids, and this swelling soon spreads to the lips and ears, 
 and may invade the hairy part of the head. The eyelids may 
 be closed or immovable, and the ears stand out from the head 
 on account of swelling of these parts from the inflammatory 
 
3 IO ECZEMA. 
 
 exudation. Hearing is rendered difficult from swelling of the 
 external orifice of the ear. The skin in a few hours from the 
 commencement of the inflammation becomes covered with 
 papules and vesicles, giving to the surface an uneven feel, so 
 different from the smooth, glazed surface present in erysipelas. 
 In a few hours more the vesicles increase in size and burst, dis- 
 charging their contents upon the free surface. The amount and 
 quantity of exudation differs in different cases, but it is usually 
 serous in character and considerable in amount — an eczema 
 madidans — and dries to corresponding crusts. There is es- 
 pecially much discharge from the skin of the ears. If the in- 
 flammation extends to the hairy part of the head, the secretion 
 drying to crusts mats the hairs together. It may last only a few 
 days, or may continue for weeks, or become chronic, when it 
 assumes the squamous form, the skin becoming dry, thickened, 
 and fissured, especially behind the ears. 
 
 Chronic eczema of the face is much more frequent than the 
 acute form. It is either local or general, and often results from 
 an extension of an eczema of the scalp to the forehead, cheeks 
 or ears. It may be erythematous, vesicular, pustular or 
 squamous in character. If vesicular or pustular, the exuda- 
 tion dries to yellow crusts, and the skin beneath is red and dis- 
 charging. In the squamous form but few scales are present, and 
 the skin may be red and slightly swollen, or almost normal 
 in appearance, presenting only a slightly roughened aspect. 
 This condition may last many years, the skin becoming some- 
 what thickened, and fissured in places. Occasional acute 
 outbreaks assist in prolonging the duration of the disease. A 
 good example of this condition is seen in chronic eczema of the 
 cheeks in young or nursing children. An eczema of the cheeks, 
 and sometimes forehead also, will last months or years without 
 extending to the nose or the skin below the eyes. 
 
 The localized forms of eczema of the face require some addi- 
 tional consideration. 
 
 Eczema of the forehead is either acute or chronic and unless 
 caused by some local irritant, as from pressure, and sweat from 
 wearing a hat, it rarely exists alone, but is usually found in 
 
ECZEMA. 311 
 
 association with eczema of neighboring parts, especially of the 
 scalp. 
 
 Eczema of the eyebrows appears especially in the pustular or 
 squamous form. When pustular, the part becomes covered with 
 thick yellow crusts and the inflammation frequently extends 
 around the hair follicles like in sycosis. In the chronic squa- 
 mous form, the skin is thickened, red, and covered with scales. It 
 is generally symmetrical. 
 
 Eczema of the eyelids is frequent. It is either acute, or 
 chronic ; and vesicular, or squamous in character. Pustules 
 often form around the root of the hair. The lids become swollen, 
 conjunctivitis is generally present, and fissures form at the an- 
 gles of the lids. When it becomes chronic, crusts form between 
 the hairs, and the eyelids stick together from drying up of the 
 exudation. 
 
 Eczema of the nose is generally chronic, and occurs as eczema 
 rubrum or eczema impetiginosum. It occurs most frequently 
 on the alae, and at the angle where this joins the lip. It is met 
 with especially in scrofulous persons, associated with a 
 nasal catarrh. In the mucous membrane it passes down around 
 the hair follicles, producing a sycosiform eruption. The amount 
 of crusting is considerable, so that the patients often are obliged 
 to breathe entirely through the mouth, the nasal orifices be- 
 ing closed by dried crusts. 
 
 Fissures very frequently form at the angles of the alae and 
 near the septum, at the junction of the cutaneous and mucous 
 surfaces. Beneath the crusts, the skin is red, and discharges 
 a sero-pus. If this exudation becomes confined beneath the 
 dried crusts and decomposes it may be absorbed by the lym- 
 phatics and produce an erysipelas. This absorption of pus from 
 the nasal mucous membrane, is probably the most frequent 
 cause of facial erysipelas. 
 
 Eczema of the lips usually arises from eczema of the face or 
 nose. It appears in the impetiginous or squamous form, is usu- 
 ally symmetrical, and very obstinate to treatment. It is present 
 either on the cutaneous or mucous surface, or both combined, 
 and gives rise to deep, painful fissures, especially at the angles 
 
312 ECZEMA. 
 
 of the mouth. A form which is frequently observed in women 
 consists of fissures confined to the vermilion portion of the lips. 
 They are very deep, bleed easily, and are covered with thin ad- 
 herent crusts. Eczema of the lips is frequently observed in 
 scrofulous persons in conjunction with eczema of the eyelids 
 and nose. 
 
 Eczema of the ears arises either independently or in connection 
 with eczema of the face or scalp. It is either acute or chronic. 
 Acute eczema of the ears is usually of the vesicular form, and 
 is characterized by great heat and swelling of the part, and by 
 a large amount of exudation. There is much itching present, 
 and hearing may be difficult from partial closure of the exter- 
 nal auditory canal consequent on the swelling of the organ. 
 The exudation on the ear dries to thick crusts, and within the 
 auditory canal there is much scaling. The disease is usually sym- 
 metrical. 
 
 When chronic, the part becomes thickened and deep fissures 
 form behind the ear where it joins the side of the head. Fur- 
 uncles frequently form in the external auditory canal. 
 
 Eczema barbed is a very frequent condition, and is often 
 mistaken for sycosis. It is either acute or chronic, and the 
 eruption is rarely limited to the part covered with hair. When 
 acute, the part becomes red, swollen, tender, and there is con- 
 siderable exudation and matting of the hairs from the dried 
 crusts which form. Beneath the crusts the skin is moist and 
 weeping. Pustules around the hair follicles, as in sycosis, are 
 often present, and the term eczema sycosiforme is used to de- 
 signate this condition. When chronic the skin is red, and scal- 
 ing and itching are prominent symptoms. 
 
 Eczema of the head generally spreads to the surrounding 
 parts, as the cheeks and neck. 
 
 Eczema of the chin and neck rarely occurs alone. Eczema 
 of the neck may arise from irritation caused by a collar, in 
 which case it remains limited, but its most frequent cause is 
 from pediculi of the head, and then it is associated with 
 eczema of the scalp. It is generally chronic in character and 
 squamous in form. 
 
ECZEMA. 313 
 
 Umbilical region. — Eczema of the umbilicus occurs either 
 alone or in connection with eczema of the surrounding skin. 
 It usually occurs as eczema rubrum, and is met with especially 
 in fleshy persons and in those with a depressed navel. It is 
 usually caused by irritation from collection and decomposition of 
 sebaceous matter. The part is red and swollen, and there is 
 frequently considerable exudation. It is very obstinate and 
 difficult to cure. 
 
 Nipple and Mamma. — Eczema of this region is very frequent 
 in nursing women after confinement. Eczema of the nipple 
 and areola is also common in connection with scabies in women. 
 The forms met with are e. rubrum and e. impetiginosum. 
 Usually both nipples are affected. Longitudinal and horizon- 
 tal fissures form and discharge a sero-purulent fluid which dries 
 to crusts. The nipple soon becomes broader and flatter, and 
 there is much pain and itching. Nursing increases the inflam- 
 mation, and purulent mastitis often results. 
 
 Eczema of the genitals. — Eczema of the penis and scrotum 
 may be acute or chronic. In the acute affection the penis is 
 much swollen, especially in its lower part next the scrotum ; 
 the glans penis is unaffected, and the prepuce sometimes 
 swollen and cedematous. The scrotum is much swollen, itches 
 intensely, and the amount of discharge is very great. Owing to 
 decomposition of the secretion from the sebaceous glands, the 
 discharge has a very bad odor. The eruption is liable to ex- 
 tend to the mons veneris, thigh and perinseum. In females 
 the labia are much swollen and tender, the amount of exuda- 
 tion is considerable, and the itching is severe. It is most fre- 
 quent in stout individuals. It is liable to extend to the vaginal 
 mucous membrane, causing a leucorrhoeal discharge ; or down 
 the thigh ; or up over the abdomen as far as the umbilicus. 
 
 Chronic eczema of the genitals in males is generally confined 
 to the scrotum, and frequently to that portion only which is in 
 contact with the thigh. After the eruption has lasted a long 
 time the skin becomes thickened and scaly, and forms thick 
 folds. It is very obstinate and causes great discomfort from 
 the itching accompanying it. 
 
314 ECZEMA. 
 
 Perinceum and antes. — Eczema often arises in this region on 
 account of the amount of sweating present, and the irritation 
 resulting from contact of the cutaneous surfaces, and from de- 
 composing sebaceous secretion. The part may be only red and 
 itching, or there may be considerable secretion. If it becomes 
 chronic the part is infiltrated, fissures form, defalcation is pain- 
 ful, the rectal mucous membrane may become affected, prolap- 
 sus ani occur, and blood or slimy mucus proceed from the 
 rectal mucous membrane. The disease is very obstinate to 
 treatment. 
 
 Hands and feet. — Eczema of the hands and feet may be acute 
 or chronic. When acute there is considerable swelling, with 
 heat, pain and tension. The eruption is of the vesicular, bul- 
 lous, or pustular form, and there may be only a few lesions, or, as 
 is usually the case, they are very numerous and closely studded 
 together. In children the eruption is frequently bullous in 
 character, with much cedema. The bullae are often purulent, 
 and rupturing shows a red rete or bare corium. The fingers 
 are swollen, thick and difficult to bend. One foot or one hand 
 may be attacked, but the eruption is generally symmetrical, and 
 the hands are more frequently affected than the feet. When 
 the palms or soles are affected the vesicles are not elevated and 
 remain intact a long time, as the thick epidermis prevents their 
 escape to the free surface. Neighboring vesicles may run to- 
 gether and form bullae, though this is most frequent in children. 
 On the back of the hands, dorsum of the foot, and between the 
 fingers and toes the eruption is papular or vesicular, and the 
 vesicles, especially in children, frequently form larger or 
 smaller bullae. These vesicles or bullae rupture, and then the 
 appearances are those of eczema rubrum. 
 
 In chronic eczema of the hands, all forms of the eruption may 
 be present. On the back of the hands and between the fingers 
 there may be vesicles, with gummy exudation ; and on the palms 
 the epidermis dry, and the skin infiltrated, inelastic and fis- 
 sured, the fissures being situated over the flexures of the joints 
 and in the natural markings of the palm. The eruption in the 
 palm may be general or limited in extent, and the margins 
 
ECZEMA. 315 
 
 abrupt or gradually shading off into the normal skin. It some- 
 times resembles very much a squamous syphilide of the palm, 
 but differs from the latter in that it shows no tendency to heal 
 at the center, and the sharply-limited infiltrated margin of 
 syphilis is wanting. 
 
 Eczema of the feet rarely gives the dry fissured form ob- 
 served on the palms of the hands, as the perspiration and re- 
 tained sweat softens the epidermis. The latter is thick- 
 ened, sodden-like, and separates in large flakes. Between the 
 toes especially, but also on the rest of the foot, there is much 
 itching and often pain. 
 
 Eczema of the nails. — In general eczema, and in eczema of the 
 hands, especially if the dorsal surface of the fingers is affected, 
 there is disease of the nails. Several, or all the nails may be 
 affected, although the latter is unusual in eczema of the hands. 
 The nails lose their smooth and shining aspect and become dry, 
 roughened, furrowed, honey-combed like, and brittle. The 
 furrows are longitudinal or transverse, and the affection cannot 
 be diagnosed from the condition present in psoriasis or lichen 
 ruber by examination of the nails alone. In severe cases the 
 nails exfoliate but are replaced by healthy nails if the eczema 
 is removed. 
 
 Eczema of the flexures of the joints is a frequent affection, and 
 is usually symmetrical. It is either acute or chronic. When 
 acute, it commences as an erythema intertrigo, and later as an 
 eczema intertrigo. If chronic, the skin becomes thickened, 
 reddened, scaly, fissured, painful, and movement is interfered 
 with. The chronic form is very obstinate. It is more frequent 
 in the popliteal spaces than in the fronts of the elbows. 
 
 Eczema intertrigo, which is closely related to eczema of the 
 flexures, the eruption commences as a hyperaemia and soon 
 passes on to an eczematous condition. It is met with especially 
 in children and in stout women, and occurs whenever two 
 cutaneous surfaces come in contact, as in the neck, axilla, be- 
 neath the mammae, groin, genital and anal region. In the axilla, 
 where it is usually caused by profuse sweating, the skin is red, 
 and moist, and consecutive swelling and suppuration of the 
 
316 ECZEMA. 
 
 axillary glands is a frequent occurrence. In children intertrigo 
 may be accompanied by intense phlegmonous inflammation and 
 oedema of the part, and in badly-nourished subjects, loss of 
 substance, and even gangrene. 
 
 Eczema crurale. — Eczema of the legs is often symmetrical and 
 is papular, pustular or vesicular in form. When acute, there is 
 considerable exudation which dries to yellow or brown crusts. 
 
 Chronic eczema of the legs is not so often symmetrical and is 
 usually found in elderly persons with a varicose condition of the 
 veins. It commences as an erythematous or vesicular eczema, 
 but soon appears as an eczema rubrum or squamosum. In e. 
 rubrum the skin appears of a deep red color with pointed red 
 spots, and is more or less covered with yellowish or brownish 
 crusts. In the squamous form the appearances are often very 
 much like those in psoriasis, especially if the patch is limited 
 in extent. The skin is thickened and covered by a greater or 
 less quantity of whitish crusts or scales. There may be an 
 entire absence of vesicles either in the patch or at its periphery. 
 This form is seen especially in rheumatic or gouty subjects. 
 
 Long continued eczema of the leg causes thickening of the 
 corium, a pachydermatous condition and a warty-like appear- 
 ance from hypertrophy of the papillae — eczema verrucosum. 
 
 Anatomy. — Eczema may be regarded as a simple catarrhal 
 inflammation of the skin, and, as in catarrhal conditions of the 
 mucous membrane, the changes in the part will depend upon 
 the intensity and duration of the inflammation. 
 
 In the erythematous form all the vessels of the papillary 
 layer are affected. The bloodvessels are dilated, there is exu- 
 dation and congestion and increased activity of the epidermis, 
 as shown by the scaling. In the papular form the changes are 
 primarily confined to the follicles of the skin, and especially to 
 the hair follicles. The bloodvessels are dilated, there is serous 
 exudation, with some emigration and secondary changes in the 
 corium and epidermis. The vascular changes need not be 
 described, as they are the same as occur in all inflammations. 
 The exudation causes swelling of the papillae and upper part of 
 the corium, and a more or less indistinctness of the ground sub- 
 
ECZEMA. 
 
 317 
 
 stance of these parts. A portion of the exudation passes into 
 the rete, between the cells, pushing them apart and raising the 
 corneous layer and part of the rete, forming the papule. In 
 the vesicular form the changes are simply an exaggeration of 
 those occurring in the papular stage. There is more exudation 
 and emigration and consequently more cedematous condition 
 of the papillae and corium, and probably active formative 
 changes in the connective tissue corpuscles. There is more 
 
 Fig. 39. — Vertical section of a recent vesicle of eczema. a } corneous layer ; 
 6, rete ; c, corium ; d, vesicle ; e, dilated blood vessels. 
 
 exudation into the rete and the cells are pushed further apart, 
 and some are completely separated, and lie loose in the vesicle, 
 which forms in the upper part of the rete or just beneath the 
 corneous layer. The cells of the rete do not take any active 
 process in the changes which lead to the formation of the vesi- 
 cle, and in eczema there is no reason to suppose a primary 
 nutritive change in the rete cells previous to the vascular 
 changes. No one has shown that the changes in the rete in an 
 erythematous eczema, which later assumes the papular or vesi- 
 
3i8 
 
 ECZEMA. 
 
 cular form, are different from those occurring, say in scarlatina. 
 If there is sufficient exudation to form a vesicle, the rete cells 
 swell up from imbibition of the serous liquid, and many of 
 them, especially in the interpapillary processes, undergo a 
 dropsical degeneration and finally unite their contents with the 
 serous fluid, giving rise to the gummy liquid characteristic of a 
 catarrhal inflammation of a cutaneous or mucous surface. The 
 vesicle itself consists at first of a clear liquid and a few isolated 
 or distorted rete cells, but later pus corpuscles are present, and 
 
 Fig. 40. — Section of the skin in eczema verrucosum : a, corneous layer ; 
 d, rete ; c, hypertrophied papillae ; d, corium ; e, hypertrophied corneous layer. 
 
 continue to increase in number the longer the vesicle exists. 
 The origin of these corpuscles is at first exclusively from the 
 bloodvessels, but later some at least probably come from the 
 connective tissue corpuscles and from the corpuscles of the 
 lower rete cells, the result of an irritation from the bloodvessel 
 exudation. In Fig. 39 are shown the changes occurring in a 
 commencing vesicle. 
 
 In pustular eczema the exudation and tissue changes continue 
 and there is an increase in the cell emigration and local multi- 
 plication from the emigrated and also from the connective 
 
ECZEMA. 319 
 
 tissue and rete corpuscles, hence more round cells are present 
 in the corium, rete and vesicle. In chronic eczema the process 
 extends deeper in the corium and even to the subcutaneous 
 tissue, and the part becomes thickened from the infiltration 
 and occasional new connective tissue formation. The exuda- 
 tion and round cell collection occurs especially along the 
 course of the bloodvessels. The lymph vessels become en- 
 larged, and in long continued inflammation the hair follicles, 
 sweat and sebaceous glands may be destroyed. The papillae 
 are enlarged and may be much hypertrophied, as occurs in the 
 verrucous form, as shown in Fig. 40. 
 
 In this form the condition should no longer be considered as an 
 eczematous condition, but one of hypertrophy, as shown by the 
 active new formation of bloodvessels and connective tissue. 
 The rete is not much changed, but their cells do not undergo 
 the usual horny transformation process, but assume a pearly 
 appearance and are cast off in lamellae instead of in scales. 
 
 In ordinary chronic eczema rubrum the corium is thickened 
 from exudation and round cell collection as already described. 
 The papillae are enlarged from the same causes. The boundary 
 between the corium and rete is often absent, as the round cell 
 collection and the inflammatory changes on the one hand and 
 the changes in the rete on the other destroy their characteristic 
 appearance. In the rete the lowest rows cells are separated 
 from each other and are mixed with round cells, either from the 
 corium and bloodvessels, or from those, and from rete cells 
 which have returned to an embryonic condition. The corneous 
 layer is partly or completely absent, and, if present, its cells 
 are abnormal in character, as shown by the number which still 
 retain their nucleus. The surface of this layer is also very 
 irregular, as shown in Fig. 41. 
 
 In chronic eczema rubrum we have the changes in the 
 corium and epidermis ; the corium, including the papillae, 
 being in an inflammatory condition, with the changed blood- 
 vessels, exudation, cell emigration and embryonic cell forma- 
 tion from the connective tissue of the corium. The rete is 
 changed, in that the lowest rows of cells are separated from 
 
3 2 ° 
 
 ECZEMA. 
 
 each other, and many of them are producing embryonic bodies. 
 The upper part of the rete is more normal in appearance. The 
 upper part of the corneous layer is absent, and the remainder 
 is uneven and shows an interference with the horny transfor- 
 mation change. 
 
 Fig. 41. — Section from a case of chronic eczema rubrum of the leg : a, cor- 
 neous layer ; d, stratum lucidum ; c, papillae ; d, interpapillary rete ; e, deep part 
 of corium. 
 
 In many cases of chronic eczema the changes in the epi- 
 dermis here described do not occur, the part appearing to be 
 in an almost normal condition, except the corneous layer. 
 
 In chronic eczema squamosum the corium and papillae show 
 dilated bloodvessels and round cell collection, with changed 
 connective tissue corpuscles and more or less disappearance of 
 the ground substance. The epidermis appears normal, except 
 that there is active cell desquamation from the corneous layer, 
 the result probably of the increased nutrition consequent on 
 
ECZEMA. 321 
 
 the chronic hyperaemic condition of the corium. In fig. 42 is 
 represented a horizontal section of the skin from the palm of 
 the hand in a case of squamous eczema with but slight in- 
 filtration. The disease disappeared in two or three weeks 
 later. Four papillae are shown containing dilated bloodvessels 
 and embryonic cell collection. The rete cells are shown to be 
 normal in appearance and to be connected to each other by 
 filaments. 
 
 Fig. 42. — Horizontal section of the skin in chronic squamous eczema. 
 
 Etiology. — The cause of an eczematous inflammation may 
 depend upon an external irritation acting directly upon the 
 skin, or an internal irritation depending upon certain condi- 
 tions of the system. External local causes are either mechani- 
 cal or chemical. The rubbing of two surfaces against each 
 other, especially if moist from sweat or other secretions ; 
 scratching, parasites, etc., are examples of the disease from 
 direct mechanical irritation. Croton oil, strong potash prepa- 
 rations, blue ointment, sulphur, mineral acids, arnica, turpen- 
 tine, etc., are examples of chemical causes. Venous hyperaemia 
 leading to transudation of serum in the tissues, and later to 
 dermatitis, as observed on the leg and around the anus from 
 varicose veins, is a frequent cause of eczema of these regions. 
 
 Among the many causes acting from within are dyspepsia, 
 21 
 
322 ECZEMA. 
 
 diabetes, albuminuria, deficient excretion of solids by the kid- 
 neys; and constipation. The changed condition of the blood 
 produced by these abnormal conditions either causes the blood 
 to act as a direct irritant as it passes through the capillaries of 
 the skin, or so changes the constitution of the tissues that they 
 are more liable to react to external irritants. We do not 
 think that at any time such conditions as scrofula, anaemia 
 chlorosis, etc., produce an eczema, except in an indirect man- 
 ner by increasing the irritability of the elements of the skin, 
 or lessening their power to withstand direct irritation either 
 from within or without. As lesions to be the result of consti- 
 tutional causes must be shown to be the direct cause of a gen- 
 eral condition in the system ; that is, of a general disease, as for 
 instance is the case in affections of the joints in rheumatism ; 
 and as we know of no disease of the general system in which it 
 has been shown that it can directly produce an eczema, we are 
 obliged to hold the view that eczema is an affection of local 
 origin. Certain conditions of the system, as quoted above, 
 predispose to the disease, and these same conditions will 
 prolong the duration of an eczema, however produced, unless 
 they be removed. This is especially the case with acid dyspep- 
 sia, rheumatism and gout. 
 
 As regards the eczema of children, it is found in both 
 healthy and sick children. It is frequently observed in those 
 who have an acid dyspepsia or other digestive troubles, but it is 
 also met with in those who are robust. In the latter their proto- 
 plasm is very active, and reacts upon slight irritation, and in 
 many of these cases the eruption is seated on the cheeks, where 
 the capillaries are active and unusually near the free surface, 
 as shown by the red cheeks of these children. Dentition is no 
 more a cause of eczema than it is of the score of other 
 troubles which are innocently laid to its charge. 
 
 Diagnosis. — Eczema is a polymorphous eruption, and in en- 
 deavoring to arrive at a conclusion as to whether a definite 
 eruption is eczematous or not, we must remember that it may 
 appear singly or combined in any of its forms. It has no defi- 
 nite course ; it may appear upon any part of the body ; it may 
 
ECZEMA. 323 
 
 be dry or moist ; the area affected maybe limited or very exten- 
 sive, and finally it may be complicated by other conditions. 
 The diagnosis can only be made with certainty when the path- 
 ological character of the eruption is understood ; when one 
 understands the changes which must occur before a given 
 eruption can constitute a catarrhal inflammation of the skin. 
 The signs of inflammation must always be present, nutritive 
 changes must occur in the skin, and there must be signs of 
 exudation. The history of the case, whether a similar or any 
 eruption has previously occurred, and the appearance and 
 course of that eruption, the manner in which it commenced, 
 whether vesicles or discharge was present, etc., are all to be 
 noted in cases difficult to diagnose. 
 
 The eruption may resemble somewhat lichen ruber, lichen 
 planus, herpes, a small papular or vesicular syphilide, erythe- 
 matous lupus, psoriasis, seborrhcea, syphilis of the palms, pity- 
 riasis rubra, erysipelas, scabies, sycosis, tinea tonsurans, pem- 
 phigus foliaceus, or urticaria. 
 
 Lichen ruber commences as papules, and remains as such 
 during their whole existence. There are never any vesicles 
 present. They form slowly, and there are firmly adherent 
 scales on their apex. 
 
 Lichen planus sometimes closely resembles a follicular eczema 
 of the legs or forearms, the papules, however, never become 
 vesicles, their course is slow, they are often umbilicated, are 
 violaceous in color, have a tendency to group and the eruption 
 is symmetrical. In eczema some of the papules become ves- 
 icles, the lesions run an acute course, they are generally 
 acuminated, of a bright red color, are irregularly distributed, 
 and the eruption is generally unsymmetrical. 
 
 In Herpes the vesicles are grouped, the individual vesicles 
 of a group are of the same age and stage of development, and 
 they tend to dry up without rupturing. In eczema the vesicles 
 of a patch are of all ages and they tend to rupture. 
 
 In the small papular syphilide the papules are hard, the red- 
 ness does not disappear upon pressure, they show some ten- 
 dency to grouping, the eruption is more or less general over 
 
324 ECZEMA. 
 
 the whole body and larger papules, or other signs of syphilis 
 are present. 
 
 A flat papule at the angle of the mouth resembles very much 
 a fissured eczema of this region, but the history of the case, 
 the presence of other lesions on the body or mucous membrane 
 of the mouth, and the single deep horizontal fissure are suffi- 
 cient for the diagnosis. 
 
 A pustular syphilide of the head resembles an impetiginous ec- 
 zema in the crusting and general distribution, but removal of 
 the crusts shows in syphilis a deep ulceration with a dirty base, 
 whilst in eczema ulceration never occurs. 
 
 Syphilis of the palms is very difficult to diagnose from a squa- 
 mous eczema. In syphilis, both hands and feet are usually 
 affected, and there are syphilitic lesions on the mucous mem- 
 brane of the mouth or general cutaneous surface. In syphilis 
 the infiltration is firmer, it sits deeper, extends a short distance 
 beyond the scaling area, itches little, if any, the redness does 
 not disappear upon pressure, and the patch spreads by extension 
 at the periphery. 
 
 In eczema vesicles are to be seen, the patches of eruption 
 are generally larger than in syphilis, the disease is not so fre- 
 quently symmetrical, the central part of a patch does not clear 
 up as in syphilis, the margins are irregular, and there is an ab- 
 sence of the dark-brown, deeply-seated, sharply-limited infil- 
 tration of syphilis. 
 
 Erytheinatous lupus. — This disease resembles somewhat a 
 limited patch of squamous eczema, but the course of the dis- 
 ease is very slow, requiring months or years to become half an 
 inch in diameter, there are no vesicles present at any time, the 
 scales are few and firmly attached, and are provided on their 
 under surface with plugs of sebaceous matter which dip into 
 the follicle. The eruption is well-defined, spreads very slowly, 
 does not itch, and cicatrical tissue is always formed, commenc- 
 ing in the central part of the lesion. In eczema the eruption 
 spreads more rapidly, there is often a history of weeping or 
 papule formation, the amount of scaling is greater, the 
 scales are loose and not provided with sebaceous plugs on 
 
ECZEMA. 325 
 
 their under surface, the margin of the patch is rarely abrupt, 
 and there is no formation of cicatricial tissue. 
 
 Psoriasis. — In psoriasis there are scales and not crusts, the 
 scales are plentiful, and not thrown off in lamellae, and are 
 pearly white in appearance. The eruption is sharply limited, 
 never commences as vesicles, there is never any history of 
 moisture, the patches spread at the periphery whilst the center 
 clears up, giving a ring-form to the eruption, it is met with es- 
 pecially on the exterior surfaces of the knees and elbows, it 
 itches but little, and removal of the scales and scraping the 
 skin beneath, causes oozing of blood. In eczema the scales or 
 crusts are not pearly white, they are not thrown off as lamellae, 
 the eruption is rarely sharply limited, there is usually a history 
 of moisture, the patches spread by the formation of new pap- 
 ules or vesicles, the center of a patch shows no tendency to 
 heal, but on the contrary is usually the most infiltrated, itching 
 is generally present, scratching of the surface after removal of 
 the scales does not show isolated oozing points, and the flexures 
 are more frequently attacked than the extensor surfaces. Pso- 
 riasis of the palms is a very rare affection and is never met with 
 on these parts alone. 
 
 In pityriasis rubra the scales are large and thin, like paper ; 
 there are no papules, no moisture or special infiltration of the 
 the skin, the scales are rapidly reproduced, itching is slight 
 and the eruption tends to spread over the whole body. In ec- 
 zema there is usually papules and some moisture if the erup- 
 tion is at all extensive, and if it has lasted a short time there is 
 more or less infiltration of the skin. The scales are not so 
 thin, or so numerous, and itching is much more severe than in 
 pityriasis rubra. 
 
 In seborrhea the skin is normal or pale red in color, the 
 eruption extends over the whole head as a rule, the glands are 
 not swollen, there is no weeping, and the scales or crusts are 
 fatty or oily in character. In eczema the eruption is limited 
 in extent, the skin is red, inflamed, the glands are often swol- 
 len, weeping is frequently present, and the crusts or scales con- 
 sist of epithelial cells or dried exudation. 
 
326 ECZEMA. 
 
 In erysipelas there is more redness, swelling and fever, the 
 disease commences in one spot and spreads rapidly, the skin 
 has a shining, tense appearance and is smooth or studded with 
 deep vesicles or with bullae. The disease is acute in its course, 
 and is ushered in with chills and other symptoms of general 
 disturbance. In eczema there is less fever, heat, red- 
 ness and swelling of the skin, the eruption does not commence 
 at a point and spread rapidly at the periphery, the skin has not 
 a tense, shining appearance and the margin is not so sharply 
 limited. 
 
 In scabies the situation of the eruption, the history of the 
 case as regards contagion, the presence of characteristic fur- 
 rows, and the intense itching as compared to the number of 
 vesicles present, are sufficient for the diagnosis. In children 
 the furrow may not be found, but the situation of the eruption 
 and the bullous or pustular character of the lesions, its symmet- 
 rical occurrence and presence on the forearms as well as on the 
 hands, are characteristic. 
 
 In sycosis the eruption is confined to the hairy part of the 
 face, the crusts are smaller, and a hair is present in the center 
 of every pustule. In eczema the eruption generally extends 
 to the neighboring parts and does not remain limited to the 
 hairy regions, there is considerable exudation and crust forma- 
 tion, the skin is infiltrated, and the pus does not come from the 
 peri-follicular region. 
 
 Tinea tonsurans is sometimes very difficult to diagnose from 
 an eczema. In ringworn of the scalp the patches are circular 
 in form, the scales are grayish white, the hairs are dry and 
 broken, and the eruption spreads by peripheral growth. In 
 eczema there is more discharge, the patches are not so circular 
 in form nor do they increase in size by peripheral growth, and 
 the hairs are unaffected. 
 
 In ringworm of the body it is sometimes impossible to 
 diagnose the eruption without the aid of a microscope. If the 
 ring-form is present, or a history of contagion, then there is 
 no difficulty. 
 
 In eczema marginatum the sharp limitation, its growth be- 
 
ECZEMA. 327 
 
 yond the place of scrotal contact, the greatest intensity of in- 
 flammation at the peirpheral part, whilst the center has partly or 
 almost completely healed, are generally sufficient for the diag- 
 nosis. When in doubt, the microscope should be used. 
 
 In pemphigus foliaceous, the eruption commences as bullae, 
 the scales are large and flat, the skin is not infiltrated and the 
 eruption tends to become general over the whole body. 
 
 Liche?i urticatus resembles somewhat a papular eczema in 
 children, but the history of the case and the presence of 
 wheals will prevent a mistake. 
 
 Prognosis. — The prognosis of eczema is so far favorable in 
 that it can almost invariably be cured, but the length of time 
 required for its removal differs very much in different cases. 
 Some forms run an acute course whilst others are very obsti- 
 nate. Acute vesicular eczema does not usually last as long as 
 the papular form. A follicular eczema of the leg is always 
 chronic in its course and difficult to completely remove. 
 Eczema of the scrotum is generally very obstinate, as is also an 
 eczema depending on a varicose condition of the veins. 
 Chronic eczema of the hands in persons who are obliged to put 
 their hands occasionally in water is very troublesome to re- 
 move. In general eczema of old persons, associated with in- 
 tense itching, the prognosis is not very favorable. The cause 
 of the eruption, the general condition of the patient, and the 
 history as regards previous attacks of the disease should all in- 
 fluence our prognosis as to the chances of rapid recovery and 
 liability to relapse. 
 
 Treatment. — The treatment of eczema is both local and 
 internal. The internal treatment consists in the adminis- 
 tration of remedies for the removal of any abnormal con- 
 dition of the general system or disease of an internal organ. 
 As already mentioned when discussing the etiology of eczema, 
 very many of the cases of this disease are either indirectly 
 caused or are prolonged in their existence by abnormal condi- 
 tions of the general system, or of other organs, and consequently 
 internal treatment is required in all these cases to aid the local 
 treatment and to prevent a relapse of the disease. We will not 
 
328 ECZEMA. 
 
 endeavor to give the treatment for these abnormal conditions 
 as that belongs to the subject of internal medicine, but will 
 briefly note the indications in general. Purgatives and 
 aperients are indicated in cases of constipation of the bowels 
 in robust and fleshy persons, who are accustomed to excess in 
 eating or drinking, but they should not be given if the indi- 
 vidual is anaemic. In these latter cases a combination of iron 
 and aloes, with or without quinine or strychnine, is indicated. 
 Saline laxatives are useful in the acute inflammatory forms 
 of eczema, and may be employed in the form of rochelle 
 salts, sulphate of magnesia, Hunyadi janos water, etc. 
 
 Diuretics are indicated in functional derangement of the 
 kidneys, and in all cases of acute inflammatory eczema, to re- 
 lieve the skin. Alkaline diuretics, as the acetate or citrate of 
 potash, should be used. A good combination is that of acetate 
 of potash and sweet spirits of nitre combined with syrup of 
 orange and an aromatic water. In gouty or rheumatic states of 
 the system these alkalies can be given in combination with the 
 wine of colchicum. They should be administered in large 
 quantities of water to . get their proper diuretic effects. 
 Alkalies should also be given for their antacid effects in cases 
 of excessive acidity of the system consequent on an acid dyspep- 
 sia. They are useful in cases of acid stomach from improper 
 food or from the inordinate use of stimulants. The liquor 
 potass, twenty drops three times a day, bicarbonate of soda 
 or the carbonate of ammonia, ten to thirty grains, three times 
 a day, are the best preparations to counteract this acidity. If 
 the bowels are at the time constipated, the ordinary rhubarb 
 and soda mixture answers the object very well. Cod-liver oil 
 should be given in all scrofulous or strumous cases, and is fre- 
 quently sufficient of itself to remove eczema in these subjects. 
 Iron, etc., should be given in cases of anaemia. The diet should 
 always be regulated according to the individual case. Plethoric 
 persons should have a light, easily-digested diet, and meat 
 should be taken only in very small quantities. Wines or stimu- 
 lants, tea or coffee should not be used. In anaemic, debilitated 
 persons a liberal diet with stimulants are generally necessary. 
 
ECZEMA. 329 
 
 Arsenic may be given in all cases of chronic eczema, but it 
 is contraindicated in acute cases. It is most useful in the 
 chronic squamous form. Fowler's solution is a useful form, 
 and should be given after meals, commencing with small doses 
 and gradually increasing the quantity every three or four days 
 until some physiological effect is produced. This full dose is 
 continued until the eruption disappears, and then it is con- 
 tinued a short time longer in smaller doses. In anaemic cases 
 it should be combined with some preparation of iron. Chil- 
 dren can take comparatively large doses. It is one of our most 
 useful remedies for eczema, and when given in the proper dose 
 and for the chronic forms of the disease, it rarely fails to 
 act beneficially. Unfortunately some persons cannot take it 
 on account of the gastric disturbance or irritation of the con- 
 junctiva which it causes. 
 
 Local Treatment. — The local treatment is regulated by the 
 pathological condition present, whether the eruption is acute 
 or chronic, erythematous, papular, vesicular, pustular or squam- 
 ous, and the extent of area affected. Our success in the local 
 treatment of eczema will depend upon our ability to appreciate 
 the nature of the changes occurring in the skin, the condition 
 of the tissues in the different stages of inflammation, and the 
 action of the remedies to be employed. The treatment for acute 
 and chronic eczema is entirely different; in the former soothing 
 remedies are to be employed, and in the latter more or less ir- 
 ritating ones. 
 
 ACUTE ECZEMA. 
 
 In the acute stage of eczema all irritating applications are 
 to be avoided and soothing ones only employed. The in- 
 flamed skin is to be protected from irritation from the air, 
 heat, the rubbing of the clothes, etc., and the itching and burning 
 of the part relieved. To protect the skin from the air and re- 
 duce the irritation, itching, burning and inflammation, the part 
 should be dusted with protecting powders as lycopodium, tal- 
 cum venetum, starch, etc. If there is much itching, camphor 
 (2 per cent.) can be added. For general use starch is as bene- 
 
330 ECZEMA. 
 
 ficial as any of the powders, and is preferable to the toilet 
 powders of commerce. It can be medicated according to the 
 method suggested by Dr. Faithful of Australia. The fluid ex- 
 tract of the substance desired to be added is dissolved in alco- 
 hol, ether or chlorform, and the tincture or solution then 
 thoroughly mixed with the starch, and afterward the alcohol, 
 ether or chloroform allowed to evaporate. Any substance 
 soluble in alcohol, ether or chloroform, may be used according 
 to the indications to be fulfilled. Further experience in the 
 use of these medicated powders will undoubtedly enable us 
 to make such combinations as will allay the troublesome itch- 
 ing and burning in this disease. In intertrigo the parts should 
 be powdered with starch mixed withboracic acid (i per cent.), 
 or salicylic acid (i per cent.), and absorbent cotton (borated) 
 placed between the opposing surfaces. In papular eczema the 
 intense itching can be treated by dusting with an anodyne 
 medicated powder, or the part may be washed with alcohol and 
 carbolic or salicylic acid (i per cent.), or simply with cologne 
 water or a weak solution of vinegar. 
 
 If the eczema is vesicular in form or weeping the same appli- 
 cations can be used as for the acute erythematous and papular 
 forms. If the inflammation is intense and there is much pain, 
 a lead and opium wash, or cold water should be applied by 
 means of linen cloths kept constantly moist with the liquid. 
 If a very large surface is affected, alkaline baths may be em- 
 ployed, or if the area affected is limited, an alkaline lotion, 
 bicarbonate of soda or borax, one-half drachm to a pint of 
 water may be used instead of the lead and opium wash. 
 McCall Anderson recommends a solution of dilute hydro- 
 cyanic acid, 3 ii. to aquae Oj. as a lotion to relieve the itching. 
 These protecting powders and soothing and antiphlogistic ap- 
 plications are all that can be used locally during the inflamma- 
 tory stage when there is much heat, redness, swelling and itch- 
 ing, or pain. Internally, a low diet and alkaline mineral waters, 
 and perhaps saline aperients should be ordered. 
 
 When the inflammation has somewhat abated in intensity, 
 use may be made of ointments to protect the surface and reduce 
 
ECZEMA. 331 
 
 the irritation. The ointment must be non-irritating, homoge- 
 neous, and not liable to become rancid. The benzoated 
 oxide of zinc fulfills these indications perhaps better than any 
 other ointment. It may be necessary in some cases to reduce 
 the strength of the oxide of zinc, but usually it can be ordered 
 of the full strength. It must not be used as long as the inflamma- 
 tion is very acute, if otherwise the irritation of the skin would 
 be still further increased. 
 
 McCall Anderson recommends the following ointment as the 
 most soothing, with which he is acquainted : r>. Bismuthi 
 oxidi, § i. ; acidi oleici, 3 viii. ; cerae albae, 3 iii. ; vaseline, 
 § ix. ; olei rosae ; M. v. Mix. 
 
 In Vienna they use the diachylon salve of Hebra, which at 
 present is generally made by mixing together equal parts of 
 vaseline and simple lead plaster. In my experience it is much 
 more irritating than the zinc salve, and if applied too early 
 sometimes aggravates the eruption. 
 
 If crusts have formed from drying up of the exudation, these, 
 if of any amount, must be removed before applying the salve. 
 As good a plan as any is to thoroughly saturate them with oil, 
 and in a few hours wash the part with warm water ; or a poul- 
 tice may be applied instead of the oil. 
 
 Ointments may be either rubbed into the skin or applied on 
 strips of cloth and bound upon the part. Whenever practi- 
 cable the latter method should be followed, as the results are 
 more satisfactory when the ointment is applied in this manner. 
 
 Where large surfaces are affected I have lately used with 
 satisfactory results, a preparation of oxide of zinc mixed with 
 mucilaginous acacia and glycerine, as recommended by Unna, 
 of Hamburg. The advantages of the preparation are its cheap- 
 ness, the ease of application, and the completeness of protec- 
 tion to the inflamed surface. It is prepared as follows : I£. 
 Zinci ox., 3 i. ; Muc. gum arab. ; Glycerini aa, § ii. It can 
 be applied with a brush two or three times a day. If there is 
 much itching salicylic acid, or carbolic acid (1$) may be added. 
 In some few cases the glycerine has irritated the skin too 
 much. 
 
332 ECZEMA. 
 
 As the eruption approaches the chronic stage, the diachylon 
 ointment of Hebra can be used, or the zinc ointment with or 
 without bismuth, or the mucilage paste of Unna. Ointments 
 when used should always be renewed twice daily, and should 
 be spread so thick upon the cloths that they will not become 
 dry before the time for renewal. 
 
 During the acute stage the parts should not be washed by 
 soap and water, as that operation irritates the skin and inten- 
 sifies the inflammation. 
 
 In the squamous stage of an acute eczema, continued use is 
 to be made of the previously mentioned ointments, and if the 
 scaling does not cease in due time, recourse must be had to a 
 tar preparation. 
 
 CHRONIC ECZEMA. 
 
 In chronic eczema the indications for treatment are first 
 the removal of crusts, or epidermic masses, and secondly, to 
 treat the inflammation and infiltration. For the removal of 
 the crusts oil can be employed in the manner already de- 
 scribed. It is especially indicated in eczema of hairy parts. 
 On non-hairy parts fresh lard, or a simple non-irritating oint- 
 ment spread upon cloths may be used. Water in the form of 
 baths, douches and with cloths has been recommended, but is 
 not so reliable, as the water may irritate the skin. If the scales 
 are not removed by these applications, recourse must be had 
 to green soap. This is to be applied to the part and then 
 rubbed with a flannel dipped in warm water until a lather 
 forms, when it is washed off with warm water and an 
 ointment applied. On the hairy part of the head the spiritus 
 saponis kalinus of Hebra (saponis viridis, g i., spirit, rectif. f ii.,) 
 maybe used instead of the green soap. The thickened epider- 
 mis masses present in eczema squamosum of the palms can be 
 removed by green soap, caustic potash, hydrochloric acid, or an 
 ointment of salicylic acid. The last preparation is preferable 
 and can be used spread upon cloths or rubbed in hourly. 
 
 Having removed the crusts or scales the inflammation and 
 infiltration are to be treated. Use should still be made of dia- 
 
ECZEMA. 333 
 
 chylon salve, zinc salve, etc., as for the previous stage, and the 
 applications made twice daily. If they are not sufficient to 
 remove the eruption, recourse must be had to stronger reme- 
 dies. If the patch is small, and the infiltration is not great, 
 the daily washing with green soap and subsequent application 
 of diachylon salve, etc., is generally sufficient. Instead of 
 green soap, liquor potassae may be brushed on the part and 
 then washed off with tepid water. If stronger applications are 
 necessary, use may be made of potassa fusa in the strength 
 of two to thirty grains to the ounce of water, the strength de- 
 pending upon the indications of the case. The strong solution 
 should be quickly washed off, and should not be applied oftener 
 than once a day. Hebra used, occasionally, a solution of the 
 strength of one part of the potash to two of water, twice a 
 week, as long as the infiltration lasted. 
 
 Usually, the green soap application is sufficient, and it should 
 be continued, in conjunction with an ointment, until the skin 
 is smooth and the infiltration has disappeared. The soap re- 
 moves the upper layer of epidermis, destroys the vesicles 
 beneath, and relieves the capillary vessels. If the soap is 
 spread upon flannel and applied over night, the effect is much 
 greater than from washing, and can be so used in obstinate 
 cases. If, finally, some slight thickening remains, use must be 
 made of tar preparations. 
 
 Oil of cade is the tar preparation most frequently employed, 
 but oleum rusci is pleasanter to the smell. Tar may be used 
 either pure or in the form of an ointment or solution. It 
 should never be employed in cases of acute eczema. As an 
 ointment it is used in the strength of one part of 6ar to one to 
 twenty parts of lard. On hairy parts it is applied as a liquid 
 by mixing equal parts of tar and alcohol. The pure tar and 
 the ointment are to be rubbed into the skin with the hand, and 
 the tincture is applied with a brush ; after the application the 
 part is to be powdered with starch. If the skin becomes some- 
 what irritated from the air, tar and ointment may be subse- 
 quently applied. " The liquor picis alkalinus " of Bulkley, 
 (picis liquidae, 3 ii.; potassae, 3 i.; aquae destillatae, 3 v.) is a useful 
 
334 ECZEMA. 
 
 preparation, as it can be combined with water to form a lotion 
 of any desired strength. Usually, it may be employed in the 
 strength of one to four drachms to a pint of water. 
 
 Tar should be applied once or twice a day, and its use con- 
 tinued until the hyperemia and scaling have entirely disap- 
 peared. 
 
 The only objection to tar is, that it is a treacherous remedy, 
 and will sometimes irritate the* skin and produce an acute 
 eczema when it seemed strongly to be indicated. Last winter 
 I applied pure tar to a case of chronic squamous ecezma of the 
 wrists, and in twenty-four hours an acute dermatitis, extending 
 to the elbows, resulted. 
 
 Blistering with cantharides is sometimes useful in obstinate 
 cases of limited extent. Tincture of iodine may also be ap- 
 plied in similar cases. Chronic eczema of the legs, with thick- 
 ening, may often be successfully treated by the rubber band- 
 age. The same condition of the hands may be treated with 
 rubber gloves. Rhagades may be treated by green soap or by 
 a ten per cent, solution of salicylic acid in liquor gutta per- 
 chse. Instead of tar, the infiltration in chronic cases of eczema 
 may be treated by the washing with green soap and the subse- 
 quent application of a mercurial salve added to the diachylon 
 or zinc ointment. 
 
 The special treatment for eczema of the different regions 
 requires brief notice. 
 
 Eczema Capitis.— -If lice are present they must be destroyed 
 by kerosene. Crusts are to be removed by oil, and, in 
 the case of children, the hair should be cut short, so as to 
 allow of the application of ointments. In acute cases, alkaline 
 lotions are to be used ; in subacute, ointments ; and in the 
 squamous form, either washing with green soap or using a tar 
 preparation. 
 
 Eczema of the Face should be treated by zinc or diachylon 
 salve and tar, according to the pathological condition. When 
 seated in the hairy part, the hairs should be cut short with 
 scissors in preference to shaving. If very persistent, epilation 
 may be necessary. 
 
ECZEMA. 335 
 
 Eczema of eyelids is sometimes very obstinate. If it does not 
 yield to the usual treatment it is better to epilate and apply a 
 solution of caustic potash to the lids, as already described for 
 chronic eczema. An ointment of the red iodide of mercury 
 (vaseline § i. ; hydr. biniod. gr. i.), applied along the edge of 
 the lid once a day is often very useful. 
 
 Eczei?ia of the lips is to be treated in the usual manner for 
 eczema of the general surface. Any nasal catarrh present 
 should be treated. Rhagades are to be touched with green 
 soap. An ointment of zinc, bismuth and glycerine (ung. zinci 
 oxidi, 3 i. ; bismuth, subnit. 3 i. ; glycerine 3 ii.) is useful in 
 healing the fissures and keeping the parts soft. 
 
 Eczema of the nipples is usually very obstinate. After each 
 time of nursing the nipple should be washed with warm water 
 and borax, then dried, and the mucilage preparation of Unna 
 applied. Bismuth powder is often of benefit. Fissures should 
 be touched with nitrate of silver to prevent mastitis if possible. 
 
 Eczema of the ge?iitals is to be treated on the same principles 
 as eczema of the general surface. The parts should be separ- 
 ated as much as possible with absorbent borated cotton in the 
 acute stage. Hot water applications are sometimes useful for 
 the removal of the infiltration and itching of the scrotum. In 
 eczema of the anal region the bowels should be kept regular 
 and any fissures present treated. A suspensory bandage should 
 be worn. 
 
 Eczema of the hands and feet. — Eczema of these parts has 
 a tendency to assume the chronic squamous form. The acute 
 stage is to be treated in the usual manner. In the chronic stage 
 if fissures form between the toes each toe should be separately 
 enveloped with diachylon salve spread on strips of linen. Rub- 
 ber gloves soften the epidermis and remove the fissures in the 
 dry squamous form. They should be constantly worn on the 
 hands, and washed twice a day with cold water. 
 
 Eczema of the nails. — When the nails are attacked they 
 should be scraped thin and tar applied. Green soap can be 
 used by means of a glove finger. 
 
 Eczema cruris. — In this form the cause requires special at- 
 
336 DERMATITIS. 
 
 tention. Varicose veins and an cedematous condition of the 
 tissues demand support in the form of a bandage. If the case 
 is severe it may be necessary to confine the patient to bed and 
 elevate the leg so as to get rid of the stasic hyperemia and 
 oedema. The eruption is to be treated on the principles already 
 laid down. In chronic cases with considerable scaling and 
 thickening, the rubber bandage is of great service, as it sup- 
 ports the bloodvessels, removes the oedema, and thins the 
 epidermis by preventing evaporation of the sweat. This re- 
 tention of the sweat, however, in some cases gives rise to an 
 acute eczema, so that in subacute cases I have applied the ban- 
 dage over a linen one in order not to lose the beneficial effects 
 of the constant support it gives to the bloodvessels. In this 
 article we have followed the plan of basing the indications for 
 treatment upon the pathological conditions present and not 
 upon the duration of the disease in a clinical sense, hence each 
 patch of eruption, if there are more than one present, must 
 have its appropriate treatment independently of the condition 
 of the other patches. Thus it may happen that on the same 
 individual the soothing, the stimulating and the absorbent 
 remedies are being applied at the same time to different parts 
 of the body. In all cases we must not forget to attend to any 
 internal disorders, either functional or organic, if we wish to 
 cure our patient rapidly and prevent relapses. 
 
 DERMATITIS. 
 
 Dermatitis, or inflammation of the skin, occurs under a vari- 
 ety of conditions ; for either the essential or some secondary 
 phenomenon of many of the affections considered in this work, 
 consists of an inflammatory condition of the general integu- 
 ment. Thus the skin lesions of the eruptive fevers, of some of 
 the animal poisons, or of the exudative diseases, are varieties of 
 dermatitis. But the forms of dermatitis, we are at present 
 considering, are those in which the inflammation is the primary 
 lesion, and is directly caused by irritants to the skin, either 
 from without, or through the medium of the blood. 
 
DERMATITIS. 337 
 
 The inflammation thus set up may vary in intensity from a 
 state which is hardly more than an erythema to a papular, ves- 
 icular, pustular, bullous, or even gangrenous condition. The 
 ordinary phenomena of inflammation, heat, redness, pain, and 
 swelling are present ; and the process may end in resolution, in 
 suppuration, or even in necrobiosis ; or again, it may only par- 
 tially subside, and a chronic dermatitis result. This idiopathic 
 dermatitis may be divided, from an etiological point of view, 
 into two main classes : First, der?natitis traumatica, being that 
 variety due to the action of external irritants or violence ; and, 
 second, dermatitis venenosa, the kind due to the action of sub- 
 stances, usually medicinal, which act as irritants during the 
 process of excretion. Dermatitis calorica, including both com- 
 bustio and congelalio, would probably come under the first head, 
 but their common occurrence and practical importance renders 
 it necessary for us to give special attention to these forms of 
 dermatitis, and their consideration is deferred until the dis- 
 cussion of the more infrequent varieties. 
 
 From a pathological, or rather from a clinical point of view, 
 other divisions are to be observed. Thus we have d. erythema- 
 tosa, the least severe form of the disease, characterized by 
 redness and slight serous infiltrations, and usually ending in 
 resolution ; d. phlegmonosa, with increased plastic infiltration, 
 and a tendency to suppuration ; d. diphtheritica, where there is 
 marked fibrinous exudation ; d. eschar otica et gangrenosa, the 
 process being severe enough to cause death en masse of the 
 affected portions of skin ; d. bullosa , with enough serous exu- 
 dation present to raise the upper epidermic layer into blebs ; 
 d. circwnscripta s. diffusa, etc., etc. 
 
 Dermatitis trau??iatica is commonly caused by concussions, 
 pressure, as of tight clothing, or bandages, etc. Excoriations 
 from scratching are one of its commonest manifestations, and 
 form an important part of the lesions of the itchy skin diseases, 
 as pediculosis, scabies, eczema, pruritus, etc. The dermatitis 
 thus set up usually quickly subsides on removal of its cause, 
 often leaving a pigmentation of the skin behind. This is es- 
 pecially marked in cases that have suffered for years from pe- 
 22 
 
338 DERMATITIS. 
 
 diculosis, in which the constant pressure of excoriations on vary- 
 ing parts of the skin cause a peculiar general patchy, dark- 
 brown discoloration. The dermatitis itself subsides rapidly 
 on removal of the cause and use of some soothing applications. 
 
 Dermatitis venenata. — Among the agents well known to pos- 
 sess the power of causing inflammation of the skin when 
 brought in contact with it, apart from the chemical irritants, 
 the plants of the rhus family stand prominent. The poison- 
 ous principle is reported by Dr. Maisch to be a volatile acid — 
 toxicodendric acid — and is present in several members of the 
 family. Two varieties of rhus are well known in North Amer- 
 ica ; they are r. venenata, the poison sumach or poison dog- 
 wood, and r. toxicodendron, the poison ivy or poison oak. The 
 poison is very volatile, and actual contact is by no means nec- 
 essary for the production of the peculiar dermatitis. Suscepti- 
 bility to its influence varies much ; some persons are poisoned 
 by merely passing in the vicinity of these plants ; others seem 
 to be able to handle them with impunity. 
 
 The dermatitis caused by rhus may be simply erythema- 
 tous, or it may be vesicular, pustular, or bullous. In most 
 cases the plant has been handled, and, by means of the 
 hands, other parts, notably the face and genitals, become 
 also affected. The eruption begins with redness, heat, swell- 
 ing, oedema of the skin, and much itching. The dermatitis, 
 though chiefly located around the parts mentioned, is not con- 
 fined to them, but spreads to a greater or less extent over the 
 whole body. The lesion is most often an erythema ; vesicles 
 are commonly present ; they are quite small, and situated on 
 an oedematous, inflamed base,and afterward often become pustu- 
 lar. In some cases the serous infiltration and swelling is very 
 marked, and causes considerable disfigurement, especially is 
 this the case around the male genitals, on acconnt of its 
 specially loose subcutaneous connective tissue. 
 
 Ultimately the vesicles rupture and dry up into crusts ; 
 these fall off, and the erythema subsides. The disease is acute, 
 and runs its course in from two to six weeks. 
 
 As regards treatment, soothing lotions and bland alkalies in 
 
DERMATITIS. 339 
 
 ternally, are indicated, as also are alkalies, bicarbonate of soda 
 and borax locally, in solution or as dusting powders. Lead 
 and opium wash, or black wash are useful. It is claimed that 
 one of the best means of treatment is by grindelia robusta, 
 which maybe used as a lotion in the strength of 3 i. of the fluid 
 extract to § vi. of water. The vegetable astringents are to be 
 recommended. Later, when the process has become more 
 chronic, corrosive sublimate wash, gr. i. to the ounce, or the 
 usual remedies for chronic dermatitis may be used. 
 
 Various other substances, though less commonly, cause der- 
 matitis when brought in contact with the skin. Thus, many of 
 the aniline dyes used for coloring cheap flannel goods are 
 poisonous. The feet are sometimes inflamed from wearing 
 the cheap, highly-colored stockings before they are washed ; 
 and the dye of the common red flannels so extensively used for 
 underwear, causes a papular or even pustular eruption upon 
 some skins. 
 
 Various drugs, cantharides, savin, tartar emetic, mezereon, 
 etc., will cause dermatitis if applied locally, as will arnica occa- 
 sionally. The small pustular eruption of croton oil is well 
 known. Mercurial ointment, if very freely applied, causes a 
 similar eruption. 
 
 A peculiar form of inflammation of the skin is the so-called 
 dermatitis gangrenosa, of which we distinguish an idiopathic 
 and a symptomatic variety. Idiopathic gangrenous dermatitis 
 begins as circular, erythematous, dark red spots, which tend to 
 appear symmetrically, and may be hyperaesthetic or anaesthetic. 
 General symptoms, malaise and feverishness accompanying the 
 disease. The skin lesion goes on to gangrene and sloughing ; 
 it usually ends in recovery, but may have a fatal termination. 
 A remarkable case of the disease has been reported by Rooke, 
 in which no less than thirty-six different patches of skin, vary- 
 ing in size form an area which could be covered by a quarter of 
 a dollar to one which embraced one-third of the superficies of a 
 mamma, became gangrenous, sometimes with extraordinary 
 rapidity ; the case ended in recovery. Fagge, Brodie, and 
 Stockwell have reported cases. Petri has described his own 
 
34° DERMATITIS. 
 
 case. Considerable general disturbance preceded the appear- 
 ance of numerous hemorrhagic macules, which were markedly 
 anaesthetic. Later, large blebs, often bloody, formed ; there 
 was extreme exhaustion, and superficial gangrene of the arm 
 occurred. It was six months before he finally recovered. 
 
 Spontaneous gangrene of the skin is known to occur in con- 
 nection with diabetes. The rapidity with which local gangrene 
 occurs under the slightest provocation in some paraplegias and 
 hemiplegias, and in some of the nervous diseases is well recog- 
 nized. It may occur in a few days, or even in a few hours, 
 after the onset of the nervous symptoms. 
 
 Cases are on record in which various agents have been em- 
 ployed by persons who desired to simulate these forms of der- 
 matitis ; acids and cantharides for bullae, turpentine to imitate 
 erythema, etc. 
 
 Dermatitis medicamentosa. — There remains to be considered 
 a set of skin eruptions of inflammatory nature which are of 
 especial interest because they occur as the result of the ex- 
 hibition of medicinal agents, and also because in many cases 
 they simulate very closely other integumentary disorders. Of 
 late years quite a number of drugs have been added to the list 
 of those that are known to cause eruptions and efflorescences 
 upon the skin ; probably they number twenty or more, most of 
 them in common use. 
 
 In general, persons with coarse, oily skins are more prone 
 than others to suffer from these eruptions. Some of them 
 come on only after the system has been thoroughly impreg- 
 nated with the drug. They are usually pustular, and the par- 
 ticular substance has in many cases been found in the pus. 
 They seem to be largely due to an attempt on the part of the 
 glandular structures of the skin to eliminate the foreign matter, 
 with consequent irritation and inflammation of these organs. 
 The common iodine and bromine eruptions are familiar exam- 
 ples. Others, again, cause an exanthematic eruption, with gen- 
 eral symptoms, chill, fever, gastric disturbance, malaise, etc. 
 Here saturation of the system does not seem necessary, the 
 cutaneous symptoms appearing very soon after the absorption 
 
DERMATITIS. 341 
 
 of the medicine ; nor is the immediate local cause present, as in 
 the first case. 
 
 Arsenic. — Arsenic usually causes a papular eruption, looking 
 like syphilis or erythema multiforme. Occasionally it may be 
 more diffuse, like an erysipelas ; or it may be vesicular, like her- 
 pes ; or pustular. It usually occurs on the face, neck and hands, 
 and lasts one to two weeks. An eruption resembling urticaria, 
 and even a purpuric one has been described. 
 
 Atropia or belladonna causes a scarlatinoid rash, which is 
 liable to appear within a very short time after the exhibition of 
 even very small doses of the drug. It usually affects only the 
 face, neck and chest, and is more often seen in children than 
 in adults. Dryness of the throat, headache and general malaise 
 accompany it. There is no fever or subsequent desquamation. 
 It may be caused by external applications, as by the use of 
 belladonna ointment. It is one of the commonest of the class 
 of eruptions from drugs. 
 
 Bromine — Bromides. — Here the eruption does not usually 
 occur until the system has been saturated with the drug. It 
 consists of an acne, which appears first on the forehead and 
 face, later affecting the chest and back. Occasionally furuncles, 
 or more diffuse purulent accumulations, may occur. Some- 
 times papules as well as pustules may be present, and the 
 disease simulate a maculo-papular syphiloderm very closely. 
 Bullous and eczematous eruptions are also described. These 
 troubles are all more likely to occur in individuals with thick, 
 oily skins ; the plan of giving a small dose of arsenic together 
 with the bromide has been successful in preventing the erup- 
 tion. Bromine has been demonstrated in the contents of the 
 pustules. Ringer states that the ammonium bromide is most 
 likely to cause acne. 
 
 Cannabis Indica. — A papulo-vesicular eruption of small size, 
 and covering the whole body has been recorded. It occurred 
 within twelve hours after a full dose of the drug, and disap- 
 peared in a few days. It is very rare. 
 
 Chloral is liable, especially if given with stimulants, to cause 
 a dusky red erythematous, or scarlatinoid eruption, occurring 
 
342 DERMATITIS. 
 
 on the face, neck and extremities. Under prolonged use of 
 the drug, fever, glandular enlargements, vesicles, petechias, ulcer- 
 ation, etc., may occur ; and death, with symptoms of purpura 
 hemorrhagica, has been recorded. 
 
 Copaiba quite commonly causes a rash, sometimes almost 
 immediately after ingestion of the drug. It consists of bright 
 red papulae or maculo-papules, resembling urticaria and 
 erythema multiforme, and very itchy. It occurs by preference 
 upon the extremities, but may cover the whole surface. It 
 lasts only a few days. 
 
 Cubebs very rarely causes a skin eruption, and then only in 
 young subjects who are saturated with it. It consists of a 
 more or less extended, bright red discoloration of the skin, 
 with millet-seed papules, coalescent in places, scattered 
 over it. There are no other symptoms, and it disappears 
 with brawny desquamation a few days after the medicine is 
 stopped. 
 
 Digitalis. — Papular and scarlatiniform eruptions have been 
 observed from digitalis. 
 
 Iodine — Iodides. — These are very common causes of medicinal 
 rashes, which exhibit themselves in a variety of forms. An ery- 
 thematous form appears on forearms, face and neck. The papu- 
 lar form is rarer, as is the vesicular, which occurs on the chest and 
 limbs, etc., and is accompanied by severe itching. A markedly 
 eczematous eruption with abundant secretion has been noticed. 
 The pustular eruption is the commonest, and resembles that 
 from bromine, both in appearance and in site. It is usually 
 acne form, but may be more diffuse. Iodine has been found 
 in the pus. A bullous eruption has been seen, occurring chiefly 
 on the head and neck. The small vesicles gradually become 
 blebs, and their contents may remain serous, or become puru- 
 lent, or even sanguinolent. Purpura from iodine is also known. 
 It usually appears on the legs ; it may become haemorrhagic, 
 and has been known to prove fatal. All the lesions usually 
 disappear rapidly when the remedy is discontinued. 
 
 Mercury. — A diffuse, deep red erysipelatoid eruption has 
 been seen from small doses of hydrargyrum. The skin is 
 
DERMATITIS. 343 
 
 smooth and itchy ; first the face alone is invaded, but it gradu- 
 ally extends over the body. 
 
 Opium. — Morphia. — An erythematous eruption, looking usu- 
 ally like the punctiform scarlatina rash, appears upon the chest 
 and flexor surfaces of the limbs in some cases. In certain indi- 
 viduals very minute doses of morphia will cause it. According 
 to the severity it may only last a few hours and disappear, or it 
 may persist for several days, and be followed by desquamation. 
 Strange to say, profuse sweating and sudamina have also been 
 noticed. 
 
 Phosphoric Acid. — A bullous eruption, looking like pemphigus, 
 has been reported from this drug. 
 
 Quinine. — An eruption, erythematous in character, and some- 
 times resembling measles, and at other times looking like scarla- 
 tina, has been quite frequently noticed after the exhibition of 
 quinine, even in very small doses. It first appears on face and 
 neck, and then spreads over the body. A chill, fever, nausea, 
 headache, etc., precede the eruption, and injection of the con- 
 junctivae and redness and dryness of the naso-pharyngeal pas- 
 sages accompany it. Burning and itching is severe, and it ends 
 in desquamation. A papular and a purpuric form have also 
 been noticed. 
 
 Salicylic Acid. — Diffuse erythema, with general symptoms, 
 fever, etc., has been noticed from large doses of this drug. 
 An urticaria has also been described, as also has the occur, 
 rence of ecchymotic patches upon the back, and vesicles 
 and pustules upon the hands and feet, with much sweating. 
 Small doses do not seem to cause the eruptions. They soon 
 disappear when the remedy is stopped. 
 
 Santonine. — Urticaria, with oedema of the lids, etc., has been 
 reported from santonine. It subsided in a short time. 
 
 Stramonium. — An erythema has been noticed from its use. 
 
 Strychnia. — A scarlatina form of rash has been reported after 
 the use of 1-24 grain of the remedy. 
 
 Turpentine. — Large doses may cause an erythematous, or 
 even papular rash over the face and upper trunk. It is usually 
 very itchy. A vesicular eruption has also been observed. 
 
344 COMBUSTIO. 
 
 A more detailed account of this interesting set of erup- 
 tions, as well as a fairly full bibliography of the subject, 
 is to be found in Duhring — Diseases of the Skin ; article, Der- 
 matitis. 
 
 COMBUSTIO. 
 
 Synonyms.. — Dermatitis combustionis ; burns. 
 
 Definition. — An inflammation of the skin, or of the skin and 
 the deeper tissues, caused by the action of excessive heat. 
 
 Symptoms. — Following Kaposi, we will divide burns of the in- 
 tegument into three classes — the classes being named in accord- 
 ance with the lesion of the skin produced by the destructive 
 agent. These classes are : 
 
 i . Dermatitis ambustionis erythematosa. 
 
 2. Dermatitis a??ibustionis bullosa. 
 
 3. Dermatitis ambustionis eschar otic a. 
 
 Symptoms. — The dermatitis from heat like that caused by 
 cold, ought perhaps not to be considered separately from 
 inflammations of the skin from other causes, such as der- 
 matitis venenata, or dermatitis traumatica. Pathologically, 
 the processes are alike. But inflammations of the skin from 
 this cause are so common, and of such practical importance, 
 that, under the name of combustio, they usually receive special 
 consideration in works on dermatology. Both burns and scalds 
 are included under this head. We will consider it under its 
 three heads or varieties, taking up first the erythematous 
 form. 
 
 1. Dermatitis Ambustionis Erythematosa. — In this, the least 
 severe of the various forms of burn under consideration, the 
 action of the irritant, be it flame, or steam, or hot solids or 
 liquids, has been momentary, or its intensity has not been great. 
 The skin is hypersemic, and evenly-colored pink or reddish. It 
 looks very like a patch of erysipelas, but the redness is not so 
 vivid, nor are the borders so distinct. The redness disappears 
 on pressure, and leaves a yellowish stain behind. There is slight 
 swelling, and some stinging, burning pain. 
 
 The inflammation does not advance beyond the first stage, 
 
combustio. 345 
 
 and soon commences to retrogress. The dilatation of the 
 small vessels passes away, the moderate amount of exudation 
 which may be present is soon absorbed. The redness fades 
 within a few days into a brownish tint, and the process ends 
 with desquamation of the epidermis. 
 
 In sensitive cases a moderate degree of fever accompanies 
 the local swelling, heat, and pain. 
 
 A moderate dermatitis of this kind is common enough from 
 the effects of the summer sun on exposed parts of the person, 
 or from the action of moderately hot water, or from momentary 
 contact with flame. The process lasts perhaps two weeks, and 
 leives the skin somewhat pigmented. 
 
 2. Dermatitis Ambustionis Bullosa. — In this form of burn 
 the irritant is of far greater intensity ; the hyperemia is very 
 marked, and liquid and formed elements escape from the ves- 
 sels, the transudation of serum into the upper layers of the epi- 
 dermis causing the formation of bullae and blebs. It corres- 
 ponds to the second degree of burn of the surgeons. 
 
 The bullae vary much in size. Where the skin is thin, they 
 form large semi-transparent, globular blebs, filled with yellow- 
 ish serum ; where it is thick, as on the palms of the hands and 
 the soles of the feet, they form flat elevations. If the amount 
 of exudation is very great, the epidermis may be detached over 
 large extents of tissue, or hang in shreds from the surface. 
 Usually some parts only of the surface are affected to this de- 
 gree, the rest being only of the erythematous form. 
 
 Under the serum we find the vessels of the subjacent papillae 
 dilated ; the connective tissue fibres are swollen and inter- 
 spersed with cells. When the top of the bleb is removed, and 
 the fluid drains off, we see below the yellowish-gray pulp of the 
 swollen rete-cells. 
 
 A more prolonged contact with hot air or flame, or steam or 
 hot metals, etc., is needed to produce this more intense degree 
 of burn. 
 
 The local dermatitis runs its course, and when it has ceased, 
 and no more exudation and proliferation occurs, the blebs and 
 their contents, if left to themselves, dry up into crusts, and 
 
346 COMBUSTIO. 
 
 epidermis formation takes place beneath them. If on the other 
 hand they have ruptured, the cell-proliferation of the tissue 
 beneath becomes very active ; the young cells accumulate in 
 such quantities as to be cast off as pus, and the papillae appear 
 as red points on a grayish, suppurating base. As the inflam- 
 mation subsides, cell proliferation becomes less active, pus for- 
 mation diminishes and eventually stops, and the new cells be- 
 gin, to undergo the ordinary changes, and form a new epi- 
 dermis. 
 
 In this degree of combustio scar-tissue is not necessarily 
 formed, though small cicatrices may occur where the papillae 
 have been destroyed. 
 
 The pain and the febrile reaction is far severer in this than 
 in the erythematous form. It is especially painful when the 
 blebs are ruptured and the papilla exposed over large tracts of 
 surface. Swellings of the neighboring lymphatic glands com- 
 monly occur. Extensive cases of burn to this degree, or even 
 more limited cases when they occur in children, or in old per- 
 sons, or in those debilitated from any cause, are very serious 
 indeed, and present clinically most of the features of the third 
 and severest degree of burn. 
 
 3. Dermatitis Ambustionis Escharotica. — Here the irritant 
 has been severe enough to cause mortification, absolute death 
 of the skin and perhaps deeper tissues. It includes all burns 
 beyond the third degree of the ordinary classification. We see 
 it from the direct application of flame, of molten metals, of ex- 
 ploding gas or steam, or boiling liquids. We find the 
 skin usually brownish, or black, though it may occasionally be 
 white and smooth, and apparently unaltered ; but it is always 
 dead ; sensation is gone ; and it feels hard and dry to the 
 touch. In the worst cases the skin is absolutely carbonized ; 
 it is a dead, dark brown mass, marked by arborescent tracings 
 which show where once were bloodvessels and their contents. 
 If hot steam or water has been the active agent, the skin is 
 tough and white, as if boiled. In other cases, as from lime 
 burns, it is tanned. But in every case it is entirely destroyed 
 as a living tissue. 
 
COMBUSTIO. 347 
 
 The dead mass acts exactly like any other mortified part ; 
 it causes inflammation of the surrounding skin, which has 
 probably already been irritated by the less intense action of the 
 same agent that caused the slough. By the third to the fifth 
 day reactive inflammation sets in, and a line of suppuration 
 begins to mark the division between the living and the dead 
 tissue. In one to two weeks the mortified mass is cast off, and 
 leaves a deep, irregular, suppurating wound. This wound heals 
 by granulation, and when the cavity is filled, the new epider- 
 mis starts from the healthy margin and from any papillae that 
 may have been left intact in any part of the wound. Scar- 
 tissue, new connective tissue without papillae, hair follicles or 
 glandular structures, replace the destroyed integument, it 
 shrinks, and various deformities are caused by the contraction 
 of the irregular and nodular cicatrix. 
 
 If the deeper parts, the muscles, etc., are affected, the injury 
 is usually so severe as to destroy life at once by shock. 
 
 Such then, in a brief way, are the local effects of heat applied 
 to the surface of the body ; but there are certain very import- 
 ant general symptoms that demand our attention. In severe 
 cases, whether from depth of tissue or extent of surface in- 
 volved, the general condition completely overshadows the local 
 trouble. Perhaps the following description of a typical case, con- 
 densed from Kaposi, will give us the best possible picture of the 
 effects of a grave injury of this nature. The patient is suffering 
 from an extensive burn due to the setting on fire of the clothing : 
 
 " An hour or so after the catastrophe we find the following 
 state of affairs : 
 
 " The hair of the face and head is singed ; and parts of the 
 hands, arms, face, neck, trunk, and legs are burnt to a varying 
 degree. Where the clothing has fitted tight, as around the 
 waist, the damage is usually least. 
 
 ci The greater part of the lesion is of the first or second de- 
 gree ; the skin is reddened over a greater or lesser extent ; 
 blebs are present on various parts. But there are spots on the 
 face, on the breast and back, which are black, carbonized, and 
 show where the burn has reached the third degree. 
 
348 COMBUSTIO. 
 
 " As soon as the wounds are properly dressed, the furious 
 excitement and wild cries of the patient subside ; the pain 
 ceases ; and he becomes rational, and can give a detailed ac- 
 count of the occurrence of the accident. 
 
 "He lies in comparative quiet for several hours. He still 
 suffers burning pain, which he expresses by a low moaning. No 
 urine is voided, and if we pass in a catheter, we usually find 
 none in the bladder, or at most a few drops of albuminous or 
 even bloody fluid. 
 
 " By five or six hours the patient's quietude begins to 
 deepen into apathy, though he can still be roused, and an- 
 swers questions intelligently, he sighs and gapes occasionally, 
 and lies with closed eyes. Repeated deep inspirations, with 
 ructus or singultus, now appear, signs all of evil omen ; soon 
 vomiting of the remains of food, or of bile, or, rarely, of blood 
 occurs. 
 
 A stage of restlessness now sets in ; the patient throws him- 
 self about the bed ; he no longer answers questions rationally. 
 He loses consciousness, and clonic spasms and opisthotonos 
 appear. The delirium is followed by sopor ; or the apathetic 
 stage may merge into this without the intervention of the de- 
 lirious one. The respirations become rapid and shallow ; the 
 pulse is quick and feeble. 
 
 " The patient dies either in a stupor, or in a condition of 
 excitement and wild delirium. Death occurs in eighteen to 
 forty-eight hours." 
 
 What then is the cause of death in these cases ? Surely not 
 the local lesion directly, since the patient sinks before any in- 
 flammation can begin. Various theories have been advanced. 
 Tappenier holds it to be due to the sudden abstraction from 
 the system of so large an amount of lymph. But in death from 
 diffuse burns of the first degree this can hardly be the cause. 
 Von Lesser has drawn attention to the fact that many of the red 
 corpuscles in these cases are changed in shape or destroyed, 
 whilst even of those apparently intact, many have lost their 
 oxygen and nutrition-bearing powers ; in other words, the 
 patient is suffering from acute oligocythaernia, and he dies from 
 
combustio. 349 
 
 consequent fall of the body temperature. Hoppe-Seyler 
 favors the older theory that the lethal issue is due to the re- 
 tention in the system of the products of excretion and of the 
 disintegrated tissues (especially ammonia carbonate). Sonnen- 
 berg believes death to be due to superheating of the blood and 
 consequent cardiac failure ; yet the immediate sinking of the 
 body temperature is a well known fact in these cases. It is 
 held by others that the destruction of the perspiratory glands 
 over so large a tract of surface is the cause, and they refer to 
 the rapid death of animals whose skins have been varnished ; 
 though there is no good reason why the remaining sweat- 
 glands and the kidneys should not be able to do the work of 
 the destroyed emunctories. In fact, in the majority of cases 
 the kidneys themselves cease to act. Probably the correct 
 view is the one adopted by Erichsen, viz., that death in these 
 faudroyante cases is due to nervous shock pure and simple. 
 Hence it occurs in burns of every kind, from any cause, and 
 whatever chemical change has been wrought in the tissues. 
 
 If the patient survives this first stage, the local trouble rises 
 into prominence, and inflammation, suppuration, loosening of 
 the slough and granulation occur as above described. The 
 injured person is subject, of course, to the ordinary dangers 
 which surround any surgical patient — erysipelas, pyaemia, 
 pneumonia, etc. ; but in some cases they die rapidly of col- 
 lapse, even in the second and third weeks, after the granulation 
 process is fully established. 
 
 Anatomy. — The pathology is simply that of a dermatitis, 
 more or less acute, and perhaps combined with inflammation 
 of the deeper parts, together with certain secondary lesions. 
 On the skin itself we find the appearances described in the 
 symptomatology ; simple hyperaemia, or severer inflammation, 
 sloughs, suppurating wounds. Only in the severest forms do 
 the deeper parts, the muscles, etc., participate in the inflam- 
 matory process. In the worst cases the affected areas are 
 dead, even carbonized. 
 
 A curious sequela which occurs during the stage of reaction 
 and inflammation, is the perforating ulcer of the duodenum, 
 
35° COMBUSTIO. 
 
 The cause of the ulceration is not known. It may cause 
 death by perforation and peritonitis, or by opening a branch of 
 the hepatic artery. They usually occur about the tenth day, 
 and sudden collapse is frequently the only symptom by which 
 they make their presence known, though bloody stools, pain in 
 the right hypochondriac region or vomiting, may occur. 
 
 Pneumonia is a not uncommon occurrence, and presents no 
 special appearance ; nor do erysipelas, septicaemia, etc. 
 
 In the " faudroyante " cases congestion of the brain and 
 membranes, as well as of the various other organs, is found. 
 
 Etiology. — The action of flame or of hot or exploding 
 vapors, of hot solids or liquids, of caustics, acid or alkali, 
 of lightning, of electricity, or of the sun, are the cause of these 
 injuries. 
 
 Diagnosis is clear ; the history is always obtainable from the 
 patient or his friends, or can be surmised from surrounding 
 circumstances. 
 
 Prognosis. — The prognosis of burns depends upon a vaiiety 
 of circumstances, but especially upon the extent and depth of 
 the lesion, and the age and general condition of the patient. 
 Generally it is favorable in burns of the first and second de- 
 grees, provided they are not too extensive ; but it is unfavor- 
 able in any case in persons of delicate health, or in infants, or 
 in those suffering from Bright's disease, etc. Burns of the 
 third degree, even when of slight extent, and in young persons, 
 are often fatal ; they are almost invariably so if conjoined 
 with burns of the first or second degree involving as much 
 as one-third of the surface of the body. 
 
 The occurrence of ischuria after an accident of this kind, or 
 the appearance of singultus or vomiting, is of bad omen. 
 
 The cicatrices left by burns may cause deformities ; occur- 
 ring round the limbs or fingers, may hinder the patient in his 
 avocation, or cause disgusting deformities of the face. 
 
 Treatment. — As far as the constitutional treatment goes, our 
 main effort, in severe burns, is to tide the patient over the 
 stage of depression into which he falls soon after the injury. 
 He is in pain, is pale, 'cold, and perhaps sinking from shock ; 
 
COMBUSTIO. 351 
 
 he should have a moderate dose of an alcoholic, preferably 
 hot, together with a full dose of opium. 
 
 In the later stages general stimulating and tonic treatment, 
 wines, quinine and good nourishment must be employed, with 
 morphine, as may be necessary. 
 
 As regards local treatment, our first object must be to allay 
 the agonizing pain, and for that purpose it is necessary to pro- 
 tect the injured surface from the air. Often the sprinkling of 
 the part with starch or flour, or cold water applications, etc., 
 will be sufficient, especially in burns of only the first erythe- 
 matous grade. Bullae, which by their tension increase the 
 pain, should be pricked, but not cut away, since they form the 
 best possible protection for the denuded corium. 
 
 In burns of the severest kind the burned clothes should be 
 cut away, the patient laid upon a blanket, and the first dressing 
 applied. Sprinkling the whole surface thickly but evenly with 
 fine wheaten flour by means of a dredger is to be recom- 
 mended, this forms with the serum and discharges a thick and 
 impervious coating. Carron oil (equal parts of ol. lini and 
 aq. calcis) or olive oil alone are good. The dressings of lint 
 or cotton should be well soaked in them. Powdered soda, in 
 slight cases, or a two per cent, solution of soda in burns of the 
 second and third degree, are excellent. Mitzeche paints the 
 burns with several layers of varnish to which, while warm, five 
 per cent, of salycilic acid has been added. Whatever applica- 
 tion is used, it is important not to remove the dressings for 
 several days, in fact, until loosened by the discharge ; and 
 they should be kept in good condition by renewed applications 
 of the agent used. 
 
 But in cases where it can be employed there is no treatment 
 so warmly to be recommended as that of Hebra's water-bed. 
 Protection, avoidance of pain, cleanliness, etc., all the indica- 
 tions are well filled by this mode of treatment ; it needs, of 
 course, certain special appliances, but its advantages are mani- 
 fest. As soon as seen after the injury, the patient may be 
 placed in the bath. Its temperature at first miist be low, but 
 as soon as the patient is in it, it must quickly be raised to 100°, 
 
352 CONGELATIO. 
 
 or till the patient feels comfortable. He may lie on a mattress, or 
 better, on a framework that can be raised or lowered by rack 
 and pinion. In this bath the patient must stay day and night, 
 being only raised up occasionally to meet the demands of 
 nature. He very soon feels the benefits of the treatment by the 
 absence of pain, and the return of sleep and appetite. In the 
 water the granulation of his wounds goes on splendidly, even 
 exuberantly ; there are not retained foul and decomposing secre- 
 tions ; there are no adherent dressings to be removed ; cleanli- 
 ness is secured to an extent which not the most careful nurse 
 could obtain with the ordinary treatment. The sloughs are 
 cast off more quickly; the fever goes, and there is less danger than 
 with any mode of treatment of the occurrence of erysipelas or 
 septicaemia. 
 
 If the patient be not treated by this plan, one of the afore- 
 mentioned applications must be used. In three to five days 
 suppuration will have begun, and it will be necessary to remove 
 the dressings to prevent retention and decomposition of the 
 secretions. The wounds are then to be dressed with any simple 
 ointment, — zinc oxide, carbolic acid ointment, iodoform in 
 ointment, or powder, etc. The granulations are very liable to 
 be exuberant, and they are to be repressed by the solid stick, 
 by a one-fourth to one per cent, solution or ointment of nitrate 
 of silver. This is a very important point, for if the granulations 
 are exuberant the scars will be very thick and nodular, the 
 contractures and deformities far greater than is necessary. 
 
 When these contractures and deformities have occurred, 
 various remedial operations may be undertaken, which will be 
 found detailed in the text books on general surgery. 
 
 CONGELATIO. 
 
 Syn. — Dermatitis congelationis ; frost-bite. 
 
 Definition. — Inflammation of the skin, combined perhaps 
 with inflammation of the deeper parts, caused by exposure to 
 excessive cold. 
 
 Symptoms. — Dermatitis is not so commonly due to cold as it 
 
CONGELATIO. 353 
 
 is to heat ; yet it is seen even in the more temporate climates 
 during the winter. As in combustio, we may divide the inju- 
 ries due to low temperature into three degrees. 
 i. Dermatitis congelationis erythematosa. 
 
 2. Dermatitis congelationis bullosa. 
 
 3. Dermatitis congelationis escharotica. 
 
 In healthy and vigorous individuals long continued expo- 
 sure to cold is necessary before inflammation is set up ; but 
 in weakly and predisposed persons a temperature even of 
 several degrees above the freezing point will cause these 
 changes. Especially is this the case with the first or slightest 
 degree of congelatio, which we will first consider. 
 
 1. Der??iatitis congelationis erythematosa corresponds to the or- 
 dinary chilblains, or perniones. They occur on the hands and 
 feet, more rarely upon the other extremities, as the nose and 
 ears. They consist of elevations of a bright red, or livid color, 
 and about the size of a small nut. When exposed to the cold 
 they are anaemic, white, and without sensation ; but when 
 warmed they become livid, and cause a most intolerable itching- 
 heat, and pain. Hence they are noticed chiefly in the evening, 
 when sitting by the fire, or when warm in bed ; during the day 
 they often do not trouble the patient at all. Eventually paresis 
 and excessive dilatation of the vessels occurs at the spot ; pas- 
 sive hyperemia, serous infiltration and sluggish inflammatory 
 processes set in. Bullae may appear, which, when they break 
 leave behind an indolent, ulcerating surface — pernio ulcerans, 
 which may be accompanied by constitutional symptoms. This 
 forms the second degree, or 
 
 2. Der?natitis congelationis bullosa. Here the inflammation 
 has been intense enough to cause serous transudation and 
 the formation of blebs on the surface. The appearance and 
 course of the inflammation is exactly the same as in the bullous 
 form of combustio, to which the reader is referred. 
 
 3. Dermatitis congelationis escharotica. In this, the severest 
 form of frost-bite, either the skin is covered with large bullae, 
 with perhaps hemorrhagic contents, or it may be only turned 
 to an ashen-white color, and is cold and senseless. The vitality 
 
 23 
 
354 CONGELATIO. 
 
 of the part may be entirely destroyed, or it may be merely sus- 
 pended. In the latter case, as the tissues regain their warmth, 
 the part becomes red, hyperaemic, the patient suffers from burn- 
 ing and tingling pain, and a more or less severe inflammation 
 is set up. If on the other hand the vitality of the cells has 
 been entirely destroyed, it appears mottled from the retained 
 and frozen blood ; it is gangrenous when thawed out ; and the 
 usual changes, reactive inflammation of the healthy parts, 
 formation of a line of suppuration, casting off of the slough, 
 etc., occur. It may take several days, or even weeks before it 
 becomes evident how much of the tissue has been destroyed. 
 Phlebitis, septicaemia, and death often occur in the gangrenous 
 form of congelatio. 
 
 Besides these local effects, certain well-known constitutional 
 results of cold must be mentioned. There is first a period of 
 general stimulation, but on prolonged exposure, the patient be- 
 comes dull and stupid. The dilation is followed by contraction 
 of the superficial vessels ; the blood accumulates in the central 
 organs. An overwhelming desire to sleep comes over the suf- 
 ferer ; he becomes comatose, and dies a probably painless death. 
 
 Anatomy. — Is in the main the same as in dermatitis calorica. 
 The appearances in the first and second degrees of frost bite 
 have been described under the head of symptomatology. 
 In the third degree the part is at first white, cold, and sense- 
 less, or if it has been thoroughly frozen, it may look mottled. 
 Later the inflammation of the skin, the phlyctenae, the 
 sloughs, and the ulcerations, present nothing to distinguish 
 them from dermatitis from other sources. 
 
 Duodenal ulcers occur with dermatitis from this cause as 
 well as from heat ; they have the same appearance and run a 
 similar course. 
 
 Congestion of the internal organs, especially of the lungs and 
 brain, is found in cases that die early. In those that succumb 
 later, the ordinary lesions of phlebitis, pyaemia, etc., will be 
 found. 
 
 Etiology. — Contact with cold air, with ice or snow, with very 
 cold metals, are the usual sources of this trouble. 
 
CONGELATIO. 355 
 
 Diagnosis. — The history can almost always be obtained, 
 either from the patient or his friends, or from the surrounding 
 circumstances. Sometimes frost-bites of the second and third 
 degrees are very difficult to distinguish from burns or dermatitis 
 from poisons. 
 
 Prognosis is good in frost-bites of the ordinary kind, of the 
 first and second degrees. But it is always doubtful in the 
 escharotic form ; for its very occurrence is an indication of 
 low vital powers ; reaction is very slow ; it is many days before 
 it can be said which parts will, and which will not be saved. 
 Even where only a few fingers and toes are involved, it is not 
 possible to say how far the gangrenous forces will extend. 
 
 Anaemic and weakly individuals are especially predisposed to 
 injuries from cold ; they have chilblains and frost-bites at 
 temperatures where ordinary individuals suffer no inconveni- 
 ence at all. 
 
 Exposure to cold is very rapidly fatal to infants and old 
 people. 
 
 Treatment. — For the constitutional effects of cold various 
 measures are to be employed, including the removal out of the 
 cold atmosphere, the administration of hot alcoholic drinks, 
 frictions of the surface, etc. 
 
 As regards the frozen part itself, one thing must always be 
 borne in mind, namely, that either in the part itself, if it has 
 not been destroyed, or in the neighboring tissues, if complete 
 disorganization has occurred, dermatitis, inflammatory action, 
 will necessarily set in. We must, therefore, avoid any method 
 of treatment that will tend to increase the violence of the inev- 
 itable reaction in the tissue whose vitality was probably not 
 up to the normal in the first place, and which has been still 
 further lowered by the injury. We must endeavor to bring 
 about reaction as slowly as is compatible with the patient's 
 safety. He should be put in a cold room, the frozen parts 
 rubbed with snow, or with cloths dipped in cold water ; a little 
 later dry cloths may be employed, and a warm drink given. In 
 cases apparently dead, artificial respiration must be employed, 
 and should be persisted in for a long time even when there is 
 
356 CONGELATIO. 
 
 no sign of life ; for persons have recovered after several hours 
 of suspended animation from cold. 
 
 Neurotic portions of tissue should be left to detach them- 
 selves ; as little interference as possible is the rule. As regards 
 amputation of hopeless parts, it is best to wait for a line of 
 demarcation before operating, since, according to the best 
 authorities, more tissue is often saved thus than would at first 
 have appeared possible. 
 
 For ordinary chilblains many remedies are recommended ; 
 hot baths, tincture of iodine, collodion, acetate of lead (10$ 
 in ointment), camphor, balsam of Peru, etc. Tight boots must 
 especially be avoided, since by hindering the circulation they 
 predispose to the trouble ; the feet should be warmly clad. 
 Kaposi recommends $. Camp, rasae, 1 part ; cerae alb., 40 
 parts ; ol. lini, 80 parts ; bals. Peruv., 150 parts. 
 
 In anaemic individuals subject to the first and second degrees 
 of this trouble, general tonic treatment and good nourishment 
 is important. Tincture of the chloride of iron, given for a 
 length of time, is often of decided benefit. 
 
CLASS IV. 
 HiEMORRHAGIE : HAEMORRHAGES. 
 
 Under this heading we classify those diseases of the skin in 
 which the essential lesion consists in the presence of blood in 
 larger or smaller quantities outside the vascular walls, in the 
 skin. It is true that this is occasionally seen in such diseases 
 as zoster, small-pox, etc. ; but it is as an accident, not as the 
 principal element of the malady. It is by no means necessary 
 for the occurrence of such haemorrhages that actual rupture of 
 the capillaries occur ; both liquor sanguinis and corpuscles 
 can make their way through the unbroken vessel wall. 
 
 Pressure, either internal or external, may cause this rupture 
 or diapedesis. Thus it occurs from blows, or squeezes, from 
 violent coughing (as in pertussis), or during an epileptic par- 
 oxysm. Any thing that weakens the resisting power of the vas- 
 cular wall will with normal blood pressure cause extravasation 
 of blood. Thus it is seen in excessive states of malnutrition, 
 and when the epidermis has been destroyed, as by a blister, 
 also upon ascension of mountains, etc., when the atmosphere 
 pressure is less than usual. A good example of this last cause 
 of extravasation is seen in dry-cupping. 
 
 In accordance with their form, a variety of extravasations 
 are to be mentioned. Thus we have petechia — small, round or 
 star-shaped, livid-red spots, varying in size from a pin-point to 
 a finger-nail ; vibices—Xoxig, narrow, streak-like lesions ; ec- 
 chymoses — irregular red patches from the size of a dollar to 
 that of the palm of the hand ; and ecchymomata — variously 
 shaped, flat or elevated tumors. 
 
 In all these cases the haemorrhages may be either in the layers 
 of the epidermis, or deeper down in the connective tissue of 
 
35$ HEMORRHAGES. 
 
 the papillae and corium. Once formed, they are permanent 
 until the hsematin of the extravasated material has undergone 
 certain changes, and become absorbed. The vivid red, changes 
 into purple, then into a greenish-yellow and brown, and even- 
 tually disappears. 
 
 Cutaneous haemorrhages, which occur as the result of exter- 
 nal injuries, are called idiopathic, whilst those which occur 
 from internal disease conditions, are termed symptomatic 
 haemorrhages. Idiopathic hemorrhages are usually the result 
 of traumatisms, and most often of a concussion or a squeeze. 
 The resulting lesion may be a haemorrhagic bulla, or an ecchy- 
 mosis, or an ecchymoma, or even a deep seated haemorrhagic 
 cyst may result. In certain cases the inflammation of the sur- 
 rounding tissue is sufficient to cause an abscess. The bites of 
 various insects produce minute, localized haemorrhages. Bed- 
 bugs, fleas, and pediculi occasion the presence of circumscribed 
 slightly swollen hypersemic patches, with a haemorrhagic point 
 representing the bite in the center ; the swelling disappears in 
 a short time, but the blood extravasation persists longer. Local 
 circulatory disturbances will also cause these idiopathic haemor- 
 rhages. Thus we see them occurring in acute inflammatory 
 and exudative processes, as in herpes, eczema, in granulating 
 wounds, and very commonly upon the lower extremity in con- 
 sequence of varicose veins. The weaker the connective tissue 
 support of the vessels, and the thinner the epidermis, the more 
 prone are they to occur. Hence, idiopathic haemorrhages are 
 common in very old people, after severe sickness, after child- 
 birth, and in those who have to stand or walk much. At first 
 such purpuric spots are of little account, but in time their oc- 
 currence becomes complicated with inflammatory changes, 
 ulceration and chronic sores. 
 
 An interesting form is the fiupura neanatorum, which is seen 
 in infants in consequence of circulatory changes. It appears 
 as numerous petechiae spread over the body, and looking like 
 flea-bites. 
 
 But little need be said concerning the treatment of these 
 idiopathic purpuras. They all tend to undergo spontaneous 
 
purpura. 359 
 
 resolution. The /bcal application of cold is always advanta- 
 geous, and when they occur upon the lower extremity, rest in 
 the elevated position is important. When they tend to occur 
 in conjunction with varicose veins, support of the over-filled 
 vessels by means of a bandage or elastic stocking is indicated. 
 
 Sympathetic Hemorrhages, on the other hand, are local ex- 
 pressions of some more deep-seated malady affecting the sys- 
 tem. Thus they are seen in the most fatal form of small-pox, 
 as pupura variolosa, haemorrhagic small-pox ; in the oriental 
 pest ; in certain snake bites ; in septicaemia, etc. They are also 
 observed in the marasma of tuberculosis, of carcinoma, and 
 of ergotism. 
 
 There is one form of symptomatic haemorrhage into the skin, 
 however, of sufficient importance to warrant our considering it 
 under a special heading, in which the purpuric spots constitute 
 the essential element of the disease. It is called purpura, par 
 excellence. 
 
 PURPURA. 
 
 Synonyms. — Haemorrhcea petechials ; purpura simplex ; p. 
 rheumatica ; p. haemorrhagica. 
 
 Definition. — Purpura consists in the appearance upon the 
 skin of various sized, flat or raised, red or purple haemorrhagic 
 patches, not disappearing upon pressure. 
 
 Symptoms. — Three varieties of purpura are described, and, as 
 they differ considerably, both as regards their etiology and 
 semiology, it will be convenient to discuss them separately. 
 
 i. Purpura Simplex. — Here the cutaneous symptoms usually 
 form the only manifestation of the disease ; in exceptional cases 
 slight malaise, indigestion, lassitude, etc., may be present for 
 some days before the eruption appears. The haemorrhagic 
 spots may come out suddenly — may come on over night — and 
 give rise to so little inconvenience that it is frequently several 
 days before their presence is accidentally discovered. They 
 form bright to bluish-red, sharply circumscribed and variously 
 shaped spots — usually pin-point or pin-head in size, but some- 
 
360 PURPURA. 
 
 times as large as a pea. They are situated deep in the skin, 
 which is not elevated over them, and they do not disappear upon 
 pressure. They occur irregularly over the body, but their com- 
 mencement seat is upon the lower extremities, and especially 
 upon the flexor aspect of the thighs. Subjective symptoms, 
 save occasionally a slight itching or soreness, are absent. In 
 the so-called purpura urticans, the marked itching and the 
 tendency to the formation of wheals near the site of the extrav- 
 asations would tend to show a combination of the two affec- 
 tions. 
 
 P. simplex has been noticed from the employment of iodide 
 of potassium, quinine, chloral, and salycilic acid (see Derma- 
 titis). In some cases malaria seems to have been the cause of 
 the eruption, and in others some fault of the nervous system 
 occasion the so-called neurotic purpura. Simple purpura is a 
 self-limited disease ; in ten to fourteen days it has run its 
 course, though the occurrence of successive " crops " of the 
 eruption may prolong it. It occurs most frequently in the 
 aged and debilitated, 
 
 2. Purpura Rheumatica, or Peliosis Rheumatica. — Here there is 
 usually more or less rise of temperature, with lassitude, costive- 
 ness, anorexia, etc., before the disease appears. It begins with 
 rheumatic pains in the joints, especially of the knee and foot, 
 either with or without swelling and exudation. In about a week 
 or earlier the eruption appears, occurring anywhere upon the 
 body, but most distinctly upon the limbs and lower part of the 
 abdomen. It consists of light-red or livid flat hemorrhagic spots, 
 not disappearing under pressure, and varying in size up to that 
 of a finger-nail. In some cases they are slightly raised. Usually 
 the rheumatic pains remit when the eruption appears ; and the 
 purpuric spots gradually fade through green and yellow tints 
 until the blood is absorbed ; which usually occurs in a fortnight. 
 But in many cases successive exacerbations of the fever and 
 rheumatoid pains, with successive crops of purpura, are 
 observed, and the disease may last for months, or even years. 
 Periodic haemorrhages from the kidneys have been noted in 
 some of these cases, as well as haemorrhagic affections of the 
 
PURPURA. 361 
 
 internal organs, and fatal haemorrhage into and gangrene of the 
 velum palati and laryngeal mucous membrane {Lewin, Henoch, 
 etc.). P. rheumatica occurs both in men and women, and is 
 usually seen during middle life. It is a rare disease, and 
 is intimately related to erythema multiforme. In some cases it 
 occurs in conjunction with that disease, and its location is usu- 
 ally the same. 
 
 3. Purpura Hcemorrhagtca, or Morbus Maculosus Werlhofii. 
 — Here the morbid process seems to occupy an inter- 
 mediate position between scorbutus and purpura simplex. 
 It begins with marked constitutional symptoms, languor, 
 headache, fever, etc., but not like the serious cachexia 
 which precedes scurvy. Soon there appear upon the skin 
 hsemorrhagic spots, varying in size from a lentil to the palm 
 of the hand. They occur all over the body ; but the face is 
 usually exempt. Petechias also appear upon the mucous mem- 
 branes, especially upon that of the mouth and fauces, and 
 haemorrhages from the mouth and nose, from the intestines 
 and kidneys, occur more often and with greater freedom than 
 in scorbutus. The constitutional symptoms may be very 
 severe, fever may run high, and the disease end in collapse and 
 death. 
 
 As a usual thing, however, Werlhofii's disease runs a benign 
 course, and ends in recovery in two to four weeks. Relapses 
 may occur. It is usually seen in the weak and debilitated, but 
 it sometimes occurs in persons enjoying apparently the best of 
 health. The petechias pass through the ordinary stages and 
 are eventually absorbed. 
 
 4. Brief reference may be made here to Scorbutus, true 
 scurvy, or sea scurvy. The purpura is very like that of pur- 
 pura haemorrhagica — but it is not so extensive — and is more 
 likely to affect the subcutaneous connective-tissue, the muscles 
 and fasciae. The gums are softened, spongy, and covered with 
 a dirty gray coating, and there is marked fcetor from the mouth, 
 painful ecchymomata are common, and lead to gangrene and 
 deep ulcerations. Complications on the part of the internal 
 organs usually occur. But the tendency to haemorrhages 
 
3 62 
 
 PURPURA. 
 
 from the mucous membranes is not so great as in morbus 
 maculosus. The disease is chronic, slow in its onset, and is 
 due to certain well known influences, and uniformly tends to 
 recovery when they are removed. 
 
 Anatomy. — The extravasated blood in purpura may be situated 
 in the papillae, or in the subcutaneous connective tissues, etc. 
 The bloodvessels in the neighborhood of the exudation are dis- 
 tended and filled with blood corpuscles. A part of the exuda- 
 
 FiG. 43. — Section through a haemorrhage papule in peliosis rheumatica. 
 a, Corneous layer ; b, rete ; upper part of corium ; d, deep part of corium. 
 
 tion arises from rupture of the bloodvessel wall and part from 
 diapedis. 
 
 The spots vary in size and shape with the amount of 
 blood and the permeability of the tissue. Once outside the 
 vessels, the blood is a foreign body, and is slowly absorbed 
 The fluid parts are taken up first, the corpuscles and coloring 
 matter being left behind. The haematin undergoes various 
 changes, and the spot goes through the regular cycle of colors 
 
PURPURA. 363 
 
 from bright to dark red, purple, blue, green, brown, yellow, 
 eventually to fade away entirely. 
 
 In scurvy there is probably some deep-rooted alteration in 
 the red-blood corpuscles themselves ; at all events Kietschy 
 has noticed them irregular and losing their shape early in the 
 disease. 
 
 Etiology. — In p. simplex no special cause can be referred to. 
 The subjects of the disease are usually ill-nourished and 
 debilitated ; but we see it occurring sometimes in persons it 
 apparently the best of health. 
 
 P. rheumatica is related, as before said, to erythema multi- 
 forme, and we know as little of the essential cause of the one 
 as of the other disease. Both diseases are oftenest seen in young 
 individuals, and in females, and tend to recur in spring and 
 autumn. It is an angio-neurosis depending upon some un- 
 known condition that changes the nutrition of the bloodvessel 
 wall. 
 
 P. Haemorrhagica occurs in many cases in persons living 
 under improper hygienic conditions, and badly nourished, or 
 who are convalescent from serious illness ; but it also attacks 
 robust individuals. It occasionally occurs epidemically. 
 
 Scorbutus, as is well-known, occurs in consequence of im- 
 proper or insufficient nourishment, want of fresh meat, of 
 vegetables, of salt, of fresh air, etc, and is seen on ship-board 
 and in large ill-kept penal institutions, etc. 
 
 Diagnosis. — In most cases the diagnosis of these different 
 forms of purpura is easy. P. simplex occurs without other 
 symptoms. In P. rheumatica the localization, pains in the 
 joints etc., are sufficiently diagnostic in conjunction with the erup- 
 tion. In p. haemorrhagica, the affection of the mucous mem- 
 brane, the haemorrhages, etc, are characteristic. Finally, in 
 scurvy the peculiar etiological conditions, the affections of the 
 gums, and the muscles, etc., will prevent mistake. 
 
 Prognosis. — In purpura simplex the prognosis is always 
 good. P. rheumatica is more stubborn, and more likely to be 
 subject to relapses. Its duration is indefinite, and, though it 
 usually tends to recovery, some of the incidents detailed in the 
 
364 HEMATIDROSIS AND HEMOPHILIA. 
 
 symptomatology may render the prognosis unfavorable. P. 
 hemorrhagica and scurvy are more serious ; it is impossible 
 to tell the course that they will pursue. The less frequent the 
 haemorrhages, the scarcer and more superficial the petechias, 
 the less fever there is, and the less the general nutrition of the 
 body has suffered, the better the outlook. 
 
 Treatment will vary, with the cause of the disease. In 
 almost all cases attention to diet and general hygiene is of 
 the utmost importance. If the haemorrhage is extensive, rest 
 in bed must be insisted on. 
 
 In p. simplex, iron, quinia, belladonna, the mineral acids, 
 etc., are useful. The chlorate of potassium, in twenty grain 
 doses, has also been recommended. 
 
 P. rheumatica is to be treated by careful regulation of the 
 diet, moderate use of stimulants, etc. Cold and anodyne lotions 
 may be used if the pain is severe. The patient should be con- 
 fined to bed. Besides the remedies above mentioned, ergot 
 internally, or ergotin hypodermically, may be employed. 
 
 P. haemorrhagica. — Here all the above remedies may be em- 
 ployed ; especially ergotin, administered subcutaneously, has 
 proven useful. Rest in bed must be insisted on. Oil of 
 turpentine, acetate of lead with opium, have been successfully 
 employed, as has electricity, after other remedies have failed. 
 Haemorrhages from the internal organs must be treated on 
 general principles. For the haemorrhages upon the skin, alum 
 or acetic acid washes may be employed. 
 
 Scorbutus demands a diet of fresh animal and vegetable food 
 fresh air, fruit, vegetable acids, etc. The reader is referred to 
 the appropriate text books for details. 
 
 H-ffiMATIDROSIS AND HiEMOPHILIA. 
 
 Two other conditions may appropriately receive mention 
 under this heading. The first is haematidrosis. 
 
 Hcematidrosis — Haemidrosis— Sudor San guinea, or bloody 
 sweat, consists in the discharge through the sweat glands of a 
 fluid containing blood. The fluid oozes out over a localized area, 
 
H/EMATIDROSIS AND HEMOPHILIA. 365 
 
 and the eyelids, cheeks, backs of the hands, and thighs have 
 been seen affected. It is not a bloody sweat at all, but a 
 cutaneous haemorrhage in which the effused fluid finds its way 
 out through the sweat ducts. It is a very rare affection, and 
 has always been noticed in connection with some defect of 
 the nervous system, or in young hysterical women with 
 menstrual irregularities. In these cases the bloody oozing has 
 been excited by passion or some intense nervous strain. In 
 most of the celebrated cases of "bleeding stigmata" the 
 haemati*drosis has occurred in connection with hysteria and 
 ecstasy, etc. The bleeding spots vary in size and shape, and 
 may occur anywhere upon the body, and is usually periodic 
 in its occurrence. Messedaglia and Lombroso, who have 
 studied this peculiar affection, consider it to be due to vascular 
 paralysis, and have used belladonna internally with success. 
 The treatment of Haematidrosis is that of purpura. 
 Finally, hemophilia occurs among individuals or families, 
 who soon become known as " bleeders." In them the slightest 
 traumatisms are sufficient to cause extensive ecchymoses and 
 violent haemorrhage — their blood seems to have lost its normal 
 coagulability, and haemorrhage of any kind in them is con- 
 trolled only with the greatest difficulty. It is hereditary, and 
 runs in families. There is no treatment for the systemic con- 
 dition — and individual cases must be managed on general sur- 
 gical principles. 
 
CLASS V. 
 
 HYPERTROPHIES. 
 
 Under this name are classed a number of affections charac- 
 terized by an increase of one or all the normal tissue-ele- 
 ments of the skin. Sometimes the epidermis — as in chloasma 
 and callositas is the part affected ; sometimes the papillae are 
 also involved — as in ichthyosis ; sometimes the corium, as in 
 elephantiasis. As a usual thing, these hypertrophies are 
 rather deformities than diseases ; the changes are slow, and 
 once formed, they usually continue indefinitely unless inter- 
 fered with. 
 
 LENTIGO. 
 
 Syn. — Freckle. 
 
 Definition. — Lentigo consists in an excessive localized de- 
 posit of pigment in various portions of the skin ; it appears as 
 round or irregular, pin-head and pea-sized spots, most fre- 
 quently seen upon the face and back of the hands. 
 
 Symptoms. — This common affection is seen as small, round- 
 ish spots, varying from a light yellow to a brown or even 
 black tint. They may be only few in number and isolated ; or 
 they may be aggregated, and coalesce. Their most usual seat 
 is upon the face, especially upon the forehead and nose ; but 
 they are common enough upon the hands and arms, and may 
 be seen upon other parts of the body. They appear in both 
 sexes, and at all ages ; in young children, however, they are 
 rarely seen. Persons with light complexion, and especially 
 with red hair, very commonly exhibit them ; but they occur in 
 brunettes, and are even seen in mulattoes. They usually 
 persist during the greater part of life, but are apt to disappear 
 when old age sets in. They are far more marked in summer 
 than in winter. They undoubtedly grow darker in color when 
 
CHLOASMA. 367 
 
 exposed to the sun ; but they occur also upon parts not usually- 
 exposed to its rays, as the buttocks and penis. There are no 
 subjective sensations whatsoever. Freckles are more a deform- 
 ity than a disease, and in many persons of blonde appearance 
 they may be numerous and dark enough to be very unsightly. 
 
 Etiology. — The summer heat and the sun's rays are the 
 usual causes of lentigo; yet they occur upon parts that are not 
 exposed, forming the so-called " cold freckles." The irregular 
 distribution of the pigment which in reality is the cause of the 
 freckles, depends probably upon a nervous influence. 
 
 Anatomy. — A freckle consists simply in a collection of pig- 
 ment granules in a circumscribed group of rete cells. Chloasma 
 differs from lentigo only in the size and shape of the affected 
 areas. 
 
 Treatment. — The treatment is essentially that of the next to 
 be considered affection — chloasma — to which the reader is 
 referred 
 
 CHLOASMA. 
 
 Syn. — Liver spot. 
 
 Definition. — Chloasma consists of an abnormal deposit of 
 pigment in the skin, appearing as smooth, yellowish-brown or 
 blackish patches of varying shape. 
 
 Symptoms. — In chloasma, as in the preceding affection, the 
 skin itself is unaltered, save in that there occurs an excessive 
 deposit of pigment in certain places. These discolored patches 
 may be of any size or shape ; they are usually of a sharply 
 limited outline. Their color varies from a light yellow, through 
 the various shades of brown, almost to black. They are usually 
 of moderate size ; but the affection may occur as a more or less 
 diffuse discoloration of the entire integument. 
 
 In accordance with their origin, chloasmata are idiopathic or 
 symptomatic. To the idiopathic chloasmata belong lentigo f 
 and ephelis j and also the group known as 
 
 Chloasma Traumaticum. — Here some external agent is the 
 cause of the increased pigmentation. Thus we see it whenever 
 there has been long-standing hyperemia of the skin — as from 
 
368 CHLOASMA. 
 
 the pressure of the clothing, belts, braces, etc. — but especially 
 from the scratching occasioned by the various itchy diseases. 
 Urticaria, scabies, prurigo, pediculosis, etc., all occasion more 
 or less discoloration of the integument ; the more marked, the 
 more violent and chronic the disease, and the consequent irri- 
 tation of the skin by the finger-nails. It shows itself as a more 
 or less diffuse brownish or grayish or sepia-tinted discoloration 
 of the skin, and has been by some erroneously described as a 
 special disease under the name of melanosis, melanoderma, 
 melasma cutis, etc. Its seat may be of assistance to us in the 
 diagnosis of the malady that occasions it ; thus in pediculosis, 
 the discoloration is most marked around the waist and upon the 
 back of the neck. In prurigo it occurs especially upon the ex- 
 terior surfaces of the lower extremities, etc. In these cases 
 the discoloration is also partly due to the remains of extra- 
 vasated blood. 
 
 Another variety of the idiopathic chloasma is chloas?na 
 caloricu?n, by which we mean the well-known brownish discol- 
 oration of the skin caused by exposure to the sun's rays. It 
 appears upon any part to which the sun, wind, etc., have free 
 access, and is very strictly limited to the exposed part. It oc- 
 curs more readily in those accustomed to an in-door life, while 
 persons with out-door occupations are usually affected to a 
 moderate degree only, and do not " tan " readily under special 
 exposure. The brown color soon fades upon withdrawal from 
 the influences which caused it. The color in these cases is 
 also partly due to a browning of the upper corneous cells. 
 
 Various chemical agents also cause discolorations of this 
 variety, forming chloasma toxicum. Sinapisms, blisters by can- 
 tharides, etc., are common causes. Occasionally the pigment 
 deposit which occurs after the use of these agents does not fade 
 away, but persists for life. 
 
 The symptomatic chloasmata occur in consequence of various 
 affections of the internal organs, as uterine diseases, tubercle, 
 cancer, etc. They may appear as localized, well-defined spots, 
 or as more diffuse pigmentations. The diffuse bronzing of the 
 skin in what is called Addison's disease, may vary from a light 
 
CHLOASMA. 369 
 
 brown to an olive or bronze-green, being most marked in those 
 places where pigment usually accumulates in quantity, as in the 
 axillae, nipples, hair, genitals, etc. It has been shown by later 
 investigations, however, especially by Overbeck, to have no 
 connection at all with degeneration of the supra-renal capsules, 
 and to be due to marasmus from various causes as tuberculosis, 
 malaria, etc. Chloasma also occurs in lepra, scleroderma, mor- 
 phcea, etc. 
 
 The most important, however, of the symptomatic chloasmata 
 is the one that is known as chloasma uterinum — chloasma hep- 
 aticum — or liver-spot. It occurs usually upon the face, and is 
 most often seen to occupy the forehead and temples. The pig- 
 ment is deposited in varying amount, but most abundantly in 
 those of naturally dark skin — in brunettes. It most often ap- 
 pears as a larger or smaller patch upon the forehead, often ex- 
 tending from the scalp to the eyebrows, even upon the lids, and 
 from temple to temple. It may also occur upon the abdomen, 
 about the nipple, etc. The patches may vary from a yellowish 
 to dark brown ; they may be distinctly limited, or fade grad- 
 ually into the surrounding skin. Their surface is perfectly 
 smooth and normal, though seborrhcea may occasionally be 
 present at the same time. The pigment may be evenly depos- 
 ited, or it may occur in streaks and patches over the affected 
 area. It is occasionally seen also upon the cheeks, the lips, the 
 chin, etc. It may occur at any time during menstrual life 
 and occurs in connection either with pregnancy or 
 with some abnormality or defect of the utero-ovarian system. 
 It is most commonly seen during pregnancy ; but it very often 
 occurs in sterile or unmarried women who suffer from amen- 
 orrhoea, dysmenorrhoea, hysteria, chlorosis, ovarian or uterine 
 new growths, flexions, etc. When it occurs during pregnancy, 
 it usually fades rapidly after delivery is accomplished, though 
 it may not entirely disappear. It undoubtedly has some con- 
 nection with the pigmentation which occurs round the nipple — 
 linea alba, etc., in pregnancy. 
 
 Chloasmata, like the above-mentioned form, occur in men 
 upon the forehead, and are usually seen in scrofulous subjects 
 24 
 
370 
 
 CHLOASMA. 
 
 or in those debilitated from overwork, excess, drink, etc., or 
 suffering from malarial or septicemic cachexia (cancer). They 
 are exactly like the uterine chloasmata in external appearances. 
 
 Etiology — The causes of chloasma are very varied — and 
 have been for the most part mentioned in the description of 
 the different varieties. Anaemia, according to Wilson, is at 
 least a predisposing cause to abormal pigmentary deposit. 
 Shock, and various affections of the nervous system also seem 
 to favor its occurrence. 
 
 In figure 44 is shown the situation of the pigment granules 
 in tattooing. It is found in the lymph spaces of both the 
 corium and subcutaneous tissue, whilst in chloasma proper the 
 pigment is in the rete. 
 
 Anatomy. — The skin is unaltered with the exception of the 
 deposit of an excessive number of pigment granules in and 
 round the lower rete-cells. More or less yellowish-brown pig- 
 ment grains are always found in that situation — even in the 
 
 Fig. 44. — Section of skin from a case of tattooing, a, Epidermis ; 5, corium ; c, 
 subcutaneous tissue ; d, pigment granules in lymph spaces. 
 
 fairest individuals ; and even in negroes the individual granules 
 are light brown in color, but are numerous and closely 
 packed. In the fairest individuals, pigment is found all over 
 the skin, and is especially seen in certain regions, as around the 
 anus, nipple, perinaeum, etc. 
 
CHLOASMA. 371 
 
 Diagnosis. — Pityriasis versicolor is the only affection liable 
 to be confounded with chloasma. The peculiar color, the 
 figure outline, the extent and location upon the trunk, the 
 hyperemia and the furfuraceous surface, as shown by scraping 
 with the finger nail, and, finally the microscopic appearances — 
 all very sufficiently distinguish the former disease. Chloasma 
 is usually darker, occurs as a simple patch, is small and seen 
 almost always upon the forehead, the skin is normal, and the 
 parasite will not be found in any of the scraped off scales. 
 
 Prognosis. — In itself the affection is of no account, save as a 
 deformity. Both the idiopathic and the symptomatic forms 
 frequently disappear with the subsidence of the exciting cause. 
 
 Treatment. — is essentially the same both for lentigo and 
 chloasma in all its forms. First and foremost the exciting cause, 
 be it local or general, must, if possible be removed ; otherwise our 
 efforts will be fruitless. Affections and abnormalities of the uter- 
 ine system, the action of local irritants etc., must be removed. 
 A variety of topical measures may then be employed with 
 the idea of removing the rete cells together with the abnormal 
 pigment deposited therein. Cantharides, mustard, mineral 
 acids, etc., themselves cause pigmentation, and are not to be 
 employed ; but acetic acid, strong potash and soda soaps, 
 and tincture of iodine may be used. Mercurials, however, are 
 the best. Corrosive sublimate may be used in one to five 
 grains to an ounce of water or alcohol — varying in strength 
 with the susceptibility of the patient's skin, and the extent of 
 surface to be acted upon. For the rapid removal of freckles 
 or chloasmata from the face Hebra recommends the application 
 of a 5 per cent, solution of corrosive sublimate by means of cloths 
 accurately fitted to the surface to be treated, and kept on for 
 four hours. Considerable burning is set up ; the blister which 
 forms is to be punctured in its most dependent part, and 
 dressed with starch powder. Within a week the epidermis 
 falls off, and the new skin will be devoid of pigment. Unfor- 
 funately it does not usually remain permanently so. Duhring 
 recommends the use of corrosive sublimate as a lotion, con- 
 taining two grains of the drug to half an ounce of the tincture 
 
372 CHLOASMA. 
 
 of benzoin and an ounce of almond emulsion. Tincture of 
 iodine, repeatedly employed, or sulphur paste, or soft soap, 
 applied continously for from twelve to twenty-four hours, 
 will also remove the epidermis. t 
 
 Various less intensely irritant preparations may be em- 
 ployed, causing the pigment to disappear more slowly by gradual 
 desquamation of the skin. This may be accomplished by 
 painting with diluted acetic acid, or daily washing with 
 tincture of soft soap, or by a white precipitate ointment applied 
 nightly, etc. Neumann recommends an ointment composed of 
 equal parts of white precipitate and subnitrate of bismuth. 
 Veratria ointment, grains 10 to the ounce, or the ointment of 
 the nitrate of mercury, 2 drachms to the ounce, may be em- 
 ployed. I use an ointment of equal parts of oxide of zinc and 
 white precipitate ointment with subnitrate of bismuth, twenty 
 grains to the ounce, and glycerine one to two drachms to the 
 ounce. 
 
 To complete this division of our subject, certain conditions^ 
 in which the skin is stained by other than the normal pig- 
 ment, require brief mention. Thus in icterus, or jaundice, a 
 uniform staining of the integument and mucous membranes 
 occurs, and varies from the faintest yellowish tinge to a deep 
 orange. It is due to the deposition of the biliary coloring 
 matters in the skin, and is accompanied by marked itching. 
 Its prognosis and treatment is that of the disease that oc- 
 casioned it. Argyria is the name given to the condition in 
 which the skin is stained by the deposition of metallic silver in 
 it. It is a condition rarely seen at present, since this possible 
 effect of the drug is well known, but it was formerly commoner, 
 especially among the subjects of epilepsy, in whose treatment 
 silver was used in large and long-continued doses. Cases have 
 also been reported from the use of the solid stick in the 
 pharynx — a portion having probably been swallowed. The 
 skin is stained to a bluish, grayish, slate or even black color, 
 varying with the amount of the drug deposited. The exposure 
 to light was formerly thought to occasion the decomposition of 
 the albuminate of silver, under which form it probably circu- 
 
NAEVUS PIGMENTOSUM 373 
 
 lates in the tissues ; but the fact that the blue staining occurs 
 in the internal organs and in mucous membranes not exposed 
 to the light, renders this improbable. The silver is deposited 
 in the metallic state in the connective tissue of the skin, in 
 the form of minute granules. The condition is a permanent 
 one, and the " blue-men " retain their peculiar tint for life. 
 No remedies have proven of any avail, except iodide of 
 potassium — which, in the hands of L. P. Yandell, cured two 
 cases when given in large doses ? 
 
 Occasionally we see the skin permanently discolored by the 
 process of tattooing. The practice is a common one amongst 
 various savage tribes, and amongst sailors and navvies here. 
 Pigment of various kinds — vermilion, charcoal (gunpowder), 
 indigo, etc., is rubbed into the skin by means of close-set 
 punctures. Persons are occasionally exhibited whose whole 
 skin is covered with tracings made in this manner. The pig- 
 ment granules are deposited deep in the skin, and the condi- 
 tion is a permanent one, though it fades slightly in the course 
 of time. (See Fig. 44.) 
 
 NiEVUS PIGMENTOSUM 
 
 Syn. — Naevus spilus ; Naevus verrucosus ; Naevus pilosus ; 
 Naevus materna ; Naevus lipomatodes ; Naevus molluscafor- 
 mis ; Naevus unius lateris ; Pigmentary mole. 
 
 Definition. — A circumscribed deposit in the skin ; of an ex- 
 cessive amount of pigment — perhaps combined with an hyper- 
 trophy of all of the cutaneous structures and especially of the 
 connective tissue and the hair. 
 
 Symptoms. — The term naevus is not appropriate for these 
 lesions ; they are not connected with those vascular new 
 growths to which the term is usually applied. They belong to 
 the hypertrophies, and are related to lentigo and chloasma. 
 However, when the pigment excess appears in connection with 
 more or less hypertrophy of the other structure — connective 
 tissue and hair — it is usually considered in the text book under 
 the head of pigmentary naevus. 
 
374 N.EVUS PIGMENTOSUS. 
 
 Pigmentary nsevi are usually congenital, but may be ac- 
 quired. Once formed, they show little tendency to change 
 — save to increase slightly in size as time goes on. They 
 appear as flat, slightly-raised, irregular tumors, of a color that 
 varies from a light yellowish-brown almost to a chocolate 
 black. They are usually round, and often resemble a coffee- 
 grain very closely. In size they range from that of a split 
 pea to several inches square. They usually occur upon the 
 trunk, neck, and back, or on the face ; but they may appear 
 anywhere. There may be only one, or there may be many 
 hundreds, of varying appearance, upon a single individual. 
 When large they frequently assume curious shapes and appear- 
 ances which are usually referred by the patient's friends to 
 maternal " impressions " ; for these, like the vascular naevi, are 
 popularly supposed to be due to influences acting upon the 
 pregnant woman. 
 
 If the surface of the pigmented papule is normal and smooth 
 we have the nsevus spilus ; if it is rough and warty, we have 
 the nsevus verrucosus. If there is a growth of hair upon it 
 we have the nsevus pilosus ; this hair is usually stiff but may 
 be lanugo. If the connective tissue increase is very marked, 
 as it sometimes is even to the extent of forming large sessile or 
 pendant tumors, we have nsevus lipomatodes. In this latter 
 case, however, the growth is really not a nsevus pigmentosus at 
 all, but a connective tissue hypertrophy which is more or less 
 pigmented. 
 
 In extensive cases these naevi seem, like the vesicles of 
 zoster, to follow the nerve-tracts ; they may be limited to one 
 side of the body, or to one special region. 
 
 Pigmentary nsevi occur with equal frequency in both sexes. 
 In women they usually become of a darker tint during preg- 
 nancy. 
 
 Rindfleisch lays stress upon the danger of these growths 
 forming the starting point for pigmentary sarcoma. 
 
 Anatomy. — The normal coloring matter of the skin consists 
 of yellowish-brown granules which lie among the cells of 
 the lower layer of the rete. They occur in greater or less 
 
NAEVUS PIGMENTOSUS. 375 
 
 number in accordance with the race and tint of the individual. 
 Even in the same person they occur in some places, as around 
 the genitals, in comparatively greatly increased quantity. 
 
 A circumscribed and usually congenital increase in the 
 number of these granules constitutes a pigmentary naevus. 
 There is always some connective tissue hypertrophy, for with- 
 out it the disease would be a simple discoloration — a lentigo. 
 If the papillae also are enlarged, we have naevus verrucosus ; if 
 the hair-bulbs are increased in size and number, we have 
 naevus pilosus. 
 
 Etiology. — The cause of these localized hypertrophies is un- 
 known. 
 
 Prognosis. — Pigmentary naevi usually remain stationary for a 
 lifetime, and do not show, like the vascular naevi, any tendency 
 to retrogressive changes. 
 
 Treatment. — We are not often called upon to treat these 
 growths, save when they cause disfigurement by appearing 
 on the face, etc. 
 
 A 10 per cent, solution of corrosive sublimate applied for a 
 few hours by means of a moist cloth will cause blistering and 
 remove the pigment which does not usually reappear when the 
 new epidermis is formed. The sore surface may be kept dusted 
 for a few days with any ordinary powder. Tincture of iodine, 
 caustic potassa, and ethylate of sodium work in the same way. 
 Naphthol, tincture of green soap, pyrogallic acid, and chrysaro- 
 bin all act as pigment destroyers. 
 
 Tattooing of these naevi has been tried, and Sherwell claims 
 to have had good results from the use of a 25 per cent, solu- 
 tion of chromic, or a 50 per cent, solution of carbolic acid 
 with his needles ; but it is impossible to imitate the natural 
 color. 
 
 Naevus verrucosus and naevus lipomatcdes are to be treated 
 by thorough cauterization and excision. 
 
 Kaposi (Haut-Krankheiten, p. 528) gives in extenso a 
 number of formulae which he has found useful in the treat- 
 ment of n. pigmentosus. 
 
376 KERATOSES. 
 
 KERATOSES. 
 
 Keratoses are localized or general hypertrophies of the epi- 
 dermic layer of the skin. The papillary layer is also affected 
 in some cases ; indeed, so far as we know, the epidermic cells 
 derive their nourishment and their power of growth entirely 
 from the looped vessels of the papillae ; but the numerical 
 hypertrophy of the epithelia of the horny layer is the prom- 
 inent pathological factor in the keratoses ; and we may divide 
 them into pure keratoses without papillary hypertrophy, and 
 keratoses with papillary hypertrophy. To the first class belong 
 callositas, clavus, cornu cutaneum, keratosis pilaris, psoriasis 
 and lichen ruber ; and to the second verruca and ichthyosis. 
 
 PURE KERATOSES. 
 
 CALLOSITAS. 
 
 Synonyms. — Callus ; tyloma ; tylosis ; callosity. 
 
 Definition. — A more or less localized numerical hypertrophy 
 of the cells of the horny layer of the epidermis ; forming 
 thickened patches of grayish or yellowish-brown, translucent 
 skin upon various parts of the body, especially upon the hands 
 and feet. 
 
 Symptoms. — Simple thickenings of the horny layer of the 
 skin occur in patches of varying size and shape, but are not 
 usually very extensive. They generally appear as semi-trans- 
 lucent yellowish gray or yellowish brown patches ; they are 
 thickest in the center, where they may attain a diameter of 
 4 to 5 mms., whilst they fade off into the normal epidermis at 
 their periphery. They may be flat plates ; or, if of larger ex- 
 tent, are moulded to conform to the shape of the surface that 
 they cover. In callosities of moderate thickness, the lines and 
 furrows of the skin are preserved ; but in old and thick ones 
 the surface is perfectly smooth. 
 
 The hypertrophy is usually artificial in origin, but it may 
 also occur, though rarely, without any mechanical cause. Art- 
 
CALLOSITAS. 377 
 
 ificial callosities are most often found upon the hands and 
 feet, since there the causal agencies are most active. Upon 
 the feet they are very common over the heel and on the ball of 
 the great toe, sometimes covering the greater part of the sole 
 with a thick yellow plate. They are also met with on the 
 outer surface of the little toe, and over the instep. 
 
 The parts most frequently affected are the hands, and 
 especially the palms. Various trades, professions, and amuse- 
 ments cause long continued pressure upon different parts of the 
 hands and consequent callosities. Thus in carpenters they 
 occur from the use of the plane in the cleft between the first 
 finger and thumb of the right hand ; in tailors, from the use of 
 the flat iron, upon the middle of the right palm, and upon the 
 tips of the fingers from repeated needle-pricks ; among cob- 
 blers upon the inner surface of the fingers from pulling thread, 
 and also upon the right knee from pounding leather, and upon 
 the nates from sitting constantly upon wooden stools. Players 
 upon the harp, violin, guitar, etc., have them upon the tips of 
 the fingers ; oarsmen and base-ball players upon the palms, 
 and especially at the roots of the fingers. Servants have them 
 upon the hands from the hot water and alkalies used around 
 the house ; mechanics and chemists from the use of acids, etc. 
 They are occasionally seen among physicians who practice 
 much immediate percussion upon the backs of the fingers. 
 
 In all these cases the thickening of the epidermis is, of 
 course, a conservative process ; it protects the deeper and more 
 important structures. But impressions are very much 
 dulled by transmission through the mass, and movement is in- 
 terfered with to such an extent as to prevent many of the more 
 delicate uses of the hands. The thickened skin also is liable 
 to crack, especially when it occurs around the joints, and to 
 form painful and persistent fissures. 
 
 The callosities last as long as the cause which produced 
 them remains active, and they disappear spontaneously in time, 
 if that ceases. It is possible by their means not only to tell 
 in many cases the occupation of a mechanic, but, what is some- 
 times more important, whether he has been working lately or 
 
37*$ CALLOSITAS. 
 
 not. Occasionally, from the pressure of the callosity, con- 
 joined with some accidental injury, inflammation of the sub- 
 jacent corium occurs, pus is formed under the horny plate, and 
 it is thus detached and cast off. 
 
 Idiopathic callosities are rarely seen ; but we do meet with 
 them occasionally upon the palms of the hands and the backs 
 of the fingers in persons whose occupation affords no explana- 
 tion of their occurrence. 
 
 Anatomy. — The callus is simply the accumulation in abnor- 
 mal numbers of the layers of epithelial cells of the epidermis. 
 The amount of pressure, of wear and tear, regulates generally 
 the thickness of these layers. But when the skin is subjected 
 to more than the ordinary pressure, and especially when it is 
 subjected to it at a place where counterpressure by some bony 
 prominence is active, there the hypertrophy sets in. It is a 
 purely conservative effect on the part of nature to protect the 
 deeper structures. The corium is not involved to any extent ; 
 yet the excessive cell growth must derive its basis from the 
 vessels of the true skin. 
 
 On section, we find the corium normal, the epidermis thick- 
 ened, and the upper layers of cells so closely packed as to re- 
 semble bone substance. 
 
 Etiology. — This is sufficiently dwelt upon in the Semiology 
 and Anatomy. 
 
 Diagnosis. — This is usually easy ; the callus is generally 
 smooth, it fades away at its margins into the healthy skin, and it 
 finds an explanation in the occupation or habits of the patient. 
 But upon the palms and soles it is very liable to be fissured, and 
 then it presents no small likeness to eczema, or even to psori- 
 asis, syphilis, ichthyosis, etc. Its strict limitation will be of use, 
 of course, in the differentiation of callus from all these ; but 
 the reader is referred to the various diseases for the points of 
 differential diagnosis. 
 
 Prognosis. — The callosity will last as long as the cause that 
 produces it remains active ; it will disappear of itself when 
 that cause is removed. It may be cast off by suppuration. 
 
 Treatment. — In a large number of cases the callosity is pro- 
 
clavus. 379 
 
 tective, and ought not to be removed so long as the cause can- 
 not be avoided ; and even if it is removed it will return unless 
 that be done. Various agents may be employed to soften the 
 horny mass. Hot baths, poultices, enveloping the part in rub- 
 ber, the use of soft soap as ointment, alkalies such as caustic 
 potash (to be cautiously used in i to 2 per cent, solution, since 
 its action is liable to reach down to the true skin), acid, such as 
 vinegar or acetic acid, mercurial plaster, etc., may be used. 
 Any of these will soften the callosity and permit its removal 
 by scraping with scissors and knife. 
 
 To prevent its return, if removal of the cause is not possible, 
 the spot may be protected by anything that will relieve the 
 pressure — gloves, rings of leather or rubber, cotton, etc., etc. 
 
 CLAVUS. 
 
 Synonym, Corn. 
 
 Definition. — Clavus is a small, strictly localized, numerical 
 hypertrophy of the horny layer of the epidermis, painful upon 
 pressure, and usually situated about the toes. 
 
 Symptoj?is. — Corns occur as circumscribed horny masses, 
 usually not larger than a split pea, and smooth and shining 
 upon the surface. They are, in fact, callosities ; but they differ 
 from the formations described under that head in the fact 
 that they are small in extent, and that instead of lying like 
 flat plates upon the corium, they are cone-shaped, and their 
 apices dip down into the true skin. The latter characteristic 
 gives the corn the name of clavus, meaning a nail. 
 
 Corns occur almost invariably upon the feet, and most com- 
 monly upon the outer surface of the little toe. They are also 
 seen upon the upper or under surfaces of the other toes, or 
 upon the soles of the feet. They are not much elevated above 
 the surface ; they are smooth ; and they are often very painful 
 upon pressure, the deep core impinging upon the sensitive skin in 
 which it lies. When corns v^ccur between the toes the constant 
 maceration causes them to become soft and spongy ; hence 
 they are called soft, in contradistinction to the ordinary or hard 
 corns. 
 
380 CLAVUS. 
 
 In the slight form, corns are an affection of little conse- 
 quence ; but in severe cases they may prevent walking 
 entirely. 
 
 Anatomy. — Clavus is in reality only a very strictly localized 
 callosity. It is in the same way a hypertrophy of the horny 
 layer of the skin — but not evenly spread over the corium. It 
 consists of a horn-like mass in the shape of an inverted cone, 
 with its base level or nearly level with the surface, and its 
 tapering apex down in the rete. The cone is composed of 
 concentric layers of closely packed epidermic cells. 
 
 More or less hypertrophy of the papillae at the circumfer- 
 ence of the corn is to be observed ; but where the core dips 
 down the papillae are atrophied and may have disappeared ; 
 or even the whole corium may be perforated by the pressure 
 of the " nail." 
 
 Though at first the corn is an attempt toward the protection 
 of parts subjected to direct and very localized pressure, and 
 counter-pressure, there is soon set up, as Lesser points out, a 
 circulus vitiosus. The more the epidermis thickens, the greater 
 the pressure ; and the more the pressure increases, the greater 
 will be the thickening of the horny layer. 
 
 Etiology. — Long continued pressure and counter-pressure is 
 the cause of clavus. In the feet — the portion of the body 
 most neglected and most imposed upon by the dictates of 
 fashion — this cause is most active. Almost all corns occur 
 upon the feet, and are due to shoes improper in size or shape. 
 
 Prognosis. — If the cause is removed the cure of clavus is 
 usually easy ; without that, it may be mitigated but not re- 
 moved. 
 
 Treatment. — Is very much the same as that for callositas. 
 The prime requisite is the removal of the cause. A rational 
 covering for the feet, which conforms in some measure to their 
 natural shape, must be insisted upon. Besides this, the corns 
 may be relieved from pressure in various ways ; rings of rub- 
 ber, of plaster, of wadding, felt, etc., may be used. Not only 
 will the pain be relieved, but the constant tendency to increased 
 growth will be obviated. 
 
CORNU CUTANEUM. 381 
 
 Any of the means mentioned in the previous section may be 
 used to soften the corn and permit its extraction. Continuous 
 soaking in warm water, or poulticing, will accomplish this per- 
 fectly well. The poultices are to be put on for several nights 
 in succession. Resin, pitch, galbanum or diachylon plasters may 
 be employed. Salicylic acid in solution sometimes acts 
 promptly. Gezou's remedy for corns and warts is prepared as 
 follows : acid salicylic, grs. xxx. ; ext. cannabis indie, grs. x. ; 
 collodion, 3 iv. This is to be applied twice a day with a 
 brush. The results are said to be gratifying. 
 
 After softening, and at once in soft corns, their removal may 
 be affected by digging out the mass with the knife-point or 
 curette ; or nitrate of silver in the solid stick, or caustic potash 
 ( 3 ss, to 3 i to § i of alcohol) may be cautiously used. 
 
 It is to be borne in mind that small bursse mucosae are com- 
 mon at the seats of election of clavus, and that there is a pos- 
 sibility of serious results if they are opened. 
 
 CORNU CUTANEUM. 
 
 Synonymes. — Cornu humanun ; cutaneous horn; horny excres- 
 cence, horny tumor. 
 
 Definition. — A circumscribed hypertrophy of the epidermic 
 layer of the skin, forming a horny outgrowth of variable size 
 and shape. 
 
 Symptoms. — Horns growing from the skin are occasionally 
 observed, bearing the greatest resemblance in appearance to the 
 horns of the lower animals. They form one of the rarest of 
 the anomalies of the skin, since Hebra with all his experience, 
 had in 1876 seen but three of them. 
 
 These horny outgrowths are of various sizes and shapes. 
 Usually they are more or less tapering ; they may be straight, 
 or curved in various directions like a ram's horn ; their ends 
 may be clubbed or broken ; their surface is more or less ir- 
 regular and fissured. In color they are usually of a grayish- 
 yellow tint ; but they may be brownish, or even blackish, es- 
 
382 CORNU CUTANEUM. 
 
 pecially if they are old. They are usually small in size, and 
 are generally short ; though Kaposi mentions one that was 
 twenty-five centimetres long, and Porcher has reported the 
 case of a negress from whose forehead sprang a horn seven 
 inches long, and two and three-quarter inches in diameter. 
 Their width at the base, their thickest part, does not usually 
 exceed half an inch at the most ; and from that on they taper 
 to the end. 
 
 These horns rest upon a broad, flattened, or concave base, 
 which lies directly upon the skin. The tissues upon which 
 they rest may be normal ; but very often there is more or less 
 hypertrophy of the papillae ; in fact, some observers have 
 found groups of greatly enlarged papillae running up some dis- 
 tance in the center of the horny mass. 
 
 Cutaneous horns have been seen on all parts of the body, but 
 most frequently occur about the head, and next oftenest upon 
 the male genitals. The skin of the nose, ears, eyelids, lips, cheeks 
 and scalp may all afford a seat for the growth. Dr. Gottheil 
 saw lately in a woman at sixty-five, one horn about five-eighths of 
 an inch long which grew from the center of the right eyebrow, 
 whilst another one-quarter of an inch long was upon the right 
 cheek, just below the middle of the lower lid. They may be 
 single, but are very often multiple. Thus Boettge describes a case 
 where a man of sixty had six horns upon his face, and another 
 in which a young girl had the entire lower half of her body 
 studded with them, there being one six inches long upon one 
 labium. They commonly occur in elderly people, though 
 Lesser has seen two horns upon the lower lip of a girl twenty 
 years old. Around the genitals they sometimes begin as what 
 are called venereal warts. Pick has collected nine cases of 
 horns of the penis, in some of which the sulcus below the glans 
 was entirely occupied by small horns, which had begun in this 
 way. Cutaneous horns are dry and somewhat brittle ; they 
 are not as hard as the nail-substance. is. After having attained 
 a certain size they tend to break off, but they always grow 
 again. They are not painful, save when injured or irritated ; 
 in which latter case inflammation of the base of the growth 
 
CORNU CUTANEUM. 383 
 
 may cause it to be cast off. They have been noticed among 
 the lower animals. 
 
 Anatomy. — Essentially these cutaneous horns are hypertro- 
 phic warts, and it is the peculiarity of their appearance alone 
 which entitles them to separate consideration here. 
 
 They consist of accumulations of epidermic cells closely 
 agglutinated. They originate always from the stratum mucosum, 
 either that lying over the papillae of the corium, or that lining 
 the gandular structures. As a usual thing a number of hyper- 
 trophic papillae form the core of the horn, and above them the 
 horny cells are ranged in columnar order. Sections low down 
 will strike the papillae and bloodvessels, surrounded by the 
 columns ; sections higher up will show the columns of dry 
 cells alone. In the columns themselves the cells are often 
 arranged in concentric rings. Even if the base of the column 
 be sunk into the skin, the hypertrophic papillae in whose growth 
 the horn originated will be found there. According to Rind- 
 fleisch, even those horns which apparently originated in a 
 glandular structure, have a papillary outgrowth for a begin- 
 ning, though the gland epithelium may have participated in 
 the epithelial proliferation. 
 
 In a number of cases epitheiiomatous degeneration of these 
 growths has been reported. 
 
 Etiology is obscure; the cause of this rare affection is not 
 known. 
 
 Prognosis. — Cutaneous horns usually grow very slowly. In 
 some of Pick's cases, however, they grew at the rate of more 
 than two inches in six months. When simply broken or cut 
 off they almost invariably reappear. There is no pain, save 
 when they are injured. Their liability to epithelioma in the 
 old people in whom they usually occur, is an argument as 
 powerful as their unsightliness for their destruction. 
 
 Treatment. — Both the horn and its base must be destroyed. 
 The growth may be cut or broken off, and the base excised, or 
 cauterized with the galvano-cautery, or with chloride of zinc 
 paste, caustic potash, etc. 
 
384 KERATOSIS PILARIS. 
 
 KERATOSIS PILARIS. 
 
 Synonyms. — Lichen pilaris ; pityriasis pilaris. 
 
 Definition. — Keratosis pilaris depends upon a localized 
 hypertrophy of the horny cells of the epidermis around the 
 orifices of the hair follicles, and appears as scattered, pin-head 
 sized, conical elevations, each usually pierced in the center by 
 a hair. 
 
 Symptoms. — The disease appears as a number of grayish or 
 whitish elevations of pin-head size scattered over the skin, the 
 surface of which is rough, dry and harsh. In bad cases the 
 epidermis feels like a nutmeg-grater. 
 
 Each little papule is due to a localized overgrowth of the 
 epithelia and accumulation of sebaceous matter around the orifice 
 of a hair follicle ; the hair itself usually protrudes through the 
 lamina heaped up around its base. In some cases the hairs are 
 imprisoned, and are found coiled up within the epithelial mass ; 
 or they may be broken off short at the apex of the whitish 
 papule giving it the appearance of having a dark center. 
 
 Keratosis pilaris occurs to a slight extent upon every one, es- 
 pecially upon the arms. Its favorite seat is upon the extensor 
 surfaces of the limbs, and especially upon the thighs ; but it 
 may occur everywhere upon the body. It usually develops at 
 puberty when the lanugo begins to grow with increased vigor, 
 and once formed tends to last indefinitely. It is easy to under- 
 stand why it is more common in those who do not bathe often. 
 
 Anatotny. — Lichen pilaris is a simple accumulation of epithe- 
 lial cells and sebum around the orifices of the hair follicles ; 
 sometimes imprisoning in its mass the hair itself. 
 
 Etiology. — Probably the omission of the frequent use of hot 
 water and soap has as much to do with its occurrence as any 
 thing. The fact also that the cells lining the hair follicles and 
 sebaceous glands partake of the increased activity manifested 
 by the various structures of the skin at puberty may help to cause 
 the affection. 
 
 Diagnosis. — Cutis anserina is due to a temporary erection of 
 
PSORIASIS. 385 
 
 the hairs under the influence of cold or heat or nervous excite- 
 ment ; keratosis pilaris is permanent. 
 
 Lichen pilaris resembles a good deal a desquamating miliary 
 papular syphiloderm, but differs from it in not being grouped, 
 and in being less deeply seated, less scaly, and not red in color. 
 In lichen scrofulosus the lesions are somewhat larger, tend to 
 occur in groups, and appear especially upon the abdomen. 
 
 Prognosis. — The trouble lasts indefinitely if uninterfered with, 
 but is quite amenable to treatment. 
 
 Treatment. — Hot baths, with strong alkaline soaps, such as 
 sapo viridis, must be employed. The various emollient oint- 
 ments, glycerine, etc., are also useful. 
 
 PSORIASIS. 
 
 Syn. — Lepra ; psora ; lepra Willani. 
 
 Definition. — A chronic affection of the skin characterized by 
 the formation of patches of variable size and shape, formed of 
 slightly adherent lamellae of whitish, mother-of-pearl like epi- 
 thelial scales situated upon a thickened, reddened and easily 
 bleeding base. 
 
 Symptoms. — Psoriasis always commences as small, pin-head 
 sized, brownish or pale red, elevated spots, upon which, in a day 
 or two, bright scales formed of epidermic cells commence to 
 collect. These spots or papules are rarely ever present singly, 
 a number generally making their appearance at the same time. 
 The papules increase in size by peripheral growth, sometimes 
 quickly, sometimes slowly, and may spread so as to cover a con- 
 siderable area. As the eruption always spreads by peripheral 
 growth, the patches resulting from extension of individual 
 papules will always be more or less circular in form. When a 
 patch has reached the diameter of about an inch, more or less, 
 it frequently shows a tendency to clear up in the center by a 
 diminution in the elevation and in the amount of scaling, at the 
 same time that the eruption continues to spread at the periphery. 
 In this manner the patch assumes a ring form and in its subse- 
 quent growth this form remains, as the healing process extends 
 25 
 
386 PSORIASIS. 
 
 from the center in direct ratio to the extent of peripheral growth 
 of the eruption. All patches, however, even among those which 
 acquire a considerable size, do not take on this ring form, but 
 form areas of variable size, covered everywhere by a large num- 
 ber of whitish epithelial scales. The size also attained by in- 
 dividual papules varies greatly ; some remain pin-head in size, 
 while others spread to form a patch of perhaps several inches 
 in diameter ; and between these are all gradations of size. No 
 matter whether large or small, they all possess the same charac- 
 ters. They are elevated, with a reddish base, and covered by 
 lamellae of epithelial cells, which are but slightly adherent to the 
 underlying rete. Upon removal of the scales, slight scratching 
 of the part will cause oozing of blood from the papillae beneath. 
 This oozing is rather characteristic of an active psoriasis ; in 
 the stage of disappearance the difficulty of producing it is 
 in direct proportion to the extent of progress in the healing 
 process. 
 
 On account of the differences in the size and shape 
 of the patches present in psoriasis, special names have been em- 
 ployed to represent the different forms ; thus, when the spots 
 are about the size of a pin-head or less, it is called psoriasis 
 punctata ; if of the size of a split pea, psoriasis guttata ; if as 
 large as a twenty-five cent piece and with the center still scaly, 
 psoriasis nummularis ; or if a large extent of surface is 
 affected, psoriasis diffusa. If the patches heal in the center, 
 giving the eruption a ring form it is called psoriasis circinata or 
 orbicularis, and if neighboring rings coalesce and form bands, 
 the intervening skin becoming normal, it is called psoriasis 
 gyrata. All the forms of eruption must commence as psoriasis 
 punctata. In that new spots of eruption are constantly arising 
 and afterward spreading by peripheral growth to assume 
 one or other of the above forms, we find in nearly every case of 
 psoriasis of some duration all the different forms described 
 present. The eruption which at first was isolated becomes, by 
 the formation of new papules and peripheral spreading 
 of the patches, more or less confluent, so that finally 
 larger or smaller areas or a large portion of the cutaneous sur- 
 
PSORIASIS. 387 
 
 face may be occupied by it. As already stated, soon after the 
 appearance of the eruption as a small, reddish, papular eleva- 
 tion, whitish scales begin to appear on the summit of the 
 papulae, and increase in quantity as long as the disease is 
 actively increasing in extent. The amount of scaling varies in 
 different persons, in the different patches of the eruption in the 
 same person, and in an individual patch, according to the 
 duration of existence and to the condition of the eruption. 
 More scales are present when the disease has lasted some time 
 and is still in an active condition, than at the commencement 
 of the eruption, or during the period of disappearance. The 
 amount of scaling is less when the nutrition of the skin is inter- 
 fered with, either from general mal-nutrition or from an acute 
 febrile disease. Generally fewer scales are formed on females 
 than on males, and on patches situated on the flexor surfaces 
 of the body, than on the extensor surfaces. Generally fewer 
 scales are present in very young persons than in adults. In 
 short, where the epidermis is thin, the scales are less in quan- 
 tity than where this layer is strongly developed. The whitish 
 appearance of the scales is due to the presence of air in the 
 spaces between the shriveled and dried-up epithelial cells. 
 Psoriasis may continue to exist on the skin for years, either by 
 continuation of the pathological process in already existing 
 patches, or by the formation of new spots of eruption in addition 
 to those already existing ; or the older spots may disappear and 
 the eruption be prolonged by the constant formation of new 
 patches. Patches sometimes exist for years without showing 
 any increase in size, the disease remaining confined to the origi- 
 nal seat. The whole eruption, however, is liable to temporarily 
 disappear spontaneously from the body by a process of involu- 
 tion. The first symptoms of involution are as follows : The 
 scales are no longer so adherent or formed as rapidly as before; 
 they are easily removed or fall off spontaneously, leaving a 
 slightly reddened spot behind. These spots gradually 
 lose their color ; sink to the level of the skin, do not 
 show oozing of blood upon scratching, are covered with fewer 
 and fewer scales, until finally the skin resumes its normal 
 
388 PSORIASIS. 
 
 appearance, with the exception of temporary pigmentation. 
 This process of involution may occur in all the patches or 
 psoriasis at the same time or only in some patches, while others 
 continue to increase in size or new ones to develop. In un- 
 complicated cases there is never any vesiculation, pustulation or 
 discharge of any kind to be observed. In some cases, especially 
 when the eruption spreads rapidly there may be considerable 
 inflammation, with burning, itching, etc., present, but usually the 
 redness at the seat of the patches is due to hyperemia only, or 
 if inflammation is present, it is secondary to the nutrition change 
 occurring in the epidermis. When a patch has existed for some 
 time there is, owing to this secondary inflammatory condition, 
 more or less infiltration of the skin and diminution in the 
 elasticity of the part. On account of this thickening and loss of 
 elasticity, the surface of the affected part may become cracked 
 and fissured, and an eczematous condition be produced. The 
 part may also present more of the characters of a chronic eczema 
 than of a psoriasis when the secondary inflammatory process, 
 which is always present, becomes the principal pathological 
 condition. The favorite seats for the development of psoriasis 
 are the elbows and knees, but it may appear upon any part of 
 the cutaneous surface. It never appears on a mucous mem- 
 brane. It is very rarely present upon the palms of the hands 
 or upon the soles of the feet. The nails of the fingers and toes 
 are frequently affected. They become thicker, uneven, ridged, 
 dark-colored and friable, the free ends breaking off easily. It is 
 rare for all of the nails to be affected at the same time. The 
 hair, even in psoriasis of the scalp is rarely affected in its nutri- 
 tion. 
 
 Anatomy. — Psoriasis consists in a hyperplasia of the rete and 
 corresponding structure of the hair follicles. Examining a sec- 
 tion from psoriasis punctata of a few days duration, the corne- 
 ous layer is found to be but slightly changed, while the rete 
 shows marked hyperplasia. 
 
 While the normal Malpighian layer on both sides of the sec- 
 tion in Fig. 45 shows an almost level under surface, i. e., the 
 papillae are but very slightly developed, that portion of the layer 
 
PSORIASIS. 
 
 3 S 9 
 
 occupying the center of the section, and corresponding to the 
 region of the papule, presents more or less deep and broad pro- 
 longations downward into the cutis. These prolongations are 
 larger in the central part of the papule than at its margin. As 
 a consequence of this growth downward of the interpapillary 
 portion of the Malpighian layer, there is a larger papillary space 
 in this region than exists in the normal tissue. This growth 
 inward of a conically-shaped structure, having the apex of the 
 cone downward, produces in proportion to the length of the 
 cones a corresponding increase in the length of the space separ- 
 ating them. This prolongation downward being greater at the 
 
 Fig. 45. — Section of a pin-head size papule of psoriasis, drawn with a low 
 magnifying power. Healthy tissue is present on both sides of the section, ex- 
 ternally from on the left side and from G on the right side, a, orifices of hair 
 follicles ; &, orifice of sweat duct ; c, hair follicles cut obliquely. 
 
 center of a young papule than at the margin, on account of the 
 greater age of the former structure, the long axis of the inter- 
 Malpighian space in the former is greater than in the latter. 
 
 In the papillae and superficial part of the corium within the 
 psoriasis region, there are seen enlarged bloodvessles and round 
 bodies in varying numbers in the surrounding tissues, while in 
 the non-papular region no enlargement of bloodvessels is, as a 
 rule, observed, and also no white blood corpuscles. 
 
 The deeper parts of the cutis appear normal, as well as the 
 sebaceous and sweat glands. 
 
 The increase in the size of the Malphigian layer arises from 
 
39° 
 
 PSORIASIS. 
 
 an increase in the number of rete cells. This increase is some- 
 times very great. 
 
 In Fig. 46 I have drawn the appearances presented near the 
 center of the papule a few days old. It will be seen by reference 
 to that figure that there is a great increase in the size of the 
 
 Fig. 46. — Section of the center of a psoriasis papule of a few days duration. 
 
 Malpighian layer throughout its whole extent, and especially in 
 its interpapillary portion. In order to have a correct idea of 
 the amount of increase of this layer in a papule not larger than 
 a pin's head, I have represented, in Fig. 47, surrounding normal 
 
 Fig. 47. — Section of normal skin from the periphery of the papule represented 
 in fig. 46. 
 
 tissue, which was removed along with the papule from which 
 the section represented by Fig. 46 was made. Both figures are 
 magnified the same number of diameters. 
 
PSORIASIS. 
 
 391 
 
 The bloodvessels in the papillae are more or less dilated, 
 this dilatation, together with emigration of white blood cor- 
 puscles, increasing with the duration of the eruption. All the 
 inflammatory changes, however, in the cutis are secondary to 
 the hyperplasia of the rete. 
 
 The longer the acute process lasts the greater is the amount 
 of hyperplasia of the rete, and also of inflammatory changes in 
 the corium. In chronic cases there may be considerable infil- 
 tration of the cutis with round cells, while the bloodvessels are 
 
 Fig. 48 shows how the bloodvessels may be dilated in psoriasis. The corneous 
 layer has been accidentally removed. 
 
 dilated and the papillae increased in length from the growth of 
 the rete downward. In fig. 49 are represented the changes oc- 
 curring when the eruption has lasted some time. 
 
 The hair in psoriasis becomes changed at the commence- 
 ment. The external root-sheath, the structure corresponding 
 to the rete, becomes increased in size in the same manner as 
 the latter structure. There is a real hyperplasia, with an ex- 
 tension of the hyperplastic structure into the surrounding cutis. 
 This growth occurs principally at the root of the hair, though 
 it is met with also along the rest of the follicle. In Fig. 50 is 
 represented a hair follicle which was present in the papule 
 from which Fig. 45 was drawn. Every hair situated within a 
 
392 
 
 PSORIASIS. 
 
 psoriasis papule has this hyperplasia of its external root 
 sheath. 
 
 In all the other forms of eruption in psoriasis, we have only 
 to do with differences of degree in the pathological process, 
 
 Fig. 49. — Section of patch of psoriasis nummularis. The hyperplasia of the rete 
 is marked, a, Dilated bloodvessel ; b, peri-vascular cell infiltration. 
 
 the nature of the disease remaining the same as in psoriasis 
 punctata. In psoriasis guttata, psoriasis nummularis, and 
 psoriasis diffusa, the process has simply extended over a larger 
 
PSORIASIS. 
 
 393 
 
 area of skin, and as a consequence ; the process of hyperplasia 
 being the essential process in the production of the increase in 
 size, we can expect to find but little, if any, changes in the 
 Malpighian layer in the later stages of the eruption different 
 from those observed in the papular stage, except in the extent 
 of the hyperplasia, and the consequent increased thickness of 
 the rete Malpighii. As regards those secondary processes 
 which showed marked differences in different papules in the 
 early period of the eruption, they will naturally show differ- 
 ences in the other forms, and conse- 
 quently there will be observed in differ- 
 ent patches differences in the amount 
 of dilatation of the bloodvessels, in the 
 amount of oedema in the surrounding 
 tissue from transudation of serum, and 
 in the number of emigrated white blood 
 corpuscles. 
 
 During the period of disappearance 
 of the disease there is a gradual return 
 to the normal condition, until the hyper- 
 plasia, dilatation of the bloodvessels, and 
 cell infiltration has completely disap- 
 peared. The Malpighian prolongations 
 become smaller and smaller until the 
 layer attains its normal size ; the 
 bloodvessels gradually return to their normal diameter, and the 
 round cells and serous exudation return to their normal chan- 
 nels. Of these pathological processes, the cell infiltration and 
 oedema generally disappear first, and the hyperplasia last. 
 
 Etiology. — In many cases of psoriasis the cause of the disease 
 is unknown. In the majority, however, it will be found that 
 there is an hereditary predisposition to the disease, that one or 
 other of the parents, grandparents or relatives have had the 
 eruption. It is unusual for all the members of a family to have 
 the predisposition to the disease, although in a family under 
 my care four of the five children besides the father had psoria- 
 sis. It occurs equally in chlorotic, tuberculous, and well-nour- 
 
 Fig. 50. 
 
394 psoriasis. 
 
 ished healthy persons. It is somewhat more frequent in males 
 than females. The seasons exert but little influence in its de- 
 velopment, the majority of cases probably are worse in winter 
 and better in summer, but the reverse is often observed. It 
 frequently disappears if the system becomes much weakened 
 from other diseases, especially acute conditions. External ir- 
 ritation, as scratching, can call into action the hyperplastic pro- 
 cess, provided there is a predisposition in the skin to the dis- 
 ease. For the same reasons it has been observed to follow 
 vaccination. In these cases, if the person has not previously 
 had the eruption they would have acquired it later. It gener- 
 ally makes its first appearance between the period of puberty 
 and twenty or twenty-five years of age. It has been observed 
 in a child eight months old (Kaposi), and again it may not ap- 
 pear until late in life. 
 
 Diagnosis. — Psoriasis may be confounded with eczema squa- 
 mosum, seborrhcea, tinea trichophytina, pityriasis rubra, lupus 
 erythematosus, lichen ruber and the papulo-squamous syphi- 
 lide. 
 
 In eczema the scales are fewer ; are not so bright, mother- 
 of-pearl-like ; consist of epithelium and dried exudation and 
 not of dry epithelial cells alone as in psoriasis ; are not situated 
 upon a raised base, and scratching of the part after their re- 
 moval is not followed by oozing of blood. In psoriasis the 
 patches are always well-defined and dry, and there is no history 
 of vesicles or moisture having been present at any time in the 
 course of the eruption ; in eczema the patch is rarely sharply 
 limited, there are generally vesicles or isolated inflammatory 
 papules at the periphery, and if the patch is dry at the time of 
 observation there is always a history of a previous moist stage 
 to be obtained. A patch of eczema is generally more infil- 
 trated and has more scales at the center than at the peripheral 
 part ; in psoriasis the scaling and elevation is greatest at the 
 periphery. Psoriasis is generally present on the outer surfaces 
 of the elbows and knees, while eczema is rare on those situa- 
 tions. Itching is generally present in both diseases, but is al- 
 most invariably much greater in eczema. In gouty and rheu- 
 
psoriasis. 395 
 
 matic subjects circular patches of eczema situated on the lower 
 extremities especially, bear very frequently a close resemblance 
 to psoriasis, both as regards the amount of scaling and the 
 sharp limitation of the patch. The history of the case, the 
 non-lamellar character of the scales, and the absence of 
 psoriasis on other parts, are the points of reliance in the diag- 
 nosis. If psoriasis becomes complicated by eczema then the 
 primary disease may not be recognizable. 
 
 Seborrhoea resembles psoriasis only when seated upon the 
 scalp. Seborrhoea never appears as circular patches or rings, 
 the scalp is almost always pale, occasionally slightly hyperaemic, 
 but not elevated ; the secretion consists of thick, friable crusts, 
 or fine, grayish or yellowish greasy scales ; while psoriasis ap- 
 pears as circular patches or rings composed of dry epidermic 
 non- greasy scales situated upon a red, elevated base. Psoriasis 
 also generally extends a distance on the forehead or neck as 
 bands of characteristic appearance, while seborrhea remains 
 confined to the scalp. 
 
 In ringworm of the scalp the patches bear some resemblance 
 to psoriasis, but the amount of scaling is much less and the 
 scales are finer. In ringworm the hairs are always affected ; in 
 psoriasis they are normal. Psoriasis of the scalp never exists 
 alone, ringworm often does. In cases of doubt examination by 
 the microscope will decide the question, as fungi are never 
 present in psoriasis. In ringworm of the body, the small 
 amount of scaling, the presence of vesicles at the periphery, the 
 want of symmetry, psoriasis being generally a symmetrical affec- 
 tion, and the absence of the eruption on the knees and elbows 
 are sufficient to make the diagnosis easy. 
 
 In pityriasis rubra the eruption is general over the whole 
 body, the scales are either fine or very large and thin ; they do 
 not accumulate, but are being constantly exfoliated ; there are 
 no papules, the skin is not infiltrated and removal of the scales 
 shows a red, tender, non-elevated skin beneath. 
 
 In erythematous lupus, the eruption is generally situated upon 
 the cheeks or nose, the patch spreads very slowly, the scales 
 are few but firmly adherent, and upon removal show attached 
 
396 PSORIASIS. 
 
 to their under-surface plugs of sebaceous matter extracted from 
 the dilated sebaceous gland-ducts. Lupus always causes des- 
 truction of tissue with subsequent formation of cicatricial tissue; 
 psoriasis never destroys tissue, but when it disappears it leaves 
 normal tissue behind. 
 
 In lichen ruber the papules are all about the same size, they 
 do not increase by peripheral growth and have a tendency to 
 invade the whole body. At first the scaling is slight, but if a 
 diffuse patch is formed from the constant production of new 
 papules between existing ones, then the scaling and dryness of 
 the patch may resemble the eruption in psoriasis. At the peri- 
 phery of such a patch, however, characteristic papules of lichen 
 ruber are always present. 
 
 In the papulo-squamous syphilide the papules are not so 
 symmetrically arranged as in psoriasis ; they are more frequent- 
 ly confined to a part of the body, while psoriasis attacks sev- 
 eral regions, the papules are darker in color and covered with 
 fewer scales. The scales are also very firmly adherent, and 
 upon their removal scratching of the base does not produce 
 oozing. There is more infiltration than in psoriasis, and the 
 knees and the elbows are seldom attacked. In cases of syphilis 
 other forms of the disease are generally present, as the eruption 
 rarely maintains for any length of time a single form of lesion. 
 The history of the eruption will also aid greatly in forming a 
 diagnosis. 
 
 Prognosis — The prognosis in psoriasis is favorable as regards 
 the removal of the existing eruption, but we are unable to pre- 
 vent a return of the disease. Outbreaks of the eruption may 
 occur even during treatment, or relapses may take place within 
 a few weeks or months ; rarely does it remain absent a number 
 of years ; consequently we can never promise the patients that 
 they will not have a return of the disease, nor can we tell how 
 soon a relapse will occur. 
 
 Treatment. — The treatment is either internal or local. 
 
 Internal treatment consists in the administration of arsenic 
 for its special effect on psoriasis and alkalies against hyper- 
 acidity of the system. Although alkalies are not sufficient of 
 
psoriasis. 397 
 
 themselves to remove the eruption, yet, in the majority of cases, 
 arsenic will be found to act much more rapidly and effectually 
 when given in combination with alkalies than when adminis- 
 tered alone. The amount to be given depends upon the general 
 condition of the person ; the urine must be kept alkaline ; 
 plethoric, gouty and rheumatic persons require larger doses 
 than other persons. They should be given after meals and 
 in large quantities of water. The liquor potassse, citrate of 
 potash, acetate of potash or bicarbonate of soda may be 
 given, but I prefer the acetate of potash on account of its di- 
 uretic effects also. In gouty and rheumatic subjects colchicum 
 should be added. I use the following for gouty or plethoric 
 subjects, if there are considerable urates present in the urine : 
 $. Potass, acet., § i. ; spirits eth. nit., 3 iv. ; vin. colchici, 3 ii.; 
 syr. aurantii § iss. ; aq. carui, ad. J vi. ; M. Sig. A desert- 
 spoonful three times a day after meals in a wineglassful of 
 water. 
 
 Fowler's solution of arsenic is to be added to this in the 
 strength suitable for each case. The bowels should be kept 
 regular by saline cathartics ; dyspepsia if present, must receive 
 careful attention. An acid dyspepsia keeps the system in a 
 condition most unfavorable for the cure of a psoriasis of any 
 extent. The diet should be regulated, food should be nourish- 
 ing and easily digestible. Acid substances, fat and malt 
 liquors should be avoided. Meat should be partaken of some- 
 what sparingly, and only beef, lamb or mutton, or poultry eaten. 
 The meat should be prepared in the most digestible form. By 
 attention to the foregoing we can, by the use of arsenic, cause 
 the majority of cases of psoriasis eruption to disappear in a 
 few weeks, even if it be very extensive. 
 
 The guttate form is the easiest cured. The diffuse psoriasis 
 is much more obstinate. Arsenic may be given in the form of 
 arsenious acid, Fowler's or Pearson's solution. The dose is to 
 be regulated partly by the manner in which it is borne. One 
 should commence with small doses, and every two or three 
 days increase the arsenic, if the stomach will stand it, until a 
 fair dose is taken. Children can take comparatively large 
 
39$ PSORIASIS. 
 
 doses without causing intestinal disturbance. As a rule it 
 should be given after meals, although some prefer to take it upon 
 an empty stomach. After a maximum dose has been reached 
 in an individual case, this quantity should be given until the 
 eruption has subsided, when small doses should be given for 
 some time longer. Sour stomachs generally cannot bear 
 the smallest doses of arsenic. In these cases we must de- 
 pend on local treatment alone. 
 
 Arsenious acid is given in pill form, combined with black 
 pepper to form the so-called Asiatic pills, their formula : Acid 
 arsenicosi, 4,00 ; piperis nigri pulv., 35,00 ; gum arabic, 7,50 ; 
 aq. dest., q. s. ; ft., in pill., No. 800. One pill should be taken 
 three times a day at first, and gradually increased until, per- 
 haps, four pills are taken three times a day. Their use is to 
 be continued in the manner already described for arsenic. If 
 they cause griping or diarrhoea, small doses of opium should be 
 taken also. If Fowler's solution is used, the commencing 
 dose should be for an adult, three or four drops after meals, 
 three times a day, and this dose gradually increased and 
 continued in the manner above described. 
 
 If the stomach does not bear the larger doses we must be 
 content with smaller ones, or try one of the other preparations. 
 
 Pearson's solution is to be given in the same manner as 
 Fowler's, as a rule it is not better borne by the stomach than 
 the potash combination. Cases of general psoriasis and of p. 
 guttata, and of p. punctata may be treated by arsenic alone ; 
 but in the other forms, and in inveterate psoriasis it is neces- 
 sary to combine local treatment with it. 
 
 Other substances have been recommended for the cure of 
 psoriasis. Tr. cantharides, colchicum, jaborandi, have all been 
 recommended, but are very uncertain in their action. 
 
 Oil of cade, twenty drops mixed with syrup, or in capsules, 
 and carbolic acid in pill are sometimes useful in the early 
 stage of the eruption. On account of their action, however, on 
 the epithelium of the liver and kidneys they must be used 
 with caution. 
 
 Local treatment consists in the use of water, soap, tar, sul- 
 
psoriasis. 399 
 
 phur, mercurial preparations, and chrysarobin, and pyrogallic 
 acid. 
 
 Water may be used in the form of warm or cold baths, or 
 steam, or douche baths, or wet-packs. 
 
 The long continued use of water in one of these forms will 
 finally cause maceration of the scales, disappearance of the in- 
 filtration and removal of the psoriasis eruption. It is to be 
 recommended only in chronic and obstinate or diffuse eruptions. 
 
 The use of soap, either alone or dissolved in alcohol, will, if 
 energetically applied, cause the eruption to disappear. It may, 
 be used in cases of diffuse psoriasis and where there is con- 
 siderable infiltration. Green soap is the best preparation. 
 
 If the eruption is very extensive the treatment should be 
 conducted in the following manner : 
 
 The soap is to be thoroughly rubbed into the skin and al- 
 lowed to remain. The rubbing is to be repeated twice a day 
 for four or six days, then for three or four days, once a day, 
 and then nothing is applied for four days when a bath is 
 to be ordered. The bath is taken only after the epidermis has 
 begun to loosen itself ; if taken too soon, retention and shrink- 
 age will be so great as to interfere with movements of the 
 body. If the eruption consists only of limited deeply infil- 
 trated chronic patches, the soap will act better by spreading it 
 as thick as an ointment upon a piece of flannel, and binding it 
 upon the part. Soap dissolved in alcohol is a useful form for 
 psoriasis of the scalp. It may be applied by means of a flan- 
 nel as above described, or with a stiff brush, using at the 
 same time warm water douche. 
 
 Oleum rusci ; oleum cadini, or common tar may be used. 
 This can be used either in the form of solution or in combina- 
 tion with soap or ointments. As an ointment one to two drachms 
 of tar to an ounce of lard, or in solution in the strength of one 
 to eight drachms of tar to an ounce of alcohol, or as a soap 
 in the proportion of one part of green soap to two of tar and 
 three of lard can be used. 
 
 The tar preparations should be well rubbed into the skin 
 either with a flannel or stiff brush. They should be applied 
 
400 PSORIASIS. 
 
 once or twice a day. If a large surface is affected the patient 
 should lie between woolen blankets or wear woolen undergar- 
 ments for at least two hours after the application, until the tar 
 has become sufficiently dry. The scales should be removed 
 before each application of the tar, by baths and soap. 
 
 Tar, by means of a bath, acts more energetically than by 
 means of an ointment. The mode of procedure is as 
 follows : the patches of psoriasis are first washed with soap, 
 and then one of the tar applications energetically rubbed 
 in and the patient immediately put in a bath, to remain 
 there four to six hours, then washed off, dried and rubbed with 
 fat or simple ointment. This bathing is to be repeated until 
 the eruption has disappeared. 
 
 Occasionally tar gives rise to unfavorable symptoms either 
 local or general. Sometimes it produces inflammation of the 
 skin, especially where two surfaces come in contact. This can 
 be prevented by the use of powder and charpie. 
 
 Occasionally it causes inflammation of the sebaceous glands, 
 producing an acne, especially on the extensor surface of the 
 lower extremities and on hairy parts of the body. If they 
 appear the use of tar must be discontinued. 
 
 In some cases even after the first application of tar, symp- 
 toms of general disturbance — intoxication symptoms — from 
 absorption of the tar occur. Among the symptoms are to be 
 noted fever, coated tongue, nausea, eructations, vomiting of 
 dark tar-containing fluid, diarrhoea, dark colored faeces, ischuria, 
 strangury, dark colored, tar-containing urine. If the use of the 
 tar ceases the symptoms gradually subside and finally disappear 
 without evil consequences. As the susceptibility of different 
 persons is different in respect to the effects of tar the first few 
 applications to the skin should be limited in extent ; afterward 
 larger surfaces may be tarred. 
 
 Sulphur may be used as ordinary sulphur baths or as artifi- 
 cial baths prepared with Vleminckx's solution ; it is applied in 
 the same manner as the tar preparation. The patient being 
 first washed with soap in a bath and the solution applied with 
 a brush he is allowed to remain several hours, or the patient re- 
 
PSORIASIS. 401 
 
 mains in the bath one hour after the application and is afterward 
 washed with luke warm water, and rubbed with lard or oil. It 
 can only be applied on small regions at a time, and should not 
 be used when the skin is tender, or upon the face. 
 
 Wilkinson's ointment, as modified by Hebra, is also useful. 
 $. Sulphuris sublim., ol. cadini, aa, 3iv.; saponis viridis, 
 adipis, aa, 3 i., pulv. cret. alb. 3 iiss. M. 
 
 The salve is to be applied twice daily for six days without a 
 bath ; only after the epidermis has loosened, which occurs about 
 the tenth or twelfth day, is a bath to be ordered. 
 
 The energetic modes of treatment are only necessary in cases 
 of chronic, inveterate, infiltrated patches. 
 
 Some of the mercurial preparations are of advantage in some 
 of the forms of psoriasis, the ointment of the nitrate of mercury, 
 full strength or weaker, or an ointment of the biniodide ten to 
 thirty grains to the ounce, or the Ung. Rochardi (Iodi. puri 
 gr. i., calomel 3i., ung. rosse. 3 ii.) may be used if the patches 
 are small and few in number. The oleate of mercury in 
 the strength of from two to ten per cent., is also of service in 
 small patches with considerable infiltration of the corium. 
 These mercurial preparations cannot be used over large sur- 
 faces on account of the danger from absorption ; they are 
 especially serviceable for small patches situated upon the face. 
 
 All of the above mentioned preparations for local treatment 
 are as a rule of much less value than that of chrysarobin, which 
 was first introduced to the profession for the treatment of 
 psoriasis by Balmano Squire of London. It was formerly called 
 chrysophanic acid, and is used either in the form of an oint- 
 ment mixed with lard or vaseline in the proportion of five to 
 forty or sixty grains to the ounce, generally from ten to twenty 
 grains is the strength required, the former for young persons 
 and those with tender skin, and the latter for non -irritable 
 surfaces. 
 
 The objections to the use of the chrysarobin ointment, are the 
 discoloration of the skin, and the irritation it sometimes pro- 
 duces. It also stains the clothing and bed clothes, when em- 
 ployed as an ointment, and consequently frequently cannot be 
 26 
 
402 PSORIASIS. 
 
 ordered. When used it should be well rubbed into the patches, 
 care being taken not to go beyond the limits of the affected 
 part. Lately these objectionable features have been overcome 
 to a great extent by combining it with a solution of gutta 
 percha — the liq. gutta percha of the pharmacopcea ; it can be 
 used in the same strength as the ointment. If many scales are 
 present they should be first removed and the solution then ap- 
 plied with a brush for a few minutes until a coating has been 
 produced ; this is to be repeated every two or three days, or as 
 often as the previous application tends to become loose and 
 separate. If an ointment is used it should be applied daily. 
 
 Chysarobin applied in either of the above methods will 
 sometimes cause a psoriasis patch which has resisted other 
 treatment to disappear in a few days. When it does act it acts 
 rapidly, but like all methods of treatment its effects are not 
 permanent, the psoriasis will return sooner or later. It is es- 
 pecially serviceable in old and obstinate cases ; if the skin is 
 irritable or if the eruption is acute in character, it should not 
 be employed. Neither should it be employed in psoriasis of 
 the face or scalp ; its use should not be continued after the dis- 
 appearance of the eruption. 
 
 If the eruption is general or acute in character, it is better to 
 rely on the internal treatment previously recommended. 
 
 The discoloration of the skin can be frequently rapidly re- 
 moved by the use of white precipatate ointment. 
 
 Some prefer goa powder to chysarobin on account of its 
 cheapness and better action (Behrend). 
 
 Pyrogallic acid was recommended by jarisch, as a substitute 
 for chysarobin because it does not discolor the clothing. It is 
 not painful and does not irritate the skin. 
 
 It acts slower, but sometimes very favorably ; it is used as an 
 ointment in combination with vaseline, i to 10, and applied in 
 the same manner as chysarobin ; it should only be applied 
 when the affection is limited and the patches small, as it is not 
 without danger to the system from absorption. Strangury and 
 excretion of dark colored, tar containing urine, nausea, etc,, as 
 by tar .poisoning are the result of absorption of too large a 
 
 
LICHEN RUBER. 403 
 
 quantity of the acid. On account of this danger in its use, it 
 is not to be ordered indiscriminately, if at all. 
 
 After the eruption has disappeared by any of the foregoing 
 means, we should endeavor to prevent a relapse, and thus, per- 
 haps, finally cause the skin to lose its tendency to take on the 
 psoriatic process upon slight irritations. The system should be 
 kept more or less under the influence of alkalies, malt liquors 
 should be avoided, dyspepsia prevented by the use of only 
 easily-digested articles of food, and non-irritating undercloth- 
 ing should be worn. If a relapse occurs, it should receive 
 prompt treatment. 
 
 LICHEN RUBER. 
 
 Definition — A chronic affection of the skin characterized by 
 the formation of discrete or confluent, pin-head or somewhat 
 larger sized, firm, acuminated, scaly, red papules, having a 
 tendency to invade the whole surface and thus produce maras- 
 mus and death. 
 
 Symptoms. — At the commencement of the disease the erup- 
 tion consists of isolated, slightly scaly, millet-sized papules, 
 which appear in two forms : in the one form they are dissemi- 
 nated, of a bright or brown-red color, very dense in consist- 
 ence, conical in shape, and the apex covered with a firmly 
 adherent, dry, white, scaly mass, which gives a rough feel to 
 the touch In the other form they are also disseminated and of 
 similar size as those of the preceding form, but are pale-red in 
 color, of a waxy shining appearance, the surface is smooth, 
 rounded, and has a small central depression. This central 
 depression corresponds to the orifice of a hair-follicle. The 
 eruption may appear on any part of the body, but generally 
 commences on the thorax or abdomen and afterward extends 
 to the extremities, genital regions, and other parts of the body. 
 The papules preserve their original dimensions during their* 
 entire existence, never increasing in size by growth at the 
 periphery, the extension of the eruption always depending upon 
 the formation of new papules of similar size and appearance to 
 
404 LICHEN RUBER. 
 
 the already existing ones. These new papules which are being 
 continuously formed arise either in an irregular manner upon 
 the skin, or in a row-like arrangement around or between ex- 
 isting papules. From the constant formation of new papules 
 the skin over a greater or less area becomes more and more 
 occupied by the eruption, until finally the whole area is covered 
 by them, and consequently neighboring papules come in con- 
 tact. When this last condition is present the eruption appears 
 as a connected, red, infiltrated, patch, covered with scales, and 
 having a dry, rough, uneven surface. At the periphery of such 
 an area or patch, characteristic individual papules are always 
 to be observed. 
 
 Instead of this irregular and diffuse manner of formation of 
 subsequent papules, they sometimes arise in the form of several 
 circles of closely seated papules around an already existing 
 one. Afterward the more centrally seated papules sink in, 
 become absorbed, and finally disappear, generally leaving the 
 skin pigmented and atrophied in spots. In this manner vari- 
 ously sized patches arise, the central part of which is pigmented 
 and contains atrophic depressions, while the periphery is 
 formed of one or more rows of wax-like, shining, umbilicated 
 papules. The umbilication of these papules depends upon the 
 retrograde process taking place in them, and is not a primary 
 condition, as in lichen planus. The papules never undergo any 
 changes except resolution from cessation of the formative pro- 
 cess, or atrophy from degeneration of the elements forming the 
 papule. 
 
 The irregular and diffuse form of extension of the eruption 
 is much more frequent than the aggregated and circular, and is 
 generally the only form present, but the other may also occur 
 exclusively, or, as occasionally happens, both forms are observed 
 on the same person ; in which case the former is met with prin- 
 cipally on the trunk, and the latter on the extremities. No 
 tnatter in which form the eruption spreads, or whether it is 
 accompanied by atrophy and pigmentation or not, it finally, as 
 a rule, extends so as to occupy the whole cutaneous surface, 
 when all signs of papule formation disappear, and the skin 
 
LICHEN RUBER. 405 
 
 appears everywhere reddened, thickened, furrowed, and covered 
 with numerous thin, whitish scales. The skin of the face 
 becomes dry, cracked, and scaly, the lower lids ectropic, the 
 upper lids droop. 
 
 The thickening of the skin is especially to be observed on the 
 palms of the hands and on the soles of the feet, where the 
 eruption does not appear as papules, but as great thickening of 
 the corneous layer. In consequence of this thickening the 
 fingers and toes stand out apart from each other, half bent, 
 and show, besides redness and infiltration, deep fissures and 
 rhagades. Muscular movement is interfered with, especially at 
 the joints, so that the patient can only with difficulty keep the 
 extremities fully extended or flexed, and consequently seeks a 
 position between these two conditions. When the eruption is 
 general over the whole surface the nails always become affected ; 
 they are greatly thickened from a deposit of nail-substance 
 from the bed of the nail, are of a yellowish-brown color, very 
 brittle, and have an uneven surface. If the deposit takes place 
 from the matrix alone, then the nail consists only of a short, 
 thin, brittle plate, which projects from the flesh. The nutrition 
 of the hairs at the seat of the eruption is always interfered 
 with, the hair becomes thinner, falls out, and is replaced by 
 lanugo hairs. The hair of the head, axillae, and pubis, situa- 
 tions where it grows strongest and is most deeply seated in the 
 skin, resists the process longer than that of the rest of the body. 
 The eruption appears without prodromal symptoms, and the 
 papules, if situated on tbe covered parts of the body, may 
 have developed without the knowledge of the individual 
 affected. During the first stage, and also subsequently, there 
 may be considerable itching present, but it bears no relation 
 to the intensity of the eruption, and is much less than that 
 accompanying many other skin affections. The general 
 nutrition of the body is not interfered with until the eruption 
 occupies a considerable area, when it suffers, and if the 
 entire cutaneous surface is occupied by the disease the system 
 becomes more and more affected, and after a few years the 
 person passes into a marasmic condition, from which he dies ; 
 
406 LICHEN RUBER. 
 
 unless he previously succumbs to complications depending 
 upon this marasmic condition, as pneumonia, pleurisy, intestinal 
 diseases, etc. This is the natural history of the disease, but 
 under proper treatment the eruption may disappear without 
 affecting the general constitution, or leaving traces of its pre- 
 vious existence upon the skin. When removed by treatment 
 the disease is not liable to return. If it is not very exten- 
 sive it may also disappear spontaneously. 
 
 Anatomy — Microscopical examination of a recent papule 
 shows the corneous layer to be greatly hypertrophied from an 
 increase in the size and number of the corneous elements. 
 The individual elements also show an aberration from the nor- 
 mal process of corneous transformation, as many of the cells 
 are incompletely transformed, as shown by the presence of 
 nuclei and their coloring with carmine. The nuclei are either 
 granular in appearance or vesicular in form (aufgeblseht). 
 These incompletely changed cells are seen especially about the 
 orifices of the sweat ducts and hair follicles. All the corneous 
 cells are much larger than normal and more polygonal in shape, 
 especially in the lower strata. The rete mucosum is hyper- 
 trophied in some places and normal in others. There is a 
 slight growth downward of the inter-papillary part, and 
 a more marked growth of the rest giving to the upper 
 part of this layer an uneven surface. The rete bodies 
 are of normal size and appearance. The granular and 
 stratum lucidum layers are not as distinct as usual. The 
 papillae are increased in size from the growth of the rete 
 downward ; their bloodvessels are somewhat dilated, and a few 
 emigrated corpuscles are present outside the vessels. There is 
 no appreciable oedema of the connective tissue, except that 
 some of the bloodvessels are dilated and a few emigrated cor- 
 puscles are found near them. The sweat glands are normal 
 except the duct in the corneous layer, the walls of which are 
 formed by large cells, some of which have vesicular nuclei. The 
 hair follicles are unaffected except at the orifice, where there 
 is a large collection of corneous cells. The muscle-bundles 
 are much hypertrophied. 
 
LICHEN RUBER. 407 
 
 In papules which have existed for a considerable length of 
 time there is a continuation of the processes observed in the 
 recent papule and afterward retrograde changes leading to 
 atrophy of the part, or there is a return to the normal condi- 
 tion by cessation of the abnormal keratosis process. The 
 corneous layer is much thicker than in recent papules, but the 
 character of its elements as regards size, shape and structure 
 remain the same. The rete is somewhat thicker than normal 
 and its upper surface is very uneven. This unevenness of the 
 surface depends upon the hypertrophied corneous layer, and as 
 this is greatest at the orifice of the sweat ducts and hair fol- 
 licles, it is here that the projections extend furthest downward. 
 The rete cells are not increased in size, but in many places are 
 
 Fig. 51. — Vertical section of a recent papule of Lichen Ruber, a, corneous 
 layer ; &, rete mucosum ; c, corium ; d, unstriped muscle-bundles cut transversely ; 
 e, sweat-ducts ; /, hair-follicle. The section includes normal skin at the periphery. 
 
 small from pressure by the corneous layer. The cutis papillae 
 are but slightly enlarged, the papillary bloodvessels somewhat 
 dilated, and there are a few round cells outside the vessels. 
 The corium is normal except in the neighborhood of the 
 bloodvessels. The majority of the bloodvessels are dilated, 
 and scattered lymph corpuscles are seen around them. The 
 muscles are hypertrophied. Some hair follicles show hyper- 
 trophy of the external hair sheath while others are normal. 
 
 In the center of old papules a retrograde process often oc- 
 curs, consisting in a degeneration of the rete and destruction 
 of a portion of the underlying corium. 
 
 Lichen ruber is therefore a para-typical keratosis, as shown 
 by the digression which occurs from the normal process of 
 
408 
 
 LICHEN RUBER. 
 
 transformation of the corneous cells as regards size, shape, 
 structure, chemical constitution, and manner of being cast off. 
 Upon these grounds I have placed it among the hypertrophies 
 of the epidermis and not among the inflammatory diseases, as 
 done by the majority of writers. 
 
 Fig. 52. — Vertical Section of a papule of Lichen Ruber which had existed sev- 
 eral weeks. (More highly magnified than Fig. 50.) «, corneous layer ; 3, rete 
 mucosum ; c, region of sweat-duct orifice ; d, corium ; e, unstriped muscle-bun- 
 dle. (From the lumbar region.) 
 
 Etiology. — The cause of the affection is not known. In all 
 of Hebra's cases the eruption appeared upon previously 
 healthy persons. It is more frequent in males than females, 
 and appears generally between the ages of ten and forty. It 
 is neither hereditary nor contagious. Direct irritation of the 
 skin in the neighborhood of papules causes a more rapid de- 
 velopment of new papules in that situation. 
 
 Diagnosis. — When the eruption is disseminated it may be 
 confounded with psoriasis punctata, eczema papulosum, lichen 
 planus, and the papular syphiloderm. In psoriasis the spots 
 soon increase in size by peripheral growth and form scaly 
 patches, which never occurs in lichen ruber. As some of these 
 
LICHEN RUBER. 409 
 
 larger patches are always present the diagnosis is easy. In 
 papular eczema, the papules either rapidly retrograde and dis- 
 appear, or some of them become vesicles. The whitish scales 
 and dark color of lichen are also absent. In the papular 
 syphiloderm the papules increase in size by peripheral growth, 
 they have very few, if any, scales on their summit, they appear 
 rapidly over the whole body, and disappear by degeneration, 
 leaving atrophic spots. When the lichen ruber is universal it 
 may resemble psoriasis universalis, eczema chronicum squa- 
 mosum, or pityriasis rubra universalis. In psoriasis the scal- 
 ing is very considerable and there are generally places of 
 healthy skin from which the eruption has already disappeared. 
 On the extensor surfaces the scales are very thick and easily 
 detached ; in lichen they are finer and more adherent. In 
 psoriasis, the palms of the hands and soles of the feet almost 
 invariably escape, while in lichen they are much thickened. In 
 chronic eczema there are always some situations where the 
 symptoms of acute eczema vesicles are present. In pityriasis 
 rubra universalis there is no inflammatory thickening of the 
 skin and the scaling which is always extensive, consists of very 
 large thin -or fine branny scales. There are no papules present 
 at any time in this disease. 
 
 Prognosis. — The disease, if allowed its natural course, in- 
 variably proves fatal, as shown by the first fourteen cases ob- 
 served by Hebra. When treated by arsenic in the proper 
 manner, the eruption can always be removed, unless the person 
 is already in a very advanced stage Of marasmus. 
 
 Treatment. — With the exception of arsenic there is no sub- 
 stance, applied externally or given internally, which is known 
 to have any specially favorable effect upon the course of the 
 eruption. Arsenic, however, may be regarded as almost a 
 specific, if given in sufficiently large doses and its use continued 
 long enough. The dose should be at first small and gradually 
 increased every four or five days until the maximum dose 
 which can be well borne by the individual is reached, and 
 this quantity is then continued until the eruption has disap- 
 peared, when a small quantity is to be given for three or four 
 
410 VERRUCA. 
 
 months longer. To abate the itching, alkaline baths or oint- 
 ments containing carbolic acid, salicylic acid, oxide of zinc etc. 
 may be employed the same as for itching in other affections. 
 The general nutrition of the body should be attended to. A 
 starch diet with plenty of milk is probably to be preferred. 
 
 KERATOSES WITH PAPILLARY HYPERTROPHY. 
 
 Here not only the epidermis, but the papillae also are hypertro- 
 phied. This was probably the case to a small degree in cornu 
 cutaneum — which, indeed, bears a very close relationship to the 
 first affection we shall consider under this head — verruca. 
 
 VERRUCA. 
 
 Syn. — Wart. 
 
 Definition. — Verruca consists of a localized hypertrophy of 
 the papillae and of the superincumbent epidermis, forming 
 more or less prominent, circumscribed, hard or soft papillary 
 elevations of the skin. 
 
 Symptoms. — The papillary elevations of skin which are com- 
 monly called warts are always acquired formations ; the various 
 pigmentary and hairy growths described by Hebra and Kaposi 
 under the name of verruca congenita belonging more properly 
 to the naevi, where they will be considered under the title of 
 n. verrucosus and n. pigmentosus. 
 
 Warts appear under a variety of forms, in accordance with 
 their locations and the accidents of their growth. The com- 
 monest of all are the ordinary warts, or verrucse vulgares. 
 These occur in by far the greater number of cases upon the 
 hands, though they are sometimes seen on the feet and upon 
 the face and head. They almost always appear in young in- 
 dividuals, in males more frequently than in females ; they come 
 spontaneously, grow to a certain size, remain stationary for a 
 longer or shorter time, and usually eventually disappear of 
 themselves. They consist of small circumscribed growths 
 
VERRUCA. 4 H 
 
 seated firmly by a broad base upon the skin, and rarely exceed 
 a large pea or a bean in size. Sometimes a number of them 
 situated close together become confluent and form larger 
 masses. They may. be soft in consistence, but are usually 
 hard and horny upon the surface. When young they are 
 smooth, but later the drying and splitting of the horny layer 
 gives them a roughened or even stubby brush-like appearance 
 at the apex. Their color is usually like that of the surround- 
 ing skin, though they may be yellowish-brown, or even blackish 
 at times ; the darker shades being due to the accumulation of 
 dirt in the interstices of the horny covering. They are not 
 sensitive. They may appear singly, but often come in groups, 
 or rather in crops ; some individuals exhibiting a marked ten- 
 dency to their formation. Each wart persists for a varying 
 time — perhaps for months or years — and then disappears spon- 
 taneously. Occasionally they last for life. There is absolutely 
 no foundation for the popular belief in their contagiousness, 
 nor in the ordinary ascribed causes. A local mechanical irri- 
 tation is probably the main factor in their production. 
 
 Another and rarer variety of wart is the kind that is seen in 
 old people, and usually upon the back, and which is known 
 as verruca senilis, or, from their shape, v. plana. They occur 
 upon the trunk — sometimes upon the face or arms, as flat 
 papillary elevations varying in size from a small pea to a finger- 
 nail. Their surface is soft, fairly smooth and often of a dark 
 brown or blackish color ; hence another name by which they 
 are known — keratosis pigmentosa. They may become quite 
 large and sometimes appear in numbers upon the face ; they 
 are an expression of the well-known tendency of the epithelial 
 tissues to hypertrophy during later life. They consist mainly 
 of hypertrophied epidermis, the papillae being but slightly 
 affected. 
 
 Filiform warts. — V. filiformis are commonly seen upon the 
 face, eyelids and neck. They are generally single, and consist 
 of small, thread like or sessile tumors, usually not longer than 
 an eighth of an inch. 
 
 A wart very like the plana form is found upon the scalp of 
 
412 VERRUCA. 
 
 certain individuals, and consists of a flat, broad, slightly 
 elevated papillary formation, perhaps as large as a finger-nail. 
 They may be single or multiple. When warty growths remain 
 unchanged for long periods of time they are called v. perstans j 
 when they fall off from time to time and are succeeded by 
 others the affection is designated v. caduca. 
 
 There remains for consideration a variety of wart which is 
 of considerable interest in an etiological and diagnostic point 
 of view, namely the verruca acuminata, or venereal wart — or 
 pointed wart. The affection rejoices in quite a variety of 
 names, amongst which are, besides those already mentioned, 
 the following : Condylomata acuminata, verruca elevata, 
 cauliflower excrescence, moist or fig wart, etc., etc. They form 
 the great mass of the growths commonly called venereal warts, 
 but they are not venereal in any thing save that they occur 
 around the genitals. They consist of pointed, club-shaped or ir- 
 regular, raspberry-like elevations, situated upon the normal skin 
 or mucous membrane in the vicinity of the male and female 
 genital organs. In color they are bright red or even purple, in 
 accordance with the vascularity of the part. Their surface is 
 soft and moist ; their consistency is succulent. They may oc- 
 cur as isolated pedunculated tumors or as irregular, more or less 
 solid masses of vegetations. They are most commonly found 
 upon the penis, springing from the glans and sulcus, and the 
 inner surface of the prepuce ; in the female they are oftenest 
 found upon the inner surface of the labia and in the vagina. 
 They often spread from these situations on to the outer surface 
 of the penis and labia ; in which case they will not be soft, 
 but are dry and hard — more like ordinary warts. In the 
 female they sometimes cover the entire perinasum, and are found 
 around the anus and on the rectal mucous membrane as far as 
 the external sphincter. They have also been seen in the mouth, 
 axilla, umbilicus and between the toes. When they occur 
 upon the moist genitalia they are usually covered with yellow- 
 ish, decomposing pus, of a most offensive odor. Blenorrhcea 
 is almost always present, and more or less inflammation of the 
 skin upon which the growths are situated results from the irri- 
 
VERRUCA. 413 
 
 tation. In neglected cases in females — and it is in these cases 
 that the best examples of venereal warts are found — the large, 
 fungating vivid red masses covering the labia and perinaeum, 
 bathed in yellow decomposed pus from the intense vaginitis 
 and gonorrhoea form a very disagreeable condition for the 
 patient. 
 
 Venereal warts grow quite rapidly ; they may become very 
 large in a few weeks. Though they sometimes occur among 
 the better classes, they do not usually attain any size in those 
 who pay due attention to their personal cleanliness. 
 
 Anatomy. — In most warts the essential pathological change is 
 a hypertrophy of the papillae and the epidermis. In the ordi- 
 nary cutaneous wart we find one or more greatly enlarged 
 papillae, with a capillary loop running up through the centre. 
 The rete cells are immensely hypertrophied, and many of them 
 are in a state of active proliferation. Above this there is a 
 more or less thick layer of densely packed corneous cells. 
 
 The filiform wart frequently found upon the delicate skin of 
 the breast, the neck, and the eyelids, does not seem to involve 
 the papillae. It consists of a small outgrowth of connective 
 tissue from the depths of the skin, carrying a bloodvessel in its 
 center. Anatomically, therefore, it approximates very closely 
 to fibroma molluscum. 
 
 The venereal warts consist of hypertrophic papillae, but are 
 largely formed of new connective tissue cells. Usually a bundle 
 of papillae lying side by side are affected; hence their spread- 
 ing, cauliflower-like mode of growth. As they are usually kept 
 moist and warm, the horny layer is generally wanting; the cells 
 of the mucus layer are very numerous and active; the growths 
 are delicate, bleed easily, and grow rapidly. The presence of 
 more or less cell-infiltration explains the presence of connective 
 tissue in them when of long standing. 
 
 Etiology. — We do not know what influences the production of 
 these growths. They are of frequent occurrence in children, 
 and especially in those of scrofulous tendency. 
 
 Venereal warts are always caused, primarily, by the initiation 
 of a gonorrhceal discharge, though they may persist long after 
 
4H VERRUCA. 
 
 it has stopped. They are contagious only in so much that one 
 of them will cause the development of a similar growth in any 
 contiguous surface; but no real transmission has ever been ob- 
 served. Dirt and neglect have much to do with their develop, 
 ment. 
 
 Diagnosis. — This is always easy, and requires no special 
 description beyond that given in the symptoms. . 
 
 Prognosis. — Is good. Repeated applications or excisions 
 may be necessary. Large ones should be removed piecemeal 
 to avoid excessive haemorrhage; as the soft venereal warts 
 bleed freely when cut. 
 
 Treatment. — These excrescences may be removed in various 
 ways. Excision is as good a method as any, care being taken 
 either to remove the papillae at the base or to cauterize it after the 
 mass is cut off. The softer ones may be snipped off with a 
 pair of scissors, or scraped out with the dermal curette. If they 
 are very vascular it may be preferable to use the galvano- 
 cautery, or the wire ecrasure, or an elastic ligature. The ordi- 
 nary warts may be removed without any such " operative " 
 procedure as is recommended above. The acid nitrate of 
 mercury, any of the mineral acids, chloride of zinc, caustic 
 potassa, nitrate of silver, or even tincture of the chloride of 
 iron will do it. Before any of these are used, however, the 
 hard surface of the wart should be softened by poulticing or by 
 alkaline washes, and the surrounding healthy skin protected by 
 wax, or oil, or plaster, etc. 
 
 For the venereal warts, nitric, sulphuric, hydrochloric, 
 chromic, or carbolic acids are usually sufficient. Sometimes 
 merely keeping the surfaces dry and clean, and using calomel 
 or lycopodium, will cause them to shrivel up and disappear. 
 Alum or acetate of lead lotions will do the same. If peduncu- 
 lated the base should be tied with a thread, when the wart falls 
 off in a few days ; the base can then be touched with a 
 caustic. 
 
 Nitric acid is the best application for large non-peduncula<ted 
 warts. 
 
ICHTHYOSIS. 415 
 
 ICHTHYOSIS. 
 
 Synony?ns. — Fish- skin disease; Xeroderma. 
 
 Definition. — Ichthyosis is a chronic, hypertrophic, hereditary, 
 general or local disease of the skin, characterized by dryness or 
 scaliness of the integument. 
 
 Sympto7iis. — Ichthyosis is rather to be regarded as a deform- 
 ity than as a disease, in the strict sense of the word. It de- 
 pends upon an innate tendency of the skin of certain persons 
 toward an excessive formation of epidermis. The entire cu- 
 taneous surface may exhibit this peculiarity, in which case we 
 call the affection ichthyosis diffusa j or only certain portions of it 
 may show it, giving us ichthyosis follicularis. The latter variety 
 is very rare. Still a third form is the ichthyosis congenita. 
 
 The diffuse ichthyosis, which is practically the only variety 
 with which we have to deal, is found in two forms, differing 
 from one another, however, simply in degree. The milder 
 cases are designated ichthyosis simplex, and the severe ones 
 ichthyosis hystrix. The appearances presented by these two 
 forms vary to some extent, and they merit a separate descrip- 
 tion. 
 
 1. Ichthyosis simplex. — The very mildest form of the affec- 
 tion has been designated xeroderma by Wilson and Tilbury 
 Fox. In it, the integument is dry and harsh, somewhat thick- 
 ened, with the natural furrows and marking moderately exag- 
 gerated. Actual scaling does not take place, only a slight fur- 
 furaceous exfoliation. In a somewhat more marked form, which 
 is the usual state in which we encounter the disease, the forma- 
 tion of the corneous epithelium is more rapid, and it accumu- 
 lates upon the skin in the form of dry scales and plates. They 
 correspond in their shape and direction to the normal lines and 
 furrows of the part they cover, forming upon the extremities 
 small polygonal or diamond-shaped plates; they may be very 
 small, thin, and furfuraceous, or they may be thick and horny. 
 In the lighter forms the scales are white and pearly, but if very 
 thickly developed they become more or less dark in color, 
 
416 ICHTHYOSIS. 
 
 sometimes even olive green or greenish black. This coloration 
 is not due entirely to the presence upon and among the scales 
 of extraneous matter, dirt, etc., alone, for the subjacent skin 
 itself becomes darker in color, and pigment granules have been 
 demonstrated among the scales. They are generally rather 
 firmly attached to the deeper tissues, but can usually be re- 
 moved from the surface without causing bleeding. The 
 roughened and dry integument covered with polygonal 
 scales bears considerable resemblance in feeling to the skin of 
 a serpent or a fish ; hence the name of the disease. Frequent 
 bathing, etc., tends to prevent the accumulation of scales; but 
 if left undisturbed they grow in size, and may form laminae of 
 considerable thickness. 
 
 Ichthyosis Hystrix — In this, the most advanced stage of the 
 disease, the corneous cells accumulate until they form various 
 sized, rough, heaped-up masses of epidermal tissue. Horny 
 papules and large irregular plates appear, in which, however, 
 the normal lines and furrows of the skin are not only pre- 
 served, but intensified. This variety is not likely to be so uni- 
 formly developed as the other ; it is most often seen as 
 solid, warty, corrugated plates or streaks upon one or a num- 
 ber of portions of the body. In some cases there is marked 
 papillary outgrowth, and spines several lines in length may 
 stick out from the tuberous mass. From their resemblance to 
 the quills of a porcupine comes the designation hystrix. The 
 patches are yellowish, brownish or greenish in color ; the older 
 they are, the darker they become. The epidermic desquama- 
 tion is marked, and the patient leaves piles of dried scales in his 
 clothing and bedding. 
 
 Ichthyosis of either variety may be general, spreading over 
 almost the entire surface of the skin, or localized ; but it 
 affects by preference certain parts, and is more advanced in 
 these parts even when the eruption is diffuse. Those portions 
 are the skin covering the extensor aspects of the limbs and 
 joints, situations where the integument is normally thick. In 
 mild cases the disease usually shows itself first upon the skin 
 covering the knees and elbows. The opposite surfaces of 
 
ICHTHYOSIS. 417 
 
 these points are rarely affected, and the contrast between the 
 two is often striking. The backs of the hands and feet, the 
 skin of the thighs and shoulders, as well as the trunk, often 
 exhibit the malady to a marked degree. As a general thing, 
 even in the most advanced and diffuse cases, certain parts 
 escape ; these are the face, the palms and soles, and the glans 
 penis and prepuce. Nevertheless cases have been seen in which 
 the palms and soles have not only been affected, but have formed 
 the chief seat of the disease, and in any case we generally find 
 the extremities cold and blue. 
 
 In almost all instances, no sign of the disease is visible at 
 birth. The child appears to be perfectly healthy, and it is not 
 until the end of the second month at the earliest that it first 
 appears ; often it remains latent until the second year. It 
 begins gradually, being first noticed as a slight roughness and 
 dryness of the skin at its points of election — viz. : the extensor 
 surfaces of the limbs, and especially of the elbows and knees, 
 and whatever the grade of the disease it is at those points, as we 
 have seen, that it is always most markedly developed. In many 
 cases a noticeable advance in the condition occurs at the period 
 of puberty. Once having reached its height, the course of the 
 disease is chronic, and but little subject to change. It lasts for 
 life — being always better in summer, when the increased activ- 
 ity of the sweat-glands macerates and renders easy of removal 
 the superabundant epidermis ; but the malady speedily re- 
 turns to its old state when the cold weather sets in. In some 
 cases a regular "moulting " has been observed; during the 
 summer the epidermic plates and scales fall off, leaving the 
 skin for a short time in an almost normal condition. The 
 same thing has been observed when ichthyotic patients are at- 
 tacked by severe general diseases ; the only cases in which a 
 complete cure has occurred are two reported by Hebra, in 
 which the deformity completely vanished after attacks of one 
 of the exanthematic fevers. 
 
 Patients suffering from ichthyosis usually enjoy excellent gen- 
 eral health ; even in its most advanced degree it does not seem 
 to exercise any deleterious influence upon the organism at large. 
 27 
 
41 8 ICHTHYOSIS. 
 
 3. Ichthyosis congenita. — In a certain small proportion of 
 cases, ichthyosis begins as an intra-uterine affection, and is 
 present in marked degree at the time of birth. Whilst the 
 pathological process is exactly the same as in the more 
 ordinary forms of the disease, the appearance and course of 
 this variety of the malady differs from them in many re- 
 spects. 
 
 Such children are usually born before the ninth month, and 
 are correspondingly small and puny. Their entire body is 
 found covered with horny plates and scales, varying in size 
 from a line to half an inch or more. Upon the trunk the deep 
 furrows that divide them from one another run transversely ; 
 upon the limbs they are disposed longitudinally, save at the 
 flexures of the joints. The armor-like skin seems to have 
 entirely lost its elasticity, and is split and fissured as the foetus 
 has grown. The lips are wanting and the horny plated skin of 
 the chin ends in the alveolar processes. Eyelids and external 
 ears are also wanting. The fingers and toes are shortened and 
 bent by the unyielding skin. 
 
 As might be supposed, these monstrosities, if born alive, usually 
 live but a few days. Nine days is the longest period of post 
 natal life, and occurred in a case recorded by Jahr. The ex- 
 tensive alterations in the skin an organ even more important 
 in infant than in adult life, together with the impossibility of 
 suckling, from the absence of the lips, accounts for the 
 uniformly fatal issue of these cases. 
 
 Anatofny. — According to Neumann, the papillae are enlarged, 
 their bloodvessels dilated, the cutis dense, the lumen of the 
 veins narrowed by growth from the interior, the corneous layer 
 thickened, consisting of superimposed lamellae, and the rete 
 between the papillae much hypertrophied. The hair follicles 
 are lengthened and contain lanugo hairs, the external root- 
 sheath hypertrophied, the sebaceous glands dilated to a cyst 
 form, the sweat glands dilated and the subcutaneous fat dimin- 
 ished. In severe cases the hair follicles are absent, and 
 the epidermis consists of yellowish- brown to dark-brown 
 lamellae. 
 
ICHTHYOSIS. 
 
 419 
 
 According to Barensprung, the papillae are enlarged, pig- 
 mented, the vessels dilated, the follicles diminished in number, 
 and those present but very small, the sweat glands unaffected, 
 and a new growth in the subcutaneous fat tissue. 
 
 G. Simon found the epidermis, cutis and papillae thickened 
 and the glands unchanged. In a case reported by Kaposi, the 
 sebaceous and sweat glands were absent, the hair follicles were 
 normal, the papillae enlarged, the bloodvessels dilated and there 
 were round cells in the cutis. 
 
 In a well marked case of ichthyosis I found the corneous 
 layer greatly hypertrophied and consisting of thick superim- 
 posed lamellae. The upper three -fourths of the corneous layer 
 was frequently separated from the lower part by narrow or 
 broader clear spaces. The rete was unchanged as far as could 
 be judged ; the papillae and their bloodvessels were slightly 
 
 Fig. 53. — Section ot ichthyotic skin, a ana b, corneous layer with space between , 
 c, rete ; d, upper part of corium ; e, sweat glands ; /, orifice of sebaceous 
 gland ; g, sebaceous gland proper ; h, slight round cell infiltration. 
 
420 ICHTHYOSIS. 
 
 enlarged, and a few round cells were observed in the papillae 
 and upper part of the corium. The subcutaneous fibrous con- 
 nective tissues were normal. The sweat glands were plentiful 
 and of normal appearance and size. The hair follicles were 
 unchanged. The secreting portions of the sebaceous glands 
 were very small and undeveloped ; instead of two or more as- 
 cini there was only a single small undeveloped gland struc- 
 ture. In Fig. 53 is represented a section from this case. 
 
 In ichthyosis, then, different morbid conditions have been 
 found in different cases. All agree that the corneous layer is 
 hypertrophied and otherwise unchanged. Although the skin is 
 dry the sweat glands are probably usually well developed. 
 The dry condition of the skin depends upon the amount of 
 scales and perhaps deficiency of sebaceous matter. The inflam- 
 matory condition described by some as existing can not be an 
 integral part of the ichthyosis. 
 
 Etiology. — Ichthyosis depends upon a congenital predisposi- 
 tion of the skin to the disease. In almost every case it may be 
 clearly shown to be an hereditary affection. One of the pa- 
 rents or grandparents has had it, perhaps only in a slight form. 
 It is usual for the father to transmit it to the male children only, 
 and the mother to the females ; but there are many instances 
 of transmission from father to daughter, and from mother to 
 son. When there are several children, more than one are usually 
 affected. 
 
 It has been claimed by some authorities that race and cli- 
 mate are important factors in the etiology of the disease, and 
 they point to the fact of its being endemic in certain portions 
 of the world as proof. Thus it is very common in Par- 
 aguay, and in the Moluccas at least five per cent, of the pop- 
 ulation suffer from it. Nevertheless, it has not been proved 
 that either race or climate have any thing to do with it ; for all 
 hereditary diseases tend to spread in isolated regions where 
 " interbreeding is the rule." 
 
 We know nothing at all of the real cause of the malady. 
 Heredity is not so well proven a factor in the congenital form 
 of the disease. 
 
SCLERODERMA. 42 I 
 
 Prognosis. — As regards the removal of this condition, the 
 prognosis is unfavorable ; the scales continue to form in spite of 
 all treatment. Mild cases improve sometimes with advancing 
 age. The disease has no effect upon the general health. 
 
 Treatme7it. — Internal treatment seems to be of little avail ; 
 with the exception perhaps of oily substances. I have seen 
 linseed oil do some good occasionally. It should be given in- 
 ternally and applied externally also. Arsenic, jaborandi, etc., 
 have no effect upon the cutaneous condition. 
 
 The excess of epidermis can be removed by frequent warm 
 baths containing soda or common salt, or by washing with a 
 strong soap and subsequently rubbing in olive oil, cod liver 
 oil or linseed oil. The water removes the superabundant epi- 
 thelium and the oil keeps the skin moist and pliable. As this 
 procedure is not curative, but simply removes a portion of the 
 abnormal layer, it must be repeated as often as the scales 
 show themselves. 
 
 In ichthyosis hystrix it may be necessary, in addition to the 
 above described means, to employ caustics or the knife for the 
 removal of the horny patches which form. 
 
 SCLERODERMA. 
 
 Syn. — Scleroma ; s. adultorum ; scleriasis ; dermatoscle- 
 rosis ; cutis tensa chronica ; sclerosis corii. 
 
 Definition. — Scleroderma is a chronic non-inflammatory af- 
 fection of the skin, characterized by a diffuse or circumscribed, 
 pigmented, rigid, hide-bound and shortened condition of the 
 integument. 
 
 History. — Scleroderma of adults is a disease of great variety, 
 and one concerning which our ideas are by no means settled. 
 Alibert, in 1817, was the first who unmistakably described the 
 affection. Since that time a considerable number of cases have 
 been reported, numbering perhaps as many as 80 in all. In 
 spite, however, of extensive studies by competent observers, it 
 is doubtful if to-day we possess any more knowledge about it 
 than a fairly exact appreciation of its external symptomatology. 
 
422 SCLERODERMA. 
 
 Its- etiology, pathology, and certainly its treatment, are prob- 
 lems for the future to elucidate. 
 
 Symptoms. — Scleroderma sets in, as a rule, without either 
 general or local subjective phenomena. In exceptional cases 
 chilliness, and slight fever, numbness or formication of the part 
 is noticed ; but usually there is nothing to draw the patient's 
 attention to the changes beginning in his skin until he appre- 
 ciates a slight stiffness or rigidity of some portion of the integ- 
 ument. This rigidity increases in extent and severity with 
 greater or less rapidity, until the disease has attained its full 
 extent. It is often months or years before that point is 
 reached. 
 
 The sclerosis of the skii\ may occur in localized spots, per- 
 haps as small as a silver dollar ; or it may consist of a diffused 
 and even thickening of the entire integument ; and between 
 these two extremes various extents of skin may be involved. 
 The distinction, therefore, between partial sclerema — sclerema 
 en placard, and universal sclerema, is one of extent only ; the 
 process is identical in both cases. Cases in which more than 
 half of the cutaneous surface is affected are called s. univer- 
 salis. 
 
 The skin over the affected area, be it large or small, is thick, 
 stiff, hard, brawny, or even wooden in feeling to the touch. It 
 seems cold, and Thirial aptly compares it to the feeling im- 
 parted by the skin of a frozen corpse. Its surface is smooth 
 and hard, sometimes slightly desquamating ; it cannot be 
 pinched up into folds, nor does pressure with the finger indent 
 it. As the disease advances the subcutaneous connective tissue, 
 fasciae and muscles become firmly bound to the skin. 
 
 The sclerosed tissue passes imperceptibly into the healthy 
 skin ; there is no line of demarcation, though there may be a 
 faintly defined hyperaemic area just outside it. It may be 
 slightly raised or level with the skin, or even sunken. Its sur- 
 face is usually smooth ; but in some cases more or less papil- 
 lary hypertrophy, resembling a localized ichthyosis, is present. 
 Its color may be dull-white and waxy, or white and shining ; 
 but it is very often pigmented either a diffuse reddish-brown 
 
SCLERODERMA. 423 
 
 or bronze, or a more or less extensive yellowish or brownish 
 spotting, intermingled with dull white patches. In all cases, 
 as the disease advances, the subjective disturbances become 
 marked. The patient feels hide-bound, his skin literally be- 
 comes too small for him ; for whilst in the early stages the 
 skin is increased in volume, later, a stage of atrophy sets in, and 
 the integument is actually shortened. The joints may become 
 fixed in a semi-flexed condition. The face appears frozen ; the 
 hardened features no longer reflect the emotions of the mind ; 
 the orifices of the mouth and eyes are diminished in size, and 
 can hardly be opened, and a case is reported by Fagge in 
 which the patient actually starved to death from inability to 
 chew his food. The immobility of the fingers may render the 
 patient incapable of earning his living. The mucous mem- 
 branes near the integument, as that of the mouth and vagina, may 
 show the same hard, thickened, pigmented patches of sclerotic 
 tissue. The temperature of the sclerosed skin may be normal, 
 bat is often depressed a degree or two. The sense of touch is 
 usually unaltered over it ; none of the secretory and other 
 functions of the integument seem to be affected. The part is 
 just as liable as the normal skin to inflammation when irritated, 
 and erysipelas, acne, variola and zoster have been observed 
 upon it. As a rule, the general health remains good, though 
 rheumatism and neuralgia have been noted in some cases. 
 
 The malady is usually symmetrical, and any part of the body 
 may be attacked ; it most often occurs upon the neck, face, 
 shoulders, back, and arms. 
 
 The process has reached its height when the sclerosed 
 patch (plaque) is fully developed. The further course of the 
 disease varies in different cases. In a certain number of in- 
 stances the affected part now undergoes a process of involu- 
 tion. In the course of from a few days to many months the 
 hard, board-like feeling gradually disappears ; the skin regains 
 its normal size and pliability, and returns to its usual state. 
 Nevertheless, though this is the case with individual spots, 
 the process as a whole does not usually disappear. New 
 patches replace the old ones, or spots already healed are again 
 
424 SCLERODERMA. 
 
 attacked. Eventually, in some cases sooner, in others later, 
 the atrophic stage sets in. 
 
 In this stage an atrophy replaces the former hypertrophy, 
 an atrophy in which not only the skin, but the subjacent tissues 
 participate. The integument becomes thin, parchment like, 
 dull white or rosy or irregularly pigmented ; it is even tenser 
 and more stretched than it was during the first stage. Under 
 the ever-increasing pressure, fat and muscle gradually disap- 
 pear, until the limbs seem to consist solely of bone covered 
 with tightly adherent skin. There occur ulcerations of the 
 tense skin over the flexor surfaces of the joints, pseudo- 
 anchylosis, etc. A return to the normal condition is now no 
 longer possible. 
 
 Thus the disease varies from month to month, and from 
 year to year ; leaving one surface to attack another, and in but 
 few cases going on to a complete cure. Most often the total 
 affected area slowly but surely increases. In the early stages, 
 for years the general health may remain good ; but then comes 
 a time when, from the neuralgic and rheumatic pain, the want 
 of sleep, the physical depression, etc., a state of general maras- 
 mus sets in. Nevertheless, in all the recorded fatal cases the 
 patient has died from some intercurrent disease— Bright's, 
 phthisis, pneumonia, etc. 
 
 A number of cases have been reported in which patches of 
 morphcea accompanied the disease under consideration ; and 
 indeed morphcea offers many points of resemblance with par- 
 tial sclerema. Schwimmer asserts that morphcea localis and 
 limited scleroderma are one and the same thing. 
 
 Anatomy. — The immediate pathological process in the skin 
 consists, according to many observations, made both upon the 
 living and the dead subject, in an increase and crowding to- 
 gether of the connective tissue of the skin. The number of 
 elastic fibres in the tissue is increased. The fat is atrophied, 
 and its place is occupied by the new tissue ; and the thickened 
 skin rests directly upon the bones. The papillae are unaltered, 
 save when the warty condition before mentioned occurs ; then 
 they are hypertrophied. The corium and the subcutaneous 
 
 
SCLERODERMA. 425 
 
 tissue are the parts chiefly affected. Secondary pathological 
 effects are the increased amount of pigment in the rete or 
 corium, the hypertrophy of the muscular fibres, dilatation of 
 the sweat glands, etc. The vessels are diminished in calibre by 
 the connective tissue that presses upon them. The perivascu- 
 lar lymph spaces are crowded with cells, in some cases forming 
 close heaps situated between the vessel and the surrounding 
 connective tissue. 
 
 In the atrophic stage the new tissue shrinks, and largely dis- 
 appears. The glandular structures also become deformed and 
 atrophied. 
 
 In conclusion, we may say that the disease seems to consist 
 of a diffuse or circumscribed connective tissue hypertrophy and 
 new growth of the skin, ending in resolution, or in atrophy, and 
 due to some unknown nervous disturbance. 
 
 Etiology. — There is but little to be said in regard to the eti- 
 ology of scleroderma. We know that it occurs at all ages — 
 though most often during adult life ; and that for some unex- 
 plained reason women are far more liable to it than are men. 
 Violent nervous shock — as well as the usually appealed to agent, 
 exposure to cold, has been regarded as influential. In many 
 cases an attack of rheumatism has been noted to precede the 
 onset of the disease. 
 
 Heller, basing his conclusions upon the post-mortem findings 
 of a single case, has affirmed that a closure of the thoracic 
 duct or other lymphatic canals and a backward pressure and 
 stagnation in the lymph in the ducts was the cause of the mal- 
 ady. The constancy of that lesion has not been verified by 
 subsequent observers. Nor do the locations of the individual 
 scleremic patches correspond to the distributions of the branches 
 of the lymph channels. And, further, lymph stasis causes 
 quite another disease — namely pachyderma. 
 
 A variety of lesions in the central and peripheral nervous 
 system, and in the sympathetic system, have also been observed 
 in individual cases, such as sclerosis of the anterior horns, fatty 
 atrophy of peripheral nerves. But their great variety and their 
 inconstancy must cause us to regard them as accidental, and 
 
426 SCLERODERMA. 
 
 not as essential lesions. In default, therefore, of a better ex- 
 planation, we must regard scleroderma as a trophoneurosis — ■ 
 an opinion which is strengthened by the fact that it undoubtedly 
 has occurred after violent mental emotions, and, that in a case 
 of Eulenberg's, progressive facial atrophy (an acute tropho- 
 neurosis) occurred together with scleroderma of that locality. 
 
 Diagnosis. — The diagnosis of scleroderma is usually not dif- 
 ficult, as the solid, white or pigmented, hard, frozen-corpse-like 
 feel of the otherwise unaltered skin should be sufficient to re- » 
 veal it. Two affections only can be confounded with it. The 
 first is the true keloid — which, however, is always very limited 
 and is not nearly so stiff and immovable. More difficult, in 
 many cases, will be the diagnosis between scleroderma and 
 morphcea. Many authorities — especially those of the English 
 school — regard the latter disease as a localized scleroderma ; and 
 it must be admitted that in many cases the distinction is difficult 
 to make, and that the two diseases may possibly be closely 
 connected with one another. Scleroderma is usually extensive, 
 and may be universal in its distribution, and is not limited by 
 any distinct line of demarcation ; morphcea appears in small 
 areas, and has a distinct boundary line marked by a pinkish bor- 
 der. In scleroderma the skin is hard and stiff from the begin- 
 ning — it appears as if frozen, but is otherwise unaltered ; mor- 
 phcea commences with hyperemia, is usually softer, and the skin 
 can be raised in folds. Scleroderma tends to be symmetrical, 
 and comes on without any subjective sensations ; morphcea 
 usually occurs on one side, begins with marked pain and ting- 
 ling, and moreover usually corresponds to definite nerve-tracts. 
 Finally, the striae atrophias and enlarged vessels are absent in 
 scleroderma ; nor does the disease have so universally a 
 chronic course as does morphcea. 
 
 Prognosis. — Is unfavorable upon the whole. As a usual 
 thing, it goes on until the stadium atrophicum is reached, and 
 contractions, immobility of parts, ulcerations, etc., occur. 
 Meanwhile, the patients usually die of intercurrent diseases. 
 Recovery sometimes occurs, but is only to be hoped for during 
 the hypertrophic stage. 
 
SCLEREMA NEONATORUM. 427 
 
 Treatment. — Although there is no known method of treat- 
 ment by which scleroderma can be cured, there are a variety of 
 measures which have done good in certain cases. Above all 
 things, general hygiene is important. Tonics, iron, quinine, cod 
 liver oil, arsenic, etc., are to be recommended, as are sea voyages, 
 mountain air, vapor baths, etc. 
 
 Various local applications have seemed serviceable. Mercu- 
 rial ointment inunctions especially, together with massage, 
 may be thus employed ; as may be also the iodine ointment, 
 glycerine, etc. The constant galvanic current has been recom- 
 mended, especially by Schwimmer and Piffard. 
 
 SCLEREMA NEONATORUM. 
 
 Syn. — Sclerosis ; induratio telae cellulosse neonatorum ; skin- 
 bound ; algidite progressive. 
 
 Definition. — A disease of infancy, occurring generally a few 
 days after birth, commencing usually upon the lower extremi- 
 ties and characterized by oedema, discoloration, hardness and 
 coldness of the skin over a greater or less area. 
 
 Symptoms. — The disease is either congenital or appears two 
 or three days after birth, and rarely as late as the second year. 
 The intensity of the disease varies greatly in different cases. 
 In the milder forms, after one or two days of restlessness, the 
 skin, especially upon one or more of the extremities, becomes 
 swollen, pale or slightly erythematous, colder, and somewhat 
 swollen. There is increased transudation in the part, the skin is 
 dry, tense, transparent, with diminished sensibility, and, if icterus 
 is present, of a pale yellow color. This condition may increase 
 and assume a severe form, or there may be a return to the nor- 
 mal state. When this latter occurs the skin becomes softer, 
 paler, moist, and in one or two weeks is normal. This form is 
 met with principally in the fat parts, as the calves of the legs, 
 soles of the feet, fingers, hands and cheeks (Herring). 
 
 The more severe form of the disease occurs generally within 
 the first week of extra-uterine life, and commences usually on 
 the lower extremities, but may appear on any other part of the 
 
428 SCLEREMA NEONATORUM. 
 
 body. It rarely extends over the whole surface. The order of 
 frequency in which the different regions are affected is — lower 
 extremities, pubis, arms, abdominal region to umbilicus, feet, 
 hands, face, buttock, back, hips, neck. 
 
 After a few hours or several days of restlessness, and often in- 
 testinal and urinary derangement, the skin on the part becoming 
 affected is paler than normal, and of a whitish or yellowish- 
 brown with sometimes a reddish tinge, wax-like, cedematous, in- 
 sensible and cold. Sometimes it is at first bluish, and afterward 
 reddish or dirty-yellow brown. The amount of oedema and swell- 
 ing varies ; sometimes the skin is tense, hard, but not swollen. 
 To the feel it is as if diffusely infiltrated, hard, dense, cold, a feel- 
 ing like that conveyed by a half-frozen corpse, pits upon deep 
 pressure, and the epidermis is movable over the underlying in- 
 filtrated tissue. After a few days the oedema diminishes, and 
 the part may be smaller than normal, hard, wrinkled, mummified 
 and movement of the muscles interfered with. If the disease 
 is seated on the face, the latter is wrinkled, fixed, giving an old 
 appearance to the expression. If the lips are infiltrated, nursing 
 is impossible. In some cases the infiltration creeps along the 
 muscles, but generally it extends along the corium and subcuta- 
 neous tissue. It generally extends from the legs and arms down- 
 ward to the feet and hands, and rarely in the opposite direction. 
 When located in the pubic region it extends both upward and 
 downward, and if upward, then seldom further than the um- 
 bilicus. Sometimes the margin of the infiltration is sharply 
 limited, especially when extending along the muscles ; at other 
 times it is ill defined. 
 
 The respiratory, circulatory, intestinal and urinary organs are 
 generally more or less diseased, and their derangements are to 
 be regarded as a frequent cause of the sclerema. Respiratory 
 movement is not interfered with unless the thorax is affected or 
 there is disease of the lungs. Nasal haemorrhage is rare and is 
 an unfavorable sign. Cough is frequent from bronchitis, pleu- 
 risy or pneumonia, conditions frequently present. Pulmonary 
 oedema occurs before death. The pulse may be unaffected, but 
 is generally small and slow. There is almost invariably marked 
 
SCLEREMA NEONATORUM. 429 
 
 diminution in the temperature. In one case under my care, and 
 exhibited to the New York Uermatological Society, the pulse 
 was increased in frequency, and there was no diminution in the 
 temperature, although there was no inflammation of the intesti- 
 nal or respiratory organs to have kept it from being below 
 normal. Diarrhoea generally precedes or accompanies the 
 disease. The passages are thin, greenish and rarely bloody. 
 Vomiting and icterus, with distension of stomach and intestines 
 from gas, are generally present. The urine is small in quan- 
 tity and clear or yellowish-white in color. 
 
 The disease lasts in favorable cases from two to twenty days, 
 and in unfavorable cases from two to thirty-seven days, death 
 resulting in these latter cases generally before the eighth day, 
 from weakness and consequent oedema of the lungs, or from 
 some complication, as pleurisy, pneumonia, peritonitis, etc. 
 
 Anatomy. — Opinions differ as to the nature of the process 
 and the changes produced by it in the skin. It is evidently 
 due to interference in the capillary circulation, an inflamma- 
 tory stasis, a process between ordinary non-inflammatory 
 oedema and an acute dermatitis. The coldness of the skin de- 
 pends upon the stasis, the diminished respiration, and dimin- 
 ished tissue-change. After death the hardness diminishes and 
 the part pits only upon firm pressure. The skin is paler than 
 during life, and upon cutting with the knife, a dark liquid first 
 flows, and afterward there is a thin yellow transudation, fol- 
 lowed by disappearance of the oedema. The fat tissue is hard, 
 from a " stearine-like " mass imbedded in it. Sometimes there 
 is no serum in the subcutaneous tissue. The corium is less 
 elastic, friable, and infiltrated by a thick, brown, sticky sub- 
 stance. According to some it contains collections of young 
 embryonic tissue. Congestion, or bullae with purulent con- 
 tents have been occasionally found on the ankles. According to 
 the causes, complications or consequences of the disease, as the 
 case may be, pneumonia, pleurisy, bronchitis, peritonitis, or 
 intestinal catarrh, are frequently present. The liver is con- 
 gested, friable and yellowish from bile. 
 
 Etiology. — The disease may depend upon direct irritation to 
 
43° SCLEREMA NEONATORUM. 
 
 the part, or arise in consequence of disease of internal organs, 
 especially of the heart or lungs, or be the result of general 
 malnutrition. Cold bathing, or exposure to cold, are examples 
 of direct irritation. The disease is more frequent in winter 
 than summer. Heart disease, pneumonia, diarrhoea, hydroceph- 
 alus, meningeal apoplexy, premature birth, syphilis, weak res- 
 piration leading to collapse of the lungs, tying of umbilical 
 cord before respiration is well established, deficient nutrition 
 and general weakness are to be regarded as indirect causes of 
 the disease from their action upon the peripheral circulation. 
 
 Diagnosis. — The only diseases with which it could be con- 
 founded are erysipelas and the scleroderma of adults, but the 
 induration, oedema, color and coldness of the part render the 
 diagnosis easy. 
 
 Prognosis. — The prognosis depends upon the intensity of 
 the disease. In mild cases, as already described, the prognosis 
 is favorable, but in the severe forms it is a very fatal disease. 
 About three-fourths of all cases die, and generally before the 
 eighth day of the disease. The unfavorable symptoms are 
 nasal haemorrhage, pyaemia, diarrhoea, icterus, pulmonary com- 
 plications, or location of the hardening in the oesophageal re- 
 gion, interfering with deglutition. In favorable cases there is 
 often a long continuance of the oedema, with irregular pulse 
 and labored respiration. 
 
 Treat??ient. — In the treatment of this affection, particular at- 
 tention must be directed to the predisposing cause. If there 
 is disease of the circulation, or respiratory system, care must be 
 taken that depressing remedies be not used in their treatment. 
 If pneumonia is present, cold applications to the chest should 
 not be used unless the fever is high. In pulmonary collapse 
 the result of general weakness and superficial respiration, warm 
 mustard baths and stimulants should be used. The diarrhoea 
 is to be treated by antacids and astringents, with regula- 
 tion of the amount and quality of food. If the child is 
 prematurely born, it should be kept in a warm room, and 
 wrapped in cotton and oiled-silk. Sweet oil or olive oil can 
 be used with the cotton. The child should be allowed or made 
 
MORPHCEA. 43I 
 
 to cry good, so as to assist the pulmonary circulation. Baths 
 are of advantage to the skin condition, but are not always well 
 borne. The general nutrition of the child must receive special 
 attention. 
 
 MOEPHCEA. 
 
 It is impossible to give any exact definition of the condition 
 chacterized by this name, since it is one, the essential charac- 
 teristics of which are still a matter of dispute. Indeed, it is a 
 question in the minds of many dermatologists whether the af- 
 fection deserves a special place or a special name at all ; they 
 holding that it is merely a localized scleroderma. Neverthe- 
 less, there are many points in favor of its being considered a 
 distinct and separate disease, the more important of which I 
 will endeavor to describe. 
 
 Symptoms. — Morphcea appears under several distinct forms ; 
 and these forms may run into one another as the disease pro- 
 gresses, or it may preserve its original appearance from the be- 
 ginning to the end of its course. 
 
 It most frequently commences by the appearance of circum- 
 scribed, rounded, or oval, or elongated hyperaemic patches from 
 one-half to two inches in diameter. These patches are pink or 
 purplish in color, distinctly circumscribed, and are surrounded 
 by a more or less well-marked pink zone of injection, upon 
 which, as well as upon the patch itself, congeries of enlarged 
 capillaries can often be observed. In this, the earliest stage, 
 the affected area is slightly swollen, and rises moderately above 
 the level of the surrounding skin. 
 
 At a later stage the elevation disappears, and the patch be- 
 comes level with the skin, or even slightly depressed. It grows 
 tough, leathery, or brawny to the feel, and can be with difficul- 
 ty pinched up. The surface becomes smooth, whitish or yel- 
 lowish, or pinkish, looking like polished ivory ; more often it 
 appears lardaceous, and has been likened to a piece of bacon set 
 into the skin. 
 
 In this state the patches may remain for an indefinite time ; 
 
432 MORPHCEA. 
 
 or they may sooner or later begin to undergo a process of spon- 
 taneous involution, resulting in a return of the integument to 
 its normal condition. But in most cases there comes a time 
 when atrophic changes begin ; the skin becomes contracted, 
 dry, thin, parchment-like, or shriveled. It may become immov- 
 ably bound down to the subjacent tissues. The fat and 
 muscle atrophy, and eventually round, elongated or variously 
 shaped cicatriform lesions are left, with considerable loss of 
 power and deformity. 
 
 Besides these hypertrophic and atrophic forms of morphcea 
 it may appear as more or less numerous small pit-like scars 
 scattered over the affected area, and interspersed with glazed, 
 pearly-white atrophic macules and streaks, forming the maculae 
 et striae atrophica?. A varying amount of yellowish or brown 
 pigmentation is usually present, especially at the margins of the 
 patches, as well as reddish or purplish telangiectasic spots. 
 
 The lesions of morphcea are asymetrical ; they may appear 
 anywhere upon the body, but occur by preference upon the 
 face, neck, breast, arms, and thighs. As a usual thing, they 
 correspond to distinct nerve tracts — as the fifth or the branches 
 of the sciatic. But in many cases they are quite irregular. 
 Subjective sensations are usually absent, though precedent or 
 accompanying pain and tingling have been noted. The glandu- 
 lar structures of the skin are usually atrophied, and the secre- 
 tion of sweat and sebum correspondingly diminished. It is a 
 chronic disease, lasting for many years. A considerable number 
 of cases recover. It is a rare disease, but not so rare a one as 
 scleroderma. 
 
 Anatomy. — But little is known concerning the pathology of 
 morphcea. In the early stages, Crocker found pigmentation of 
 the deeper epithelial layers, atrophied papillae, and an increase 
 of round cellular tissue among the gland structures and ves- 
 sels. In the later stages he noticed that the cells had become 
 developed into new connective tissue with an abundance of 
 elastic fibres ; that this shrunk, and caused atrophy of the 
 sebaceous glands, and obliteration of the sweat-ducts and blood- 
 vessels. The subcutaneous fatty tissue disappeared early. 
 
MORPHCEA. 433 
 
 Crocker came to the conclusion that the process was the same 
 as in scleroderma, only more superficial. Duhring found only 
 condensation of the connective tissue of the corium, with 
 shrinkage of the papillary layer. 
 
 Etiology. — We are entirely in ignorance concerning the cause 
 of morphcea. It occurs in all constitutions, and at all ages ; 
 but far more frequently among women than among men. The 
 fact that it sometimes occurs in connection with distinctly 
 neurotic affections, would lead us to regard it as a trophoneu- 
 rosis. 
 
 Diagnosis. — For the points of differential diagnosis between 
 morphoea and scleroderma, the reader is referred to the latter 
 disease. Whether the two names represent two distinct 
 disease processes is still a matter of question. 
 
 The striae atrophica can in some cases hardly be distinguished 
 from the lineae albicantes so often seen upon the abdomen. 
 
 The spots of anaesthetic lepra bear a very strong resemblance 
 sometimes to the morphcea-patches. The other symptoms 
 which invariably accompany the graver disease are sufficient 
 to prevent all error. That the two phenomena should re- 
 semble one another is not surprising, their probable neurotic 
 origin in morphcea, and their certainly neurotic source in lepra. 
 Vitiligo is an affection of the skin-pigment alone ; there is no 
 other change in the integument. It ought not to be mistaken 
 for morphoea. 
 
 Prognosis. — There is a considerable tendency toward spon- 
 taneous recovery during the hypertrophied stage: when atrophy 
 has set in the skin can never return to its normal state. It is 
 often extremely chronic, lasting for life. 
 
 Treatment. — Arsenic, exhibited for long periods of time, and 
 pushed to the maximum dose the patient will bear, together 
 with the galvanic current, has seemed to be useful. Tonics, 
 iron, cod liver oil, and general hygiene are undoubtedly of 
 importance. Some cases have made good recoveries without 
 treatment, as occurred in a case I have had under observa- 
 tion the last three years. 
 
 It is perhaps proper to mention here a localized form of 
 28 
 
434 ELEPHANTIASIS. 
 
 atrophy in which the process is deeper-seated than in morphcea, 
 but seems to be closely related to it. I allude to the affection 
 known as hemiatrophia facialis, or unilateral atrophy of the 
 face. Not only the skin, but the subcutaneous connective- 
 tissue, the muscles, and even the bones of the whole or a part 
 of one side of the face are involved. In some cases character- 
 istic morphcea of other regions has been observed in connection 
 with it. The affection belongs more probably to the depart- 
 ment of neurology, and merely requires mention here. 
 
 ELEPHANTIASIS. 
 
 Syn. — Pachyderma ; e. arabum ; bucnemia tropica ; ele- 
 phant leg ; Barbadoes leg. 
 
 Definition. — A circumscribed chronic hypertrophy of the skin 
 and subcutaneous tissue, due to local circulatory disturbances 
 from repeated vascular and lymphatic obstruction, due to in- 
 flammation, erysipelas, and perhaps embolism by fllaria san- 
 guinis or its ova, and appears as an immensely enlarged, 
 thickened, indurated, pigmented condition of the skin of a 
 part — usually a limb. 
 
 Symptoms. — The disease occurs everywhere — but with such 
 especial frequency in some parts of the world as to appear al- 
 most endemic there. This is especially the case in certain trop- 
 ical regions — the West Coast of Africa, Brazil, the West In- 
 dies, and especially India ; it is also moderately common in 
 the Mediterranean regions and Arabia. Barbadoes leg is a 
 name given to its commonest form from its frequency upon 
 that island. Elsewhere it is a rare disease. 
 
 Pachyderma, or elephantiasis, occurs on various parts of the 
 body, but affects pre-eminently the leg and the genital organs. 
 Only exceptionally does it appear upon the nose, ears, cheeks, 
 back, etc. Two main forms, elephantiasis cruris and elephan- 
 tiasis genitalium are to be described. 
 
 In both forms the disease begins with a series of inflamma- 
 tory attacks in the skin of the affected part, which may have 
 their starting point in some local lesion, wound or scar, 01 
 
ELEPHANTIASIS. 435 
 
 may occur in apparently perfectly healthy skin. These attacks 
 may be of erysipeloid, or of a deeper dermatitis character, 
 or they may consist only of a painful erythema. Fever, swell- 
 ing of the skin, pain, redness, lymphangitis, or even phlebitis, 
 accompany the attack. After lasting a variable time it sub- 
 sides, to reappear shortly, either spontaneously or from some 
 such cause as induced the first onset. Each attack leaves 
 the skin somewhat swollen — the lymphatic glands somewhat en- 
 larged. (It will be remembered that, when speaking of ery- 
 sipelas, it was noticed that repeated attacks were liable to leave 
 the part in a permanently hypertrophied condition). In the 
 course of a year or two the repeated inflammations have in- 
 creased the size of the part considerably ; the skin and lym- 
 phatic glands present in slight degree the characters to be de- 
 scribed of the fully developed disease. Eventually a station- 
 ary period is reached, in which the erysipelatous attacks no 
 longer occurs, and the patient is left with the permanently de- 
 formed part. 
 
 E. cruris is the commoner form of the disease in this conti- 
 nent, and forms the well-known Barbadoes leg. In the course 
 of years, perhaps five or ten, the limb has become uncommon- 
 ly swollen from the soles of the foot to the upper part of the 
 thigh. All the natural contours are entirely obliterated ; the 
 foot, leg, and thigh are " bolstered " with a tremendous mis- 
 shapen mass of dark, tuberculated skin. The leg may meas- 
 ure seventy centimetres or more in circumference — and the foot 
 and thigh are equally enlarged. Hence the well-merited name 
 of rhinoceros leg and elephantiasis. The surface of the skin 
 covering this enormous limb is dry, studded with tubercles, or 
 perhaps smooth and shining, and of a dirty black color from 
 pigment deposit and decomposed sebaceous and epidermic 
 remains. The epidermis is at places smooth as parchment 
 (e. glabra) — or scaly ; but in its most characteristic condi- 
 tion it is irregularly warty or tubercular, the tuberosities 
 being moist and foul, or dry and brush like (e. tuberosa, s. 
 verrucosa, s. papillaris). Excoriations, superficial or deep 
 ulcers with callous edges and foul necrosing base, add their 
 
436 ELEPHANTIASIS. 
 
 secretions to those of the eczema which is usually present in 
 places. 
 
 All the tissues of the limb seem to be matted together into 
 one hard mass. The muscles cannot be distinguished, and in 
 bad cases even the bones, as the tibia, are enlarged and send 
 rough processes into the sclerotic mass. The ulcerations may 
 be so deep as to destroy fascia, muscles, and even bone. 
 
 A prominent feature of the disease is the involvement of the 
 lymphatic vessels and glands. These latter are swollen from 
 the beginning, and attain an enormous size in the later stages. 
 The vessels are prominent, thick, hypertrophied, and filled 
 with lymph. Occasionally they burst, and a more or less con- 
 stant lymphorrhcea — a trickling away of the lymphatic fluid 
 over the tubercular, ulcerated, cracked surface, already suffi- 
 ciently obnoxious from the decomposing secretions and abund- 
 ant remains of epidermis and sebum occurs. 
 
 As a usual thing, only one leg is affected ; certainly in the 
 severest forms ; many authors, however, mention a double 
 elephantiasis. 
 
 E. genitalium (s. scroti, penis, labiorum pudendorum et 
 clitoridis), is the other most common form of the malady. 
 Here the hypertrophy is even more enormous at times, and it 
 certainly is even more unendurable to the unfortunate posses- 
 sor than is e. cruris. The scrotum and labia, are most com- 
 monly affected, and from them tumors of really stupendous 
 size may grow. Those of the scrotum are the largest of all. 
 Thus Clot-Bey removed one weighing one hundred and ten 
 pounds, and as great a weight as one hundred and twenty 
 pounds has been recorded by Prosper Alpin and Larrey. The 
 clitoris and labia have been known to grow to growths weighing 
 fifty to sixty pounds. Some of these tumors are so large as to 
 reach below the knees, even to the ankles of their unhappy 
 possessors. 
 
 The disease begins as a hard lump in the testicle or labium, 
 which gradually grows in size and hardness under the attacks 
 of erysipelas before mentioned. Gradually the skin of all the 
 surrounding parts is drawn into the tumor, until all the geni- 
 
ELEPHANTIASIS. 437 
 
 tals, the thighs, and the lower part of the abdomen are in- 
 volved. The penis gradually disappears as the sheath be- 
 comes involved, and is eventually represented by a funnel- 
 shaped orifice, from the ulcerating mouth of which the urine 
 exudes, and deep down in which is the glans ; the ostium 
 vaginae, and clitoris disappear in the same way. The tumor 
 itself forms a mass covered, like the leg, by an immensely hy- 
 pertrophied epidermis. It may be elastic to the feel, but is 
 usually hard and knotty. The skin is rough, hard, tubercu- 
 lated and warty ; its color varies from a light to a blackish- 
 brown. Fissures, ulcerations of varying depth, secondary 
 eczema, etc., occur here also. Vesicles occasionally form, 
 from which, after breaking, lymph may drip for days ; or the 
 lymphorrhcea may occur from direct bursting of the overfilled 
 lymphatic vessels. 
 
 Such monstrous growths are of course in the highest degree 
 obnoxious from their size alone ; but Rayer states that among 
 the Arabs the impossibility of gratifying their sexual desires 
 forms not the least important part of their sufferings. Patients 
 suffering from quite advanced degrees of this affection have 
 been known, however, to procreate ; and it is probable that 
 the function of the testicle is not interfered with. 
 
 Besides these places, elephantiasis occurs, though rarely, 
 upon other portions of the body. Thus after recurrent facial 
 erysipelas, it may appear as permanent thickening of the ears, 
 lips, and cheeks. It has also been known to happen upon the 
 arms, back, etc. 
 
 The subjective symptoms may be described in a few words. 
 The inflammatory attacks at the beginning give the ordinary 
 symptoms, and when the permanent thickening has occurred, 
 the patient complains of a feeling of tightness, with occasional 
 neurotic pains. Later, there is the permanent sense of weight 
 and " deadness " of the limb. 
 
 Pachyderma is almost invariably seen between the ages of 
 twenty and forty, though Schwimmer mentions a case occur- 
 ring in a boy of twelve years, who, after three years of the dis- 
 ease, measured forty centimetres around the ankle. There 
 
438 ELEPHANTIASIS. 
 
 was formerly a case in the Dermatological wards of Charity 
 Hospital at least seventy years old. 
 
 There remains to be mentioned certain so-called forms of 
 elephantiasis which probably belong more appropriately under 
 other headings. Thus some described cases are more properly 
 called molluscum fibrosum, and others, in which a vascular 
 new growth formed a large part of the tumor, will be described 
 among the nsevi under the title of elephantiasis telangiectodes. 
 
 Anatomy. — The essential point in the pathology of elephan- 
 tiasis is the lymphatic obstruction, though we are still un- 
 certain as to its exact cause. Very early in the disease the 
 lymphatic glands are swollen, the lymphatic vessels prominent 
 and surcharged with fluid. In consequence of the repeated 
 attacks of inflammation, there is set up a stagnant oedema, 
 and consequently a new growth of connective tissue in all 
 parts of the skin. Virchow lays stress upon the fact that it 
 is not a fluid from the abnormal bloodvessels, as in inflam- 
 mation, but one coming from normal vessels from mechanical 
 causes (glandular obstruction). It is a true lymphatic oedema, 
 and the abundant active leucocytes it contains not only directly 
 become connective tissue corpuscles, but induce also a hyper- 
 plasia of the fixed cells already present. 
 
 Microscopically, a more or less fully developed connective 
 tissue is found in all the parts of the cutis and epidermis, but 
 especially in the papillae. So abundant is this fibrillar growth 
 that all the other structures of the skin and deeper parts are 
 pushed aside, pressed upon, and atrophied. The glands are 
 deformed, or destroyed ; those that remain have their endothe- 
 lium granular and swollen; the fat is atrophied; the muscles are 
 discolored and have undergone fatty degeneration. The blood- 
 vessels themselves are thrombosed, and have thickened walls. 
 The lymphatic system is enlarged throughout, the vessels 
 are swelled and filled with lymph ; the lymph spaces enlarged 
 and in places dilated. 
 
 The macroscopical appearances corroborate the minute find- 
 ings. Bands of connective tissue are everywhere evident as 
 we cut through the hypertrophied mass. All the subcutane- 
 
ELEPHANTIASIS. 439 
 
 ous tissues are matted together into a homogeneous, larda- 
 ceous mass, from which a yellowish fluid, the lymph, trickles 
 abundantly upon pressure. Vessels, nerves, muscles, can 
 hardly be distinguished ; only the fatty mass with bands of 
 more fully formed connective tissue running through it. In 
 some places the connective tissue is older, hard, almost schir- 
 rhous (e. dura) ; in others it is newer and gelatinous (e. mollis). 
 Enlarged lymphatic vessels and lymph lacunae are found 
 throughout. Even the bones may be thickened. Though the 
 nerve-sheaths frequently suffer, the nerves themselves usually 
 escape degeneration. 
 
 Etiology. — Elephantiasis is due to inflammation and ob- 
 struction of ihe lymphatics. What the cause of this obstruc- 
 tion is, is not absolutely known, but it is extremely probable that 
 it is due to the presence in the lymphatic vessels of a minute 
 animal — the filaria sanguinis, and its ova. These are micro- 
 scopic little thread-worms, which have been found adhering in 
 immense numbers to the walls of the lymphatics and blood- 
 vessels in this disease. They are to be found in numbers only 
 during certain hours of the day. It is believed that they and 
 their ova cause bloodvessel and lymphvessel embolism and 
 stasis ; proofs that this is the correct etiology of the disease 
 are continually accumulating from the countries where it is 
 common. Other diseases, such as lymph-scrotum, are looked 
 upon as related to pachyderma, and are thought to be due to 
 the same causes ; they are spoken of as the filaria diseases. 
 According to Manson, a certain species of mosquito is said to 
 be instrumental in propagating the filaria and communicating 
 the disease. 
 
 In the light of these facts, we may cast aside at once all the 
 theories which have made elephantiasis dependent upon atmos- 
 pheric or teluric influences ; but there must be mentioned 
 certain secondary or contributing causes. Thus anything 
 which causes inflammation or current stoppage in the lym- 
 phatic or vascular system of the skin might tend to produce 
 the malady. Thus repeated erysipelas, chronic ulcers, chronic 
 eczemas, dilatations or obliterations of the vessels, varices, 
 
44° ELEPHANTIASIS. 
 
 thromboses, etc. Syphilis and lupus may cause such exten- 
 sive vascular obstruction in the skin as to occasion the disease ; 
 Schwimmer mentions the case of lupus upon the buttock of 
 ten years standing, in which there ensued a high degree of 
 pachyderma of both legs, the hypertrophied skin being 
 studded over with numerous lupus nodules. 
 
 In the countries where it is common, the disease occurs far 
 more frequently among the poor than among those who are 
 well cared for. The Chinese attribute it to exposure, especi- 
 ally to wading in the icy streams in early spring. It is not a 
 contagious disease, nor is it proven to be hereditary. 
 
 Diagnosis. — The diagnosis can hardly present any difficul- 
 ties in a disease which shows such marked features. Certain 
 cases may be hard to distinguish from, and in fact may be 
 transition forms between it and molluscum or dermatolysis. 
 
 Prognosis. — Elephantiasis is always a very serious, though 
 but seldom a fatal disease. The mere fact of having to carry 
 about so disgusting and so disabling a deformity, causes con- 
 siderable mental disturbance. Hebra has seen several cases 
 perish from pyaemia, but as a usual thing they learn to ac- 
 commodate themselves to their increasing burden, and live for 
 many years. Hendy maintains that spontaneous cure occa- 
 sionally occurs in the earliest stages. 
 
 If treatment is vigorously pursued during the earlier stages 
 of the disease, there may be a hope of cure ; later but little 
 can be done save to alleviate the trouble ; over fully formed 
 connective tissue so widespread in situation, medicine and sur- 
 gery have but little power. 
 
 Treatment. — The early attacks of inflammation are to be 
 treated in exactly the same way as we would treat ordinary 
 erysipelas. Rest in bed, hot or cold applications, lead and 
 opium wash, etc. Quinine and iron internally may be em- 
 ployed. 
 
 In the case of e. cruris, we may endeavor by various means to 
 diminish the oedema left by the first onsets of inflammation. 
 Local blood-letting, opening of the saphenous or femoral vein, 
 will hardly be recommended to-day, as the consequent weaken- 
 
ELEPHANTIASIS. 44 1 
 
 ing of the system rather predisposes to the occurrence of transu- 
 dations. But multiple scarifications, as recommended by 
 Lisfranc, either alone or with methodical compression of the 
 entire limb, may be of service. A rubber or ordinary bandage 
 is to be firmly and evenly applied from the toes to the thigh ; 
 in the beginning it must be reapplied often, even several times 
 daily, so as to maintain continuous pressure. Complete rest 
 and elevation of the limb must be insisted on during the treat- 
 ment. Inunctions of iodine or mercurial ointments, vapor- 
 baths, etc., may be used from time to time to soften the skin 
 and assist absorption. By these means not only can the lymph 
 be drained from the part, but much of the new connective- 
 tissue be made to undergo reabsorption ; and Schwimmer says 
 that in his hands this treatment continued for months has 
 caused the disappearance of infiltrations an inch or more in 
 thickness. 
 
 Various efforts have been made to influence the growth of 
 the connective tissue by surgical interference with the vascu- 
 lar or nervous supply. As long ago as 1851 Dr. Carnochan, 
 of this city, cured an advanced case of the disease by ligation 
 of the external iliac artery. Leonard, a short time ago, col- 
 lected 69 cases in which this arterial ligature was performed, 
 with recovery in 40 and benefit in 13 cases. Some of the pa- 
 tients succumbed to pyaemia, and in the others the malady re- 
 appeared in other parts ; but on the whole the records have 
 been very favorable, and the operation is to be looked upon as 
 a valuable means of relief. Digital and instrumental compres- 
 sion have yielded almost as good results. Morton, in a case 
 of fourteen years' standing, in which the external iliac had been 
 fruitlessly ligated, excised a portion of the sciatic nerve, 
 and within six weeks saw the limb reduced to one-half its 
 former size. 
 
 Quite recently the use of the constant current has been 
 claimed to give good results in the treatment of pachyder- 
 ma. Two Brazilian physicians, Moncorro and Silva Aranjo, 
 have reported astonishing results from the use of the cur- 
 rent of from six to sixty elements, continued for periods of 
 
44 2 DERMATOLYSIS. 
 
 one to two years. E. C. Mann has reported a case in which 
 galvanism reduced the limb from 25 to 17 inches in 3^ 
 months. Seventeen cells were used. 
 
 In otherwise hopeless cases, amputation, though danger- 
 ous, offers a chance of relief. 
 
 E. genitalia is only to be treated by operative procedure. 
 Gaetam-Bey has systematized the operation, and the most 
 enormous masses have been successfully removed by the knife. 
 Details of the operative procedures will be found in the surg- 
 ical text books. 
 
 Ulcerations, eczematous processes, warty growths are to be 
 treated by ointments, caustics, etc., upon general principles. 
 The general health must be carefully looked after, and any 
 thing tending to produce additional congestion or oedema of 
 the limb, most carefully avoided. Change of climate is one of 
 the most valuable therapeutic measures at our disposal during 
 the early stages of the malady. 
 
 DERMATOLYSIS. 
 
 Syn. — Pachydermatocele ; elephantiasis telangiectodes (He- 
 bra, Kaposi) ; cutis pendular. 
 
 Definition. — A more or less circumscribed hypertrophy of 
 all parts of the integument and subcutaneous tissue ; the skin 
 is thickened and redundant in places, and hangs down in loose 
 folds. 
 
 Symptoms. — Derm atoly sis consists simply in a redundancy 
 of the normal skin. It occurs in various situations, but has 
 been found most often and most extensively affecting the skin 
 of the abdomen, back, thighs, and scalp. The hypertrophy 
 which is the cause of the disease is general over the area af- 
 fected ; the glandular stuctures, the connective tissue and mus- 
 cular fibres, as well as the subcutaneous areolar tissue are in- 
 volved. Even pigment is deposited in excess. The surface of 
 the skin is uneven, for the natural folds and rugae are mag- 
 nified ; but it is smooth to the touch, and shows none of the 
 rough tuberous elevations which characterize elephantiasis. 
 
DERMATOLYSIS. 443 
 
 The skin is usually more or less brownish-black in color from 
 excessive pigmentation. 
 
 Wherever it occurs the integument is superabundant and 
 hangs down in folds of greater or less extent ; they may over- 
 lap one another, or envelop the lower parts as with a loose 
 garment. John Bell gives a graphic account of a remarkable 
 case, in which there was an enormous development of the skin 
 of the abdomen and breast. The growth hung down from her 
 ears and neck, and involved all the skin of the abdomen and 
 trunk below. The enormous mass, the author says, "rolls out 
 like bowels when she opens her tattered clothes ; the rolls of 
 skin, fleshy and red, turn over one another and are set in ver- 
 micular motion by the slightest touch, and form a sight at once 
 disgusting and horrible ; she carries the tumor before her, 
 slung in an old table cloth, when she walks, as a sower does a 
 bag of corn." In Keen's case, the disease began upon the neck 
 and shoulders, and hung down like a cloak to the buttocks. 
 With all this the skin is normal in consistency, soft and pliable 
 to the touch. 
 
 Erasmus Wilson, to whom much of our knowledge upon this 
 subject is due, describes as cases of dermatolysis those con- 
 genital deformities in which, from a partial absence of the 
 usual amount of subcutaneous connective tissue, the integu- 
 ment can be moved to a surprising extent upon the deeper 
 structures, with which it is only very slightly connected. Thus, 
 in the case of Georgius Albes, the skin of the right side of the 
 body seemed to be made of India rubber ; the skin of the right 
 breast could be drawn to the left ear, and that under his chin 
 extended until it touched the vertex. The left side of his body 
 was normal. The so-called " rubber man " who was lately ex- 
 hibited in New York City was an example of this deformity, 
 general over the body ; the skin could be drawn into the most 
 extraordinary shapes, but immediately returned to its proper 
 position. This mobility of the skin is due to an absence, to a 
 very large extent, of the subcutaneous areolar tissue, and aeon- 
 sequent increase in the amount of motion usually possible for 
 the skin upon the deeper parts, and appears to be a congenital 
 
444 DERMATOLYSIS. 
 
 deformity. The integument itself is not altered in any way ; 
 there is no hypertrophy of it ; and there is certainly no hyper- 
 trophy of the subcutanea. It is simply a congenital deformity, 
 and ought not to be classified with the acquired and progressive 
 hypertrophies of the cutaneous and subjacent tissues before 
 mentioned. 
 
 By the German writers dermatolysis is classified under the 
 head of pachyderma or elephantiasis arabum. The lesions are 
 very much the same, but the appearance and course of the two 
 diseases justify us in following the majority of English authori- 
 ties, and considering them as distinct. One form of simple 
 hypertrophy of the skin, accompanied with marked new growth 
 of vascular tissue, has been considered among the naevi under 
 the head of elephantiasis telangiectodes. 
 
 Dermatolysis may be multiple or single. It is sometimes 
 congenital, but usually begins to grow during early life ; its 
 increase may be rapid at first, but it becomes stationary or 
 nearly so later on. In Bell's case the disease had begun during 
 middle life, and had been five years in existence at the time the 
 description was written. It is injurious to the general health 
 only on account of its size. 
 
 Anatomy. — All parts of the integument partake of the hyper- 
 trophy, but the subcutaneous connective tissue is affected most 
 of all. We are entirely in the dark as to what causes the exuber- 
 ant growth of the dermic and subdermic tissues. As before 
 stated, certain cases of telangiectasis, in which the connective- 
 tissue new growth is prominent, occupy the border-land between 
 that disease, dermatolysis and elephantiasis. They are called 
 by Kaposi elephantiasis telangiectodes. Dermatolysis is also 
 closely related to molluscum fibrosum. 
 
 Diagnosis. — From the above-mentioned forms of telangiec- 
 tasis the disease may be distinguished by its non-compressi- 
 bility and the evidently essentially vascular character of 
 the latter growth. Elephantiasis may be differentiated by 
 the roughness, tuberculation, hardness, ulceration, and 
 lymphorrhcea which distinghish it from the normal consistency 
 and appearance of the skin in dermatolysis. 
 
HIRSUTIES. 445 
 
 Prognosis. — Is good. The disease is only hurtful in so far 
 as it is a deformity or impedes locomotion. Operative meas- 
 ures have yielded good results. 
 
 Treatment. — Excision is the plan which is indicated, and it 
 has given very good results, especially when the disease is not 
 very extensive. The galvano-cautery may be applicable to 
 some cases. 
 
 HIRSUTIES. 
 
 Syn. — Hypertrichosis ; hypertrichiasis ; polytrichia ; hyper- 
 trophy of the hair. 
 
 Definition. — An abnormal increase in the size and length of 
 the hair. 
 
 Symptoms. — Hirsuties is either hereditary (hirsuties adanata), 
 or acquired (hirsuties acquisita). It may also be general (h. 
 universalis), or local (h. partialis). The general cutaneous 
 surface, with the exception of the palms of the hands and soles 
 of the feet and the dorsal surfaces of the terminal phalanges of 
 the fingers and toes, is provided with long or short hairs. The 
 scalp, eyebrows, axilla, pubis, lower part of face of adult males, 
 have normally thick and long hairs, whilst the rest of the 
 body has lanugo hairs. Hirsuties includes all cases of in- 
 crease in size or number above the normal of the hair of the 
 body. 
 
 The hair may be of the average thickness, or coarser, or 
 finer, with increase of the length. Following Beigel, we may 
 describe three forms of abnormal growth of hair : 
 
 First. An increase in the size or length of the hair on places 
 normally provided with coarse hair, as eyebrows, scalp, etc. 
 
 Examples of inordinate growth of the hair of beard or scalp 
 are very frequent. 
 
 Second. When there is an inordinate growth of hair in 
 women and children in situations usually occupied by lanugo 
 hairs, but in males by coarse hair. 
 
 Some children are born with a more or less developed 
 beard, and in women, especially at the climacteric period, the 
 
446 HIRSUTIES. 
 
 hair frequently grows to a considerable length and thickness 
 on the upper lip and chin. This same abnormal growth of 
 hair on the lip and chin is sometimes seen on younger females 
 suffering from menstrual difficulties. Finally, a number of 
 cases have been observed of females with well developed full 
 beards ; more or less marked examples of these latter are 
 frequently seen in our dime museums. 
 
 Both of the above forms are local. 
 
 Third. There is an increase in the size or length of the hairs 
 over the whole body, or on certain parts ; it may be either 
 congenital or acquired. Examples of congenital hirsuties of 
 this form are seen in the cases of the so-called hairy men 
 found in some eastern countries. These cases are generally 
 congenital. Deficient development of the teeth is a marked 
 feature in some of these cases. Acquired hirsuties from lanugo 
 hairs is always local. Examples are found in the case of hairy 
 moles (nsevus pilosus). These are found especially on the 
 scalp or forehead, and contain short, stiff, or long hairs. 
 
 When the hairs take an abnormal direction, as occurs on the 
 scalp or eyebrows, the condition is called trichiasis. 
 
 Etiology. — The condition may be either congenital, acquired, 
 or hereditary. It occurs more frequently in dark than in 
 light persons ; has been observed to follow nerve injuries, and 
 to occur on those parts of the skin which have been in a con- 
 dition of subacute inflammation for a lengthened period, and 
 in which increased amount of nutrition has been carried to the 
 part. It is thus seen after fractures of bones, and in connec- 
 tion with chronic eczema of the scalp ; or follows the use of 
 irritants to the skin, as vesicators, rubefacients, etc. 
 
 It appears during the climacteric period in females and in 
 younger women suffering from uterine trouble ; temporary 
 hirsuties has been observed to occur during pregnancy, and to 
 disappear after parturition when the menses have been re-estab- 
 lished. 
 
 Treatment. — General hirsuties does not admit of treatment. 
 If only small areas are affected, the hairs can be removed by 
 shaving, by caustic, or by electrolysis. The question of shav- 
 
HIRSUTIES. 447 
 
 ing need not be here discussed. I prefer cutting the hair 
 closely with a pair of scissors, as there is less irritation of the 
 skin produced, and consequently less nutritive material brought 
 to the hair follicles, and a less rapid growth of the hair. 
 
 Depilatories can be used to destroy the upper part of the 
 shaft of the hair, if a fairly large area is to be acted upon. 
 They all act as caustics, and destroy the hair and shaft as deep 
 down as the neck, but the removal is not permanent, and after 
 two or three weeks requires to be repeated. 
 
 The substances generally used are the sulphide of arsenic, 
 sodium, barium, or calcium ; these are made into a paste and 
 laid on the part as a thin coating for ten or fifteen minutes 
 or until there is a feeling of heat in the skin, when they are to 
 be removed and the part washed with water, and powdered and 
 rubbed with oil. Duhring recommends a sulphide of barium 
 paste prepared as follows: 5- Barii. sulphidi, 3 ii., pulv. 
 zinci. ox., pulv. amyli, aa 3 iii. M. This to be mixed with water 
 to form a paste, and applied in the manner already described. 
 
 If the number of hairs to be removed is not too great, de- 
 struction of the hair follicle by means of electrolysis, as origin- 
 ally suggested by Michel and Hardaway of St. Louis, is the 
 best method of removing hair, as it does its work effectually 
 and without producing visible scars. 
 
 It requires much time and patience, and sometimes produces 
 considerable pain, especially in hirsuties of the upper lip ; only 
 the larger hairs should be removed, and if the hairs are closely 
 seated, only a certain munber should be removed at one sit- 
 ting, and these should be removed some distance from each 
 other, because, if a number of closely seated hair follicles are 
 destroyed, the resulting inflammation and destruction of tissues 
 may be sufficient to produce visible scarring. 
 
 The operation itself is easily performed with or without the 
 use of a lens. A fine needle is passed into a hair follicle to its 
 base and connected with the negative-pole of a galvanic bat- 
 tery of from six to fifteen cells, and the circuit completed by 
 the patient holding a sponge electrode in the hand. The 
 needle is held within the follicle until the hair becomes quite 
 
44 8 ONYCHOGRYPHOSIS. 
 
 loose, when it is removed before breaking the circuit. Some- 
 times the operation must be repeated subsequently, as the 
 follicle base is not always fully destroyed at the first sitting. 
 
 ONYCHOGRYPHOSIS. 
 
 Syn. — Hypertrophy of the nails, onychauxis. 
 
 Definition. — An increase in the size or thickness of the nail, 
 from any cause. 
 
 Symptoms. — Hypertrophy of the nails may occur as an idio- 
 pathic disease, or as a consequence of some affection, or in 
 connection with other diseases. The nail may be increased in 
 size, either by increase in its length, breadth, or thickness, or 
 all combined. A nail may be long and of normal width, direc- 
 tion and constitution ; or thin and brittle ; or broad and thick, 
 uneven, and degenerated ; or simply broader and bent or curved 
 at the sides. 
 
 Nails in which onchogryphosis has occurred, that is, in 
 which there is an increase in the size and thickness of the nail 
 from an excessive formation of nail substance, are usually long 
 and do not break off easily. The surface is uneven, has 
 furrows and ridges, and appears as if composed of many 
 lamellae. 
 
 Sometimes nails are deformed, discolored, curved, twisted, 
 conical, or cubical in form, bent forward, or elevated from 
 their bed. When they are broader and curved at the sides, 
 they generally irritate the tissue sufficient to produce an inflam- 
 mation — paronychia. 
 
 Sometimes the nail is detached from its base by collections 
 of a dirty, brownish, lamellar mass beneath ; the bed of the nail 
 is then shortened, thinned, and the nail furrowed and ridged. 
 
 The nails of the large toes are the most frequently affected, 
 and those of the fingers least. 
 
 Hypertrophies of the nails are met with in eczema, lichen 
 ruber, ichthyosis, syphilis, etc. In syphilis the change is caused 
 by syphilitic infiltration of the matrix. The nailifold becomes 
 of a brown or reddish color, and the infiltration usually extends 
 
ONYCHOGRYPHOSIS. 449 
 
 to the surrounding tissue, producing redness, swelling and 
 ulceration. 
 
 In eczema, psoriasis, lichen planus, and onchomycosis, the 
 nails are thickened, brittle, and very uneven on the surface. 
 
 Anatomy. — In pure hypertrophy there is no change in the 
 structure. In excessive and chronic forms the papillae of the 
 matrix are enlarged and the bed of the nail hypertrophied. In 
 those cases in connection with eczema, etc., there is degenera- 
 tion of the nail substance, and on that account should not be 
 classed among the hypertrophies. 
 
 Treatment. — As the nail grows from the matrix our efforts 
 should be to produce a healthy condition of this latter structure. 
 All sources of irritation should be removed, pressure from tight 
 shoes prevented, and the nails be properly trimmed. If a 
 chronic inflammation is present it should be treated by proper 
 ointments, application of iodine, etc. 
 
 Deformed, thickened, curved nails may require the use of 
 scissors, or even a saw to remove the superabundant mass. If 
 the sides of the nail are curved in too much, and cause inflam- 
 mation, they should be treated by the daily application of 
 cotton and charpie between the nail and skin-fold, by which 
 means the nail will gradually be brought to its proper posi- 
 tion. Such nails should always be trimmed by cutting them 
 transversely and not circularly. If the deformity depends 
 upon other diseases than those of the matrix alone, as in 
 eczema and psoriasis, these conditions must be cured before the 
 nail can regain its proper shape. 
 
 29 
 
CLASS VI. 
 
 ATROPHIA. 
 
 Under the term atrophy of the skin are included those con- 
 ditions characterized by simple, numerical or degenerative 
 atrophy of the elements of the skin without a proportionate 
 substitution by new elements of similar physiological value. In 
 simple atrophy there is a diminution in the size ; in numerical 
 atrophy a diminution in the number ; and in degenerative 
 atrophy a change in the quality of the normal elements of the 
 skin. 
 
 Congenital deficient formation of some of the elements 
 (albinismus), though strictly not an atrophic affection, is placed 
 in this class owing to the similarity in the resulting pathological 
 condition with numerical atrophy of the same elements. 
 
 As in the hypertrophies, the atrophy can effect exclusively or 
 principally certain elements of the skin, the pigment, cutis, 
 hair or nails. This class of diseases is consequently divided 
 into the following groups : atrophy of pigment ; atrophy of 
 connective tissue ; atrophy of hair, and atrophy of the nails. 
 
 ATROPHY OF PIGMENT. 
 
 Achromatia, leucoderma, leucopathia, denotes the absence, 
 either in patches or over the whole surface, of the normal pig- 
 ment of the rete Malpighii and hairs. Where the pigment is 
 absent the structures appear of a milk-white or gray color. 
 Atrophy of the pigment of the epidermis is either congenital 
 (albinismus), or acquired (vitiligo). 
 
 ALBINISMUS. 
 
 Syn. — Congenital achroma ; congenital leucopathia ; congen- 
 ital leucasmus. 
 
 Definition. — Congenital absence of pigment in the skin. 
 
ALBINISMUS. 451 
 
 Symptoms. — Albinismus may be general, that is, present over 
 the whole body, when it is called " albinismus universalis ; " or 
 limited in extent, occurring in isolated patches — albinismus 
 partialis or leucopathia. Those individuals in whom it is 
 universal are called albinoes. In these persons there is more 
 or less complete absence of pigment in the skin, hair, iris and 
 choroid. The pupils appear red, the skin is of a milky white 
 or of a reddish tinge, and the hairs of the whole body fine, soft, 
 silky, and generally either of a clear white or yellowish-white 
 color. Owing to the absence of pigment in the choroid and 
 iris, and consequent non-absorption of transmitted rays, the 
 eyes are very sensitive to light ; with a bright light photopho- 
 bia is present ; the pupils contract and dilate continuously and 
 sight is better by a dim than by a bright light. The absence of 
 pigment in albinoes continues throughout their whole life. 
 These people are generally of short stature, and physically and 
 mentally below the normal standard. The pulmonary organs 
 are supposed to be especially predisposed to disease. 
 
 Etiology. — The cause of the deficient development of pig- 
 ment is not known. It is met with in all races and in all 
 climates, but is most frequent among the negroes of warm 
 countries. Normally pigmented individuals can produce albi- 
 noes, but it is not known if albinoes can generate albinoes. 
 
 Albinismus partialis appears more frequently in the colored 
 than in the Caucasian race. This form of albinismus consists 
 in the existence of one or more non-pigmented, whitish or 
 pinkish-white spots of various size and shape, though generally 
 limited in extent and more or less circular in form. They 
 may be present upon any part of the body, are generally irregu- 
 larly situated, but sometimes arranged symmetrically or follow 
 peripheral nerve distribution. They are most frequently pres- 
 ent upon the genital region, hairy part of head and face, nip- 
 ples, back of hands and fingers. The eyes are not affected. 
 The hairs existing upon the patches are often white. 
 
 The patches seldom undergo change during life, but some- 
 times they increase in size, and may even extend so as to cover 
 a large area of surface, or new patches may appear in previously 
 
452 VITILIGO. 
 
 normal skin. Sometimes the patches assume their proper color 
 from a re-deposit of pigment. The hairs change their color as 
 a rule, and become white, or white hairs appear upon normally 
 pigmented skin (leukosis canities). The patches are normal in 
 every respect excepting that of pigmentation, and the remaining 
 skin is normal in character. 
 
 Partial albinismus is frequently, though not always, inherited, 
 and only one of a family may be affected. Cases of semi- 
 albinismus have been described as occurring in Africa ; the 
 complexion in these persons is cafeau lait, the hair a dull 
 yellow, short, kinky, and the pupils light brown. 
 
 Treatment — There is no known means by which pigment 
 can be permanently produced in cases of albinismus. 
 
 VITILIGO. 
 
 Syn. — Acquired leucoderma ; acquired leucopathia ; ac- 
 quired leucasmus ; acquired achroma ; piebald skin. 
 
 Definition. — Vitiligo consists of one or more round, oval or 
 irregularly shaped, sharply limited, smooth white spots, which 
 tend to continuously increase in size, and are generally sur- 
 rounded by abnormally darkly pigmented skin. 
 
 Symptoms. — The disease occurs more frequently in men than 
 in women, and is rare in children. It begins as one or more 
 non-pigmented, white, circular, sharply limited spots which con- 
 tinue to increase in size at the same time new ones make their 
 appearance. In that they increase in size, they may change 
 their form and become angular, etc. Their surface is smooth, 
 without scales, and on a level with the neighboring skin. The 
 skin of the spots is unchanged as regards its resistance, thick- 
 ness, structure, temperature, sensation or its secretory func- 
 tions. Their outlines are sharply defined and are almost inva- 
 riably surrounded by abnormally darkly pigmented skin, which 
 gradually passes into the normally pigmented beyond. This 
 increased pigmentation in the immediately adjoining skin is, 
 when present, characteristic and striking, but is not a constant 
 feature of the disease. 
 
VITILIGO. 
 
 453 
 
 The affection is very chronic in its nature ; in the course of 
 months or years the patches increase rapidly or slowly 
 in size and number, and may occupy the greater por- 
 tion of the cutaneous surface. From their manner of 
 spreading peripherically the white spots generally have convex 
 borders, and the surrounding darkly pigmented skin con- 
 cave borders toward the white patches. At first, on 
 account of the small size of the vitiligo patches, the most 
 striking appearance on the individual is the white spots ; 
 afterward if the non-pigmented spots cover a greater area than 
 the rest of the skin, then the pigmented spots are the most 
 striking feature and may be easily regarded as the abnormal 
 condition. Frequently neighboring spots coalesce by exten- 
 sion, and the patches then assume a gyrate form. The contrast 
 between the white spots and the surrounding darkly pigmented 
 skin is greater in summer than in winter on account of the in- 
 creased pigmentation of the latter at that time. 
 
 Fig. 54. — Leucoderma in a colored woman. 
 
 The accompanying illustration, for which I am indebted to 
 
454 VITILIGO. 
 
 Dr. Johnson of Wilmington, N.C., shows well-developed leuco- 
 dermic patches. 
 
 The spots frequently originate in the immediate vicinity of 
 a pigmented nsevus or of a brown wart, or they commence on 
 the forehead, hairy portions of the head, back of the hands, 
 genitals or mons veneris. 
 
 The hair upon the vitiligo spots is generally white and if 
 seated upon the hairy scalp the white tuft in the surrounding 
 black hair is very conspicuous. Apart from the absence of 
 pigment, the skin always remains, as far as can be observed, 
 perfectly normal, and the general condition of the system is 
 unaffected by the disease. 
 
 Non-pigmented spots are met with as consecutive conditions 
 of some other morbid states of skin, for instance in morphcea, 
 scleroderma, lepra, furunculosis, variola, lupus, ulcerations, 
 broad condylomata, gummata, pressure, etc. These are not 
 true idiopathic vitiligo spots, and will be described in connect- 
 ion with the disease by which they are produced. 
 
 Anatomy. — The only changes which have been observed in 
 the skin are, an absence of pigment in the white patches, and 
 an increase of pigment in the surrounding abnormally dark 
 skin. 
 
 Etiology. — Vitiligo appears more frequently in negroes, and 
 in warm climates. It appears most frequently in middle life ; 
 is more frequent in men than in women, and is rare in chil- 
 dren. It attacks robust as well as ill-nourished persons. 
 In some cases disturbance of general innervation, the result of 
 exhausting diseases, causes its appearance. In the majority of 
 cases the etiology is unknown. 
 
 Diagnosis. — Vitiligo may be confounded with morphcea or 
 lepra. In morphoea, besides the white spots, there are marked 
 structural changes in the corium which are never met with in 
 vitiligo, the skin in the latter being apparently normal in every 
 respect except as regards pigmentation. In lepra white spots 
 surrounded by hyper-pigmented skin are present. Sometimes 
 the spots are of irregular shape, not sharply defined, and the 
 skin is thickened and often anaesthetic. 
 
CANITIES. 455 
 
 Prognosis. — The patches generally increase slowly or rap- 
 idly through life until a large portion of the surface is changed. 
 One or all of the spots may temporarily, or even permanently, 
 cease spreading, and some few cases have been reported in 
 which the skin has again become normal. This return to a 
 normal condition is however a very rare occurrence. The dis- 
 ease has no effect upon the constitution, the only unpleasant 
 result being the disfigurement produced when present upon ex- 
 posed parts of the body. 
 
 Treatment. — The general condition of the system must re- 
 ceive strict attention and any functional derangement, more 
 especially of the nervous system, demands its appropriate 
 treatment. Arsenic should always be administered internally, 
 and its use continued for some time. With reference to local 
 treatment there is no known agent by which pigment can be 
 permanently reproduced, or the spots hindered from extend- 
 ing, or the development of new spots prevented. By the ap- 
 plication of substances which irritate or inflame the skin, as 
 tincture of cantharides, croton oil, mustard blisters, and sul- 
 phuric acid, a patch can temporarily be colored brown. The 
 newly produced pigment, however, soon disappears, and no 
 new pigment is subsequently formed. As the only unpleasant 
 feature of the disease is the disfigurement of the exposed por- 
 tions of the body, this can be best remedied by the removal 
 of the pigment from the brown patches. For this purpose 
 those substances are made use of which have already been de- 
 scribed when treating of chloasma ; for instance acetic, hydro- 
 chloric and nitric acids, potash, soda, ammonia, bismuth, white 
 precipitate and corrosive sublimate. For the mode of applica- 
 tion the reader is referred to the article on chloasma. 
 
 CANITIES. 
 
 Syn. — Poliosis; trichonosis discolor (Wilson); grayness of 
 the hair. 
 
 Definition. — Grayness or whiteness of the hair from diminu- 
 tion or absence of pigment. 
 
456 CANITIES. 
 
 Symptoms — Deficient pigment in the hair may be general or 
 partial, hereditary or acquired. 
 
 Hereditary deficiency is seen in albinismus, when it is either 
 general or partial. When general, there is absence of pigment 
 in the skin also (general albinismus.) In hereditary partial 
 canities the non-pigmented hairs may be seated upon pig- 
 mented or non-pigmented skin. 
 
 Acquired canities can be either physiological or patholog- 
 ical, that is, it may occur as the result of the normal physiolog- 
 ical changes in the tissues, the result of advanced age — canities 
 senilis ; or it may occur before the normal or proper time — 
 canities prematura. 
 
 Canities Senilis. — The period at which this form occurs va- 
 ries in different persons but always takes place in the individ- 
 uals who live to an advanced age. It generally commences on 
 the temporal region, a few isolated hairs first becoming gray, then 
 more and more, the area of grayness constantly increasing, un- 
 til finally all the hairs of the head become changed. Those of 
 the occipital region, at its lower part are generally the last to 
 change. Sometimes the beard changes before the hair of the 
 head. The hairs of the whole body finally change. Dark 
 brown hair changes earlier than blonde. The skin of the 
 affected parts retains its normal amount of pigment. 
 
 Canities prcematura. — Grayness of the hair before the normal 
 physiological period may be either general or partial, extending 
 over the whole head and beard or present only in patches. 
 The color can vary from slight grayness to white. The first 
 gray hairs often contain some pigment. Frequently a pig- 
 mented hair falls out and is replaced by a non-pigmented one. 
 Individual hairs may be speckled, pigmented alternating with 
 non-pigmented rings. This arises from the pigment being ir- 
 regularly distributed by the papilla to the growing hair. Hairs 
 always become gray at the bottom first, so that at the com- 
 mencement of the process, the distal portion of the affected 
 hairs is of the normal color and the inner part non-pigmented ; 
 except in the case of the falling out of a pigmented hair and 
 its substitution by a new non-pigmented one. 
 
CANITIES 457 
 
 A follicle from which a gray hair has formed, generally pro- 
 daces subsequently only gray hairs, but sometimes, perhaps 
 only after a long period has elapsed, partly or fully pigmented 
 hairs are again produced. Hairs may be grayish in winter and 
 darker again in summer (Wilson.) The skin at the seat of the 
 canities is generally pigmented. 
 
 Etiology. — Canities depends upon a deficient production of 
 pigment. The color of the hair depends principally upon the 
 pigment contained in the fibrous portion of the hair shaft. If 
 the peripheral layer of the hair shaft contains air and no pig- 
 ment, whilst the central part is pigmented, the hair will appear 
 to be white. The black, brown, or blonde color of hair de- 
 pends upon the quantity and manner of distribution of the pig- 
 ment. All the pigment comes from the papilla, hence in ca- 
 nities less pigment than normal is furnished by this structure. 
 The conditions which interfere with the normal production of 
 pigment are not always clear. Premature canities is often he- 
 reditary. Conditions interfering with the nutrition or innerva- 
 tion of the part, as seborrhcea, or with nutrition in general, as 
 chlorosis, typhus, scarlatina, are sometimes followed by grayness 
 of the hairs. Hair has turned gray after ligature of the carotid 
 (Med. Chir. Trans., 1881. p. 252), and after injury to nerves. 
 Grayness seldom occurs before adult life. Premature grayness 
 is frequently hereditary. As the change in color depends 
 upon a deficient supply of pigment, from the papilla to the 
 hair shaft, hence grayness occurs only as rapidly in an individ- 
 ual hair as the time required for the physiological growth of 
 the hair to the length of the gray portion. Whether hair ever 
 becomes suddenly white from fright or anxiety is still a matter 
 of dispute. Until positive proof is produced as to its occur- 
 rence we are justified on physiological grounds in doubting its 
 possibility. 
 
 Prognosis. — Canities partialis is generally permanent. Gen- 
 eral premature canities is usually permanent, but sometimes the 
 hair becomes pigmented again. Canities following typhus, chlo- 
 rosis, scarlatina, may be only temporary. 
 
 Treatment. — As there are no known means by which pig- 
 
458 
 
 CANITIES. 
 
 ment can be furnished the hair from the papilla we must rely 
 upon dyes to remedy the premature grayness. The objections 
 to their use are the discoloration of the scalp, the dry, dead 
 condition, as a rule, of the hairs from the application ; and on 
 account of the constant growth of the hair the necessity for 
 frequent applications to the part next to the skin. The dye in 
 most frequent use is probably the nitrate of silver in watery so- 
 lutions of different strength according to the effect desired. 
 The mode of application is as follows : first wash the hair with 
 soap and water, then dry well and apply the nitrate of silver 
 solution. To prevent discoloration of the surrounding skin, the 
 latter should be washed with a solution of chloride of sodium. 
 The sunlight soon changes the hair to a brown or black. So- 
 lutions of nitrate of silver and sulphuret of potash in varying 
 strength according to the effect desired, the one solution to be 
 applied directly after the other, are often used. All fat oils give 
 a darker color to the hair ; they can be used alone or as a 
 pomade thus : 
 
 Olei ovorum 20 
 
 
 3v. 
 
 Medull. ossium bovis. 20 
 
 
 3v. 
 
 Lact. Ferri 1 
 
 5° 
 
 31 
 
 01. Cassiae aeth. 1 
 
 
 grs. xv. 
 
 Pfaff. 
 
 Kaposi gives the following formulae for dyes : 
 To produce a black color. 
 
 $ Argent. Nit. 
 Ammon. Carb. 
 Ung. emoll. 
 
 1 
 
 5° 
 30 
 
 3 
 
 $ 
 
 Argent. Nit. 1 
 
 Aquae destil. 60 
 
 Liq.Hydrarg.Nit.oxyd. 5 
 Spir. Resedae 5 
 
 Argent. Nit. 
 
 5 
 
 Plumbi Acet. 
 
 1 
 
 Aquae Rosse 
 
 100 
 
 " Colog. 
 
 1 
 
 grs. 
 
 XV. 
 
 grs. xxii. 
 
 grs. 
 
 5 
 
 3 
 
 XV. 
 
 ii. 
 
 iv. 
 
 3 
 
 iv. 
 
 3 
 
 iv. 
 
 grs. 
 
 1 
 
 XV. 
 
 iii 
 
 grs. 
 
 XV 
 
ATROPHIA CUTIS PROPRIA. 459 
 
 For a brown shade. 
 
 3 Acid, pyrogall. i 
 
 Aq. Rosae. 40 
 
 Spir. Colog. 2 
 
 grs. xv. 
 3 x. 
 
 3 ss. 
 
 For coloring the hair black the Persians use the powder of 
 dried henna plant and powdered indigo plant. The hair is first 
 well washed with soap and water, then the powered henna is 
 made to a thick paste with lukewarm water, and applied to the 
 hair. This is left an hour, then removed with lukewarm water, 
 when the hair will have assumed an orange or saffron color. 
 Then the leaves of the indigo plant are powdered and made to 
 a paste with water and applied. This second application is left 
 one hour and a quarter and then removed by means of water. 
 In a few hours the hair will have become black. If a light or 
 dark chestnut brown is desired, take one part of henna and three 
 parts of indigo, mix, make into a paste and apply. The longer 
 the paste remains on the hair the darker will be the color. For 
 a clear brown leave one hour, and for a dark, one hour and a 
 quarter. (Polak quoted from Neumann.) 
 
 ATROPHIA CUTIS PROPRIA. 
 
 Definition. — Diminution in the bulk or quantity, generally 
 both, of the elements composing the skin. 
 
 Symptoms. — Atrophy of the skin may be idiopathic or 
 consecutive, diffuse or partial. Idiopathic atrophy may be 
 diffuse or partial. As examples of the diffuse form, we have 
 xeroderma and senile atrophy. As examples of the partial form 
 are the atrophic lines and spots — striae et maculae atrophicae. 
 General idiopathic atrophy of the skin is rare, and according 
 to Kaposi, is found under two forms. A case of the first form 
 he describes as follows : " The skin of the face, ears, neck, 
 shoulders and breast, to a level with the third rib, was tightly 
 stretched, felt very thin and could with difficulty be raised in 
 folds. The surface was smooth in some places, in others, desqua- 
 mating or finely fissured, wrinkled, parchment-like and tightly 
 stretched. Small and large freckle-like yellowish-brown spots 
 
460 ATROPHIA CUTIS PROPRIA. 
 
 were present, and between them the skin was either normal or 
 contained cicatrices like those following small-pox. Here and 
 there were bright red, small telangiectases. The subcutaneous 
 tissue was not specially diminished. Sensibility was normal. 
 The skin on the rest of the body was normal. General health 
 was good. It had commenced in early childhood and showed 
 constant increase." 
 
 The disease may appear on other parts of the body, as the 
 dorsum of the foot. It commences apparently, first, by dilata- 
 tion of the bloodvessels and pigmentation, then destructive retro- 
 grade changes occur and cicitricial tissue forms; later, on account 
 of the shrinking, rhagades, inflammation or ulceration may 
 occur. If the eruption is seated upon the face, as it was in the 
 case above reported, the nasal and aural orifices become con- 
 tracted and ectropia is produced. 
 
 According to Geber, this form commences as a proliferation 
 of the connective tissue of the corium and endothelial of the 
 bloodvessels with subsequent atrophy, then destruction and 
 consecutive pigmentation. 
 
 There is proliferation of the inter-papillary rete, and degen- 
 eration of glandular epithelium. 
 
 The prognosis is unfavorable. 
 
 Treatment. — This consists in relieving the subjective symp- 
 toms, pain, dryness of the skin, and attention to any rhagades 
 or ulcers which may form. 
 
 In the second form of the disease the affection extends from 
 the middle of the thigh to the foot, more rarely does it occur 
 upon the arms ; the skin is white, stretched, difficult to raise in 
 folds, and the epidermis is thin, wrinkled and desquamating. 
 On the tips of the fingers, palms of the hands and soles of the 
 feet, the sensibility to pressure is very great on account of the 
 absence of the protecting epidermis. This form remains station- 
 ary from childhood, and the treatment is purely symptomatic. 
 
 Senile atrophy. — This condition of the skin is the result of 
 old age and the structural change may be that of simple 
 atrophy, or of the nature of a degenerative process, or of both 
 combined. 
 
ATROPHIA CUTIS PROPRIA. 46 1 
 
 In simple atrophy the skin is thin, the surface sallow, dark- 
 brown in color, dry and scaling (pityriasis tabescentium). 
 
 The anatomical changes are as follows : The epidermis is thin, 
 the papillae small or absent, the corium is thin, and its bloodves- 
 sels are partly destroyed or dilated. The hair is fine or absent. 
 The sebaceous glands are dilated in places and the epithelium 
 degenerated. The fat cells of the subcutaneous tissue are soft 
 or absent. 
 
 In the degenerative form the connective tissue undergoes an 
 amyloid, colloid, waxy or fatty degeneration. 
 
 Glossy skin. — This condition is secondary to some disorder of 
 nervous system, and is the result of impaired nutrition of the 
 part. It follows wounds, intractable neuralgias and other 
 lesions of the nerve trunks. It may occur also in progressive 
 muscular atrophy. The skin has a purplish, reddish, smooth, 
 shining and glossy appearance, like in chilblains; the hair of the 
 part usually falls out ; the natural lines of the skin disappear ; 
 fissures and excoriations may be present, and a burning pain. 
 
 Strice et maculce atrophica. — This consists in the formation 
 of lines or spots of atrophied tissue, and is either idiopathic or 
 symptomatic. 
 
 The idiopathic form appears as lines, streaks or spots, but 
 most frequently as lines ; these lines are one to two inches in 
 length ; the spots are roundish or ovalish in shape, and from 
 pin-head to finger-nail in size ; at first they are erythematous 
 in appearance, and afterward resemble scars ; they are smooth, 
 glistening, of a whitish, grayish or mother-of-pearl color and de- 
 pressed beneath the general surface. The lines are parallel 
 with each other, run in an oblique direction, and there are usu- 
 ally several in the same region. Spots, when present, are usually 
 isolated. 
 
 The atrophy may occur on any part of the body, but is most 
 frequent on the buttock, around the pelvis and on the thighs, 
 and is rare on the body, neck and arms. The spots appear 
 equally on both sexes, at all periods of life, last many years, 
 and cause no inconvenience. 
 
 The changes which occur in the skin are similar to those 
 
462 ALOPECIA. 
 
 already described as occurring in general atrophy ; there are 
 first changes in the bloodvessels, then atrophy of the epider- 
 mis, corium, subcutaneous tissue and the bloodvessels. 
 
 In the symptomatic form the atrophy may be simple, or of a 
 degenerative nature ; simple atrophy is caused by pressure 
 upon the tissues, leading to their atrophy, rupture or inflamma- 
 tion. 
 
 If the extension of the tissues is temporary, as occurs in 
 pregnancy, then atrophic lines result. 
 
 In symptomatic degenerative atrophy the same changes occur 
 in the skin as in senile atrophy. 
 
 The usual cause is chronic inflammation and new growth 
 formation in the general surface. It may also arise from chronic 
 eczema, pemphigus, pityriasis rubra, etc. 
 
 ALOPECIA. 
 
 Syn. — Calvities. 
 
 Definition. — Alopecia consists of a partial or complete de- 
 ficiency of hair due to a variety of causes. 
 
 Under the designation of alopecia we include not only those 
 more marked forms of baldness affecting the hair of the head, 
 beard, eyebrows, etc., but also those partial losses of hair 
 known as effluvium pilorum, or madesis, etc. In a large ma- 
 jority of cases the hair of the head alone is affected ; in rarer 
 instances the disease attacks the beard and eyebrows ; and 
 very exceptionally it invades the hair of the genital and pubic 
 regions, the axillae, etc. Cases of baldness have also been 
 noticed in which the hair of the entire body, even the lanugo, 
 hairs has been affected. 
 
 Certain varieties of baldness are not properly classified under 
 the head of simple alopecia, and by their exclusion the field of 
 the disease is considerably narrowed. Alopecia areata is im- 
 portant enough, and is possessed of enough points of distinc- 
 tion to merit a separate mention. The baldness that occurs in 
 ringworm and favus is secondary and symptomatic, and will be 
 fully described under the heading of these diseases. Lastly, 
 
ALOPECIA. 463 
 
 alopecia furfuracea is the direct result of seborrhcea, and has 
 been considered with it. 
 
 There remain for consideration various forms of baldness, 
 some hereditary and some acquired. It will be appropriate to 
 mention the causes and symptoms of the several varieties sep- 
 arately, and then to consider collectively their prognosis and 
 treatment. 
 
 1. Alopecia Adnata. — Congenital alopecia may consist of an 
 entire absence of hair over greater or less extensive surfaces 
 usually covered by it, or it may appear as a general scantiness 
 of these appendages. In certain rare cases there is an entire 
 absence of hsir, and microscopic examination has demonstrated 
 the absence of hair bulbs from the skin. The condition is 
 to be regarded as an arrest of development, and is sometimes 
 associated with deficient formation of other structures, as the 
 teeth. Hereditary predisposition is marked, and the deficient 
 development of the hair often runs in families. 
 
 2. Alopecia acquisita naturally includes all forms of simple 
 alopecia, beginning in extrauterine life. We divide them again 
 into a. senilis and a. prematura, according as they manifest 
 themselves in old age or during early adult life. 
 
 Alopecia senilis. — Senile calvities, the baldness of old age, 
 is but one of the many evidences of diminished nutrition, and 
 atrophy of the tissues which accompany advancing years. 
 When the subcutaneous tissues begin to atrophy, the glandular 
 structures, including the hair bulbs, share in the process. 
 Usually, the hairs first turn gray, then become dry and thin, 
 and when they fall, are not replaced by a new growth. The 
 process usually begins upon the forehead, and extends back- 
 ward until the whole vertex is bare ; but the hair almost 
 always persists over the occipital and temporal regions. The 
 affected skin shows other signs of retrogressive change ; it is 
 smooth, shining, lightly stretched and adherent to the subja- 
 cent tissues. A few soft, woolly hairs may still be present, 
 but in advanced cases the orifices of the glandular structures 
 are hardly visible. Microscopically, the sebaceous glands of 
 the affected skin are found deformed, the hair follicles are 
 
464 ALOPECIA. 
 
 atrophied, the papillae absent in many cases, and some, per- 
 haps, contain a stunted and minute hair. The fat cells of the 
 subcutaneous tissue are shrunken in size and diminished in 
 number ; the corium is thinned, and its connective tissue 
 bundles have undergone a fatty, colloid, or pigmentary degene- 
 ration. 
 
 Senile alopecia is generally, but by no means invariably, 
 preceded by grayness of the hair. It is curious that, though 
 the atrophic processes are quite general throughout the body, 
 the hair of the beard and other parts is but rarely affected. 
 It is also to be remarked that women seldom suffer from this 
 variety of baldness. 
 
 Under alopecia prematura, we class the various forms of 
 simple idiopathic or symptomatic baldness occurring during 
 early life. 
 
 Of these, alopecia prematura idiopathica is one of the com- 
 monest. The disease commonly manifests itself during the 
 third decennium of life, and begins with an increase above 
 the normal in the number of hairs cast off daily. At first, 
 these hairs are replaced by others, thinner and shorter ; but at 
 last they cease to be reproduced, and a gradual diffuse thinning 
 of the hair results. Withal the scalp continues apparently per- 
 fectly healthy ; there is no seborrhcea and no atrophy. The pro- 
 cess may be rapid ; but it usually takes years to run its course, 
 and results in permanent baldness. Its location is the same as 
 that of the senile alopecia ; and like the latter affection, it is 
 much more frequently found in men than in women. Micro- 
 scopically, an increase in the connective-tissue elements of the 
 skin, with consequent contraction, compression of the vessels, 
 and interference with the blood supply, has been observed. 
 
 A. prematura symptomatica includes the remaining forms of 
 simple alopecia. Falling of the hair, and more or less extensive 
 baldness is apt to occur during convalescence from certain 
 acute diseases, especially the fevers, and has also been noticed 
 as a consequence of severe nervous shock, or long-continued 
 mental strain. In these cases the alopecia is usually only 
 temporary. Under this head is also to be mentioned the 
 
ALOPECIA. 465 
 
 alopecia resulting from affections of the skin involving the hair 
 follicles. Thus in variola, acne, lupus, ulcerative syphilitic 
 affections, etc., the hair is destroyed over more or less exten- 
 sive areas. In certain affections the hair papillae are compro- 
 mised by the small-celled infiltration which occurs ; as is the 
 case in lichen ruber, lupus erythematosus, and in the small 
 papular syphilide. In sycosis non-parasitica or perifolliculitis 
 barbae, the hair papillae are destroyed by the periglandular in- 
 flammation. In favus and trichophytosis, the parasite invades 
 the hair follicles, causes the hair to loosen and fall out, and 
 eventually causes destruction of the papillae. Acute eczema- 
 tous processes, erysipelas of the head, etc., also cause loosen- 
 ing and falling of the hair. In all these cases the alopecia is 
 symptomatic and merely deserves mention here ; under the 
 heading of each disease the subject will be more fully dis- 
 cussed. 
 
 It remains for us to notice briefly the alopecia of syphilis. 
 Falling of the hair occurs in syphilis, during the early stages, 
 as one of the secondary symptoms. Later on it may occur in 
 consequence of the general cachexia, or over localized patches, 
 from specific ulceration and destruction of the skin. The 
 early syphilitic alopecia is one of the most constant manifes- 
 tations of the disease. It generally occurs during the first six 
 months ; the hairs become dry and brittle, and fall out in 
 varying quantity. Usually only part of the hairy covering is 
 lost, but in some cases complete baldness results, even the hair 
 of the eyebrows and lashes, of the pubis and general surface, 
 falling off. However extensive the alopecia from this cause 
 may be, it is not permanent ; in a few months or a year or two, 
 the hair is reproduced, especially if the patient be under ap- 
 propriate treatment. The alopecia resulting from the later 
 ulcerative lesions is of course permanent. 
 
 Etiology. — Lately the contagious character of alopecia 
 prematura has been proclaimed. Positive proof thereof is not 
 as yet before us, but a series of experiments undertaken in 
 1882 by Lasser and Bishop, render it probable that the 
 affection is sometimes communicable from one individual 
 30 
 
466 ALOPICIA. 
 
 to another. These observers succeeded in causing baldness in 
 various animals by inunctions of ointments, which con- 
 tained the fallen hair and epidermis scales obtained from the 
 brushes of a marked case of alopecia prematura. Under a 
 vigorous plan of treatment the patient recovered, and it was 
 found that baldness could no longer be produced by the ap- 
 plication to the skin of animals of the detritus from his 
 brushes. The whole subject is as yet an obscure one ; but in 
 view of extensive use of common brushes in the barber-shops 
 to-day, it is one of special interest to many persons. 
 
 The etiology of the other forms of alopecia, in so far as we 
 know anything about them, may be gathered from the descrip- 
 tions of the individual varieties. 
 
 Diagnosis. — The determination of the kind of baldness 
 present is usually easy when the extent and location of the 
 process, together with the age of the patient and the presence 
 or absence of other affections causing baldness, is taken into 
 account. 
 
 Prognosis. — Senile alopecia, being one of the inevitable re- 
 trogressive changes of advanced life, cannot be remedied. Con- 
 genital alcpecia is usually partial and does not need treatment. 
 Syphilitic alopecia tends to recovery of itself. Simple prema- 
 ture alopecia usually admits of good prognosis ; whilst that of 
 the symptomatic forms naturally depends upon the disease 
 that causes them. 
 
 Treatment. — In a general way, the treatment of alopecia is 
 the same as that prescribed at length for alopecia areata. 
 Attention to the general health, together with the prolonged 
 use of the various stimulating and irritating lotions, keeping 
 the scalp permanently red and increasing the vascular and nu- 
 trient supply of the hair-follicles, are the main points. For 
 the details of treatment the reader is referred to a. areata. 
 
 Congenital alopecia is usually slight — and does not require 
 treatment. In the senile forms it is useless to attempt it. But 
 in the premature baldness much good may be done by appro- 
 priate measures. 
 
 In symptomatic baldness the treatment is necessarily that of 
 
ALOPECIA AREATA. 467 
 
 the primary disease — eczema, psoriasis, favus, ringworm, 
 syphilis, seborrhcea, etc. In conjunction therewith the vari- 
 ous local measures detailed under the head of the treatment of 
 alopecia areata may be employed. 
 
 ALOPECIA AREATA. 
 
 Syn. — Area Celsi, alopecia circumscripta, porrigo decalvans, 
 tinea decalvans. 
 
 Dcfiiiition. — Alopecia areata is an atrophic affection of the 
 hairy system characterized by the more or less sudden ap- 
 pearance of one or more circumscribed, whitish, bald patches, 
 varying in size or shape. 
 
 Symptoms. — Alopecia areata affects most often the scalp, but 
 is also met with occasionally upon other hairy portions of the 
 body ; no subjective symptoms of any kind mark its onset. 
 The patient may wake up in the morning to find a quantity of 
 loose hair upon his pillow and a bald spot upon his head. Or 
 he may simply notice for several days or weeks that his hair 
 is falling out, until at length the spot has attained such a 
 size that it is discovered by himself or his friends. These 
 bald patches are circular or oval in out-line ; at first quite 
 small, they may gradually increase until they cover surfaces 
 as large as the palm of the hand. One patch only, or 
 several may be present ; their commonest seat is over the 
 parietal regions. The skin of the affected area does not 
 look natural, it is smooth, shiny, chalky white ; but there 
 is no desquamation, or the slightest sign of inflammation. (See 
 fig. 55). At the periphery of the patch the hairs are thin, short, 
 and quite loose ; a very moderate amount of traction is suf. 
 ficient to pull them out. By the falling of these peripheral 
 hairs the disease gradually extends. The patches become 
 larger, and adjacent ones coalesce, until, perhaps, eventually 
 only a thin fringe of hair remains extending from each ear 
 to the nape of the neck, or the whole surface may even become 
 as smooth as a billiard ball. Often the disease is unilateral. 
 
 In these extensive cases the skin becomes dry and thin; the 
 
468 
 
 ALOPECIA AREATA. 
 
 orifices of the follicles become inappreciable ; and the shining 
 surface looks like the scalp of alopecia senilis. Usually thin 
 lines of lanugo hair remain to mark the divisions of the original 
 areas. 
 
 After persisting for a variable time, usually for months, the 
 
 Fig. 55. — Case of alopecia areata. 
 
 process comes to a standstill. Then after a short time, a thin 
 growth of lanugo hair begins to appear upon the previously 
 hairless areas. These short and woolly hairs may gradually 
 become stronger ; but in most cases they also fall out, perhaps 
 more than once, before the real growth begins. In the most 
 
ALOPECIA AREATA. 469 
 
 promising cases it takes six months before a growth of vigor- 
 ous hair is re-established, and it is often several years before 
 the normal amount returns. In some cases nothing stronger 
 than lanugo hairs ever grows from the affected follicles. 
 
 In a considerable number of cases the hair of other 'por- 
 tions of the body is involved at the same time. Everywhere 
 the process begins at the characteristic circular bald spots. 
 Beard, eyebrows, axillary and pubic hair may all fall, and in 
 certain cases the entire skin becomes as smooth as that of an 
 eel. 
 
 As before stated, subjective symptoms are almost always 
 absent. Burning and itching, etc., have been observed in some 
 cases. 
 
 Anatomy. — Nothing very positive has been found in the 
 microscopic examinations which have been made. There is 
 more or less atrophy of the hair shafts and bulbs, sometimes 
 bulging or breaking of the hair. The hairs, in fact, are in the 
 condition of hairs that have reached the end of their life- 
 history. Most competent observers have failed to find any 
 constant alteration either in the glandular structures, or in the 
 constituents of the skin itself. The question as to whether the 
 affection is parasitic in origin or not is still undecided. There 
 are many points in its clinical history that favor the parasitic 
 theory, but the failure of so many competent observers to 
 find a fungus and the absence of any apparent contagiousness 
 leaves the matter in doubt. I have examined many hundred 
 sections and hope soon to arrive at some definite conclusion in 
 the matter. 
 
 The appearances of extracted hairs are shown in figs. 56, 57, 
 58 and 59. 
 
 Diagnosis. — Ringworm of the head is the disease most liable 
 to be confounded with alopecia areata. In tinea tonsu- 
 rans the baldness is incomplete, the patch is reddened, thicken- 
 ed, and slightly scaly ; in fact the symptoms of the accompany- 
 ing eczema are almost always to be found. The short, rubbed- 
 off and split hairs also are characteristic of the parasitic dis- 
 ease ; and there is almost always to be obtained the history of 
 
47o 
 
 ALOPECIA AREATA. 
 
 contagion. Finally, in doubtful cases, the microscope will 
 always settle the difficulty. In alopecia areata there is atrophy 
 of the hair and bulb : in tinea tonsurans the trichophyton will 
 
 Fig. 56. 
 
 Fig. 57. 
 
 Fig. 58. Fig. 59. 
 
 always be found in the follicle, and is often seen invading the 
 hair-bulb and shaft itself. 
 
 Favus can hardly be mistaken for alopecia areata, distin- 
 guished as the former disease is by the characteristic yellowish 
 crusts and the cicatrices. 
 
 Etiology. — The etiology of alopecia areata is as yet one of 
 the disputed points in dermatology. The disease occurs most 
 commonly in children ; the majority of these patients are from 
 six to twelve years of age. It almost invariably begins before 
 
ALOPECIA AREATA. 471 
 
 puberty. A single congenital case is reported by Michelson. 
 It is commoner in the male than in the female sex. 
 
 It has been claimed that the disease is invariably seen in 
 patients suffering from defective nutrition of some kind. This 
 is certainly not the case ; children of the sturdiest growth seem 
 to be just as liable to it as those affected by rachitis, scrofula, 
 etc. It is surely not contagious, though a certain number of 
 cases are on record in which two or more members of the same 
 family have suffered from it. 
 
 Various observers have claimed for alopecia areata a para- 
 sitic origin. Gruby, in 1843, described a parasite which he 
 called the microsporon Audouini, and more recently Melassez 
 and Eichorst and Thin have made observations which support 
 his claims. Nevertheless, in the vast majority of cases, and by 
 the greater number of competent observers, no parasite has 
 been found ; and its evidently non-contagious character militates 
 against the view. 
 
 We are forced, then, to refer alopecia areata to nervous influ- 
 ence, and at the present day most dermatologists look upon the 
 affection as a trophoneurosis. Its occurrence together with 
 neuralgias, morphcea, and other distinctly neurotic affections, as 
 well as its appearance after nervous shocks, frights, etc., points 
 in that direction. In fact, the falling of the hair is to be looked 
 upon simply as one of the effects of the impaired nutrition of 
 the skin. Perhaps the disease has been entirely too sharply 
 distinguished from the other varieties of baldness. Bohn re- 
 gards it as a special kind of alopecia prematura, differing from 
 the ordinary varieties in its frequently sudden onset, its peculiar 
 localization, and its better prognosis. 
 
 Prognosis. — In young individuals the ultimate prognosis is 
 almost always good, though it may be months or years before 
 recovery takes place. In older cases recovery does not so often 
 occur ; but even in the worst instances the patient suffers from 
 nothing more than the deformity which the malady occasions. 
 
 Treatment — A variety of local and general measures are em- 
 ployed in the treatment of alopecia areata ; but it does not 
 seem that by their use we can with certainty cut short the 
 
47 2 ALOPECIA AREATA. 
 
 natural cause of the disease or prevent new centres of baldness 
 appearing. This is not surprising if we consider that, to the 
 best of our present knowledge, alopecia areata is a trophoneu- 
 rosis, regarding the real cause of which we are entirely ignorant. 
 Nevertheless, a vigorous internal and external treatment does 
 perhaps stimulate the growth of strong hair on the affected 
 spots, and is certainly of benefit in sustaining the morale of the 
 patient during the tedious course of the malady. 
 
 The general treatment is of the most moment. It should 
 consist in the use of tonics — iron, quinine, cod-liver oil, the 
 mineral acids, etc., continued for long periods of time. Arsenic 
 seems to be of especial importance, and it should always be 
 used in conjunction with other measures. Any concomitant 
 disease or diathesis should also be appropriately treated . 
 
 A wide field is open to us in our choice of local remedies to 
 apply to the affected skin ; but they all consist of applications 
 that stimulate the vascular supply of the diseased tissues and 
 thus better the nutrition of the papillae and hairs. Alcoholic 
 and etherial fluids form the basis of most of the recommended 
 lotions, and with them may be combined various rubefacients 
 and irritants — cantharides, mercurials, capsicum, etc. Perhaps 
 as good a one as any is a one to three-grain solution of the 
 corrosive chloride of mercury to the ounce of alcohol or 
 cologne water. An ounce each of the tincture of capsicum, of 
 the tincture of cantharides, and of alcohol, together with a 
 drachm of castor oil is also beneficial. The oleate of mercury, 
 2 $to lofo solution, does very well in many cases. Hebra and 
 Kaposi recommend the etherial oils in alcoholic solution — thus 
 I£. 01. macis, 3 ii. ; spts. vini rect, spts. lavand, aa § ii. Tar 
 or carbolic acid, 3 i. to § vi. of alcohol, with 5 i. of glycerine, 
 may also be employed. Tincture of aconite, and tincture of 
 veratrum viride, combined with some of the above solutions, are 
 useful. Aq. ammonia forms one of the commonest of the 
 applications used in the disease. The tincture of green-soap 
 may also be used. 
 
 Various ointments maybe employed. Chrysarobin, in 5-15$ 
 ointment, each application being preceded by vigorous friction 
 
ATROPHIA P1LORUM PROPRIA. 473 
 
 of the scalp with soap and water and a rough towel, is very 
 good. 
 
 Blistering the affected areas has been successfully used in 
 many cases. Oil of turpentine, oil of almonds, etc., may be 
 rubbed into the scalp with a hard brush twice daily. In very 
 obstinate cases the scalp may be kept reddened by the use of 
 croton oil, one part to two or four of olive oil. 
 
 Finally, in the most obstinate cases, electricity may be em- 
 ployed, and quite recently the subcutaneous injection of 
 muriate of pilocarpin has been recommended. 
 
 As a rule, all these cases can bear strong applications ; which- 
 ever one we employ we must use it strong enough and often 
 enough to keep the skin of the affected areas permanently 
 reddened. 
 
 ATROPHIA PILORUM PROPRIA. 
 
 Atrophy of the hair occurs under a variety of conditions, 
 most of which, however, are symptomatic. To this class be- 
 long those instances of impaired nutrition of the hair which we 
 remark in syphilis, and during the course of the various fevers ; 
 as also that occurring in the parasitic diseases, tinea tonsu- 
 rans, favus, and also that seen in seborrhcea of the scalp. In 
 fevers the hair becomes dry and lustreless, exactly as the 
 analogous structure, the epidermis, becomes harsh and devoid 
 of moisture. The hairs are very hygroscopic and usually ab- 
 sorb a large part of both the insensible and the sensible per- 
 spiration from the scalp. During the febrile process the amount 
 of moisture excited by the perspiratory glands is much les- 
 sened, and the hairs suffer. In tinea and favus the parasite 
 invades the hair shaft, the cortical substance is split by the 
 proliferating mass, the hair breaks off, leaving the proximal end 
 projecting like a minute brush above the surface of the skin. 
 These varieties of atrophy of the hair are, however, more prop- 
 erly considered elsewhere. Here we have to describe two 
 forms of idiopathic atrophy of the hair, namely, fragilitas 
 crinium, and trichorexis nodosa. 
 
474 ATROPHIA PILORUM PROPRIA. 
 
 Fragilitas crinium. — A tendency of the hair to break after it 
 has attained a certain length is not uncommon. In its simple 
 form it occurs both on the head and the beard, but is most 
 often seen in women. Sometimes some or all of the hairs tend, 
 after they have attained a certain length, to split into filaments. 
 Both forms may be easily explained by the supposition that 
 when the oldest portion of the hair gets to be so far off from 
 the rooL" that moisture is no longer transmitted through the 
 medulla, it becomes dry, and either breaks off or splits up into 
 filaments. In some of these cases, however, the hair shows an 
 abnormality of nutrition from the beginning, it being irregular 
 of formation, or thicker at some points than at others. 
 
 Duhring has described another form of defective nutrition of 
 the beard characterized by marked atrophy of the bulb and 
 splitting of the hair shaft, while still within the substance of the 
 skin. The filaments grow separately, and cause considerable 
 irritation of the tissues. The disease is not parasitic. 
 
 Trichorexis Nodosa. — Beigel and Kaposi have described an- 
 other peculiar affection of the hairs, which the latter has des- 
 ignated trichorexis nodosa. It consists in the formation upon 
 the hair of one or several shining, semi-transparent rounded 
 swellings. As many as half a dozen may be present at dif- 
 ferent places upon a single hair. At first sight they look like the 
 "nits " of pediculi, but closer inspection shows them not to be 
 foreign bodies glued to the hair, but swellings of the hair-struc- 
 ture itself. At the points where these swellings occur the hair 
 is very liable to break, and hence in bad cases a large propor- 
 tion of the hair ends at the centre of one of these swellings, and 
 it looks as if the hair or beard had been " singed." Almost 
 always the beard, mustache, or eyebrows, are the parts affected ; 
 rarely does the affection attack the hair of the head. Microscopic 
 examination of these hairs has revealed the fact that the 
 medullary as well as the cortical substance is swollen ; that as 
 the marrow becomes larger the cortex splits and the continuity 
 of the hair is only maintained by the interlacing of the cortical 
 filaments, giving a rhomboid form to the mass ; and that there 
 is no trace of any parasite. Nothing is known as to the cause of 
 
ONYCHATROPHIA. 475 
 
 this peculiar affection. Beigel supposes that gas is developed 
 in the medulla, and that this swells it out and splits the cortex. 
 The only means of treating the affection is by shaving. In a 
 certain number of cases the new growth of hair has been nor- 
 mal ; but Kaposi tells us that three colleagues of his who are 
 affected with the disease have, in the course of years, sacrificed 
 their beards a number of times, only to find the new hair 
 present the same abnormality as the old. In bad cases the 
 affection is quite disfiguring. 
 
 Treatment. — Beyond shaving, we cannot accomplish anything 
 by treatment. 
 
 ONYCHATROPHIA. 
 
 Atrophy of the nails may be congenital or acquired. In 
 congenital there is either absence of the nail, or defective de- 
 velopment on ill-developed fingers or toes ; if all are defective, 
 then it is associated with absence of hair. 
 
 Acquired atrophy of the nails may be either idiopathic or 
 consecutive. It occurs as a consequence of injury or disease 
 of the nerves of the part, or in consequence of some general 
 disease, as syphilis, or in association with a weak, debilitated 
 state of the system. All of the conditions mentioned as 
 causing hypertrophy, as eczema, psoriasis, etc., may produce 
 atrophy or degeneration of the nail. Atrophied nails are smaller 
 and thinner, or brittle and split, or soft and degenerated; their 
 color varies in different cases. They may be pale, or opaque, or 
 dark in color. The treatment depends upon the cause. 
 
CLASS VII. 
 
 NEOPLASMATA— TUMORS. 
 RHINOSCLEROMA. 
 
 Definition. — Rhinoscleroma consists of a circumscribed, flat- 
 tened, irregularly-shaped, very hard, dense, inflammatory, new- 
 growth seated in the nasal region. 
 
 Symptoms. — This disease is confined to the nose and imme- 
 diately surrounding cutaneous tissue and neighboring mucous 
 membrane. The alae nasi, and apex of nose are hard, dense, 
 and without much increase of volume in the beginning of the 
 disease. It appears in the form of brownish-red, somewhat 
 elevated, sharply limited, isolated or confluent, hard, flat tuber- 
 cles, painful upon pressure and which afterward increase in 
 size. They appear especially upon the cutaneous surface and 
 afterward upon the nasal mucous membrane, at the inner angle 
 of the eye, and on the upper lip next the nose. It is in firm 
 connection with the skin, and is only movable in connection 
 with the latter. The apex of the nose and the alae, become of 
 ivory-like hardness, immovable ; the surface either smooth or 
 uneven, and of normal color, or a dark brown-red, crossed by 
 some vessels, shining, and devoid of glands and follicles ; like 
 a keloid or hypertrophic scar. The nose becomes broader, 
 sometimes deformed from thickening of the alae ; the nasal 
 orifices are at first narrowed, afterward closed by the new 
 growth ; the surrounding skin is normal in character. 
 
 The disease begins either on an ala or on the septum, as a 
 thickening and hardening, without any accompanying inflam- 
 matory symptoms, and gradually assumes the characters already 
 described. The sense of smell is but little altered, the mucous 
 membrane of the pharynx, the uvula, tonsils, soft palate, the 
 
RHINOSCLEROMA. 477 
 
 posterior pharyngeal wall, show granulations and ulcers, which 
 are characterized by their hardness. The gums appear un- 
 evenly swollen, the teeth become loose and fall out ; this condi- 
 tion generally occurs late in the disease. The affection is always 
 chronic, though the rapidity of its course is according to the 
 situation ; in the soft palate the tissues soon break down ; in 
 the nose, ulceration or any retrograde metamorphosis peculiar 
 to new growths never occurs. Occasionally there may be flat 
 excoriations, or the new tissue become softer in consistence. 
 If a portion is removed the remaining part does not suppurate 
 or break down, but the raw surface is soon covered with a thin 
 crust, and heals in a short time. The growth reproduces itself 
 very rapidly, even if the whole tumor has been removed. As 
 subjective symptoms, nothing is to be observed except slight 
 pain upon pressure, and the interference with respiration from 
 the narrowing of the nasal orifices, or of the pharynx or larynx. 
 The disease has no influence upon the general system. It ap- 
 pears generally between the fifteenth and fortieth year of life. 
 
 Anatomy. — Kaposi classes it as a small-celled sarcoma. He 
 found the epidermis and rete normal, and in the papillae and 
 corium a dense infiltration of small cells. Also in the mucous 
 and sub-mucous tissue a dense infiltration and connective 
 tissue new growth is to be observed. There was also a cell 
 infiltration even in the cartilage. The cells are smaller than 
 the so-called granulation cells met with in acute and chronic 
 inflammations of the skin, they are finely granular, refract 
 light feebly, are well preserved, have a sharp outline and dis- 
 tinct small nuclei. The deeper layers of the corium show a 
 dense connective tissue felt-work. According to Mikulicz, 
 rhinoscleroma is a chronic inflammatory process with small cell 
 infiltration by which the normal tissues are displaced. The 
 infiltrated round cells change into spindle cells, and later into 
 a connective tissue network. In the alveoli of this network lie 
 round cells ; these also afterward disappear and a firm connec- 
 tive tissue remains. The principal part of the growth shows a 
 homogeneous, bacon-like appearance, feels hard, but is easily 
 cut with a knife. The infiltration process passes from the 
 
47 8 
 
 RHINOSCLEROMA. 
 
 depth toward the surface. The sebaceous and sweat glands 
 are destroyed ; the nerves are unchanged. In the later forms 
 the adventitia of the blood and lymph vessels and their neigh- 
 borhood is infiltrated with cells. They are large, branched, 
 swell up and are fatty degenerated ; later the epithelium breaks 
 down and forms prolongations ; the smooth muscles are waxy 
 degenerated, or form connective tissue. The cartilage is un- 
 changed or thinner. The bones are unaffected. 
 
 Prognosis. — The prognosis is unfavorable, as the disease 
 always continues to spread, even if repeatedly extirpated. The 
 
 Fig. 60. — Case of rhinoscleroma — Hebra. 
 
 interference with respiration from closure of the respiratory 
 orifices can also be serious. 
 
 Etiology. — The cause is not known. Some regard it as a re- 
 sult of hereditary syphilis. Against this view is the complete 
 resistance it offers to anti-syphilitic treatment, and the persist- 
 ence of the infiltration. 
 
 Diagnosis. — The location and the symptoms above described 
 suffice for the diagnosis of rhinoscleroma from lupus, syphilis, 
 keloid and epithelioma. 
 
 Treatment. — Treatment is necessary to prevent interference 
 with the respiration and death from suffocation. Destruction 
 
LUPUS ERYTHEMATOSUS. 
 
 479 
 
 with caustics, dilatation of the nasal passage with sponge tents, 
 or extirpation with the knife, of a part or whole of the mass 
 may be resorted to, but the disease returns after a time. For- 
 tunately it is a very rare disease, especially in this country. 
 The only case I have seen was in Vienna, and the above de- 
 scription is compiled from the writings of Hebra and Kaposi. 
 
 LUPUS ERYTHEMATOSUS. 
 
 Syn. — Lupus erythematodes ; seborrhcea congestiva ; lupus 
 sebaceus ; lupus superficialis. 
 
 Definition. — Lupus erythematosus is a small-celled new 
 growth of the skin, and appears as one or more circumscribed, 
 variously-sized, round or irregular reddish patches, covered 
 with grayish-yellow, adherent scales. 
 
 Symptoms. — Lupus erythematosus was described by Hebra in 
 1845, under the title of seborrhcea congestiva, and was given 
 its present name by Cazenave in 185 1. 
 
 The malady commences as one or more red, pin-head to pea- 
 sized, very slightly elevated patches, shining, and somewhat 
 depressed in the centre, or covered with a thin, firmly adherent 
 scale. Most often we see a small, yellowish, soft, sebaceous 
 looking scale, surrounded by a pinkish raised border. This 
 forms what is called the primary efflorescence ; all the lesions 
 begin in this way, but their further course of development may 
 be in either one of two distinct lines of growths, giving the two 
 forms of the matured disease. In the first form, called lupus 
 erythematosus discoides, the one or more spots that form the 
 primary efflorescence increase very slowly by peripheral growth, 
 and take months or years to attain their complete development. 
 If there be more than one spot they eventually coalesce and 
 form more or less irregular marginate patches. At length we 
 have a pinkish-red discoid surface, of any size, from a pea to 
 that of the palm of the hand. The centre of the patch is 
 depressed, shining, and somewhat cicatricial in appearance, or 
 it may be covered with fine, yellowish-gray, firmly adherent 
 scales. The margins of the patch are red or violaceous, ele- 
 
480 LUPUS ERYTHEMATOSUS. 
 
 vated, and very distinct ; it is often surrounded with comedones 
 and the opening of the dilated gland ducts. The amount of 
 scaling varies much in different cases ; often it is very marked, 
 and Hebra therefore called the disease a congestive seborrhoea. 
 When the scales are removed, the small projecting processes 
 which dipped down from their under surface into the mouths 
 of the patulous ducts of the sebaceous glands are plainly visible. 
 
 The patch once formed, slowly increases, and eventually 
 reaches a stationary period, in which it may remain for months 
 or years. The peripheral cell-growth may then cease, and 
 the process stop ; the margin disappears, the color fades, and 
 at last only the thin, shining and very superficial scar is left. 
 Individual patches may last many years, and very often a suc- 
 cession of them may prolong the disease. 
 
 Lupus erythematosus discoides is usually found upon the 
 cheeks and the nose. Upon the latter situation it is very apt to 
 commence upon the bridge, and extend downward on either 
 side, forming the well-known appearance called the " butterfly 
 lupus." Other parts of the nose, as the tip and alse, the eye- 
 lids, the ears, the lips, etc., may be affected ; as may also in 
 rare cases the fingers and toes. When it occurs upon the hairy 
 parts, as the scalp, it causes destruction of the hair follicles 
 and permanent baldness over the affected area. 
 
 The general health of these patients is almost invariably 
 good ; there are no subjective sensations ; the patch is more 
 annoying as a deformity than troublesome as a disease. 
 
 The second variety, or lupus erythematosus disseminatus is 
 a more general and more serious affection. It begins as the 
 primary efflorescence, as above described, but instead of one or 
 two, a number of patches are present from the beginning. They 
 exhibit no tendency to peripheral growth, but the disease in- 
 creases by the continuous appearance of new patches among 
 the old ones. In this way extensive surfaces upon the face and 
 other portions of the body become the seat of the disease. 
 Not only may the ckeeks, lips, ears, scalp, etc., be affected, but 
 the hands and feet, the arms and legs, and the trunk itself, may 
 be involved. Large portions of the body may be thickly sown, 
 
LUPUS ERYTHEMATOSUS. 
 
 481 
 
 as it were, with these lupus nodules, and in rare cases the 
 disease may be nearly universal. In these latter instances the 
 affection sometimes has an acute febrile invasion ; obstinate 
 erysipeloid inflammation of the face occurs during its course, 
 with high temperature and sometimes the typhoid state ; it 
 terminates in death in at least half the instances. 
 
 In these extensive cases each single patch goes through 
 exactly the same course as was described in the discoid form, 
 save that they do not tend to extend peripherally. 
 
 Lupus erythematosus has been seen upon the mucous mem- 
 branes of the gums and upon the inner surface of the cheeks. 
 In either the single or the disseminate form, the disease per- 
 sists for many years. Whenever it disappears it leaves charac- 
 teristic, very superficial, shining scars behind. It is said in some 
 cases not to cause a loss of tissue and a connective-tissue new 
 growth. The hair is always permanently removed. 
 
 Anatomy. — No specially characteristic morbid appearances 
 are to be found in the portions of integument which are 
 
 Fig. 61. — Lupus erythematosus papule under a low power, a, epidermis ; b, 
 embryonic cell collection ; d, muscle ; c, subcutaneous tissue ; e y fat cells. 
 
 the seat of lupus erythematosus. In its essence the pro- 
 cess consists of a chronic inflammation of the cutis, lead- 
 ing to degeneration and eventually to atrophy. By the older 
 investigators the sebaceous glands were considered to be the 
 31 
 
482 
 
 LUPUS ERYTHEMATOSUS. 
 
 parts in which the disease originated, and indeed Hebra at first 
 designated the affection as seborrhcea congestiva. In a certain 
 proportion of cases this is undoubtedly the fact ; but in the 
 large majority of instances the disease affects all the constit- 
 uents of the skin, and may originate in any one of them, even 
 in the subcutaneous connective tissue. 
 
 In accordance with the superficial or deep origin of the 
 individual foci, will the spots of lupus be superficial, ele- 
 
 FiG. 62. — Section from peripheral part of a patch of lupus disseminatus. a, 
 corneous layer ; b, rete mucosum ; c, upper part of corium ; d, completely 
 changed tissue, only embryonic cells being present. 
 
 vated, and bright-red, or appear as deeper, hard, cedematous 
 papules and tubercles. 
 
 In its essence, lupus erythematosus consists of a chronic 
 inflammatory process, appearing at separate foci, commenc- 
 ing most often in the glandular structures of the skin, but very 
 frequently finding its origin and chief seat in the other dermal 
 structures, and even in the underlying connective tissue ; never 
 ending in the formation of pus, but going on to absorption of 
 the existing, and to production of new connective tissue. 
 
LUPUS ERYTHEMATOSUS. 483 
 
 Microscopic examination of patches shows the ordinary- 
 appearances of inflammation, affecting chiefly now one, now 
 the other, layer or structure of the skin. The sebaceous glands 
 are enlarged, and their walls are filled with small-celled infil- 
 tration. The bloodvessels are dilated, the surrounding con- 
 nective tissue is infiltrated with embryonic corpuscles. In fact, 
 the whole affected part is filled with a small-celled inflammatory 
 new growth, derived partly from the vessels and partly from the 
 connective-tissue cells of the part. 
 
 If the infiltrate is situated in the lower part of the corium we 
 get the deep-seated papules and tubercles ; if in the upper layers 
 we get the red spots of the more superficial forms. The increased 
 proliferation of the cells of the sebaceous glands, causing 
 seborrhcea, the swelling of the skin and scaling of the epidermis 
 are all effects of the localized inflammation. In some cases 
 the process is more acute. Serum, which may even be bloody, 
 exudes between the layers of the epidermis ; blebs are formed, 
 and small haemorrhages into the corium occur. In no case, 
 however, is the infiltrate abundant enough to compromise the 
 circulation and form pus. 
 
 The further course of the process varies in different cases. 
 The inflammation may cease, absorption may occur, the new 
 cells disappear, and the parts return to their normal state. But 
 more usually, degenerative changes with subsequent new tissue 
 formations take place. The small- celled infiltrate undergoes a 
 partial fatty degeneration ; the vessels are diminished, the fat 
 of the panniculus adiposus disappears wholly or in part ; the 
 glandular structures are atrophied and deformed ; the hairs 
 lose their pigment, or fall out ; the connective-tissue ele- 
 ments themselves undergo a sort of hyaline degeneration. 
 Finally, as the usual result of the process, new connective tissue 
 is formed ; cicatricial tissue replaces to greater or less extent 
 the normal elements of the skin, and scars of varying extent 
 mark the spot that has been affected by lupus erythematosus. 
 
 Etiology. — There is but little to be said under this head. 
 When commencing around the sebaceous glands congestion is 
 undoubtedly often the first stage of the malady, but it may 
 
484 LUPUS ERYTHEMATOSUS. 
 
 occur on parts where there are no sebaceous glands, as the 
 palms of the hands. The affection is seen most often during 
 early adult and middle life, rarely occurring before puberty. 
 Both forms are more frequent among women than among men 
 in the proportion of two to one. 
 
 A variety of affections of the internal organs have been 
 noted among the women affected with lupus erythematosus, 
 especially of the disseminated and febrile form, such as anae- 
 mia, chlorosis, uterine diseases, etc., but we cannot regard 
 them as anything save accidental complications, and men sub- 
 ject to the disease may enjoy excellent health. Some of the 
 cases I have seen have subsequently died of tuberculosis. 
 
 Diagnosis. — The more limited, discoid forms of the disease 
 will rarely give rise to any errors in diagnosis. The peculiar 
 shape and location of the disease ; the central and superficial 
 scar ; and the extreme chronicity of its course are all distinc- 
 tive. The disseminated form is more liable to be mistaken for 
 other affections. 
 
 The other maladies with which lupus erythematosus of either 
 form is liable to be confounded, are ringworm, psoriasis, ec- 
 zema, syphilis, and lupus vulgaris. Tinea tonsurans is charac- 
 terized by a non-infiltrated margin, outside of which we will 
 almost invariably find some scattered vesicles and papules ; 
 by a centre either slightly reddened and eczematous, con- 
 sisting of normal integument ; by its rapid course ; and finally, 
 by the nibbled-off hairs and the presence of the peculiar para- 
 site as seen under the microscope. In erythematous lupus 
 the margin is hard and infiltrated, the central portion, over 
 which the disease has passed, is covered by a superficial scar ; 
 nibbled-off hairs, and fungi are never present ; and the affec- 
 tion lasts far longer, as it spreads very slowly, requiring years 
 to extend as far as ringworm does in a few days. An impetig- 
 inous or squamous eczema may at times look very like the 
 disease under consideration ; but its course, the presence of 
 itching and of exudation, and the absence of scarring, and of 
 the firmly adherent scales with their sebaceous plugs should 
 prevent all error. 
 
LUPUS ERYTHEMATOSUS. 485 
 
 Syphilis is characterized by ulceration and by the peculiar 
 infiltrated margin, by the rapidity of extension, the absence of 
 sebaceous plugs and the presence of the disease on other parts 
 of the body. From lupus vulgaris the disease may be distin- 
 guished by the evident involvement of the sebaceous glands, as 
 shown by the oily scaling, the enlarged gland mouths and the 
 comedones ; by the absence of ulceration ; by the greater super- 
 ficiality of the scar, which does not, as does very commonly lu- 
 pus vulgaris, involve the cartilaginous structures ; by its usual 
 non-appearance until the age of puberty ; and, finally, by the 
 absence of the brownish-red soft papules which characterize 
 the latter disease. 
 
 Psoriasis should never be confounded with lupus erythema- 
 tosus ; the whole history, course, and general appearance of 
 the two diseases are so different. 
 
 Prognosis. — The prognosis of lupus erythematosus in the lim- 
 
 d disc-like form, which is the one we most commonly see, is 
 goou. Some atrophy, loss of hair, and scarring occurs ; but the 
 general health is in no way interfered with, and the disease tends 
 ultimately to recovery, even if left alone. In the more general, 
 disseminated cases of the disease, it is otherwise. Acute exac- 
 erbations are liable to occur, brain symptoms are not un- 
 common, and a certain number of cases end fatally. Chest 
 complications, phthisis and pneumonia, are also observed. Fi- 
 nally, the wide extent of the disease in these cases renders lo- 
 cal treatment both difficult and unsatisfactory. 
 
 Treatment. — Although the disease is to be mainly managed 
 by local applications, general treatment must not be neglected. 
 Iodized starch has been recommended by McCall Anderson, 
 in doses of a teaspoonful taken in milk ; and iodoform by 
 Besnier. A general tonic treatment — iron, cod-liver oil, cold 
 baths, change of climate, is of benefit, as a considerable pro- 
 portion of patients suffering from lupus erythematosus show an 
 impaired nutrition, anaemia, or chlorosis. Arsenic also seems 
 in some cases to exert a beneficial effect. 
 
 It is the local treatment of the disease, however, to which we 
 must particularly direct our attention. A number of remedies 
 
486 LUPUS ERYTHEMATOSUS. 
 
 have been successfully employed, but it is not possible, in the 
 present state of our knowledge of the subject, to give the exact 
 indications for the use of any of them. In every case it is 
 necessary to proceed tentatively; to try first one and then another: 
 and in not a few cases we will run through a long list before we 
 find anything that will effect a cure. We must never lose sight 
 of the fact, however, that the course of the disease is an exceed- 
 ingly variable one. Patches of lupus erythematosus may re- 
 cover spontaneously — or from the effects of treatment, within 
 a comparatively short time ; they usually leave scars and local 
 telangiectasis, but they may heal without leaving anything but 
 the normal skin-structure behind ; they may be very amenable 
 to the simplest procedures, but may also obstinately resist any 
 but the most radical measures. We must remember that in the 
 majority of cases a recovery would eventually be reached with 
 but a very slight and superficial cicatrix ; and we must choose 
 our therapeutic measures accordingly, commencing with the 
 simplest remedies, and only using the severer means when the 
 former have had a thorough trial so as not to produce 
 unnecessary scarring. As the commonest seat of the disease 
 is on the face, it is important to accomplish our end 
 with the least possible amount of disfigurement. Even when 
 we are compelled to use the stronger applications, it is 
 proper, as soon as the margin of the patch begins to get pale 
 and flatten out, to return to the milder measures before tried, 
 and to continue the treatment by their means. 
 
 One of the best of the more superficial remedies, and the one 
 with which in most cases, the treatment should commence, 
 is green soap. This may be rubbed daily into the patch 
 alone, or with water, or, better, with an equal part or half the 
 quantity of alcohol as the tincture sapo viridis. Spread upon 
 a cloth, and bound down to the part, it acts yet more vigor- 
 ously. Any simple ointment may be used after the applica- 
 tion. Very superficial cases may be cured by this means 
 alone ; and in any case it is useful to remove the scales and 
 prepare the patch for future treatment. 
 
 Mercurial preparations should probably stand next upon our 
 
LUPUS ERYTHEMATOSUS. 487 
 
 list. Kaposi claims to have obtained brilliant results both in 
 the discoid and the disseminated form from the use of mercu- 
 rial plaster, having by this means alone cured otherwise obsti- 
 nate cases in a few days or weeks. The oleate of mercury, 
 in ten per cent solution, may be daily brushed over the diseased 
 spot instead of the plaster. 
 
 Should these means not suffice, the tincture of iodine may 
 be used, either alone or with glycerine ; or chrysophanic or 
 pyrogallic acids, in ten per cent, ointment ; or carbolic acid in 
 the same form. Sulphur ointments and alcoholic sulphur lo- 
 tions are highly spoken of by Duhring. Ung. naphthol, five 
 per cent., may also be tried. Tar, oleum cadini, and oleum 
 rusci are of service and may be used as ointments alone, or 
 combined with sulphur and green soap. The officinal com- 
 pound iodine ointment has done well in some cases, as has also 
 brushing the patch daily with aqua ammonia, and acetic acid. 
 
 If it becomes necessary to have recourse to deeper-reaching 
 measures, we may try a solution of caustic potash, i to 2 or 4 
 of water, applied every fifth day or so. The action of the 
 caustic should be neutralized a few minutes after the applica- 
 tion by the use of dilute acetic acid. Or we may try the min 
 eral acids — nitric, sulphuric, chromic, etc., or the acid nitrate of 
 mercury or chloride of zinc, or the nitrate of silver may be 
 used. These severer measures must be cautiously employed, 
 and a soothing ointment should follow their use. In a larger 
 proportion of cases some of the milder measures detailed in 
 the preceding paragraph will be found quite sufficient for the 
 treatment of the malady. 
 
 The method described by Th. Veiel has proven quite suc- 
 cessful in obstinate cases. The diseased patch is either scari- 
 fied or blistered, and then cauterized with a mixture composed 
 of equal parts of alcohol and chloride of zinc. In ten days 
 the procedure must be repeated, and some half dozen scarifica- 
 tions and cauterizations are usually necessary. The patch 
 should then be treated with mercurial plaster, and later by 
 mildly stimulating lotions or ointments. 
 
 The dermal curette has been successfully employed in many 
 
488 LUPUS VULGARIS. 
 
 cases, and is especially recommended by Neumann and Aus- 
 spitz. It is especially applicable for the more limited, but deep- 
 seated varieties of lupus. The galvano-cautery has also been 
 satisfactorily used. 
 
 In the more acute diffuse cases, when there is considerable 
 inflammation and a good deal of pain present, it may be neces- 
 sary to use cold applications, or lead lotions, etc. Kaposi 
 claims to have seen spontaneous retrogression of many nodules 
 under this treatment. 
 
 Whatever means we may employ for the treatment of lupus 
 erythematosus, as soon as the infiltrated margins of the patch 
 become pale and less prominent, the curative process has 
 begun, and we should immediately revert to the green-soap lo- 
 tions, or even to a simple ointment for its completion. 
 
 In extensive disease of the hairy scalp, caustics cannot be 
 used. Here I prefer the use of the green soap and alcohol 
 daily, followed after each rubbing by a solution of bicarbonate 
 of soda or of subacetate of lead to limit the pain and burning, 
 
 LUPUS VULGARIS. 
 
 Syn. — Lupus exedens ; lupus vorax ; noli me tangere. 
 
 Fr. eg. — Scrofulide tuberculeuse. 
 
 Definition. — Lupus vulgaris is a chronic, non-contagious 
 disease of the skin and adjoining mucous membranes, due to 
 the presence in them of a cellular new growth, and character- 
 ized by variously sized, soft, reddish-brown, deep-seated papules, 
 or larger infiltrations, and eventually terminating in ulceration 
 and cicatrization. 
 
 Symptoms. — Lupus vulgaris occurs under a variety of external 
 appearances, but, as in the case of lupus erythematosus, all 
 forms of the disease begin in one and the same way. This first 
 appearance we may appropriately call the primary efflores- 
 cence, and its characteristic features are visible to a greater or 
 less extent in every variety of the affection. 
 
 The primary efflorescence with which common lupus begins 
 consists in the appearance of small, deep-seated, pin-head to 
 
LUPUS VULGARIS. 489 
 
 small pea-sized, brownish-red or yellowish papules, situated 
 deep down in the true skin. These papules are very soft, and 
 are not perceptible to the touch, and in introducing the point of 
 a pin into one of them, it is easy to demonstrate that their com- 
 position is much looser and softer than is that of the normal 
 tissues. They increase very slowly in size, and in the course 
 of months become elevated enough to be felt. All the varied 
 forms into which the disease subsequently grows, are due to the 
 development in different directions of these peculiar papules, 
 and in every case they will be visible in some part of the 
 diseased tissue. They even recur in the cicatricial tissue which 
 forms where the malady has previously existed. 
 
 By the aggregation and merging together of a number of 
 these papules larger masses are formed, and lupus tuberculosis 
 results. This is the variety of the disease that most commonly 
 comes under our notice. The papules are painless, brownish- 
 red in color, of the size, perhaps, of a pea, and are usually 
 grouped. 
 
 After remaining in this condition for a varying time, usually 
 for many months, retrogressive changes set in. There may 
 occur a simple, fatty degeneration of the cells composing the 
 tubercles, ending in absorption of the new growth. The papule 
 gradually disappears, leaving a more or less atrophied spot be- 
 hind, covered with a shining and desquamating epidermis and 
 then called lupus exfoliativus. Or, on the other hand, disinte- 
 gration and ulceration of the infiltrated skin may occur, giving 
 us the lupus exulcerans or exede?is. This latter is perhaps the 
 more common mode of termination. The lupus ulcerations 
 appear as rounded, shallow excavations in the skin, bounded 
 by reddish and soft borders. Their base is quite red, usually 
 covered with granulations and bleeds easily. As a rule they 
 are painless. Pus secretion and crusting are present to a mod- 
 erate extent. Partly by ulceration, and partly by absorption, 
 the lupoid tissue is gradually removed, and the sores heal event- 
 ually with the formation of soft, superficial scars. In many 
 cases papillary outgrowths occur in the healing ulcers, and a 
 more or less warty cicatricial tissue takes their place. In some 
 
49° LUPUS VULGARIS. 
 
 cases the warty excrescences may be very small, and they have 
 been designated lupus verrucosus. 
 
 In every case of lupus vulgaris the cell accumulations go 
 through this same course ; after persisting for a varying time 
 they all end either in absorption and exfoliation, or in ulcera- 
 tion and cicatrization. 
 
 A number of other varieties of the disease may be men- 
 tioned, based upon differences of location and grouping. As 
 long as the individual papules remain separate from one an- 
 other, the affection is called lupus discretus. If the papules are 
 comparatively few, and spread over a wide surface, it is called 
 lupus disseminates, etc. 
 
 Not only the skin, but the deeper parts, the subcutaneous 
 connective-tissue and the cartilages, especially those of the nose 
 and ears, may be involved. The mucous membranes, as well as 
 the skin, may be the seat of the disease. Upon the mucous 
 membranes of the gums, nose, velum, and even larynx, the 
 lupus tubercles appear as soft, easily bleeding, brownish or red 
 nodules, forming eventually larger patches and ulcerating sur- 
 faces, and terminating in cicatrization. 
 
 The most common seat of lupus is upon the nose. Here the 
 disease may occasion great deformity, causing loss of the alse, 
 and of the cartilages, and sometimes complete occlusion of the 
 nostrils. It often occurs on the mucous membranes, either pri- 
 marily or by extension, and causes great destruction, ulcera- 
 tion, perforation and loss of the septum and other cartilages. 
 The affection also occurs upon the cheeks, chin, and neck ; and 
 may occasion great deformity by affecting the lips, eyelids, or 
 ears. Lupus of the conjuctivae and cornea is also to be noted ; 
 it happens most often from extension from the eyelids. It ap- 
 pears very much like ordinary trachoma, and leads to pannus 
 and considerable interference with vision. In the mouth, 
 pharynx, and larynx lupus is sometimes seen ; causing in the 
 former cases ulceration of the gums and tongue, falling out of the 
 teeth, etc., and in the latter hoarseness, ulceration of the vocal 
 cords, perichondritis and chondritis. 
 
 Upon the trunk lupus vulgaris may occur in any situation. 
 
LUPUS VULGARIS. 49I 
 
 It is then usually diffuse or serpiginous in character, may 
 affect large areas, and is very chronic. Upon the lower extrem- 
 ities it often leads to extensive warty outgrowths, with thick- 
 ening of the skin and consolidation of all the tissues — lupus hy- 
 pertrophicus j a condition very like that described as elephant- 
 iasis arabum. 
 
 Lupus vulgaris, as a rule, begins in childhood, about the 
 fourth or fifth year. One single spot only may be affected, or 
 it may cover very extensive surfaces. Favorable cases are cir- 
 cumscribed, last for a varying number of years, and disappear 
 leaving cicatrices. In other cases the affection is widespread, 
 and very obstinate ; it may disappear, either spontaneously, or 
 as the result of treatment, but it is liable to return upon the same 
 or upon another portion of the body. It is common for it to last 
 fifteen to twenty years. 
 
 Anatomy. — The pathology of lupus vulgaris has been the 
 subject of much study by a multitude of observers, and its re- 
 lations to tubercle and other chronic inflammatory processes 
 is as yet by no means settled. The morbid process shows itself 
 as a chronic inflammation, consisting essentially of a small- 
 celled infiltration which primarily affects the deep corium, but 
 which spreads in the later stages of the disease to all the tissues 
 of the skin. 
 
 If we make a section of a portion of tissue containing one of 
 the deeper and more recently formed characteristic soft papules, 
 it is found to be composed of a delicate network of connective 
 tissue, in the interstices of which are heaped a multitude of 
 round cells with large and prominent nuclei. The entire 
 nodule is surrounded by a dense layer of connective tissue, 
 and is sharply limited from the normal corium in which it 
 lies. Free nuclei are present in varying quantity, as are also 
 the so-called giant cells. These latter consist of large, irregular 
 homogeneous or finely granular masses of protoplasm, in which 
 are from half a dozen to twenty shining oval nuclei. These 
 are the cells which have been long known to occur in certain 
 other morbid processes, notably in tubercle, and which were 
 first described by Virchow and Billroth. Their occurrence 
 
492 
 
 LUPUS VULGARIS. 
 
 was supposed to be pathognomonic of the tubercular process, 
 and upon this account Friedlaender claimed that lupus was essen- 
 tially a tuberculosis of the skin. But though we do not know 
 their mode of origin, it is a well-established fact that the giant 
 cells are present in many various morbid processes, being found 
 in gummata and even in ordinary granulation tissue. The 
 greater part of the cellular constituents of a lupus nodule may 
 be removed by shaking ; the connective tissue network and the 
 numerous bloodvessels being then left. 
 
 Fig. 63. — Section of a lupus nodule under a low power, a, epidermis ; 3, 
 lupus nodule ; c, hair follicle ; d, upper part of corium ; e, deep part of corium ; 
 /", muscle bundle. 
 
 In figure 63 the situation of the nodule beneath the papillary 
 region, and its sharp limitation is well shown. 
 
 In its further development and in the retrogressive changes 
 which sooner or later occur, the lupus process presents a very 
 complicated morbid picture, involving, as it does eventually, all 
 the elements of the cutis. As regards the nodule itself, after 
 it has existed for a varying time, the retrogressive changes 
 begin in its central portions. There the vascular supply is in- 
 terfered with by the abundant small-celled new growth ; the 
 
LUPUS VULGARIS. 493 
 
 cells become granular and fatty, and eventually break down. 
 The greater part of the lupus nodule is incapable of organiza- 
 tion, and is at last either absorbed, or, if situated superficially, 
 cast off. But a portion of the tubercle becomes organized into 
 connective tissue, which subsequently undergoes the usual con- 
 traction. 
 
 So much for the course of a single circumscribed lupus 
 nodule. In very many of them, however, the process becomes 
 much more widely spread. The small-celled infiltration 
 spreads along the vessels of the corium and papillae, both hori- 
 zontally and into the deeper portions of the skin. At length 
 the different inflammatory centres coalesce ; the entire inter- 
 vening connective tissue becomes involved in the inflammation, 
 and eventually we have an irregular diffuse cell infiltration of 
 all portions of the affected skin. These larger infiltrated areas 
 undergo the same changes as do the individual nodules. Fatty 
 degeneration and absorption of the infiltrate, with cicatricial 
 contraction of the skin and its glandular elements occurs, but 
 in many cases chronic inflammatory changes take place in the 
 affected connective tissue. Hypertrophic changes are seen, 
 especially affecting the papillae, and giving us then the form of 
 the disease known as lupus verrucosus. 
 
 The epithelial structures are usually involved early in the 
 disease. When the infiltration dips down and commences to 
 affect the papillary layer, proliferation and fatty degeneration of 
 the rete cells takes place ; when the rete is destroyed by sup- 
 puration the lupus nodules are exposed and ulceration occurs. 
 Very early also hypertrophy and degeneration of the cells 
 lining the hair follicles and the sweat and sebaceous glands 
 occur. The hair papillae atrophy, and the hairs fall out ; the 
 ducts of many of the sebaceous glands are closed by the 
 atrophic changes, and the dilated glands appear as milium- 
 corpuscles in the affected tissue. 
 
 Kaposi figures one form of lupus vulgaris in which, besides 
 the small-celled infiltration, the most prominent pathological 
 appearance is the occurrence of simple or branched outgrowths 
 of the epithelium, which dip down deeply into the corium ; 
 
494 LUPUS VULGARIS. 
 
 eventually forming, together with epithelial outgrowths from the 
 cells of the sweat glands and hair-root sheaths, an epithelial 
 network throughout the affected tissue. The appearance is of 
 importance as forming the histological basis for the develop- 
 ment of epithelioma, the combination of which with lupus, or 
 its occurrence in tissues where the lupus process has run its 
 course, has been noticed in a number of instances. 
 
 As regards the genesis of the lupus infiltrate, it must be re- 
 garded, in accordance with the latest researches of Lang, 
 Stilling, Jarisch and others, as due chiefly to the proliferation 
 of the cells of, and outgrowths from the protoplasmic walls and 
 adventitia of the bloodvessels and lymphatic channels. These 
 produce the network of fibrous tissue, the vessels and a portion 
 of the cellular infiltration ; the remainder of the new growth 
 owing its origin to the fixed and wandering connective-tissue 
 cells of the inflamed stroma of the cutis. 
 
 Diagnosis. — Although lupus vulgaris usually presents a suf- 
 ficiently characteristic appearance to remove all doubts as to 
 the nature of the disease, yet in some cases its diagnosis pre- 
 sents considerable difficulties. It may be confounded with 
 lupus erythematosus, epithelioma, eczema, psoriasis, acne 
 rosacea, lepra, and finally, with syphilis. 
 
 There should rarely be any difficulty in differentiating it 
 from lupus erythematosus. The entire absence of ulceration 
 in the latter disease, not to speak of the absence of the small, 
 soft, rose papules of lupus vulgaris, should suffice for the dis- 
 tinction. Besides this, erythematous lupus appears as superfi- 
 cial, reddish, circumscribed patches, covered with thin, adherent 
 fatty scales ; the sebaceous system is markedly involved ; and 
 the disease rarely begins until after puberty. 
 
 Epithelioma is peculiar in the amount of pain accompanying 
 it, in the hard, everted waxy borders of the ulcer, with blood- 
 vessels running to the very edge ; in the uneven, proliferating 
 base; in the scanty, thin secretion ; in the location of the malady, 
 and in the advanced age of the patient. Lupus ulcers are 
 not so painful, have not the indurated edges, show no 
 traces of an epithelial hyperplasia, have a reddish granu- 
 
LUPUS VULGARIS. 495 
 
 lating base and more abundant secretion, and usually begin in 
 childhood. Epithelioma usually begins at one point — lupus at 
 several ; nor does the latter occasion anything like the amount 
 of tissue destruction which is caused by the former. The 
 deep-seated, reddish-brown, soft papules observed in the cicatrix 
 and outside the general patch are characteristic of lupus. Cases, 
 though rare, have been described in which both diseases have 
 been present in the same area. 
 
 Certain cases of localized papular eczema may, very rarely, 
 cause difficulties in diagnosis. This occurs in some of the 
 forms of eczema caused by the application of metallic substan- 
 ces in the form of ointments to the skin. But eczema runs a 
 more rapid course than lupus ; the infiltration is never so deep- 
 seated ; cicatrices are entirely absent ; and the specific, brownish- 
 red papules, always to be found around the periphery of a 
 lupus patch, are never present. 
 
 Psoriasis may be distinguished from the exfoliative form of 
 lupus vulgaris by its favorite location upon the flexor surfaces, 
 and by its appearance over large areas of the surface of the body. 
 Lupus is usually quite localized, and appears most commonly 
 upon the face. Besides this, if we remove the scales from the 
 surface of a patch of lupus exfoliativus we get an infiltrated 
 corium unmarked by bleeding points ; in psoriasis we get a 
 normal, reddened, and easily bleeding surface. 
 
 Acne rosacea might possibly be confounded with a tubercu- 
 lar lupus. But rosacea always occurs in a certain location affect- 
 ing the central zone of the forehead and face ; comedones, pus- 
 tules, and dilated bloodvessels are present, and the disease 
 most frequently comes on during or after middle life. Besides 
 this, the papules of acne are larger, harder, and far more prom- 
 inent than are those of lupus vulgaris. 
 
 Some forms of lepra tuberculosa may resemble a tubercular 
 lupus very closely. The reader is referred to the sections upon 
 the etiology and course of leprosy for the points of distinction 
 between the two diseases. 
 
 It is with syphilis, however, that lupus vulgaris is most fre- 
 quently confounded, and the differential diagnosis is sometimes 
 
49^ LUPUS VULGARIS. 
 
 a very difficult one. The serpiginous forms of the late tuber- 
 cular and ulcerative syphiloderms may sometimes resemble 
 lupus very closely. The main points of distinction are as fol- 
 lows : Lupus is far slower in its course than syphilis, taking 
 years to destroy as much tissue as syphilis will do in a few 
 weeks. Lupus never affects the bony structures ; syphilis does, 
 and often causes the loss of entire masses of bones, as of the 
 vomer and nasal bones. The lupus papulae are at first not 
 elevated, are small, soft and appear in the scar ; syphilitic 
 papules are always elevated, are larger and harder, and 
 are never seen in the track over which the ulceration has 
 passed. The scar of lupus is always white ; that of syphilis 
 often pigmented. The ulceration of lupus usually starts from 
 multiple points ; in syphilis they are single, or soon coalesce. 
 The single ulcers of lupus are less extensive and less deep than 
 those of syphilis ; their borders are not well defined, their 
 secretion is slight and odorless, their crusts are scanty and 
 brownish ; the edges of syphilitic ulcers are sharp, hard, and 
 infiltrated ; there is much offensive secretion, and the crusts 
 are often large, like oyster-shells in shape, and of a greenish 
 color. The history of the two diseases is different ; lupus 
 commences almost invariably during childhood, and runs an 
 extremely chronic course ; syphilis usually begins only after 
 adolescence, and is far more rapid in its march. Often also, other 
 evidences of specific disease may be found upon the syphilitic 
 patient. After due consideration of all these points a diagnosis 
 ought always to be reached ; at all events, treatment for a fort- 
 night or four weeks by specific remedies, and especially by the 
 local application of the mercurial plaster, which has such bril- 
 liant effect in the late tubercular syphilide, should clear up all 
 doubts. It ought never to be necessary, as Kaposi says, to 
 make a provisional diagnosisof " lupus syphiliticus." 
 
 In any doubtful case, our main reliance is to be placed upon 
 the presence or absence of the primary efflorescence — the 
 characteristic soft, small, reddish-brown, subcutaneous papule. 
 It will always be found present even in the more extensive and 
 ulcerating forms of the disease upon the periphery of the patch. 
 
LUPUS VULGARIS. 497 
 
 Etiology. — Our knowledge of the etiology of lupus vulgaris is 
 very imperfect. It has been thought to be intimately connected 
 with scrofula — perhaps caused by it ; indeed the French writers 
 call lupus a scrofulide. I agree with those who consider thai 
 it is related to the ordinary scrofulodermata. It has nothing 
 to do with syphilis, either hereditary or acquired ; but is prob- 
 ably nearly related to tuberculosis. 
 
 Lupus vulgaris is never a congenital disease, though it appears 
 first in early life. It is doubtful if it is in any way hereditary. 
 In Germany the disease is very common ; here it is a rare 
 affection, occurring with about the same frequency as does 
 lupus erythematosus. It occurs in both sexes ; sometimes in 
 the poor and the badly nourished, but at other times among 
 those apparently in the best of health. 
 
 Progiiosis. — As regards the condition of the general health 
 the prognosis of lupus is usually good. In most instances 
 none of the bodily functions are interfered with, no matter how 
 long the disease may last. A certain proportion of cases die 
 eventually from tuberculosis of the lungs. 
 
 We cannot speak so favorably as regards the local process. 
 In most events the disease runs out its slow course in spite of 
 all our efforts. Relapses are so frequent as to be almost the 
 rule. New lupus nodules appear in the scars left from former 
 attacks — coming perhaps long after the process is supposed to 
 be at an end. The more localized the affection the better is 
 our chance of influencing it by external remedies. The scars 
 left are usually very deforming, and contractions of joints, des- 
 truction of cartilages, and closure of various orifices, as of the 
 nostrils, are not uncommon. 
 
 Treatment. — In the treatment of lupus vulgaris we aim, in 
 the first place, to prevent the development and spread of the 
 disease, and, in the second place, to effect the removal of the 
 morbid products that are already present. A large number of 
 remedies have been employed to effect these ends ; but they 
 are all of them more or less uncertain, and some obstinate cases 
 seem to defy them all. 
 
 To prevent the spread of the disease we may employ internal 
 32 
 
49 8 LUPUS VULGARIS. 
 
 medication, or we may endeavor to destroy the lesion in situ. 
 As regards the treatment of lupus by internal remedies, but 
 little good ean be said as a rule to follow their use. Usually 
 we cannot by their means either prevent the further spread 
 of the disease or obviate relapses. Iodoform (gr. ss. in 
 pill-form t. d.) has recently been employed by Besnier, 
 and Neisser believes that he has seen good result from 
 its use. Iodide of potassium has failed in almost all cases, as 
 have also arsenic, iron, quinine, etc., except in so far as their 
 general tonic properties have endowed the body with a greater 
 power of resistance to the spread of the malady. Cod-liver 
 oil, given for long periods of time, does undoubtedly do good 
 in this way, even if it has not that specific effect upon the dis- 
 ease that has been claimed for it. It is well to combine a small 
 quantity of pure iodine (gr. ss. — § i.) or some iron or arsenic 
 with the oil. I have lately employed the muriate of lime in 
 twenty grain doses three times a day, and the sulphide of lime 
 in small doses, with apparently good results. 
 
 General hygiene must not be lost sight of. The food should 
 be of the best, and easily assimilable. The bowels should be 
 kept regular ; and the good effects of mountain air, sea baths, 
 etc., should not be omitted, when they can be obtained. 
 
 To destroy the virus of the disease, and to effect the re- 
 moval of the morbid products already present, a great number 
 of measures may be employed. We may endeavor either to 
 cause absorption of the small-celled growth, or to destroy it in 
 loco. 
 
 It is always well to make an attempt to procure absorp- 
 tion before proceeding to more radical and more violent 
 measures. For this purpose we may use the iodized glycerine, 
 as recommended by Richter, thus : Iodine and iodide of po- 
 tassium, aa 3 ss., glycerine § i. This must be painted every 
 other day over the affected part, which is then to be covered 
 with rubber plaster to prevent the evaporation of the iodine 
 vapor. But little pain is caused by the application, which is 
 chiefly useful for 1. exfoliativus. Mercurial plaster seems to be 
 a remedy of considerable value in some cases. It is to be ap- 
 
LUPUS VULGARIS. 499 
 
 plied freely, and renewed every twenty-four hours. It is 
 claimed that the macular form of the disease is cured some- 
 times by this means alone. Finally, it may be mentioned, the 
 ointments of chrysarobin and of tar, oleum rusci, etc., have 
 done good in some cases. 
 
 Kaposi denies ever having seen permanent benefit from any 
 of these applications, and he claims that they merely do good by 
 macerating the epidermis, softening and removing crusts, etc. 
 
 If now, we turn our attention to the more radical means at 
 our disposal for the cure of lupus vulgaris, we must be careful, 
 in our endeavors to remove the disease, not to cause scarring 
 and deformity, more than that occasioned by the malady itself. 
 This is especially the case, as lupus is more frequent among 
 women than men, and occurs most often upon the face. 
 
 In a general way it may be said that chemical are better 
 than mechanical means for the destruction of the new growth. 
 No knife can search out the diseased tissue as well as some of 
 the caustics mentioned below ; and even if we decide to rely 
 upon operative procedure, it is well to complete our work by 
 the use of a cauterizing paste. 
 
 It is hardly ever necessary to employ destructive agents like 
 caustic potash, Vienna paste, etc. They affect the healthy skin 
 as well as the morbid tissue, and their action is unnecessarily 
 severe. 
 
 One of the mildest, and at the same time one of the best, 
 caustics we can employ is pyrogallic acid. This remedy, first 
 introduced by Jarisch, acts only upon the lupoid tissue ; normal 
 skin is not affected by it. It possesses considerable penetrating 
 power, and searches out the diseased tissue better than can the 
 eye of the surgeon. Above all, the scars left after its use are 
 smooth, thin, and white. It may be employed in a ten per cent, 
 ointment, applied on a piece of linen to the affected spot and 
 firmly bound down. The dressing should be renewed night 
 and morning for three or four days, until the swollen tissues 
 have become quite soft and black. The slough is then to be 
 removed by means of a poultice, and the wound dressed either 
 with a simple ointment, or better, with unguentum iodoformi. 
 
500 LUPUS VULGARIS. 
 
 This latter acts not only as a disinfectant, but also relieves the 
 pain, which, however, is not severe, and only begins when the 
 sloughs are being cast off. In three to four weeks cauterization 
 is usually complete. It is generally necessary to repeat the 
 process three or four times ; and in every case the recently 
 formed scar should be protected from the renewed action of 
 the acid. The healthy skin is only discolored, or perhaps 
 slightly vesicated by it. 
 
 Another local application which has found considerable favor 
 is that of iodoform. It is to be applied in powder thickly and 
 uniformly spread over the diseased tissue. Where the infiltra- 
 tion is very deep seated the superficial layer of the epidermis 
 should be removed by a i to 2 solution of caustic potash in water. 
 The epidermis over the diseased tissue swells up and becomes 
 transparent ; water may then be applied, and the epidermis 
 gently removed. A dressing of powdered iodoform is put on, 
 and over it a thick layer of cotton ; this need not be disturbed 
 for a week. Suppuration does not occur, and the lupus 
 nodules are quickly destroyed. Two or three repetitions are 
 here also often necessary. The process is only painful during 
 the application of the potash. 
 
 The solid stick of nitrate of silver is often useful in the 
 treatment of lupus. It should be made quite sharp, and should 
 be bored into all the nodules that are visible. Healthy tissues 
 afford a degree of resistance to the pencil so much greater 
 than the pathological one that there is no danger of destroying 
 them. The cauterization should be done twice a week ; it 
 causes considerable pain for several hours, but leaves smooth 
 and white scars. It is especially useful for very circumscribed 
 cases of the disease, and for lupus of the mucous membrane, 
 and of the cornea and conjunctiva. It has the disadvantage 
 of acting only upon the tissue immediately next to it. 
 
 Arsenical pastes are useful in many instances. It is especially 
 to be recommended in the form of Cosme's paste, as modified 
 by Hebra, viz.: IjL Ac. arseniosi, gr. 20; cinnibaris, 3 i ; 
 ung. simpl., § i. It should be applied upon linen, and 
 renewed every twenty-four hours. There is considerable pain 
 
LUPUS VULGARIS. 501 
 
 and swelling by the third day. When the action of the caustic 
 is complete, the lupus nodules appear as black, necrosed spots 
 in the midst of otherwise unaffected tissue. Even the scar- 
 tissue is not hurt by the paste. Cicatrization is very rapid, 
 and the cicatrices obtained are very favorable. Absorption of 
 the arsenic and poisonous symptoms rarely, if ever, occur; never- 
 theless, it is not wise to cauterize a surface larger than the palm 
 of the hand at once. 
 
 The other caustics, as has already been said, are not so ap- 
 plicable. Caustic potash, whether used by itself or in the form 
 of Vienna paste, forms a concentrated solution with the various 
 fluids of the part, and destroys all the tissues, healthy and dis- 
 eased, over a wide area. The pain is very great, the scar 
 large and hard. Nevertheless, when it is desirable to destroy 
 thoroughly a circumscribed patch of lupus upon some covered 
 portion of the body, or when, upon the face, the nose or lip is 
 in danger from the disease, it may be necessary to employ it. 
 The same may be said of the chloride of zinc. 
 
 A number of mechanical means for the treatment of lupus 
 vulgaris remain to be mentioned. The oldest, as well as the 
 most radical of these is that of excision. It is very rarely to 
 be recommended. The scar is necessarily deep and disfigur- 
 ing ; healthy tissue must be removed together with the diseased 
 parts ; and it offers no greater security against a return of the 
 disease than other and better methods. Even in transplanted 
 skin the nodules have made their appearance. Better results 
 are obtained by the use of the sharp spoon, or dermal curette, 
 as recommended by Volkmann. Only the morbid tissue can be 
 scraped out by this means ; the healthy parts resist the pres- 
 sure. The operation should be done quickly and thoroughly ; 
 it may be necessary to freeze the skin, or even to anaesthetize 
 the patient. The amount of pain caused is considerable ; 
 there is but little bleeding, and the scars are soft and white. 
 Nevertheless, we can rarely penetrate with this instrument into 
 the interstices of the tissues and remove all the new growth ; 
 and it is always advisable to use one of the above mentioned 
 caustic agents after curetting. 
 
502 SCROFULODERMA. 
 
 The galvano-cautery is strongly recommended by Neumann. 
 He employs a needle point of platinum, and pierces the indi- 
 vidual lupus nodules with it while it is heated to a dull red. 
 Neumann claims for the method a great advantage in rapidity 
 and in absence of pain over the others, together with the best 
 of results. 
 
 Scarification, according to the method of Balmanno Squire, 
 has been recommended by Vidal and Besnier. The linear 
 or punctiform method may be employed, and an ordinary 
 lancet, or the instrument devised by Squire, maybe used. The 
 method is applicable to all cases in which ulceration is not 
 present. Every two or three days another area of the diseased 
 tissue is to be taken in hand and thoroughly " cross-hacked," 
 the cuts to extend as deeply down as does the soft new-growth. 
 There is but little pain, and the bleeding is easily controlled 
 by pressure. Any simple dressing may be used after the scari- 
 fication. This is one of the best means we possess of healing 
 non-ulcerating lupus, and Volkman reports most excellent re- 
 sults from its use. The multiple division of the vessels causes 
 anaemia of the part and an early tendency of the new-growth 
 to undergo retrogressive changes ; whilst the papules them- 
 selves are interfered with and broken up by the cuts. Aus- 
 spitz recommends that the knife blade be dipped into an iodine- 
 glycerine solution (1-20) before each cut. 
 
 In the very worst cases of lupus of the extremities amputa- 
 tion has been resorted to. 
 
 Intercurrent diseases and complications, such as caries, 
 necrosis, erysipelas, etc., must be treated on general prin- 
 ciples. We have no means at our disposal to prevent the 
 occurrence of relapses. 
 
 SCROFULODERMA. 
 
 A number of morbid conditions of the skin occur in conse- 
 quence of the presence of the general condition known as 
 scrofula or struma. This vague and rather indefinite morbid 
 state has of late received great attention ; it has shared in the 
 
SCROFULODERMA. 503 
 
 renewed interest awakened by the labors of Cohnheim, Klebs, 
 Koch, and many others, in the chronic infectious disease pro- 
 cesses, especially tuberculosis. At the present time we regard 
 tuberculosis, scrofula, and lupus as three very closely related, 
 if not identical, conditions ; all due to the presence in varying 
 parts of the system, and in different degrees of activity, of the 
 specific infectious agent, the bacillus of Koch. Its etiological 
 importance has been actually proven in almost all the ordinarily 
 recognized tubercular and strumous processes ; and although 
 not yet demonstated in lupus, it is probable that the proof of 
 its activity there will soon be forthcoming. 
 
 Scrofulosis seems to stand in a middle position, as regards 
 the other two conditions. In tuberculosis the infection is 
 thorough and deep-seated enough to permeate the whole or- 
 ganism, and possibly destroy life within a short time. In lupus 
 the virus is received in a comparatively unfavorable nidus, the 
 skin, and is so situated as to offer the least possible opportunity 
 for absorption and system infection. In scrofula the in- 
 fecting organism penetrates the tissues to a varying degree, 
 but is usually arrested in the lymphatic channels and glands. 
 Then it grows and causes the various chronic inflammatory 
 affections of the joints, skin, mucous membrane, and lymphatic 
 glands which have so long been grouped together under the 
 title of struma. 
 
 The granulation tumor, or granuloma (Virchow), which is 
 the direct cause of the different destructive processes, is due to 
 the activity of the infecting agent. In scrofuloderma these 
 small-celled masses form tumors of varying size in the subcu- 
 taneous connective tissue, cause a very chronic inflammatory 
 process in the superjacent skin, which becomes fused with the 
 tumor, turns violaceous, and eventually breaks down to form 
 the well-known scrofulous ulcers. 
 
 As a usual thing the lymphatic glands are the tissues affected, 
 though the process may begin as a nodule or granuloma in the 
 skin or subcutaneous tissue. The gland slowly increases in size 
 in the course of months, none of the ordinary signs of inflam 
 mation, such as redness, heat, or pain, being present. Having 
 
504 SCROFULODERMA. 
 
 attained a certain extent, the process may stop, the develop- 
 ment of the infecting agent ceases, and the granuloma, in the 
 course of time, undergoes fatty or cheesy degeneration or calci- 
 fication. But more usually the tumor increases in size till it 
 equals a large nut or an egg, the skin becomes involved, the 
 new-cell growth breaks down, and the cold abscess opens, or is 
 opened, and a thick cheesy pus mixed with blood is evacuated. 
 There is little tendency to reactive inflammation or repair in 
 the sluggish ulcers that are thus left. They are irregular or 
 oval in shape, with edges deeply undermined, thin, and violace- 
 ous (since the original opening in the skin is always smaller 
 than the subcutaneous granulation mass). Their bases are 
 uneven and covered with pale, unhealthy granulations ; deep 
 sinuses may run in various directions. If there is any scab, it 
 is thin and gray, or brownish ; on removal the surface tends to 
 bleed on the slightest touch. The discharge is usually scanty, 
 thin, and watery. The flatter and more superficial ulcerations 
 are from granulation masses in the skin or underlying tissues ; 
 those from lymphatic glands being deeper, more rugged, and 
 often sending processes deep down among the muscles and 
 fasciae. In some cases the infiltration is very widespread and 
 the resulting ulceration very deep, so that even cartilage and 
 bone may be destroyed. 
 
 Gradually and slowly cicatrization sets in, and an irregular, 
 knotty, contracted, and often hypertrophic scar is left. The 
 disease manifests itself most commonly upon the neck and 
 under the lower jaw. There is usually only one or two such 
 processes present, though there may be as many as six at once. 
 Almost always other evidences of scrofula will be present, as 
 chronic inflammatory affections of the mucous membranes, 
 coryza, and conjunctivitis, or purulent otitis media, chronic 
 joint swellings, old scars from previous lesions, etc., etc. 
 
 Several less common varieties of scrofuloderma are described. 
 Thus, there is an eruption consisting of one to three large, flat, 
 oval pustules situated upon an inflamed or violaceous base, 
 which, when ruptured, show the appearance above described 
 as characteristic of the scrofulous ulcer. They run a chronic 
 
SCROFULODERMA. 505 
 
 course, and leave soft, flat, superficial scars. Again, there are 
 sometimes seen papillary or fungoid growths closely resembling 
 lupus verrucosus. Their color is of a more or less bright, or dull 
 violaceous red, their surface secreting pus freely. They are 
 usually met with about the hands, are very chronic, and lead to 
 deep seated ulcerations, which may affect even the bones, and 
 cause great deformity. It is doubted whether these are really 
 of the same nature as the ordinary scrofuloderma. Duhring 
 describes still another form, which manifests itself as small, 
 pin-head to split-pea-sized flat pustules upon a red or viola- 
 ceous base, very like the small pustular syphiloderm, which dry 
 up in a short time, and leave deep, punched-out scars. They 
 appear irregularly, and all over the body, though they espec- 
 ially affect the face and upper extremities. Neisser regards this 
 as an acne cachecticorum, and not as an essentially scrofulous 
 process at all. 
 
 Etiology. — The essential cause of scrofula is, of course, the 
 specific infecting agent, the bacillus. But a variety of other 
 conditions have long been supposed to be influential, and un- 
 doubtedly do predispose the system to receive the materia 
 morbis. The most important is, perhaps, that congenital 
 " weakness " of tissue-life which we see in those born of stru- 
 mous, or syphilitic, or tubercular parents, and in those who 
 exemplify the evil effects of " in-breeding " in the human 
 race. Negroes seem specially predisposed to it, and exposure 
 to cold and wet, want of pure air, of sufficient food, and exer- 
 cise, all seem to favor its development. 
 
 Diagnosis. — There are usually other symptoms of scrofulosis 
 present in the patient ; strumous affections of the joints, bones, 
 eyes, and mucous membranes. The important differential 
 diagnosis is from the gummatous ulcerations of syphilis. But 
 the history, the occurrence singly, and often in persons of oth- 
 erwise good general health (tertiary stage) ; the favorite loca- 
 tion upon the long bones and forehead, and the non-origin in 
 the lymphatic glands ; the specific infiltration present at the 
 margins of every syphilitic ulceration, no matter how extensive ; 
 the slight gummy secretion ; and, finally, the effects of iodide of 
 
506 MOLLUSCUM CONTAGIOSUM. 
 
 potassium ; all these distinguish the ulcer of syphilis from that 
 of scrofula. 
 
 Treatment. — Cod-liver-oil, syrup of iodide of iron, phospho- 
 rus, sulphide or muriate of lime, etc., are the class of remedies 
 which will be found serviceable. Locally, the softening or 
 cheesy masses must be removed with the curette, the thin, over- 
 hanging walls of the resulting ulcers cut away, and stimulating 
 applications applied to the sluggish sores. Mercurial ointments; 
 corrosive sublimate and alcohol lotions (grs.i to 2 — f i.); nitrate 
 of silver ointment (1 to 2$); but best of all, iodoform as powder, 
 ointment, or dissolved in ether (1: 15). This last may be used 
 as a spray for the nasal mucous membrane, etc. Cheesy lym- 
 phatic glands must be extirpated ; fistulse scraped and revivified. 
 
 General tonic treatment, diet, exercise, etc., is important, 
 and chlorate of potassium has proved serviceable in Shoe- 
 maker's hands. 
 
 MOLLUSCUM CONTAGIOSUM. 
 
 Syn. — Molluscum sebaceum ; molluscum epitheliale ; epithe- 
 lioma molluscum ; molluscum sessile ; condyloma subcutaneum ; 
 acne variolaform. 
 
 Definition. — Molluscum contagiosum is an affection of the rete 
 mucosum, and is characterized by the appearance upon the skin 
 of globular or wart-like papules and tubercles of a semi-trans- 
 parent, whitish or pinkish color, varying in size from that of a 
 pin-head to that of a pea. 
 
 Symptoms. — The affection was first described and given its 
 somewhat misleading name by the English dermatologist Bate- 
 man. As usually seen, the molluscum consists of a firmly- 
 seated or sessile round tumor, of about the size of a split pea. 
 In color it does not vary from that of the part upon which it is 
 situated, but it has a peculiar waxy, semi-transparent look, from 
 the stretching of the skin over the little tumor. Its summit is 
 flattened, marked by a slight depression, in the centre of which 
 a small dark point, the opening of the follicle, can almost always 
 be detected. It is moderately firm to the touch. A small 
 
MOLLUSCUM CONTAGIOSUM. 507 
 
 amount of pressure will immediately cause the contents of the 
 tumor to exude. Under the microscope, the greasy mass thus 
 obtained is seen to consist of flattened epidermic cells, fat glob- 
 ules, and fat crystals. Besides these, there are seen a varying 
 number of the peculiar bodies known as molluscum corpuscles. 
 These are rather large oval bodies, non-nucleated, and lying 
 either free, or partially or wholly enveloped in an outer cover- 
 ing. They have erroneously been supposed to be peculiar to 
 this affection, and to be the essential bearers of its supposed 
 contagious properties. 
 
 These peculiar little tumors may be present singly, but they 
 usually appear in considerable numbers upon some limited area 
 of the body. They are commonest, perhaps, about the geni- 
 tals, on the penis, scrotum, and labia ; next most frequently 
 upon the face and neck ; and more rarely upon the flexor 
 surfaces of the extremities. One only, or from twenty to one 
 hundred, may be present. In an example of the affection, 
 where the sheath of the penis and the mucous membrane cover- 
 ing the glans was involved, some sixty, in various stages of de- 
 velopment, were present. The whole organ, from tip to root, 
 was studded with them ; and not a single tumor was present 
 upon any other portion of the body. 
 
 The little tumors grow very slowly, and when formed, may 
 persist for months and years. Some undergo spontaneous ab- 
 sorption ; others are accidentally torn out by scratching ; and 
 still others cause a certain amount of inflammation in the sur- 
 rounding tissues, and are cast off. In ^hese latter cases a 
 scar is left, which may be of importance when the disease affects 
 the other portions of the body. No subjective symptoms of 
 any kind are present. 
 
 The affection occurs oftenest in children. It has been 
 rather frequently noticed around the genitals in connection 
 with gonorrhoea, and upon other portions affected by prurigo, 
 eczema, hyperidrosis, etc. The disease never occurs upon the 
 palms of the hands or the soles of the feet. 
 
 In spite of its name, the malady is in no way contagious. 
 It has been observed to occur in several members of the same 
 
508 
 
 MOLLUSCUM CONTAGIOSUM. 
 
 family, etc. ; but all attempts to inoculate it have failed. Nor 
 would the nature of the affection, so far as we know it, lead 
 us to presuppose any such quality for it. 
 
 It is a rather rare affection. 
 
 Anatomy. — The pathology of molluscum contagiosum has 
 
 Fig. 64. Section of a small molluscous tumor 
 hair ; e, periphery of tumor. 
 
 a, corneous layer ; b, rete ; c , 
 
 been the subject of much discussion. The older authorities 
 claimed it to be an affection of the sebaceous glands ; but ac- 
 cording to most of the recent authorities, the seat of the dis- 
 ease is in the rete mucosum. The molluscum corpuscles 
 before mentioned are epithelial cells that have undergone a 
 peculiar degeneration. 
 
 Fig. 65. — #, corneous layer ; b, rete ; c, central orifice corresponding to follicle 
 orifice ; d, inter-acinous connective tissue ; e, changed rete-cells. 
 
 According to Virchow the disease begins by a hyperplasia 
 of the epidermis lining the hair-follicles. The cells upon 
 the free surface of the epidermis surrounding the follicle soon 
 become affected, and the epidermis growing downward into 
 the cutis, the successive layers of new formed cells become 
 
MOLLUSCUM CONTAGIOSUM. 
 
 509 
 
 each in turn the seat of the morbid change. Kaposi does not 
 regard the occurrence of the molluscum corpuscle as peculiar 
 to this malady, but states that they are formed in other dis- 
 eases ; in fact, wherever epithelium cells lie long unchanged, as 
 in epithelioma and comedo. The rete cells first become granu- 
 lar, and then vacuolated ; the granules then fuse into a homo- 
 geneous mass, and the nucleus of the cell is lost. Gradually 
 
 Fig. 66. — Commen cement of the tumor from the external root-sheath of the 
 hair ; a, neck of the follicle ; b, changed rete cells ; c, part of previous hair shaft ; 
 d, base of follicle. 
 
 the new substance fills the cell and renders it globular in shape; 
 but the horny capsule remains unchanged. 
 
 I have examined a considerable number of molluscum tumors, 
 and have never found them to be connected with the sebaceous 
 gland, and they are certainly not retention tumors of these 
 structures. They arise from the rete by a process of prolifera- 
 
5IO MOLLUSCUM CONTAGIOSUM. 
 
 tion, associated with a tendency to a peculiar transformation of 
 their substance. In all of my specimens the disease com- 
 menced in the rete cells of the external sheaths of hair (see Fig. 
 66). The change in growth may commence near the neck or near 
 the root of the hair. After the tumor has existed a time, the 
 hair falls out, as the proper kind of cells for its formation are no 
 longer produced. The orifice of the hair follicle makes the 
 
 Fig. 67. — Cells from peripheral part of an acinus ; a, surrounding connective 
 tissue ; b, rete cells gradually undergoing change. 
 
 central opening above referred to. (See Figs. 64 and 65.) The 
 contents of the tumor never, at any time, present the appear- 
 ance of the fatty epithelial cells of glands. In fig. 64 and 65 
 are presented sections of two tumors showing the acinous-like 
 form of the tumors and the central orifice. In fig. 65 the 
 arrangement of the cells is shown. In fig. 67 are represented 
 the first few rows of cells. The transformation commences 
 
 Fig. 68. — More or less completely changed cells. 
 
 already in the first row. The cells of this row are much larger 
 than the normal cells of the external hair sheath. As the centre 
 of the tumor is approached, the nucleus disappears and the cell 
 body becomes completely transformed, except the peripheral 
 part. In fig. 67 are represented some cells in which the nucleus 
 has vanished and the transformation process is far advanced. 
 In fig. 68 the cells are almost completely changed, except the 
 peripheral part. Those shown in fig. 69 represent the so-called 
 
MOLLUSCUM CONTAGIOSUM. 511 
 
 molluscum corpuscles. The exact nature of the transformation 
 is not known. I have placed this affection among the new 
 growths, to which, in my opinion, it undoubtedly belongs. 
 
 Fig. 69. — Molluscum corpuscles from central part of tumor. 
 
 Diagnosis. — The only disease with which this affection is 
 liable to be confounded is molluscum fibrosum. Yet there are 
 distinctive points enough to prevent our ever making a mis- 
 take. Thus, as regards location, molluscum contagiosum occurs 
 often about the face, while molluscum fibrosum is often spread 
 over the entire body. The tumors of molluscum contagiosum 
 are usually comparatively few ; they are waxy and semi-trans- 
 parent, are prominent and superficial ; those of mollus- 
 cum fibrosum are larger and more numerous, they are hard 
 and fibrous, and are seated deep down in the skin. In mol- 
 luscum contagiosum the opening of the follicle can always be 
 seen as a minute black point situated in a depression at the 
 apex of the tumor ; nothing of the kind is visible in fibrous 
 molluscum. Finally, the disease under consideration usually 
 begins very early during life, while molluscum fibrosum most 
 commonly affects adults. 
 
 Prognosis. — The disease tends eventually to spontaneous re- 
 covery. Once thoroughly removed the bodies do not return ; 
 but unless the bases be well cauterized another molluscum 
 will form from it in. time. 
 
 Treatment. — Local measures only are needed. We may pro- 
 ceed at once to the more radical means, or we may endeavor first 
 to procure absorption of the little tumors. Friction with tinc- 
 ture of green soap, or white precipitate ointment, or sulphur ap- 
 plications, may be used for this purpose, especially when the 
 
512 LEPRA. 
 
 tumors are numerous. But more decisive measures are usually- 
 necessary. If there are but few tumors they may simply be 
 squeezed, or be scraped out with the sharp spoon. Often free 
 incision over the top of each tumor and removal of the whole 
 cell wall with forceps, forms the best mode of treatment. 
 The base should then be cauterized with nitrate of silver. 
 The ligature may also be tried, followed by local cauter- 
 ization. 
 
 LEPRA. 
 
 Syn. — Elephantiasis grsecorum ; lepra verae ; leontiasis ; saty- 
 riasis ; leprosy ; Fa Fung (China). 
 
 Definition. — Lepra is a chronic, malignant, contagious, para- 
 sitic disease, the lesions of which are due to the development 
 of inflammatory new growths in the skin, the mucous mem- 
 branes, the connective tissue of the peripheral nerves and the 
 internal organs. Its cutaneous manifestations consist of yellow- 
 ish red or dark-brown discolorations, reddish and bronzed 
 tubercles and infiltrations and various paresthesias. It causes 
 or predisposes to various affections of the internal organs, 
 and eventually occasions death either by these affections or 
 by the specific marasmus of the disease. 
 
 History. — Leprosy, one of the most interesting of the dis- 
 eases with which we are concerned, possesses a history that 
 can be traced back almost as far as written history itself ex- 
 tends. Though rarely seen at the present day in the more 
 civilized portions of the globe, it is in many countries a very 
 common disease, and certainly merits our careful consideration. 
 
 Lepers exist in Norway, Iceland, Spain, Portugal, Italy and 
 Southern Russia. In the east of Europe, however, the disease 
 has entirely disappeared ; so entirely, that until very recently 
 it was so little known in the medical centres as to have become 
 almost mythical. It rehabilitation is largely due to the Nor- 
 wegian physicians, notably Boeck and Daniellsen, and to 
 European surgeons practicing in the East-India and China, 
 where leprosy still flourishes. 
 
LEPRA. 513 
 
 At the present day its geographical distribution is a peculiar 
 one. Its chief seat is in India, where it is found everywhere 
 from Ceylon to the Himalayas. It prevails extensively in 
 China, especially in the southern provinces ; and Chinese 
 coolies bring it wherever they are extensively employed, as in 
 Australia and California. It is well known in Japan. It is 
 found in South Africa at the Cape Colony. In Asia Minor it 
 exists in Syria, chiefly at Jerusalem, though there are lepers at 
 Damascus, and exclusively among Mahometans. It prevails in 
 all the islands of the Archipelago and on the Ionian Islands ; 
 in Crete alone there are over 1,000 lepers to a population of 
 250,000. Throughout Central Asia it is common among the 
 wandering Mongol tribes, as among the Persians and Afghans. 
 In Europe, besides the northern and southern peninsulas 
 already mentioned, it prevails to a small extent in Turkey, 
 especially in Thessaly and Macedonia. 
 
 In our own hemisphere its chief seat is in South America, in 
 the Guianas, Brazil and the West Indies, especially in Jamaica 
 and Barbadoes, where it is very common. In North America 
 it is found in California among the Chinese, and among the 
 Norwegian colonies of the Northwest. A small leper colony 
 also exists at Tracadie in New Brunswick. Cases have also 
 been reported from the Southern States, notably no less than 
 thirteen (black and white) from Charleston, S. C. There are 
 probably at least 100 lepers in the United States, and it is 
 upon the increase here. Cases are occasionally seen in New 
 York ; at least three well marked ones have been inmates of 
 the dermatological wards of Charity Hospital within the last 
 few years. 
 
 A notable instance of the power of extension possessed by 
 lepra under favorable circumstances, is afforded by the Sand- 
 wich Islands. Forty years ago it did not exist there ; now 
 one-tenth of the population are lepers. The Chinese are re- 
 sponsible for its introduction there. 
 
 This widespread distribution accounts for the great variety 
 of local names by which lepra is known. 
 
 Symptoms. — Lepra is a constitutional disease which affects 
 33 
 
514 LEPRA. 
 
 the entire system, and whose manifestations are seen in 
 almost all the organs of the body. An essential feature in 
 its life history is its extreme chronicity, and in this it ex- 
 ceeds even syphilis, the disease with which it is most fre- 
 quently compared. Many years usually elapse after the first 
 symptoms before the malady reaches its termination, and the 
 patient often succumbs to intercurrent disease before he has 
 had time to die of leprosy. Nevertheless, the disease shows a 
 regular and orderly progression, and goes from bad to worse ; 
 for, unfortunately, in spite of the utmost efforts of our thera- 
 peutics, all that it has yet been possible to attain has been to 
 affect a temporary stay in the march of the malady. Gold- 
 schmidt, as the result of his extensive observations of the dis- 
 ease upon the Island of Madeira, places its average duration 
 at twelve years, while the most chronic case he saw was one 
 that had existed twenty-two years. It is doubtful if it ever 
 terminates until several years after its first outset. 
 
 Various premonitory symptoms occur before the actual in- 
 vasion of the disease ; but they are indefinite in character, and 
 would only give rise to suspicion in localities where lepra is 
 endemic. They consist of general lassitude, insomnia, gastric 
 disturbances, diarrhoea, irregular fever, etc., etc. ; in fact, such 
 symptoms as might be ascribed to various trivial derangements, 
 or mark the advent of many diseases. But they are always 
 present, no matter what form the malady is going to take, and 
 they may last for weeks, or months, or even years before the 
 real symptoms of leprosy come on. One peculiar symptom, 
 however, which very commonly occurs during this preliminary 
 period, is the occasional appearance of bullae, like those of 
 pemphigus, upon the skin. They may appear very seldom and 
 never be present as more than one at a time ; or one or more 
 may arise every day. Each bulla persists for a few days, and 
 then dries up. Another symptom belonging to this period has 
 been described by Dr. D. B. Simmons, and is regarded in 
 Japan, where leprosy is common, as pathognomonic, and that 
 is a deep flushing or lividity of the face which comes on after 
 indulgence in wine or spirits. It is looked upon in the East 
 
LEPRA. 515 
 
 as sufficient for a diagnosis of the disease. Still another 
 marked feature of this stage are the febrile attacks which come 
 on from time to time. They aire quite severe, and are usually 
 mistaken for malaria. After a varying time, then, of what we 
 may justly call the prodromal stage, the real disease or stadium 
 eruptionis sets in, and its manifestations may be various. The 
 skin symptoms are usually the earliest to appear, and generally 
 remain the most prominent feature of the malady ; hence the 
 propriety of classifying a systemic disease under the head of 
 affections of the skin, and considering it in a work upon derma- 
 tology. These lesions, like those of syphilis, appear in the 
 most varied forms, and in accordance therewith we distinguish 
 different phases of the malady. 
 
 Usually but two forms of leprosy are spoken of, the tuber- 
 cular and the anaesthetic, but Kaposi, and I think correctly, 
 recognizes three, viz.: tubercular, macular, and anaesthetic 
 leprosy. Under one of these three forms the disease begins, 
 but no advanced case exhibits any one of them without ad- 
 mixture of one or both of the others. 
 
 1. Lepra tuber osa. — Lepra tuberculosa, or tubercular leprosy, 
 commences as moderate tubercles or larger tuberculated 
 masses situated in the skin, prominent and circumscribed, 
 varying in size from that of a finger-nail to areas as large 
 as a whole hand, irregular in shape, reddish in color, and 
 fading under pressure at first, but later becoming of a more 
 permanent dark sepia, brown or bronze color. The infiltrate 
 forming these masses is firm, and it is more or less painful upon 
 pressure. They may appear anywhere upon the body, even 
 upon the palms of the hands and soles of the feet ; but they 
 have a special predilection for the face. They are common 
 also upon the legs, buttocks, anus, etc. Besides the tubercles, 
 there is more or less general oedema of the skin in their neigh- 
 borhood. It takes usually a period of months or years before 
 the individual tubercles have coalesced so as to form the infil- 
 trations so characteristic of the disease. 
 
 When these masses appear upon the countenance they cause 
 the peculiar facies to which the disease owes its name of leon- 
 
5i« 
 
 LEPRA. 
 
 tiasis. They usually occur upon the forehead, parallel to the 
 eyebrows, upon the cheeks, and upon the malar bones, and 
 give a heavy, scowling, leonine aspect to the face. Upon the 
 nose, chin, and cheeks, etc., they may occur as irregular viola- 
 ceous shining tubercles, or as more extensive raised and bronzed 
 patches. The lips are infiltrated and swollen, and project 
 forward horizontally, and the ears, especially the lobules, are 
 thick and stiff. These appearances, together with the leonine 
 brow and the generally stupid, sullen aspect, present a charac- 
 teristic and not easily forgotten picture of the disease. 
 
 Iltlfflf 
 
 Fig. 70. — Case of lepra tuberosa. (Neumann.) 
 
 The lymphatic glands of the face and body are greatly en- 
 larged, and are visible as prominent swellings. All over the 
 body the tubercles, with the accompanying oedema, are liable 
 to occur ; when on the palms or soles, they sometimes look 
 remarkably like the tubercles of syphilis. They are often 
 painful, sometimes to such an extent as to completely disable 
 
LEPRA. 517 
 
 the patient, who hardly dares move to perform the most neces- 
 sary acts of life. Not only the skin, but various other portions 
 of the body, may suffer from these localized infiltrations of 
 leprous material. The various mucous membranes, and espe- 
 cially the naso-pharyngeal, are often affected ; tubercles appear 
 in the mouth, nose, throat, upon the epiglottis, and in the 
 larynx. When they break down, as many of them eventually 
 do, indolent ulceration and extensive destruction of tissue 
 occurs. The nose sinks and the voice becomes rough and 
 toneless. Aphonia, and even oedema of the glottis, is liable to 
 occur. The tongue is infiltrated, swollen, and fissured, and a 
 peculiar sickly, sweetish odor is perceptible in the breath. 
 Taste and smell are usually preserved ; tubercles may appear 
 upon the cornea, and conjunctivitis, keratitis, pannus, perfora- 
 tion, loss of lens and total destruction of the eye-ball eventu- 
 ally occur. Atrophy of the testicles has been noticed in many 
 cases. 
 
 Once formed, the tubercles persist for a long time. They 
 but rarely undergo any changes, and the general health — at all 
 events, in the earlier stages — may be quite good and the mental 
 functions seem unimpaired. Almost invariably some of the 
 other lesions are found upon the skin in conjunction with the 
 tubercles. They shall be considered further on. Sooner or 
 later, as the disease progresses, the tubercles change, usually 
 in conjunction with the phenomena of an attack of erysipelas, 
 to be mentioned below. Some may undergo absorption, leav- 
 ing behind atrophied, pigmented spots ; but more commonly 
 the cell proliferation which has existed so long begins to break 
 down, perhaps from accidental, mechanical injuries. 
 
 The life of this tissue of low vitality is compromised by the 
 slight additional blood stasis of inflammation, and ulcerations, 
 the leprous ulcers, result. Occasionally the process may be 
 more acute, and death en masse occur. It is in these latter 
 cases that the lesions of lepra mutilans are seen ; the ulcera- 
 tions may open into or cause suppuration of the various joints, 
 knee, ankle, or fingers and toes ; or necrosis of bone occur, 
 and whole parts, as a hand or foot, may be lost. Nevertheless, 
 
518 LEPRA. 
 
 these ulcerations are no more an essential part of the disease 
 than is the pneumonia which so often ends it ; they are acci- 
 dental, occurring from various causes. 
 
 More or less fever is noticed at various times during the 
 progress of the disease, and intercurrent attacks of erysipelas 
 are common. During such an attack of pseudo-erysipelas, the 
 disease usually makes a sudden forward movement, a varying 
 number of new tubercles appear upon the part, usually the 
 face ; but sometimes an extremity is affected, and the course 
 and symptoms of the disease vary in no way from an ordinary 
 case of erysipelas, save in the extreme slowness with which 
 reaction takes place. Sometimes a number of tubercles are 
 absorbed and disappear during such an attack. In one of the 
 cases at Charity Hospital the man had, every year, one or two 
 attacks of erysipelas of the face, with very high temperatures, 
 after which some change would always be noticed in the tuber- 
 cles ; some of the old ones had gone away, but more new ones 
 had appeared. Recovery was always very slow indeed, though 
 between the attacks the man, who worked as a deck hand upon 
 the island steamboat, seemed to enjoy the most robust health. 
 
 Irregular febrile attacks also occur without the external 
 signs of an erysipelas, and usually mark the invasion of some 
 internal organ by the disease. The immediate prognosis is 
 worse after each febrile attack. The fever is irregular and 
 mostly intermittent in type. It is the real leprous fever. 
 
 Eventually the skin lesions increase in number and severity, 
 the internal organs become involved, the mucous membranes, 
 the glands, the testicles, and the eyes become affected. Mental 
 symptoms appear, the patient becomes helpless, and suffers 
 from profuse diarrhoea, and at last many of them are carried 
 off by pneumonia, phthisis, Bright's disease, or pleurisy. In 
 other cases the attacks of fever occur seldom, and are of slight 
 severity, the affection of the skin progresses very slowly and 
 the patient dies of other diseases. It is by no means certain 
 that the affections of the internal organs are leprous in char- 
 acter, though Cornil has lately found in the cirrhotic liver, and 
 Hansen in the cirrhotic spleen of a leper the bacillus leprae. 
 
LEPRA. 519 
 
 However good the general health at any one period may be, 
 there comes a time when the disease begins to tell upon the pa- 
 tient, and he falls into a condition of general marasmus. It is 
 often eight to ten years before this occurs. On the other hand, 
 the phase of the disease may suddenly change, and a patient 
 who has suffered from tubercular leprosy for years may have 
 later anaesthetic leprosy or lepra nervorum. 
 
 2. Lepra maculosa. — This is often the first form in which the 
 leprosy makes its appearance, though it rarely remains long 
 its sole manifestation. It appears as smooth, glistening, 
 slightly infiltrated patches, reddish or brownish in color ; 
 or as dark pigmentations of the skin, either punctate or 
 in areas of greater or less extent. They are found all over 
 the body. When they are numerous, these pigmented patches 
 form a strange contrast to the normal skin between and 
 around them. ' L. maculosa is almost always associated either 
 with tubercles or with anaesthetic areas. In fact, the pig- 
 mented patches are often coextensive with the paraesthetic 
 ones. By many authorities the macules are looked upon, not 
 as a variety of cutaneous lepra, but as one of the trophic 
 changes following the nerve lesions. These other trophic 
 changes are indeed often found in conjunction with the 
 macules, the pigmented skin being atrophied, smooth, and 
 shining. Accidental ulcerations, etc., may appear on these 
 discolored patches. 
 
 The ultimate symptoms and course of macular leprosy differ 
 in no way from those of the tubercular or anaesthetic forms. 
 Destructive processes, ulcerations, loss of members, internal 
 complications, attacks of leprous fever and erysipelas, occur in 
 this, exactly as in the tubercular form. 
 
 3. Lepra Ancesthetica. — Lepra nervorum (Virchow), elephan- 
 tiasis glabra (Bock) or anaesthetic leprosy, may occur in con- 
 junction with the other forms, but often appears as the very 
 earliest manifestation of the disease. For purposes of con- 
 venience we may divide its course into three stages, and its 
 symptoms into three sets — not that they are be seen sharply 
 defined and divided from one another — even the whole nerv- 
 
520 LEPRA. 
 
 ous leprosy is not a distinct entity, but represents a type of the 
 disease in which a certain set of phenomena are the most prom- 
 inent. But the divisions will be of use to aid us in classifying 
 and arranging a rather numerous and varied set of appearances- 
 
 We therefore speak of a prodromal stage of anaesthetic 
 leprosy — a stage of commencing neuritis ; of an " eruptive " 
 stage — in which the effects of the nerve-lesions become fully 
 developed ; and a permanent stage, with the trophic lesions. 
 The symptoms themselves may be considered as sensory, or 
 motor, or trophic ones ; and, in addition, there are the morbid 
 appearances of the peripheral nerve trunks. The sensory and 
 motor symptoms present no special features ; but the trophic 
 changes are of considerable interest. They consist of lesions 
 of the skin, namely atrophy (glossy skin), pigment anomalies, 
 and the appearance of bullae ; of atrophy of the muscles from 
 destruction of the contractile elements ; and of affections of 
 the bones and joints, necroses, etc.; these latter being usually, 
 in part at least, due to direct mechanical injuries. 
 
 During the prodromal stage the symptoms of nerve irrita- 
 tion are prominent. The patient complains of formications — 
 of sharp lancinating pains, or of excessive sensitiveness to the 
 touch of certain areas of the skin. The integument may be 
 reddened or slightly cedematous, and even at this early stage 
 various superficial nerves are swollen and painful. The areas 
 affected may be many or few, large or small, and do not usually 
 correspond to any special nerve distribution. They are liable 
 to change their seat without appreciable cause. 
 
 By the time the second stage comes on these irritation symp- 
 toms have entirely subsided, and the paretic and anaesthetic 
 ones appear. The pains and hyperesthesia remit, and the 
 patient begins to lose the sensibility and power of motion of 
 certain parts. Irregular patches of anaesthesia appear upon the 
 trunk and limbs ; sometimes coinciding with discolored or 
 tubercular areas ; but often coming in places where the skin 
 looks perfectly normal. These sensationless areas gradually 
 extend and coalesce, and at last cover large tracts of the sur- 
 face of the body. Sensibility to pressure, pain, and temperature 
 
LEPRA. 521 
 
 are lost, and eventually a more or less extensive, but complete, 
 anaesthesia justifies the name of this form of the disease. 
 
 This anaesthesia of lepra is peculiar in more than one respect, 
 and in the section upon the pathology of the disease some at- 
 tempt will be made to explain it. It is irregular, and rarely 
 coincides with any definite nerve tract. Anaesthetic and nor- 
 mal patches lie unevenly distributed, side by side, or even 
 within one another. When the trophic changes have occurred 
 the anaesthesia is permanent and complete. 
 
 These trophic changes constitute the third set of symptoms, 
 and are those that more particularly mark the last stage of the 
 disease. They do not differ in their nature from those that oc- 
 cur in ordinary neuritis. To them is to be reckoned the 
 bullae (pemphigus leprosus) which sometimes make their ap- 
 pearance so suddenly upon the skin, springing up in the night 
 and reaching maturity before morning. They rarely appear other 
 than singly, though there may be a constant succession of them ; 
 their size varies from that of a lentil to that of the palm of 
 the hand ; their contents are clear or yellowish. After 
 persisting for a few hours, or a day or two, they break and 
 leave behind them either shallow excoriations, or white or pig- 
 mented spots, which almost invariably become anaesthetic as 
 the inflammation of the nerve-stems is succeeded by atrophy. 
 Though essentially a part of the later stages, isolated bullae of 
 this kind may appear even in the prodromal period. 
 
 The pigmentary changes consist of smooth, perhaps 
 slightly elevated, patches of varying size and shape, of a red- 
 dish or dark-brown color — a condition hardly to be distinguish- 
 ed from what we have described as macular leprosy. More 
 rarely the change consists in the disappearance of pigment from 
 more or less extensive areas of the skin ; hence the term vitiligo 
 applied to this phase of the disease by the classical physicians. 
 
 The integument itself is atrophied, thin, wrinkled, and 
 smooth (1. glabra) ; it is dry from destruction of the sweat 
 glands. The finger points are clubbed ; the nails are fissured 
 and brittle ; the hair loses its gloss, and at length falls out over 
 the whole body. 
 
522 LEPRA. 
 
 The changes in the muscles consist of a gradually progress- 
 ing paresis with atrophy. This atrophy may be partly due to 
 the motor paralysis, but that it is not wholly so is shown by 
 the fact that even in the early stages we find the fibres them- 
 selves swollen and their striae indistinct, and the interstitial 
 connective tissue increased in amount. As the paresis pro- 
 gresses, more and more of the muscles of the hand and foot, 
 arm and leg, face and trunk become involved. The counte- 
 nance becomes expressionless, or is deformed by the unbalanced 
 action of the unaffected muscles ; the eyelids and lips droop, 
 and the tears and saliva escape and flow away over the surface. 
 The strength of the limbs gradually decreases ; and, from the 
 preponderance of the flexors, the hands assume a permanently 
 bent position. The gait becomes weak and dragging, and 
 eventually the patient is reduced to utter helplessness. 
 
 The condition of the larger nerve trunks now attracts our 
 attention. Sooner or later, often quite early in the disease, 
 some of these nerves become tender and swollen in places. 
 Especially is this the case with the ulnar nerve, upon which 
 the swelling behind the internal condyle may be so marked as 
 to be visible to the eye. These swellings are painful, either 
 spontaneously or on pressure, and they form a prominent 
 symptom in many cases of the disease. After the ulnar> 
 the peroneal nerve is most commonly affected. The neuritis 
 which causes this as well, as all the other symptoms of nerv- 
 ous leprosy, will be fully considered in the pathology. 
 
 At length, as in other forms, the appearances grouped to- 
 gether as 1. mutilans set in. Indolent ulcerations appear 
 around the joints, and extend into the deeper parts ; articula- 
 tions are opened, bones are destroyed ; the muscles and 
 fasciae are laid bare, and whole parts may drop off. It 
 is needless to recapitulate the various other changes that 
 occur in the eye, the mucous membranes, etc. ; they are exactly 
 the same as those occurring after 1. tuberosa. Pyaemia and 
 erysipeloid complications are common; attacks of leprous fever 
 occur as before. 
 
 Thus the patient gradually sinks. The sexual functions are 
 
LEPRA. 523 
 
 depressed from the beginning, assertions and a name of the 
 disease (satyriasis) notwithstanding. The intellect becomes 
 dull ; the sick man lies quiescent for days at a time. His 
 bodily functions must be attended to like those of a child. 
 Sinking vitality marks every manifestation of life ; the pulse is 
 slow, the heart feeble, the breathing shallow. At length death 
 relieves them from their sufferings. The end is usually due 
 to complications, to diarrhoea, pneumonia, pleurisy, Bright's 
 disease, tetanus, etc. The anaesthetic is the more chronic 
 form of the disease, and often lasts 15 to 20 years from the 
 first appearance of the symptoms. 
 
 Complications. — Of course, in a disease of such extreme 
 chronicity many complications of the lesions of the skin may 
 occur. Thus there has been noticed the coincident occurrence 
 of favus, of eczema universalis, of syphilis, of molluscum fibro- 
 sum, of elephantiasis arabum, and of scabies. Especially 
 common among the lepers in some countries is that inveterate 
 form of the itch, known as scabies Norwegica. Syphilis is 
 the only one that would probably cause difficulty in its recog- 
 nition. 
 
 The various internal complications have been repeatedly 
 mentioned, and do not present any special features. Pneu- 
 monia, pleurisy, pericarditis, peritonitis, chronic hepatitis, affec- 
 tions of the eyes, pyaemia, etc., are seen. Very frequent are 
 attacks of erysipelas, especially e. faciei, each onset of which is 
 followed by an advance in the lesions of the skin. 
 
 Anatomy. — Much new light has been shed upon the pa- 
 thology of leprosy by the labors of Daniellsen and Bock, 
 Virchow, Bergman, Kaposi, and others. Thanks to their 
 efforts we possess a pretty definite knowledge of the pathology 
 of lepra in all its forms. 
 
 Now the essential point is, that all the manifestations of the 
 disease are caused by the presence in the tissues of the specific 
 bacillus lepra. This micro-organism will be described, and 
 its pathological value discussed, in the etiology. The lesions 
 of lepra are due to a new growth caused by the bacillus ; a new 
 growth composed of numerous small round cells, more or less 
 
524 LEPRA. 
 
 closely aggregated together. In fact, each lesion is a granula- 
 tion tumor, and is, in so far as its anatomy is concerned, in 
 very intimate relationship with the lesions of lupus and syph- 
 ilis. The cells themselves do not differ from those of lupus, 
 except, perhaps, that they are slightly larger, and are not so 
 distinctly encapsulated. Syphilis, lupus, and lepra, all three 
 are granulation tumors, so called, and all three tend either to 
 absorption or eventually to disintegration. In lupus the pro- 
 cess is slower than in syphilis ; in lepra it is slowest of all. 
 
 This small-celled accumulation begins in the walls of the 
 bloodvessels, and spreads thence to the rete, where it grows 
 and forms the tubercles so characteristic of the disease. 
 Gradually the new growth infiltrates the various structures of 
 the skin, and by pressure and interference with the blood sup- 
 ply, causes destruction of the sweat and sebaceous glands, 
 the hair follicles, etc. The cell mass is not circumscribed or 
 encapsuled ; it spreads through the tissues, though a varying 
 amount of new connective tissue is formed, and is seen as 
 fibrous bands running through the infiltrated mass. When all 
 the structures of the skin are infiltrated by the small-celled 
 collection, and the vascular supply becomes compromised, fatty 
 degeneration of the new cells occurs ; the mass breaks down, 
 and the sluggish ulcerative processes begin. As before stated, 
 the inflammation caused by some accidental injury usually 
 occasions the final process. Like the infiltrations that preceded 
 them, the ulcers run a markedly sluggish course. Not only the 
 skin, but the mucous membranes, especially those of the nares, 
 fauces, larynx and trachea are also liable to this infiltration. 
 The ulcerations in the nose may destroy the septum and cause 
 flattening of the organ ; perforations of the palate occasionally 
 occur. Laryngeal stenosis may occur from the tubercles, or 
 oedema of the glottis renders tracheotomy necessary during the 
 destructive stage. 
 
 As regards lepra nervorum, no lesions of the central organs 
 have yet been positively demonstrated. In the peripheral 
 nerves there occurs a neuritis, at first acute and liable to dis- 
 appear, later chronic and permanent. The fibres themselves 
 
LEPRA. 525 
 
 are not at first affected, for it is an interstitial neuritis, occur- 
 ring perhaps only in microscopic spots. As the inflamma- 
 tion progresses, a connective tissue new growth gradually 
 presses increasingly upon the nerves, and ultimately fatty 
 degeneration and destruction of the fibres occurs. Upon 
 post-mortem we find many of the nerves, especially the ulnar, 
 median, radial, musculo-cutaneus and peroneus, swollen along 
 their whole length, or in places hard to the touch, and of a 
 grayish or smoky tint. In anaesthesia of the face the Gasserian 
 ganglion has invariably been found thus affected. 
 
 There exists some difference of opinion as to the exact 
 nature of the new growth, it being regarded by some authori- 
 ties as a true leprous infiltration, analogous to that of the 
 tubercles ; others look upon it as a simple interstitial 
 neuritis, differing only in unimportant particulars from an 
 ordinary nerve inflammation. The specific bacillus has not, to 
 my knowledge, been demonstrated in the affected nerves. 
 
 The modifications of cutaneous sensibility which form so 
 prominent a feature of the disease are fully explainable by the 
 nerve lesions. The hyperesthesia of the skin marks the stage 
 of inflammation and irritation ; the anaesthesia, that of pressure 
 and nerve degeneration. The process in the nerve tissue be- 
 ing an extremely irregular one, the paraesthesias are also irreg- 
 ular in their development. The first acute processes doubtless 
 often end in resolution, and hence the passing hyper- and 
 anaesthesias. Later processes are profounder, depend upon 
 actual degeneration, and are permanent. The trophic changes 
 are exactly similar to those of neuritis from other causes. 
 According to Kaposi, however, a part, at least, of the nervous 
 phenomena is due to the direct pressure of the cutaneous in- 
 filtration upon the terminal nerve filaments themselves. 
 
 Various lesions of the central nervous system have been re- 
 ported by Neumann, Langhans, Rosenthal, etc., including 
 softening of the cord, and myelitis of the posterior horns. 
 But their occurrence has been denied by Neisser, Leyden, 
 Hillis, and other equally trustworthy observers, and they were 
 probably merely accidental complications. 
 
526 LEPRA. 
 
 All the internal organs may be, and in advanced cases are, 
 affected with the same small-celled infiltration of the connec- 
 tive tissue and subsequent parenchymatous atrophy. The 
 pathological process is a general one, and the lungs, liver 
 spleen, kidneys, testicles, intestines, eyes, etc., have been found 
 affected. Here also the bacillus has been found. When 
 speaking of leprous fever I stated that each new attack of 
 fever probably marks the advance of the infecting bacillus and 
 consequent small-celled new growth into fresh territory — 
 sometimes of the skin, sometimes of the internal organs. 
 
 Besides these, the lesions of the various intercurrent affec- 
 tions from which most patients suffer, and of which many die 
 during the course of this most chronic disease, will be found. 
 Thus tubercular deposits in different organs, especially the 
 lungs ; chronic inflammatory processes of the liver, or kidneys, 
 amyloid degenerations ; the lesions of pyaemia, etc., are often 
 present. 
 
 Etiology. — The etiology of lepra has long been the subject 
 of dispute, and it is only quite recently that light has been 
 thrown upon it. Thanks to the labors of Hirsch, Neisser, and 
 others, we do to-day possess some definite knowledge regard- 
 ing its causation. We know that it depends upon the intro- 
 duction into the system and the multiplication there of a 
 specific micro-organism — the bacillus leprae. 
 
 Leprosy occurs in the most various races, in different cli- 
 mates, and under the most divergent habits of life. It pre- 
 vails in the tropics of America, as in Northern Iceland ; 
 among Africans, as among the Chinese ; in the lowest classes of 
 Madeira as in the highest of Rio Janeiro. It is improbable that 
 it can be due to any of the various climatic agencies to 
 which its onset has been ascribed. Thus it has been claimed 
 to be due to atmospheric, to telluric influences, to malarial 
 agencies, etc. But lepra exists in inland as well as in littoral 
 districts, in mountainous as well as in flat and sandy regions, 
 in moist as well as in dry climates ; it is at home among the 
 mountains of Norway, in the swamps of the Crimea, and on the 
 fertile plains of India. 
 
LEPRA. 527 
 
 Improper diet has next been invoked as a cause, especially 
 the consumption of salted or stale fish, and of fish-oils. This 
 is the reason assigned by the natives of Norway and Iceland for 
 the prevalence of the disease among them. But the Egyp- 
 tians, the Mexicans, the Hawaians, do not live upon such food, 
 and amongst all these, the disease is endemic and finds to-day 
 its most chosen seats. 
 
 Bad hygienic surroundings, foul air, filthy dwellings, im- 
 proper personal habits are supposed by some to be influential 
 in causing lepra. But these conditions prevail more or less 
 everywhere, and leprosy does not ; they are most strikingly 
 exemplified in the large European cities, where leprosy is vir- 
 tually unknown. On the other hand, in some parts of the 
 world, as in Brazil, the richest and best-cared-for classes fur- 
 nish a proportionately large number of cases. 
 
 Contagion is the next factor that demands our attention, and 
 the immense mass of the evidence in our possession shows that 
 the disease may spread in that way. Many cases are re- 
 corded in which persons with absolutely no leprous family his- 
 tory, and who have resided but a short time in infected dis- 
 tricts or together with a leper, have contracted the disease. 
 Thus one of the cases in Charity Hospital has resided but a 
 short time, one year, in Bermuda ; his parents and grandparents 
 had been absolutely healthy, and had lived all their lives in the 
 Northern States. Kaposi relates an analogous case, of an 
 Italian and his wife, whose history was perfectly clear from 
 taint, and who contracted the disease during a two years' so- 
 journ in Egypt. On islands and other isolated districts the 
 disease has spread in a manner which leaves contagion as the 
 only available hypothesis. Thus, in 1859, the two first cases of 
 leprosy ever known upon the Sandwich Islands occurred in the 
 persons of two Chinese coolies ; and the cases were accurately ob- 
 served by Hilleb rand. In seven years (1866) the disease had 
 spread to such an extent that the Government found it necessary 
 to interfere, and ordered the segregation of the lepers upon the 
 Island of Molokai. There were then found 400 lepers. In 
 1 88 1 there were 800 lepers on Molokai ; whilst it was esti- 
 
528 LEPRA. 
 
 mated by the Honolulu Board of Health that there are at least 
 4,500 lepers upon the Islands, comprising one-tenth of the 
 total number of inhabitants. It is worthy of note that the na- 
 tives have obstinately stood in the way of the authorities in 
 their efforts to limit the disease, and have afforded leprosy, as 
 they did syphilis, all possible opportunity to spread. In Trini- 
 dad, while in 1805 there were three lepers, in 1878, with but 
 four times as many people, there were 860. On the neighbor- 
 ing Island of Curacoa, meantime, where stringent measures have 
 long been in vogue, the disease is on the decrease. The same 
 is happening in Norway, and Western and Central Europe un- 
 doubtedly owes its freedom from leprosy to the rigid segrega- 
 tion that followed the terrible epidemics of the disease in the 
 13th and 14th centuries. Nevertheless, the fact that the con- 
 tagiousness of leprosy is not of the ordinary active kind is evi- 
 denced by the fact that lepers have lived in our general hospi- 
 tals for years ; they have mixed freely with the patients, in 
 many of whom the ordinarily enumerated predisposing condi- 
 tions, constitutional disease, bad hygiene and bad personal 
 habits, were certainly present ; and yet they have not commun- 
 icated the malady to others. Julius Goldschmidt could find only 
 one example of pure contagion, of origination of the disease 
 in a person of a healthy family and association, in Madeira, 
 where there are 600 lepers in a population of little over 
 100,000. The general contagious nature of lepra is recognized, 
 however, in almost all its endemic sites ; hence the segregation 
 of the lepers so universally adopted. 
 
 All authorities agree in considering leprosy contagious by 
 inoculation. The accounts of the origin of the disease in lo- 
 calities where it is prevalent nearly all give this history. Thus 
 the first case of the disease in New Brunswick occurred in a 
 woman who was said to have contracted it from washing the 
 clothes of some leprous French sailors. In no other way than 
 by contagious inoculation can we reconcile the facts, on the one 
 hand, of the immunity of those who though living under the 
 same roof with lepers, yet exercising ordinary precautions, 
 entirely escape the disease ; and on the other, of the phe- 
 
LEPRA. 529 
 
 nomenal spread of the disease in the Sandwich Islands, 
 where the universal immorality in sexual matters and the prev- 
 alent disbelief in the inoculability of the disease, makes them 
 excellent breeding beds for it, as also for syphilis. It is of 
 course difficult to find thoroughly authenticated instances of 
 this mode of origin, which is not wondered at when we con- 
 sider the absence of any marked inoculation lesion, the long 
 prodromal period, and the slow course of the disease. Experi- 
 ments upon the lower animals have until now invariably failed 
 to reproduce lepra. Only very recently, extensive work has 
 been done by Kobner of Berlin, Annauer Hausen of Bergen, 
 and Damsch of Gottingen in this direction ; various animals 
 from apes to fishes, being inoculated. The utmost that has 
 been accomplished so far is the production at the site of the 
 inoculation of a local new growth whose anatomical structure is 
 exactly analogous to a leprous tubercle, and which contained in 
 abundance the specific bacilli. Again, cases are related, like 
 that of a man in New Brunswick, who lost three wives in suc- 
 cession from leprosy, yet escaped the disease himself. But 
 these negative results have little weight as against the mass of 
 evidence on the positive side ; and we must admit the un- 
 doubted inoculability of lepra, under favorable circumstances, 
 upon the human subject. 
 
 Lepra has long been regarded as an indubitably hereditary 
 disease ; but lately grave doubts as to its transmissibility in 
 this way have arisen. That a contagious disease of this nature 
 should prevail in families is not surprising ; in fact it would be 
 astonishing if children who spend their lives in daily contact 
 with lepers, and usually lepers only, should not contract the 
 disease. The phenomena of the disease very rarely appear in 
 these children until they are three to five years, and often not 
 till they are fifteen or twenty years, old. Again, children have 
 been born in the lazaretto of leprous mothers, have grown up 
 within its walls, and have still remained healthy. Hillis, one 
 of the chief English authorities, still maintains the possibility 
 of hereditary transmission, but most of the late writers, like 
 Neisser, deny it altogether, regarding the leprosy of children of 
 34 
 
53© LEPRA. 
 
 leprous parents as the results of the almost certain inoculation 
 for which so many channels stand open during the early years 
 of life. It is possible that, as in the case of tuberculosis, there 
 may be inherited a predisposition to receive the disease. 
 
 Direct proof that the bacilli found in the leprous infiltrations 
 are the etiological factors in the production of the disease, is as 
 yet wanting ; but there is such a strong probability of that be- 
 ing the case, the proofs to that effect accumulating every day, 
 that I have not hesitated to define lepra as a parasitic disease. 
 Experiments made with intent to reproduce the disease by in- 
 oculation of animals with the bacilli and their spores have, it is 
 true, so far failed ; but the general evidence in favor of the 
 theory is such that we can confidently hope for experimental 
 proof of its correctness in the near future. Nevertheless, it is 
 well to remember that Kobner, a most ardent advocate of the 
 bacillar etiology, only claims for it a very strong probability. 
 
 In view of these facts, we may say, in conclusion, that lepra 
 is a disease that may possibly be contagious, but is certainly 
 inoculable ; that its mode of spreading is probably by inocula- 
 tion, and inoculation alone, though heredity may exercise a 
 predisposing influence ; that the infective material con- 
 sists almost certainly of a specific micro-organism — the 
 bacillus lepra, and its spores ; that the bacillus, or more prob- 
 ably its spores, obtain access to the lymphatics by some 
 lesion of the upper epithelial layers, when, after lying quiescent 
 for a variable time, they multiply, wan- 
 der into different parts of the organism, 
 and cause the varied symptoms of the 
 disease. 
 
 In figure 71 are represented lepra cells 
 
 containing bacilli, and isolated bacilli 
 
 with spore formation. The drawing is 
 
 copied from Neisser's article in Ziem- 
 
 men's Handbuch der Haut-Krankhei- 
 
 Fig. 71. ten. 
 
 Diagnosis. — In spite of the polymorphous character of the 
 
 disease, its diagnosis in the fully developed form presents few 
 
LEPRA. 531 
 
 difficulties. In regions where it has its home, the prodromata 
 might attract attention ; thus, in Japan, the deep flushing of 
 the face, which is apparent in the very earliest stages after 
 indulgence in alcoholics is sufficient to brand the leper and 
 drive him at once into exile. But with us — where the dis- 
 ease is of extreme rarity — the general symptoms of malaise 
 would necessarily be ascribed to some other, perhaps trivial, 
 cause. 
 
 Perhaps with no disease is there greater danger of confounding 
 the macular and tubercular phases of lepra, than with syphilis. 
 The two affections stand at opposite poles as regards frequency 
 of occurrence, and, whilst syphilis would hardly be mistaken 
 for leprosy — a limited macular or tubercular lepra might 
 be treated as a syphiloderm. But in the rarer disease, the 
 color and situation of the tubercles — the co-existence of macu- 
 lar and anaesthetic patches — the occurrence of large persistent 
 infiltrated areas — the atrophies of skin and muscle, and the 
 distortion of the extremities — the history and extreme chron- 
 icity of the disease — the failure of the specific treatment, and, 
 finally, the presence of the characteristic bacilli, would certainly 
 suffice for the diagnosis. 
 
 In any case, great stress must necessarily be laid upon the 
 history. If the patient was born, or has lived, in a place where 
 lepra is endemic, the diagnosis of the disease acquires great 
 probability from that fact alone : while, on the other hand, it 
 is almost without parallel in all the accorded experience of 
 leprosy for it to develop in one who has never been exposed 
 to these local influences. 
 
 L. maculata may be confounded with vitiligo ; but vitiligo 
 consists simply of an absence of pigment in a localized area of 
 the skin, with a slight increase of it at the margin of the 
 patch. The general health remains good, no trophic changes 
 occur, and the integument is normal in all respects, save in its 
 color. On the other hand, the maculae of leprosy consist of 
 patches which feel as if firm lardaceous material were deposi- 
 ted in the skin ; they are paraesthetic, and the skin is changed 
 in appearance. 
 
532 
 
 LEPRA. 
 
 Morphoea, though claimed by some writers to be a circum- 
 scribed benign remnant of the ancient epidemic leprosy, is con- 
 ceded to be an affection of an entirely different nature. Its 
 patches are normal in sensibility ; there are no other symp- 
 toms ; and the disease tends towards spontaneous recovery. 
 
 It would seem hardly possible to mistake the tubercles of 
 leprosy upon the face for acne rosacea, or lupus, or pigmen- 
 tary sarcoma. The diseases have but the most superficial re- 
 semblance to one another. 
 
 Finally, in any case, examination of the blood from suspect- 
 ed lesions would confirm or nullify the diagnosis. 
 
 Prognosis is always most unfavorable. The disease once es- 
 tablished, it keeps up its regular and progressive march, 
 broken only, perhaps, by periods of apparent quietness. Indi- 
 vidual tubercles, or anaesthetic spots may disappear, or one 
 form of the disease give place to another ; but leprosy is not 
 cured by us. Lepers die, after a longer or shorter time, of the 
 specific marasmus, of complications, or of intercurrent dis- 
 eases. 
 
 The immediate prognosis depends, of course, upon the age 
 of the disease, and upon its type. Patients in the early stages 
 of anaesthetic leprosy usually survive many years, perhaps at 
 least eight or ten, upon an average. In the tubercular and 
 ulcerative stage the downward progress is more rapid, and 
 some forms, with well-marked fever, etc., may terminate fatally 
 in a few months. Erysipelas, pyaemia, pneumonia, etc., modify 
 the immediate prognosis according to their own gravity and 
 the patient's condition. 
 
 According to Hillis, the ultimate causes of death may be 
 classified as follows : 
 
 Bright's disease, . 
 
 . 22.5 
 
 Lung diseases, 
 
 . . . 17 
 
 Diarrhoea, 
 
 10 
 
 Anaemia, 
 
 • 5 
 
 Remittent fever, . 
 
 . 5 
 
 Peritonitis, . 
 
 .-" • 2.5 
 
LEPRA. 533 
 
 Direct consequences of lepra ; exhaustion 
 from leprous ulcerations ; leprous stenosis 
 of larynx ; lepra of internal organs, maras- 
 mus, atrophy, etc 38 <fo 
 
 Treatment. — The therapy of leprosy is undoubtedly the 
 most unsatisfactory part of its history. No specific treatment 
 can be recommended ; of the multitude of curative measures 
 which have from time to time been advanced, not one but has 
 failed to fulfill its early promise. To all intents and purposes, 
 lepra is to-day an absolutely incurable disease. 
 
 The ordinary measures of general hygiene must be insisted 
 on. The patient must leave the place where he contracted the 
 disease, and live in a locality were lepra is not endemic. Every 
 possible means must be employed to sustain his general health, 
 diet, exercise, mountain air, sea bathing, etc. Quinine in full 
 doses, cod-liver oil, arsenic, iodine, etc., may be employed. 
 Local sedatives must be used for the hyperesthesias, and the 
 galvanic current for the anaesthesias. Local symptoms, tuber- 
 cles, ulcers, etc., must be treated on general surgical principles, 
 and sulphur baths, iodine, blisters, mercurials, may be used to 
 promote absorption of the infiltration. By means of these gen- 
 eral measures, and in young individuals with whom the disease 
 is not too far advanced, good may be done and life prolonged. 
 
 Among the multitude of different specifics used in different 
 countries for the treatment of the disease itself, there are but 
 few that need detain us. Creosote in half-drop doses, given 
 in pill form t. d., has been highly lauded by Langherans and 
 Perez ; as also has salycilate of soda ( 3 ss. — 3 i. d. die) by 
 Daniellsen and Kobner. Hoang-nan, the powdered bark of 
 the strychnos gaultheriana, a Chinese remedy, given in three 
 grain pills, once to thrice a day, has not proved much more 
 useful in the experience of others, than it did in the one case 
 in which I observed its effects. The drug contains strychnia 
 and brucia — but may be continued indefinitely in moderate 
 
534 LEPRA. 
 
 doses. Gurjun oil has been lately very favorably reported on 
 by Hillis and Espinet, it being even claimed that in some cases 
 so great an amelioration of the symptoms of leprosy has been 
 effected by its continued use, that patients were enabled to re- 
 turn to their families. In British Guiana, a large number of 
 cases were treated by it, and Hillis regards the drug as a most 
 useful one in all forms of leprosy, retarding the disease, and in 
 some instances apparently curing it. Gurjun oil is also to be 
 used externally, as an ointment, or in emulsion with lime-water, 
 one to three. 
 
 The best promise, however, is held out by chaulmoogra oil 
 (ol. guiocardiae, from guiocardia adorata). Many of the East 
 and West Indian surgeons have spoken very favorably of it ; 
 it has been used here by Sturgis, with benefit. I have seen it 
 persistently employed, both internally and. externally, with 
 hardly any positive result. It is to be exhibited internally in 
 gradually increasing doses, from five minims upward, in milk or 
 emulsion ; externally it may be used as an ointment, twenty 
 grains to the ounce. 
 
 These five drugs, then, are those which to-day represent what 
 little promise direct therapy offers in the treatment of lepra. 
 Neisser, Kaposi, etc., simply content themselves with stating 
 the absolute inutility of any of them. 
 
 We possess a somewhat greater power in the direction of 
 prophylactic treatment. The first measure is to insure the 
 absolute segregation of leprous patients. This is fully re- 
 cognized in leprous districts, but not carried out with the 
 cases which appear elsewhere. In the second place, we must 
 endeavor to secure the disinfection of all secretions, etc., by 
 which the disease may be conveyed. Especially must we do 
 this with the discharges from the leprous ulcerations, which have 
 been found to contain the infective bacilli and their spores in 
 abundance. By the use of chrysarobin, we may endeavor to 
 secure the absorption of tubercles before they break down ; 
 and by various antiseptic appliances try to destroy the virus 
 where ulceration has occurred. 
 
 Strict measures should be employed to prevent all chances 
 
SARCOMA. 535 
 
 of immediate contagion. And in the last plan may be men- 
 tioned the careful disposal of the remains of dead lepers. 
 
 SARCOMA. 
 
 Sarcoma upon the skin occurs mostly in consequence of 
 metastasis from the lymphatic glands, though it may manifest 
 itself primarily upon the epidermis. In its commonest form it 
 appears as melanotic sarcoma, a form of malignant tumor not 
 very uncommonly met with upon the skin. The growths are 
 usually multiple, and are often quite small in size, especially 
 at the beginning. They consist first of discrete, rounded, pea 
 or bean-sized papules or tubercles of a bluish-black, graphite- 
 like, or a brownish, or an iron-gray color. They gradually in- 
 crease in size, and tend to coalesce ; then they form variously 
 shaped, irregular, flattened or prominent masses. Later they 
 grow into mushroom-like forms, and soon ulcerate. The 
 nodules begin most often upon the back of the hands and feet, 
 or on the fingers and toes, and on the genitals. The disease is 
 usually primary upon the skin, which organ, together with the 
 eye, forms its seat of election. It often begins in a pigmentary 
 mole or nsevus. The internal organs soon become involved ; 
 they become studded with nodules, composed like those of the 
 skin, of dense masses of pigmented cells. Like all the sarco- 
 mata, the disease runs a rapid and malignant course. 
 
 Two other forms of sarcoma cutis may be briefly mentioned 
 here. One is the " idiopathic multiple melanotic sarcoma," of 
 which cases have been described by Wigglesworth, Kaposi, 
 etc. They appear upon either surface of the hands and 
 feet, as reddish or bluish, round, fairly hard tubercles, at 
 first discrete, but later fusing into larger irregular masses. 
 They gradually extend up the extremities to the trunk and 
 face. The skin of the affected parts is thickened by the irreg- 
 ular infiltrations ; it is stiffened, and is painful both on touch 
 and spontaneously. Ulceration rarely occurs ; after the indi- 
 vidual masses have lasted for a varying number of months 
 they undergo atrophic changes, leaving darkly pigmented and 
 
536 CARCINOMA. 
 
 depressed scars. After several years the face becomes af- 
 fected, the bluish-red, sponge-like masses appearing in varying 
 situations. Then diarrhoea, fever and marasmus soon lead to a 
 lethal termination. Post mortem, all the internal organs are 
 found infiltrated to a greater or less extent with the character- 
 istic nodules. 
 
 Another form of sarcoma of the skin has been described by 
 Duhring, Geber and others, under the title of " inflammatory 
 fungoid neoplasm of the skin." There appears upon various 
 portions of the body red, flat or prominent papules and tubercles, 
 gradually growing and coalescing until in a few weeks they 
 form larger irregular masses. Atrophic changes, with de- 
 pressed and pigmented scars were seen in some instances ; in 
 others, large, irregular fungoid masses with a pultaceous black- 
 ish-red, easily bleeding surface were noticed. Death occurred 
 in all cases from general marasmus within three years of the 
 inception of the disease. Exact pathological data concerning 
 the affection is as yet wanting, but it is undoubtedly a form of 
 malignant sarcoma cutis. 
 
 Diagnosis. — Sarcoma of the skin may be confounded with a 
 tubercular syphilide, with lupus, and with lepra. It is needless 
 to recapitulate the points of distinction which characterize these 
 affections. 
 
 Prognosis. — The prognosis is very unfavorable. Neither ex- 
 tirpation of the sarcomata when they first appear, nor internal 
 medication, has any effect. As a usual thing the disease lasts 
 several years before a fatal termination is reached. 
 
 Treatment is necessarily confined to mitigating the patient's 
 sufferings. For the disease itself we can do nothing, unless 
 arsenic should prove to be of benefit as maintained by some. 
 
 CARCINOMA. 
 
 Several varieties of carcinoma occasionally affect the general 
 integument. By far the most common is the epithelial carcino- 
 ma ; and next to this, but occurring far less frequently, is 
 scirrhus cancer The so-called carcinoma melanodes is more 
 
CARCINOMA. 537 
 
 properly classified under the sarcomata ; but in its clinical 
 features it is closely connected with the scirrhus cancer. 
 
 Reserving for the present the consideration of epithelioma, 
 we find that carcinoma, where it does affect the skin, is of the 
 scirrhus variety. Sometimes it occurs primarily in that situa- 
 tion ; more usually it is secondary to a like affection of the fe- 
 male breast or of some part of the alimentary canal. It occurs 
 either in the lenticular or in the tuberous form. 
 
 Carcinoma lenticulare is almost always a secondary affection, 
 and is most commonly seen on the skin covering the breast 
 affected with the same disease. It is a form in which the malady 
 is very likely to occur after extirpation of the breast. It ap- 
 pears as various-sized, hard, smooth, and glistening nodules or 
 tubercles, flat or raised, and of a dull brownish or pinkish 
 color. There are usually a number of these spread over the 
 surface of the skin ; at first discrete, they soon coalesce and 
 form larger tubercular masses, and then the whole integument 
 is irregularly indurated and thickened, and its surface smooth 
 and glistening. Extensive cases, in which the new growth in- 
 filtrates and involves large tracts of tissue on the front and 
 side of the thorax, form the " cancer en cuirasse " of Velpeau. 
 Sooner or later the vascular supply is interfered with by the 
 abundant new connective-tissue development ; softening and 
 ulceration occur, and marasmus and death end the process. 
 The pain accompanying the disease is generally considerable. 
 
 Carcinoma tuberosian is more rarely seen. It may be a pri- 
 mary or a secondary manifestation, and usually occurs in indi- 
 viduals of moderately advanced age. It appears as circum- 
 scribed, flat or elevated, rounded nodules or tubercles deeply 
 seated in the skin, and varying in size from a pea to a small 
 egg. Their color is usually a dull brown or violaceous hue. 
 They are disseminated over the entire surface, and usually 
 remain discrete during their entire course. Eventually, as in 
 the lenticular form, and from the same causes, they break 
 down, ulcerate, and end fatally. 
 
 As regards their anatomical structure, both varieties consist 
 of a variable amount of connective tissue stroma grouped into 
 
53& EPITHELIOMA. 
 
 alveoli, the meshes of which are crowded with cells of an epi- 
 thelial type, without any intercellular substance. The retro- 
 gressive changes occur from the excessive development of the 
 fibrous stroma, causing obstruction and obliteration of the vas- 
 cular supply, and degeneration and death of the cellular ele- 
 ments. 
 
 Diagnosis. — The carcinomatous forms can hardly be con- 
 founded with any other affection. Papular syphilis, tubercular 
 or papular lupus, and lepra may possibly present difficulties in 
 the diagnosis. 
 
 Prognosis. — Is unfavorable. The carcinomata usually take 
 a little longer to reach a fatal termination than do the sarco- 
 mata, but neither local extirpation or internal treatment seem 
 to have any effect upon the course of the malady. 
 
 Treatment. — Little need be said under this heading. The 
 carcinomata of the skin are usually secondary, and local re- 
 moval is followed only by a return and an increased rapidity in 
 the course of the malady. The local lesions and the general 
 health of the patient must be treated secundum artem to the 
 best of our power. 
 
 EPITHELIOMA. 
 
 Epithelioma of the skin is an affection of sufficiently common 
 occurrence to merit some considerable attention on our part. 
 We recognize at least three different forms of the affection, 
 which we shall describe separately, leaving till later the more 
 general considerations concerning their etiology, prognosis and 
 treatment. They are the superficial, the deep-seated, and the 
 papillary varieties of epithelioma. 
 
 1. Superficial epithelioma begins as one or more neighboring 
 pale-red or yellowish-white and waxy hard nodules. Their 
 surface is shining, and they are usually aggregated into irregu- 
 lar, wart-like masses. They early show a disposition to fissure 
 and excoriate, and become covered with thin, dark crusts, on the 
 removal of which a surface secreting a scanty viscid fluid is left. 
 In fact, in this early stage, the epithelioma looks exactly like a 
 
EPITHELIOMA. 539 
 
 wart the surface of which has been irritated by scratching. It 
 very slowly spreads peripherically, taking years perhaps to 
 attain the size of a bean. As the nodule becomes older and 
 larger, however, it commences to grow more rapidly. New de- 
 posits appear immediately about the circumference of the 
 primary area, and sooner or later the whole mass breaks down 
 into a superficial ulcer. As a usual thing the disease is not 
 brought under our notice until ulceration has occurred ; but 
 the primary nodules are always quite characteristic and enable 
 us to recognize the malady long before the patient becomes 
 concerned about it. They appear as small, shining, white, 
 mother-of-pearl-like bodies, so superficial as to be easily dug 
 out of the skin. In fact they look very like milium corpus- 
 cles. Under the microscope, the little tumor is readily seen to 
 be composed of a closely-packed mass of epitheloid cells of 
 varying form and shape. These little bodies have long been 
 known as cancroid corpuscles. 
 
 The ulcer eventually formed slowly increases in size, until it 
 may attain the dimensions of a large coin or more. It is rounded 
 or irregular in shape ; its edges are sloping, raised, transparent 
 and indurated ; its base is reddish and uneven, and bleeds 
 easily ; a scanty, viscid, yellowish secretion exudes from its 
 surface. As a general thing, when it has attained a certain 
 size, it begins to involve the deeper tissues, and merges insen- 
 sibly into the form of the disease next to be described ; but it 
 may remain for years in an almost stationary condition, the 
 patient enjoying the best of health. 
 
 The disease long designated as rodent ulcer by the English 
 surgeons, is simply a form of this variety of epithelioma. It 
 consists, as usually seen, of a rounded, sharply circumscribed 
 superficial ulceration, with brownish or yellowish-red irregular 
 and granular base, and secreting a viscid fluid. Its edges are 
 prominent and well defined ; and a varying number of the 
 peculiar cancroid corpuscles are visible upon its surface. It 
 spreads very slowly indeed, and involves every tissue with which 
 it comes in contact, even bone. Rodent ulcer is most frequently 
 seen upon the upper part of the face, on the eyelids, nose, etc 
 
54° EPITHELIOMA. 
 
 The further course of the superficial epithelioma is a varying 
 one. Cicatrization of the central portions of the ulcer is often 
 seen in old standing cases, even to such an extent as to reduce 
 the area of ulceration to a narrow rim around the borders of 
 the scar. In some cases the outlying nodules are absorbed, 
 and the disease, in the course of many years, undergoes spontan- 
 eous cure. But as a rule the affection persists until the patient 
 dies of some intercurrent affection. 
 
 Warts, especially those called verrucae senilis, are very liable 
 to form the starting point of this variety of epithelioma. 
 The general health usually remains good throughout the entire 
 course of the disease ; nor are the neighboring lymphatic 
 glands ever involved. 
 
 2. Deep-seated epithelioma commences in the form of 
 rounded or conical tubercles, varying in size from a split-pea 
 to a bean. Usually a number of them are found closely packed 
 together in a limited area of skin. The nodules are very deep- 
 seated, reaching down into and intimately united to the sub- 
 cutaneous connective tissue ; they are hard to the touch, and 
 semi-transparent, though slightly reddish or purplish in color. 
 Usually the entire growth is elevated ; but it may take the 
 form of a diffuse, flat infiltration not rising above the level of 
 the skin. In the course of months or years, the closely aggre- 
 gated mass of nodules has grown perhaps to the size of a nut, 
 and forms a prominent, rounded, hard tumor, whose shining, 
 waxy surface is covered with finely-branched bloodvessels. 
 Very often a spontaneous atrophy of the centre of the tumor 
 gives it an umbilicated appearance. The margins of the growth 
 are steep, and often exhibit the above mentioned cancroid 
 corpuscles. At length, as in the case of the superficial variety, 
 isolated nodules, resembling in all essential characteristics the 
 primary mass, appear in its neighborhood. Sooner or later 
 ulceration occurs, and there arises a deep, rounded or irregular 
 excavation, with steep, puffed out, everted, purplish edges, from 
 which, by pressure, the peculiar cheesy, comedo-like plugs, the 
 cancroid corpuscles, may be expressed. The ulcer secretes a 
 yellowish, viscid fluid, and bleeds readily when touched. The 
 
EPITHELIOMA. 
 
 541 
 
 cancerous infiltration spreads with a varying degree of rapidity 
 and the ulceration progresses correspondingly. The deep 
 tissue, cartilage, muscles and bones may be involved. Pain, 
 which is present throughout the disease, becomes very marked 
 in the later stages. The lymphatic glands are involved, and 
 the patient eventually dies of exhaustion. Though the affection 
 is usually a very slow one, it occasionally runs its entire course 
 in a year or two. 
 
 3. Papillary epithelioma or malignant papilloma, is the most 
 rapidly fatal form of epithelial cancer. It is usually seen dur- 
 ing the course of either one of the other varieties, though 
 it may occur as a wart-like growth from the beginning. Gen- 
 erally it appears as a raspberry-like mass elevated several 
 centimetres above the surface of the integument, and varying 
 in size from that of a split pea to that of a nut. In other cases 
 they form larger, lobulated and spongy masses. Their surface 
 may be covered by a thin layer of dried, yellowish epidermis ; 
 or it may be macerated and moist ; it is often bathed in a 
 viscid, bloody secretion. As the granulations become more 
 and more abundant, fissures and excoriations occur, an offen- 
 sive fluid is poured out, and brownish crusts and scales cover 
 part of the growth. Finally, the whole papillomatous mass 
 breaks down, and an ulcer, exactly as in one of the two 
 previously described forms of the disease, is left. If the 
 cutis under a malignant papilloma is only slightly infiltrated, 
 the resulting ulcer runs the course of the superficial variety 
 of epithelioma ; if the infiltration has spread deeply down, 
 it runs the quicker course of the more malignant variety. 
 
 Epithelioma is especially prone to occur upon the face, be- 
 ing most common upon the eyelids and in their vicinity, and 
 upon the nose — and less frequently upon the lips, cheeks and 
 forehead. From the lids the disease may spread to the con- 
 junctiva. Upon the forehead the deep seated variety is most 
 common. A very favorite location is upon the sides of the 
 bridge of the nose, near the inner canthus. Upon the tip 
 and alae of the nose it frequently affects the cartilages and the 
 bony structures, vomer, superior maxilla, etc. Upon the lips 
 
54 2 EPITHELIOMA. 
 
 the deep variety is most common, the lower lip being one of 
 the favorite seats of the disease ; it often spreads thence on to 
 the mucous membrane of the mouth and the tongue. In some 
 cases most extensive destruction of tissue has been noticed, 
 the antrum of Highmore and the frontal cells opened, the skull 
 perforated, and the brain exposed, etc.; but the large majority 
 of the epitheliomata found about the face are of the superficial 
 variety. 
 
 The genitals, the penis and scrotum of the male, and the 
 labia of the female, are quite common seats of epithelial can- 
 cer. Upon the glans penis it is ■ very liable to assume the pa- 
 pillomatous form and to resemble somewhat closely the or- 
 dinary venereal wart. The superficial variety upon the prepuce 
 forms the well known ' chimney-sweepers' cancer. On the 
 female genitals the affection is rarer, but either the superficial 
 or the deep form may occur. The nipple, navel, etc., may be 
 affected, as may also be any indifferent portion of the skin. 
 
 The nasal and buccal mucous membranes, the conjunctiva, 
 and the lining of the vagina and rectum may be the seat of the 
 disease, either primarily or as spreading from the neighboring 
 skin. They are usually considered in connection with epithe- 
 lioma of the integument. Epithelial cancer of the vagina, 
 often of the papillary form, and more rarely epithelioma of the 
 tongue and buccal mucous membrane, is sometimes to be diag- 
 nosticated from the initial lesion of syphilis. In all these sit- 
 uations the characters of the affection are essentially the same 
 as those presented by it when it occurs upon the skin. 
 
 Anatomy. — Epithelioma consists in the downward growth 
 and continuous proliferation of epithelial cells from the rete. 
 As the cutaneous surface is composed of stratified pavement 
 epithelium, so the form of epithelioma met with is always of 
 the pavement variety. In the earliest stage of the process a 
 vertical section of the skin shows only an increase in the size 
 of the interpapillary processes of the rete, a growth extending 
 further downward into the corium. In this early stage its na- 
 ture cannot be distinguished from the changes occurring in 
 some other diseases, as, for instance, psoriasis. 
 
EPITHELIOMA. 
 
 543 
 
 V£ 
 
 £b 
 
 s 
 
 OJ 
 
 <*-. '-n 
 
 Om 
 0) 
 
 _, o 
 rf o 
 
 o ^ 
 
 I.I 
 
 As the process, however, continues and the epithelial collec- 
 tions extend deeper into the corium, changes characteristic of 
 epithelioma occur. From the great number of new cells pres- 
 ent, they become pressed against each other and tend to form 
 compact masses. The cells of the central portion of these 
 collections undergo the horny transformation, and then we 
 have the characteristic cell collections of epithelioma, the so- 
 
544 
 
 EPITHELIOMA. 
 
 called cell-nests or globes, consisting in the centre of horny 
 transformed cells, and externally of laminae of flattened epithe- 
 lium. These horny, transformed and flattened cell collections 
 are not present in every case of epithelioma, nor is their pres- 
 ence always necessary for a diagnosis. The proliferatory 
 epithelium may extend in the form of conical or tubular col- 
 lections in which the horny transformation does not occur. 
 
 I 
 
 Fig. 73. — A section of an epithelioma showing the arrangement of the cells in 
 the so-called cell-nests, a, portion nearest the surface of the skin ; &, deep por- 
 tion of the epidermic mass ; c, cell nest forming. 
 
 This rapid proliferation and new formation of tissue cannot 
 occur without an increased supply of nutriment being brought 
 to the part, consequently the bloodvessels are always found 
 enlarged. As the new growth extends, it also sets up an irrita- 
 tion and consequent inflammation in the surrounding tissue, so 
 that the latter is infiltrated with serum and round cells and its 
 bloodvessels dilated and otherwise changed, as is seen in fig. 72. 
 Finally, the central portion of the mass can no longer be sup- 
 plied with the proper amount of nutritive material and conse- 
 quently degenerates, breaks down, and ulceration occurs. As 
 this breaking down only occurs in parts removed from the 
 bloodvessel supply, so at the margin of every epitheliomatous 
 ulcer there is still present an area of active epithelial formation. 
 
 Secondary tumors in epithelioma form in the lymphatic 
 
EPITHELIOMA. 545 
 
 glands first, as the lymph vessels are in closer connection than 
 bloodvessels to the primary tumor. 
 
 In epithelioma death occurs from the ulceration and its con- 
 sequences, as septicaemia, etc., or by attacking some vital organ 
 either directly or indirectly. 
 
 Some observers have maintained that the new cells in epithe- 
 lioma may come from endothelial cells, from connective tissue 
 corpuscles, or from embryonic cells of whatever origin. As it 
 has never been proven that the epidermis is regenerated in any 
 other way than by the epithelial cells of the rete mucosum, so 
 no one has ever yet satisfactorily shown that the epithelial 
 cells in epithelioma come from other than pre-existing epithe- 
 lium. 
 
 The flat epithelioma, then, may be considered to come from 
 the general rete, the nodular or deep-seated form from the in- 
 terpapillary portions of the rete especially, and the papillary or 
 cauliform form to arise from a combination of epitheliomatous 
 formation, and papillary hypertrophy the result of nutrition 
 changes in the papillary connective tissue from irritation by 
 the tumor cells. 
 
 Etiology. — We are still in the dark as regards the etiology of 
 all the carcinomatous diseases. As regards epithelioma proper, 
 whilst we do not know its original cause, we recognize certain 
 conditions or anomalies of the integument which strongly pre- 
 dispose to its development. In many cases an hereditary 
 influence can be early traced. I know of cases of epithelioma 
 occurring in three successive generations. Advanced age seems 
 to be an important factor, for the large majority of epitheliomas 
 occur in patients over forty years of age. Occasionally it is 
 seen in younger persons, and sometimes even in children ; but 
 these instances are exceptional, and are looked upon by Bohn 
 as cases in which the tissue of the skin prematurely assumes 
 the characteristics proper to integument of elderly persons. 
 
 It is a well-recognized fact that certain pathological condi- 
 tions, depending upon altered nutritive relations between the 
 different elements of the skin, often prove the starting point of 
 an epitheliomatous degeneration. Thus the senile changes of 
 35 
 
546 EPITHELIOMA. 
 
 the integument, xeroderma, lupus, many of the keratoses, 
 warts especially of the pigmentary variety, condylomata, 
 cutaneous horns, etc., are favorite points of development for 
 the malady. Direct mechanical or chemical irritation often 
 causes the affection. Thus the irritation set up by the use of a 
 pipe is a well-known cause of epithelioma of the lip, which 
 often starts from some long irritated fissure. The affection, in 
 general, is far commoner among men than among women, from 
 what cause we are unable to say. 
 
 Diagnosis. — The diagnosis of epithelioma is generally easy, 
 but sometimes presents considerable difficulties. Beginning, as 
 it often does, as a simple wart, it is sometimes almost impossible 
 to decide whether the affection is cancerous or not. The age 
 of the patient and the rapidity with which the tumor has devel- 
 oped will aid us ; but it is often necessary to withhold a diag- 
 nosis until the affection has been under observation for some 
 little time. Besides this, the non-ulcerated epithelioma, especi- 
 ally when it occurs about the genitals, requires to be diagnosed 
 from the initial lesion of syphilis, and here, again, the age of the 
 patient and the nature of the base and margin are the points 
 upon which we must rely. 
 
 The epitheliomatous ulcer is to be differentiated from tertiary 
 syphilis, and from lupus vulgaris. As regards the specific 
 disease, the points of distinction are as follows : Syphilitic ulcers 
 run a far more rapid course than do epitheliomatous ones ; 
 several points of ulceration, not one alone, as in cancer, usually 
 exist ; the secretion is abundant, foul, and creamy ; in epithe- 
 lioma, viscid, stringy, and bloodstreaked ; the surrounding in- 
 duration is small in amount, while in cancer it is widespread 
 and hard, and the edges waxy in appearance ; finally, there is 
 but little pain in syphilis, while it is a marked feature in the 
 deeper varieties of epithelioma. The differences between 
 lupus and epithelioma are many. Lupus usually starts in child- 
 hood ; epithelioma in middle-life or old age. Lupus is mul- 
 tiple, and often invades wide areas ; epithelioma starts from a 
 single spot, and never attains any thing like the extent of the 
 former disease. In lupus, almost always, the peculiar papules 
 
EPITHELIOMA. 547 
 
 will be found around the periphery of the patch, or in the scar 
 tissue. Besides this, the lupus ulcer has an abundant, yellow, 
 puriform discharge, the cancerous one a pale, scanty, viscid 
 secretion. The two diseases are sometimes found together. 
 
 The papillary form of epithelioma is sometimes in its earliest 
 stages very difficult to distinguish from an ordinary condyloma. 
 The age of the patient may help us to some extent, but it is 
 often impossible to decide positively as to the nature of the 
 growth. It is advisable in that case to treat it as a case of the 
 less serious affection, reserving more radical measures till later. 
 When the skin in the neighborhood of the papillary growth 
 begins to get hard and infiltrated, and when fissures and sup- 
 purating points begin to appear upon its surface, all doubts as to 
 the diagnosis are at an end. 
 
 It seems hardly necessary to speak of the diagnosis between 
 a localized eczema of the nipple and a commencing epithelioma ; 
 the presence of itching, and the immediate good result of sim- 
 ple treatment, soon show the absence of the more dangerous 
 malady. 
 
 Prognosis. — This varies considerably in different cases. The 
 more superficial forms may run on for many years without 
 giving rise to any serious trouble ; or they may sooner or later 
 be transformed into the deeper-seated kinds. The length of 
 time the disease persists is also very variable. The deeper epi- 
 theliomata are more rapid in their course than are the rodent 
 ulcers, etc.; they usually last several years, though cases are on 
 record in which they have caused a fatal termination in one or 
 two years. Recurrences are very common in either form. In 
 general, the patient's age and the locality, type and course of the 
 disease will determine the immediate prognosis. 
 
 Treatment. — The treatment must be entirely local ; internal 
 remedies have no effect upon the course of the disease. The local 
 new growth must be removed either by chemical or mechanical 
 means. Dermatologists generally have preferred one of the caus- 
 tics, while surgeons have been accustomed to rely upon the knife. 
 Both methods of treatment have their value ; the caustics being 
 better for the superficial varieties, whilst operative procedures 
 
548 EPITHELIOMA. 
 
 are more appropriate for the more deeply-seated kinds. As 
 regards caustics, in a general way, the same preparations may be 
 employed as were recommended for lupus vulgaris. Caustic 
 potash, in stick form, or as a strong solution, has long been 
 used ; it should be thoroughly applied, even into the borders 
 of the sound tissues. Neutralization by dilute acetic acid im- 
 mediately afterward relieves the pain, which is not very intense. 
 The sound parts may be distinguished by the greater resistance 
 they offer to the caustic stick. A dressing of simple ointment 
 or olive oil may follow the operation ; it should be renewed 
 twice daily, and the wound washed with soap and water. In a 
 fortnight the eschar will have separated, and a healthy granulat- 
 ing surface is usually left. 
 
 Arsenic, in the form of Marsden's paste, is very useful. This 
 consists of equal parts of arsenious acid and powdered gum 
 acacia, with just enough water to form a fairly soft paste. It 
 should be thickly applied, and then confined to the part by a 
 good piece of rubber plaster. It may be left on for twelve to 
 twenty-four hours, as long as the patient can stand the pain, 
 which is quite severe ; after using some soothing ointment, or 
 linseed poultices, for a few days until the slough has separated, 
 it should be applied again if necessary. Two cauterizations 
 are generally sufficient. A poultice should then be re-applied to 
 loosen the slough, after which the wound may be dressed with 
 diachylon or zinc ointment. A small amount of sulphate of 
 morphia may be added to the paste to mitigate the pain. 
 Healthy tissue is entirely unaffected by the application. The use 
 of Marsden's paste forms one of the best possible means of 
 treating both the more superficial and the papillomatous varieties 
 of epithelioma. It must not be applied over an area larger 
 than two to three square inches at one time, and should not 
 be used on mucous surfaces. Pyrogallic acid is strongly 
 recommended by many of the German authorities. It is to be 
 used as an ointment, 1 to 4, 6, or 8, and kept constantly ap- 
 plied to the part for a week or more. It is not painful and is 
 very highly spoken of by Jaricsh and others. The oleate of 
 arsenic I have not found to be of any benefit. 
 
KELOID. 
 
 549 
 
 The chloride of zinc, either solid, as stick or powder ; or 
 made into a paste, with flour, is also a favorite application. It 
 is, however, intensely painful and though quite effective, is 
 hardly to be recommended. 
 
 In the very superficial forms, the stick of lunar caustic may 
 be employed in the manner described in the treatment of lupus 
 vulgaris. For the very superficial cancers, I prefer the nitric 
 acid application, as its action is certain and the pain produced 
 is not great. 
 
 Whatever caustic be chosen, its extent of efficacy is soon 
 apparent. If the entire epitheliomatous mass has been de- 
 stroyed, the wound will heal entirely ; but if in any corner 
 of it cancerous tissue be left, that portion will not heal, will 
 commence to break down afresh, and will soon show the char- 
 acteristic edges of an epitheliomatous ulcer. 
 
 If the disease is very extensive, or if caustics previously ap- 
 plied have failed to arrest its course, it becomes necessary to 
 use the knife. On certain situations, as upon the lip, this 
 forms our best means of treating the disease, if the tumor 
 has attained any considerable extent. Simple excision, 
 or excision followed by the replacement of the lesion by 
 a flap of sound skin, taken preferably from some distant 
 part, may be tried. For details, the reader is referred 
 to the text-books on operative surgery. The galvano-cautery 
 has been successfully employed. The use of the dermal cu- 
 rette, followed by a caustic application, is a very favorite 
 method in Vienna, and is very successful, especially in the 
 more superficial forms of the malady. New nodules appear- 
 ing after the operation must be immediately destroyed by one 
 of the means before mentioned. 
 
 KELOID. 
 
 Syn. — Cheloid, keloid (true and false, cicatricial and spon- 
 taneous) ; cheloid of Addison, of Alibert, etc. 
 
 Defi?iition. — Keloid is a circumscribed connective-tissue 
 new growth of the skin, characterized by the appearance 
 
55© KELOID. 
 
 therein of one or more irregular, elevated, firm, smooth, red- 
 dish and somewhat elastic cicatriform tumors. 
 
 Etiology. — We know but little concerning the cause of 
 keloid. The false or cicatricial variety arises always in places 
 where there has already been some new growth of connective 
 tissue, as in the scar from a cut or burn, or even in the minute 
 cicatrix left by a leech-bite, or an acne or variola pustule. 
 Most frequently it occurs in the hypertrophic scar left by a 
 burn or scald ; it is often seen in the lobe of the ears where 
 they have been pierced. Some individuals are especially prone 
 to it, the very smallest lesions causing a new growth of connec- 
 tive tissue. Negroes seem to possess a special predisposition 
 for the disease, most of the cases we see here being in persons 
 of that race. 
 
 As regards the true, spontaneous keloid, we are quite in the 
 dark concerning its etiology. Here, too, we know that some 
 families, and some races (notably the negro), are specially lia- 
 ble to it, but we know nothing as to the real cause of the 
 tumors. 
 
 Both forms occur in adult life ; they have not been observed 
 in infancy. They are said to be more common in women than 
 in men (Follin). 
 
 Keloid shows a special disposition to appear on certain parts 
 of the body, notably upon the sternum. 
 
 Symptoms. — The term keloid is one that has been rather loosely 
 used ; it has been applied to various lesions, and much confu- 
 sion has thereby arisen. The original keloid, which Ali- 
 bert first described in 1830, was an hypertrophy < of the 
 connective tissue of a scar, though he seems to have 
 included under the term certain growths which were malig- 
 nant, and which we now know are of an entirely differ- 
 ent nature. Twenty-four years later, Dr. Addison first 
 made the distinction between this keloid disease of Ali- 
 bert and another analogous affection which he called " true 
 keloid," and which has since been known as Addison's keloid. 
 This latter is a much more important and extensive affection, 
 and does not depend upon the presence of a previous new 
 
KELOID. 551 
 
 growth of connective tissue for its development ; to it the 
 term " keloid " simply should be restricted. Thus we have 
 the true, or spontaneous, or Addison's keloid, and the false, or 
 cicatricial, or Alibert's keloid. Nevertheless, the two diseases 
 depend upon essentially the -same pathological process ; in the 
 one case appearing widespread through the body, and without 
 definite cause, and in the other case limited usually to one 
 spot, and that spot one where connective tissue new growth 
 has already occurred — a scar. 
 
 Still another form must be included under the general desig- 
 nation of keloid, since it stands between the two other varie- 
 ties, touching on the one hand the cicatricial, and on the other 
 hand the spontaneous keloid, viz. the hypertrophic scar. 
 Under the head of anatomy, I shall refer to this relationship 
 again. 
 
 It is very certain that some, at least, of the growths described 
 by Alibert, Addison, Retz, and others, under the name of 
 keloid, were not the benign new growth which we are consid- 
 ering at all, but were examples of true sarcoma. Alibert de- 
 fined keloid simply as a cicatrix-like tumor of the skin ; a 
 sarcoma may start from a scar, or from a true or a false keloid. 
 Hence the malignant course and the fatal termination of some 
 of the growths described under that name. 
 
 Still further confusion was introduced into the nomenclature 
 of this disease by the fact that at least two other affections, 
 now looked upon as distinct, were included by the older 
 authors under cheloid. They are scleroderma and morphcea. 
 The reader is referred to the appropriate headings for their 
 further consideration. 
 
 True keloid begins as a small, pale, pea- si zed nodule 
 situated in the skin. It may be single, but often becomes 
 multiple in time. It very slowly increases in size, and eventu- 
 ally, after years, becomes stationary and ceases to grow. As 
 we usually see it, it has existed for some time, and appears 
 as a sharply circumscribed, hard and elastic tumor, elevated 
 three to four mm. above the general integument. Its color 
 is pink or reddish, or again it may be white. Its surface 
 
552 KELOID. 
 
 is smooth and shining. It is usually elongated, or circular in 
 form, but it is especially likely to bear a more or less marked 
 resemblance to a crab, the central part of the tumor forming 
 the body, and the long processes extending in various directions 
 into healthy skin, resembling the legs. It may vary in size from 
 that of a small pea to an area of several square inches. The 
 surface of the tumor is smooth, the epidermis covering it is 
 thin and elastic ; few, if any, hairs or sebaceous glands are 
 present, though sweat glands in abundance have been found in 
 some of them. Along the margins of the tumor a slight puck- 
 ering of the healthy skin marks the line of advancement of the 
 disease. The tumor is moderately elastic to the touch, and 
 may be tender on pressure. 
 
 In by far the greater number of cases we find the disease 
 upon the trunk and especially, as before stated, upon the ster- 
 num, whence it spreads laterally, sending out prolongations 
 along the ribs. It occurs, however, on other parts of the body, 
 as on the mammae, the ears, the arms, and the genitals. There 
 may possibly be slight, spontaneous pain, or itching, especially 
 when warm in bed, or during hot weather. 
 
 Once formed, keloid usually lasts for life. It becomes sta- 
 tionary after a certain time, and does not tend to undergo any 
 further change. A very few cases have been reported in which 
 complete involution occurred. It never ulcerates, or exhibits 
 malignancy. As I have stated elsewhere, those cases in which 
 a malign course was observed were cases of sarcoma, not of 
 keloid. 
 
 Usually single in number, keloid may be multiple, a consid- 
 erable number of tumors of varying size and shape being situ- 
 ated on different parts of the body. 
 
 The false or cicatricial keloid is almost exactly similar to the 
 true one in appearance, but it is usually single. It is espec- 
 ially apt to occur in the scars of burns. Its course does not 
 differ from that of the former variety. 
 
 In both forms of keloid, a marked amount of pain, either 
 constant or paroxysmal, may be present. 
 
 One point remains to be noticed in the semiology of ke- 
 
KELOID. 553 
 
 loid, and that is. its decided tendency to recur after removal. 
 This occurs even when the knife has been carried clear into 
 the healthy skin. It will be again adverted to in the consider- 
 ation of the treatment of the disease. 
 
 The hypertrophic cicatrix is exactly like a false keloid, but 
 differs from it in being limited in size to the area of the origi- 
 nal scar tissue. Its history is that of cicatricial keloid. Cer- 
 tain peculiarities in its structure are touched upon under the 
 head of anatomy. 
 
 Anatomy. — The new growth of connective tissue is usually 
 sharply limited, and is situated in the corium. The fibres 
 are united into dense bands, and the bands generally run 
 parallel to the surface of the tumor. 
 
 Warren, Rokitansky and Virchow have studied the pathol- 
 ogy of the spontaneous, and Kaposi that of the cicatricial ke- 
 loid. According to this latter there are three distinct forms to 
 be considered, namely : i. True keloid ; 2. The hypertrophic 
 scar ; 3. The cicatricial keloid. 
 
 1. In keloid proper, the tumor is composed of bundles of 
 whitish connective tissue in the corium, and disposed parallel 
 to the skin. But few spindle-cells or nuclei are to be seen, for 
 the growth consists almost entirely of fibres. At first there are 
 a considerable number of vessels ; but these seem to become 
 compromised as the tissue contracts, and in the older parts of 
 the tumor the vascular supply is very limited. The papillae 
 are intact, and herein lies the essential histological difference 
 between this and the succeeding keloidal forms ; for the co- 
 rium has not been destroyed by previous inflammation. 
 
 2. In the hypertrophic scar, on the other hand, not a single 
 papilla is to be seen ; for the ulceration, etc., that preceded 
 the scar has destroyed them. The points of distinction be- 
 tween this and the third form are, first, that the new tissue 
 never spreads beyond the limit of the original scar, and sec- 
 ondly, that the connective tissue fibres are not gathered into 
 close parallel layers, but are loose, run in isolated bundles, and 
 form an irregular network of tissue. 
 
 3. False keloid gives us a combination of the characters of 
 
554 KELOID. 
 
 the true keloid and of the hypertrophic scar. The papillae 
 are gone, as in the scar, but, like true keloid, the connective 
 tissue bundles are dense, without cell forms, and the growth is 
 not limited to the site of the cicatrix. 
 
 Diagnosis. — Keloid in general is easily recognized from its 
 striking appearance. It is difficult to distinguish a false 
 keloid from a cicatricial scar. The diagnosis can be made 
 with the microscope, but practically is often difficult to reach. 
 The more like ordinary skin the surface of the tumor is, the 
 more the normal papillae and follicles are preserved the 
 more likely is it that we are dealing with a keloid, and not with 
 an ordinary scar. Its occurrence on the sternum, etc., also 
 favors keloid. The situation, tubercles, color, etc., distinguish 
 rhinoscleroma from keloid. The absence of circumscrip- 
 tion and the wide extent of the disease serve to differentiate 
 scleroderma from it. 
 
 Prognosis — is not very good, for spontaneous involution is 
 rare, and we can hardly cure it. It does not itself usually in- 
 terfere with the comfort or well being of the individual. It 
 tends, after a long time, to cease to grow, and then persists 
 until death. It is almost certain to return if removed by op- 
 erative procedure. 
 
 Treatment. — It sometimes becomes necessary to attempt the 
 treatment of these tumors on account of the deformity they 
 occasion, but more often on account of the pain that some- 
 times accompanies them. 
 
 Excision is inapplicable ; the tumor almost invariably re- 
 turns, even though the incisions be carried wide of the tumor, 
 through healthy skin. So long as the tumor is growing, opera- 
 tive procedure must not be employed. To allay the pain, 
 morphia may be injected into the part; or chloroform liniment 
 or belladonna ointment, or cold employed locally. Multiple 
 scarification, as done for rosacea, is recommended by Vidal. 
 Duhring speaks well of caustic potash, though I agree with 
 Follin in considering the use of caustics as improper. 
 
 We may make an attempt to promote absorption of the 
 growth by the diligent use of lead, or mercurial plasters, or 
 
MOLLUSCUM FIBROSUM. 555 
 
 iodine, which may possibly be efficacious so long as the con- 
 nective tissue is yet young. Wilson recommends that the 
 growth be painted with a mixture of a drachm of iodide of po- 
 tassium, an ounce of soft soap, and an ounce of alcohol, fol- 
 lowed by the persistent use of lead plaster. 
 
 For the paroxysmal pains quinine and arsenic may be used. 
 
 MOLLUSCUM FIBROSUM. 
 
 Syn. — M. simplex; m. non-contagiosum ; m. pendulum; fibro- 
 ma molluscum. 
 
 Definition. — The disease consists of a connective-tissue new 
 growth of the skin, characterized by the appearance therein of 
 sessile or adherent, rounded, painless, soft or firm tumors, vary- 
 ing from the size of a split pea to that of an egg, or larger. 
 
 Symptoms. — In almost all cases a considerable number of 
 these connective tissue tumors are present upon the patient, 
 some so small as to be barely perceptible underneath the skin, 
 whilst others may be as large as a clinched fist, or even as a 
 child's head. Their shape varies considerably ; some are firmly 
 seated in the subcutaneous connective tissue by means of a 
 broad base, whilst others are connected with the deeper parts 
 by their peduncles, and hang down into a bag of loose skin. 
 The integument covering them is usually normal, though some- 
 what pale ; over the larger ones it may be tightly stretched, 
 bluish-red in color, and showing many dilated vessels. They 
 vary in the impression conveyed to the touch ; some of them 
 feel quite soft, as if the sacs were partly empty, or filled with 
 some gelatinous material ; others again are harder and more 
 fibrous. 
 
 The tumors are almost always multiple, and are sometimes 
 present in very large numbers. Hundreds may be perceptible 
 in various stages of development in the skin of different parts 
 of the body ; most of them are of small size, but in some cases 
 individual tumors may weigh many pounds. They occur all 
 over the body, and are quite common upon the scalp and face, 
 and on the genitals. No subjective symptoms of any kind at- 
 
55 6 MOLLUSCUM FIBROSUM. 
 
 tend their growth, though of course the heavier ones and those 
 situated upon such parts as the eyelids, penis, etc., may give 
 rise to much annoyance. They may make their appearance 
 upon the body at any period of life, but almost always in child- 
 hood. Once present, they usually grow, though generally very 
 slowly, during life. Most commonly, having attained a certain 
 size, they remain stationary ; but the larger ones may cause in- 
 flammation and gangrene of the superjacent skin from pressure. 
 Spontaneous involution of these tumors has been known to oc- 
 cur. 
 
 Anatomy. — There is some difference of opinion as to the 
 precise structure in the skin in which these tumors originate. 
 According to most authorities, including Virchow and Kaposi, 
 
 Fig. 74. — Molluscum fibrosum. — (Virchow). 
 
 they spring from the connective tissue frame work of the fatty 
 tissue. Rokitansky maintains that they begin in the connec- 
 tive tissue of the corium, whilst Fagg and Hawse place their 
 origin in the connective tissue walls of the hair-sac. The first 
 view is probably the correct one. As they grow out, they lift 
 up the skin, and eventually project as simple or lobulated, more 
 or less pendent tumors. The sheath is not united to the super- 
 jacent skin, save in the middle line, where the connective tis- 
 sue fibres of its capsule and of the skin blend with one another. 
 If we cut into one of these tumors we find it composed of a 
 white fibrous mass, inclosed in a dense connective tissue cap- 
 sule. The central portion is more or less soft and pulpy, and 
 a little yellowish fluid may be squeezed from it. The peri- 
 
MOLLUSCUM FIBROSUM. 557 
 
 pheral portions are more firmly organized. The very young 
 tumors are composed of gelatinous, newly-formed connective 
 tissue ; the cells are abundant, and the fibrillar, minute and 
 irregular. The very old growths, on the other hand, consist 
 entirely of a dense, firmly-packed fibrous tissue. Comedones 
 and dilated sebaceous glands are common in the skin covering 
 the tumors. 
 
 Etiology. — The cause of the disease is entirely unknown. It 
 is supposed to be hereditary, and in one of Virchow's cases it 
 manifested itself in three successive generations. It sometimes 
 attacks several members of one family. Whilst it seems itself to 
 exercise no special deleterious effects upon the general health, 
 it has been noticed by many that patients suffering from mol- 
 luscum fibrosum, are stunted both in their mental and in 
 their physical development. 
 
 The disease occurs with about equal frequency in both sexes, 
 but is quite rare in this country. 
 
 Diagnosis. — The differential diagnosis from molluscum con- 
 tagiosum is given at length under the heading of that disease. 
 Suffice it to mention here that there is no visible depression or 
 aperture upon the summits of the tumors as in m. contagiosum ; 
 and that they are situated deep in and under the skin, and do 
 not stand forth as prominent superficial growths. 
 
 The tumors might possibly be confounded with multiple neu- 
 romata, or with lipomata ; but the pain accompanying the 
 one, and the lobulated structure and soft feel of the other, 
 should be sufficient to obviate all error. 
 
 Prognosis. — Is not good. Involution is rare spontaneously, 
 nor can we bring it about by remedies. The tumors run 
 their course, increase in number and size to a certain extent, 
 and then remain stationary. Marasmus and tuberculosis lead- 
 ing to a fatal termination has been noticed in some cases. 
 
 Treatment. — The tumors may be excised or ligatured, if not 
 too numerous. Even if present in numbers, the largest and 
 most annoying may be removed in this way. The galvano- 
 cautery has been successfully used in these cases. 
 
55^ XANTHOMA. 
 
 XANTHOMA. 
 
 Syn. — Xanthelasma (Wilson) ; vitiligoidea (Addison-Gull) ; 
 fibroma lipomatodes (Virchow). 
 
 Definition. — A connective tissue new growth of the integu- 
 ment, the mucous membranes, the subcutanea and submucosa, 
 characterized by the formation of yellowish, circumscribed, 
 variously sized macules or tubercles. 
 
 History. — The disease was first accurately described by Ad- 
 dison and Gull, in 185 1, who called it vitiligoidea ; for which 
 Erasmus Wilson very properly substituted the commonly re- 
 ceived terms of xanthoma or xanthelasma. Most of the cases 
 seen so far have come from England, where Pavy, Fagge, 
 and Wilson have recorded them. In Germany Hebra, Cohn, 
 Virchow, Waldeyer, and Kaposi, have studied the pathology of 
 the disease. 
 
 Symptoms. — Xanthoma occurs in two distinct forms, which 
 must be separately considered, namely, as x. planum, and x. 
 tuberosum. 
 
 Xanthoma planum, xanthelasma, consists of variously-sized, 
 elongated plates, situated usually in the integument. They are 
 yellowish, straw-colored, or creamy, and often look just like 
 patches of chamois-skin " let " into the epidermis. They vary 
 in size from a pin's head to a finger-nail, or even more. They 
 have a sharply defined and usually oval border, but are smooth 
 and even to the touch ; and when the fold of skin containing 
 them is taken up between the fingers, it feels perfectly natural. 
 Their commonest site is on one or more of the eyelids, most 
 often at the inner angle of the upper lids, then on the lower, 
 and sometimes surrounding both lids entirely. They are often 
 arranged symmetrically on the two halves of the face. They 
 may also occur on other parts, on the cheeks, nose, ears, neck, 
 extremities, and even on the lips, palate, trachea, the lining 
 membranes of the bile ducts in the subperitoneal connective 
 tissue, and in the abdominal muscles. In shape they are usually 
 elongated, with semi-circular borders. There may be smaller 
 isolated patches outside the principal formation. 
 
XANTHOMA. 559 
 
 Xanthoma tuberosum occurs as papules or tubercles, varying 
 in size from a pin's head to a bean. They are whitish or yel- 
 lowish, and may be isolated, or united into plaques of greater or 
 less extent. These plaques may be striated on their surface. The 
 papules are e^vated to a variable degree, perhaps as much as 
 4 mm. above the level of the surrounding skin ; their consis- 
 tency is very little greater than that of the rest of the integu- 
 ment. This form of the disease is more liable to occur upon 
 cheeks, on the elbows and knees, fingers and toes, palms and 
 soles ; it has been seen on the head, and on the penis and 
 labia. It may occur in conjunction with the other form. 
 
 X. tuberosum may be slightly painful, but usually, there is 
 no subjective sensations in either form of the disease. The 
 tubercles, when occurring on the hands, have been known to be 
 sensitive enough to prevent the patient handling anything. 
 
 Xanthoma occurs at all ages, but is more common during mid- 
 dle or advanced life. The lesions are usually single, but there 
 is a multiple form (x. multiplex), which is sometimes seen. Here 
 the disease usually begins as the macular variety at the inner 
 canthus of the lids, and gradually invades palms, soles, face, 
 ears, flexures of joints, and trunk, perhaps the mucous mem- 
 branes. Sometimes we see a patch of x. planum which has 
 become tuberous at its margins. 
 
 The malady runs a very slow course, and usually lasts through 
 life. But some acute cases of x. planum et tuberosum are 
 recorded by Korach and Hertzka in which it spread more or less 
 over the whole body in a few weeks, accompanied by icterus 
 and pruritus. The patches have been known to disappear 
 spontaneously ; and the disease is commoner in women than in 
 men. 
 
 Anatomy. — Xanthoma is a connective tissue growth, in 
 which fatty degeneration readily occurs ; the characters of 
 the tissue vary as one or the other process predominates. 
 It consists essentially, according to Pye Smith, of a chronic 
 hyperplasia of the deeper layer of the cutis, in which the 
 papillae and the epidermis on the one hand, and the subcuta- 
 neous connective tissue on the other, are only secondarily 
 
560 XANTHOMA. 
 
 involved. The young leucocytes may go on to form new 
 connective tissue cells, and ultimately adipose tissue, or 
 they may never become organized, undergo granulo-fatty de- 
 generation, and ultimately result in a detritus of oil-drops, 
 calcareous particles and cholesterine crystals. Hebra, how- 
 ever, (and he is supported in his opinion oy Geber and 
 Simon) maintains that two distinct processes are concerned in 
 the production of xanthoma ; first, a form in which there is 
 hypertrophy and degeneration of the sebaceous glands, being 
 really identical with milium, and which he calls vitiligoidea ; 
 and, secondly, a form in which there is a true connective tissue 
 new growth, which he denominates fibroma lipomatodes. 
 
 The first view is, however, the correct one ; and under the 
 head of diagnosis will be given the points showing that there is 
 never any demonstrable affection of the sebaceous glands, save, 
 perhaps, secondarily, in true xanthoma. 
 
 Etiology. — Nothing positive is known in regard to the etiology 
 of this remarkable condition. It has been claimed that it has 
 some connection with diseased states of the liver ; and in fact 
 jaundice has been noticed either just previous to the develop- 
 ment of the disease or during its course in quite a number of 
 cases — perhaps in over half of those recorded. Especially is 
 this the case in the multiple form of xanthoma. In the twenty- 
 seven cases collected by Kaposi it was observed in fifteen. It 
 has been supposed by Fagge and Murchison to be due to the 
 circulation of bile-pigment in the blood. But in very many 
 cases no anomaly of the liver at all was noticed, and this idea 
 as to its causation is rejected by many authorities. It has been 
 noticed to be hereditary in some cases. 
 
 Diagnosis is easy. Its color, site, structure ; its circum- 
 scribed, roundish form, and its occurrence in tubercles and 
 laminae sufficiently characterize the disease. Only one affection 
 can be confounded with it ; milium may be mistaken for the 
 small, tuberculous form of xanthoma — or vice versa. An aggre- 
 gation of milium papules, which may occur in the characteristic 
 situation, may look like xanthoma, but on breaking the epider- 
 mis over one of them the characteristic contents can be 
 
LIPOMA. 561 
 
 squeezed out. This is never the case with the disease under 
 consideration ; only a little blood and serum, never any fatty 
 substance, can be thus obtained from them. 
 
 Prognosis. — Xanthoma is a very slowly progressive disease, 
 and may last a lifetime. It has been observed to undergo 
 spontaneous resolution. (Legge). Beyond the disfigure- 
 ment, it occasions no inconvenience, save perhaps when by 
 occurring on the hands it interferes with the patient's avocation. 
 It has never been known to undergo any deleterious degenera- 
 tion. 
 
 Treatment. — It may be necessary for appearance' sake to 
 destroy the growth. Excision may be practiced, to be care- 
 fully done when the disease occupies its usual site, the eyelids, 
 to avoid ectropion. The curette may be used, or even caustics. 
 Erasmus Wilson believes in the connection of the disease with 
 liver trouble, and recommends nitro-muriatic acid and bitters, 
 combined with an occasional dose of blue pills ; later, arsenic 
 may be employed. Besnier claims that he has seen rapid dis- 
 appearance of the tubercles under the use of phosphorus inter- 
 nally, followed by turpentine. 
 
 LIPOMA. 
 
 Syn. — Fatty tumor ; steatoma ; adipoma. 
 
 Definition. — Lipoma is a circumscribed or diffuse cutaneous 
 or subcutaneous tumor composed of fatty tissue. 
 
 Symptoms. — Lipomata may occur in any of the places where 
 fat naturally exists in the body ; and most commonly in the 
 integument or subcutaneous tissue. They are sometimes con- 
 genital, but may appear at any time ; and they are far oftener 
 found in the female than in the male subject, the proportion 
 being something like three to one. They are usually single, 
 but sometimes the whole integument is studded with them ; I 
 have seen a case in which several score were situated under 
 the skin upon various parts of the body, and Weber has counted 
 two hundred on one person. When single, they may be very 
 large, weighing several pounds ; when multiple they are usually 
 36 
 
562 LIPOMA. 
 
 small. They usually appear as circumscribed, subcutaneous, 
 freely movable tumors, the skin over which is entirely normal, 
 and generally freely movable. They are not painful, save 
 when they accidentally cause nerve pressure. When the lipoma 
 is diffuse it appears simply as an excessive accumulation of fat 
 in some special part, as is seen in the common double-chin. 
 
 The encapsulated variety may change its position in the 
 course of time from its own weight ; thus there is recorded a 
 case where one commenced at the umbilicus and finally slid 
 down under the skin until it found a resting place in the peri- 
 naeum. 
 
 Anatomy. — Lipomata are tumors composed of ordinary 
 fatty tissue, 1. e., of connective tissue the cells of which 
 are distended with oil globules. But the cells are larger 
 than in the ordinary tissue ; and the amount of fluid is 
 the cause of the false fluctuation so plainly perceived in 
 many of them. Though usually only present upon the skin, 
 they have been found upon the mucous membrane of the 
 stomach and intestines. Fibrous tissue, or even bone may be 
 found combined with the fatty growth. They are occasionally 
 pedunculated. They may persist unchanged for a lifetime, or 
 undergo a fatty or calcareous degeneration or necrosis. These 
 circumscribed fatty growths possess a life to a certain extent 
 independent of that of the rest of the organism. Cornil and 
 Ranvier state that they do not partake in the emaciation from 
 fevers, wasting diseases, etc., when the latter attack their pos- 
 sessors. 
 
 Diagnosis. — Neither the diffuse nor the circumscribed form 
 can well be mistaken for anything else. In the latter form the 
 tumors are more or less firm or lobulated ; they are usually 
 freely movable, but in some cases the skin may be attached to 
 the growth. 
 
 Prognosis. — They are perfectly benign in spite of their occa- 
 sional heteroplastic origin. They may be very discommoding 
 by reason of their size or situation. 
 
 Treatment. — Unless they are serious inconveniences the cir- 
 cumscribed tumors should be left alone. Excision is the proper 
 
ANGIOMA. 563 
 
 plan to resort to. With even greater force does this apply to 
 the diffuse form ; much dissection is required, and the operation 
 is often formidable. 
 
 ANGIOMATA. 
 
 Angiomata are new growths composed of vascular tissue ; 
 either the blood or the lymphatic vessels being chiefly involved. 
 It is important to distinguish simple dilatations of pre-existing 
 vessels from real new growths, where new vascular tissue has 
 been formed. Where these tissues are composed of blood- 
 vessels they form the angiomata proper ; when they are com- 
 posed of lymphatic vessels they are designated lymphan- 
 giomata. 
 
 ANGIOMA. 
 
 Syn. — Naevus vascularis ; naevus sanguineus ; angio-ele- 
 phantiasis ; telangiectasis ; tumor cavernosus ; naevus flam- 
 mens ; fungus hsematodes ; aneurysma spongiosum, etc. Port- 
 wine stain ; mother's mark, etc. 
 
 Definition. — New growths of the skin composed of vascular 
 tissue. They are distinguished by their color, which varies 
 from light red to deep blue, according to the relative amount 
 of arterial and venous radicles involved, and by their com- 
 pressibility. 
 
 Symptoms. — In spite of so many designations, we speak of all 
 these growths under the general name of naevus. For con- 
 venience, however, naevi have been classified under four heads, 
 in accordance with certain variations in their intimate structure 
 and external appearance. These subdivisions, under which we 
 shall consider them, are : 
 
 1. Telangiectasis. 
 
 2. Ncevus vascularis. 
 
 3. Angiq- Elephantiasis. 
 
 4. Tumor Cavernosus. 
 
564 ANGIOMA. 
 
 Various other affections of the skin are also called nsevus. 
 Thus we have naevus pigmentosus, n. spilus, n. verrucosus, n. 
 lipomatodes, n. pilosus, n. papillaris, n. unius lateris, etc. 
 These, however, are not vascular new growths, to which it 
 would be desirable to restrict the term naevus. Most of these 
 will be found described under the head of nsevus pigmentosus. 
 
 1. Telangiectasis. — Nsevus flammens, telangiectasie, tache, 
 port-wine stain, mother's mark, etc., consists of a dila- 
 tation of the capillaries and fine arterial and venous 
 branches in a certain area of skin, together probably with a 
 very small new growth of vessels of the same order. In ap- 
 pearance they form a simple stain in the skin or a plexus of di- 
 lated vessels, perhaps the color of which varies from bright red 
 to a blue, or even a dark purple color — depending upon the 
 preponderance of arterial or of venous branches in the spot. 
 Their size ranges from that of a small pea to large diffuse areas 
 of dilated vessels. They are seen chiefly on the face and chest. 
 They all possess the peculiarity of being compressible ; pres- 
 sure empties the vessels and the color fades out, to return 
 again as soon as the weight is removed. In some very 
 extensive cases, however, only a small proportion of the vessels 
 at any one spot are dilated, and there is consequently not a 
 circumscribed patch of the disease, but a diffuse marbling 
 of the skin. This has been observed to involve both entire 
 legs, and even larger areas. 
 
 Telangiectasis, unlike most nsevi, do not begin in childhood ; 
 they commonly appear during middle life, and increase in size 
 and number as the patient progresses toward old age. These 
 are most commonly found upon the eyelids, also nose, cheeks, 
 ears, and neck ; more seldom they appear upon other parts of 
 the body. When situated about the nasal or buccal orifices 
 they may spread to the mucous surfaces, they are then very 
 liable to be injured, and to bleed profusely. Occasionally they 
 cover, more or less completely, wide areas of the skin. The 
 rosacea, which we see so commonly on the central region of 
 the face, with or without the concomitance of acne, is a symp- 
 tomatic telangiectasis ; as is also the dilatation of vascular 
 
ANGIOMA. 565 
 
 areas which we see in connection with thoracic tumors, cardiac 
 lesions, etc. We sometimes find the minute vessels enlarged- 
 in cicatricial tissue, especially in that left after the subsidence 
 of the lupus diseases. 
 
 Such dilated vascular areas may be distinguished from hy- 
 peraemic redness by the absence of heat, pain and swelling, and 
 by their history. They usually persist for life when once 
 formed, and are not liable to undergo change. 
 
 2. Ncevus Vascularis. — Nsevus sanguineus, nsevus congeni- 
 tale, the nsevus par excellence, is an abnormal vascu- 
 larization of a portion of the integument,- with sufficient 
 new vessels and new connective tissue to form a distinct 
 tumor. They are either congenital, or are acquired during the 
 first few months of life. They appear in varying form and 
 size. Sometimes they are merely small bluish-red or violaceous 
 tumors, but little elevated above the skin ; or they may form 
 prominent, turgescent, or even pulsating masses. Their surface 
 is usually smooth ; if it be rugose they form the naevus tuber- 
 osum. They vary much in size. They are most commonly 
 found about the head ; are single or multiple, and may be pig- 
 mented or associated with warty growths (angioma pigment- 
 osum et verrucosum). The tumors are always compressible, 
 and lose their characteristic color when deprived of blood ; 
 those around the face become turgid when the patient coughs 
 or cries, and fade away almost entirely when, as in the fainting 
 condition, the blood leaves the peripheral portions of the 
 body. 
 
 These ordinary nsevi are very common, indeed. According 
 to Depaul, one-third of all the children born at the Clinique 
 de la Faculte Medicine at Paris, come into the world with these 
 malformations, which in most cases disappear spontaneously 
 during the first month of their life. They are commoner in 
 males than in females. 
 
 3. Angio- Elephantiasis. — Angioma elephantiaticum, a. lipo- 
 matodes, or a. neuroticum, is a form of vascular new growth, 
 which begins in the subcutaneous connective tissue and spreads 
 only secondarily to the skin. It occurs in large tumors of 
 
566 ANGIOMA. 
 
 characteristic compressibility and color, which may cover the 
 greater part of the limb with their sponge-like masses. On 
 elevating the tumor it rapidly empties itself and collapses ; 
 but swells out again immediately, when the pendent position 
 is reassumed. The new connective tissue growth here plays a 
 much more important part than in the ordinary naevi ; the 
 tumors sometimes grow rapidly and cause, by their pressure, 
 degeneration of muscle and nerve, and atrophy of bone. 
 They are often found combined with painful neuromata. 
 
 4. Tumor Cavernosus differs in various ways from the ordi- 
 nary naevus. In the first place the tumor is limited by a con- 
 nective tissue capsule, then a framework of the same tissue 
 ramifies through the growth and forms septa, which extend 
 through it in various directions. In the interspaces between 
 the septa the blood circulates freely ; in fact, the whole struc- 
 ture is analogous to that of cavernous tissue, as seen normally 
 in the genital organs. They possess, to an eminent degree, 
 the properties of compressibility and erectility. They are 
 not very often seen on the skin. In appearance they are much 
 the same as an ordinary naevi. 
 
 Etiology. — We can not say anything with certainty in re- 
 gard to the etiology of the angiomata or naevi. In popular 
 estimation, "impressions," etc., made upon the mother during 
 pregnancy are looked upon as causative, and many stories 
 are told where a sudden fright, the sight of blood or of 
 a conflagration, a blow, or other injury about the mother's 
 face, has been followed by naevi on the child, corresponding, 
 perhaps, in color or site, to the impression. But this etiology, 
 to-day at least, is not proven, and we know absolutely noth- 
 ing as to their real cause. 
 
 Course. — These vary very much. A certain number of these 
 vascular naevi undergo retrogressive changes during the first 
 year or so of life, and eventually disappear, either wholly or 
 in part, leaving white, shining, scar-like pigmented spots. 
 Others again, increase in size during the first years of in- 
 fancy, and then remain stationary during the lifetime of the 
 individual, perhaps to undergo involution if the patient 
 
ANGIOMA. 567 
 
 attains old age. The more vascular and erectile they are, 
 the more likelihood there is of their increasing in size. 
 Sometimes they remain quiescent for years, and then, without 
 appreciable cause, begin to grow, invading the neighboring 
 skin and mucous membranes, the subcutaneous tissue, and 
 causing degeneration and atrophy of the deeper parts ; they 
 then form the angio-elephantiasis ; once stationary, they are 
 injurious chiefly as deformities, though the liability to danger- 
 ous haemorrhage when they are wounded must be borne in 
 mind. The telangiectases are usually congenital, and undergo 
 but very little change. 
 
 They all tend, after a time, to become stationary in their 
 growth, and then to degenerate. They may undergo degen- 
 eration by ulceration, or even sloughing, and the process is 
 accelerated when the individual is in poor health. We often 
 see them disappear rapidly after measles or other fevers. 
 Cystic degeneration is also met with. 
 
 Anatomy. — Naevi are usually situated in the skin, in 
 the papillary and upper layers of the corium, and in the 
 subcutaneous connective tissue. They consist of capillaries, 
 small arteries, and small veins, most of them of new for- 
 mation ; they are dilated and deformed, as are also the 
 original vessels of the part. These vessels are contained 
 in a fibrous stroma ; for there is, probably, always more or less 
 of a new growth of connective tissue in these tumors, though 
 in the telangiectasis it may be hardly discernible. The color 
 varies in accordance with the preponderance of venous or arte- 
 rial radicles in the tissue. In the simple, flat angioma, the 
 naevus flammens, the dilated and hypertophied vessels, new 
 and old, are chiefly capillaries, and are in the upper part of the 
 true skin. In the lobular angiomata, or naevi proper, and in 
 the larger tumors, there is always more or less connective tis- 
 sue between the convoluted vessels. Hair-bulbs, sweat, and 
 sebaceous glands are occasionally found involved in these 
 tumors. They may, as before stated, be verrucous or pigmented. 
 
 In the angio-elephantiasis we see the greatest amount of 
 connective tissue growth. 
 
568 ANGIOMA. 
 
 The cavernous angiomata (tumeurs erectiles of Dupuytren) 
 are composed of ordinary erectile tissue. The alveoli commu- 
 nicate irregularly with each other, and blood circulates freely 
 in the cavernous system, which stands between the arteries and 
 veins instead of the usual capillary one. The circulation in 
 them is very active, and they are liable to sudden changes of 
 volume. The walls of the alveoli are composed of connective- 
 tissue ; they may contain organic muscular fibres, or nerve 
 filaments, or even vasa vasorum. The alveoli themselves are 
 lined by an endothelium exactly similar to that which lines 
 the veins. Exercise or emotion causes turgescence of these 
 erectile tumors ; they often pulsate. 
 
 Diagnosis can give but little difficulty. The flat claret- 
 stains, or the red or blue erectile tumors are unmistakable. 
 
 Prognosis must always be cautiously expressed. In general, 
 the simple, flat, claret-stains give a more favorable prognosis 
 than the erectile tumors. It is impossible to tell, save by 
 watching its course, whether a nsevus will remain stationary 
 or will retrograde, or whether, on the other hand, it will extend 
 and form one of the above-mentioned large, erectile tumors. 
 We can rest satisfied so long as the naevus does not extend ; 
 when it begins to spread rapidly we must interfere. 
 
 Treatment. — An ordinary angioma need not be treated un- 
 less it is growing rapidly, or is so situated as to be an eyesore. 
 It will sooner or later, if left to itself, retrogress. If, however, 
 it is decided to treat it, its removal may be effected in a variety 
 of ways. 
 
 For the telangiectasis, Squire's method of linear scarification, 
 or Sherwell's of punctate scarification, have given good results. 
 The former consists in the " cross-hatching " with the knife of 
 the surface of the naevus by a series of parallel lines about one- 
 sixteenth of an inch apart. The ether spray may be used 
 before operating to avoid pain, and pressure employed for a 
 short time afterward to prevent bleeding. It is the treatment 
 that has been successfully employed in advanced cases of 
 rosacea, which is really a telangiectasis. Sherwell uses a num- 
 ber of needles arranged in a bundle, about one-sixteenth of an 
 
ANGIOMA. 569 
 
 inch apart, which can be made, by means of a spring, to pene- 
 trate the naevus. It is often advisable to use a 50$ to 90$ solu- 
 tion of carbolic, or a 25$ solution of chromic acid on the 
 needles. When the bleeding ceases, the parts should be washed 
 with alcohol, and a thick layer of collodion applied. 
 
 In the smaller port-wine stains good results have been ob- 
 tained by the use of the curette, which may also be employed 
 for the warty and pigmented naevi of moderate size. 
 
 If the spots are very small, simple puncture with a red-hot 
 needle, or a needle dipped in nitric acid, will suffice for the 
 destruction of the growth. Even simply painting the surface 
 with nitric acid may be sufficient in very superficial cases. 
 
 Duhring calls special attention to the use of iodium ethylate 
 in these cases, as well as in the smaller forms of naevus proper. 
 To Dr. B. W. Richardson is due the credit of its introduction. 
 Metallic sodium is to be added to absolute alcohol, and applied 
 at once by means of a glass rod to the affected part. It is im- 
 portant to have absolute alcohol ; for if it contain water, 
 caustic soda and not sodium in the nascent state is set free. 
 The pain is not severe, and it can be lessened, if need be, by 
 the addition of an alcoholic solution of opium to the ethylate 
 of sodium. 
 
 Caustic potash ( 3 i.-iv. to § i.) may be used, two or three ap- 
 plications generally sufficing. Chloride of zinc may also be 
 employed. 
 
 Bligh recommends painting the growth with liquor plumbi 
 subacetatis daily, and says that usually in about four months it 
 becomes clotted over with white spots, which increase in size 
 and coalesce, until the whole disappears. 
 
 For the vascular naevi injections of various substances, cal- 
 culated to cause coagulation of the blood in their vessels, have 
 been employed. The tissue of the tumor must be torn up with 
 a needle, and then about twenty drops of a solution of chloride 
 of zinc (grs.-xii. to § i.), or tannin ( 3 i. to § i.), or of the tincture 
 of the chloride of iron, or of the chloride of manganese, or of 
 cantharidin, may be injected into the centre of the tumor. But 
 this method is open to the serious objection that it often causes 
 
57° ANGIOMA. 
 
 inflammation, suppuration, or even sloughing of the growth, 
 and thus a greater deformity than is necessary. There is also 
 the danger from gangrene or pyaemia, or from embolism ; and 
 that this latter is not a fanciful one is shown by the fact that 
 Bryant lost a patient a few minutes after operating by this 
 method on a naevus of the cheek. He recommends the appli- 
 cation of a ligature to the base of the growth, or a metallic 
 ring, before injecting. 
 
 When the nsevus is pendulous and can be isolated, or when 
 it is of the angio-elephantiasis variety, excision or ligature, or 
 a combination of them, will probably have to be resorted to. 
 It is best to pass ligatures or pins through the base of the 
 growth, so that pressure may be quickly applied in case of ex- 
 cessive haemorrhage. If it is decided to use the ligature, it is 
 often sufficient to secure a part of an extensive growth, since 
 the inflammatory action thus set up extends to the rest. A pin 
 may be passed under the growth and a needle with double lig- 
 ature at right angles to it ; the naevus may then be tied wholly 
 or in part. The strangulated part should be punctured to per- 
 mit of more perfect occlusion. But for the details of the best 
 mode of operative procedure for these tumors the reader is re- 
 ferred to the surgical text books. 
 
 Electrolysis is one of the latest and most eligible methods of 
 treating naevi. It has been very successful ; it is safe ; there is 
 no subsequent pain, and the scarring is reduced to a minimum. 
 Six to twelve cells are needed ; one or more platinum or steel 
 needles are connected with the negative, and one needle, or a 
 charcoal point, if the growth is large, to the positive pole. 
 Small gas bubbles appear at the side of. the needle, the blood 
 clots, and the tumor turns bluish white. It is said that slough- 
 ing and even suppuration may be avoided in this method of 
 procedure. 
 
 The galvano-cautery is highly recommended by many au- 
 thorities. The knife must be white-hot to retain its 
 heat in the deeper tissues. It is said by Dawson to produce a 
 clot which is rapidly organized.- In large naevi a part only 
 should be operated on at a time. 
 
LYMPHANGIOMA. 571 
 
 Besides these, collodion and corrosive sublimate (gr. viii.- 3 i.) 
 has been successfully used. Neumann recommends an oint- 
 ment composed of tartar emetic, gr. ix., emplastrum adhe- 
 sivum, 3 L, for smaller naevi, especially of the scalp. It causes 
 little pain, suppuration ensues, and eventually a flat, thin, soft 
 scar is left. 
 
 Vaccination has been very satisfactorily employed for the 
 removal of naevi. The vaccine matter should be very freely 
 spread over the surface of the tumor. It is better to make the 
 punctures with a strong needle, as the blood following lancet 
 cuts is apt to wash away the vaccine matter. The punctures 
 should be half an inch apart, and may be made in the tumor or 
 in its immediate circumference. It is said that large tumors 
 have thus been cured, and Ragaine and Paul report numerous 
 erectile nsevi successfully treated in this way. 
 
 Finally, in the large angio-elephantiasis and cavernous 
 tumor, extensive surgical operations, even amputation of a 
 limb, may be required. 
 
 LYMPHANGIOMA. 
 
 Syn. — Lymphangiomata ; lymphangioma tuberosum multi- 
 plex (Hebra) ; lymphangiectodes (Tilbury Fox) ; lymphatic 
 warts. 
 
 Defi?iition. — A new growth of the skin composed of dilated 
 and hypertrophied lymphatic vessels. 
 
 Symptoms. — Hebra first described this very rare disease, and 
 a representation of the case is to be found in his atlas of skin 
 diseases. Kaposi has seen a single case (Haut krankheiten, p. 
 630); Pospolow has reported one (Viertelj. fur Derm. u. Syph. 
 1879); and, finally, Van Harlingen has described one (Trans. 
 Am. Dermat. Assoc, 1881). They all agree in their essential 
 features, and definitely fix the existence of the malady. The 
 disease exists in the cutis alone, and is to be distinguished from 
 the cavernous lymphatic new growths which have been de- 
 scribed by Billroth and others under the name of makrochiiie, 
 in which the dilated lymphatic vessels start from the subcu- 
 
572 LYMPHANGIOMA. 
 
 taneous connective tissue, and only secondarily involve the 
 skin. 
 
 The disease appears in the shape of a varying number 
 of slightly elevated tubercles. They do not itch ; they 
 are round or oval, and are of a brownish-red color. Special 
 attention is called to their peculiar transparency. They 
 are moderately hard, are situated in the cutis, and can be 
 readily made to sink below the level of the surrounding skin. 
 Their surface is smooth and flat, and they bear considerable 
 resemblance to the large papular syphiloderm. In color they 
 are whitish, or even of a lilac tinge. The tumors are usually 
 multiple ; Kaposi's case had hundreds of them ; Van Har- 
 lingen's, also, a great number. In size they vary from a small 
 pin-head to hazelnut size ; they are usually compressible. They 
 have been found in connection with dilated bloodvessels (telan- 
 gectiases) and pigmented spots. 
 
 They are generally congenital, or appear in early youth. 
 They grow very slowly, and never show any tendency toward 
 malignancy. In the reported cases two have occurred in 
 women, and all the patients were of middle age. 
 
 Anatomy. — These tumors have been examined by Kaposi, 
 Biesiadecki, and Van Harlingen, and have been found to con- 
 sist in every case of immensely dilated and hypertrophied 
 lymphatic vessels. The whole corium is perforated by these 
 channels, and there is, as in the analogous blood-vascular 
 form of disease, a considerable amount of connective-tissue 
 new growth. 
 
 On excision of a papule, it is found to consist of a pearly- 
 white gelatine-like substance. Under the microscope are seen 
 enormously developed lymph -vessels, still lined with epithe- 
 lium, imbedded in a stroma of small-celled and fibrous tissue. 
 
 Etiology. — We know as little in regard to the cause of the 
 dilatation of lymphatic vessels as we do of those of the blood- 
 vascular system. 
 
 Diagnosis. — Peculiar stress is laid on the transparency of the 
 tumors. Its history, microscopical structure, and course, dis- 
 tinguish it from syphilis, the only disease which it resembles. 
 
NEUROMA. 573 
 
 Prognosis. — The little tumors are harmless and injure only 
 by their unsightliness. Occasionally they are somewhat pain- 
 ful to the touch. They increase but very slowly, and show no 
 tendency toward malignant degenerations. 
 
 Treatment. — Is of no avail. The general health remains 
 good, and surgical interference is out of the question. 
 
 NEUROMA. 
 
 Definition. — Single or multiple, pin-head or nut-sized, usually 
 painful papules or tubercles situated in the skin. 
 
 Symptoms. — This is a very rare disease. All cases which 
 have been observed, have occurred in men at middle or ad- 
 vanced life. It appears on the shoulders, arms, thighs or but- 
 tock, in the form of numerous, disseminated, pin-head to hazel- 
 nut, round or ovalish tubercles or nodules, which at the outset 
 are either painful or painless, and later painful. They are 
 firm, immovable and elastic. In Dr. Duhring's case the disease 
 began at the age of sixty years, and consisted of small rounded 
 tubercles seated upon the shoulder and attended with itching 
 but not pain. The number of tubercles continued to increase, 
 and finally the eruption consisted of a large number of closely- 
 seated, small, split-pea sized, firm, flattened tubercles, immov- 
 able, firmly incorporated with the skin and extending to the 
 subcutaneous tissue. They were of a pinkish color, and fine, 
 laminated, glistening scales were produced over them. Violent 
 paroxysmal pain, which did not appear until the disease had 
 lasted three years, was present. The paroxysms of pain lasted 
 usually one hour. The general health of the patient was 
 good. Microscopical examination of the tumors showed them 
 to be composed of nerve fibres, yellow elastic tissue, bloodves- 
 sels and lymphoid cells. 
 
 MYOMATA. 
 
 Myomata of the skin have been described by Virchow, Foer- 
 ster, Besnier and others. 
 
 They consist either of single tumors, the size of a lentil to 
 
574 OSTEOMATA. 
 
 that of an apple, situated on the nipple, scrotum, labia majora, 
 thigh, hand, foot ; or as numerous growths scattered over the 
 whole body. They are either flat or pedunculated, and generally 
 painless, though sometimes tender upon pressure. They are 
 round or oval in form, pale red color, and have a smooth sur- 
 face. 
 
 Anatoi?iy. — They probably arise from the muscles of the skin, 
 and consist either entirely of unstriped muscle fibres or of 
 these and some connective tissue. 
 
 OSTEOMATA. 
 
 Osteomata have been observed by Wilchens and Virchow. 
 They arise generally in old persons and appear as small bodies 
 superficially seated in the skin. A considerable number may 
 be present. They consist of genuine bone structure and are 
 derived from the connective tissue. 
 
 ADENOMATA. 
 
 Adenomata arise either from the sweat or sebaceous glands, 
 according to a number of observers, but whether the tumors 
 referred to have been examples of true adenomata or of a can- 
 cerous nature still remains a matter of some doubt. 
 
CLASS VIII. 
 
 NEUROSES. 
 
 The functional disturbances of innervation of the skin com- 
 prise but few affections. There may be derangement of motil- 
 ity, of sensibility, or of the vasomotor functions (including the 
 secretory and trophic changes under this head). 
 
 Of late years it has become the custom to refer many of the 
 diseases of the skin considered in other sections of this work 
 to neuropathic influences. Undoubtedly zoster, atrophy and 
 hypertrophy, anidrosis and hyperidrosis, and many others, 
 are trophoneurotic in origin ; but it is well to reserve the 
 title of neuroses for those affections of the skin in which 
 there occurs no demonstrable change in any of its structures. 
 Their symptoms are purely subjective, though various second- 
 ary lesions, such as excoriations and blood-crusts, may be 
 accidentally present. 
 
 The only disorder of motility to be referred to here is the 
 "cutis anserina" — "goose-skin," in which the skin on 
 various parts or over the entire body is transiently 
 covered with small white, pin-head papules, most of which 
 are pierced in the centre by a hair. The condition is due 
 to a spasmodic contraction of the arrectores pilorum un- 
 der the influence of sudden changes of temperature, 
 psychic impression, such as fear, horror, etc. The hair 
 displaced from its normal axis, causes traction upon and slight 
 elevation of the skin around its base. Cutis anserina is a 
 physiological and not a pathological appearance. 
 
 Vasomotor disturbances, though essentially neuropathic, are 
 not to be considered here, inasmuch as they necessarily cause 
 some objective symptoms. 
 
57^ HYPERESTHESIA. 
 
 Disturbances of sensibility comprise, therefore, all the true 
 neuroses to be described here. They consist of hyperesthesia, 
 and anaesthesia, hyperalgesia and analgesia, pruritus, etc. All 
 these sensory disturbances occur, it is true, as symptoms of 
 various diseases of the central nervous system and internal 
 organs ; but they also occur as idiopathic neuroses, or idio- 
 neuroses (Ausspitz) ; and as such we will describe them here. 
 
 HYPERESTHESIA. 
 
 Hyperesthesia of the skin in the immense majority of cases 
 is a symptom — and a symptom alone. As such we see it oc- 
 curring in various inflammatory and other affections of the 
 central nervous system, or in conditions affecting the peripheral 
 nerve branches, as their infiltration by lepra-bacilli or the 
 inflammation of the spinal ganglia in zoster. As a neurosis 
 it occurs oftenest in hysteria, of which it forms a well recog- 
 nized symptom. But hysteria is an affection of the central 
 nervous system, and hyperesthesia cutis is but one of its multi- 
 form manifestations. As an idiopathic neuro-dermatopathy 
 pure and simple it rarely or never occurs. 
 
 The hyperesthesia may be general or circumscribed, it may 
 affect one lateral half of the body, or individual limbs, or even 
 spots of skin of very small extent. In marked cases the 
 slightest pressure, even that of the clothing, becomes unbear- 
 able. It may be temporary or permanent. Its prognosis and 
 treatment is in every case that of the affection which causes it. 
 
 AKZESTHESIA. 
 
 Anesthesia may vary just like hyperesthesia cutis ; it may 
 be local or general, diffuse or circumscribed. The integument 
 is numb and senseless, but otherwise usually unchanged. An- 
 esthesia of the skin may be idiopathic, as from cold ; but it is 
 usually symptomatic, as from injuries to nerves, diseases of the 
 central nervous system, leprosy, and syphilis. Hysteria is a 
 frequent cause. 
 
DERMATALGIA. 577 
 
 The affection is rarely a dermato-neurosis, pure and simple. 
 
 Hyperalgesia and analgesia may be regarded as varieties of 
 hyperesthesia and anaesthesia. They may occur alone or in 
 connection with them. The excessive sensitiveness or absence 
 of sensitiveness to pain may be symptomatic or idiopathic ; in 
 fact, the same remarks apply to both sets of affections. 
 
 DERMATALGIA. 
 
 Syn. — Dermalgia ; neuralgia of the skin ; rheumatism of the 
 skin. 
 
 Definition. — Dermatalgia is an idiopathic functional nervous 
 affection of the integument, characterized by pain in the skin 
 alone, perhaps accompanied by morbid sensitiveness, and un- 
 attended by any objective symptoms. 
 
 Symptoms. — Dermatalgia consists of attacks of pain in the 
 skin, usually in conjunction with a more or less pronounced 
 sensitiveness of the part. The pain is spontaneous, constant, 
 or intermittent ; it may be slight or severe, and is often of a 
 burning, pricking or boring character. The peculiar sensitive- 
 ness is in many cases very marked ; the slightest touch or 
 pressure being sufficient to induce an attack of the pain. Vol- 
 untary motion is just as effective as contact with foreign sub- 
 stances. 
 
 As is the case with the other affections of this section, der- 
 matalgia may, though very rarely, occur idiopathically ; it is 
 usually dependent upon some more deep-seated affection, usu- 
 ally some lesion of the nerve-centres. 
 
 The affection may be local or general, the skin itself be- 
 ing entirely unchanged in any respect. It is seen oftener 
 in women than in men, and on hairy than on smooth por- 
 tions of the skin. While slight touches seem to be very 
 painful, severe pressure will sometimes relieve dermatalgia. 
 Once developed, the disease tends to last indefinitely. 
 
 Etiology. — In cases dependent upon organic disease the 
 etiology is plain, as it also is in those dependent upon 
 anaemia, chlorosis, etc. We do not know the cause of the 
 37 
 
SyS PRURITUS. 
 
 idiopathic variety. It has been ascribed to rheumatism, and, 
 indeed, most cases give a history of that disease. Some 
 cases seem to be due to the direct influence of cold. 
 
 Diagnosis. — Its extreme superficiality, and the possibility of 
 causing its onset by the slightest touch, will serve to distinguish 
 it from pains situated in the muscles or deeper structures. It 
 can hardly be confounded with anything else. 
 
 Treatment. — The underlying disease, if there is one, must be 
 treated. Rheumatism must be always looked for. In idiopathic 
 cases the galvanic current, or blisters, or belladonna ointment, 
 or tincture of iodine may prove useful. 
 
 PRURITUS. 
 
 Definition. — A disease of the skin, characterized by the sub- 
 jective sensation of itching alone, and without any structural 
 alteration. 
 
 Symptoms. — Itching occurs as a symptom in many of the af- 
 fections of the skin, especially in eczema, prurigo, scabies, ur- 
 ticaria, pediculosis, etc. But in the affection that we are now 
 considering it forms the entire symptomatology of the disease, 
 the other lesions of various kinds being merely secondary and 
 caused by the scratching which the patient inevitably re- 
 sorts to. 
 
 The itching of pruritus may be slight in degree, like that 
 caused by the contact of rough clothing with the skin, or it 
 may be very severe. In some cases a feeling of formication, 
 rather than of itching, is felt. It may be partial or general 
 over the body, intermittent or continuous. In many cases it is 
 usually worse at night. 
 
 In accordance with the degree of itching will be the amount 
 of scratching, and the extent and depth of the secondary 
 lesions found upon the skin. Excoriations, blood-crusts, pa- 
 pules, etc., may be present to a varying degree. Sometimes, 
 however, there are but few marks or none upon the skin, and 
 we must rely upon the patient's statement for our diagnosis. 
 
 Several varieties of pruritus are mentioned, according to the 
 
pruritus. 579 
 
 location of the disease. One of the commonest is pruritus 
 universalis. Here the skin of the entire body is more or less 
 affected. The itching is not continuous, but occurs in par- 
 oxysms ; the immediate cause of an attack being usually 
 changes of temperature, especially warmth, as when the pa- 
 tient is in bed. Violent motions of the body, or enforced 
 quiet, and even psychic influences, such as a sudden thought 
 on the patient's part of fear less the itching should begin, 
 especially when he happens to be in some place where 
 scratching is impossible, are sufficient to start the pruritus. 
 A slight tickling sensation begins on some part of the skin, 
 and gradually grows in intensity and extent. For a while 
 the patient resists the impulse to scratch himself, but the 
 very effort at self-restraint increases the feeling ; the itching 
 becomes more and more violent, and the patient strives by 
 rubbing and pressure to still it. At length there comes a 
 moment when self-control gives way, and the temptation to 
 scratch becomes absolutely irresistible. Often his nails are 
 not sufficient, and he has recourse to stiff brushes and rough 
 bodies of all kinds to reinforce them. 
 
 At length, when the peccant skin has become crimson and 
 bloody under his efforts, a feeling of burning from the irrita- 
 tion replaces the unbearable itching, and, tired out, he has ob- 
 tained relief for a time. 
 
 The integument of a patient subject to pruritus universalis 
 of any intensity shows the results, recent and past, of this 
 active counter-irritation. Excoriations of varying extent, blood 
 crusts, patches of reddened and hyperaemic skin are mingled 
 with the dark brown pigmentation left from innumerable like 
 lesions of the past. The skin may simply be dry and harsh ; 
 and there is often more or less of an urticarial eruption during 
 the paroxysms of scratching. 
 
 Thus the disease lasts for years. Sleep is disturbed, for the 
 attacks of itching are specially prone to come on in bed ; and 
 the patient spends night after night in fighting the enemy with 
 the finger nails, brushes, cold water, etc., sinking exhausted 
 into an uneasy slumber as morning approaches. Nutrition is 
 
580 PRURITUS. 
 
 impaired ; the mind sometimes gives way ; and suicide has 
 been known to result from the misery caused by pruritus 
 universalis. 
 
 In the majority of cases, however, the disease is limited to 
 some special part of the body, and is then called pruritus 
 localis. Vaiious varieties are to be considered. Puritus 
 vulvce or better,/, pudendorum is one of the most frequent 
 kinds. The labia and clitoris are chiefly affected, and the con- 
 tinued rubbing and scratching eventually cause vaginitis, ecze- 
 matous inflammation of the surrounding skin, hypertrophy of 
 the clitoris, besides the immediate wounds and scratches. It 
 occurs most often in women of middle age, and is sometimes 
 combined with nymphomania, and very generally with the 
 various phenomena of hysteria. In the male, the scrotum is 
 most usually affected (/. scroti ) though the perineum and anus, 
 but especially and most painfully the meatus and urethral 
 mucous membrane may be involved; pruritus ani, affecting not 
 only the skin of the anus and its neighborhood, but even the 
 rectal mucous membrane as well. It often occurs in conjunc- 
 tion with piles. Eczema of the skin around the anus, and 
 proctitis are commonly present. It occurs in both sexes, and 
 even in children. It forms one of the most intolerable of these 
 local pruriti. There may also be mentioned pruritus palmce 
 manus et plantcz pedes often combined with hyperidrosis ; and/. 
 linguee, which is very rare. 
 
 The p. hiemalis to which Duhring has recently called atten- 
 tion, and which occurs during the winter months, is believed 
 by Kaposi not to be a true neurosis, but an itching due to the 
 presence of cutis anserina from the low temperatures, and the 
 dryness of the skin natural at that season. P. senilis is an in- 
 tractable form of the disease occurring in old people. 
 
 Anatomy. — Pruritus is a purely functional affection ; a dis- 
 turbance of sensation. There is no structural change, save 
 secondary ones, no matter how long the disease may last. 
 
 Etiology. — The causes of the different kinds of pruritus are 
 very various. In females, affections of the genito-urinary sys- 
 tem, dysmenorrhoea, leucorrhcea, vulvitis, etc., or even the ad- 
 
PRURITUS. 581 
 
 vent of gestation or of the menopause may cause it. In both 
 sexes gastro-intestinal disorder, dyspepsia, costiveness, etc., are 
 etiological factors. Bright's disease, tuberculosis, carcinoma 
 of internal organs, and especially diabetes may cause it. 
 The urine should always be examined for sugar in obstinate 
 cases. Cutaneous pruritus occurs perhaps in half the cases of 
 jaundice. It usually lasts but a few days during the onset of 
 the trouble, but it may persist, and prove very annoying. It is 
 generally supposed to be due to the deposition of bile pigment 
 in the skin. 
 
 Various affections of the nervous system may cause pruritus ; 
 as may psychic impressions, violent emotions, grief or anger. 
 
 Finally there remains to be mentioned haemorrhoids in 
 elderly people, and worms in children, as causes of p. ani. Cer- 
 tain drugs, amongst which opium is the most common, also 
 cause pruritus. 
 
 P. senilis is due to senile marasmus ; the skin is faded, dry, 
 and wrinkled. 
 
 Diagnosis. — Various diseases must be excluded before we 
 can make the diagnosis of pruritus upon a patient who comes 
 to us complaining of incessant itching. Yet the diagnosis 
 ought not to be difficult, if we recollect that pruritus is a 
 disease with but one symptom, and that any other symptom 
 than itching, save the secondary phenomena of inflammation 
 of the skin, unmistakably point to some other disease. Prurigo 
 is a distinctly papular affection. In pediculosis the scratch- 
 marks and pigmentations are specially localized on the loins and 
 neck, and the parasite is present in the clothing. In scabies the 
 location and the tracks of the itch-insect will mark the disease. 
 In eczema the itching is comparatively slight, and entirely 
 secondary to the eruption. For the minor points of differen- 
 tial diagnosis, the reader is referred to the appropriate head- 
 ings. 
 
 Chronic urticaria and pemphigus pruriginosus would be more 
 difficult to distinguish from pruritus. 
 
 Prognosis is moderately favorable. Pruritus sometimes dis- 
 appears spontaneously or from therapeutic effort. But it may 
 
582 PRURITUS. 
 
 last for years in spite of all we can do ; or it may be entirely 
 incurable. 
 
 In pruritus senilis the prognosis is absolutely bad ; it usually 
 lasts till death ends the patient's sufferings. 
 
 Treatment. — Innumerable are the plans of treatment and 
 drugs recommended for this obstinate and distressing com- 
 plaint, and very often the physician runs, in the course of time, 
 through the whole list, to leave the pruritus at the end of the 
 treatment just as bad as it was at the beginning. I shall men- 
 tion only a few of the most useful remedies. 
 
 In the first place, the cause is to be treated, wherever that is 
 possible. If the liver or gastro-intestinal tract is at fault, 
 rhubarb, soda, magnesia, and the natural mineral waters of 
 Carlsbad or Marienbad, etc., may be employed as indicated. 
 Sexual and genito-urinary derangements are to be treated by 
 appropriate 'sanitary and therapeutic measures. The general 
 health should be carefully attended to ; appropriate diet and 
 exercise must be prescribed. Quinine, strychnine, iron, ol. 
 morrhuae are useful adjuvants to this part of the treatment. 
 
 Several internal remedies are recommended. Murchison 
 speaks highly of the bicarbonate of potassium when the pruri- 
 tus is due to jaundice. The tincture of gelsemium, ten to 
 fifteen drops every half hour, is thought very useful by Bulk- 
 ley. Pick recommends pilocarpin muriate, grains one-eighth 
 to a quarter hypodermically twice a day. Carbolic acid is of 
 value taken in pills of one-half grain several times a day. 
 Finally, Fowler's solution has been successfully used. 
 
 It is hardly to be expected that we shall cure the disease by 
 means of local applications, yet the palliative treatment in this 
 disease is always as important as the curative, and is too often 
 the only one of much avail. 
 
 Cold or hot baths and douches, or vapor baths ; alkaline 
 baths ( 1 iv. of bicarbonate of sodium or borax or alum to the 
 bath); sulphur baths (sulphuret of potassium § i— iv. to the 
 bath), may all prove useful, especially if some bland oil or 
 glycerine, etc., be rubbed into the skin afteward. Cold, applied 
 by painting the part with alcoholic or etherial evaporating 
 
PRURITUS. 583 
 
 lotions, is beneficial in many cases. Carbolic acid is one of the 
 most useful of the local remedies at our disposal. It may be 
 used with potassa (ac. carbol. 3 i, potassa 3 ss, aq. § viii.), or 
 as a wash, m. v-x. to the ounce, together with a drachm each 
 of alcohol and glycerine. 
 
 Ointments are sometimes very serviceable, especially of car- 
 bolic acid or of tar. Any of the ordinary formulae may be 
 used. Camphor and chloral hydrate, aa 3 i. to § i. of simple 
 cerate is a most useful one. 
 
 In pruritus vulvae injections are serviceable ; of astringents, 
 alum, tannin, etc., or tampons soaked in the same solutions, 
 may be employed. An etherial solution of iodoform in spray, 
 or an iodoform ointment, is occasionally serviceable. 
 
 For pruritus ani any of the above may be tried, but it is 
 often necessary here to use anodyne suppositories, morphine, 
 belladonna, etc. Equal parts of mercurial and belladonna 
 ointment is useful. Very hot compresses will sometimes relieve 
 the itching when nothing else will. Fissures may be treated by 
 the solid stick, etc. 
 
 The secondary dermatitis, eczema, etc., must be treated on 
 general principles. In extreme cases the internal use of nar- 
 cotics, chloral, morphia, or even the internal inhalation of 
 chloroform, may be necessary to procure rest. 
 
CLASS IX. 
 
 PARASITE ; PARASITES. 
 
 In accordance with the majority of writers upon derma- 
 tology, and on practical grounds, I have in this work placed as 
 a separate class certain pathological conditions of the skin 
 caused by the presence of certain vegetable and animal para- 
 sites. In reality such a division is inconsistent, and should not 
 be admitted into a classification which has histology and not 
 etiology as its basis. The changes caused by these parasites 
 are the same as have already been described in treating of the 
 inflammatory affections, the special clinical characters of the 
 eruptions depending greatly upon the location and character 
 of the parasite. As their mere presence upon the skin is not 
 sufficient of itself to constitute a cutaneous affection, this latter 
 existing only when they act as an etiological factor in pro- 
 ducing nutrition changes in the tissues, changes corresponding 
 to those already described among the inflammatory diseases, 
 they should be regarded simply as one of the causes of this or 
 that form of eruption. This was done by Hebra in the case of 
 scabies, which he described under the head of eczema, and 
 should have been followed in the case of the other parasites. 
 The parasites which inhabit the skin are either vegetable or 
 animal. The vegetable parasites belong to the class of fungi, 
 and are met with almost exclusively in the epidermis, hair and 
 nails. They have a local or mechanical effect upon the ele- 
 ments of the part, and by irritation produce a greater or less 
 amount of inflammation, a hyperaemia, or exudation, or pustu- 
 lation, or abscess formation. They are all contagious, but 
 require suitable ground for their growth and development, 
 hence all persons are not equally liable to be attacked by them. 
 
TINEA TRICHOPHYTINA CAPITIS. 585 
 
 The vegetable parasitic affections are tinea trichophytina, tinea 
 favosa, and tinea versicolor. 
 
 TINEA TRICHOPHYTINA. 
 
 Syn. — Ringworm ; herpes circinatus ; herpes tonsurans. 
 
 Definition. — A contagious affection of the skin caused by 
 the fungus trichophyton tonsurans and characterized by the 
 formation of circles of vesicles, or reddish, scaling patches, or 
 deep infiltrations, with broken off, stubbed hairs in the affected 
 area. 
 
 Symptoms. — As the symptoms and treatment differ according 
 to the part of the body attacked, it is necessary to describe 
 separately the disease as it appears upon the scalp, bearded 
 part of the face, non-hairy parts of the body, the genito-crural 
 region, and the nails. According to its seat, it has received 
 different names ; thus, when seated on the scalp, it is called 
 tinea trichophytina capitis or tinea tonsurans ; when on the 
 bearded part of the face, tinea trichophytina barbae, or tinea 
 sycosis ; when on the body, tinea trichophytina corporis or 
 tinea circinata ; when on the genito-crural region, tinea tricho- 
 phytina cruris or eczema marginatum ; and when on the nails, 
 onychomyosis. 
 
 TINEA TRICHOPHYTINA CAPITIS. 
 
 This affection is met with almost exclusively in children, 
 especially in those with deficient nutrition, badly nourished and 
 scrofulous, and is very rare in adults. It commences as one or 
 more small, round, erythematous, scaly spots ; or by a group of 
 small vesicles. These spots soon increase in size by peripheral 
 growth to form circular patches of various size, each patch 
 being elevated, circular in form, covered with whitish, dry, 
 adherent scales, and provided with hairs of irregular 
 length, stubbed, broken off near the skin. As the patch 
 spreads peripherically, small vesicles may sometimes be seen 
 
586 TINEA TRICHOPHYTINA CAPITIS. 
 
 at the margin, whilst the the remainder of the patch is covered 
 with the thin, dry, whitish, adherent scales. Sometimes the 
 scales are grayish or slate-color in the central part and yellow- 
 ish or blackish-brown at the margin from drying up of the ex- 
 udation in the vesicles. The skin may be almost normal in 
 color but is generally red, swollen, elevated and tender. The 
 hairs become affected early in the disease, the fungus passing 
 down into the hair follicle and into the shaft of the hair, interfer- 
 ing with its nutrition and making it dry, brittle, and easily frac- 
 tured. The hairs over the affected area lose their lustre, be- 
 come dusty-looking, some fall out, others break off either within 
 the follicle or at various distances from the free surface, so that 
 the part is covered with dusty-looking hair of uneven length, 
 the majority looking as if they had been nibbled off near the 
 skin. Sometimes all the hairs of the affected part fall out, 
 producing a temporary baldness, and if the skin is not red, ap- 
 pearances are produced exactly like in alopecia areata. Gene- 
 rally a number of patches are present, and as all do not form at 
 the same time or grow with equal rapidity, we often have patches 
 varying in size from that of a pea to an inch or more in diameter, 
 on which all of the above characters may be observed on one or 
 the other. A distinct ring-formed eruption is rare upon the 
 head, as the centre remains elevated and scaling while the patch 
 spreads at the periphery. By the union of neighboring patches 
 large areas of eruption form, or the disease may occupy the 
 greater part or the whole of the scalp, and then it resembles very 
 closely a chronic squamous eczema. If but a single patch 
 forms it rarely becomes larger than one inch or an inch and a 
 half in diameter. Such a patch, with its sharp limitation, 
 whitish or slate-color, dry, adherent scales, and short, stubby 
 hairs is very characteristic and easily diagnosed. In ill-nour- 
 ished and scrofulous children the inflammation produced by 
 the fungus is much greater than the amount described above, 
 so that instead of slightly raised, scaly patches there may be 
 much infiltration and swelling of the part and formation of 
 thick, yellowish scabs. 
 
 Tinea kerion {kerion Celsi). — In some cases of tinea tonsurans 
 
TINEA TRICHOPHYTINA BARBAE. 587 
 
 of the scalp, especially in scrofulous children, a peculiar form 
 of ringworm eruption occurs to which the name of tinea kerion 
 or kerion Celsi has been applied. It bears the same relation to 
 ordinary ringworms of the scalp that parasitic sycosis bears to 
 ordinary ringworm of the head. The fungus passes deep into 
 the hair follicles and there sets up an inflammation, the inten- 
 sity of which governs the appearance of the eruption. As 
 ordinarily met with, it generally begins like an ordinary patch 
 of ringworm and afterward the affected portion of skin be- 
 comes swollen, elevated, red, shining, tender to pressure, boggy 
 to the feel, sharply limited at its margin, and covered with a 
 transparent, mucoid secretion which oozes from open hair 
 follicle mouths. The patch is rarely larger than from one to 
 two inches in diameter, and is round or oval in form. The 
 condition of the hairs is similar to that in ordinary ringworm 
 of the scalp. At first they are stubbed and later, many of them 
 lie either loosely in the follicle or fall out, leaving the patch more 
 or less bald. At first a little pus is present around the hairs, 
 and later the part is studded with foramina corresponding to 
 the open mouths of the follicles through which a mucoid secre- 
 tion is poured. Although the patch is always boggy to the 
 feel, there is no real purulent collection in the tissue unless there 
 has been a much more intense inflammation present than is usu- 
 ally the case. When the inflammation is intense, the secretion 
 which is poured out upon the free surface may be sero-purulent 
 instead of mucoid in character. The posterior cervical glands 
 are sometimes enlarged from absorption of exudation by the 
 lymphatics. Kerion generally results from the passing of the 
 trichophyton fungus deep into the hair follicles ; but, according 
 to some, it may also be the result of over treatment of ordinary 
 ringworm, or may follow eczema or sycosis of the scalp. The 
 disease is generally chronic in its course and may, if untreated, 
 persist a very long time. Sometimes, especially if the inflam- 
 mation is intense, it disappears spontaneously. 
 
 Tinea trichophytina barbae, (parasitic sycosis). — This affection 
 depends upon the trichophyton tonsurans fungus, the peculiar 
 symptoms attending it depending upon the anatomical charac- 
 
588 TINEA TRICHOPHYTINA CORPORIS. 
 
 ter of its seat. The fungus passes down into the hair follicles, 
 then into the shaft of the hair, and is found in the matrix and 
 between the hair sheaths. The presence of the fungus inter- 
 feres with the normal growth of the hair and acting as a for- 
 eign body, produces irritation and perifollicular inflammation, 
 the intensity of which differs in different cases. The disease 
 usually commences as a small, red, itching, scaly spot, like an 
 ordinary ringworm, upon which in a few days vesicles, tubercles 
 or pustules form, accompanied with swelling and induration of 
 the part, and change in the character of the hairs in the affected 
 area. Soon the whole part presents a nodular appearance, from 
 the formation of deep seated tubercles, the result of a deep 
 perifollicular inflammation. The tubercles vary in size from 
 that of a pea to that of a cherry, and are either isolated or ag- 
 gregated. There may be only one, or there may be several. 
 When several are closely situated they form a circular mass, or 
 are arranged in the form of a circle or a part of a circle, form- 
 ing a nodular mass with sharply limited margin, broad, firm 
 base deeply seated in the subcutaneous tissue, and an uneven, 
 fissured and desquamating surface studded with broken and 
 loose hairs. There is often a foul-smelling, sero-purulent secre- 
 tion on the surface, which dries into a thick scab like an impetig- 
 inous eczema. If the scab is removed all the loose hairs will 
 be removed with it, as their upper part is imbedded in the dried 
 secretion. The amount of pustulation present varies much, 
 depending upon the amount of irritation produced by the fun- 
 gus. The hairs are affected in the same manner as in ringworm 
 of the scalp. They are either broken off near the skin, or 
 easily fractured, or lie loose in the follicle, surrounded or not by 
 pus. Sometimes the hair follicles are destroyed by the inflam- 
 matory process and permanent alopecia results. The eruption is 
 usually seated on the chin or submaxillary region. Patches of 
 ringworm are generally present on other parts of the body. 
 The course of the disease is very chronic, the eruption 
 having a tendency to spread slowly but continuously, unless 
 treated. 
 
 Tinea trichophytina corporis (tinea circinata). — Tinea circinata, 
 
TINEA TRICHOPHYTINA CORPORIS. 589 
 
 or ringworm of the body, usually begins by the formation of 
 one or more roundish, slightly elevated, sharply limited, some- 
 what scaly, hyperaemic spots, the redness of which disappears 
 almost entirely upon pressure. The patches soon increase in 
 size by peripheral growth, the eruption continuing to retain its 
 original character as regards shape, margin and redness, but 
 with an increase in the amount of scaling. After attaining the 
 size of from half an inch to an inch in diameter, the central 
 part, as a rule, commences to return to a normal condition by a 
 subsidence in the inflammatory processes shown by the sinking in 
 and pale color of the part. In that the patch continues to in- 
 crease in diameter by peripheral growth whilst the centre closes 
 up, a ring-like eruption results. When fully developed, a 
 ringed patch consists of a normal central part ; a more exter- 
 nal, pale reddish, scaly portion ; and the most peripheral part 
 of a sharply limited, red, elevated, scaly circle. Sometimes a 
 patch never develops to the ring-form, but remains as a 
 diffuse, sharply limited, elevated, red, scaly eruption. Instead 
 of the above manner of appearing, the eruption some- 
 times commences as a group of very small vesicles and spreads 
 by peripheral growths of similar vesicles. This form is met 
 with especially when the eruption spreads rapidly, or the skin 
 is very irritable, and consequently reacts very actively to an 
 irritant. Sometimes even pustules or bullae form, the skin 
 becoming much inflamed, and crusts forming from drying up 
 of the exuded material. 
 
 If two or more rings coalesce the resulting patch has 
 a gyrate form. There is rarely more than a few patches 
 present on the skin at the same time, and individual 
 patches rarely occupy a large area. After attaining a certain 
 size they usually cease to grow at the periphery, but 
 remain stationary, especially if seated where two surfaces touch 
 each other, as in the axilla, groin, and breasts. The eruption 
 may be seated upon any part of the body, but is most frequent 
 upon the face, neck and back of the hands. It may be acute 
 or chronic in its course, lasting only a few weeks and disap- 
 pearing spontaneously, or continuing for years, in which case 
 
59° TINEA TRICHOPHYTINA CRURIS. 
 
 it resembles patches of chronic superficial eczema. Itching is 
 almost always present, and if vesicles or pustules form there 
 will be a burning feeling in the part. If conveyed from the 
 lower animals to man the eruption, it seems to me, spreads 
 more rapidly and is accompanied with more intense inflamma- 
 tion of the parts than when conveyed from man to man. 
 
 Tinea trichophytina cruris {eczema marginatum). — This condi- 
 tion, which was regarded by Hebra as an eczema, but which has 
 been shown to be produced by the trichophyton fungus, the 
 special clinical symptoms depending upon the region affected; 
 is found especially in the groin, commencing on that part of the 
 thigh which comes in contact with the scrotum, and is more 
 frequently on the left than on the right side, as the 
 scrotum on the right side is generally separated 
 from the thigh by the clothing. The eruption commences 
 as a larger or smaller, roundish or oval, pretty sharply limited, 
 red, elevated, discharging patch, which itches greatly. The 
 eruption soon spreads peripherally until the whole area of 
 scrotal contact is occupied, when it may remain almost station- 
 ary as regards extent, or it may extend down the thigh, over 
 the buttocks, mons veneris, and to the other side, forming a 
 symmetrical eruption. When the patch occupies an area even less 
 than that of the scrotal contact the eruption shows the most 
 active process to be taking place at the peripheral part. Here, 
 as in ordinary ringworm papules, vesicles or even pustules are 
 present, whilst the central part is red, elevated, discharging; 
 with a few vesicles here and there, or perhaps only darkly 
 pigmented from previous scratching. The margin is not always 
 circular and sharply limited, but is sometimes irregularly 
 shaped, with a raised border of discrete papules or vesicles. 
 Sometimes a few small, circular, elevated spots like tinea cir- 
 cinata of the body are present outside the general patch. If 
 the eruption is of long standing the skin becomes considerably 
 thickened and much pigmented. The hairs do not lose their 
 normal characters or break off. The course of the disease is 
 very chronic, lasting, if untreated, perhaps many years, and if 
 cured is very liable to return. It is not a frequent disease in 
 
TINEA TRICHOPHYTINA. 591 
 
 New York, but is often met with in tropical countries, especially 
 in India. 
 
 Tinea irichophytina unguium (pnychymycosis). — Occasionally 
 the trichophyton fungus attacks the nail and produces, by its in- 
 terference with its nutrition, changes in its shape and appearance. 
 The nail becomes dry, opaque, dirty-white, thickened, of 
 irregular shape, bent and soft, brittle and laminated, especially 
 at the free border. It is generally met with on the fingers, 
 the nails of the toes being very rarely affected, and it 
 is very unusual for more than two or three nails to be affected 
 in the same individual. The disease is very chronic in its 
 course and difficult to cure. It is generally associated with 
 patches of tinea trichophytina on other parts of the body, but 
 may be alone present, the fungus in the nail remaining long 
 after its disappearance on the cutaneous surface. 
 
 Anatomy. — The fungus produces more or less inflammation 
 and structural changes in the skin in every form of the disease, 
 the extent depending upon the situation of the fungus and the 
 degree of nutrition and irritability of the skin. In tinea 
 trichophytina capitis, if the fungus remains in the corneous 
 layer there will be slight superficial inflammation, or perhaps 
 only a hyperaemia ; but if it passes down into the hair follicles 
 and into the hair shaft, or, as I have observed, even into the 
 perifollicular tissue, then the nutrition of the hair is interfered 
 with and the perifollicular inflammation will be considerable, 
 especially in scrofulous and ill-nourished children. As the 
 fungus passes into the hair shaft the latter suffers in its nutrition, 
 becomes lustreless, disintegrates and is easily broken. (See 
 fig s - 76, 77, 79 and 80.) The perifollicular inflammation 
 may be slight or of such extent as to destroy the hair 
 follicle and produce permanent alopecia. In tinea kerion 
 the glands of the skin seem to be affected as well as the 
 hair follicles, and pour out a mucoid secretion. In this form, 
 though there is no true suppurative process, the inflammation 
 in the given area is so general, deep and long continued 
 that the follicles are destroyed and permanent alopecia 
 results. In tinea trichophytina barbae the hairs are affected 
 
592 
 
 TINEA TRICHOPHYTINA. 
 
 early in the disease, becoming opaque, brittle and detached 
 from the follicle wall. The amount of perifollicular inflamma- 
 tion is very great, much more than in any of the cases of tinea 
 trichophytina capitis, and consequently the hair follicles are fre- 
 quently destroyed. In tinea trichophytina corporis there is 
 more or less superficial dermatitis, as in mild cases of eczema. 
 In eczema marginatum the condition is more similar to that in 
 vesicular eczema. 
 
 The disease is caused by the vegetable fungus tricho- 
 phyton tonsurans, the appearance of the eruption in the 
 different forms of the disease depending upon the anatomical 
 seat of the fungus and the degree of irritability of the tissue 
 
 Fig. 75.— Mycelia and spores from a rapidly spreading case of tinea trich- 
 ophytina corporis. The source of contagion was a cat. 
 
 of the part affected. The fungus consists of spores and my- 
 celium. The slower the process of multiplication of the fun- 
 gus, the greater is the number of spores present in proportion 
 to the amount of mycelium, and vice versa. As the eruption 
 always spreads by peripheral growth, more mycelia are 
 present in proportion to the spores at the periphery that in the 
 central part of the affected area. In tinea trichophytina capitis 
 and barbae especially, there are generally very few mycelia as 
 compared with the number of spores present. 
 
 When conveyed to man from one of the lower animals, my- 
 
TINEA TRICHOPHYTINA. 
 
 593 
 
 celia are generally numerous. The spores are round, small, 
 highly refracted and either single or arranged in rows, which 
 are isolated or joined to mycelium. The mycelium generally 
 consists of long, slender, sharply contoured, straight or crooked 
 threads which send off, at irregular intervals, a few branches, 
 and contain spores and granules. (See fig 75.) The anatomical 
 
 ^_ 
 
 Fig. 76. — Free end of a hair shaft invaded by spores of trichophyton ton- 
 surans, a, free surface of skin ; 6, hair stump. 
 
 The free end of the shaft is jagged, bristly, and consists of broken filaments. 
 
 seat of the fungus differs in different cases. In some cases of 
 tinea trichophytina capitis it is situated only in the corneous 
 layer, or, in addition, in the upper part of the hair shaft, in- 
 
 Fig. 77. — Portion of a hair shaft invaded by the trichophyton tonsurans. 
 
 terfering with the nutrition of the latter and dividing it into 
 
 more or less broad longitudinal fibres, as seen in figure 76, 
 
 or completely disintegrated, as seen in figure 77, in which 
 
 a portion of a shaft of a hair is shown, crowded with spores 
 
 and almost destroying all signs of structure. 
 38 
 
594 
 
 TINEA TRICHOPHYTINA. 
 
 There are always more fungus elements in the affected hairs 
 than in the epidermis, and they consist almost exclusively of 
 spores. 
 
 In severer cases of tinea trichophytina capitis the fungus 
 passes down into the hair follicles and root of the hair, and may 
 
 Fig. 78. — Section of hair and adjoining skin in a case of tinea trichophytina 
 capitis. Spores and mycelium are seen in the hair shaft, internal root sheath, 
 corneous layer, mucous layer, and corium. 
 
 pass into the perifollicular tissue, as shown in fig. 78. This 
 probably occurs in those cases which resemble in their clinical 
 features cases of alopecia areata. Fungi may be found in all 
 parts of the hair situated within the skin, but the greatest 
 
TINEA TRICHOPHYTINA. 
 
 595 
 
 number is present in that part seated above the neck of the 
 follicle. 
 
 If the hair shaft is invaded, the effect may be a bending and 
 subsequent breaking of the affected hair at a point midway be- 
 tween the rete and root of the hair, the bending and breaking 
 being due to the pressure exerted upon the disintegrated hair 
 by the normal growth of the shaft upward. This condition is 
 shown in figures 79 and 80. In these cases no hairs may be 
 seen in the openings of the hair follicles, or they may appear 
 as black specks. 
 
 In tinea trichophytina barbae the fun- 
 gus is principally seated in the lower part 
 of the hair follicle. 
 
 In ringworm of the body the hairs are 
 free, the fungus being in the corneous 
 layer. 
 
 Figs. 79, 80. — Hairs showing; bent shaft from upward pressure by normal 
 growth of hair upon disintegrated portion. 
 
 In onchymycosis it is in the substance of the nail. 
 
 Ringworm will not grow upon every skin. For a suitable 
 ground, the skin should be in a condition of mal-nutrition. It 
 is more frequent in children than in adults. It is rare in 
 infancy, and after puberty. It is met with most frequently in 
 damp seasons and with persons who live in damp dwellings. 
 
596 TINEA TRICHOPHYTINA. 
 
 It is very contagious if the ground is suitable for its growth. 
 It is frequently conveyed to man from the lower animals, as 
 the cat, dog, horse, and cattle. When conveyed from these 
 animals it generally rapidly multiplies on the new habi- 
 tation. 
 
 Diagnosis. — Tinea Trichophytina Capitis. — Circular patches, 
 covered with fine scales and provided with stumpy, nibbled-off 
 hairs, are easily diagnosed, but in other forms the eruption 
 may be confounded with eczema squamosum, seborrhcea, 
 psoriasis, or alopecia areata. Eczema squamosum often re- 
 sembles a tinea trichophytina capitis in the color and scaling, 
 but the history of the eruption is different ; it does not com- 
 mence as a small spot and spread circularly and peripherally, 
 the margin is irregular, and the hairs are firm, not loose and 
 not fractured or nibbled off. In seborrhcea there are no signs 
 of inflammation, the scales are fatty, not dry, the margin is 
 irregular and the hairs are not broken off. In psoriasis the 
 scaling is much greater, the hairs are unaffected and the erup- 
 tion is generally present also on the extensor surfaces of the 
 body. The greatest difficulty is sometimes to diagnose between 
 alopecia areata and tinea trichophytina capitis. In alopecia 
 areata there are no inflammatory symptoms present, no scaling, 
 no nibbled-off hairs, but the patch is circular, and occasionally 
 atrophic hairs are present in the affected area. Now, some 
 cases of ringworm of the head show no signs of inflammation, 
 no appreciable scaling, and no nibbled-off hairs, unless, per- 
 haps, here and there black specks are seen with hair follicles, 
 the end of a broken hair. Many of these cases are diagnosed 
 alopecia areata, and the truth can only be arrived at by a 
 microscopical examination of corneous cells at the margin of 
 the patch, or of some hairs. If the case of ringworm, however, 
 is classical in character, then the diagnosis is very easy, as in 
 alopecia areata there are no broken hairs or scaling. 
 
 In tinea kerion, the boggy feel, the mucoid secretion, the 
 foramina, the loose hairs, and the microscopical examination 
 and detection of fungi in doubtful cases make up the diagnostic 
 points in this form of the disease. 
 
TINEA TRICHOPHYTINA. 597 
 
 Tinea trichophytina barbae may be mistaken for sycosis, 
 acne, and the vegetating syphiloderms. I refer to the article 
 on sycosis for all the points for diagnosis between the two dis- 
 eases, which, in reality, bear but little resemblance to each other 
 except in name. 
 
 In sycosis there is no fungus, there is active inflammation 
 and suppuration, which is confined to the perifollicular region, 
 and, consequently, there is a hair in the centre of every pus- 
 tule. There are no deep-seated tubercular masses of infiltra- 
 tion, the hairs are healthy, and, at first, firmly seated in the 
 follicle. When the papules of a syphilitic eruption appear as 
 superficially eroded, moist papules arranged in circles or 
 groups, the diagnosis is made by the presence of ulceration, 
 the absence of fungus, and the history of the case. 
 
 Acne appears especially on non-hairy parts of the face, is 
 generally a pustular eruption, the pustules being of short dura- 
 tion and discrete. Other symptoms are not necessary for a 
 diagnosis. 
 
 Tinea circinata resembles eczema, seborrhcea, psoriasis, syphi- 
 lis. In eczema the eruption is rarely circular in form, the mar- 
 gins are not sharply limited, except in gouty or rheumatic in- 
 dividuals, the inflammation and scaling is usually greater, and 
 there is no tendency to clearing of the centre and assuming 
 the ring-form. Seborrhcea, when located on the chest and 
 back, often consists of circular patches, with or without a clear 
 centre, and covered with scales. The scales, however, are 
 greasy in character and they are seated upon a non-inflamed 
 skin. In ringworm the scaling is always the result of a derma- 
 titis. Psoriasis always commences and spreads in the same 
 manner as tinea circinata, and, after attaining a certain size, 
 clears up in the centre and forms rings with a sharply limited 
 margin and normal centre. In psoriasis, however, the scaling 
 is very considerable in amount, and consists of dry corneous 
 cells, and not of cells and exudation as in cases of dermatitis. 
 The patches are never formed of vesicles or inflammatory 
 papules, they do not itch or discharge, they are generally scat- 
 tered over a considerable part of the body, and, if limited in 
 
59& TINEA TRICHOPHYTINA. 
 
 number, are almost always present upon the extensor surfaces 
 of the knees and elbows. In syphilis, when the small papules 
 are arranged to form circles there is some resemblance in the 
 eruption with that of ringworm, but the symmetrical character 
 of the eruption, its distribution over a large part of the body, 
 the history of slow formation cf the ring, the elevation and 
 dark color of the papules, are sufficient'for the diagnosis. 
 
 Tinea trichophytina cruris bears the closest resemblance to 
 an ordinary eczema of this region. In eczema the patch is like 
 ordinary intertrigo, its greater portion consisting of a red, non- 
 scaly, discharging surface, whilst the margin is irregular in out- 
 line, not sharply limited, and usually less inflamed than the 
 more central portions. It may also last a number of years 
 without extending beyond the area where two cutaneous sur- 
 faces come in contact. 
 
 Tinea trichophytina unguium cannot be diagnosed from 
 psoriasis, eczema or lichen ruber of the nails without the micro- 
 scope unless cutaneous lesions are present, as the appearances 
 are similar as regards changes in the nail in these different 
 diseases. 
 
 I have given the diagnosis between tinea trichophytina and 
 those diseases having a resemblance in eruption, as it is to be 
 made, from clinical observations, but in cases of doubt the 
 microscope should always be employed. Especially is this 
 necessary in cases resembling alopecia areata, and in onchymy- 
 cosis. Scales from the periphery of a patch, or broken hairs, or 
 scrapings of the nail should be examined in a five to fifty per 
 cent, solution of caustic potash, the strong solution being used 
 for nail substance, and examined after a few minutes with a 
 lens, giving five or six hundred diameters at least. If the scales 
 are very dry the air should first be removed by alcohol. The 
 potash should never be mixed with glycerine as they form 
 deceptive pictures. Unless the observer is a competent micro- 
 scopist he should never pass an opinion upon shining bodies 
 situated in epithelial cells, or in the centre of a hair shaft, as 
 fat globules resemble spores in every particular, as shown under 
 the microscope. They can only be diagnosed after coloring, 
 
TINEA TRICHOPHYTINA. 599 
 
 or treating by agents, which dissolve fat. If mycelium is 
 present then there is no difficulty in diagnosis. 
 
 Prognosis. — The prognosis depends upon the situation of the 
 disease, and the constitution of the individual affected. Mild 
 cases of the scalp in well nourished persons can be quickly cured. 
 In hospital cases and in scrofulous or badly nourished children, 
 it is very obstinate. Tinea kerion is difficult to cure and 
 generally produces baldness in the affected area. Tinea trich- 
 ophytina barbae is easily cured, but unless treated early the hair 
 follicles may be permanently destroyed. 
 
 Ringworm of the body is generally easily cured, but relapses 
 are not infrequent, if the general nutrition of the system is 
 impaired. Tinea trichophytina cruris is usually very obstinate, 
 and relapses are frequent. Onychymycosis is obstinate and re- 
 quires long continued treatment. 
 
 Treat?nent. — The treatment is both local and constitutional. 
 Many of the children affected with ringworm suffer from mal- 
 nutrition. This condition must be remedied. Proper food, 
 good air, cleanliness, and appropriate tonics should be given. 
 Cod-liver oil and iron are always of benefit in these cases. 
 
 The local treatment depends upon the situation of the 
 disease, and the anatomical seat of the fungus. In mild cases 
 of tinea trichophytina capitis in which the fungus has not 
 penetrated- deeply into the hair follicle, the head should be well 
 washed with soap and water every day, the hair in and some- 
 what beyond the affected area cut as short as possible, and 
 anti-parasitic applications employed. I prefer a solution of cor- 
 rosive sublimate, two grains to an ounce of alcohol, the solution 
 to be applied with a stiff brush or spray, twice a day, until the 
 fungus is no longer to be detected by the microscope in the hairs 
 or scales. After removal of the disease, the washing of the head 
 with soap and water should be continued for some time longer 
 to prevent a relapse. Instead of the corrosive sublimate solu- 
 tion any of the mild parasiticides may be employed in the man- 
 ner to be described for ringworm of the body. If the fungus 
 passes down into the hair follicle and into the hair shaft, it is 
 necessary not only to use parasiticides but also to epilate. All 
 
600 TINEA TRICHOPHYTINA. 
 
 loose hairs and all broken ones should be removed. This should 
 be repeated daily, for by this epilation we not only remove an 
 immense amount of fungus with the extracted hair shaft but 
 are the better enabled to apply the parasiticide to the seat of 
 the fungus. The parasiticide is to be applied each time after 
 epilation. The corrosive sublimate solution can be employed, 
 or one of the many anti-parasitic remedies. A six per cent, solu- 
 tion of oleate of mercury, applied every second day, is some- 
 times very efficient, as it penetrates the tissues. I have found 
 it especially useful when the patches resemble those of alopecia 
 areata where a penetrating preparation is indicated, as some of 
 the fungus is seated in the perifollicular tissue. If applied too 
 frequently it may irritate the skin too much, and it is contra- 
 indicated if the eruption covers a large area. While precipitate 
 ointment or an ointment of the yellow sulphate of mercury, half 
 a drachm to the ounce, well rubbed in, may be used with good 
 effect. If the case resists the above treatment and becomes 
 chronic, it may be necessary to produce an acute inflammation in 
 the part. Glacial acetic acid, or cantharidal collodion may be 
 painted upon the part once a week, and mild parasiticides used 
 during the interval. Croton oil, either pure or mixed with olive 
 oil, according to the amount of irritation desired, is the most 
 manageable substance. It is always necessary to produce a 
 considerable amount of inflammation. After its production 
 mild applications are to be employed. This procedure, how- 
 ever, is rarely necessary, as persistent epilation, an application 
 of suitable parasiticides, together with internal treatment to 
 improve the general nutrition, generally removes the disease. 
 If the eruption is general, lotions or ointments should be em- 
 ployed. Lotions, when used, are to be kept constantly applied. 
 
 In tinea kerion all the hairs should be extracted and mild 
 parasiticides afterwards employed. A weak solution of corro- 
 sive sublimate, or a lotion of carbolic acid, answers well. It is 
 not necessary to first reduce the inflammatory condition present 
 by usual antiphlogistic measures, as this is best accomplished by 
 removal of the fungus. 
 
 In tinea trichophytina barbas epilation should always be per 
 
TINEA TRICHOPHYTINA. 6oi 
 
 formed and oleate of mercury employed to destroy the fungus. 
 The face should be shaven daily. The disease is easily re- 
 moved. 
 
 Tinea trichophytina corporis is to be treated by mild para- 
 siticides. Before applying them, the part should be well 
 washed with warm water and soft soap. The corrosive subli- 
 mate solution is a very efficient remedy, and should be applied 
 once a day at least. White precipitate ointment or the oint- 
 ment of the yellow sulphate of mercury is good. An ointment 
 of chrysophanic acid is of decided benefit in tinea tricophytina of 
 the body, but not so useful in that of the scalp. Lotions of 
 sulphurous acid, either pure or diluted to the strength of one, 
 two, three or four of carbolic acid ; of hyposulphite of sodium, a 
 drachm to the ounce, constantly applied, arc generally efficient 
 parasiticides when the fungus is seated superficially, as is usually 
 the case in ringworm of the body. Glacial acetic acid, tinc- 
 ture of iodine, carbolic acid, half a drachm to an ounce of gly- 
 cerine, may be employed. Thymol, half a drachm, mixed with 
 two drachms of chloroform and six drachms of olive oil, is 
 highly recommended. If the disease shows a tendency to 
 become disseminated, warm baths, washing with soft soap and 
 subsequent sponging with alcohol, or the hyposulphite of sodium 
 solution is advisable. 
 
 In tinea trichophytina cruris, the same measures are to be 
 employed as for ringworm of the body ; but the applications 
 should, as a rule, be more powerful. An ointment of chrys- 
 arobin, five grains to an ounce of ointment, or goa powder, 
 ten to forty grains to an ounce of ointment, is often more 
 efficacious than the previously mentioned remedies. Kaposi 
 recommends a mixture consisting of one hundred parts of 
 green soap, two parts of naphthol, and ten parts of spirits of 
 lavender, to be rubbed in for two or three nights. Woolen 
 clothes to be worn during its use. 
 
 For onchymycosis, the nail should be scraped as thin as 
 possible without producing pain, and a corrosive sublimate 
 solution, from two to five grains to an ounce of alcohol, ap- 
 plied two or three times a day. Oleate of mercury is useful, 
 
602 FAVUS. 
 
 but will not cure it unless the nail is scraped, as in my experi- 
 ence it will not penetrate nail substance. Creosote or carbolic 
 acid, pure, or as a strong solution, may be used. The con- 
 stant application of sulphurous acid should be tried if the 
 other applications fail. Whatever treatment is followed, it 
 must be persisted in for a length of time, as these cases are 
 obstinate and difficult to cure. If the nail is very hard it can 
 be previously softened with liquor potassae, and the anti-pari- 
 siticide then applied. 
 
 Cases of tinea trichophytina should be isolated as far as pos- 
 sible, especially if occurring in an hospital. All contact 
 should be avoided with lower animals having the disease, as it 
 is much more contagious from them to man, than from one 
 person to another. 
 
 FAVUS. 
 
 Syii. — Tinea favosa ; porrigo favosa ; dermatomycosis favo- 
 sa ; crusted ringworm ; honeycomb ringworm. 
 
 Definition. — Favus is a contagious, vegetable, parasitic dis- 
 ease, due to the growth in and upon the skin of the achorion 
 Schonleinii, and characterized by the appearance of small, pea- 
 sized, circular, yellow, cup-shaped crusts, each perforated by a 
 hair. 
 
 Symptoms. — Favus attacks especially the hairy portions of 
 the body, and is found most commonly upon the scalp ; but it 
 may also affect the nails, and even the non -hairy portions of 
 the general integument, as the skin of the shoulders, thighs, 
 penis, scrotum, etc. The disease begins as a more or less 
 circumscribed superficial inflammation of the skin, accom- 
 panied with slight scaling. Itching is quite marked over the 
 patch, and is usually the symptom that first directs the patient's 
 attention to it. Within a short time one or more yellowish 
 points appear underneath the epidermis, and surrounding a 
 hair shaft ; these are the beginnings of the well-known favus- 
 sculuta or cups. In the course of a few weeks the yellowish 
 points, at first pin-head in size, grow to the size of perhaps 
 
FAVUS. 603 
 
 split peas, and appear as sulphur-colored, round or oval plates, 
 with depressed centres, each one pierced through its middle by 
 a hair. The margins of the crust are elevated above the level 
 of the surrounding skin ; its centre is depressed and umbili- 
 cated. By means of a pair of forceps it may be detached 
 from its base, and drawn away along the shaft of the hair ; 
 an excavated, reddened, and perhaps moist surface is left be- 
 hind, in which, however, the epidermis soon swells up and 
 regains its normal level when the pressure is removed. 
 
 The favus crusts are composed of a series of concentric 
 layers closely packed together. They are very friable, and 
 break down easily under pressure. At first discrete, as the dis- 
 ease advances they fuse together into irregular masses ; and 
 in cases of some standing the individual cups may be no 
 longer recognizable, the surface being covered with a thick, 
 yellowish-white, crumbly, mortar-like mass, on removal of 
 which an atrophied, dry or inflamed and moist, hairless surface 
 is left. The amount of inflammation varies much in different 
 cases. Pustulation or suppuration may be visible in or around 
 the crusts ; or the skin under them may simply be smooth, 
 depressed, and atrophied. 
 
 Sooner or later the parasite invades the papillae and hair 
 shaft. The nutrition of the hair is interfered with, it becomes 
 dry and lustreless and breaks off or falls out. Finally, the 
 papillae themselves are destroyed. The constant pressure of 
 the growing fungus causes atrophy of the skin, which becomes 
 depressed, hard, shining, and in which all glandular structures 
 are destroyed. Actual ulceration does not occur. 
 
 Favus may remain for long periods confined to one spot, and 
 is then called/, discretus. If it involves large surfaces, as the 
 entire scalp, the name /. confertus is applied to it. It is a dis- 
 ease of essentially chronic course, lasting in some cases twenty- 
 five years or more. It tends in the course of time to a spon- 
 taneous cure. After all the glandular structures are destroyed, 
 the parasite, no longer finding a suitable nidus, disappears from 
 the skin. In fact, the plant seems to thrive only in the gland- 
 ular structures. When favus occurs upon non-hairy parts, as it 
 
604 FAVUS. 
 
 sometimes does, it usually ends of itself in a few months. It 
 may occur as the discrete or more diffuse crusts ; but the 
 delicate follicles of the lanugo hairs are soon destroyed ; the 
 cups are detached, the hair falls out ; but rarely does any 
 atrophy or scarring result from the process. 
 
 Favus of the nails, onychomycosis favosa or tinea favosa 
 unguium, is of rare occurrence, and is occasioned in favus 
 patients by scratching the head and receiving the parasite under 
 the finger-nail. Yellowish white mortar-like masses appear 
 under the edge of the nails and in their substance ; the organs 
 are thickened, often split, and seem to undergo a kind of 
 cheesy degeneration. The affection is a very obstinate one. 
 
 One other symptom of favus remains to be mentioned, and 
 it is so peculiar a one, that with its help, in otherwise doubtful 
 cases, we may arrive at a conclusion as to the nature of the dis- 
 ease. I refer to the odor always developed in well-marked 
 cases of the affection. It has been described as a mouse-like 
 smell ; it is difficult to characterize it, but once appreciated it 
 forms a fairly reliable symptom of the malady. Exactly the 
 same odor occurs in the lower animals affected with favus. 
 
 As before stated, favus is almost always seen upon the 
 scalp, but may occur upon other portions of the body. It hap- 
 pens with moderate frequency in the lower animals, especially 
 among cats, mice, rabbits, horses and dogs. Cats often suffer 
 from it, getting it from mice ; and they in turn transmit it to 
 the children that play with them. 
 
 Anatotny. — Favus is caused by the growth in the upper 
 layers of the skin of a fungus discovered by Schonlein in 
 1839, and called by Remak, achorion Schonleinii. It may 
 easily be seen by placing under the microscope a small portion 
 of a favus-cup moistened either with water or better with dilute 
 liquor potassse. The mass is composed almost wholly of the 
 luxuriant vegetable growth in various stages of development. 
 The most apparent is the mycelium in the shape of 
 flat, narrow threads, branching and inosculating with one 
 another in various directions. Their diameter is about the 
 1-800 part of an inch, and their color a pale gray, sometimes 
 
FAVUS. 
 
 605 
 
 tinged with green. When in a state of fructification, these 
 tubes are divided into numerous small compartments by deli- 
 cate cross-lines, sometimes with constrictions, giving a chain- 
 like appearance ; and in each compartment are seen young 
 spores in various stages of growth. The spores or conidia are 
 present in abundance amid the meshes of the parent growth. 
 They are very small, of varying form, round, oval, flask or dumb 
 bell shaped, and of a pale greenish color. Intermediate forms 
 between the spores and mycelium are always present, and 
 fungoid growths of various kinds, as well as micrococci and 
 bacteria, are often accidentallv in the field of view. 
 
 Fig. 81. — Spores and mycelium from a favus scutulum. 
 
 The parasite first obtains a lodgment in the funnel-shaped 
 depression in the epidermis through which the hair-shaft emerges 
 upon the surface. It grows luxuriantly in the upper part of the 
 hair-sac, and insinuates itself on all sides between the superficial 
 layers of the epidermis. When it reaches a short distance on all 
 sides of the follicle-mouth, it breaks the looser layers and ap- 
 pears on the surface, giving us the familiar cup-shaped bodies. 
 It also invades the hair-shaft itself, though not to the extent 
 that the trichophyton parasite does. It penetrates between 
 the cellular layers of the root sheath, and multiplies in the cor- 
 tical substance of the hair. The nutrition of the hair is inter- 
 fered with by the mechanical pressure of the growth upon the 
 papillae. The hair falls out, and eventually in many cases the 
 
606 FAVUS. 
 
 papilla atrophies, and a new growth becomes impossible. In 
 cases of any standing the parasite may be demonstrated, not 
 only in the cortical, but in the medullary substance of the hair. 
 Splitting of the hair may occur, as in tinea tonsurans, but as 
 a usual thing the hair falls out before that occurs. 
 
 In the skin itself the parasite usually confines itself to the 
 upper corneous cells, and does not extend to the living tissues. 
 In cases where the surface is covered by irregular, mortar-like 
 masses of parasite — the entire upper layer of the epidermis 
 will be found infiltrated with the achorion. 
 
 The corium itself is usually in a state of chronic inflamma- 
 tion, and suppuration, which may be quite abundant, often occurs 
 under the crusts. Even where no pus is found the pressure of 
 the parasite causes atrophy of the skin, and at last pit-like de- 
 pressions or more extensive reddened scars are left. When the 
 glandular structures are entirely destroyed, the achorion no 
 longer finds a suitable nidus, and the disease, at that spot, is 
 at an end. 
 
 Etiology. — Favus may occur at all ages, and in all conditions 
 of life, but the individual susceptibility to its contagium va- 
 ries greatly. We do not know the conditions that predis- 
 pose to the reception of the parasite, but it occurs most often 
 among the poor, and in children. In most instances a history 
 of contagion may be obtained. It is probable that it is often 
 transferred from dogs, cats, chickens, mice, etc., to children. 
 In some cases, however, there seems to be no possibility of 
 direct contagion, and we are compelled to assume that the 
 spores have been carried to the patient in the atmosphere. 
 The contagion is not very active. One member of a family 
 often has it for a time without any one else being affected ; 
 and in the wards of our hospitals the favus patients mix freely 
 with the other inmates for months without communicating the 
 disease. In other cases it may run through a whole family ; 
 thus Duhring mentions an instance in which thirteen members 
 of the same family suffered at various times from the disease. 
 
 Favus is a far commoner affection in Europe than it is here, 
 forming in some places as much as one-half per cent, of all ob- 
 
FAVUS. 607 
 
 served skin diseases. In America it occurs not oftener than 
 once in four or five hundred dermatological cases. 
 
 Diagnosis. — Usually the recognition of favus is easy. The 
 peculiar, pale, sulphur yellow, friable, cup-shaped crusts, sur- 
 rounding a hair ; the inflammatory and depressed basin upon 
 which the crusts are situated, and the mousy odor, are not 
 found in any other affection of the skin. Even when the disease 
 has ended, the cicatricial, depressed, glandless areas are quite 
 characteristic. 
 
 But when the masses of the parasite have accumulated into ir- 
 regular, heaped-up, mortar-like masses, intermingled perhaps 
 with dirt and with dried pus, the affection may bear considerable 
 resemblance to an impetiginous eczema. But in eczema the 
 crusts are hard, moist, greenish-yellow, and a reddened, weep- 
 ing corium is left on their removal ; in favus the crusts are 
 dry, brittle, straw-colored or grayish-white, and the subjacent 
 skin is red, but is covered with normal epithelium. The 
 changes in the hair in favus, the odor, and the atrophy of the 
 skin are also useful in the differentiation. 
 
 If seems hardly likely that psoriasis or lupus erythematosus 
 can be mistaken for favus. In any case the microscope would 
 soon settle the question. Tinea tonsurans is wanting in the 
 cups and mortar-like masses, and shows an abundance of nib- 
 bled-off hairs, is not usually so chronic in its course, and causes 
 no scarring. 
 
 Prognosis — Is good as regards the general health, though not 
 always favorable in respect to the local affection. Sooner or 
 later the disease ends of itself, but leaves permanent baldness, 
 atrophy of the skin, and cicatrices behind. The earlier in the 
 disease treatment is commenced, the better the chance of mas- 
 tering the affection. Some cases seem to resist all our efforts 
 to destroy the fungus. Favus of the nails is liable to be espe- 
 cially obstinate. 
 
 Treatment. — The time required to treat successfully a case 
 of favus of any extent will always be a long one. It usually 
 takes months before we succeed in destroying the last spores 
 of the parasite. 
 
608 FAVUS. 
 
 The first thing to be done is to thoroughly remove all the crusts 
 and cups. This is readily done in twenty-four hours by soften- 
 ing them with oil, either simple or containing carbolic acid or 
 naphthol. A few washings with soap and hot water, or with 
 the tinctura sapo viridis will then suffice to remove as much of 
 the fungus as is upon the surface. The task before us now is 
 to destroy it in the hair-follicles, for, if left to itself, it takes 
 but a few weeks to attain its former luxuriance. 
 
 To effect this end it has been proposed to cause such an 
 amount of inflammation of the scalp that folliculitis and peri- 
 folliculitis is set up, and the hair-sac with the parasite, is cast 
 off. Croton oil, turpentine, etc., have been used. It is not 
 advisable to attempt this. The process is painful, and, from 
 the possibility of extension of the inflammation to the deeper- 
 tissues, even dangerous. Then again, it destroys the innocent 
 with the guilty, the diseased with the sound follicles ; and 
 above all, it destroys some, but not all the affected hair-bulbs, 
 and some of the parasite is almost certain to be left behind. 
 
 Epilation, either as commonly done, or in the way recom- 
 mended by Kaposi, is the proper step to take. In the ordin- 
 ary method, the hair is first cut close to the skin. After 
 anointing the surface to be operated on with almond oil, a 
 number of the hairs should be seized with the broad-bladed ep- 
 ilation forceps, and pulled out by traction in the direction of 
 their long axes ; if extracted carelessly they are liable to break 
 off level with the skin. After a sufficient surface has been 
 cleared, some one of the parasiticides mentioned below should 
 be immediately and thoroughly applied. This process is to be 
 repeated day after day, until the whole diseased surface has 
 been treated. Sometimes it is necessary to go twice or thrice 
 over it. 
 
 This mode of epilation is painful to the patient and tedious 
 for the physician, and here again affected and unaffected hairs 
 are extracted indiscriminately. Kaposi's method is better. 
 The hair is not to be cut at all ; epilation is done daily by 
 drawing the hair fairly vigorously between the thumb and an 
 ordinary tongue spatula. Only the fungus-infected, loose 
 
FAVUS. 609 
 
 hairs come out, and the patient suffers no pain at all. After 
 the process the surface should be thoroughly washed with the 
 tincture of green soap. 
 
 Whichever mode we employ, our final effort is by means of 
 some parasiticide to destroy the fungus. A variety of measures 
 stand at our disposal. Such should be selected as possess the 
 greatest penetrating power, so that they shall make their way 
 into the follicles, now empty of their hairs. The ethereal oils, 
 ol. caryophylli, ol. macidis, are quite effective. Corrosive 
 sublimate, one half per cent, solution in alcohol and ether, is one 
 of the best parasiticides we possess. Oleate of mercury, twenty 
 per cent. ; benzine, one-half per cent, in alcohol ; naphthol ; 
 petroleum ; creosote; carbolic acid ; oil of cade ; balsam of Peru, 
 are all efficient. If we prefer to use a salve, white precipitate 
 or citrine ointment, or tar, carbolic acid, or sulphur ointments 
 may be employed. Whatever remedy is selected should be ap- 
 plied with the utmost thoroughness. Fresh areas should be 
 epilated daily, and a constant watch kept on the parts already 
 gone over. When the hair-follicles have not been destroyed 
 by the disease, the hairs grow rapidly after epilation. After 
 several months' treatment the scalp should be left to itself for a 
 time, and not even be washed. If after three or four weeks, 
 we notice that the new hairs are firmly seated, and that no new 
 scutulae have appeared, we may rest our efforts for a time, 
 though still keeping the patient under observation. If a few 
 isolated crusts appear, showing that in individual follicles the 
 fungus has not been entirely destroyed, we should at once epi- 
 late all the hairs in that immediate neighborhood, and apply 
 some vigorous parasiticide. Microscopical examination of the 
 epilated hairs may also be employed to ascertain whether they 
 are still diseased or not. 
 
 Favus of the non-hairy portions of the body is easily treated. 
 The crusts should be softened with some oily application, and 
 a mild parasiticide applied. Simply washing with the tincture 
 of green soap will often suffice. 
 
 In favus of the nail, as much as possible of that organ and 
 the underlying parasitic mass should be cut and scraped away. 
 
6lO TINEA VERSICOLOR. 
 
 Some efficient parasiticide should then be well rubbed in and 
 under the nail. Mercurial plaster may be applied when the 
 discoloration of the nail shows that the fungus has advanced 
 into its substance. 
 
 TINEA VERSICOLOR. 
 
 Syn. — Pityriasis versicolor ; chloasma (Wilson.) 
 Definition— A. vegetable parasitic disease characterized by 
 pale yellowish, yellowish brown, dark brown or fawn colored, 
 irregularly shaped furfuraceous patches, occurring especially 
 upon the anterior portion of the thorax. 
 
 Symptoms. — This disease occurs mostly upon those parts of 
 the body covered by clothing and especially upon the neck, 
 thorax, abdomen and groin. It is also occasionally present 
 upon the face, and flexures of the elbow and knee, but is never 
 met with on the hands or feet. It commences as yellowish or 
 brownish, fawn-colored, flat or somewhat elevated, rather 
 sharply limited, furfuraceous patches, which subsequently in- 
 crease in size by peripheral extension. From the increase in 
 size of the original patches, and by the formation of new ones, 
 the eruption may rapidly occupy a considerable extent of sur- 
 face. If neighboring patches coalesce the resulting spot will 
 be of irregular shape. Sometimes a patch heals in the centre 
 and thus acquires a circular form. The number of patches 
 present varies very greatly ; there may be only one or two, or 
 they may be quite numerous. Furfuraceous desquamation 
 is almost invariably present, the amount depending greatly 
 upon the amount of perspiration occurring, and upon the fre- 
 quency with which the parts are washed. When this desqua- 
 mation is present, scratching the part with the finger nail 
 loosens the scales in the form of lamellae or rolls. The scales 
 are very fine and furfuraceous in character unless stuck to- 
 gether by the sweat. In some cases no scales can be raised 
 even by deep scratching, the fungus being in the deeper layers 
 of the corneous cells. Upon removal of the scales the skin 
 beneath may show some slightly bleeding spots. 
 
TINEA VERSICOLOR. 
 
 611 
 
 Sometimes the skin has a reddened and punctated appearance 
 or may become inflamed and assume an eczematous condition. 
 More or less itching is generally present. The course of the 
 disease is very variable ; sometimes the eruption spreads very 
 rapidly, at other times slowly, a spot retaining the same size 
 for weeks or months. It is more frequent in winter than in 
 summer. Relapses are very frequent. 
 
 Anatomy. — The fungus present in this disease is the micro- 
 sporon furfur. It is found in the upper layers of corneous cells 
 and consists of mycelium and spores. They do not invade the 
 hair structure. The spores are round or ovalish in form, 
 sharply contoured, with a nucleus and slightly granular plasma, 
 and from 0.007 to 0.500 mm. in diameter. The spores are 
 generally collected in groups which may contain only a few or 
 many hundred of them, though the usual number is from 
 twenty to fifty. Isolated spores are always present in the space 
 between the groups. The spores grow from the end of the 
 mycelia. 
 
 Fig. 82. — Spores and mycelia of tinea versicolor. 
 
 The mycelia vary greatly in size and form ; they are straight 
 or curved, twisted, wavy, angular, and generally short. They 
 are homogeneous or granular in appearance, and often contain 
 spores, especially at the joints. The nature of the fungus is 
 still undecided. 
 
6 12 TINEA VERSICOLOR. 
 
 Etiology. — The disease is the fungus microsporon furfur. 
 Although a parasitic disease and the fungus very abundant and 
 seated in the superficial portions of the epidermis, yet it is but 
 slightly contagious ; a person may even sleep in the same bed 
 for years with one having the disease, and not have it com- 
 municated to him. A special condition of the nutrition of the 
 skin seems necessary for its habitation and growth. It is 
 found upon those with lowered nutrition, and is especially met 
 with in persons having pulmonary phthisis. It is also often seen 
 upon persons who subsequently get consumption, and its pres- 
 ence upon the chest in those who do not sweat greatly and who 
 change their underclothing sufficiently often is to be regarded 
 as a suspicious occurrence, and frequently indicates future pul- 
 monary trouble. It is also met with in fairly nourished persons 
 who sweat much and do not bathe their bodies or change 
 their underclothing often enough. It is never met with in 
 young children or old people. Tinea versicolor is a much 
 more frequent disease than statistics by dermatologists would 
 imply as cases of this disease are more frequently seen by the 
 general practitioner than by the specialist in skin diseases. 
 
 Diagnosis. — The disease may be confounded with chloasma, 
 seborrhcea of the chest, erythematous eczema and macular 
 syphilide. In all cases of doubt the microscope should be 
 employed, and if the affection is tinea versicolor the fungus is 
 very easily recognized. A few scales placed upon a slide with 
 a few drops of a weak solution of caustic potash and examined 
 with a high power will show the characteristic mycelia and 
 spores already described. 
 
 In chloasma the patches are of somewhat similar color, but 
 are smooth, not furfuraceous, of irregular shape and indefinite 
 margin, do not itch and are found especially upon the hands, 
 face and forehead. The pigment in chloasma is seated in the 
 rete, consequently can not be removed by scratching, whilst in 
 tinea versicolor, the fungus which causes the discoloration is 
 seated in the superficial layer of cells of the epidermis and are 
 easily removed. 
 
 In seborrhcea of the chest the patches are circular in form, 
 
TINEA VERSICOLOR. 613 
 
 more or less reddish in color, have greasy scales and there is 
 no parasite present. 
 
 Erythematous or slightly papular eczema of the chest, when of 
 limited extent and seated over the sternum, is sometimes diffi- 
 cult to diagnose from tinea versicolor without the aid of the 
 microscope. The patch is roundish in form, but with an irregu- 
 lar indefinite margin, papulae are always present and there is 
 slight scaling but not furfuraceous desquamation. 
 
 In the macular syphilide the history of the case and the seat, 
 color, shape, extent of the patches and absence of a parasite en- 
 ables the diagnosis to be made. There is an antecedent history of 
 roseola or congestion of the throat, the eruption is seated upon 
 all parts of the neck, chest, face and extremities, the color 
 is dirty brown or coppery, not fawn colored ; the patches are 
 often of circular form, not so irregularly shaped and variously 
 sized as those of tinea versicolor, they do not itch or des- 
 quamate, a fungus is not present and there are often other 
 forms of secondary syphilis present on other parts of the body. 
 The two diseases may be present upon the same person, but the 
 points already given suffice for the diagnosis. 
 
 Prognosis. — The prognosis is favorable ; the eruption can 
 with certainty be removed in two or three weeks, but relapses 
 are very liable to occur in the case of ill-nourished or phthisical 
 persons. The fungus itself exerts no injurious effect upon the 
 economy. 
 
 Treatment. — The treatment for the removal of the fungus is 
 the same as that for herpes tonsurans maculosus. Any of the 
 anti-parasiticides can be employed, though some act better than 
 others. On account of cleanliness it is better to try solutions 
 before prescribing ointments. The majority of cases will be 
 cured by soap and a solution of corrosive sublimate in alcohol 
 used as follows : The parts of the body affected to be thor- 
 oughly washed with soft soap and warm water, the soap being well 
 rubbed in with a piece of flannel ; this alkali removes the upper 
 layer of corneous cells, and after drying, the part is then 
 sponged with a solution of corrosive sublimate in alcohol — two 
 grains of sublimate to an ounce of alcohol, and this allowed to 
 
614 SCABIES. 
 
 remain upon the skin. This procedure can be repeated two 
 or three times a week, but the body should be washed daily 
 with the soft soap and afterwards sponged with pure alcohol. 
 When the fungus has been removed ordinary baths are all that 
 is necessary. Dr. Tilbury Fox always pursued the following 
 course : first, have the part washed with yellow soap, then 
 sponge with a little weak vinegar and water, and apply freely a 
 solution composed of four or six drachms of hyposulphite of 
 soda and six ounces of water. If the case was obstinate a hy- 
 posulphite bath was also ordered. Besides these there are a 
 number of other remedies of service in this affection, sulphur- 
 ous acid in solution or full strength ; sulphur vapor baths, 
 a saturated solution of boracic acid ; salicylic acid in alcohol ; 
 chloral hydrate — a twenty per cent, solution in water ; an oint- 
 ment of chrysarobin applied daily for three or four days ; 
 Vleminckx's solution diluted to one-third the strength ; com- 
 pound tincture of green soap ; alkaline baths, etc. Before 
 using ointments the surface should be washed with soft soap 
 and water. 
 
 Treatment is always to be continued for some time after the 
 fungus has been removed. To prevent relapses attention must 
 be directed to the general nutrition of the body and appro- 
 priate tonics ordered. In many cases other than phthisical, cod- 
 liver oil is of much benefit. If the person affected sweats 
 much the underclothing must be changed every few days. 
 
 SCABIES. 
 
 Syn. — The itch. 
 
 Definition. — Scabies is a contagious animal parasitic disease, 
 due to the presence in the skin of the acarus scabiei, and char- 
 acterized by the presence of the itch-insect, its burrows and 
 eggs in the integument, by itching, and by the varying evi- 
 dences of the secondary general dermatitis and its results, 
 papules, vesicles, pustules, excoriations, and crusts. 
 
 Anatomy. — The itch-insect, acarus scabiei, sarcoptes scabiei 
 or sarcoptes homini, is a minute insect belonging to the class 
 
SCABIES. 615 
 
 arachnoidea, order acarina, family acaridse. Both male and 
 female are present on the skin ; but the latter are not only by 
 far the more numerous, but are the real cause of the symptoms 
 of the disease. The female insect is just visible to the naked 
 eye as a yellowish-white, rounded object. Under the micro- 
 scope it appears as an oval, crab-shaped creature. The body 
 is inclosed in a hard casing, on the surface of which are a 
 varying number of transverse lines or furrows, which mark the 
 breaks in the carapace provided to facilitate motion. The 
 dorsum is convex, the ventral surface flattened. The back is 
 studded with a varying number of short, thick spines, as well 
 as several long spike-shaped processes, all set with their points 
 directed backwards. The head is oval, and is provided with 
 four pairs of half-mandibles, and with two three-jointed palpi. 
 There are eight legs, the two hinder pairs of which are provided 
 at their tips with long hairs, whilst the anterior ones are shorter, 
 thicker, conical, and jointed, and have shorter hairs and a cup- 
 shaped sucker at their tips. Posteriorly, between the two oval 
 bristles is situated a cleft leading into the genital sheath. Upon 
 the ventral surface is the ovarian orifice. An intestinal canal, 
 air sac, ovaries, etc., have been found, though neither a circu- 
 latory nor a nervous system has been positively demonstrated. 
 The entire insect is about one-fifth of a line in length. 
 
 The male acarus is much smaller, perhaps half the size of 
 the female. It has suckers instead of bristles upon its last pair 
 of legs, and between is a horse-shoe-shaped depression in which 
 is sunk the forked penis. Its general structure is otherwise 
 the same as that of the female. Eyes are absent as in the 
 female insect. It is present only in small numbers in compar- 
 ison with the female insect, and either roams free upon the 
 surface, or burrows but a short distance into the skin near the 
 nests of the females. It takes but little part in the production 
 of the symptoms of the disease, and is said to die within a week 
 after having impregnated the females. Hebra has witnessed 
 the act of copulation itself under the microscope. 
 
 It is now necessary to follow the further course of the female 
 acarus. Once impregnated, she seeks for herself a place to 
 
6l6 SCABIES. 
 
 deposit her eggs in security, and in so doing gives rise to all the 
 unpleasant symptoms of the disease. She cuts through the 
 epidermis with her sharp mandibles, bores her head into the 
 skin, and soon disappears from view. As she burrows her way 
 obliquely into the deeper and juicier layers of the skin, she 
 lays a varying number of eggs — one or two a day — and dies 
 after having deposited from twenty to fifty of them. 
 
 The oval eggs are placed across the burrow, and measure 
 about one-twelfth line in their long diameter. In them the 
 embryos will be found in various states of development, the 
 
 Fig. 83. — Male acarus (Neumann). 
 
 eldest being of course those deposited first near the mouth of 
 the burrow. In a week the larvae have developed. They have 
 in general the same appearance as the parent insect, but pos- 
 sess only two pair of hind-legs. They reach the external in- 
 tegument by crawling through the burrow, and after spending 
 a short time upon the surface, they bore a superficial nest in 
 the integument, in which they remain while they shed their 
 skin. This process occurs four times, and each time the larva 
 finds a new nest, leaving its skin behind in the old one ; at the 
 last shedding the acarus has its full complement of legs and 
 
SCABIES. 
 
 6l 7 
 
 spines, and a developed sexual apparatus, and begins the whole 
 process just described over again. 
 
 The burrow formed by the adult female deserves a little 
 closer attention. As before stated, it runs obliquely down- 
 ward through the skin, as the insect in its search for nutriment 
 penetrates toward the rete. The whole passage is one-half to 
 one inch in length, straight or zig-zagged, with a rather broad, 
 funnel shaped opening upon the surface, and at the other end 
 
 \ 
 
 Fig. 84. — Female acarus (Neumann). 
 
 — a minute raised yellowish-gray point — the acarus. Along the 
 passage lie the numerous eggs, and small black masses of 
 faeces ; these latter are visible to the naked eye, and render the 
 course of the insect plain. The mite itself may be obtained by 
 means of a needle or any appropriate instrument ; or the entire 
 passage may be carefully clipped off with scissors, and put 
 under the microscope compressed between two slides. 
 
6i8 
 
 SCABIES. 
 
 The burrowing of the insect through the skin naturally 
 causes a certain amount of irritation, which varies, however, 
 very much according to the susceptibility of the individual in- 
 teguments. Sometimes enough inflammatory reaction to cause 
 the formation of pus is set up, and pustules result ; in other 
 cases papules or vesicles are seen, or a more diffuse dermatitis 
 arises. Though the parasites may be present on large tracts of 
 skin, or even over the whole extent of the surface of the body 
 the dermatitis and eczema are always more violent where the 
 burrows are seated in abundance. Certain localities seem to be 
 the favorite area for the deposition of the ova. These are the 
 flexor surfaces of the wrists, the sides and clefts of the fingers, 
 
 f \ 
 
 Fig. 85. — Burrow with eggs and developing acari. From Neumann. 
 
 the female breasts, the navel, the penis and scrotum, and the 
 gluteal regions. Localities where the skin is thin and pressed 
 upon by the clothing, as the axillae, are also favored. 
 
 All the varying appearances of eczema and dermatitis are 
 caused by the presence of the acari, male and female, and their 
 larvae. Papules, vesicles, pustules, excoriations, crusts, all are 
 caused by the insect or by the scratching which is necessitated 
 by the intense itching it causes. In a sensitive skin, predis- 
 posed to eczematous eruptions, the symptoms may be very 
 marked. 
 
 Etiology. — Scabies is caused solely by the reception upon the 
 
SCABIES. 619 
 
 skin of the itch insect, from individuals affected by the dis- 
 ease. The itch in animals appears to be caused by the same 
 species of acarus, and a certain number of cases occurring in 
 stablemen, menagerie attendants, etc., have been directly traced 
 to this source. 
 
 Probably, in most cases, it is the larvae, wandering free upon 
 the surface of the skin, which are transferred from one indi- 
 vidual to another. The impregnated females are rarely seen 
 upon the surface. A neglected and dirty skin undoubtedly 
 offers a favorite habitat to the parasite. 
 
 At night, when the patient is warm in bed, the acarus is 
 most active, and then it is that itching becomes almost in- 
 tolerable. It is at night, also, that it is transferred from one 
 individual to another. The fear of acquiring the itch from 
 simple contact with persons affected with it, is entirely ground- 
 less ; nor is it likely to remain in the clothing. In almost every 
 case of the itch, a history of having contracted it from a bed- 
 fellow is to be obtained. 
 
 Scabies occurs at all periods, and in all conditions of life. 
 It is far commoner in Europe than it is here, forming all the way 
 from 3 to 25 per cent, of all cases of skin disease. In Glasgow, 
 it seems to be specially prevalent, over 2,500 examples having 
 occurred in 10,000 consecutive cases of skin disease recorded 
 by Anderson. In the larger sea-board cities of the United 
 States it is seen to a moderate extent, being in many cases 
 traceable to a direct importation from Europe. It rarely forms 
 more than a fraction of one per cent, of the observed cutaneous 
 disorders here, and in the interior of the country it is very rare. 
 
 Symptoms. — The symptoms caused by the advent of the 
 first parasite upon the skin are few and insignificant, and are 
 always neglected by the patient. It is only after a number of 
 days, or several weeks have passed, when the new broods de- 
 veloped from the parent insect begin to burrow their way into 
 the skin, that the irritation caused by the disease becomes an- 
 noying, and the patient seeks medical advice. 
 
 The chief symptom that the patient then complains of is 
 the itching. This varies much in intensity in different persons, 
 
620 SCABIES. 
 
 but is usually quite severe. It is especially marked upon those 
 portions of the body where the parasites burrow, but is by no 
 means confined to these regions. It is usually slight during 
 the day, but becomes intensely annoying at night, when the 
 patient gets warm in bed. This itching, together with the pres- 
 ence of a limited number of papules and vesicles, and the 
 characteristic burrows, form the only symptoms due to the ac- 
 tual presence of the acarus. 
 
 But a second set of appearances are always to be found ; in 
 their extent and intensity usually exceeding by far those men- 
 tioned above. These are the symptoms caused by the second- 
 ary dermatitis or eczema due conjointly to the parasite and the 
 patient's finger nails. The lesions caused will be manifest, and 
 vary with the number of acari present and the irritability of 
 the patient's skin. Papules, vesicles, pustules, excoriations, 
 blood-crusts, urticarial wheals, etc., may be present in varying 
 quantity upon different portions of the skin. Sometimes they 
 are confined to the regions where the acarus most frequently 
 burrows, the anus, nates, genitals, finger-clefts, etc. ; but often 
 the eczematous affection is widespread, and sometimes it affects 
 the entire surface of the body. In old standing cases a peculiar 
 pigmentation of the skin is seen, from the repeated hemor- 
 rhages into the cutis caused by the scratches, just as the same 
 pigmentation is noticed in old cases of pediculosis, etc. 
 
 The localization of the eczema, secondary to scabies, is an 
 important point. Even when the dermatitis is universal, or 
 nearly so, the inflammation will be most acute upon the places 
 where the skin is thin and the acarus is most frequently found. 
 Thus it is most intense around the anterior surface of the 
 wrists, the sides of the fingers, the flexor surfaces of the elbow 
 and knee, around the breast, on the scrotum, penis and labia, 
 etc. In children, the palms are a favorite location. 
 
 In any case, absolute certainty may be obtained by finding 
 the burrows. They should be sought for on the spots where 
 the itching and dermatitis are most intense. The peculiar 
 dotted lines, half an inch or so in length, with the elevations 
 marking at' one end the point of entrance, and at the other the 
 
SCABIES. 621 
 
 present resting place of the acarus, are characteristic. The 
 color of the burrows in persons not too cleanly in their habits, 
 is dark ; the loosened epidermis of the funiculus retains dirty 
 particles more tenaciously than does the surrounding skin. In 
 those who wash frequently they appear as prominent whitish 
 furrows, marked with faint black spots. 
 
 The location of a multiform eczematous eruption in a 
 " shield shape " upon the genitals, lower abdomen and thighs, 
 in itself alone should lead us to suspect scabies. Of still 
 greater significance is the presence of papules or vesicles upon 
 the sheath of the penis ; it may be taken as prima facie evi- 
 dence of scabies, though, of course, absolute certainty can 
 only be reached by the discovery of the parasite or its 
 burrows. 
 
 The course of the scabies eczema varies. Any one of the 
 above-mentioned lesions may predominate. The papules, vesi- 
 cles, or pustules, are torn — the epidermis and corium is lacer- 
 ated by the finger nails, blood, serum and pus crusts are formed, 
 and a pathological appearance of the most multiform variety is 
 usually presented by the disease as it comes under our obser- 
 vation. If the cause continues active, these symptoms may 
 last for years, and thickening and pigmentation of the skin 
 result. The cause once removed, the morbid processes usually 
 soon subside, though in those predisposed to eczema the der- 
 matitis may last indefinitely, even if the scabies is cured. 
 
 Diagnosis. — The pathognomonic symptom of scabies is, 
 of course, the presence of the parasite, or its burrows, upon 
 the skin. Nevertheless, in a large number of cases we will be 
 compelled to make the diagnosis without finding either. It re- 
 quires some practice to obtain the mite itself from one of the 
 vesicles or cuniculi. The burrows are, in early stages, not 
 numerous, and, in the later, are obscured by the eczematous 
 appearances, excoriations, crusts, etc., and are, indeed, often 
 themselves destroyed by the patient's nail. The best place 
 to look for them is upon the sides of the fingers. 
 
 Failing to find either burrows or acari, there are certain 
 other symptoms which usually suffice for the diagnosis. The 
 
622 SCABIES. 
 
 peculiar appearance of the eruption, as described above, its 
 localization around the genitals and upon the fingers, and es- 
 pecially its presence upon the penis in the male, are points of 
 value. A history of contagion can often be obtained. Treat- 
 ment for scabies will in a short time settle all doubts as to 
 the nature of the malady. 
 
 There are only two diseases with which the affection is liable 
 to be confounded. In pediculosis the absence of the general 
 dermatitis and the characteristic location of the scratch-marks 
 in each variety of the disease. And above all, the finding of 
 the pediculus or its nits — usually easily accomplished — will 
 suffice. As regards the differentiation of a pustular eczema 
 from scabies, the localities affected, the steady increase of the 
 symptoms, especially of the scratching, and the history of con- 
 tagion, all distinguish the parasitic disease. Of course, the 
 finding of the burrows, or their remains, or the mite itself, 
 renders the diagnosis absolutely certain. 
 
 Prognosis is always good, even in cases of long standing. If 
 care be taken to kill all the parasites and their embryos, the 
 disease is at an end. It is rare in this country to see scabies 
 in conjunction with an obstinate pustular eczema, though it 
 more frequently occurs in Europe. 
 
 Treatment. — The primary object of our therapeutic efforts 
 is, of course, to destroy the parasite and its larvae. After that, 
 if necessary, we can treat the secondary dermatitis. The first 
 object can usually be attained in from a few hours to five or 
 six days ; the second may take several weeks. 
 
 A large number of remedies stand at our disposal for the kill- 
 ing of the acari. The commonest and one of the most efficient 
 is sulphur. This may be used as an ointment — either the ordi- 
 nary sulphur ointment of the pharmacopoeia, or, as it sometimes 
 proves irritating, a mixture of it with simple cerate. A large 
 number of compound sulphur ointments are also in vogue. 
 Hebra's modification of Wilkinson's ointment is much used — 
 viz.: $. Flor. sulph., ol. cadini aa, 40 parts ; sapo viridis, 
 axung. porci. aa, 80 parts ; pulv. cretae alb., 5 parts ; as also is 
 Helmerich's salve — tJL sulph. citrini, 10 parts ; potass, subcarb., 
 
SCABIES. 623 
 
 j part ; axungiae, 40 parts. The ordinary sulphur soap of the 
 shops is sometimes quite efficacious. 
 
 The ethereal oils of certain plants are preferred by some, as 
 oil of cloves, of peppermint, of rosemary, of staphysagria 
 seeds, etc. So also are some of the balsams and empyreumatic 
 oils — balsam of Peru, balsam of Tolu, petroleum, styrax, tar, 
 etc. These may be used by themselves, or better in conjunc- 
 tion with some one of the forms of sulphur ointment. 
 
 Vleminckx's solution is one of the quickest means at our 
 disposal for the cure of scabies ; it is much used in some of 
 the Continental armies, where scabies is very common. It is 
 said, if thoroughly applied, to destroy the parasite within two 
 hours. 
 
 Kaposi recommends naphthol as especially reliable. This, 
 made up into a compound ointment, he claims emphatically to 
 be the best remedy for scabies. His formula is as follows : IJ. 
 Axung., 100 parts ; sapon. virid., 50 parts; naphthol, 15 parts ; 
 pulv. cretae alb., 10 parts. The ointment has neither color 
 nor smell, soon renders the skin soft and smooth, and is not 
 only an efficient parasiticide, but is an excellent application for 
 the dermatitis. For mild cases, balsam of Peru, either alone 
 or with sulphur or the ethereal oils is very good. It may be 
 used as a wash with styrax as follows : $. Styracis liq., 5 parts ; 
 petrolati, ol. oliv. aa, 15 parts ; bals. Peruv., 10 parts ; tr. 
 sap. virid., 20 parts. 
 
 The above selection will suffice out of a multitude of* reme- 
 dies and formulae which might have been mentioned. The 
 usual preparatory treatment by means of baths, etc., is not 
 only unnecessary, but has a deleterious influence upon the often 
 accompanying eczema. Whatever ointment or lotion is selected, 
 it should be well rubbed into the skin either with the hand or 
 with a woolen rag. It should first be vigorously applied to all 
 those locations above mentioned as the favorite burrowing 
 places of the parasite, and then in addition be well smeared 
 over the entire skin. With the sulphur ointments several 
 applications are usually necessary. The naphthol ointment 
 requires but one thorough inunction. Woolen cloths should 
 
624 PEDICULOSIS. 
 
 then be put on, or the patient laid between blankets, as linen 
 or cotten absorbs the ointment. A slight desquamation of the 
 epidermis usually follows, and when that is complete, and all 
 the symptoms of irritation are gone, the patient may take a bath. 
 As a usual thing the cure takes from three days to one week. 
 
 As regards the treatment of the eczema which may be left 
 in severe cases after destruction of the parasite, that should 
 consist, in the first place, in the avoidance of all sources of 
 irritation which might serve to keep up the artificial eczema. 
 Bathing is to be avoided, and, if necessary, a course of treat- 
 ment with diachylon ointment, tar, etc., instituted. 
 
 Finally, the clothes worn by the patient should be baked, to 
 prevent all possibility of further contagion. 
 
 PEDICULOSIS. 
 
 Syn. — Phtheiriasis. 
 
 Definition. — Pediculosis is the name given to the symptoms 
 caused by the presence upon the skin and in the clothing of 
 certain animal parasites called pediculi. 
 
 Symptoms. — The lice which affect the human subject belong 
 to the family pediculidse, order hemiptera, class insecta. They 
 are wingless, non-metamorphosing insects, which live upon the 
 blood and secretions of the body, obtaining the nutrient fluids 
 by a process of suction. In consequence of the minute 
 wound a small amount of blood and serum exudes, and dries 
 into a crust ; more or less hypersemia and serous infiltration 
 occurs at the spot, and in consequence thereof a marked itch- 
 ing. The itching causes scratching, and to the nails are due 
 the majority of the skin lesions of pediculosis. Excoriations, 
 blood-crusts, eczematous patches, papules, vesicles, pustules, 
 urticarial wheals, and even abscesses appear as secondary 
 lesions, leaving a varying amount of pigmentation behind 
 when they disappear. All these different appearances are called, 
 on an etiological basis, phtheiriasis ; and it will sometimes be 
 necessary to make the diagnosis from them without finding any 
 of the characteristic causes of the lesions. 
 
PEDICULOSIS CAPITIS. 62 
 
 Three varieties of lice affect the human body. They are : 
 
 1. Pediculus Capitis — or head louse. 
 
 2. Pediculus Vesta??ienti. — s. p. corporis, or body louse. 
 
 3. Pediculus Pubis. — s. p. inguinalis, or crab-louse. 
 
 The three varieties are different both in their male and their 
 female forms. The territory also which each variety inhabits 
 is quite strictly limited ; the head louse being found only upon 
 the scalp, the crab louse almost always only around the external 
 genitals, and the body louse, not upon the body at all (save 
 accidentally) but in the seams and folds of the clothing. Hence 
 it is quite easy to diagnose the variety of pediculus from the 
 location of the scratch marks alone. 
 
 1. Pediculus Capitis. — The head louse is an insect of a gray- 
 ish color, and measures from one to three millimetres. It is oval 
 
 Fig. 86. — Pediculus Capitis, male. (Kuchenmeister.) 
 
 in shape, the abdomen occupying more than half its length, 
 and consisting of seven clearly defined segments, marked off 
 from one another by deep notches. The thorax is broad, and 
 from its sides project the six legs, each one hairy and pro- 
 vided with a crab-like hook at its extremity. The head is 
 somewhat triangular in shape, and is furnished with a pair of 
 short, five-jointed antennae and two black and prominent eyes. 
 The males are smaller than the females and less numerous ; the 
 last abdominal segment is very prominent ; upon their backs is 
 a large genito-anal pore, and a large, wedge-shaped penis. 
 Each one is provided with two pairs of testicles. The females 
 40 
 
626 PEDICULOSIS CAPITIS. 
 
 have a more deeply segmented abdomen, in the last division of 
 which is the anal pore ; they possess two ovaries, the oviducts 
 of which open by means of a common vaginal canal upon the 
 ventral surface. 
 
 The eggs, or "nits," are deposited upon the hairs as the 
 female slowly crawls from the roots upward ; a series of them 
 may be present upon single hairs. They are small, pear-shaped, 
 whitish bodies, about one-fourth of a line in length, and 
 securely glued to the hairs. They take only three to eight days 
 to hatch, and the young become capable of reproduction in 
 three weeks. They are extremely prolific ; the progeny of a 
 single louse may number five thousand within eight weeks. 
 
 The louse itself may be found either upon the scalp, or on 
 the hair ; they especially affect the occipital region. They are 
 most often seen in children, and are liable to spread from one 
 to another, through the large schools, etc., though they are 
 common enough among the poor of all ages. They occasion, 
 by their presence upon the scalp a catarrhal dermatitis — an 
 artificial eczema. The itching of the scalp causes continuous 
 and violent scratching ; serum, blood, and eventually, a puru- 
 lent fluid oozes out, mats the hair together and dries up into 
 crusts. Excoriations, vesicles and pustules, or diffuse eczema, 
 may extend beyond the limits of the hair, and is visible along 
 the forehead and upon the back of the neck. The amount of 
 inflammation caused by the presence of the parasite varies in 
 different cases ; being greater, of course, in those whose skin 
 is predisposed to eczematous processes, and who -are ill-nour- 
 ished and badly cared for. 
 
 The insects always deposit their nits near the root of the 
 hair, and consequently when we see them or their remains well 
 up towards its extremity we can conclude that the affection is 
 of long standing — since the eggs have advanced upward through 
 the growth of the hair. In accordance with the number of the 
 parasites and the length of time they have been permitted to 
 stay in the hair will vary the intensity of the inflammatory pro- 
 cess brought to our notice. In women and children, who, either 
 from neglect or sickness, have omitted frequent bathing and 
 
PEDICULOSIS CORPORIS. 627 
 
 fine-combing, the spectacle is sometimes a most disgusting one. 
 The long, dirty hair is matted and twisted together, glued up 
 with decomposing pus and blood crusts ; the hairs are full of 
 nits ; the odor is nauseous, and the lively motions of the innum- 
 erable parasites when you disturb the hair give to it a tremu- 
 lous, apparently alive or writhing motion. Something of this 
 nature was the condition called plica polonica, so long looked 
 upon as a specific disease of the hair and scalp. 
 
 If the affection is at all extensive the neighboring lymphatic 
 glands become swollen and tender from the inflammation and 
 pus absorption. The general health, even if good at first, may 
 soon deteriorate from the worry, loss of sleep from the itching, 
 etc. Though almost invariably limited to the hairy scalp, 
 pediculus capitis has been seen on feeble and bedridden 
 individuals on other parts of the body, and even affecting the 
 whole body 
 
 ,1 
 
 Fig. 87. — Pediculus Corporis, female. (Kuchenmeister.) 
 
 2. Pediculus Corporis. — More properly p. vestamenti. The 
 body louse resembles in general the above-mentioned variety, 
 but is larger, measuring from one to four millimetres. When 
 empty of blood their color is of a dirty white, or grayish hue. 
 Here again the male is smaller than the female ; the penis is 
 very large and wedge-shaped, and rises from the middle of the 
 dorsal surface of the abdomen. The female is elongated and 
 
628 PEDICULOSIS CORPORIS. 
 
 oval in shape, with an abdomen broader than that of the male, 
 and ending in a triangular notch. In both sexes the abdominal 
 segments are less distinctly marked than in p. capitis ; the 
 thorax is square, and furnished with six three-jointed hairy- 
 legs armed with stout claws ; the head is acorn-shaped, with 
 eyes and two five-jointed antennae. 
 
 This variety of pediculus does not live upon the skin at all. 
 It dwells in the clothing ; only coming upon the integument to 
 feed. Its eggs, which are like those already described, but 
 larger, are deposited in the seams and folds of the clothing. 
 Their period of growth is about the same as that of the last- 
 mentioned variety, and their reproductive powers at least as 
 great. 
 
 This louse, therefore, is to be sought for not upon the skin, 
 but in the clothing of the patient. Where they are abundant 
 we usually find some upon the integument, which have been sur- 
 prised there while in the act of feeding, and have not had time 
 to escape. They may be seen running rapidly across the skin 
 trying to find some nook to conceal themselves in. They ob- 
 tain nourishment exactly in the same mode as the p. capitis. 
 
 The presence of the body louse in the clothing causes a 
 number of quite characteristic appearances. The parasites live 
 especially in the seams and folds of the undergarments, and 
 therefore the lesions they occasion are found around the neck 
 and shoulders, the waist, wrists, nails, etc. The large size of 
 the louse causes a more prominent lesion to follow its bite. A 
 wheal, followed by intense itching, is caused ; scratching is 
 often very violent, and the patient digs and tears the skin with 
 his finger-nails. Long and broad excoriations cover the sides 
 of the abdomen ; sometimes the distinct parts of the four 
 parallel fingernails can be recognized. After a time dark, pig- 
 mented streaks replace the excoriations. 
 
 In bad cases, when the parasites have infested the patient's 
 clothing for a long time, the secondary lesions may be both 
 numerous and varied. Multiple and deep excoriations, pus 
 and blood crusts, papules and pustules, diffuse dermatitis, fur- 
 uncles, abscesses, or even gangrene, may be occasioned by the 
 
PEDICULOSIS PUBIS. 
 
 629 
 
 irritation set up by these creatures. Eventually, a diffuse 
 brownish or blackish pigmentation of the skin appears — at first 
 affecting only the waist, neck, etc., later perhaps spreading over 
 the entire trunk. As pediculosis corporis of this grade occurs only 
 in tramps and homeless persons, whose systems are debilitated by 
 exposure, want, syphilis, malaria, etc., and in whom the exposed 
 parts of the skin are usually sun-burned and weather-stained, 
 there is no doubt, as Kaposi states, that many of them have 
 served for the diagnosis of a case of the so-called Addison's 
 disease. 
 
 Since the pediculi reside only in the clothing, a patient need 
 but change it, and, though he presents all the evidences of 
 phtheiriasis corporis, not a single parasite will be found. It is 
 necessary then, to make the diagnosis fron the general charac- 
 ter and location of the eruption, a thing usually easy to do, 
 since in any but its slight forms the affection never occurs save 
 in the lowest classes, who frequent cheap lodging-houses, po* 
 lice stations, and the large public institutions. 
 
 Fig. 88. — Pediculus pubis ; female ; under surface. 
 
 3. Pediculus pubis, or phtheirius inguinalis, or the crab- 
 louse. This is the smallest of the three varieties, meas- 
 
 Its body is short, 
 
 uring only from one to two millimetres 
 
630 PEDICULOSIS. 
 
 rounded, and flat, and upon it is set the oval head, which is 
 furnished with two long, five-pointed antennae, and a pair of 
 small eyes. The thorax and abdomen are merged into one ; 
 and six hairy, three-pointed claws, hooked at the end, project 
 from its anterior part. The margin of the abdomen is slightly 
 indented, showing its segmented origin, and from it project 
 eight stubby, prehensile legs, armed with stout hairs. Their 
 color is yellowish-gray, and they are more or less transparent. 
 As in the other cases, the female animal is the largest, and 
 possesses a triangular shaped notch at the extremity of the 
 abdomen. 
 
 P. pubis lives any where upon the body where there are 
 hairs, with the exception of the head. They are especially 
 common on the pubic regions, the chances for communication 
 from person to person being greater there (hence their name) ; 
 but they are also found in the axillae, upon the breast, on the 
 limbs, in the beard and mustache, and in the eyebrows and 
 lashes. The more hirsute the individual the more liable are 
 they to spread from the pubes over the whole body. 
 
 They are usually hard to detect, on account of their transpar- 
 ency and because they move but little, lying stern upward 
 along a hair, closely clutching it with their claws, while their 
 heads are buried deep in the follicles. The ova are smaller 
 than those of p. capitis, but are similar in construction, and 
 are attached to the hairs in the same way. They are frequent- 
 ly seen like small pearls upon the eyelashes. The excrement of 
 the parasite may be found in the form of minute reddish parti- 
 cles lying around the bases of the hair. 
 
 The amount of irritation and consequent scratching effected 
 by the presence of this variety of louse varies much in differ- 
 ent cases. They usually cause considerable itching, and a 
 more or less marked eczema, generally of the papular variety. 
 They are almost always contracted during sexual intercourse. 
 
 Etiology. — It is probable, according to recent investigation, 
 that the pediculus does not possess a mouth and mandibles, 
 by means of which it first pierces the skin, and then feeds upon 
 the blood, but that it is provided with a sucker, or haustellum, 
 
PEDICULOSIS. 631 
 
 which it inserts into the follicles, thus obtaining the nutrient 
 fluid by suction. 
 
 The original lesions are the minute haemorrhages produced 
 by the pediculi from the irritation of which springs the pruritus 
 that causes the secondary effects. 
 
 Diagnosis. — As regards pediculosis capitis it seems impossi- 
 ble that a mistake should occur ; yet it happens occasionally 
 that it is long treated as eczema, without the physician 
 discovering the parasite. The nits are prominent, and the an- 
 imals themselves will always be found upon a moderately care- 
 ful search. It is to be remembered, however, that a long con- 
 tinued eczema capitis with the consequent avoidance of soap 
 and comb, offers an excellent breeding place for any parasites, 
 while may accidentally lodge upon it. Eczema of the occipital 
 region should always make us suspect pediculi. The characters 
 of ezcema from this cause have been already described in the 
 chapter on eczema. 
 
 In pediculosis vestamenti, the parasite and nits must be 
 sought for in the seams and folds of the underclothing, espe- 
 cially of the body linen. As a usual thing no parasite will be 
 found upon the skin. But the peculiar location and appear- 
 ance of the scratch-marks alone will in most cases suffice 
 for a diagnosis. It is needless to say anything about the dif- 
 ferential points between this disease and pruritus, prurigo and 
 scabies ; they will be found under their respective headings. 
 
 Pediculosis pubis is sometimes overlooked, or mistaken for 
 eczema or pruritus. The parasites are small and transparent, 
 and rather difficult to see. They often look like dirt-specks 
 upon the skin. They may cause remarkably little annoy- 
 ance. 
 
 It should not be forgotten that many persons whose habits 
 are irreproachable are liable to be occasionally affected with 
 pediculi, getting them accidentally from other people, or from 
 infected chairs, clothing, or bedding ; and in some such cases 
 there is noticed a persistent search for the pediculi, and con- 
 tinuous dread of infection, amounting to a pediculi-phobia. 
 
 Treatment. — Various measures may be employed to destroy 
 
632 PEDICULOSIS. 
 
 the parasites and their ova. Strict personal cleanliness is of 
 course absolutely necessary. Powders, ointments, or lotions 
 containing tobacco, carbolic acid, petroleum, sulphur, mercur- 
 ials, staphysagria (from the seeds of delphinium staphysagria), 
 etc., may be employed. The secondary lesions are then easily 
 cured or heal of themselves. 
 
 Pediculosis capitis. — One of the commonest and best means 
 which we can employ in this variety is petroleum, which may, 
 to render it less inflammable, be mixed with half its bulk 
 of olive oil, and one-quarter its bulk of balsam of Peru ; or be 
 used as kerosene, to be well soaked into the hair every night, 
 and then the head to be bandaged. Naphthol in five per cent, 
 oily solution may be used instead. In twenty-four hours by 
 this means all the lice and their eggs should be dead. Hot 
 water and soap, or tincture of green soap, may now be used to 
 remove the parasites, the crusts, and the dead lice. The sur- 
 face is left clean, though red, and the hair can be carefully, 
 combed. The eczema is to be treated by means of emollient 
 salves and oils, and the head to be washed daily. It is never 
 necessary to cut off a patient's hair, but it facilitates treatment, 
 and in children may be done. 
 
 Lotions of corrosive sublimate, grains 2-5 to the ounce of 
 water, or alcohol and some essential oil, form neat and effica- 
 cious means of treatment. White precipitate ointment, grains 
 twenty, and staphysagria ointment are also useful. 
 
 By one of these means the parasite and its eggs may soon be 
 destroyed ; but the resisting " nits " remain, and annoy the 
 patient with the appearance of lousiness, though he is quite 
 clean. Vinegar or dilute acetic acid, will soften them, when 
 they may be removed by a diligent use of the fine tooth 
 comb. 
 
 Pediculosis Corporis. — The clothes should be treated — not 
 the patient. The entire wearing apparel should be changed, 
 and then immersed in boiling water, or baked by subjecting it 
 for a considerable time to an elevated temperature. Repeated 
 examinations, and most careful ones, should be made of the 
 clothing, otherwise some eggs or pediculi will be overlooked, 
 
PEDICULOSIS. 633 
 
 and become the parents of another crop. Alkaline baths, 
 such as one of bicarbonate of soda, six ounces to the bath, or 
 lotions containing three drachms of carbolic acid and half an 
 ounce of glycerine to the pint of water are useful to allay 
 itching and relieve the excoriations. Attention to these details 
 will speedily cure all cases. 
 
 Pediculosis Pubis. — Almost any of the remedies previously 
 spoken of may be used. Very appropriate is the corrosive 
 chloride lotion above described ; but it is unreliable and if too 
 freely or too often applied it is liable to cause an acute and 
 quite painful inflammation of the skin of the scrotum. Blue 
 ointment is the most efficient remedy we possess for destroying 
 or removing the pediculi. One or two applications are generally 
 sufficient and it must not be rubbed too energetically into the 
 skin. The objections to its use are that it is a dirty prepara- 
 tion, soiling the underclothing and that it sometimes causes an 
 eczema. When the affection extends over the greater part of 
 the body mercurials are dangerous and carbolic acid lotions or 
 tobacco infusions should be employed instead. A five to ten 
 per cent, solution of naphthol in olive-oil, or a white precipitate 
 ointment, or petroleum and balsam of Peru in equal parts are 
 also efficacious. 
 
INDEX. 
 
 Acarus scabiei 614 
 
 Achorion Schonleinii 604 
 
 Achroma, congenital 450 
 
 " acquired 452 
 
 Acne 256 
 
 symptoms of 257 
 
 etiology of 261 
 
 anatomy of 200 
 
 diagnosis of 261 
 
 prognosis of 261 
 
 treatment 261 
 
 Acne albida 71 
 
 artificialis 259 
 
 atrophica 259 
 
 bromine 259 
 
 cachecticorum 259 
 
 disseminata 256 
 
 hypertrophica 259 
 
 indurata 258 
 
 mentagra 269 
 
 papulosa 258 
 
 picealis 259 
 
 punctata 258 
 
 pustulosa 258 
 
 rosacea 56 
 
 sebacea 56 
 
 variolaform 506 
 
 vulgaris 256 
 
 Adenomata 574 
 
 Adipoma 561 
 
 Albinismus 450 
 
 symptoms of 451 
 
 etiology of 451 
 
 treatment of 452 
 
 Albinismus partialis 451 
 
 Albinoes 451 
 
 Algidite, progressive 427 
 
 Alopecia 462 
 
 anatomy of 462 
 
 etiology of 465 
 
 diagnosis of 466 
 
 prognosis of 466 
 
 treatment of 466 
 
 Alopecia acquisita 463 
 
 adnata 463 
 
 areata 467 
 
 circumscripta 467 
 
 congenital 463 
 
 of syphilis. 465 
 
 prematura 464 
 
 prematura idiopathica. 464 
 
 symptomatica 464 
 
 senilis 463 
 
 Anaesthesia 576 
 
 Analgesia 577 
 
 Anatomy of hair follicle 27 
 
 of hair 27 
 
 of nails 28 
 
 of nerves. . . : 17 
 
 of Pacinian corpuscles 21 
 
 of sebaceous glands. . 24 
 
 of the skin 9 
 
 of sweat glands 21 
 
 of tactile corpuscles. . 18 
 
 Angio-elephantiasis 565 
 
 Angioma 563 
 
 symptoms of 563 
 
 etiology of 566 
 
 anatomy of 567 
 
 diagnosis of 563 
 
 piognosis of. 568 
 
 treatment of 568 
 
 Anidrosis 80 
 
 symptoms of 80 
 
 treatment of 81 
 
 Anomaliae secretionis et excre- 
 
 tionis 55 
 
 Anthrax 118 
 
 history of 118 
 
 etiology of 120 
 
 symptoms of 121 
 
 pathology of 122 
 
 diagnosis of 123 
 
 prognosis of 123 
 
 treatment of 123 
 
 Area Celsi 467 
 
 Argyria 372 
 
 Asiatic pills. 398 
 
 Asperitudo cutis 66 
 
6 3 6 
 
 INDEX. 
 
 Asteatosis cutis 66 
 
 symptoms of.. . . 66 
 
 prognosis of . . . . 67 
 
 treatment of 67 
 
 Atheroma 74 
 
 Atrophia cutis propria 459 
 
 pilorum propria 473 
 
 Atrophia 450 
 
 Atrophy of pigment 450 
 
 Baldness 462 
 
 Bandages in eczema 336 
 
 Barbadoes leg 434 
 
 Blattern 105 
 
 Blebs 39 
 
 Bloody sweat 84 
 
 Body louse 627 
 
 Boils 291 
 
 Brandy nose 265 
 
 Bromidrosis 81 
 
 symptoms of 81 
 
 etiology of 82 
 
 diagnosis of 82 
 
 treatment of 83 
 
 Bucnemia tropica 434 
 
 Bullae 39 
 
 Burns 344 
 
 Callositas 376 
 
 Callosity 376 
 
 Callus 376 
 
 Calvities. .- 462 
 
 senile 463 
 
 Canities. 455 
 
 prematura 456 
 
 senilis 456 
 
 Carbuncle 296 
 
 symptoms of 296 
 
 anatomy of 298 
 
 etiology of 298 
 
 diagnosis of 298 
 
 prognosis of 298 
 
 treatment of 298 
 
 Carcinoma 536 
 
 lenticulare 537 
 
 tuberosum 537 
 
 diagnosis of 538 
 
 prognosis of 538 
 
 treatment of 538 
 
 Carron oil 351 
 
 Cauliflower excrescence 412 
 
 Charbonous fever 120 
 
 Cheiro — pompholyx 246 
 
 Chicken pox no 
 
 Chilblains 353 
 
 Chloasma 367 
 
 symptoms of 367 
 
 etiology of. 370 
 
 anatomy of 370 
 
 diagnosis of 371 
 
 prognosis of 371 
 
 treatment of 371 
 
 Chloasma (Wilson) 610 
 
 caloricum 368 
 
 hepaticum 369 
 
 symptomatic 368 
 
 traumaticum 367 
 
 uterinum , . 369 
 
 Chromidrosis 83 
 
 symptoms of 83 
 
 anatomy of 86 
 
 etiology of 89 
 
 diagnosis of. .... 89 
 
 prognosis of 89 
 
 treatment of 89 
 
 Chrysarobin in psoriasis 401 
 
 in Tinea tricophytina 601 
 
 Cicatrices 46 
 
 Classification of skin diseases. . 51 
 
 Clavus 379 
 
 symptoms 379 
 
 anatomy 380 
 
 etiology of 380 
 
 prognosis of 380 
 
 treatment of 380 
 
 Clothes louse 627 
 
 Colored sweat 83 
 
 Combustio 344 
 
 symptoms of 344 
 
 anatomy of 349 
 
 etiology of 350 
 
 diagnosis of 350 
 
 prognosis of 350 
 
 treatment of 350 
 
 Comedo 67 
 
 symptoms of 67 
 
 anatomy of 68 
 
 etiology of 69 
 
 diagnosis of 70 
 
 prognosis of 70 
 
 treatment of 70 
 
 Condylomata 152 
 
 Condylomata acuminata 412 
 
 Congelatio 352 
 
INDEX. 
 
 637 
 
 Congelatio, symptoms of. .... . 352 
 
 anatomy of 354 
 
 etiology of 354 
 
 diagnosis of 355 
 
 prognosis of 355 
 
 treatment of 355 
 
 Corium 16 
 
 Corn 379 
 
 Cornu cutaneum 381 
 
 humanum 381 
 
 Corpuscle, Pacinian 20 
 
 tactile 18 
 
 Vater 20 
 
 Cosme's paste 500 
 
 Cow pox 112 
 
 Croton oil — eczema from 301 
 
 Crustse 43 
 
 Crusted ringworm 602 
 
 Cutaneous horn 3S1 
 
 Cutis anserina 575 
 
 pendular 442 
 
 tensa chronica 421 
 
 unctuosa 56 
 
 Cyst — sebaceous 73 
 
 Dactylitis syphilitica 183 
 
 Dandruff 56 
 
 Depilatories 447 
 
 Dermatalgia 577 
 
 symptoms of 577 
 
 etiology of 577 
 
 diagnosis of 578 
 
 treatment of 578 
 
 Dermatitis 336 
 
 ambustionis bullosa 345 
 erythe- 
 
 matoso 344 
 
 Dermatitis ambustionis escharo- 
 
 tica 346 
 
 Dermatitis calorica 337 
 
 combustionis 344 
 
 congelationis 352 
 
 bullosa 353 
 eschar- 
 
 otica 353 
 
 Dermatitis contusiformis 193 
 
 exfoliativa 288 
 
 medicamentosa 340 
 
 traumatica. 337 
 
 venenata 338 
 
 from arsenic 341 
 
 atropia 341 
 
 Dermatitis f om belladonna. . . . 341 
 
 bromine 341 
 
 canabis indica. 341 
 
 chloral 341 
 
 copaiba 342 
 
 cubebs ....... 342 
 
 digitalis 342 
 
 iodine 342 
 
 mercury ...... 342 
 
 opium 343 
 
 phosphoric add 343 
 
 quinine 343 
 
 salicylic acid . . 343 
 
 santonine 343 
 
 stramonium . . 343 
 
 strychnia 343 
 
 turpentine . . . 343 
 
 Dermatolysis 442 
 
 symptoms of 442 
 
 anatomy of 444 
 
 diagnosis of. .... . 444 
 
 prognosis of 445 
 
 treatment of 445 
 
 Dermatomycosis favosa 602 
 
 Dermatoscierosis 421 
 
 Dermalgia 577 
 
 Diachylon ointment 79 
 
 Diagnosis, general 48 
 
 light in 49 
 
 temperature of apart- 
 ment in 49 
 
 Disorders of secretion 55 
 
 Dysidrosis. 246 
 
 Ecchymomata 357 
 
 Ecchymoses 357 
 
 Ecthyma 284 
 
 symptoms of 284 
 
 anatomy of 286 
 
 etiology of 286 
 
 diagnosis of 286 
 
 prognosis of 287 
 
 treatment of 287 
 
 Ecthyma syphiliticum 159 
 
 Eczema 301 
 
 symptoms of 301 
 
 acute 304 
 
 erythematous 304 
 
 papular .... 305 
 
 pustular .... 306 
 
 squamous. . . 307 
 
 vesicular .... 305 
 
6 3 8 
 
 INDEX. 
 
 Eczema, symptoms of, barbae ... 312 
 
 crurale 316 
 
 ears 312 
 
 eyebrows ... 311 
 
 eyelids 311 
 
 face and head 309 
 flexure s of 
 joints. ... 3T5 
 Eczema, symptoms of, forehead, 309 
 
 genitals 313 
 
 hands and 
 
 feet 314 
 
 Eczema, symptoms of , intertrigo 315 
 
 lips 311 
 
 nails 315 
 
 neck 312 
 
 nipple and 
 mammas. . . 313 
 
 Eczema, symptoms of, nose 311 
 
 perineum and 
 
 anus 314 
 
 Eczema, symptoms of, scalp. . . 308 
 umbilical re- 
 gion 313 
 
 Eczema, anatomy of 316 
 
 etiology of 321 
 
 diagnosis of, 327 
 
 from erysip- 
 elas 326 
 
 Eczema, diagnosis of, from ery- 
 thematous lupus 324 
 
 Eczema, diagnosis of, from flat 
 
 papule at angle of mouth .... 324 
 Eczema, diagnosis of, from herpes 323 
 Eczema, diagnosis of, from lichen 
 
 planus 323 
 
 Eczema, diagnosis of, from lichen 
 
 ruber 323 
 
 Eczema.diagnosis of, from lichen 
 
 urticatus 327 
 
 Eczema, diagnosis of, from pem- 
 phigus foliaceus 327 
 
 Eczema, diagnosis of, from pity- 
 riasis rubra. . . 325 
 
 Eczema, diagnosis of, from pso- 
 riasis 325 
 
 Eczema, diagnosis of, from pus- 
 tular syphilide of head 324 
 
 Eczema, diagnosis of, from sca- 
 bies 326 
 
 Eczema, diagnosis of, from sebor- 
 
 rhcea 325 
 
 Eczema, diagnosis of, from small 
 pustular syphilide 323 
 
 Eczema, diagnosis of, from syco- 
 sis 326 
 
 Eczema, diagnosis of, from syph- 
 ilis of the palms 324 
 
 Eczema, diagnosis of, from tinea 
 
 tonsurans 326 
 
 Eczema, prognosis of 327 
 
 treatment of 327 
 
 acute 329 
 
 capitis .... 334 
 
 chronic. . . . 332 
 
 cruris 335 
 
 eyelids 335 
 
 face 334 
 
 genitals . , . 335 
 hands and 
 
 feet 335 
 
 Eczema, treatment of nails .... 335 
 
 nipples 335 
 
 vesicular form 329 
 
 Eczema marginatum 590 
 
 Electrolysis 447 
 
 Elephantiasis 434 
 
 symptoms of 434 
 
 anatomy of 438 
 
 etiology of 439 
 
 diagnosis of 440 
 
 prognosis of 440 
 
 treatment of 440 
 
 Arabum ... 434 
 
 cruris 435 
 
 genitalium 436 
 
 glabra 519 
 
 Graecorum 512 
 
 telangiectodes. . . . 442 
 
 Elephant leg 434 
 
 Encysted sebaceous tumor 74 
 
 Ephidrosis 76 
 
 Epidermis 1 1 
 
 Epithelioma ... 538 
 
 anatomy of 542 
 
 etiology of 545 
 
 diagnosis of 546 
 
 prognosis of 547 
 
 treatment of 547 
 
 deep seated 540 
 
 molluscum 506 
 
 papillary 541 
 
 superficial 538 
 
 tubercular 540 
 
 Equinia 125 
 
 history of 125 
 
 etiology of 126 
 
 symptoms of 126 
 
INDEX. 
 
 639 
 
 Equinia, pathology of 128 
 
 diagnosis of 129 
 
 prognosis of 129 
 
 treatment of 129 
 
 Erysipelas 130 
 
 anatomy of 135 
 
 etiology of ... , 136 
 
 prognosis of 139 
 
 treatment of 140 
 
 bullosum 133 
 
 capillitii 134 
 
 cellular 130 
 
 cellulo-cutaneous 130 
 
 crustosum 133 
 
 cutaneous 130 
 
 extremitalium 134 
 
 faciei 133 
 
 gangrenosum 133 
 
 genitalium 134 
 
 migrans 133 
 
 neonatorum puerperale 134 
 
 pustulosum 133 
 
 umbilici 134 
 
 universalis 133 
 
 vaccinale 134 
 
 vesiculosum 133 
 
 Erythema 91 
 
 annulare 188 
 
 bullosum 1S9 
 
 caloricum 92 
 
 circinnatus 189 
 
 diphtheriticum 189 
 
 gyratum 1S8 
 
 idiopathic 91 
 
 iris 188 
 
 marginatum 188 
 
 multiforme 187 
 
 nodosum 193 
 
 papulatum 189 
 
 simplex 91 
 
 solare 92 
 
 symptomatica 92 
 
 traumaticum 91 
 
 tuberculatum 189 
 
 venenatum 92 
 
 vesiculosum 189 
 
 Essential charbon 120 
 
 Etiology general 47 
 
 Examination of patients 49 
 
 Excoriationes 44 
 
 Exudationes 94 
 
 Fa Fung 512 
 
 Farcy 125 
 
 Fatty tumor 561 
 
 Favus 602 
 
 symptoms of 602 
 
 anatomy of 604 
 
 etiology of 606 
 
 diagnosis of 607 
 
 prognosis of 607 
 
 treatment of 607 
 
 Favus confertus 603 
 
 discretus 603 
 
 Febris anginosa 99 
 
 urticata 196 
 
 Fever sores 219 
 
 Fibroma molluscum 555 
 
 Fish skin disease 415 
 
 Fissures 44 
 
 Follicle, hair, anatomy of 27 
 
 Follicular tumor. 74 
 
 Folliculitis barbae 269 
 
 Fragilitas crinium 474 
 
 Freckles 366 
 
 Frostbite 352 
 
 Furunculus 291 
 
 Furuncles 291 
 
 German measles 97 
 
 Glanders 125 
 
 Glands, sebaceous 24 
 
 sweat 21 
 
 development of 23 
 
 Glossy skin 520 
 
 Goose skin 575 
 
 Grayness of the hair 455 
 
 Green soap in psoriasis 399 
 
 Grutum 71 
 
 Gulta rosea 265 
 
 Hsematidrosis 364 
 
 Haemophilia 364 
 
 Haemorrhcea petechialis 359 
 
 Hair, anatomy of 27 
 
 atrophy of 473 
 
 development of 28 
 
 dyes 458 
 
 follicles.. . . 27 
 
 papilla '. 27 
 
 Head louse 625 
 
 Helmerich's salve 622 
 
 Hereditary syphilis 178 
 
640 
 
 INDEX. 
 
 Hereditary syphilis, treatment of 186 
 
 Hemiatrophia facialis 434 
 
 Hemorrhagise 357 
 
 idiopathic 358 
 
 sympathetic 359 
 
 Herpes 219 
 
 circinatus 585 
 
 facialis 219 
 
 febrilis 219 
 
 gestationis 223 
 
 iris 221 
 
 labialis 219 
 
 praeputialis 222 
 
 progenitalis 222 
 
 pustulosus mentagra. . . 269 
 
 tonsurans 585 
 
 zoster 224 
 
 zoster hemorrhagicus. . . 225 
 
 Hirsuties 445 
 
 symptoms of 445 
 
 etiology of 446 
 
 treatment of . . . . .... 446 
 
 Hives .*... 196 
 
 Honeycomb ringworm 602 
 
 Horny excrescence 381 
 
 tumor 381 
 
 Hydroa 242 
 
 history of 242 
 
 symptoms of 243 
 
 etiology of 244 
 
 diagnosis of 244 
 
 prognosis of 245 
 
 treatment of 245 
 
 bulleux .... 243 
 
 febrilis 219 
 
 herpetiforme 243 
 
 pruriginosum 243 
 
 simplex 243 
 
 Hydrosis 76 
 
 Hyperemias 90 
 
 active. 91 
 
 cutaneous 90 
 
 idiopathic 91 
 
 passive 92 
 
 symptomatic 92 
 
 treatment of 93 
 
 Hyperesthesia 576 
 
 Hyperalgesia 577 
 
 Hyperidrosis 76 
 
 symptoms of 76 
 
 anatomy of 77 
 
 etiology of 77 
 
 diagnosis of 78 
 
 prognosis of 78 
 
 Hyperidrosis, treatment of 78 
 
 Hypertrophies 366 
 
 Hypertrophic scar 553 
 
 Hypertrichosis 445 
 
 Hypertrichiasis 445 
 
 Hypertrophy of the hair 445 
 
 nail 448 
 
 Ichthyosis 415 
 
 symptoms of 415 
 
 anatomy of 418 
 
 etiology of 420 
 
 prognosis of 421 
 
 treatment of 421 
 
 congenita neonatorum 57 
 
 congenita 415 
 
 diffusa 414 
 
 follicularis 415 
 
 hystrix 416 
 
 sebacea 56 
 
 simplex 415 
 
 Idrosis 76 
 
 Ignis sacer 224 
 
 Impetigo 280 
 
 symptoms of 280 
 
 anatomy of 281 
 
 etiology of 281 
 
 diagnosis of 281 
 
 prognosis of 281 
 
 treatment of 281 
 
 Impetigo contagiosa 116 
 
 symptoms of 116 
 etiology of,. 117 
 pathology of 117 
 diagnosis of 117 
 treatment of 118 
 
 Impetigo herpetiformis 282 
 
 symptoms of 282 
 anatomy of. 283 
 etiology of. . 283 
 diagnosis of 284 
 prognosis of 284 
 treatment of 284 
 Induratio tele cellulose neona- 
 torum .... 427 
 
 Inspection of patients. 49 
 
 Integumentum commune 9 
 
 Intertrigo 315 
 
 Itch 614 
 
 Keloid 549 
 
INDEX. 
 
 64I 
 
 Keloid, etiology of 550 
 
 symptoms of 550 
 
 anatomy of 553 
 
 diagnosis of . . . 554 
 
 prognosis of 554 
 
 treatment of 554 
 
 Keloid, cicatricial 549 
 
 of Add-on. . 550 
 
 of Alibert 551 
 
 true 551 
 
 false 552 
 
 Keratoses, pure 376 
 
 with papillary hyper- 
 trophy 410 
 
 Keratosis pigmentosa 411 
 
 Keratosis pilaris 384 
 
 symptoms of. . 384 
 
 anatomy of. . . . 384 
 
 etiology of 384 
 
 diagnosis of . . . 384 
 
 prognosis of . . 385 
 
 treatment of. 385 
 
 Kerion Celsi 586 
 
 Lentigo 366 
 
 symptoms of 366 
 
 etiology of 367 
 
 anatomy of 367 
 
 treatment of 367 
 
 Leontiasis 512 
 
 Lepra Willani 385 
 
 Lepra 512 
 
 history of 512 
 
 symptoms of 513 
 
 anatomy of 523 
 
 etiology of 526 
 
 diagnosis of 530 
 
 prognosis of 532 
 
 treatment of 533 
 
 Lepra anaesthetica 519 
 
 glabra 521 
 
 maculosa 519 
 
 mutilans 517 
 
 nervorum 519 
 
 tuberculosa 515 
 
 tuberosa 515 
 
 verse 512 
 
 Leprosy 512 
 
 Lesions of the skin 35 
 
 primary 36 
 
 secondary... 42 
 
 Leucasmus, acquired 352 
 
 41 
 
 Leucasmus, congenital 450 
 
 Leucoderma, acquired 452 
 
 Leucopathia, acquired 452 
 
 congenital 450 
 
 Lice of the body 627 
 
 of the head 625 
 
 of the pubis 629 
 
 Lichen pilaris. . ♦ 384 
 
 Lichen planus 202 
 
 symptoms of 202 
 
 anatomy of 204 
 
 etiology of 208 
 
 diagnosis of 208 
 
 prognosis of 208 
 
 treatment of 208 
 
 Lichen ruber 403 
 
 symptoms of 403 
 
 anatomy of 406 
 
 etiology of 408 
 
 diagnosis of 408 
 
 prognosis of 409 
 
 treatment of 409 
 
 Lichen scrofulosus 209 
 
 symptoms of. 209 
 
 anatomy of 210 
 
 etiology of 211 
 
 diagnosis of 211 
 
 prognosis of ... 212 
 
 treatment of 212 
 
 Lichen syphiliticus 150 
 
 Lipoma 561 
 
 symptoms of 561 
 
 anatomy of 562 
 
 diagnosis of 562 
 
 prognosis of 562 
 
 treatment of 562 
 
 Livedo 93 
 
 Liver spot 367 
 
 Lupus erythematosus 479 
 
 symptoms of. 479 
 
 etiology of. . . 483 
 
 diagnosis of. . 484 
 
 prognosis of. 485 
 
 treatment of. 485 
 
 Lupus discretus 490 
 
 disseminatus 490 
 
 erythematodes 479 
 
 erythematosus discoides. . 479 
 
 disseminatus 480 
 
 exedens 488 
 
 exfoliativus 489 
 
 exulcerans 489 
 
 hypertrophicus 491 
 
 sebaceus 479 
 
642 
 
 INDEX. 
 
 Lupus superficialis 479 
 
 tuberculosis 489 
 
 verrucosus 490 
 
 vorax 488 
 
 vulgaris 488 
 
 symptoms of, . . . 488 
 
 anatomy of 491 
 
 diagnosis of 494 
 
 prognosis of 497 
 
 etiology of 497 
 
 treatment of. ... . 497 
 
 Lymphangioma 571 
 
 symptoms of . . . . 571 
 
 anatomy of 572 
 
 etiology of 572 
 
 diagnosis of 572 
 
 prognosis of. 573 
 
 treatment of ... 573 
 
 Lymphangiomata 571 
 
 Lymphangioma tuberosum mul- 
 tiplex 571 
 
 Lymphangiectodes 571 
 
 Lymphatic warts 571 
 
 Maculae 36 
 
 Maculae et stri3e atrophicse 459 
 
 Malignant pustule 118 
 
 Marsden's paste 548 
 
 Measles 94 
 
 Melanotic sarcoma 535 
 
 Mentagra 269 
 
 Mercury — mode of administering 171 
 
 Microsposon furfur 612 
 
 Miliaria crystallina 84 
 
 Milium 71 
 
 symptoms of. 71 
 
 anatomy of 72 
 
 etiology of 73 
 
 diagnosis of 73 
 
 prognosis of 73 
 
 treatment of 74 
 
 Milk crust 301 
 
 Mole pigmentary 373 
 
 Molluscum contagiosum 506 
 
 symptoms of 506 
 
 anatomy of.. 508 
 
 diagnosis of 511 
 
 prognosis of 511 
 
 treatment of 511 
 
 Molluscum corpuscles 511 
 
 epitheliale 506 
 
 fibrosum 555 
 
 Molluscum fibrosum symptoms of 5^5 
 anatomy of. . 556 
 etiology of... 557 
 diagnosis of . 557 
 prognosis of . . 557 
 treatment of. . 557 
 non-contagiosum. . .. 555 
 
 pendulum 555 
 
 sebaceum 506 
 
 sessile 506 
 
 simplex 555 
 
 Morbilli 94 
 
 symptoms of 94 
 
 diagnosis of 96 
 
 Morbus maculosus Werlhofii. . . 361 
 
 Morphcea 431 
 
 symptoms of 431 
 
 anatomy of 432 
 
 etiology of 433 
 
 diagnosis of 433 
 
 prognosis of 433 
 
 treatment of 433 
 
 Mucous patches 152 
 
 Muscles of the skin 24 
 
 Myomata 573 
 
 anatomy of 574 
 
 Naevus materna 373 
 
 molluscaformis 373 
 
 lipomatodes 373 
 
 pigmentosus 373 
 
 symptoms of 373 
 
 anatomy of. . 374 
 
 etiology of. . 375 
 
 prognosis of. 375 
 
 treatment of 375 
 
 pilosus 373 
 
 spilus 373 
 
 unius lateris 373 
 
 vascularis 565 
 
 verrucosus 374 
 
 Nail, anatomy of 28 
 
 development of 30 
 
 Neoplasmata 476 
 
 Nerves of the skin 17 
 
 Nettle rash 196 
 
 Neuralgia of the skin 577 
 
 Neuroma 573 
 
 Ointment, diachylon 79 
 
INDEX. 
 
 643 
 
 Ointment, Wilkinson's 218 
 
 Onychatrophia 475 
 
 Onychauxis 448 
 
 Onchogryphosis 448 
 
 symptoms of. . . 448 
 anatomy of . . . . 449 
 treatment of. . .. 449 
 
 Onchomycosis 591 
 
 Osmidrosis 81 
 
 Osteomata 574 
 
 Pacinian corpuscles 20 
 
 anatomy of 21 
 
 Pachydermatocele 442 
 
 Pachyderma 434 
 
 Papillae 17 
 
 Papulae 37 
 
 Parasitic sycosis 587 
 
 Panniculus adiposus 15 
 
 Paronychia syphilitica 166 
 
 Parisitae 584 
 
 Parasites 585 
 
 Pais papillaris corii 16 
 
 reticularis corii 16 
 
 Pediculosis 624 
 
 symptoms of 624 
 
 etiology of 630 
 
 diagnosis of 631 
 
 treatment of 631 
 
 Pediculus capitis 625 
 
 corporis 627 
 
 pubis 629 
 
 vestimenti .... 627 
 
 Peliosis rheumatica 360 
 
 Pemphigus 232 
 
 symptoms of 232 
 
 anatomy of 236 
 
 etiology of 238 
 
 diagnosis of 238 
 
 treatment of 240 
 
 Pemphigus circinatus 233 
 
 confertus 233 
 
 diutinus 233 
 
 feigned 240 
 
 foliaceus 235 
 
 hystericus 223 
 
 leprosus 521 
 
 neonatorum syphilit- 
 ica ... 1 79 
 
 prurigineuse 242 
 
 syphiliticus 160 
 
 vulgaris 232 
 
 Pemphigus vulgaris acute 234 
 
 vulgaris chronic. . . . 234 
 
 Perniones 353 
 
 Petechias 357 
 
 Phosphoridrosis 84 
 
 Phtheiriasis 624 
 
 Phtheirius inguinalis 629 
 
 Phymata 42 
 
 Physiology of the skin 31 
 
 Piebald skin 452 
 
 Pigmentation 47 
 
 Pigmentary mole 373 
 
 naevi 374 
 
 Pityriasis pilaris 384 
 
 rubra 288 
 
 symptoms of . . . 288 
 pathology of . . . 289 
 diagnosis of.. .. 290 
 prognosis of . . . 291 
 treatment of . . . 291 
 
 Pityriasis versicolor 610 
 
 Pocken 105 
 
 Poliosis 455 
 
 Polytrichia 445 
 
 Pomphi 40 
 
 Pompholyx 246 
 
 symptoms of 246 
 
 anatomy of 252 
 
 etiology of 256 
 
 prognosis of 256 
 
 treatment of 256 
 
 Porrigo decalvans 467 
 
 favosa 602 
 
 Prickle cells 12 
 
 Primary lesions 36 
 
 Prurigo .... 2 r 2 
 
 history of 212 
 
 symptoms of. 213 
 
 etiology of 215 
 
 diagnosis of 216 
 
 prognosis of 217 
 
 treatment of 217 
 
 Pruritus 578 
 
 symptoms of 578 
 
 anatomy of 580 
 
 etiology of 580 
 
 diagnosis of 581 
 
 prognosis of 581 
 
 treatment of 582 
 
 Pruritus hiemalis 580 
 
 linguae 580 
 
 localis 580 
 
 palmae manus et plantae 
 pedes . 580 
 
644 
 
 INDEX. 
 
 Pruritus pudendorum 580 
 
 scroti 580 
 
 senilis 580 
 
 universalis 579 
 
 vulvae 580 
 
 Psoriasis 385 
 
 circinata 386 
 
 diffusa 386 
 
 guttata 386 
 
 gyrata 386 
 
 nummularis 386 
 
 orbicularis 386 
 
 punctata 386 
 
 symptoms of 385 
 anatomy of. . 388 
 etiology of . .. 393 
 diagnosis of. 394 
 Psoriasis, diagnosis of, from ec- 
 zema squamosum 394 
 
 Psoriasis, diagnosis of, from ery- 
 thematous lupus 395 
 
 Psoriasis, diagnosis of, from lich- 
 en ruber 396 
 
 Psoriasis, diagnosis of, from pap- 
 
 ulo-squamous syphilide 369 
 
 Psoriasis, diagnosis of, from pity- 
 riasis rubra 395 
 
 Psoriasis, diagnosis of, from ring- 
 worm of the scalp 395 
 
 Psoriasis, diagnosis of, from se- 
 
 borrhcea 395 
 
 Psoriasis, prognosis of ....... . 396 
 
 treatment of 396 
 
 internal . 397 
 local. . . . 398 
 
 Psora 385 
 
 Purpura 359 
 
 symptoms of 359 
 
 symptoms of p. simplex 359 
 p. rheuma- 
 
 tica .... 360 
 p. hsemor- 
 
 rhagica. 361 
 p. scorbu- 
 tus 361 
 
 anatomy of 362 
 
 etiology of 363 
 
 p. simplex. . . 363 
 p. rheumatica 363 
 p. hsemorrha- 
 
 gia 363 
 
 p. scorbutus. 363 
 
 prognosis of 363 
 
 treatment of 364 
 
 Purpura, treatment of p. simplex 304 
 
 p. rheumatica. . . 643 
 
 p. haemorrhagia 364 
 
 p. scorbutus. . . 364 
 
 Pustulae 59 
 
 Rete malpighii 12 
 
 Rhagades 44 
 
 Rhinoscleroma 476 
 
 symptoms of . . . . 476 
 
 anatomy of .... 477 
 
 etiology of 478 
 
 diagnosis of 478 
 
 prognosis of 478 
 
 treatment of. . . . 478 
 
 Rheumatism of the skin. ...... 577 
 
 Ringworm 585 
 
 Rosacea 265 
 
 Roseola syphilitica 147 
 
 Rcetheln 97 
 
 Rubeola 94 
 
 Salt rheum 301 
 
 Sarcoma 535 
 
 Sarcoptes scabiei 614 
 
 homini 614 
 
 Satyriasis 5*2 
 
 Scabies 614 
 
 anatomy of 614 
 
 etiology of 618 
 
 symptoms of 619 
 
 diagnosis of 621 
 
 prognosis of 622 
 
 treatment of 622 
 
 Scales 42 
 
 Scars 46 
 
 hypertrophic 553 
 
 Scarlatina 99 
 
 Scarlet fever 99 
 
 Scarlet rash 99 
 
 Sclerema neonatorum 427 
 
 symptoms of 427 
 anatomy of. 429 
 etiology of. . 429 
 diagnosis of. 430 
 prognosis of. 430 
 
INDEX. 
 
 645 
 
 Sclerema, neonatorum treatment 
 
 of ... . 430 
 
 Scleriasis 421 
 
 Scleroderma 421 
 
 history of 421 
 
 anatomy of 424 
 
 etiology of 425 
 
 diagnosis of 426 
 
 prognosis of 426 
 
 treatment of 427 
 
 Scleroma 421 
 
 Scleroma aduliorum 421 
 
 Sclerosis 427 
 
 corii 421 
 
 Scrofulide tuberculeuse 488 
 
 Scrofuloderma 502 
 
 Scorbutus 361 
 
 Sea scurvy 361 
 
 Seborrhagia 56 
 
 Seborrhoea 56 
 
 symptoms of 56 
 
 anatomy of 61 
 
 etiology of. ........ . 61 
 
 diagnosis of 61 
 
 prognosis of 63 
 
 treatment of 63 
 
 capitis 58 
 
 congestiva 479 
 
 corporis 60 
 
 faciei 59 
 
 genitalium 60 
 
 local 57 
 
 nasi 58 
 
 universal 57 
 
 oleosa 57 
 
 sicca 57 
 
 Sebaceous cyst 74 
 
 symptoms of . . . . 74 
 
 anatomy of 74 
 
 diagnosis of ... . 75 
 
 prognosis of . . . . 75 
 
 treatment of 75 
 
 Sebaceous secretion 33 
 
 Secondary lesions 42 
 
 Secretion, disorders of 55 
 
 Shingles 224 
 
 Skin, absorption of 34 
 
 anatomy of 9 
 
 appendages of 9 
 
 bloodvessels of 17 
 
 corium 16 
 
 corneous layer 13 
 
 description of the differ- 
 ent tissues of. ...;.. .. 11 
 
 Skin, elastic fibres of 17 
 
 epidermis 11 
 
 general structure of 11 
 
 granular layer of 13 
 
 hair follicles of 27 
 
 hairs of 27 
 
 meduliated nerves of. . . . 18 
 
 muscles of 24 
 
 nerves of 17 
 
 Pacinian corpuscles of .. . 20 
 
 papillae of 16 
 
 pigment of 11 
 
 pigmentation of 47 
 
 protection to the general 
 
 surface of 34 
 
 reticular layer of 16 
 
 respiration of 31 
 
 subaceous glands of 24 
 
 secretions of ... 31 
 
 subcutaneous connective 
 
 tissue, layer of 15 
 
 sweat glands of 21 
 
 tactile corpuscles of. ... 18 
 
 Skin bound 427 
 
 Small pox 105 
 
 Spiritus saponis kalinus 65 
 
 Squamae 42 
 
 Steatoma 74 
 
 Steatoma 561 
 
 Steatorrhcea 56 
 
 Stinking sweat 81 
 
 Stratum corneum 13 
 
 lucidum 13 
 
 subpapillare 17 
 
 Striae et maculae atrophica? 459 
 
 Strophulus albidus 71 
 
 prurigineux 212 
 
 Subjective symptoms 35 
 
 Sudamina 84 
 
 symptoms of 84 
 
 anatomy of 86 
 
 etiology of 89 
 
 diagno-is of 89 
 
 prognosis of 89 
 
 treatment of 89 
 
 Sudamina alba 84 
 
 crystallina 84 
 
 rubra 84 
 
 Sudatoria 76 
 
 Sweat secretion ■ 31 
 
 Swine pox no 
 
 Sycosis . .- 269 
 
 symptoms of . . . 269 
 
646 
 
 INDEX. 
 
 Sycosis, etiology of 272 
 
 , pathology of 272 
 
 diagnosis of 275 
 
 treatment of 277 
 
 Sycosis barbae 269 
 
 Symptomatology 35 
 
 Symptomatic charbon 120 
 
 Symptoms, objective 35 
 
 subjective 35 
 
 Syphilis 142 
 
 color of 143 
 
 configuration of 144 
 
 course of 145 
 
 polymorphism of 144 
 
 scales in 144 
 
 seat of eruption in . . . 143 
 subjective symptoms of . 145 
 
 Syphilis, anatomy of . . 167 
 
 prognosis of 168 
 
 treatment of 169 
 
 local 176 
 
 Syphilide, bullous 160 
 
 erythematous 147 
 
 exanthematous 147 
 
 gummatous 165 
 
 large acuminated 
 
 pustular 158 
 
 large papular 151 
 
 macular 147 
 
 miliary papular 150 
 
 papular 149 
 
 papulo squamous. . . 153 
 
 pigmentary 149 
 
 small acuminated 
 
 pustular 157 
 
 small papular 150 
 
 tubercular 162 
 
 vesicular 156 
 
 Syphilis, hereditary 176 
 
 treatment of 186 
 
 Tactile corpuscles 18 
 
 Teeth, syphilitic 185 
 
 Telangiectasis 564 
 
 Temperature of body, regula- 
 tion of 33 
 
 Tinea circinata 588 
 
 decalvans 467 
 
 favosa 602 
 
 kerion 586 
 
 tricophytina 585 
 
 barbae 587 
 
 Tinea tricophytina capitis 588 
 
 corporis 588 
 
 cruris 590 
 
 unguium .... 591 
 anatomy of. . 591 
 diagnosis of. . 596 
 treatment of. 599 
 
 Tinea versicolor 610 
 
 symptoms of 610 
 
 anatomy of 611 
 
 etiology of 612 
 
 diagnosis of 612 
 
 prognosis of 613 
 
 treatment of 613 
 
 Treatment, general 49 
 
 Trichorexis nodosa 474 
 
 Trichonosis discolor 455 
 
 Tubercula 41 
 
 Tuberculum sebaceum 71 
 
 Tumors 476 
 
 Tumor cavernosus 566 
 
 Tyloma 376 
 
 Tylosis 376 
 
 Ulcera 45 
 
 Uridrosis .......... 84 
 
 Urticae. 40 
 
 Urticaria 196 
 
 symptoms 196 
 
 anatomy of 198 
 
 etiology of. 198 
 
 diagnosis of. , 199 
 
 prognosis of 200 
 
 treatment of 200 
 
 pigmentosa 202 
 
 cedematosa 197 
 
 tuberosa 193 
 
 Ung. Rochardi 401 
 
 Vaccinia 112 
 
 symptoms of 112 
 
 Varicella no 
 
 symptoms of no 
 
 diagnosis of Ill 
 
 Variola 105 
 
 symptoms of 105 
 
 diagnosis of ... 108 
 
 Verrucca 4 IQ 
 
 symptoms of 4 IQ 
 
 anatomy of 4*3 
 
INDEX. 
 
 647 
 
 Verrucca, etiology of 413 
 
 diagnosis of 414 
 
 prognosis of 414 
 
 treatment of 414 
 
 acuminata 412 
 
 caduca 412 
 
 elevata 412 
 
 filiformis 411 
 
 perstans 412 
 
 plana 411 
 
 senilis 41 1 
 
 Vesiculce 38 
 
 Vitiligo 452 
 
 symptoms of 452 
 
 anatomy of 454 
 
 etiology of 454 
 
 diagnosis of 454 
 
 treatment of 455 
 
 Vitiligoidea 558 
 
 Vleminckx's solution. . , 263 
 
 Wart 410 
 
 Wheals . . . 40 
 
 Whelk 256 
 
 Wilkinson's ointment 218 
 
 Wine nose 265 
 
 Xanthelasma 558 
 
 Xanthelasmoidea 202 
 
 Xanthoma 558 
 
 planum 558 
 
 tuberosum 559 
 
 symptoms of 558 
 
 anatomy of . . 559 
 
 etiology of. . . 560 
 
 diagnosis of . . 560 
 
 prognosis of. 561 
 
 treatment. . . . 561 
 
 Xeroderma 415 
 
 Zoster 224 
 
 auricularis 226 
 
 cervico-brachialis 227 
 
 cervico-subclavicularis. . . 227 
 
 faciei 226 
 
 frontalis 226 
 
 lumbo-femoralis. ...... . 227 
 
 occipito collaris 226 
 
 ophthalmicus 226 
 
 pectoralis 227 
 
 sacro-genitalis 227 
 
 sacro-ischiadicus 227 
 
NEW MEDICAL W ORKS. 
 
 Atlas of Female Pelvic Anatomy. 
 
 By D. Berry Hart, M. D., F. R. C. P. E., Lecturer on Midwifery and 
 Diseases of Women, School of Medicine, Edinburgh, etc. With Pref- 
 ace, by Alexander J. 0. Skene, M. D., Professor of the Medical and 
 Surgical Diseases of Women, Long Island College Hospital, Brooklyn. 
 Large quarto, 37 Plates with 150 Figures, and 89 pages descriptive 
 text. Cloth, $15.00. 
 
 " As a new work by a well-known author, there is a natural prejudice 
 in its favor, but this becomes the more deeply rooted as we constantly 
 get new views of old fields, new landmarks for better outlooks, new 
 light upon heretofore obscure points. In a word, we can, after the most 
 critical study of its contents, say with the distinguished editor, Professor 
 Skene, that ' it is far in advance of any work of its kind yet produced.' 
 As such it becomes a necessity for the progressive gynaecologist, for the 
 operating surgeon, and for the leading general practitioner. We con- 
 gratulate the publishers on the reproduction of this grand w T ork, and be- 
 speak for it a becoming appreciation by the profession of this country." — 
 Medical Record. 
 
 Diseases of the Heart and Thoracic Aorta. 
 
 By Btrom Bramwell, M. D., F. R. C. P. E., Lecturer on the Prin- 
 ciples and Practice of Medicine and on Medical Diagnosis in the 
 Extra- Academical School of Medicine, Edinburgh ; Pathologist to the 
 Royal Infirmary, Edinburgh, etc. Illustrated with 226 Wood-Engrav- 
 ings and 68 Lithograph Plates — showing 91 Figures — in all 317 Illus- 
 trations. 1 vol., 8vo, 783 pages. Cloth, $8.00 ; sheep, $9.00. 
 
 11 A careful perusal of this work will well repay the student and re- 
 fresh the memory of the busy practitioner. It is the outcome of sound 
 knowledge and solid work. The material is treated with due regard to 
 its proportionate importance, and the author has well and wisely carried 
 out his apparent intention of rather furnishing a groundwork of knowl- 
 edge on which the reader must build for himself by personal observation, 
 than of making excursions into the region of dogma and of fancy by 
 which his book might have secured a perhaps more rapid but certainly 
 a more evanescent success than that which it will now undoubtedly and 
 deservedly attain." — Medical Times and Gazette. 
 
 A Hand-Book of the Diseases of the Eye, 
 
 AND THEIR TREATMENT. By Henry R. Swanzy, A. M., M. B., 
 F. R. C. S. I., Surgeon to the National Eye and Ear Infirmary; Oph- 
 thalmic Surgeon to the Adelaide Hospital, Dublin. Crown 8vo. 437 
 pages. With 122 Illustrations, and Holmgren's Tests for Color-Blind- 
 ness. Cloth, $3.00. 
 
 New York: D. APPLETON & CO., 1, 3, & 5 Bond Street. 
 
Practical Manual of Diseases of Women 
 and Uterine Therapeutics. 
 
 FOR STUDENTS AND PRACTITIONERS. By H. Maonaugh- 
 ton Jones, M. D„ F. R. 0. S. I. and E., Examiner in Obstetrics, Royal 
 University of Ireland ; Fellow of the Academy of Medicine in Ire- 
 land; and of the Obstetrical Society of London, etc. 1 vol., 12mo, 
 410 pages. 188 Illustrations. Cloth, $3.00. 
 
 " It is seldom that we see a book so completely fill its avowed mission 
 as does the one before us. It is practical from beginning to end, and can 
 not fail to be appreciated by the readers for whom it is intended. The 
 author's style is terse and perspicuous, and he has the enviable faculty of 
 giving the learner a clear insight of his methods and reasons for treat- 
 ment. Prepared for the practitioner, this little work deals only with his 
 every-day wants in ordinary family practice. Every one is compelled to 
 treat uterine disease who does any general business whatever, and should 
 become acquainted with the minor operations thereto pertaining. The 
 book before us covers this ground completely, and we have nothing to 
 offer in the way of criticism." — Medical Record. 
 
 The Relation of Animal Diseases to the 
 Public Health, 
 
 AND THEIR PREVENTION, with a Brief Historical Sketch of 
 the Development of Veterinary Medicine, from the Earliest Ages to 
 the Present Time. By Frank S. Billings, Veterinary Surgeon, Grad- 
 uate of the Royal Veterinary Institute, Berlin ; Member of the Royal 
 Veterinary Association of the Province of Brandenburg, Prussia, etc., 
 etc. 1 vol., 8vo. Cloth, $4.00. 
 
 " This handsome volume does great credit to its author and publishers. 
 It at the very least should be in the libraries of every national, State, city, 
 town, and county Board of Health. It certainly should be studied by 
 every teacher and scientific practitioner of veterinary medicine, and will 
 be of great service to every great stock and cattle holder and dealer. . . . 
 It will take its stand alongside of the popular treatises of Hilliaid and 
 Robertson, and on all purely scientific matters will lead them. Either of 
 these works, together with Dr. Billings's, will make almost a complete 
 library on veterinary medicine." — The Journal of Comparative Medicine 
 and Surgery. 
 
 Pyuria; or, Pus in the Urine, 
 
 AND ITS TREATMENT: Comprising the Diagnosis and Treatment 
 of Acute and Chronic Urethritis, Prostatitis, Cystitis, and Pyelitis, 
 with Especial Reference to their Local Treatment. By Dr. Robert 
 Ultzmann, Professor of Genito-Urinary Diseases in the Vienna Poli- 
 klinik. Translated, by permission, by Dr. Walter B. Platt, F. R. 
 C. S. (Eng.), Baltimore. 12mo. Cloth, $1.00. 
 
 New York: D. APPLETON & CO., 1, 3, & 5 Bond Street. 
 
Osteotomy and Osteoclasis, 
 
 FOR THE CORRECTION" OF DEFORMITIES. OF THE LOWER 
 LIMBS. By Chaeles T. Poore, M. D., Surgeon to St. Mary's Free 
 Hospital for Children, New York. 1 vol., 8vo. Cloth, $2.50. 
 
 "Dr. Poore, who has already become so well known by journal arti- 
 cles on bone surgery, has condensed his experience in the work before us. 
 He has succeeded in doing this in a very satisfactory way. We can not 
 too strongly commend the clear and succinct manner in which the author 
 weighs the indications for treatment in particular cases. In so doing lie 
 shows a knowledge of his subject which is as extensive as it is profound, 
 and no one at all interested in orthopedy can read his conclusions without 
 profit. His own cases, which are carefully reported, are valuable addi- 
 tions to the literature of the subject. These, together with others, which 
 are only summarized, contain so much practical information and sound 
 surgery that they give a special value to the work, altogether independent 
 of its other excellences. It is a good book in every way, and we con- 
 gratulate the author accordingly." — Medical Record. 
 
 A Treatise on Brain-Exhaustion, 
 
 WITH SOME PRELIMINARY CONSIDERATIONS ON CERE- 
 BRAL DYNAMICS. By J. Leonard Corning, M. D., formerly 
 Resident Assistant Physician to the Hudson River State Hospital for 
 the Insane; Member of the Medical Society of the County of New 
 York, of the Physicians' Mutual Aid Association, of the New York 
 Neurological Society, of the New York Medico-Legal Society, of the 
 Society of Medical Jurisprudence ; Physician to the New York Neuro- 
 logical Infirmary, etc. ; Member of the New York Academy of Medi- 
 cine. Crown 8vo. Cloth, $2.00. 
 
 "This book belongs to a class that is more and more demanded by the 
 cultured intelligence of the period in which we live. Dr. Corning may 
 be ranked with Hammond, Beard, Mitchell, and Crothers, of this country, 
 and with Wiuslow, Anstie, Thompson, and more recent authors of Great 
 Britain, in discussing the problems of mental disturbance, in a style that 
 makes it not only profitable, but attractive reading for the student of psy- 
 chology. The author has divided the work into short chapters, under gen- 
 eral headings, which are again subdivided into topics, that are paragraphed 
 in a concise and definite form, which at once strikes the careful reader as 
 characteristic of a method that is terse, concise, and readily apprehended. 
 There are twenty-eight of these pithy chapters, which no student of mental 
 diseases can fail to read without loss." — American Psychological Journal. 
 
 Lectures on the Principles of Surgery. 
 
 Delivered at the Bellevue Hospital Medical College, by the late W. H. 
 Van Bttren, M. D., LL. D. Edited by Dr. Lewis A. Stimson. 1 vol., 
 8vo. Cloth, $4.00 ; sheep, $5.00. 
 
 New York : D. APPLETON & CO., 1, 3, .& 5 Bond Street. 
 
A TREATISE ON INSANITY, IN ITS MEDI- 
 
 CAL RELATIONS. 
 
 By WILLIAM A. HAMMOND, M. D., 
 
 Surgeon- General U. S. Army (retired list) ; Professor of Diseases of the Mind and 
 
 Nervous System, in the New York Fost-Graduate Medical School ; 
 
 President of the American Neurological Association, etc. 
 
 1 vol., 8vo, 767 pp. Cloth, $5.00 ; sheep, $6.00. 
 
 In this work the author has not only considered the subject of Insanity, but 
 has prefixed that division of his work with a general view of the mind and the 
 several categories of mental faculties, and a full account of the various causes that 
 exercise an influence over mental derangement, such as habit, age, sex, hereditary 
 tendency, constitution, temperament, instinct, sleep, dreams, and many other factors. 
 
 Insanity, it is believed, is in this volume brought before the reader in an origi- 
 nal manner, and with a degree of thoroughness which can not but lead to impor- 
 tant results in the study of psychological medicine. Those forms which have only 
 been incidentally alluded to or entirely disregarded in the text-books hitherto pub- 
 lished are here shown to be of the greatest interest to the general practitioner and 
 student of mental science, both from a normal and abnormal stand-point. To a 
 great extent the work relates to those species of mental derangement which are 
 not seen within asylum walls, and which, therefore, are of special importance to 
 the non-asylum physician. Moreover, it points out the symptoms of Insanity in 
 its first stages, during which there is most hope of successful medical treatment, 
 and before the idea of an asylum has occurred to the patient's friends. 
 
 A TREATISE ON THE DISEASES OF THE 
 
 NERVOUS SYSTEM. 
 
 By WILLIAM A. HAMMOND, M. D., 
 
 Surgeon-General U. S. Army (retired list) ; Professor of Diseases of the Mind and 
 
 Nervous System, in the New York Post-Graduate Medical School ; 
 
 President of the American Neurological Association, etc. 
 
 Seventh edition, rewritten, enlarged, and improved. In one large 8vo vol. of 929 pp., with 
 Complete Index and 150 Illustrations. Cloth, $5.00 ; sheep or half russia, $6.00. 
 
 The work has received the honor of a French translation by Dr. Labadie- 
 Lagrave, of Paris, and an Italian translation by Professor Diodato Borrelli, of the 
 Royal University, is now going through the press at Naples. 
 
 " Dr. Hammond's work has now been tical experience is large, his convictions 
 
 before the profession for many years, are positive, and he can set them forth 
 
 and its characteristics are verv generally clearly and attractively. It is not surpris- 
 
 known. The present edition has a good mg; that his book has been a very popu- 
 
 many valuable additions, but has lost lar one. And the present edition is, as 
 
 nothing of its previous individuality as a modestly stated on the title-page, ' im- 
 
 medical work. Dr. Hammond has the proved.' "—Medical Record. 
 qualities of a successful author. His prac- 
 
 New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. 
 
A DICTIONARY OF MEDICINE, 
 
 INCLUDING 
 
 GENERAL PATHOLOGY, GENERAL THERAPEUTICS, HYGIENE, 
 
 AND THE DISEASES PECULIAR TO WOMEN AND 
 
 CHILDREN. 
 
 BY VARIOUS WRITERS. 
 
 EDITED BY 
 
 RICHARD QUAIN, M. D., F. R. S., 
 
 Fellow of the Royal College of Physicians, and Physician to the Hospital for Diseases of 
 the Chest, at Brompton, etc. 
 
 In one large 8vo volume of 1,834 pages with 138 Illustrations. Half 
 morocco, price, $8.00. Sold only by Subscription. 
 
 This work is primarily a Dictionary of Medicine, in which the several diseases 
 are fully discussed in alphabetical order. The description of each includes an 
 account of its etiology and anatomical characters ; its symptoms, course, duration, 
 and termination ; its diagnosis, prognosis, and, lastly, its treatment. General 
 Pathology comprehends articles on the origin, characters, and nature of disease. 
 
 General Therapeutics includes articles on the several classes of remedies, their 
 modes of action, and on the methods of their use. The articles devoted to the 
 subject of Hygiene treat of the causes and prevention of disease, of the agencies 
 and laws affecting public health, of the means of preserving the health of the 
 individual, of the construction and management of hospitals, and of the nursing 
 of the sick. 
 
 Lastly, the diseases peculiar to women and children are discussed under their 
 respective headings, both in aggregate and in detail. 
 
 " A goodly volume of an extremely interesting and important character. Dr. 
 Quain has succeeded in bringing together and conducting a work numbering a body 
 of contributors of whose co-operation anv editor might feel proud, and whose com- 
 bined work could not fail to produce a book of the'highest authority and practical 
 value. It is noticeable that the most recent questions are dealt with, and are all treated 
 according to the most recent researches and knowledge." — British Medical Journal. 
 
 " This new Medical Dictionary contains an immense mass of information, the 
 aggregate value of which it is difficult to estimate, but which may fairly be expected 
 to satisfy the most industrious student of medical science. A very wide and liberal 
 meaning has been given to the word Medicine. To the general practitioner we can 
 most heartily recommend the work ; and it will find many readers outside the pale 
 of the medical profession. It should have a place in at le'ast every public, if not in 
 every good private, library." — Saturday Review. 
 
 " The articles we have read have struck us as models of clear and fluent scientific 
 English. The volume contains many articles on matters of general interest to the 
 public at large, though not less important on that account to the practitioner." — Lon- 
 don Spectator. 
 
 New York; D. APPLETON & CO., 1, 3, & 5 Bond Street. 
 
A PRACTICAL TREATISE ON MATERIA 
 
 MED1CA AND THERAPEUTICS. 
 
 By EOBEETS BAETHOLOW, M. A., M. D., 
 Professor of Materia Mediea and Therapeutics in the Jefferson Medical College, etc. 
 
 Fifth edition. Revised, enlarged, and adapted to " The New Pharmacopoeia. ," 1 vol.. 8vo. 
 Cloth, $5.00 ; sheep, $6.00. 
 
 From Peeface to Fifth Edition. 
 " The appearance of the sixth decennial revision of the ' United States 
 Pharmacopoeia ' has imposed on me the necessity of preparing a new edi- 
 tion of this treatise. I have accordingly adapted the work to the official 
 standard, and have also given to the whole of it a careful revision, incor- 
 porating the more recent improvements in the science and art of thera- 
 peutics. Many additions have been made, and parts have been rewritten. 
 These additions and changes have added about one hundred pages to the 
 body of the work, and increased space has been secured in some places by 
 the omission of the references. In the new material, as in the old, prac- 
 tical utility has been the ruling principle, but the scientific aspects of 
 therapeutics have not been subordinated to a utilitarian empiricism. In 
 the new matter, as in the old, careful consideration has been given to the 
 physiological action of remedies, which is regarded as the true basis of all 
 real progress in therapeutical science; but, at the same time, I have not 
 been unmindful of the contributions made by properly conducted clinical 
 observations." 
 
 He is well known as a zealous student page. Dr. Bartholow, like another expe 
 
 of medical science, an acute observer, 
 
 rienced teacher — Professor von Schrotf, of 
 
 good writer, a skilled practitioner, and an Vienna-picks out the most important 
 
 ingenious, bold, though sometimes reck- physiological and therapeutical actions of 
 
 less investigator. His present book will each drug, and gives them in a short and 
 
 receive the°cordial welcome which it de- somewhat dogmatic manner. Haying 
 
 serves, and which the honorable position formed his own conclusions, he gives 
 
 that he has won entitles him to demand them to the public, without entering so 
 
 for it. . . . Dr. Bartholow's treatise has fully as Wood into the experiments on 
 
 the merit— and a great merit it is-of in- which they are founded."— Practitioner 
 
 eluding diet as well as drugs. . r . His {London). 
 
 work does not ignore or depreciate the M We may a ^ m \^ however, that Dr. 
 value of the empirical facts of a well- B artn olow has, to a great extent, success- 
 grounded and rational professional expe- ful] ed with the difficulties of his 
 rience, but, as far as possible, it bases c i ass ifi ca ti n, and his book has also other 
 the therapeutical action of remedies upon merits to CO mmend it. It is largely origi- 
 their physiological behavior."— American ml> By this we mean ^t ft g i ves the 
 Journal of the Medical Sciences. results of the author's own study and 
 " After looking through the work, observation, instead of a catalogue of the 
 most readers will agree with the author, contending statements of his predeces- 
 whose long training shows itself on every sots."— The Doctor (London). 
 
 New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. 
 
A TREATISE ON THE PRACTICE OF MEDI- 
 
 CINE, for the Use of Students and Practitioners. 
 
 By EOBEETS BAETHOLOW, M. A., M. D., LL. D., 
 
 Professor of Materia Medica and General Therapeutics in the Jefferson Medical Col- 
 lege of Philadelphia ; recently Professor of the Practice of Medicine and of 
 Clinical Medicine in the Medical College of Ohio, in Cincinnati, etc., etc. 
 
 Fifth edition, revised and enlarged. 8vo. Cloth, $5.00 ; 
 
 or half russia, $6.00. 
 
 The same qualities and characteristics which have rendered the author's " Trea- 
 tise on Materia Medica and Therapeutics " so acceptable are equally manifest in this. 
 It is clear, condensed, and accurate. The whole work is brought up on a level with, 
 and incorporates, the latest acquisitions of medical science, and may he depended on 
 to contain the most recent information up to the date of publication. 
 
 " Probably the crowning feature of the 
 work before us, and that which will make 
 it a favorite with practitioners of medi- 
 cine, is its admirable teaching on the treat- 
 ment of disease. Dr. Bartholow has no 
 sympathy with the modern school of ther- 
 apeutical nihilists, but possesses a whole- 
 some belief in the value and efficacy of 
 remedies. He does not fail to indicate, 
 however, that the power of remedies is 
 limited, that specifics are few indeed, and 
 that routine and reckless medication are 
 dangerous. But throughout the entire 
 treatise in connection with each malady 
 are laid down well-defined methods and 
 true principles of treatment. It may bo 
 said with justice that this part of the work 
 rests upon thoroughly scientific and prac- 
 tical principles of' therapeutics, and is ex- 
 ecuted in a masterly manner. No work on 
 the practice of medicine with which we 
 are acquainted will guide the practitioner 
 in all the details ot treatment so well as 
 the one of which we are writing." — Amer- 
 ican Practitioner. 
 
 " The work as a whole is peculiar, in 
 that it is stamped with the individuality 
 of its author. The reader is made to feel 
 that the experience upon which this work 
 is based is real, that the statements of the 
 writer are founded on firm convictions, 
 and that throughout the conclusions are 
 eminently sound. It is not an elaborate 
 treatise, neither is it a manual, but half- 
 way between ; it may be considered a 
 thoroughly useful, trustworthy, and prac- 
 
 tical guide for the general practitioner." — 
 Medical Record. 
 
 u It may be said of so small a book on 
 so large a subject, that it can be only a 
 sort of compendium or vade mecum. But 
 this criticism will not be just. For, while 
 the author is master in the art of conden- 
 sation, it will be found that no essential 
 points have been omitted. Mention is 
 made at least of every unequivocal symp- 
 tom in the narration of the signs of dis- 
 ease, and characteristic symptoms are 
 held well up in the foreground in every 
 case." — Cincinnati Lancet and Clinic. 
 
 " Dr. Bartholow is known to be a very 
 clear and explicit writer, and in this work, 
 which we take to be his special life-work, 
 we are very sure his many friends and ad- 
 mirers wili not be disappointed. We can 
 not say more than this without attempt- 
 ing to' follow up the details of the plan, 
 which, of course, would be useless in a 
 brief book-notice. We can only add that 
 we feel confident the verdict of the pro- 
 fession will place Dr. Bartholow's ' Prac- 
 tice' among the standard text-books of 
 the day." — Cincinnati Obstetric Gazette. 
 
 " The book is marked by an absence of 
 all discussion of the latest, fine-spun theo- 
 ries of points in pathology ; by the clear- 
 ness with which points in diagnosis are 
 stated ; by the conciseness and perspicuity 
 of its sentences ; by the abundance of the 
 author's therapeutic resources ; and by 
 the copiousness of its illustrations." — Ohio 
 Medical Recorder. 
 
 New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. 
 
DR. W. H. VAN BUREN'S WORKS. 
 
 LECTURES ON THE PRINCIPLES OF SUR- 
 
 GERY. 
 
 Delivered at Bellevue Hospital Medical College, 
 
 By W. H. VAN BUREN, M. D., LL.D. (Yalen.), 
 
 Formerly Professor of the Principles and Practice of Surgery in the Bellevue Hospital 
 
 Medical College ; one of the Consulting Surgeons of the New York Hospital, etc. 
 
 Edited by LEWIS A. STIMSON, M.D., 
 Professor of Physiology and Clinical Surgery in the Medical Department of the University 
 of the City of New York. 
 
 1 vol., 8vo, 588 pages. 
 
 LECTURES UPON DISEASES OP THE REC- 
 
 TUM AND THE SURGERY OF THE LOWER BOWEL. 
 
 Delivered at the Bellevue Hospital Medical College, 
 
 By W. H. VAN BUREN, M. D., 
 
 Late Professor of the Principles and Practice of Surgery in the Bellevue Hospital Medical 
 
 College, etc. 
 
 Second edition, revised and enlarged. 1 vol., 8vo, 412 pages, with 27 Illustrations 
 and complete Index. Cloth, $3.00 ; sheep, $4.00. 
 
 "These lectures are twelve in number, and may he taken as an excellent epitome of 
 our present knowledge of the diseases of the parts in question. The work is full of prac- 
 tical matter, but it owes not a little of its value to the original thought, labor, and sugges- 
 tions as to the treatment of disease, which always characterize the productions of the pen 
 of Dr. Van Buren."— Philadelphia Medical Times. 
 
 A PRACTICAL TREATISE ON THE SUR- 
 
 GIOAL DISEASES OF THE GENITO-URINARY ORGANS, 
 INCLUDING SYPHILIS. 
 
 Designed as a Manual for Students and Practitioners. 
 
 With Engravings and Cases. 
 
 By W. H. VAN BUREN, A.M., M.D., 
 
 Late Professor of Principles of Surgery, with Diseases of the Genito-TJrinary System and 
 
 Clinical Surgery, in Bellevue Hospital Medical College, etc. ; and 
 
 E. L. KEYES, A.M., M.D., 
 
 Professor of Dermatology in Bellevue Hospital Medical College ; Surgeon to the Charity 
 
 Hospital, Venereal Diseases, etc. 
 
 1 vol., 8vo, 672 pages. Cloth, $5.00; sheep, $6.00. 
 
 "The authors appear to have succeeded admirably in giving to the world an exhaust- 
 ive and reliable treatise on this important class of diseases. 1 ' — Northwestern Medical and 
 Surgical Journal. 
 
 New York: D. APPLETON & CO., 1, 3, & 5 Bond Street. 
 
 
August, 1884, 
 
 EQedical and hygienic IHorks 
 
 PUBLISHED BY 
 
 D. APPLETON & CO., 1, 3, & 5 Bond Street, New York. 
 
 PRICE 
 
 BARKER (FORDYCE). On Sea-Sickness. A Popular Treatise for 
 Travelers and the General Reader. By Fordyce Barker, M. D., 
 Clinical Professor of Midwifery and Diseases of Women in the 
 Bellevue Hospital Medical College, etc. Small 12mo Cloth, $0 75 
 
 On Puerperal Disease. Clinical Lectures delivered at Bellevue 
 
 Hospital. A Course of Lectures valuable alike to the Student and 
 
 the Practitioner. Third edition. 8vo Cloth, $5.00* ; Sheep, 6 00* 
 
 BARTHOLOW'S Treatise on Materia Medica and Therapeutics. Fifth 
 edition. Revised, enlarged, and adapted to " The New Pharmaco- 
 poeia. " By Roberts Bartholow, M. A., M. D., Professor of Materia 
 Medica and Therapeutics in the Jefferson Medical College. 
 
 Cloth, $5.00* ; Sheep, 6 00* 
 
 A Treatise on the Practice of Medicine, for the Use of Students 
 
 and Practitioners. 8vo. Fifth edition, revised and enlarged. 
 
 Cloth, $5.00* ; Sheep, 6 00* 
 
 On the Antagonism between Medicines and between Remedies 
 
 and Diseases. Being the Cartwright Lectures for the Year 1880. 
 
 8vo Cloth, 1 25* 
 
 BAST! AN (H. CHARLTON, M. D., F. R. S.). On Paralysis from Brain- 
 Disease in its Common Forms. 12mo Cloth, 1 75* 
 
 The Brain as an Organ of the Mind 2 50 
 
 BELLEVUE aot> CHARITY HOSPITAL REPORTS. Edited by Pro- 
 fessor W. A. Hammond, M. D. 8vo 4 00* 
 
 BENNET (J. H.). Winter and Spring on the Shores of the Mediterra- 
 nean ; or, The Riviera, Mentone, Italy, Corsica, Sicily, Algeria, 
 Spain, and Biarritz, as Winter Climates. By J. Kenny Bennet, 
 M. D., Member of the Royal College of Physicians, London. With 
 numerous Illustrations. 12mo. New revised edition Cloth, 3 50 
 
 On the Treatment of Pulmonary Consumption, by Hygiene, Cli- 
 mate, and Medicine. Thin 8vo. Cloth, 1 50* 
 
 BILLINGS (F. S.). The Relation of Animal Diseases to the Public 
 Health, and their Prevention. By Frank S. Billings, D. V. S., 
 Graduate of the Royal Veterinary. Institute of Berlin, etc. 8vo. 
 
 Cloth, 4 00 
 
 BILLROTH (Dr. THEODOR). General Surgical Pathology and Thera- 
 peutics. A Text-Book for Students and Physicians. By Dr. Theo- 
 dor Billroth, Professor of Surgery in Vienna. From the tenth 
 German edition, by special permission of the author, by Charles E. 
 Hackley, M. D., Surgeon to the New York Eye and Ear Infirmary; 
 Physician to the New York Hospital. Fifth American edition, revised 
 and enlarged. 1 vol., 8vo , . . Cloth, $5.00* ; Sheep, 6 00* 
 
2 
 
 PRICE 
 
 BRAMWELL (BYROM, M. D.). Diseases of the Heart and Thoracic 
 Aorta. By Byrom Bramwell, M. D., F. R. 0. P. E., Lecturer on the 
 Principles and Practice of Medicine and on Medical Diagnosis in the 
 Extra- Academical School of Medicine, Edinburgh ; Pathologist to 
 the Royal Infirmary, Edinburgh, etc. 1 vol.. 8vo. Illustrated with 
 Lithographs, Ohromo-Lithographs, and numerous Wood-Engravings. 
 
 Cloth, $8.00*; Sheep, $9 00* 
 
 BUCK (GURDON). Contributions to Reparative Surgery, showing its 
 Application to the Treatment of Deformities produced by Destruc- 
 tive Disease or Injury ; Congenital Defects from Arrest^or Excess 
 of Development ; and Cicatricial Contractions following Burns. 
 Illustrated by Thirty Cases and fine Engravings. 8vo Cloth, 3 00* 
 
 CARPENTER (W. B.). Principles of Mental Physiology, with their 
 Application to the Training and Discipline of the Mind, and the 
 Study of its Morbid Conditions. By William B. Carpenter, M. D., 
 etc. 12mo Cloth, 3 00 
 
 CARTER (ALFRED H.). Elements of Practical Medicine. _ By Alfred 
 H. Carter, M. D., Member of the Royal College of Physicians, Lon- 
 don ; Physician to the Queen's Hospital, Birmingham, etc. Third 
 edition, revised and enlarged. 1 vol., 12mo. {To oe published soon.) 
 
 CHAUVEAU (A.). The Comparative Anatomy of the Domesticated 
 Animals. Translated and edited by George Fleming. 8vo. Illus- 
 trated Cloth, 6 00 
 
 COMBE (ANDREW). The Management of Infancy, Physiological and 
 Moral. By Andrew Combe, M. D. Revised and edited by Sir 
 James Clark, Bart., K. C. B., M. D., F. R. S. 12mo Cloth, 1 50 
 
 CORNING (J. L.). Brain Exhaustion, with some Preliminary Consid- 
 erations on Cerebral Dynamics. By J. Leonard Corning, M. D., 
 etc. Crown 8vo Cloth, 2 00 
 
 DAYIS (HENRY G.). Conservative Surgery. With Illustrations. 
 
 8vo Cloth, 3 00* 
 
 ELLIOT (GEORGE T.). Obstetric Clinic : A Practical Contribution to 
 the Study of Obstetrics and the Diseases of Women and Children. 
 By George T. Elliot, Jr., A. M., M. D. 8vo Cloth, 4 50* 
 
 EYETZKY (ETIENNE, M. D.). The Physiological and Therapeutical 
 Action of Ergot. Being the Joseph Mather Smith Prize Essay for 
 1881. 1 vol., 8vo Limp cloth, 1 00* 
 
 FLINT'S Manual of Chemical Examinations of the Urine in Disease; 
 with Brief Directions for the Examination of the most Common 
 Varieties of Urinary Calculi. By Austin Flint, Jr., M. D. Revised 
 
 edition Cloth, 1 00* 
 
 Physiology of Man. Designed to represent the Existing State 
 
 of Physiological Science as applied to the Functions of the Human 
 Body. By Austin Flint, Jr., M. D. Complete in 5 vols. 
 
 Yol. 1. Introduction; The Blood; Circulation; Respiration. 8vo. 
 Yol. 2. Alimentation ; Digestion ; Absorption ; Lymph ; and 
 
 Chyle. 8vo. 
 Yol. 3. Secretion ; Excretion ; Ductless Glands ; Nutrition ; Ani- 
 mal Heat ; Movements; Yoice and Speech. 8vo. 
 Yol. 4. The Nervous System. 8vo. 
 Yol. 5. (With a General Index to the five volumes.) Special 
 
 Senses ; Generation. Per vol Cloth, $4.50* ; Sheep, 5 50* 
 
 The five vols, , ? ......... T , : ... , , Cloth, $22.00*; Sheep, 27 00* 
 
FLINT'S Text-Book of Human Physiology; designed for the Use of 
 Practitioners and Students of Medicine. By Austin Flint, Jr., M. D. 
 Illustrated by three Lithographic Plates, and three hundred and 
 thirteen Woodcuts. Third edition, revised. 1 vol., imperial 8vo. 
 
 Cloth, $6.00* ; Sheep, $7 00* 
 
 The Physiological Effects of Severe and Protracted Muscular 
 
 Exercise ; with Special Eeference to its Influence upon the Excre- 
 tion of Nitrogen. By Austin Flint, Jr., M. D., etc. 12mo. . . Cloth, 1 00 
 The Source of Muscular Power. Arguments and Conclusions 
 
 drawn from Observation upon the Human Subject under Conditions 
 
 of Rest and of Muscular Exercise. By Austin Flint, Jr., M. D. 12mo. 1 00 
 
 FOURNIER (ALFRED, M.D.). Syphilis and Marriage. Translated 
 
 by P. Albert Morrow, M. D. 8vo Cloth, $2.00* ; Sheep, 3 00* 
 
 FREY (HEINRICH). The Histology and Histochemistry of Man. A 
 Treatise on the Elements of Composition and Structure of the 
 Human Body. By Heinrich Frey, Professor of Medicine in Zurich. 
 Translated from the fourth German edition by Arthur E. J. Barker, 
 M. D., and revised by the author. With 608 Engravings on Wood. 
 8vo Cloth, $5.00* ; Sheep, 6 00* 
 
 GROSS (SAMUEL W., M. D.). A Practical Treatise on Tumors of the 
 
 Mammary Gland. 8vo. Illustrated 2 50* 
 
 GUTMANN (EDWARD, M. D.). The Watering-Places and Mineral 
 
 Springs of Germany, Austria, and Switzerland. Illustrated 2 50 
 
 HAMILTON (ALLAN MoL., M. D.). Clinical Electro-Therapeutics, 
 Medical and Surgical. A Hand-Book for Physicians in the Treat- 
 ment of Nervous and other Diseases. 8vo Cloth, 2 00* 
 
 HAMMOND (W. A.). A Treatise on Diseases of the Nervous System. 
 By William A. Hammond, M. D., Surgeon-General U. S. Army (re- 
 tired). Seventh edition, rewritten, enlarged, and improved. 8vo. 
 
 Cloth, $5.00* ; Sheep, 6 00* 
 
 A Treatise on Insanity, in its Medical Relations. 1 vol., 8vo. 
 
 Cloth, $5.00* ; Sheep, 6 00* 
 
 Clinical Lectures on Diseases of the Nervous System. Delivered 
 
 at Bellevue Hospital Medical College. Edited by T. M. B. Cross, 
 
 M. D. 8vo Cloth, 3 50* 
 
 HART (D. BERRY). Atlas of Female Pelvic Anatomy. By D. Berry 
 Hart, M. D., Lecturer on Midwifery and Diseases of Women, School 
 of Medicine, Edinburgh, etc. With Preface by Alexander J. C. 
 Skene, M. D., Professor of the Medical and Surgical Diseases of 
 Women, Long Island College Hospital, Brooklyn. Large 4to, 37 
 Plates with 150 Figures, and 89 pages descriptive text. 
 
 (To be 'published soon.) 
 
 HARYEY (A.). First Lines of Therapeutics. 12mo Cloth, 1 50* 
 
 HOFFMANN-ULTZMANN. Introduction to an Investigation of Urine, 
 with Special Reference to Diseases of the Urinary Apparatus. By 
 M. B. Hoffmann, Professor in the University of Gratz, and R. Ultz- 
 mann, Tutor in the University of Vienna. Second enlarged and 
 improved edition. 8vo Cloth, 2 00* 
 
 HOWE (JOSEPH W.). Emergencies, and How to Treat Them. By 
 
 Joseph W. Howe, M. D. Fourth edition, revised. 8vo Cloth, 2 50* 
 
 The Breath, and the Diseases which give it a Fetid Odor. With 
 
 Directions for Treatment. Second edition, revised and corrected. 
 12mo Cloth, 1 00 
 
 HUXLEY (T. H., LL. D.). The Anatomy of Vertebrated Animals. 
 
 12mo. Illustrated Cloth, 2 50 
 
PRICE 
 
 JONES (H. MACNAUGHTON). Practical Manual of Diseases of 
 Women and Uterine Therapeutics. For Students and Practitioners. 
 By H. Macnaughton Jones, M. D., P. K. 0. S. I. and E., Examiner in 
 Obstetrics, Royal University of Ireland; Fellow of the Academy of 
 Medicine in Ireland; and of the Obstetrical Society of London, etc. 
 1 vol., 12mo. 410 pages. 188 Illustrations. {Ready soon.) 
 
 KEYES. The Tonic Treatment of Syphilis, including Local Treatment 
 of Lesions. By E. L. Keyes, Adjunct Professor of Surgery, and 
 Professor of Dermatology, B. H. M. C, and Surgeon to Bellevue 
 Hospital. 8vo Cloth, $1 00* 
 
 KINGSLEY (N. W., M. D.). A Treatise on Oral Deformities as a 
 Branch of Mechanical Surgery. With over 350 Illustrations. 8vo. 
 
 Cloth, $5.00* ; Sheep, 6 00* 
 
 LEGG (J. WICKHAM, M. D.). On the Bile, Jaundice, and Bilious Dis- 
 eases. With Illustrations in Chromo-Lithography. 8vo. 
 
 Cloth, $6.00*; Sheep, 7 00* 
 
 LITTLE (W. J.). Medical and Surgical Aspects of In-Knee (Genu- 
 Valgum) : its Relation to Rickets, its Prevention, and its Treatment, 
 with and without Surgical Operation. By W. J. Little, M. D. Illus- 
 trated by upward of Fifty Figures and Diagrams. 8vo Cloth, 2 00* 
 
 LUSK (WILLIAM T., M. D.). The Science and Art of Midwifery. 
 
 8vo. With 226 Illustrations Cloth, $5.00* ; Sheep, 6 00* 
 
 LUYS (J.). The Brain and its Functions. With Illustrations. 12mo. 
 
 Cloth, 1 50 
 
 MARKOE (T. M.). A Treatise on Diseases of the Bones. By Thomas 
 M. Markoe, M. D., Professor of Surgery in the College of Physicians 
 and Surgeons. With Illustrations. 8vo Cloth, 4 50* 
 
 MAUDSLEY (HENRY). Body and Mind : an Inquiry into their Con- 
 nection and Mutual Influence, specially in reference to Mental 
 Disorders. An enlarged and revised edition, to which are added 
 Psychological Essays. By Henry Maudsley, M. D. 12mo. . .Cloth, 150 
 
 Physiology of the Mind. Being the first part of a third edition, 
 
 revised, enlarged, and in great part rewritten, of " The Physiology 
 
 and Pathology of the Mind." 12mo Cloth, 2 00 
 
 Pathology of the Mind. Third edition. 12mo Cloth, 2 00 
 
 Responsibility in Mental Disease. 12mo Cloth, 1 50 
 
 NEFTEL (WM. B., M. D.). Galvano-Therapeutics. The Physiological 
 and Therapeutical Action of the Galvanic Current upon the Acoustic, 
 Optic, Sympathetic, and Pneumogastric Nerves. 12mo Cloth, 1 50* 
 
 NEUMANN (ISIDOR). Hand-Book of Skin Diseases. By Dr. Isidor 
 Neumann. Translated hy Lucius D. Bulkley, A. M., M. D. Illus- 
 trated by 66 Wood Engravings. 8vo Cloth, $4.00* ; Sheep, 5 00* 
 
 THE NEW YORK MEDICAL JOURNAL (weekly). Edited by Frank 
 
 P. Foster, M. D Terms per annum, 5 00* 
 
 General Index, from April, 1865, to June, 1876 (23 vols.) 75* 
 
 NIEMEYER (Dr. FELIX YON). A Text-Book of Practical Medicine, 
 with particular reference to Physiology and Pathological Anatomy. 
 Containing all the author's Additions and Revisions in the eighth 
 and last German edition. Translated from the German edition, by 
 George H. Humphreys, M. D., and Charles E. Hackley, M. D. 2 
 vols., 8vo Cloth, $9.90*; Sheep, 11 00* 
 
5 
 
 PRICfi 
 
 NIGHTINGALE'S (FLORENCE) Notes on Nursing. 12mo. . . .Cloth, $0 75 
 
 OSWALD. Physical Education; or, The Health Laws of Nature. By 
 
 Felix L. Oswald, M. D. 1 vol., 12mo Cloth, 100 
 
 PEASLEE (E. R.). A Treatise on Ovarian Tumors : their Pathology, 
 Diagnosis, and Treatment, with reference especially to Ovariotomy. 
 By E. R. Peaslee, M. D. In one large vol., 8vo. With Illustrations. 
 
 Cloth, $5.00*; Sheep, 6 00* 
 
 PEREIRA'S (Dr.) Elements of Materia Medica and Therapeutics. 
 Abridged and adapted for the Use of Medical and Pharmaceutical 
 Practitioners and Students, and comprising all the Medicines of the 
 British Pharmacopoeia, with such others as are frequently ordered in 
 Prescriptions, or required by the Physician. Edited by Robert Bent- 
 ley and Theophilus Redwood. Royal 8vo. . ..Cloth, $7.00*; Sheep, 8 00* 
 
 POORE (C. T.). Osteotomy and Osteoclasis, for the Correction of 
 Deformities of the Lower Limbs. By Charles T. Poore, M. D., Sur- 
 geon to St. Mary's Free Hospital for Children, New York. 8vo. 
 
 {Nearly ready.) 
 
 QUAIN. A Dictionary of Medicine, including General Pathology, Gen- 
 eral Therapeutics, Hygiene, and the Diseases peculiar to Women and 
 Children. By Various Writers. Edited by Richard Quain, M. D., 
 F. R. S. In one large Svo volume, with complete Index, and 138 
 Illustrations. Sold only by subscription Half mor., 8 00* 
 
 RANNEY (AMBROSE L.). Applied Anatomy of the Nervous System, 
 being a Study of this Portion of the Human Body from a Stand- 
 point of its General Interest and Practical Utility, designed for Use 
 as a Text-Book and as a Work of Reference. 8vo. 
 
 Cloth, $4.00*; Sheep, 5 00* 
 
 RIBOT (TH.). Diseases of Memory : an Essay in the Positive Psychol- 
 ogy. Translated from the French by William Huntington. 12mo. 
 
 Cloth, 1 50 
 
 ROSENTHAL (I.). General Physiology of Muscles and Nerves. With 
 
 75 Woodcuts. 12mo Cloth, 1 50 
 
 ROSCOE-SCHORLEMMER. Treatise on Chemistry. 
 
 Vol. 1. Non-Metallic Elements. 8vo Cloth, 5 00 
 
 Vol. 2. Part I. Metals. 8vo Cloth, 3 00 
 
 Vol. 2. Part II. Metals. 8vo Cloth, 3 00 
 
 Vol. 3. Part I. The Chemistry of the Hydrocarbons and their De- 
 rivatives 5 00 
 
 Vol. 3. Part II. The Chemistry of the Hydrocarbons and their De- 
 rivatives ". 5 00 
 
 SAYRE (LEWIS A., M. D.). Practical Manual of the Treatment of 
 Club-Foot. By Lewis A. Sayre, M. D., Professor of Orthopedic 
 Surgery in the Bellevue Hospital Medical College, etc. Fourth edi- 
 tion, enlarged and corrected. 12mo Cloth, 1 25* 
 
 Lectures on Orthopedic Surgery and Diseases of the Joints, de- 
 livered at Bellevue Hospital Medical College. New edition, illustrated 
 with 324 Engravings on Wood. Svo Cloth, $5.00* ; Sheep, 6 00* 
 
 SCHROEDER (Dr. KARL). A Manual of Midwifery, including the 
 Pathology of Pregnancy and the Puerperal State. By Dr. Karl 
 Schroeder, Professor of Midwifery, and Director of the Lying-in 
 Institution, in the University of Erlangen. Translated into English 
 from the third German edition, by Charles H. Carter, B. A., M. D., 
 B. S., London ; Member of the Royal College of Physicians, Lon- 
 don, etc. With 26 Engravings on Wood. 8vo. 
 
 Cloth, $3.50*; Sheep, 4 50* 
 
6 
 
 PRICE 
 
 SIMPSON (Sir JAMES Y.). Selected Works: Anaesthesia, Diseases of 
 
 Women. 3 vols., 8vo. Per volume Cloth, $3.00* ; Sheep, $4 00* 
 
 SMITH (EDWAKD, M. D.). Foods. {International Scientific Series.). 1 75 
 
 STEINER. Compendium of Children's Diseases : a Hand-Book for 
 Practitioners and Students. By Dr. Johannes Steiner, Professor of 
 Diseases of Children in the University of Prague, etc. Translated 
 from the second German edition, by Lawson Tait, F. R. C. S., etc. 
 8vo Cloth, $3.50* ; Sheep, 4 50* 
 
 STONE (E. FRENCH). Elements of Modern Medicine, including Prin- 
 ciples of Pathology and of Therapeutics, with many Useful Memo- 
 randa and Valuable Tables of Reference. Accompanied by Pocket 
 Fever Charts. Designed for the Use of Students and Practitioners 
 of Medicine. In wallet-book form, with pockets on each cover for 
 Memoranda, Temperature Charts, etc. By R. French Stone, M. D., 
 Professor of Materia Medica and Therapeutics and Clinical Medicine 
 in the Central College of Physicians and Surgeons, Indianapolis; 
 Physician to the Indiana Institute for the Blind ; Consulting Physi- 
 cian to the Indianapolis City Hospital, etc., etc. {In preparation.) 
 
 SWETT'S Diseases of the Chest. 8vo Cloth, 3 50* 
 
 TYNDALL (JOHN). Essays on the Floating Matter of the Air, in 
 
 Relation to Putrefaction and Infection. 12mo Cloth, 1 50 
 
 ULTZMANN (Dr. ROBERT). Pyuria, or Pus in the Urine, and its 
 Treatment. By Dr. Robert Ultzmann, Professor of Genito-Urinary 
 Diseases in the Vienna Poliklinik. Translated by permission, by 
 Dr. Walter B. Piatt, F. R. C. S. (Eng.). {Nearly ready.) 
 
 VAN BUREN (W. H.). Lectures upon Diseases of the Rectum, and 
 the Surgery of the. Lower Bowel, delivered at Bellevue Hospital 
 Medical College, by W. H. Van Buren, M. D., LL. D. Kew edition, 
 enlarged and rewritten. 8vo Cloth, $3.00* ; Sheep, 4 00* 
 
 Lectures on the Principles and Practice of Surgery. Delivered 
 
 at Bellevue Hospital Medical College, by the late W. H. Van Buren, 
 M.D., LL.D., etc. Edited by Lewis A. Stimson, M.D. 8vo. {In press.) 
 
 VAN BUREN and KEYES. A Practical Treatise on the Surgical 
 Diseases of the Genito-Urinary Organs, including Syphilis. De- 
 signed as a Manual for Students and Practitioners. With Engrav- 
 ings and Cases. By W. H. Van Buren, M. D., LL. D., and Edward 
 L. Keyes, A. M., M. D. 8vo Cloth, $5.00* ; Sheep, 6 00* 
 
 VOGEL (A.). A Practical Treatise on the Diseases of Children. By 
 Alfred Vogel, M. D., Professor of Clinical Medicine in the Univer- 
 sity of Dorpat, Russia. Translated and edited by H. Raphael, M. D. 
 From the fourth German edition. Illustrated by six Lithographic 
 Plates. 8vo Cloth, $4.50*; Sheep, 5 50* 
 
 WAGNER (RUDOLF). Hand-Book of Chemical Technology. Trans- 
 lated and edited from the eighth German edition, with extensive 
 Additions, bv William Crookes, F. R. S. With 336 Illustrations. 
 8vo, 761 pages Cloth, 5 00 
 
 WALTON (GEORGE E., M. D.). Mineral Springs of the United States 
 and Canadas. Containing the latest Analyses, with full Description 
 of Localities, Routes, etc. 12mo Cloth, 2 00 
 
 WELLS (Dr. T. SPENCER). Diseases of the Ovaries. 8vo. . . .Cloth, 4 50* 
 
 WYLIE (WILLIAM G.). Hospitals: Their History, Organization, and 
 
 Construction. By W. Gill Wylie, M. D. 8 vo Cloth, 2 50* 
 
THE 
 
 POPULAR 3GIENGE MONTHLY. 
 
 CONDUCTED BY E, L AND W, J, YOUMANS. 
 
 The Popular Science Monthly was established thirteen years ago to bring before 
 the general public the results of scientific thought on many large and important ques- 
 tions which could find no expression in the current periodicals. Scientific inquiry was 
 penetrating many new fields, extending important knowledge, and profoundly affecting 
 opinion upon numberless questions of speculative and practical interest. It was the 
 policy of this magazine at the outset, and has been constantly adhered to since, to obtain 
 the ablest statements from the most distinguished scientific men of all countries in their 
 bearing upon the higher problems of investigation. Leaving the dry and technical details 
 of science, which are of chief concern to specialists, to the journals devoted to them, 
 The Popular Science Monthly has dealt with those more general and practical subjects 
 which are of the greatest interest and importance to the people at large. 
 
 That which was at first a dubious experiment has now become an assured and perma- 
 nent success. Our Monthly is the acknowledged organ of progressive scientific ideas in 
 this country. Received with favor at the outset, it has gone on increasing in circulation 
 and in influence, until its power is felt and acknowledged in the highest departments of 
 intellectual activity, and its leadership is recognized in the great work of liberalizing and 
 educating the popular mind. 
 
 Making neither sensational appeals nor flaring announcements, we may now refer to 
 its course in the past as a sufficient guarantee that it will continue to discuss in the same 
 earnest and fearless, but always respectful manner, the various important questions fall- 
 ing within its scope that are entitled to the intelligent consideration of thinking people. 
 
 Science is the great agency of improvement in this age, private and public, individual, 
 social, professional, and industrial. In its irresistible progress it touches everywhere, 
 and affects everybody. It gives law to the material interests of the community, and 
 modifies its ideas, opinions, and beliefs, so that all have an interest in being informed of 
 its advancement. Those, therefore, who desire to know what is going on in the world of 
 thought in these stirring times, when new knowledge is rapidly extending, and old errors 
 are giving way, will find that they can keep informed only by subscribing for The Popu- 
 lar Science Monthly. 
 
 " This is one of the very best periodicals 
 of its kind published in the' world. Its corps 
 of contributors comprise many of the ablest 
 minds known to science and' literature." — 
 American Medical Journal (St. Louis). 
 
 " No scientific student can dispense with 
 this monthly, and it is difficult to understand 
 how any one making literary pretensions fails 
 to become a regular reader of this journal. 
 4 The Popular "Science Monthly ' meets a 
 want of the medical profession not otherwise 
 met. It keeps full pace with the progress of 
 the times in all the departments of scientific 
 pursuit." — Virginia Medical Monthly. 
 
 "Every physician's cable should bear 
 this valuable monthly, which we believe to 
 be one of the most interesting and instruct- 
 ive of the periodicals now published, and 
 one which is destined to play a larare part in 
 the mental development of the laity of this 
 country." — Canadian Journal of Medical 
 Science. 
 
 " Outside of medical journals, there is 
 no periodical published in America as well 
 worthy of being placed upon the physician's 
 library-table and regularly read W him as 
 4 The Popular Science Monthly.' "—St. Louis 
 Clinical Record. 
 
 TERMS: $5.00 per Annum, in advance. 
 
 The New York Medical Journal and The Popular Science Monthly to 
 the same address, $9.00 per Annum (full price, $10.00). 
 
 D. APPLETON & CO., 1, 3, & 5 Bond Street, New York, 
 
THE 
 
 New York Medical Journal, 
 
 A Weekly Review of Medicine, 
 
 PUBLISHED BY 
 
 D. APPLETON & CO. 
 
 The New York Medical Journal, now in the twentieth year of its publication, is 
 published every Saturday, each number containing twenty-eight large, double-columned 
 pages of reading matter. By reason of the condensed form in which the matter is ar- 
 ranged, it contains more reading matter than any other journal of its class in the United 
 States. It is also more freely illustrated, and its illustrations are generally better exe- 
 cuted, than is the case with other weekly journals. 
 
 The special departments of the Journal are as follows : 
 
 LECTURES AND ADDRESSES.— The effort is made to present didactic and clinical 
 lectures, each in due proportion, and to give under this head only such lectures as are of 
 interest to the great body of the profession. 
 
 ORIGINAL COMMUNICATIONS. — These articles cover the whole range of the 
 medical sciences, and include only those that are actually contributed by authors, and 
 those that have been read before societies with which the Journal has a special arrange- 
 ment (including the New York Surgical Society, the New York Obstetrical Society, the 
 New York Clinical Society, and the Medical Society of the County of Kings). 
 
 CLINICAL REPORTS. — These include reports of interesting cases in hospital practice. 
 
 BOOK NOTICES. — In this department books are noticed strictly in accordance with 
 their merits. 
 
 CORRESPONDENCE. — Under this head we include only letters from the regular cor- 
 respondents of the Journal, chance communications being given under a separate heading. 
 
 LEADING ARTICLES. — Under this head we class the longer and more formal edi- 
 torial articles. They consist either of resumes of scientific contributions, or of comments 
 on matters of interest to the profession as a class, its welfare and its dignity. 
 
 MINOR PARAGRAPHS. NEWS ITEMS. 
 
 OBITUARY NOTES refer for the most part to well-known members of the profes- 
 sion, both in this country and abroad. 
 
 LETTERS TO THE EDITOR embrace short communications from others than our 
 regular correspondents. 
 
 PROCEEDINGS OF SOCIETIES.— The Journal gives the proceedings of all the 
 leading societies, national, State, and local, in a condensed form, but with a degree of 
 fullness commensurate with their interest to the profession. 
 
 REPORTS ON THE PROGRESS OF MEDICINE include abstracts of the better 
 part of current literature, prepared by a staff of gentlemen specially employed for the 
 purpose. These reports cover the whole range of medicine. 
 
 MISCELLANY.— Under this head will be found abstracts which it is thought desirable 
 to give in advance of the regular time for their appearance in the formal reports, espe- 
 cially Therapeutical Notes, which, published in nearly every number, furnish the reader 
 with the therapeutical novelties of the day. 
 
 The volumes begin with January and July of each year. Subscriptions can be ar- 
 ranged to begin with the volume. 
 
 TERMS, PAYABLE IN ADVANCE. 
 
 One Year $5 00 | Six Months $2 50 
 
 (No subscriptions received for less than Six MontJis.) 
 Binding- Cases, Cloth 50 
 
 The Popular Science Monthly and The New York Medical Journal to the same 
 address, $9.00 per annum (full price, $10.00). 
 
 D. APPLETON & CO., 1, 3, & 5 Bond Street, New York. 
 

 LIBRARY OF CONGRESS 
 
 00DEt3lS73fl^ 
 
 
 .'Xvlv.vlvIvX