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LIBRARY  OF  CONGRESS. 


^v 


©gap. Sopijrigtjt  jf  a.. 

UNITED  STATES  OF  AMERICA. 


Case  of  Xanthelasma. 


THE 


READY-REFERENCE  HANDBOOK 


OF 


DISEASES  OF  THE  SKIN. 


BY 


GEORGE  THOMAS  JACKSON,  M.D.  (Col.)  , 


CHIEF   OF    CL1NJC   AND   INSTRUCTOR    IN    DERMATOLOGY,  COLLEGE  OF  PHYSICIANS   AND   SURGEONS, 
NEW  YORK  J    PROFESSOR  OF  DERMATOLOGY   IN    THE   WOMAN'S   MEDICAL   COLLEGE  OF  THE 
NEW  YORK    INFIRMARY;    CONSULTING   DERMATOLOGIST   TO   THE    PRESBYTERIAN 
HOSPITAL;    VISITING   DFRMATOLOGIST  TO  THE  RANDALl.'s  ISLAND  HOS- 
PITALS ;    MEMBER  OF  THE   AMERICAN    DERMATOLOGICA L  ASSO- 
CIATION  AND    OF   THE    NEW    YORK    DERMATOLOGICAL 
SOCIETY;      FELLOW     OF     THE     NEW     YORK 
ACADEMY    OF    MEDICINE,    ETC. 


WITH    FIFTY    ILLUSTRATIONS 


frTOF  cofj, 


SEP  24    1892   j 


PHILADELPHIA: 
LEA   BROTHERS   &   CO. 

1892, 


^^ 


Entered  according  to  Act  of  Congress  in  the  year  1892,  by 

LEA    BROTHERS    &    CO., 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


I)  U  K  IS  A  N ■  ,       I'EINl'ER 


PREFACE. 


The  following  pages  are  intended  to  present  the  art  of 
dermatology  as  it  now  exists.  No  attempt  has  been  made  to 
discuss  debatable  questions.  Hence  pathology  and  etiology 
do  not  receive  as  full  consideration  as  symptomatology,  diag- 
nosis, and  treatment. 

The  alphabetical  arrangement  of  the  different  diseases  has 
been  adopted  for  convenience  of  ready  reference.  It  is  hoped 
that  the  large  number  of  titles  from  foreign  languages  will 
prove  as  acceptable  as  it  is  novel,  and  that  the  pronunciations 
of  the  various  names  will  be  helpful.  I  would  impress  upon 
the  reader  the  fact  that  in  the  prescriptions  given  no  attempt 
has  been  made  to  translate  grains,  drachms,  and  ounces  into 
their  precise  equivalents  in  grammes,  but  simply  to  preserve 
the  relative  percentages  of  the  ingredients  in  the  old  formula? 
and  express  them  in  decimals.  The  decimals  may  be  regarded 
as  either  grammes  or  parts. 

It  gives  me  the  greatest  pleasure  to  acknowledge  in  this 
place  and  always  my  great  obligations  to  my  friends,  Drs. 
George  Henry  Fox,  Edward  Bennett  Bronson,  and  Robert 
William  Taylor.  To  the  first  two  I  owe  a  great  deal  of  what- 
ever knowledge  of  dermatology  I  may  possess,  and  from  all  of 
them  I  have  received  many  of  those  kindly  courtesies  that 
make  a  professional  life  worth  living. 

To  Dr.  F.  P.  Foster  I  would  return  most  grateful  thanks 
for  his  kind  permission  to  use  the  system  of  pronunciation 
from  his  admirable  Illustrated  Encyclopaedic  Medical  Dic- 
tionary, and  for  his  courtesy  in  providing  me  with  the  pro- 
nunciation of  many  names  in  advance  of  their  appearance  in 
the  same. 


IV  PREFACE. 

I  would  also  acknowledge  my  indebtedness  to  Dr.  A.  Rupp 
for  special  contributions  upon  eczema  and  furuncle  of  the 
ear,  and  to  all  those  workers  in  dermatology  from  whose 
writings  I  have  drawn  freely  so  as  to  make  this  little  book 
a  presentation  of  modern  dermatology.  The  admirable  text- 
book of  Dr.  H.  R.  Crocker,  of  London,  has  been  specially 
consulted  by  me,  and  has  guided  me  through  many  a  dif- 
ficulty. 

Messrs.  William  Wood  &  Co.  and  D.  Appleton  &  Co.  have 
most  courteously  permitted  me  to  make  use  of  some  papers 
of  mine  published  in  The  Medical  Record,  The  New  York 
Medical  Journal,  and  The  Journal  of  Cutaneous  and  Genito- 
urinary Diseases  during  the  past  years. 

14  East  Thirty-First  Street, 

New  York,  August,  1892. 


DISEASES  OF  THE  SKIN. 


PAET   I. 

GENERAL  CONSIDERATIONS. 

Anatomy  and  Physiology  of  the  Skin. 

Before  we  enter  upon  the  consideration  of  the  separate 
diseases  of  the  skin,  it  will  be  well  for  us  to  refresh  our 
memory  as  to  its  anatomy.  It  is  not  my  desire  to  give  a 
complete  and  exhaustive  chapter  on  this  subject,  but  to 
draw  attention  to  those  properties  of  the  cutaneous  envelope 
that  are  of  practical  importance  to  us.  For  a  more  extended 
consideration  of  the  subject,  the  student  is  referred  to  the 
" Handbook  of  Skin  Diseases"  of  Ziemssen's Encyclopedia,1 
where  he  will  find  Unna's  masterly  article. 

The  skin  is  made  up  of  three  distinct  layers,  namely  :  1 , 
the  epidermis ;  2,  the  derma,  also  named  the  cutis  vera  or 
corium ;  and,  3,  the  subcutaneous  connective  tissue.  The 
appendages  of  the  skin  are  the  hair  and  the  nails,  the  seba- 
ceous and  the  sweat  glands.  This  complicated  structure  is 
supplied  with  bloodvessels,  lymphatics,  and  nerves. 

Epidermis.  The  epidermis  is  composed  of  four  layers, 
called  strata,  namely :  1,  the  stratum  corneum ;  2,  the  stratum 
lucidum ;  3,  the  stratum  granulosum  ;  and,  4,  the  stratum 
mucosum.  Of  these  strata,  the  two  that  most  concern  us 
are  the  first  and  the  last — that  is,  the  stratum  corneum  and 
the  stratum  mucosum.  The  other  layers  of  the  skin  may, 
for  our  present  purpose,  be  regarded  as  simply  transition 

1  "Handbuch  der  Hautkrankheiten,"  Bd.  xiv.  Ziemssen's  Encyclo- 
paedia. 


26 


GENERAL    CONSIDERATIONS. 


layers  through  which  an  epithelial  cell  passes  on  its  develop- 
mental way  to  become  a  fully  formed  and  rightly  compacted 


Fig.  1. 


Vertical  section  through  the  skin.     (After  Heitzmann.)     Diagrammatic. 


ANATOMY    OF    THE    SKIN.  27 

corneous  cell.  Each  of  the  four  strata  of  the  epidermis  is 
divided  again  into  layers,  but  these  are  of  no  practical  im- 
portance. 

The  stratum  corneum  consists  of  a  series  of  superimposed 
layers  of  flattened,  elongated  cells,  that  increase  in  flatness 
from  below  upward.  The  upper  layers  are  called  scales. 
The  cells  of  each  layer  are  united  to  each  other  so  much 
closer  than  the  layer  itself  is  united  to  those  above  and 
below  it,  that  when  an  effusion  takes  place  into  the  stratum 
corneum  a  layer  of  cells  is  raised  in  the  affected  area,  and 
the  fluid  is  found  between  two  layers.  The  lamellated 
scaling  met  with  in  certain  scaly  diseases,  such  as  dermatitis 
exfoliativa,  in  which  great  plates  of  scales  are  readily  remov- 
able, is  likewise  due  to  this  close  relation  between  the  cells 
of  each  layer.  This  stratum  is  largely  a  protective  one,  its 
compactness  affording  a  fair  degree  of  resistance  to  injury 
of  the  underlying,  more  succulent  layers  of  the  epidermis. 

The  stratum  mucosum  is  the  deepest  layer  of  the  epi- 
dermis, and  is  seated  upon  the  papillary  layer  of  the  corium. 
It  is  composed  of  several  layers  of  cells,  but  may  be  con- 
sidered to  consist  of  two  chief  layers,  namely,  the  columnar 
epithelium  and  the  prickle  cells.  The  columnar  epithelium 
are  arranged  perpendicularly  to  the  papillae  of  the  corium, 
while  the  prickle  cells,  which  are  polygonal  in  shape  with 
spherical  nuclei  and  with  little  filaments  running  out  from 
their  sides  toward  the  neighboring  cells,  are  arranged  in 
strata  over  them.  As  the  stratum  granulosum  is  approached, 
the  prickle  cells  become  flatter,  and  finally  lie  with  their 
long  axis  parallel  to  the  general  surface.  The  stratum 
mucosum,  also  called  the  rete  Malpighii,  is  the  most  important 
stratum  of  the  epidermis,  and  the  seat  of  that  most  common 
of  all  skin  diseases,  eczema.  From  its  lower  part  it  sends 
down  projections  between  the  papillae  of  the  corium,  which 
are  called  inter-papillary  projections.  Most  of  the  pigment 
of  the  skin  is  situated  in  the  lower  part  of  the  stratum  mu- 
cosum. As  the  upper  part  is  approached,  less  and  less 
pigment  is  found.  The  pigment  itself  is  in  the  form  of 
granules  and  of  diffused  coloring  matter.  According  to 
Unna  the  pigment  is  found  even  in  the  upper  part  of  this 


28  GENERAL    CONSIDERATIONS. 

layer,  while  in  pathological  conditions  it  may  be  located  in 
the  corium. 

From  this  arrangement  of  the  cells  of  the  epidermis  it 
will  be  seen  that  nutrient  fluids  can  readily  work  upward 
from  below  by  means  of  the  little  channels  formed  by  the 
interlacing  of  the  filaments  running  between  the  cells. 

The  epidermis  has  no  bloodvessels.  It  receives  its  nutri- 
tion entirely  from  the  corium.  Though  there  are  no  true 
lymphatics  in  the  epidermis,  there  are  abundant  lymph 
spaces  between  the  cells  that  take  their  place.  Nerves  of 
the  non-medullated  variety  have  been  traced  between  the 
cells  of  the  epidermis,  and  have  been  described  by  some 
histologists  as  entering  into  the  cells  to  end  at  the  nucleus, 
though  not  to  enter  it.  The  final  distribution  of  the  nerves 
in  the  epidermis  is  not  yet  fully  determined. 

Corium.  The  corium  is  composed  of  white  fibrous  and 
yellow  connective  tissue,  disposed  in  horizontal  bundles 
above  and  in  oblique  bundles  below.  It  is  a  very  dense  and 
tough  tissue,  and  is  pierced  in  all  directions  to  allowT  of  the 
passage  of  bloodvessels,  lymphatics,  sweat  ducts,  and  nerves, 
and  aifords  lodgment  for  the  hair  follicles  and  sebaceous 
glands.  It  contains  a  considerable  amount  of  elastic  fibres. 
The  upper  part  has  been  named  the  'pars papillaris  and  the 
lower  part,  the  pars  reticularis  corii.  From  its  upper  part 
it  sends  off  a  vast  number  of  projections  called  papilloz. 
These  vary  in  length,  being  longest  and  most  marked  on  the 
ends  of  the  fingers  and  toes.  The  epidermis  follows  these  pro- 
jections, and  dips  down  between  them.  They  are  readily 
seen  as  parallel  markings  on  the  ends  of  the  fingers.  Over 
most  of  the  body  surface,  the  papillae  are  but  slightly 
raised,  and  merely  give  a  wavy  appearance  to  the  upper  edge 
of  the  corium  when  viewed  under  the  microscope.  A  fine 
basement  membrane  separates  the  corium  from  the  epi- 
dermis. As  we  reach  the  lower  part  of  the  corium  the 
bundles  of  fibres  are  less  closely  crowded  together,  and  be- 
coming successively  looser  gradually  pass  over  into  the 

Subcutaneous  connective  tissue.  This  is  a  loose  connec- 
tive tissue  with  larger  or  smaller  spaces  in  it,  which  are  filled 
with  the  adipose  tissue.     This  consists  of  fat-cells  collected 


ANATOMY    OF    THE    SKIN.  29 

into  lobulated  masses,  that  in  some  cases  have  about  them 
a  connective-tissue  sheath.  Each  lobule  is  supplied  with  an 
afferent  artery,  a  capillary  plexus  about  it,  and  efferent 
veins.  This  part  of  the  skin  is  called  the  panniculus  adi- 
posus,  and  is  found  everywhere  except  in  the  skin  of  the 
penis,  scrotum,  labia  minora,  eyelids,  pinna,  and  beneath 
the  nails.  It  contributes  to  the  roundness  and  beauty  of 
the  body,  besides  acting  as  a  storehouse  for  fuel  against 
such  times  as  the  body  cannot  gain  its  proper  nutriment 
from  food,  as  in  fevers.  It  also  gives  lodgment  to  the  coil 
or  sweat  glands.  The  lower  end  of  the  deep  hair  follicles 
are  also  in  this  part  of  the  skin.  The  subcutaneous  tissue 
merges  into  the  underlying  fasciae  of  the  muscles,  and  the 
periosteum  of  the  bones. 

Bloodvessels.  The  arteries  which  supply  the  skin 
come  up  from  below  to  form  a  horizontal  plexus  in  the  sub- 
cutaneous tissue  from  which  the  vessels  proceed  perpen- 
dicularly through  the  corium  to  form  a  second  horizontal 
plexus  just  below  the  papilla?.  From  the  lower  plexus 
small  branches  pass  to  the  fat-cells,  sweat  glands,  and,  ac- 
cording to  Unna,  to  the  papillae  of  the  hair.  From  the 
upper  plexus  branches  are  given  off  which  enter  the  papillae. 
There  are  also  branches  to  the  hair  follicles,  sebaceous 
glands,  and  the  tissue  of  the  corium  itself.  Papillae  that 
give  lodgment  to  a  tactile  corpuscle  have  no  arterial  twig. 
The  veins  follow  the  same  course  as  the  arteries,  but,  of 
course,  in  the  opposite  direction. 

Nerves.  The  skin  is  provided  with  both  medullated 
and  non-medullated  nerve  fibres.  We  have  already  learned 
that  non-medullated  nerve  fibres  have  been  traced  between 
the  cells  of  the  epidermis,  some  terminating  at,  if  not  in, 
the  nuclei  of  the  cells.  It  may  be  roughly  stated  that  the 
nerves  follow  pretty  much  the  same  arrangement  as  the 
bloodvessels,  forming  a  sort  of  plexus  beneath  the  papillae 
and  then  giving  off  branches  to  the  vessels,  to  the  tactile 
corpuscles,  to  the  papillae,  the  hair  follicles,  the  sebaceous 
and  sweat  glands,  and  the  epidermis. 

The  tactile  corpuscles  (corpuscles  of  Meissner)  are  located 
in  the  papillae.     They  are  oval  or  round  bodies,  and  their 


30  GENERAL    CONSIDERATIONS. 

long  axis  runs  longitudinally.  Not  more  than  one  papilla 
in  four  is  supplied  with  one  of  these  corpuscles,  even  where 
they  are  most  abundant — at  the  end  of  the  index  finger. 
They  are  composed,  according  to  Unna,  of  large,  flat,  con- 
nective-tissue cells  which  are  placed  one  above  the  other 
like  money-rolls,  and  take  up  between  them  the  terminal 
branches  of  the  medullated  nerves,  which  on  entering  the 
bodies  lose  their  medulla  and  finally  end  between  the  cells. 
The  transversely  striped  appearance  presented  by  the 
corpuscles  is  due  to  the  swollen  lateral  edges  of  the  cells, 
and  the  band-like  nerve  fibres  that  here  and  there  appear 
upon  the  surface. 

The  Pacinian  corpuscles  are  located  in  the  subcutaneous 
tissues,  and  also  in  connection  with  the  sensitive  nerves. 
They  are  oval  in  form,  visible  to  the  naked  eye,  and  con- 
sist in  a  colossal  swelling  out  of  the  sheath  of  Schwann, 
forming  a  thick  connective-tissue  capsule  surrounding  a 
much  smaller  cylindrical  cavity  filled  with  granular,  faintly 
filamentous  cellular  substance  through  the  axis  of  which 
passes  a  sensitive  nerve.  As  the  latter  enters  the  body  it 
loses  its  medulla,  and  either  terminates  in  the  corpuscle,  or 
passes  through  it  to  enter  one  or  more  corpuscles.  These 
corpuscles  are  most  abundant  in  the  fingers  and  toes,  and 
the  palms  and  soles. 

Hair.  The  hair  is  an  epidermic  structure  which  grows 
from  a  nipple-shaped  projection,  the  hair  papilla,  situated 
at  the  bottom  of  a  deep  slender  pocket  or  sac-like  depres- 
sion in  the  skin  which  is  called  the  hair  follicle.  Com- 
mencing at  the  papilla  it  is  bulb-shaped.  This  part  is 
called  the  bulb  and  fits  over  the  papilla  like  a  cap.  On 
leaving  the  papilla  the  body  of  the  hair  is  first  called  the 
root,  and  then  as  it  becomes  narrower  the  shaft.  The 
diameter  of  the  shaft  rapidly  decreases  until,  leaving  the  skin, 
it  terminates  in  the  point.  A  fully  formed  hair  is  hollow, 
its  central  cavity  being  called  the  medullary  canal  and 
filled  with  the  medulla.  This  is  composed  of  a  column  of 
cells  arranged  in  layers,  one  layer  being  superimposed  on 
another.  The  main  substance  of  the  hair  is  called  the 
cortex,  and  consists  of  long  spindle-shaped  epithelial  cells 


ANATOMY    OF    THE    SKIN. 


31 


flattened  out  into  fine  bands  and  running  in  the  long  axis  of 
the  hair.  This  part  of  the  hair  gives  its  substance  and  strength, 


Fig.  2. 


— v  ar; 


* 


Hair  in  follicle.     (After  Kaposi.) 

a.  Follicle  mouth,  b.  Neck.  c.  Arch  of  follicle,  d.  Outer,  e.  inner 
sheath  of  follicle.  f.  Hair  papilla,  m.  Fat  cells,  n.  Erector  pill  muscle. 
ep.  Epidermis,  s.  Mucous  layer  of  epidermis,  o.  Skin  papillae,  t.  Seba- 
cous  glands.  /.  External,  g.  internal  root  sheath,  h.  Cortex  of  hair.  k. 
Medullary  canal.     I.  Hair  root. 

and  in  it  is  placed  the  pigment  that  determines  the  color  of 
the  hair.  The  outer  layer  of  the  hair  is  called  the  cuticle. 
It  corresponds  to  the  epidermis,  and  consists  of  flattened, 


32  GENERAL    CONSIDERATIONS. 

non-nucleated,  fully  cornified  cells  which  cover  the  hair  like 
scales,  and  overlap  each  other  like  shingles. 

The  hair  follicle  is  located  for  the  most  part  in  the 
corium,  but  in  some  very  strong  hairs  it  reaches  down  into 
the  subcutaneous  tissue.  It  is  always,  excepting  at  the 
dorsal  edge  of  the  eyelids,  placed  at  an  angle  to  the  skin, 
and  is  a  permanent  structure  that  is  not  removed  when  the 
hair  is  plucked.  It  is  composed  of  three  layers,  which  are 
derived  from  the  corium  as  it  dips  down  to  form  the  follicle. 
Between  the  follicle  and  the  hair  we  have  the  root  sheath, 
which  is  derived  from  the  epidermis.  It  is  composed  of  two 
layers,  which  are  called  the  external  and  internal  root  sheaths. 
The  whole  arrangement  of  the  hair  and  its  sheath  may  be 
graphically  conceived  by  regarding  the  hair  as  a  blunt  needle 
pressed  against  the  skin.  The  needle  would  form  the  hair, 
the  epidermis  would  form  the  root  sheath,  and  the  corium 
would  be  to  the  outside  of  all  and  form  the  hair  follicle. 

Hair  is  found  on  all  parts  of  the  body  excepting  the 
palms  and  soles,  the  terminal  phalanges  of  the  fingers 
and  toes,  the  glans  penis,  prepuce,  labia  minora,  and  the 
vermilion  border  of  the  lips.  In  form  it  is  flattened  or 
rounded,  straight  or  curled.  There  are  three  main  varieties 
of  hair:  1.  Long,  soft  hair,  as  of  the  head  and  beard. 
2.  Short,  stiff  hair,  as  of  the  eyebrows  and  lashes ;  and  3, 
Lanugo,  or  soft,  downy,  colorless  hair  that  is  scattered  all  over 
the  surface  of  the  body  where  the  other  varieties  are  not. 

Nails.  The  nails,  like  the  hair,  are  epidermic  structures. 
They  are  placed  on  the  extensor  surfaces  of  the  terminal 
phalanges  of  the  fingers  and  toes.  Their  proximal  end  is 
called  the  root,  under  which  is  the  matrix  from  which  they 
grow.  On  the  way  to  their  distal  end  they  pass  over  the 
nail  bed.  This  is  separated  from  the  matrix  by  a  more  or 
less  convex  and  apparent  line  called  the  lunula.  At  their 
posterior  and  lateral  margins  they  are  imbedded  in  a  fold  of 
skin  that  is  called  the  nail  fold.  At  their  distal  extremity 
they  are  separated  from  the  end  of  the  finger  or  toe.  They 
are  formed  by  the  matrix,  but  in  passing  over  the  bed  they 
receive  a  certain  amount  of  nourishment  from  it,  and  their 
cells  become  rapidly  cornified.   They  are  slightly  curved  from 


ANATOMY    OF    THE    SKIN.  33 

side  to  side,  being  convex  above  and  concave  below,  and  are 
marked  with  fine  lines.  The  flesh  beneath  the  nail  is  the 
same  as  the  skin  in  general,  though  without  subcutaneous 
tissue.  The  nail  takes  the  place  of  the  corneous  and  granular 
layers  of  the  skin. 

Sebaceous  Glands.  (Fig.  1.)  These  glands  are  of  the 
racemose  variety,  and  are  closely  related  to  the  hairs,  from  two 
to  six  being  attached  to  each  hair,  emptying  by  their  ducts 
into  the  upper  third  of  the  follicle.  Each  gland  is  composed 
of  a  number  of  acini  that  empty  by  a  common  duct.  They 
are  composed  of  a  delicate  structureless  capsule,  the  mem- 
brana  propria,  which  continues  along  the  duct  to  merge  into 
the  hair  follicles.  This  is  lined  with  large,  though  short, 
cubical  or  cylindrical  epithelial  cells  arranged  in  one  or  two 
rows.  These  are  continuous  through  the  duct  with  cylindri- 
cal cells  of  the  outer  root  sheath  of  the  hair,  and  of  the  skin. 
The  interior  of  the  glands  is  filled  with  fatty  secretion. 
Around  the  gland  passes  the  external  layer  of  the  hair  follicle. 

The  function  of  the  sebaceous  glands  is  to  oil  the  hair 
and  skin,  thus  rendering  them  soft  and  supple,  and  giving 
lustre  to  the  hair.  This  oily  secretion  is  produced  by  the 
cells,  which,  as  they  reach  the  central  part  of  the  acini, 
undergo  fatty  degeneration.  The  glands  are  largest  in  the 
nose,  cheeks,  scrotum,  labia,  and  about  the  anus. 

Sweat  Glands.  (Fig.  1.)  The  sweat  glands  are  simple 
coil  glands  that  are  located  in  the  subcutaneous  tissue.  From 
here  their  ducts  ascend  through  the  corium  in  a  straight  or 
wavy  line  to  the  interpapillary  spaces,  where  they  enter  the 
epidermis,  and  then  the  sweat  makes  its  way  to  the  surface 
of  the  skin  between  the  epithelial  cells.  The  cells  lining 
the  coil  are  simple  cubical  epithelial  cells.  These  are 
seated  upon  muscular  fibres ;  and  a  connective  tissue,  the 
membrana  propria,  comes  outside  of  all.  The  duct  is  made 
up  of  pavement  epithelium  upon  a  membrana  propria. 
When  the  epidermis  is  reached  the  membrana  propria  is 
lost,  and  the  further  track  of  the  duct  seems  to  be  made  by 
the  sweat  working  its  own  channel  up  between  the  epider- 
mic cells.  Unna  teaches  that  the  sweat  produced  by  the 
coil  glands  is   mixed  with    other   elements  while    passing 

2* 


34  GENERAL    CONSIDERATIONS. 

through  the  epidermis,  so  that  the  secretion  that  appears  at 
the  sweat  pores  is  not  the  same  as  that  which  leaves  the  coils. 
He  further  teaches  that  the  office  of  the  coil  glands  is  not 
to  produce  sweat,  but  to  oil  the  skin.  This  theory  still 
needs  confirmation  before  it  can  be  accepted  as  absolutely 
true.  His  arguments  have  considerable  weight,  but  space 
will  not  allow  of  their  statement  here.  It  has  long  been 
known  that  there  was  a  certain  amount  of  oil  in  the  sweat. 
Sweat  glands  are  most  numerous  in  the  palms  and  soles. 

Muscles.  The  skin  is  provided  with  muscles,  both  of 
the  striated  and  unstriated  variety.  The  striated  muscles 
are  found  in  the  face  and  nose.  The  majority  of  the  muscles 
of  the  skin  are  involuntary  muscles.  In  the  scrotum  they 
run  parallel  with  the  raphe.  On  the  penis  and  about  the 
nipple  their  direction  is  circular.  The  arrectores  pilorum 
muscles  are  found  all  over  the  body,  running  in  a  more  or 
less  oblique  direction  from  the  bottom  of  several  papillae 
down  and  around  a  sebaceous  gland  to  be  attached  to  the 
bottom  of  a  hair  follicle.  By  contracting  they  raise  the 
hairs  to  a  perpendicular  position,  and  aid  in  pressing  out  the 
contents  of  the  sebaceous  glands. 


Diagnosis. 

The  Lesions  of  the  Skin.  There  once  was  a  time 
when  skin  diseases  were  classified  by  their  lesions.  A 
knowledge  of  the  lesions  of  the  skin  is  no  longerlnecessary 
for  purposes  of  classification,  but  it  is  essential  to  the  under- 
standing of  dermatological  literature.  It  is  well  to  become 
familiar  with  these  as  soon  as  possible,  for,  though  after  you 
have  once  become  versed  in  dermatology,  you  probably  will 
not  stop  to  think  whether  a  given  disease  is  papular,  vesic- 
ular, pustular,  or  not,  but  will  name  it  from  its  physiog- 
nomy ;  nevertheless,  in  doubtful  cases  the  recognition  of  the 
most  prominent  lesion  will  sometimes  aid  in  diagnosis.  Fur- 
thermore, time  will  be  saved  and  clearness  gained  by  using 
the  proper  phraseology  in  describing  a  case. 

We  speak  of  primary  and  secondary  lesions  of  the  skin. 


DIAGNOSIS. 


35 


By  the  first  of  these  terms  we  mean  the  form  assumed  by 
the  efflorescence  at  its  first  appearance.  By  the  second  of 
these  terms  we  mean  the  subsequent  changes  the  primary 
lesion  undergoes  of  itself,  or  as  the  result  of  extraneous 
causes  acting  upon  it.  In  running  its  course,  whether  in- 
fluenced by  treatment  or  not,  almost  every  disease  of  the 
skin  exhibits  more  than  one  lesion,  and  we  can  only  speak 
of  it  as  a  macular,  papular,  or  other  disease  from  its  most 
prominent  and  characteristic  lesion. 

The  primary  lesions  of  the  skin  are  the  macule,  the 
papule,  the  tubercle,  the  vesicle,  the  pustule,  the  bulla,  the 
wheal,  and  the  tumor.  The  secondary  lesions  of  the  skin 
are  the  crust,  the  scale,  the  excoriation,  the  fissure,  the 
ulcer,  and  the  cicatrix.  These  may  be  graphically  repre- 
sented, following  Piftard.1 


Macule 


Papule 


Tubercle 


Vesicle 


Pustule 


Bulla 


Fig.  3. 


Primary. 


LESIONS     OF    THE     SKIN. 


FiCx.  4. 

Secondary. 


Crust 


Scale 


Excoriation 


Fissure 


"V" 


Ulcer 


Cicatrix 


Wheal 


Tumor 


1  Cutaneous  Memoranda,  Wood,  1ST.  Y.,  1885. 


36  GENERAL    CONSIDERATIONS. 

Primary  Lesions.  A  macule  is  a  spot  or  stain  of  the 
skin  which  is  not  raised  above  its  surface.  It  may  be  of 
any  size  from  a  pin-point  to  the  palm  of  the  hand,  or  larger ; 
but  these  large-sized  and  diffused  non-elevated  lesions  are 
usually  spoken  of  as  patches.  It  may  be  white,  red,  brown, 
black,  blue,  pink,  or  yellow,  according  to  its  cause.  It  may 
be  due  to  hyperemia,  as  in  erythema  simplex ;  to  a  change 
in  the  pigmentation  of  the  skin,  as  in  lentigo  and  chloasma, 
where  there  is  increase  of  pigmentation,  or  in  vitiligo,  where 
there  is  decrease  of  pigmentation  ;  to  a  hemorrhage  into  the 
skin,  as  in  purpura;  to  a  development  of  bloodvessels  in 
the  skin,  as  in  naevus  vascularis  and  telangiectasis ;  to  a 
parasitic  growth  in  the  skin,  as  in  chromophytosis ;  or  a 
change  in  the  consistency  of  the  skin,  as  in  morphoea  and 
xanthoma. 

The  macule  may  be  evanescent  or  permanent;  may  re- 
main as  a  macule  during  its  existence,  or  may  give  place  to 
a  papule,  vesicle,  or  pustule.  It  is  the  simplest  of  all  the 
lesions  of  the  skin,  and  is  met  with  as  a  primary  lesion  of 
many  of  its  diseases. 

The  principal  macular  diseases  are  chloasma,  erythema 
simplex,  lentigo,  morphoea,  nsevus  simplex  and  spilus,  pur- 
pura, scleroderma,  chromophytosis,  vitiligo,  xanthoma,  and 
melasma. 

A  papule  is  a  circumscribed,  solid  elevation  of  the  skin. 
In  size  it  varies  from  that  of  a  pin-point  to  that  of  a  split- 
pea.  It  may  be  of  different  colors,  but  is  usually  some 
shade  of  red.  It  is  firm  to  the  touch.  In  form  it 
may  be  acuminated,  rounded,  flattened,  umbilicated,  or 
angular.  It  may  be  due  to  inflammation,  as  in  eczema ; 
to  a  hypertrophy  of  normal  structures,  as  in  verruca;  to 
the  heaping  up  of  epidermic  cells  about  a  hair  follicle,  as 
in  keratosis  pilaris  ;  or  to  the  retention  of  sebaceous  matter 
in  a  follicle,  as  in  comedo  and  milium. 

The  papule  may  remain  as  such  throughout  its  course, 
and  finally  be  absorbed ;  or  it  may  change  into  a  vesicle  or 
pustule ;  or  it  may  soften  and  break  down. 

Papular  diseases  have  received  the  name  of  lichenoid  dis- 
eases, and  at  one  time  we  had  a  goodly  number  of  lichens. 


DIAGNOSIS.  37 

Most  of  these  have  now  been  placed  under  other  headings, 
as  it  is  recognized  that  they  are  but  single  manifestations  of 
other  diseases.  Papular  diseases  are  apt  to  be  scaly  and 
itchy. 

The  principal  papular  diseases  are  :  lichen  tropicus,  lichen 
ruber  acuminatus  and  planus,  lichen  scrofulosorum,  lichen 
pilaris  or  keratosis  pilaris,  lichen  urticatus  or  papular  urti- 
caria, acne,  comedo,  milium,  prurigo,  and  psoriasis.  Like 
the  macule,  the  papule  is  found  in  many  diseases  that  cannot 
be  classed  as  papular. 

A  tubercle  may  be  thought  of  as  a  large  papule.  Like 
it,  it  is  a  circumscribed  solid  elevation  of  the  skin.  Indeed, 
the  diiference  between  a  papule  and  a  tubercle  is  mainly 
arbitrary  and  for  convenience.  Thus,  we  speak  of  a  solid 
lesion  up  to  the  size  of  a  split-pea  as  a  papule,  while  above 
that  it  is  spoken  of  as  a  tubercle.  Quite  commonly,  when 
a  lesion  is  larger  than  a  cherry  it  is  spoken  of  as  a  node. 
Auspitz1  makes  the  distinction  between  a  papule  and  tubercle 
on  more  scientific  grounds,  and  regards  a  tubercle  as  a  cell 
infiltration  into  the  corium.  A  tubercle  is  not  only  larger 
than  a  papule,  but  it  extends  deeper  into  the  skin.  In  form 
and  color  a  tubercle  corresponds  to  a  papule. 

Tubercles  may  be  absorbed  and  disappear  and  leave  no 
trace ;  or  they  may  break  down  and  ulcerate  and  leave 
scars,  as  in  syphilis ;  or  they  may  remain  unchanged  for  an 
indefinite  period,  as  in  molluscum. 

The  principal  tubercular  diseases  are :  carbuncle,  epithe- 
lioma, keloid,  lupus  vulgaris,  molluscum,  rhinoscleroma, 
and  xanthoma.  They  form  a  very  prominent  symptom  in 
leprosy,  syphilis,  and  erythema  multiforme.  Of  course, 
tubercular  used  in  this  sense  has  nothing  to  do  with  true 
tuberculous  processes. 

A  vesicle  is  a  circumscribed  elevation  of  the  epidermis 
that  contains  fluid,  mostly  serous.  In  size  it  varies  from  a 
pinhead  to  a  split- pea.  Its  color  is  crystalline  when  only 
serum  is  present ;  more  or  less  opaque  and  yellowish  when 
the  serum  is  mixed  with  pus,  and  of  a  reddish  hue  when 

1  Ziemssen's  Handbuch  der  Hautkrankheiten. 


38  GENERAL    CONSIDERATIONS. 

blood  is  effused  into  it.  It  may  be  pointed,  rounded,  flat- 
tened, or  umbilicated.  Vesicles  are  in  most  cases  due  to 
inflammation,  as  in  eczema.  They  may  be  due  to  simple 
serous  infusion,  as  in  erythema ;  or  to  the  retention  of 
sweat,  as  in  sudamina.  They  have  around  them,  in  many 
cases,  a  red  halo.  As  a  rule,  vesicles  are  superficial  eleva- 
tions of  the  epidermis,  and  readily  rupture  and  pour  out 
their  contents  upon  the  skin,  forming  a  yellowish  crust. 
They  may  be  below  the  mucous  layer  of  the  skin.  They 
may  remain  as  vesicles,  and  dry  up,  their  contents  being 
absorbed ;  or  they  may  become  changed  into  pustules. 

The  principal  vesicular  diseases  are :  eczema,  herpes, 
sudamina,  dysidrosis,  dermatitis  venenata,  zoster,  impetigo 
contagiosa,  and  varicella. 

A  pustule  is  a  circumscribed  elevation  of  the  epidermis 
containing  pus.  In  size  and  shape  it  corresponds  to  the 
vesicle.  Its  color  is  yellow  and  opaque ;  or  brown  or 
reddish  if  there  is  an  admixture  of  blood  with  the  pus.  It 
either  originates  as  a  pustule,  or  develops  from  a  vesicle  or 
papule.  As  a  rule,  pustules  are  inflammatory,  and  when 
they  appear  as  a  general  eruption  as  in  syphilis  they  indi- 
cate a  strumous  or  broken-down  condition.  Around  each 
pustule  there  is  very  commonly  a  well-marked  inflammatory 
areola. 

Pustules  are  prone  to  break  down  and  discharge  their 
contents  upon  the  skin,  forming  a  greenish  or  blackish  crust. 
If  located  deep  in  the  skin  they  may  leave  scars. 

The  principal  pustular  diseases  are  acne  vulgaris,  im- 
petigo, ecthyma,  sycosis,  and  furunculosus. 

A  bulla  may  be  considered  as  a  large  vesicle  or  pustule. 
It  is  of  irregular  oval  shape  or  umbilicated.  It  may  be  as 
large  as  a  split-pea,  or  reach  the  size  of  a  goose-egg.  It 
rises  up  from  the  skin  with  a  slight  areola  or  with  none  at 
all.  It  is  either  fully  distended  or  flaccid,  and  does  not 
rupture  readily.  It  may  be  a  bulla  from  the  beginning,  as 
we  see  in  pemphigus,  or  it  may  be  formed  by  the  coalescence 
of  two  or  more  vesicles ;  or  it  may  form  above  an  erythe- 
matous lesion,  as  in  erythema  multiforme.  Its  contents  are 
usually  serous,  but  this  may  give  place  in  time  to  pus. 


DIAGNOSIS.  39 

The  only  purely  bullous  disease  is  pemphigus,  but  bullae 
are  met  with  in  dermatitis,  dermatitis  herpetiformis,  ery- 
sipelas, and  erythema  multiforme. 

A  wheal  is  an  evanescent  round,  oval,  or  elongated  flat 
elevation  of  the  skin,  of  a  pinkish  or  white  color,  which  is 
more  or  less  firm  to  the  touch.  It  is  surrounded  by  a  red 
halo.  It  may  be  as  small  as  a  pea  or  as  large  as  the  palm 
of  the  hand.  Wheals  appear  suddenly,  and  disappear  within 
a  few  hours.  They  are  due  to  a  spasm  of  the  capillaries  and 
an  effusion  of  serum  into  the  meshes  of  the  skin,  the  raised 
part  being  the  site  of  the  effused  fluid,  and  the  halo  the 
congested  vessels  in  the  neighborhood.  The  disease  in 
which  wheals  are  met  with  is  urticaria.  They  can  also  be 
produced  by  contact  with  the  stinging  nettle,  or  by  sharp 
traumatism  on  skins  predisposed  to  urticaria. 

A  tumor  is  a  new  growth  in  the  skin  which  projects  more 
or  less  above  its  surface,  and  dips  down  into  the  subcutaneous 
tissues.  It  may  be  pedunculated.  It  is  rather  a  surgical 
than  a  dermatological  lesion.  Epithelioma,  fibroma,  and 
sarcoma  are  types  of  tumors.  They  are  met  with  also  in 
syphilis  and  scrofula. 

Secondakt  Lesions.  The  secondary  lesions  of  the  skin 
require  a  much  less  extended  description.  The  main  dis- 
tinction to  be  retained  in  the  student's  mind  is  that  between 
a  crust  and  a  scale.  This  can  be  readily  done  if  it  is  re- 
membered that  a  crust  is  formed  by  the  drying  of  some 
secretion  or  exudation  upon  the  skin ;  while  a  scale  is  a  dry, 
laminated  mass  of  epidermis  which  has  separated  from  the 
tissues  below,  the  product  of  imperfect  or  perverted  nutri- 
tion. Thus,  in  vesicular  eczema  when  the  exudation  dries 
on  the  skin  we  have  a  yellowish  crust ;  while  in  squamous 
eczema  we  have  thin  scales,  the  horny  layer  of  the  skin  not 
being  perfectly  produced.  Crusts  are  light-yellow  to  dark- 
green  or  black  in  color,  the  latter  indicating  an  admixture 
of  blood.  Scales  are  whitish,  grayish,  yellowish,  or  dirty 
yellow. 

Crusts  are  especially  characteristic  of  ecthyma,  some 
forms  of  eczema,  impetigo,  and  seborrhoea. 


40  GENERAL    CONSIDERATIONS. 

Scales  are  specially  abundant  in  dermatitis  exfoliativa, 
pityriasis  simplex,  pityriasis  rubra  pilaris,  psoriasis,  ichthy- 
osis, and  some  of  the  lichens. 

Excoriations  are  familiar  as  scratch-marks.  They  are 
superficial  denudations  of  the  skin.  They  are  of  value  as  a 
sign  of  itching,  as  scratching  is  their  chief  though  not  sole 
cause.  They  frequently  are  followed  by  pigmentation,  if 
the  irritation  causing  the  scratching  is  long-continued. 

Fissures  are  cracks  in  the  epidermis  extending  down  to 
the  corium.  They  are  usually  located  in  the  folds  of  the 
skin,  as  over  the  joints.  They  occur  in  diseases  attended 
by  infiltration  and  thickening  of  the  skin  by  which  its 
elasticity  is  interfered  with,  and  are  especially  seen  in 
eczema  and  syphilis.  They  often  bleed,  and  sometimes  are 
very  painful. 

Ulcers  are  irregularly  shaped  and  sized  losses  of  sub- 
stance. They  may  be  quite  small,  or  of  very  large  size. 
They  may  be  shallow,  deep,  excavated,  or  scooped  out. 
Their  edges  may  be  undermined,  as  in  scrofula ;  everted,  as 
in  epithelioma;  or  sharp-cut,  "  punched  out,"  as  in  syphilis. 
Their  secretion  may  be  scanty  or  abundant.  They  result 
either  from  some  previous  lesion  or  from  injury.  They 
occur  in  epithelioma,  chancre,  chancroid,  lupus  vulgaris, 
syphilis,  scrofula,  varicose  eczema,  ecthyma,  and  sometimes 
after  zoster,  dermatitis,  and  some  pustular  eruptions.  They 
always  heal  with  a  cicatrix,  leaving  a  scar. 

Cicatrices,  or  scars,  represent  the  effort  of  Nature  to  heal 
a  damage  to  the  skin  by  means  of  connective  tissue.  They 
only  occur  when  the  papillary  layer  of  the  skin  or  the  parts 
beneath  are  destroyed.  They  may  be  depressed,  as  in  small- 
pox ;  raised  and  puckered,  as  in  lupus  ;  smooth  and  white, 
as  in  syphilis. 

Other  Elements  of  Diagnosis.  Having  mastered 
the  lesions  of  the  skin,  we  are  now  prepared  to  study 
the  other  elements  of  diagnosis.  We  must  observe 
the  location,  distribution,  and  configuration  of  the  erup- 
tion, and  note  its  color  and  whether  or  not  it  itches. 
When  we  have  done  all  this,  and  have  come  to  a  probable 


DIAGNOSIS.  41 

conclusion  as  to  the  disease  before  us,  then  is  the  proper 
time  to  ask  the  patient  a  few  questions  as  to  his  sensations, 
and  the  duration  of  the  attack.  In  a  few  cases  of  doubtful 
diagnosis,  the  microscope  will  aid  us. 

Location.  Upon  the  face  we  meet  with  acne,  comedo, 
chloasma,  erythematous  eczema,  epithelioma,  herpes  febrilis, 
lupus  vulgaris,  milium,  rosacea,  sycosis,  and  xanthoma. 

An  eruption  occupying  the  middle  third  of  the  face,  fore- 
head, nose,  and  chin  is  in  all  probability  rosacea. 

An  eruption  occupying  the  bearded  portion  of  the  face, 
above  a  line  drawn  from  the  angle  of  the  mouth  to  the  angle 
of  the  jaw,  is  probably  sycosis.  Should  it  occupy  the 
bearded  portion  of  the  face  below  that  line  it  is  probably 
trichophytosis  capitis. 

If  a  scaly  patch  is  found  in  front  of  the  ears  it  should  put 
us  on  the  lookout  for  psoriasis,  which  will  often  be  found 
elsewhere  on  the  body.  This  point  may  be  useful  in  the 
diagnosis  of  a  doubtful  case.  If  a  raw  or  cracked  place  is 
found  behind  the  ears,  it  points  to  eczema. 

Upon  the  scalp  we  meet  with  pediculosis  capitis,  sebor- 
rhoea,  trichophytosis,  favus,  alopecia,  and  alopecia  areata. 

If  we  find  a  patch  of  pustular  eczema  upon  the  back  of 
the  head  and  about  the  nape  of  the  neck,  we  can  be  quite 
sure  that  the  case  is  one  of  pediculosis,  and  if  we  look  for 
the  nits  we  shall  find  them  either  at  the  site  of  the  eruption 
or  over  the  parietal  region. 

The  chest  is  the  favorite  location  for  chromophytosis  and 
keloid. 

Upon  the  back  we  meet  with  acne,  carbuncle,  and  the 
scratch-marks  due  to  the  irritation  from  pediculi.  If  you 
find  long,  parallel  scratch-marks  over  the  shoulder-blades  it 
is  quite  good  evidence  of  pediculi  in  the  clothing. 

The  extensor  surfaces  of  the  forearms  and  wrists  are  the 
favorite  sites  of  erythema  multiforme.  The  elbow  is  affected 
with  psoriasis ;  while  the  flexor  surfaces  give  lodgment  to 
lichen  planus  and  scabies,  and  the  bend  of  the  elbow  to 
eczema. 

Upon  the  legs  purpura,  erythema  exudativum,  and  ele- 
phantiasis are  apt  to  occur. 


42  GENERAL    CONSIDERATIONS. 

A  general  eruption  is  either  one  of  the  exanthematous 
fevers,  or  syphilis,  psoriasis,  dermatitis  exfoliativa,  pityriasis 
rubra  pilaris,  lichen  ruber  acuminatus,  lichen  planus,  eczema, 
erythema,  scabies,  or  ichthyosis. 

Of  these,  syphilis  is  most  marked  on  the  sides  of  the 
chest  and  abdomen,  and  upon  the  face  along  the  margin  of 
the  hair.  It  may  also  be  given  as  a  general  rule,  to  which 
there  are  many  exceptions,  that  syphilis  occupies  the  flexor 
surfaces  of  the  arms  and  the  anterior  plane  of  the  trunk, 
while  psoriasis  is  found  most  markedly  upon  the  extensor 
surfaces  and  the  posterior  plane  of  the  trunk. 

Configuration.  Certain  diseases  assume  certain  con- 
figurations, which,  if  noted,  will  sometimes  assist  in  diag- 
nosis.    Thus  we  have 

The  circular  outline  and  scalloped  border  of  syphilis. 
The  round  and  bald  patch  of  trichophytosis  and  alopecia 
areata. 

The  map-like  border  of  psoriasis. 

The  oval  or  egg-shaped  lesions  of  erythema  nodosum,  and 
the  gumma  of  syphilis. 

The  angular  papules  of  lichen  planus. 
The  annular  arrangement  in  herpes  iris  and  pityriasis 
rosea,  and  in  some  cases  of  ringworm,  psoriasis,  syphilis,  and 
seborrhoea  corporis. 

The  patches  of  grouped  vesicles  upon  reddened  bases 
located  over  the  course  of  a  cutaneous  nerve  in  zoster. 

Color.  An  eye  for  color  is  of  some  value  in  diagnosis. 
It  is  very  difficult  to  convey  by  words  a  correct  idea  of  the 
color  of  an  eruption,  but  perhaps  this  list  may  prove 
helpful : 

Raw  ham  of  syphilis. 
Brilliant  red  of  erysipelas. 
Inflammatorv  red  of  eczema. 
Dark  red  of  purpura. 
Bright  red  of  psoriasis. 
Brown  of  pigmentary  diseases. 
Sulphur  yellow  of  favus. 
Buff  of  xanthoma. 


DIAGNOSIS.  43 

Violaceous    or  dull   red  of  lichen  planus  and  lupus 

erythematosus. 
White  of  leucoderma. 

Pruritus.  It  is  important  to  know  whether  a  disease 
itches  or  not.  This  we  can  discover  by  the  presence  or 
absence  of  scratched  papules  or  scratch-marks.  The  itching 
eruptions  are  eczema,  pruritus  cutaneous,  prurigo,  urticaria, 
pediculosis,  and  scabies.  The  symptom  is  also  present  in 
the  lichens,  trichophytosis,  seborrhoea,  and  psoriasis.  It  is 
markedly  absent  in  syphilis,  though  an  occasional  case  of 
syphilis  will  be  encountered  in  which  there  is  itching. 

History.  Having  carefully  noted  all  these  objective 
symptoms,  we  have  by  this  time  pretty  well  made  up  our 
minds  as  to  the  diagnosis  of  the  case.  Now  is  the  time  to 
obtain  the  history  of  the  case,  either  for  the  purpose  of 
scientific  study  of  its  etiology  and  natural  course,  or  for  the 
purpose  of  clearing  up  some  doubt  as  to  our  diagnosis.  It 
is  so  easy  to  obtain  a  history  of  syphilis,  that  were  we  influ- 
enced by  the  history,  we  would  be  often  misled.  There  is 
no  reason  why  a  patient  with  syphilis  should  not  have  any 
other  skin  disease.  Moreover,  most  people  do  not  pay 
much  attention  to  the  history  of  their  diseases,  and  it  would 
be  difficult  for  them  to  give  a  correct  account  of  themselves, 
if  they  would.  Of  course,  a  clear  history  of  the  initial 
lesion  of  syphilis,  or  its  presence,  would  clear  up  any  doubt 
as  to  an  erythematous  rash.  The  history  of  a  scaly  disease 
recurring  at  frequent  intervals  upon  the  elbows  and  knees 
would  go  far  to  determine  the  existence  of  psoriasis.  In 
urticaria  we  have  to  rely  upon  the  statement  of  the  patient 
or  attendant  as  to  the  appearance  of  the  wheals,  as  their 
presence  at  some  time  is  pathognomonic,  and  they  are  usually 
absent  when  we  see  the  patient.  In  these  and  similar  ways 
the  history  is  useful,  but  it  should  be  entirely  subordinated 
to  the  study  of  the  objective  symptoms. 

Burning.  The  sensation  of  burning  is  one  the  exist- 
ence of  which  we  must  take  upon  the  patient's  statement. 
It  is  a  prominent  symptom  in  erythema.  Very  often  a 
patient  will  say  that  his  eruption  itches,  but  if  you  watch 
him,  he  will  soon  begin  to  gently  rub  his  skin  with  the  heel 


44  GENERAL    CONSIDERATIONS. 

of  his  hand.  This  indicates  that  the  sensation  is  one  of 
burning  and  not  of  itching.  In  itching,  the  nails  are  used, 
or  else  the  rubbing  is  vigorous. 

Pain.  Another  symptom  for  the  establishment  of  which 
we  have  to  rely  upon  the  patient  is  that  of  pain.  The  vast 
majority  of  skin  diseases,  while  they  may  cause  more  or  less 
discomfort,  are  not  painful.  But  sharp  neuralgic  pain  is  a 
prominent  symptom  in  epithelioma  and  zoster.  The  pres- 
ence of  pain  of  a  shooting  character  will  be  one  point  in  the 
differential  diagnosis  between  lupus  and  epithelioma,  and 
in  favor  of  the  latter. 

Microscope.  The  principal  use  of  the  microscope  in  the 
hands  of  the  general  practitioner  is,  as  far  as  dermatological 
diagnosis  is  concerned,  the  determination  of  the  presence  or 
absence  of  fungi  in  hair  and  scales  in  a  doubtful  case  of 
ringworm,  favus,  chromophytosis,  or  other  parasitic  disease. 
As  a  matter  of  fact  it  is  very  difficult  to  determine  whether 
the  mycelia  and  spores  found  in  a  hair  are  those  of  favus  or 
of  ringworm,  unless  the  manifestations  of  the  disease  on  the 
scalp  are  known  and  seen.  Happily  as  between  favus  and 
ringworm  we  seldom  have  need  of  the  microscope  for  diag- 
nosis, their  symptoms  being  so  pronouncedly  different. 

A  few  words  must  be  said  about  the  methods  of  examina- 
tion of  patients.  They  should  be  always  examined  by  day- 
light, or  by  electric  light.  It  is  prudent  to  refuse  to  give  an 
opinion  of  a  case  when  seen  in  a  poor  light,  or  by  artificial 
light.  If  the  patient  is  a  man,  it  is  but  just  to  yourself  to 
request  him  to  strip  from  top  to  toe,  if  there  is  the  slightest 
need  of  seeing  more  than  the  ordinarily  exposed  parts.  In 
the  case  of  a  woman  such  a  request  should  never  be  made. 
The  same  end  can  be  attained  by  exposing  one  part  after 
the  other.  By  so  doing  you  will  have  and  merit  the 
woman's  respect  and  thanks.  In  all  cases  you  are  justified 
in  refusing  to  treat  a  case  that  you  have  not  been  given 
ample  opportunity  to  examine. 

All  examinations  of  patients  should  be  made  in  a  warm 
room.  The  contact  of  cold  with  the  usually  covered  skin 
is  apt  to  give  it  a  mottled  look  that  obscures  the  diagnosis. 
It  is  well  never  to  give  a  diagnosis  of  an  obscure  case  that 


THERAPEUTIC    NOTES.  45 

is  under  local  or  constitutional  treatment,  until  all  treatment 
has  been  suspended  for  a  few  clays  and  the  disease  allowed 
to  assume  its  natural  appearance. 

Every  patient  should  be  regarded  as  out  of  health  in 
some  way  quite  apart  from  his  skin  trouble,  and  examined 
as  to  the  performance  of  all  his  functions  quite  as  carefully 
as  if  he  had  come  to  you  for  the  treatment  of  some  internal 
disorder. 

Therapeutic  Notes. 

In  the  second  part  of  this  book  there  will  be  found  the 
treatment  suitable  to  the  various  diseases.  In  this  place  my 
object  is  to  give  the  reader  a  few  notes  upon  some  of  the 
newer  remedies  for  skin  diseases.  At  present  a  new  remedy 
is  brought  out  nearly  every  month  that  promises  to  be  better 
than  any  of  its  predecessors ;  but  careful  comparative  tests 
demonstrate  that  many  of  them  are  no  better  than  the  old 
and  tried  ones.  It  is  better  for  the  general  practitioner  to 
learn  how  to  use  a  few  drugs  than  to  try  every  new  thing. 
By  practical  experience  he  will  be  surprised  to  see  how  much 
he  can  accomplish  with  a  very  small  assortment  of  drugs. 

The  old-fashioned  excipients  for  drugs  for  application  to 
the  skin  were  water,  lard,  and  oils.  Then  vaseline  and  cosmo- 
line  and  other  petroleum  derivatives  were  taken  up.  These 
were  all  disagreeable  to  use  because  they  were  greasy.  Then 
liquor  gutta-perchce  (traumaticin)  and  flexible  collodion  were 
introduced,  and  are  still  used.  They  are  not  greasy;  they 
prevent  the  clothing  from  being  soiled;  give  us  a  fixed  dress- 
ing, and  exert  a  certain  amount  of  pressure  upon  the  skin  that 
is  useful  in  some  cases.  They  are  most  used  in  the  treat- 
ment of  psoriasis,  ringworm,  and  in  circumscribed  chronic 
diseases.  In  acute  diseases,  and  specially  where  there  is 
more  or  less  exudation,  they  cannot  be  used. 

Pastes  answer  admirably  for  these  acute  and  exudative 
conditions,  as  they  protect  the  part,  and  at  the  same  time 
allow  the  exudate  to  work  up  through  them,  and  thus  escape. 
Lassar's  paste,  composed  of  zinc  oxide,  starch,  and  vaseline, 
as  set  forth  in  the  formulary  at  the  end  of  this  book,  was  one 


46  GENERAL    CONSIDERATIONS. 

of  the  first  of  these,  and  is  still  probably  more  used  than  any 
of  them.  Various  other  pastes  have  been  proposed.  It  is 
found  that  infusorial  earth  (Kieselguhr)  added  to  any  ointment 
in  the  proportion  of  10  per  cent,  will  form  a  good  paste. 

Gelatin  preparations,  one  of  which  is  given  in  the  form- 
ulary, were  introduced  as  preferable  to  ointments,  and  many 
German  and  English  authorities  speak  well  of  them.  They 
are  troublesome  to  apply  because  they  have  to  be  heated  be- 
fore being  used,  and  take  a  good  deal  of  time  to  set.  They 
have  not  become  popular  in  this  country. 

In  1891  two  excellent  excipients  were  brought  to  our 
notice :  one  that  is  made  from  gum  tragacanth,  and  called 
Bassorin ;  and  one  that  is  made  from  Irish  moss,  and 
called  Plasment.  They  both  sink  well  into  the  skin,  leav- 
ing a  protective  film  on  it  that  can  be  readily  removed  with 
water. 

Medicated  soaps,  specially  those  containing  an  excess  of 
fat,  have  been  brought  out  in  great  variety  during  the  past 
years,  and  possess  certain  virtues,  though  as  a  rule  a  soap  is 
not  the  best  vehicle  for  medication.  They  are  cleanly;  can 
be  readily  removed  from  the  skin  with  water,  and  can  be 
made  to  produce  a  greater  or  lesser  effect  according  to 
whether  the  lather  is  allowed  to  remain  or  not. 

Under  the  name  of  oleum  physeteris  or  chcenoceti,  a  spe- 
cies of  whale-oil  was  recommended  by  Guldberg1  as  an  excellent 
excipient.  Oleic  acid  is  another  vehicle  that  possesses  the 
virtue  of  penetrating  the  skin.  Lanolin  and  agnine,  de- 
rived from  the  wool  fat,  are  among  the  newer  greasy  appli- 
cations that  are  supposed  to  penetrate  the  skin.  This  prop- 
erty of  penetration  is  not  a  virtue  in  all  cases  by  any  means, 
as  in  very  many  of  our  cases  we  wish  to  provide  merely 
protection. 

In  the  way  of  drugs  of  comparatively  recent  date  we 
have : 

Anthrarobin,  which  was  proposed  as  a  substitute  for 
chrysarobin,  but  is  a  weak  preparation,  and  has  not  proved 
of  special  use. 

Aristol  is  a  good  dressing  for  ulcers  used  in  the  form  of 

1  Monatshefte  f.  prakt.  Dermat.,  1890,  x.,  No.  10. 


THERAPEUTIC    NOTES.  47 

a  powder.  It  is  expensive,  but  a  good  substitute  for  iodo- 
form in  some  cases,  as  it  is  devoid  of  odor.  I  have  made 
many  comparative  tests  with  it  and  older  remedies  in  treat- 
ing ulcers,  and  have  found  in  the  great  majority  of  cases 
that  the  old  friends  were  the  best.  In  10  per  cent,  strength 
it  has  been  commended  in  the  treatment  of  psoriasis,  ery- 
sipelas, hyperidrosis,  eczema,  acne,  rosacea,  and  all  sorts  of 
ulcers. 

Creolin,  in  1  to  5  per  cent,  solutions  in  water,  is  often 
useful  in  erysipelas,  dermatitis,  and  as  an  antiseptic.  It  is 
very  irritating  to  some  skins. 

Dermatol,  a  subgallate  of  bismuth,  is  said  not  to  cake, 
and  not  to  be  poisonous.  It  is  used  as  a  powder  for  fresh 
wounds,  forming  a  crust  under  which  healing  takes  place. 
For  excoriations,  intertrigo,  and  slightly  moist  eczema  it  is 
to  be  mixed  with  equal  parts  of  starch.  For  large,  irritable 
ulcers  it  may  be  used  as  an  ointment  of  10  per  cent, 
strength. 

Europhene.  An  amorphous  powder  of  yellow  color  and 
aromatic  odor,  containing  28  parts  of  iodine  in  100.  Insol- 
uble in  water  and  glycerin ;  readily  soluble  in  ether,  chloro- 
form, collodion,  and  traumaticin.  Useful  in  venereal  ulcers 
and  mucous  patches  in  pure  powder  or  2  to  5  per  cent,  oint- 
ment. Also  in  tertiary  syphilis  as  hypodermic  injections  in 
the  vicinity  of  the  lesion,  and  in  solution  in  oil. 

Fuchsine,  and  other  aniline  dyes,  in  1  per  cent,  solution 
in  water,  is  recommended  as  useful  in  ringworm,  inoperative 
cancerous  ulcers,  erysipelas,  and  other  local  infectious  dis- 
eases. 

Gallacetophenone,  made  by  the  action  of  acetic  acid  upon 
pyrogallol,  was  brought  out  in  1891  as  remarkably  efficient 
in  the  treatment  of  psoriasis.  It  may  be  used  in  5  to  10 
per  cent,  strength  in  ointment  or  collodion,  does  not  stain 
the  clothing,  and  thus  far  has  not  proved  poisonous. 

Hydroxylamine  is  poisonous  when  absorbed.  It  was 
commended  for  psoriasis,  but  cannot  be  used  over  large 
surfaces.  It  has  been  commended  in  lupus  vulgaris  and 
ringworm  of  the  scalp  and  beard — a  grain  and  a  half  of  the 
hydrochloride  being  dissolved  in  an  ounce  and  a  half  each 


48  GENERAL    CONSIDERATIONS. 

of  alcohol  and  glycerin.  It  has  not  gained  popular 
favor. 

IcTithyol,  especially  the  ammonio-sulphate,  is  useful,  ac- 
cording to  its  introducer,  Unna,  and  many  others,  both  for 
external  and  internal  use  in  rosacea,  acne,  eczema,  urti- 
caria erythema,  herpes,  dermatitis  herpetiformis,  seborrhoea, 
furunculosis,  erysipelas,  psoriasis,  sycosis,  lupus,  and  some 
other  dermatoses.  By  the  mouth  it  is  best  exhibited  in 
capsules,  from  three  to  fifteen  drops  being  given  during  the 
day.  Externally  it  is  exhibited  in  solution  in  water,  or  in 
paste  form,  and  in  the  strength  of  2J  to  10,  20,  or  50  per 
cent. 

Oxynaphthoic  acid  is  recommended  by  Schwimmer  for 
scabies  and  prurigo  in  10  per  cent,  strength  in  ointment. 
His  ointment  for  scabies  is  composed  of  ten  parts  each 
of  the  acid,  chalk,  and  green  soap,  to  eighty  or  one  hun- 
dred parts  of  lard. 

Resorcin  is  recommended  for  seborrhoea  capitis,  be- 
ginning in  2  per  cent,  strength,  and  increasing  up  to  5  or 
10  per  cent.,  as  the  acute  stage  lessens ;  for  psoriasis,  10  to  20 
per  cent. ;  eczema  about  the  mouth,  2  per  cent. ;  erysipelas ; 
and  as  a  plaster  for  keloid  and  malignant  growths.  Strong 
preparations,  say  20  to  30  per  cent.,  can  be  used  in  acne 
and  rosacea  for  the  purpose  of  producing  a  dermatitis,  to 
be  followed  by  peeling  off  of  the  old  skin. 

Salol,  two  parts  to  one  of  starch,  is  commended  for  use 
in  ulcers. 

Thilanin  is  lanolin  acted  on  by  sulphur,  and  containing 
3  per  cent,  of  the  latter.  Recommended  for  acute  and 
chronic  eczema. 

Thiol,  which  is  miscible  with  water,  and  is  used  in  the 
strength  of  20  per  cent,  in  liquid  or  powder  form,  is  said  to 
be  useful  in  seborrhoea,  rosacea,  acne,  eczema,  burns,  pem- 
phigus, dermatitis  herpetiformis,  impetigo,  and  zoster. 

Tumenol.  Used  in  solution  with  equal  parts  of  ether, 
alcohol,  and  water,  or  glycerin,  or  in  form  of  paste,  or  oint- 
ment. Useful  in  moist  eczema,  burns,  ulcers,  and  rha- 
gades. 


some  dermatological  don'ts.  49 

Classification. 

In  the  present  state  of  our  knowledge  it  is  impossible  to 
make  a  satisfactory  classification  of  skin  diseases.  Many 
attempts  have  been  made  to  do  this,  and  are  still  being 
made.  Nearly  every  systematic  writer  tries  his  hand  at  it 
with  more  or  less  indifferent  success.  The  most  scholarly 
classification  is  that  by  Prof.  E.  B.  Bronson  {Journ.  Cutan. 
and  Gren.-Urin.  Dis.,  1887,  v.  369),  which  is  founded  on 
that  of  Auspitz.  Hebra's  classification  modified  is  found 
in  a  great  many  text-books.  The  arrangement  of  this  book 
does  away  with  classification,  with  which  the  student  need 
not  burden  his  mind. 

Some  Dermatological  Don'ts. 

Don't  make  your  diagnosis  from  the  history  of  a  case, 
because  if  you  do  you  will  often  be  led  astray.  Make  it 
from  the  eruption  that  you  see,  and  then  substantiate  or 
destroy  this  by  the  history  of  the  case,  if  you  will. 

Don't  fail  to  think  of  the  possibility  of  every  case  being 
either  syphilis  or  eczema  ;  and 

Don't  fail  to  master  these  two  diseases  as  thoroughly  as 
possible ;  because,  if  you  learn  to  recognize  these  two,  you 
will  have  gone  a  long  way  in  diagnosis.  If  they  can  be 
excluded,  then  the  field  of  possible  "  might  be's  "  is  consid- 
erably narrowed. 

Don't  make  the  diagnosis  of  syphilis  on  account  of  a 
syphilitic  history,  because  you  can  often  get  a  history  of 
syphilis  in  a  non-syphilitic  case. 

Don't  expect  much,  if  any,  history  of  syphilis  in  a 
woman,  because  you  very  frequently  will  not  get  it.  This 
is  not  because  they  are  "gay  deceivers,"  but  because  in 
them  the  early  symptoms  of  the  disease  are  often  so  slight 
that  they  are  not  observed  by  them. 

Don't  throw  out  the  diagnosis  of  syphilis  on  account  of 
an  eruption  itching,  because  some  syphilides,  especially  the 

3 


50  GENERAL    CONSIDERATIONS. 

papular  variety,  do  itch  at  times.  The  not  itching  of  an 
eruption  is  better  presumptive  evidence  of  syphilis  than  is 
itching  positive  evidence  against  it. 

Don't  make  the  diagnosis  of  lichen  planus  from  the  pres- 
ence of  flat  angular  papules  with  depressed  centres  alone, 
because  identical  lesions  will  at  times  be  met  with  in 
eczema,  syphilis,  and  psoriasis. 

Don't  depend  upon  getting  the  bleeding-points  springing 
out  of  the  delicate  pellicle  after  carefully  scraping  off  the 
scales  for  your  diagnosis  of  psoriasis,  because  you  can  pro- 
duce the  same  thing  in  other  diseases.     In  fact, 

Don't  depend  upon  any  one  symptom,  but  make  your 
diagnosis  from  the  general  make-up  of  the  disease  as  a 
whole. 

Don't  forget  that  many  diseases  of  the  skin  are  depen- 
dent upon  disturbances  in  the  general  health  of  the  patient. 
Therefore, 

Don't  fail  to  inquire  into  the  performance  of  the  functions 
of  the  various  organs  of  the  patient,  and  to  put  him  into  as 
good  a  physical  condition  as  possible. 

Don't  tell  your  patient  that  it  is  dangerous  to  cure  his 
skin  disease  rapidly,  because  it  is  not.     If  you 

Don't  know  how  to  treat  the  case,  ask  advice  of  someone 
who  does. 

Don't  encourage  the  popular  notion  that  there  is  danger 
of  an  eruption  striking  in,  because  it  never  does. 

Don't  give  arsenic  for  every  skin  disease,  and,  especially, 

Don't  give  it  in  acute  eruptions.  Its  sphere  is  in  the 
chronic  scaly  eruptions,  such  as  chronic  psoriasis. 

Don't  forget  that  most  cases  of  pruritus  are  due  to  in- 
ternal causes,  and  that  in  them  external  treatment  is  wasted  ; 
and 

Don't  forget  the  bed-bug  and  the  pediculus  as  possible 
causes  of  the  trouble. 

Don't  forget  that  the  greatest  secret  in  the  treatment  of 
eczema,  and  many  other  skin  diseases,  is  not  what  particu- 
lar drug  or  formula  is  "  good  for  "  the  disease,  but  a  knowl- 
edge of  the  great  principle  that  acute  diseases  need  soothing 


SOME    DERMATOLOGICAL    DON'TS.  51 

remedies,  and  subacute  and  chronic  diseases  need  stimula- 
tion. 

Don't  expect  to  cure  an  inveterate  eczema  with  thickened 
skin  by  means  of  a  soothing  ointment,  such  as  that  of  the 
oxide  of  zinc,  because  you  will  only  waste  your  time  and 
the  patient's  money. 

Don't  use  tar  in  an  acute  eczema,  because  it  is  a  stimu- 
lant, and  what  we  want  at  this  time  is  to  soothe  the  in- 
flamed skin.  It  is  appropriate  to  a  subacute  or  chronic 
case. 

Don't  allow  water  to  touch  any  form  of  eczema,  because 
it  always  irritates  in  such  a  case. 

Don't  use  a  thick  ointment  on  the  hairy  scalp,  because 
it  makes  a  disagreeable  mess  of  the  hair,  and  will  not  be 
"  popular  "  with  your  patient.  Even  lard  is  not  a  pleasant 
vehicle  for  such  applications.  Vaseline  and  the  oils  are 
more  elegant  excipients. 

Don't  order  the  hair  to.be  cut  from  the  head  of  a  young 
or  old  woman  in  any  disease  of  the  scalp,  because,  except 
in  the  case  of  a  peculiarly  stupid  or  careless  patient,  it  is 
never  necessary,  and  always  disagreeable  to  the  woman. 

Don't  allow  a  patient  with  ringworm  to  go  to  school,  be- 
cause if  you  do  you  will  be  responsible  for  the  spread  of  the 
disease. 

Don't  pronounce  a  ringworm  case  well  and  incapable  of 
spreading  the  contagion  until  you  are  sure  that  it  is  well ; 
and 

Don't  be  sure  about  it  until  there  are  no  more  "  stumps  " 
on  the  scalp,  and  you  can  find  no  more  of  the  fungus  in 
the  hair. 

Don't  use  the  name  "barber's  itch"  for  anything  but 
trichophytosis  barbae,  because  it  is  well  not  to  use  terms 
loosely  to  cover  several  different  diseases. 

Don't  use  chrysarobin  on  the  face  or  scalp,  because  it 
is  very  apt  to  cause  a  good  deal  of  dermatitis  with  oedema, 
and  to  stain  the  skin  a  deep  mahogany-red. 

Don't  forget  to  caution  a  patient  to  whom  you  have  given 
chrysarobin,  not  to  touch  his  face  with    his   hands   after 


52  GENERAL    CONSIDERATIONS. 

applying  the  drug,  because  if  you  do  you  will  have  either  a 
mad  or  a  frightened  patient  in  your  office. 

Don't  pronounce  a  patient  addicted  to  the  excessive  use 
of  alcoholic  beverages  on  account  of  his  having  rosacea,  be- 
cause there  are  lots  of  other  things  besides  alcohol  that  will 
cause  it. 

Don't  use  the  positive  pole  of  the  battery  for  the  needle 
in  destroying  hair  by  electrolysis,  because  if  you  do  you  will 
leave  more  or  less  permanent  marks  in  the  skin. 

Don't  apply  a  sulphur  preparation  after  using  a  mercurial 
upon  the  face,  or  vice  versa,  because  if  you  do  you  will 
raise  a  fine  crop  of  comedones. 

Don't  use  a  camel's-hair  brush  for  making  applications 
of  corrosive  sublimate,  because  if  you  do  some  of  the  salt 
will  be  left  on  the  brush  each  time  it  is  used,  and  you  will 
soon  have  a  stronger  solution  than  you  bargained  for.  Al- 
ways use  a  little  cotton  on  a  wooden  toothpick,  or  a  splinter 
of  wood. 

Don't  allow  a  fine-toothed  comb  to  be  used  on  the 
scalp,  because  it  scratches  and  irritates  the  scalp. 

Don't  encourage  or  advise  the  use  of  pomades  on  the 
healthy  scalp,  because  they  are  prone  to  become  rancid, 
and  inflame  the  scalp.  They  are  also  unnecessary  if  the 
hygiene  of  the  scalp  is  properly  looked  after. 

Don't  forget  that  dandruff  is  the  most  frequent  cause  of 
premature  baldness,  because  if  you  remember  this,  you  may 
be  able  to  prevent  the  fall  of  someone's  hair  for  some  time. 
Therefore, 

Don't  fail  to  treat  every  case  of  dandruff. —  The  Medical 
Record,  December  29,  1838. 


PAET    II. 

THE  DISEASES  OF  THE  SKIN   AND   THEIR 
TREATMENT. 


Scheme  oe  Pronunciation. 

A,  ape ;  A2,  at ;  A3,  ah  ;  A4,  all ;  Ch,  chin ;  Ch2,  loch  (Scottish)  ;  E,  he  ; 
E2,  ell ;  G,  go ;  I,  die ;  I2,  in ;  N,  in ;  N2,  tank ;  O,  no ;  O2,  not ; 
O3,  whole ;  Th,  thin ;  Th2,  the ;  U,  like  oo  in  too ;  IP,  blue ;  U3, 
lull;  U4,  full;  U5,  urn;  U6,  like  ii  (German).1 


Abscess  (AV-se2s). 

Symptoms.  Abscesses  are  very  frequently  met  with  as 
complications  of  diseases  of  the  skin,  such  as  acne,  eczema, 
scabies,  pediculosis,  and  other  acute  dermatitides.  As  thus 
met  with,  they  are  usually  of  small  size,  though  at  times,  as 
upon  the  scalp  of  a  strumous  child,  they  may  attain  con- 
siderable dimensions.  Their  most  frequent  locations  are : 
upon  the  scalp  with  eczema ;  upon  the  face  and  back  with 
acne ;  and  upon  the  extremities  with  scabies  and  pediculosis. 
Apart  from  a  slight  amount  of  discomfort,  they  do  not  give 
rise  to  subjective  symptoms  as  a  rule,  and  are  indeed  trivial 
affections.  Of  course,  this  does  not  apply  to  abscesses  as 
seen  by  the  surgeon.  They  may  open  of  themselves  and 
discharge  their  contents  upon  the  skin.  More  commonly 
they  are  very  sluggish  in  their  course,  and  must  be  evacuated 
by  some  surgical  procedure. 

Diagnosis.  An  abscess  differs  from  a  furuncle  by  not 
being  raised,  not  having  a  central  core,  and  by  being  less 

1  From   Foster's    "Illustrated    Encyclopaedic   Medical   Dictionary," 
New  York,  1890.     By  permission. 


54  DISEASES    OF    THE    SKIN. 

firm  to  the  touch.  It  differs  from  a  carbuncle  by  an  entire 
absence  of  marked  constitutional  disturbance,  brawn y  in- 
filtration, intense  inflammation,  and  cribriform  mode  of  open- 
ing. Kerion  often  resembles  an  abscess,  but  differs  from  it 
in  its  uneven  surface  and  the  welling  up  of  a  mucoid  fluid 
alongside  of  the  hairs.  Syphilitic  gwnmata  are  sometimes 
mistaken  for  abscesses  and  opened.  They  may  be  recognized 
by  their  dark -red  color,  their  absence  of  pain  and  discom- 
fort, and  the  history  of  their  growth.  They  grow  slowly, 
beginning  below  the  skin.  There  are  generally  more  than 
one  present,  and  then  they  are  grouped.  The  aspiration  of 
the  tumor  will  decide  the  question.  From  an  abscess  we 
would  obtain  pus ;  from  a  gumma  a  little  bloody  fluid. 

Treatment.  The  management  of  the  small  cutaneous 
abscesses  that  we  meet  with  as  dermatologists  is  simple. 
The  cavity  is  to  be  opened,  the  pus  allowed  to  escape,  and 
the  part  dressed  with  carbolized  vaseline  if  small,  or  anti- 
septically  if  larger.  It  is  sometimes  necessary  to  swab  out 
the  cavity  with  a  strong  carbolic  acid  solution  to  destroy  the 
abscess  wall  and  prevent  the  re-formation  of  the  abscess. 

Absces  Tuberiformis.     See  Inflammation  of  sweat  glands. 

Abschilferung  (A3b/-shi2l-fe2r-ung).  Branny  scaling  of 
skin. 

Abschuppung  (A3br-shup-pung).     Scaling  or  chapping. 

Acantholysis  (A2k-a2n-tho2l'-i2-si2s).  A  disease  character- 
ized by  loosening  or  separation  of  the  mucous  layer  of  the 
epidermis. 

Acanthosis  (A^-a^-tho'-s^s).  A  disease  of  the  mucous 
layer  of  the  skin. 

Acne  (A2k'-ne).  Synonyms:  Varus,  Ion  thus;  (Gf-er.)  Fin- 
nen;  (Fr.)  Acn6,  Bouton ;  Stone-pock,  Whelk,  Pimple. 

Acne  is  an  inflammatory  disease  of  the  sebaceous  glands 
and  the  hair  follicles,  due  to  the  retention  of  sebum ;  char- 
acterized by  an  eruption  of  papules,  pustules,  or  tubercles 
upon  the  face,  neck,  shoulders,  or  chest ;  which  usually 
begins  at  puberty,  and  tends  to  run  a  chronic  course. 

Different   writers    and   teachers   have   applied    different 


ACNE.  55 

names  to  the  different  phases  of  acne.  These  had  best  be 
forgotten,  except  in  so  far  as  they  are  of  historical  value. 
The  term  acne  is  applied  by  the  French  school  to  all  diseases 
of  the  sebaceous  glands.  It  would  seem  to  be  the  wiser 
plan  to  reserve  the  name  for  the  disease  just  defined.  Re- 
garded thus,  we  have  but  two  varieties  of  true  acne,  and 
those  are  acne  vulgaris  and  acne  indurata. 

Acne  Vulgaris  or  Simplex  is  either  papular  or  pustular 
in  character,  though  usually  it  is  a  combination  of  the  two, 
together  with  more  or  less  comedones  scattered  about. 

Symptoms.  If  only  papules  exist  (A.  papulosa),  the  face, 
shoulders,  or  chest  will  be  found  to  be  dotted  more  or  less  pro- 
fusely with  pinhead-sized,  acuminated  elevations  of  the  skin, 
of  a  pinkish  to  red  color,  and  with  a  central  opening  at  the 
summit.  Very  often  the  central  openings  will  be  filled  by 
blackish  specks.  The  lesions  are  then  spoken  of  as  A. 
punctata.  This  term  is  used  by  some  writers  to  designate 
the  comedo,  but  improperly,  according  to  our  definition. 
It  is  rare  that  acne  exists  only  in  the  papular  form.  More 
usually  it  will  be  found  that  here  and  there  the  papules  are 
surmounted  by  a  pustule,  or  a  pustule  has  taken  the  place 
of  a  papule.  We  now  have  A.  pustulosa.  In  strumous 
subjects  the  pustular  element  preponderates  over  the  papu- 
lar, and  the  face  may  be  greatly  disfigured  by  the  large 
number  of  the  lesions  present  upon  it.  The  pustules  are 
from  pinhead  to  small  pea  size,  and  have  an  inflamed  base. 

Together  with  the  acne  and  the  comedones,  we  meet  with 
milia  quite  commonly,  and  the  affected  parts  are  usually 
greasy  to  the  feel,  showing  that  the  sebaceous  glands  sym- 
pathize in  the  disease.  We  now  have  a  fair  picture  of  a 
typical  case  of  acne  vulgaris.  The  face,  back,  neck,  or 
chest,  or  all  four,  are  dotted  over  in  an  irregular  manner 
with  blackish  points,  papules,  and  small  pustules ;  the  skin 
of  the  nose  and  forehead  looks  shiny  and  feels  greasy,  and 
perhaps  there  are  some  milia  scattered  about  the  region  of 
the  eyes.  At  times  the  face  will  look  inflamed  and  hyper- 
aemic,  especially  in  young,  otherwise  robust,  subjects.  More 
commonly  the  complexion  will  have  that  pasty  appearance 
indicative   of  what  has  from    old   times   been   called   the 


56 


DISEASES    OF    THE    SKIN, 


strumous  condition.  If  the  inflammatory  process  has  been 
unusually  severe,  we  may  find  a  considerable  amount  of 
scarring.  Usually  acne  vulgaris  does  not  leave  scars.  The 
profuseness  of  the  eruption  varies  greatly.  In  some  cases 
there  will  be  but  a  few  lesions,  while  in  other  cases  they 
will  be  present  in  vast  amount.  This  form  of  acne  gener- 
ally occurs  in  young  people.     The  duration  of  the  individual 

Fig.  5. 


Acne  indurata  of  the  back. 


lesion  is  short,  as  it  soon  either  dries  up  or  discharges  its 
contents.  If  the  papules  are  squeezed,  little  plugs  of  se- 
baceous matter  will  be  expressed.  If  the  papulo-pustules 
are  treated  in  the  same  way,  there  will  first  be  pressed  out 
a  small  sebaceous  plug,  and  then  a  drop  or  two  of  pus. 

Acne  Indurata  is  a  pustular  acne,  in  which  the  pustules 
are  of  large  size,  and  seated  upon  deeply  infiltrated  bases. 

They  are  most  commonly  sparsely  dispersed,  and  take 


ACNE.  57 

the  form  of  purplish  "lumps"  of  pea  to  bean  size,  which 
are  hard  to  the  touch.  Sometimes  they  are  more  readily 
appreciated  by  touch  than  by  sight,  being  located  deeply  in 
the  skin.  Sometimes  they  take  the  form  of  cutaneous  ab- 
scesses, and  if  by  chance  several  are  located  close  to  one 
another,  they  may  run  together  and  form  a  raised,  dark- 
red,  doughy  mass.  When  incised,  these  lesions  sometimes 
give  exit  to  a  large  amount  of  thick  pus.  They  usually 
leave  scars,  which  sometimes  are  very  disfiguring,  unless 
they  are  opened  very  early  in  their  course.  They  may  be 
the  only  form  of  acne  present,  or  they  may  be  combined 
with  acne  vulgaris.  This  form  of  acne  usually  occurs  at  a 
more  advanced  age  than  does  acne  vulgaris,  though  it  is  not 
infrequently  met  with  in  early  life. 

Etiology.  Acne  is  one  of  the  most  common  of  skin  dis- 
eases, and  its  great  predisposing  cause  is  youth.  The  dis- 
ease first  shows  itself  about  the  time  of  puberty,  and 
manifests  a  tendency  to  disappear  when  the  body  is  fully 
developed — that  is,  from  the  twenty-third  to  thirtieth  year. 
A  few  rare  cases  have  been  reported  of  acne  at  an  early 
age.  Thus,  Chambard1  has  met  with  a  case  in  a  girl  of  six 
and  a  half  years.  The  indurated  form  of  acne  appears  later 
than  the  simple  form,  usually  after  the  twenty-fifth  year. 
Both  sexes  are  affected,  but  the  disease  is  more  frequent  in 
females  than  in  males,  and  in  them  begins  at  an  earlier  age. 
The  period  of  youth  is  the  time  of  great  developmental 
activity  in  which  the  .sebaceous  glands  take  part,  and  it  is 
probable  that  there  is  a  too  great  activity  of  the  glands,  and 
an  improperly  formed  sebum  is  the  result.  Normally,  the 
product  of  the  fat  glands  is  an  oily  fat.  In  acne  an  inspis- 
sation  of  the  fat  takes  place,  forming  a  plug  that  acts  as  a 
foreign  body  and  sets  up  an  inflammation. 

Individuals  with  thick,  pasty,  pale  skins,  with  patulous 
follicular  mouths,  are  predisposed  to  acne.  These  peculiarities 
of  skin  are  met  with  in  scrofulous  subjects.  The  patulous 
follicular  mouths  give  ready  lodgment  to  foreign  matters, 

1  Anna!.  Derm,  et  Syph.,  1878-9,  x.  259. 


58  DISEASES    OF    THE   SKIN. 

and  comedones  are  thus  formed.  This  prevents  the  escape 
of  the  follicular  contents,  a  plug  is  formed,  and  we  have  an 
acne  papule  or  pustule.  Comedones  are,  therefore,  an 
exciting  cause  of  acne. 

Heredity  has  been  asserted  by  some  to  be  a  predisposing 
cause  of  acne,  but  the  disease  is  so  common  that  there  is  no 
certainty  about  this  factor. 

Of  the  exciting  causes  of  acne,  the  most  active  one  is 
some  form  of  digestive  disturbance.  This  may  take  the 
form  of  dyspepsia,  stomachal  or  intestinal ;  or  it  may  be 
mal-assimilation ;  or  it  may  be  failure  on  the  part  of  the 
liver  or  pancreas  to  perform  its  physiological  functions;  or 
it  may  be  sluggishness  of  the  large  intestine  and  consequent 
constipation. 

Next  to  disorders  of  the  digestive  organs,  those  of  the 
sexual  organs  are  supposed  to  have  most  influence  in  pro- 
ducing acne.  But,  inasmuch  as  most  cases  of  acne  are 
amenable  to  the  influence  of  diet  and  regulation  of  diges- 
tive disorders  without  any  attention  being  given  to  sexual 
disorders,  it  is  probable  that  the  latter  are  important  etio- 
logical factors  in  comparatively  few  cases.  Indeed,  it  is 
not  improbable  that  the  acne  that  appears  on  the  faces  of 
women  at  each  menstrual  period,  and  at  that  time  alone,  as 
well  as  the  aggravation  of  an  already  existing  acne,  is  due 
to  the  more  or  less  pronounced  disturbance  of  the  digestive 
organs  so  frequently  observed  at  the  same  time.  In  some 
cases  acne  does  seem  to  be  a  reflex  irritation  from  the 
uterus.  Amenorrhoea  is  the  uterine  derangement  most  fre- 
quently encountered,  but  that  condition  is  but  one  evidence 
of  a  general  constitutional  disorder,  rather  than  a  disease  in 
itself. 

Masturbation  and  continence  have  each  been  blamed  as 
excitants  of  acne.  The  former  of  these  of  itself  does  not 
cause  acne,  but  its  well-known  effects  on  the  nervous,  moral, 
and  physical  condition  of  growing  youths  would  sufficiently 
account  for  any  part  it  may  have  in  producing  acne.  There 
is  absolutely  no  proof  that  continence  causes  acne.  If  a 
boy  or  young  man  keeps  himself  in  a  constant  state  of 
unrest  by  lascivious  thoughts,  that  is  not  true  continence, 


ACNE.  59 

even  though  he  does  not  masturbate  or  copulate.  It  is  safer 
for  us  to  say  that  bad  sexual  hygiene  may  cause  acne, 
rather  than  to  ascribe  it  either  to  masturbation  on  the  one 
hand,  or  continence  on  the  other. 

It  may  be  stated,  as  a  broad  general  rule,  that  anything 
that  lowers  the  general  health  of  the  patient  contributes  to 
the  production  of  acne.  We  have  space  only  to  enumerate 
some  of  these  exciting  causes.  Thus,  we  have  the  vague 
state,  "general  debility,"  anaemia  and  chlorosis,  oxaluria 
and  uraemia,  rheumatism  and  gout,  poor  circulation,  mental 
and  physical  exhaustion,  and  chronic  malaria. 

In  1881  Denslow1  advanced  the  theory  that  a  want  of 
tone  in  the  arrectores  pilorum  muscles,  either  alone  or  to- 
gether with  an  over-production  of  sebaceous  matter,  and  its 
retention  in  the  sebaceous  glands,  was  an  important  etiologi- 
cal factor  in  acne.  As  the  muscles  failed  to  act  with  suffi- 
cient vigor  they  did  not  perform  one  of  their  offices — the 
emptying  of  the  follicles — and  this  allowed  of  the  retention 
of  glandular  products  and  consequent  acne. 

Since  the  rise  of  the  present  dynasty  of  microorganisms 
a  great  number  of  skin  diseases  have  been  declared  to  be 
parasitic.  Acne  of  the  pustular  variety  is  one  of  these,  and 
we  are  told  that  the  pustule  is  due  to  the  entrance  of  the 
staphylococcus  aureus  et  albus  into  the  follicles  which  offer 
proper  ground  for  its  growth. 

Pathology.  Acne  mav  begin  in  the  hair  follicle  or  in 
the  sebaceous  gland,  and  may  be  due  either  to  their  becom- 
ing clogged  up  by  inspissated  sebum  and  acting  like  a  thorn 
in  the  flesh,  or  to  their  invasion  by  microorganisms  which 
set  up  a  suppurative  perifolliculitis.  The  papules  of  acne 
are  located  in  the  upper  part  of  the  skin,  while  the  pustules 
are  deeper.  In  very  bad  cases  the  follicle  may  be  entirely 
destroyed  by  the  perifolliculitis,  and  scars  will  be  left.  The 
sebaceous  glands  do  not  take  a  very  active  part  in  the  pro- 
cess. 

In  acne  indurata  we  find  the  hair  follicle  enormously 
dilated,  its  orifice  filled  with  corneous  cells,  and  its  cavity 

1  Xew  York  Med.  Journ.,  1881,  xxxiii.  189. 


60  DISEASES    OF    THE    SKIN. 

almost  converted  into  a  cyst.  The  connective  tissue  about 
the  follicle  shows  decided  signs  of  inflammation,  and  may  be 
increased  in  amount.  Very  often  the  follicle  is  destroyed 
by  the  perifollicular  inflammation.  When  the  perifollicu- 
litis is  severe  and  extensive,  the  deep  layers  of  the  skin  be- 
come involved  and  we  have  abscess  formation. 

Diagnosis.  Acne  is  to  be  differentiated  from  rosacea, 
papular  and  pustular  eczema,  sycosis,  the  small  pustular 
and  tubercular  syphiloderm,  and  variola. 

Rosacea  is  due  to  a  dilatation  of  the  bloodvessels,  and  is 
attended  by  hyperemia  and  telangiectases.  If  there  are 
any  pustules  they  are  superficial,  and  if  excised  give  exit  to 
only  a  drop  of  pus.  Acne  is  a  disease  of  the  sebaceous 
glands,  and  papules  and  pustules  constitute  the  disease. 
They  are  often  large,  and  if  excised  will  give  exit  to  a  plug 
of  sebaceous  matter  and  thick  pus.  Rosacea,  as  a  rule, 
occupies  the  middle  third  of  the  face  alone,  the  forehead, 
nose,  and  chin.  Acne  is  scattered  over  the  whole  face,  and 
is  often  found  on  the  shoulders. 

Papular  eczema  may  occur  at  any  age ;  acne  usually 
occurs  between  the  ages  of  fifteen  and  twenty-five.  Papular 
eczema  rarely  is  seen  on  the  face  alone,  and  is  prone  to 
attack  the  trunk  and  extremities.  Acne  often  occurs  on 
the  face  alone,  and  is  never  disseminated  over  the  limbs  and 
trunk.  In  eczema  there  is  an  absence  of  comedones ;  the 
papules  are  often  surmounted  by  or  change  into  vesicles ; 
they  tend  to  form  patches,  and  the  disease  is  very  itchy,  so 
that  scratch-marks  are  almost  invariably  found.  When  it 
gets  well  it  leaves  no  trace  on  the  skin.  These  symptoms 
are  foreign  to  acne. 

In  pustular  eczema  or  what  has  been  called  impetigo 
simplex,  we  have  a  large  number  of  small  pustules  running 
together  to  form  patches  which  rapidly  become  covered  with 
greenish  or  yellow  crusts.  The  disease  runs  a  far  more 
acute  and  stormy  course  than  does  acne,  and  is  itchy.  It  is 
very  frequently  met  with  in  children,  whom  acne  rarely 
affects. 

Sycosis  is  a  pustular  disease  affecting  the  hair  follicles 


ACNE.  61 

alone,  each  pustule  being  pierced  by  a  hair.  Acne  occurs 
on  the  non-hairy  as  well  as  the  hairy  parts,  and,  indeed, 
shows  preference  for  regions  supplied  only  with  rudimentary 
hairs. 

The  small  pustular  syphiloderm,  or  syphilitic  acne,  is  a 
general  eruption,  and  it  is  easy  in  most  cases  to  obtain  other 
evidences  of  syphilis,  such  as  the  remains  of  the  initial  lesion, 
enlarged  lymphatic  glands,  mucous  patches,  or  the  like.  It  is 
usually  more  uniform  in  its  lesions,  and  these  are  plainly 
papulo-pustular.  The  color  of  the  areola  is  more  that  of  raw 
ham,  and  less  inflammatory-looking  than  is  that  of  acne.  The 
lesions  sometimes  show  a  tendency  to  group  into  segments  of 
circles,  and  each  lesion  undergoes  a  definite  development. 
They  sometimes  leave  small,  smooth,  white  scars  that  may  dis- 
appear in  a  few  months.  The  tubercular  syphiloderm  could 
be  mistaken  for  an  indurated  acne.  In  it  there  will  usually 
be  found  other  evidences  of  syphilis.  The  lesions  group 
themselves  into  patches  that  are  kidney-shaped  or  form 
segments  of  circles.  The  tubercles  are  dark-red  or  raw-ham 
colored,  surrounded  by  a  well-marked  areola,  firm  to  the 
touch,  and  do  not  contain  pus.  They  may  ulcerate,  or, 
being  absorbed,  leave  pigmented  and  punched-out  cicatrices, 
and,  finally,  smooth  white  scars.  The  scars  left  by  acne 
indurata  are  puckered  and  more  disfiguring. 

Variola  could  scarcely  give  rise  to  much  doubt,  as  it  has 
well-marked  constitutional  symptoms,  and  its  lesions  undergo 
a  definite  and  characteristic  development. 

Treatment.  In  the  treatment  of  acne  we  can  obtain  a 
cure  most  surely  by  attention  to  the  general  condition  of  the 
patient ;  most  rapidly  by  a  combination  of  internal  and  local 
treatment.  Of  course,  in  cases  where  only  a  single  pustule 
crops  out,  as  in  some  women  at  each  menstrual  period,  there 
is  no  need  for  any  treatment.  But  such  are  not  those  that 
ask  our  aid. 

We  therefore  begin  the  treatment  of  a  case  by  a  careful 
inquiry  into  the  general  condition  of  the  patient,  and 
endeavor  to  regulate  any,  even  the  slightest,  derangement 
of  the  internal  organs.  By  so  doing  we  may  find  no  one 
of  those  conditions  enumerated  under  the  etiology  of  the 


62  DISEASES    OF    THE    SKIN". 

affection,  and  the  patient  may  consider  himself  as  in  the  best 
condition.  Further  observation  will  probably  reveal  some 
deviation,  though  slight,  from  perfect  health.  The  relief  of 
constitutional  disorders  is  conducted  according  to  the  prin- 
ciples of  general  medicine,  and  cannot  be  given  here. 
Many  of  the  cases  require  cod-liver  oil  and  iron  as  general 
measures  quite  apart  from  any  evident  disease.  This  is 
seen  in  the  sluggish  cases  occurring  in  strumous  subjects 
with  pasty  skins.  In  plethoric  subjects  with  a  good  deal  of 
inflammation  attending  the  acne,  laxative  agents,  such  as  a 
tenth  of  a  grain  of  calomel  in  tablet  triturates,  given  three 
or  four  times  a  day  will  aid  in  a  cure,  quite  aside  from  any 
constipation. 

Diet  and  hygiene  are  agents  to  be  employed  rather  than 
drugs.  It  is  impossible  for  us  to  lay  down  fixed  principles 
of  diet,  and  it  is  better  to  study  each  case  by  itself.  The 
well-to-do  are  all  prone  to  eat  too  much,  and  it  is  remarka- 
ble how  rapidly  acne  will  improve  by  reducing  their  diet  to 
the  simplest  elements.  In  many  of  them  a  milk  diet  for  a 
few  days,  provided  milk  agrees  with  them,  will  accomplish 
a  marked  benefit.  It  is  a  good  rule  to  cut  off  from  the 
dietary  all  pastry,  cake,  candy,  sweets,  hot  breads  and  pan- 
cakes, greasy  soups,  articles  fried  in  fat,  rich  gravies — in 
fact,  all  those  things  that  are  most  apt  to  tempt  the  palate. 
Oatmeal  is  often  cited  as  a  cause  of  acne.  Hot  water  before 
meals,  a  glass  of  fluid,  either  milk  or  water,  at  meals,  and  a 
glass  of  water  two  hours  after  meals  is  a  good  direction  for  the 
use  of  things  to  drink.  Tea,  coffee,  malt  liquors,  sweet  and 
heavy  wines  are  to  be  avoided.  Exercise  must  be  insisted 
on,  an  hour  or  more  a  day  being  spent  in  walking,  riding 
on  horseback,  rowing,  or  other  out-door  exercise.  Daily 
bathing  or  dry  rubbing  will  keep  the  skin  in  healthy  condi- 
tion, and  Turkish  baths  are  often  beneficial. 

Arsenic,  sulphide  of  calcium,  glycerin,  and  ergot  are  the 
drugs  that  are  given  by  the  mouth  as  curative  in  acne. 
Arsenic  is  the  oldest  and  most  honored  of  these.  It  is  of 
use  only  in  very  chronic,  sluggish  cases,  and  the  more 
papular  the  case  the  more  useful  the  arsenic.  It  should  be 
used  as  a  last  resort,  not  as  the  first.     Fowler's  solution  is 


ACNE.  63 

the  most  frequently  used  preparation,  in  doses  of  from  three 
drops  three  times  a  day,  as  an  initial  dose,  gradually  in- 
creased to  fifteen  or  twenty  drops  or  until  the  appearance  of 
some  symptom  of  poisoning.  Piffard1  recommends  bromide 
of  arsenic  in  the  dose  of  yj-g-  to  -^  grain  two  or  three  times  a 
day  in  rather  acute  cases  of  acne.  A  convenient  method  of 
administration  is  to  make  a  one  per  cent,  solution  in  alco- 
hol, and  give  one  to  two  minims  of  that  in  a  wineglassful  of 
water.  Should  it  cause  gastric  irritation  the  dose  must  be 
lessened.  I  have  used  this  in  a  number  of  cases  and  with 
good  results.  The  sulphide  of  calcium  will  be  useful  in 
many  sluggish  pustular  cases.  It  should  be  given  in  small 
doses,  from  y^-  to  -^  grain,  in  gelatin-coated  pills  or  fresh 
tablet  triturates.  One  pill  may  be  given  four  or  five  times 
a  day  until  the  tendency  to  pustulation  is  increased.  It 
then  should  be  discontinued  until  the  exacerbation  has  sub- 
sided, when  it  should  be  again  administered.  Glycerin  was 
advocated  by  Grubler2  as  a  cure  for  acne,  and  is  well  spoken 
of  by  others.  It  must  be  given  in  doses  of  a  teaspoonful 
three  times  a  day  increased  to  a  tables poonful,  and  is  of 
most  use  in  strumous  cases.  Ergot,  either  the  fluid  extract 
in  doses  of  half  a  drachm  three  times  a  day,  or  a  correspond- 
ing amount  of  ergotin,  has  many  advocates. 

Ghrysarobin,  internally,  has  been  recommended  by  Stoc- 
quart,3  in  the  dose  of  one-sixth  to  one-half  a  grain  ;  and 
Sherwell4  advocates  the  passage  of  the  cold  sound  through 
the  urethra  of  a  young  man  suffering  with  acne.  Small 
doses  of  the  bichloride  of  mercury  are  sometimes  curative 
where  there  is  much  infiltration. 

The  objects  of  local  treatment  are  to  open  up  the  pustules 
and  papules  and  allow  of  the  escape  of  their  contents,  to 
stimulate  the  skin  to  a  more  healthful  action,  and,  accord- 
ing to  the  bacteriologists,  to  prevent  further  infection  of  the 
follicles  by  microorganisms.  To  attain  the  first  two  objects 
we  may  employ  either  a  quick  or  a  slow  method ;  to  attain 

1  Journ.  Cutan.  and  Yen.  Dis.,  1884,  ii.  71. 

2  Journ.  de  Bruxelles,  1870. 

3  Annal.  Derm,  et  Syph.,  1884,  v.  15. 

4  Journ.  Cutan.  and  Ven.  Dis.,  1884,  ii.  335. 


64 


DISEASES    OF    THE    SKIN 


the  last  object  we  employ  an  antiparasitic.  The  best  pre- 
ventive local  treatment  is  to  keep  the  skin  clean  and  its 
nutrition  good  by  the  use  of  soap  and  water. 

The  most  efficient  local  treatment  for  nearly  all  cases  of 
acne  is  to  put  the  skin  somewhat  on  the  stretch,  and  scrape 
it  somewhat  roughly  with  a  large  and  long,  blunt  dermal 
curette  with  a  fenestrated  blade  (Fig.  6).  This  tears  off  all 
the  tops  of  the  lesions,  presses  out  all  the  contents  of  the 

Fig.  6. 


Fox's  ring  curette. 

follicles,  and  stimulates  the  skin  in  a  most  vigorous  manner. 
It  is  followed  by  some  bleeding,  which  it  is  well  to  encour- 
age by  the  use  of  warm  water.  Deep  pustules  or  cutaneous 
abscesses  if  not  emptied  by  the  curetting  should  be  incised. 
All  comedones  should  be  squeezed  out.  The  after-treatment 
consists  in  washing  the  face  with  warm  water  and  soap,  and 
dusting  with  corn  starch,  to  which  may  be  added  oxide  of 
zinc.  The  scraping  is  to  be  repeated  two  or  three  times  a 
week.  The  procedure  seems  rough,  but  after  the  first  scrap- 
ing the  patients  do  not  mind  it  much,  and  the  result  is  the 

Fig.  7. 


Fox's  acne  lance  and  dermal  curette. 


attainment  of  a  smooth  skin  in  a  much  shorter  time  than  by 
any  other  method  of  treatment.  With  this  plan  we  may  use 
a  sulphur  ointment,  a  drachm  to  the  ounce,  to  be  applied 
twenty-four  hours  after  the  scraping,  or  a  wash  of  bichloride 
of  mercury,  one-half  grain  to  the  ounce  of  dilute  alcohol,  to 
which  may  be  added  a  little  glycerin.  Thus  will  we  fulfil 
all  three  of  the  indications  for  treatment. 

The  same  results  can  be  attained  in  a  slower  way  by 
opening  every  pustule  with  an  acne  lancet  (Fig.  7),  and 
squeezing  out   every  comedo.     This   is  to    be    done   once 


ACNE.  65 

or  twice  a  week,  and  a  sulphur  preparation  used  between 
times.  Very  timid  patients  who  will  allow  no  surgical  inter- 
ference may  be  treated  according  to  the  same  principles  by 
directing  them  to  scrub  their  faces  thoroughly  once  a  day 
with  green  soap,  or  tincture  of  green  soap,  and  leave  the 
lather  on.  After  a  day  or  two  of  good  scrubbing  an  amount 
of  dermatitis  will  be  excited  sufficient  to  cause  the  old  skin 
to  peel  off,  while  the  tops  of  many  of  the  lesions  will  have 
been  torn  off,  and  the  skin  will  have  been  decidedly  stimu- 
lated. Not  until  the  skin  has  become  scaly  and  feels  tense 
to  the  patient  should  a  soothing  ointment  be  applied. 
Repeated  applications  of  the  soap  frictions  will  slowly  bring 
about  improvement.  Rubbing  the  face  with  fine  sand  or 
coarse  corn-meal  will  do  good,  but  is  not  so  elegant. 

Massage  to  the  skin,  pinching  it  up  and  rolling  it  between 
the  thumb  and  fingers  does  well  in  emptying  the  follicles  and 
stimulating  the  circulation.  The  application  of  the  galvanic 
current  by  means  of  the  roller  electrode,  or  by  ordinary 
sponge  electrodes,  will  in  some  sluggish  cases  prove  helpful. 

A  vast  number  of  prescriptions  have  been  written  which 
are  "good  for  acne,"  the  majority  of  which  contain  sulphur 
in  some  form,  and  in  the  strength  of  half  a  drachm  to  one 
drachm  to  the  ounce,  and  in  ointment  or  lotion  form,  Sul- 
phur in  powder  form  is  good  if  the  patient  doesn't  mind  the 
odor.  The  ordinary  sulphur  ointment  of  the  Pharmacopoeia 
diluted  one-third  or  one-half  is  as  good  a  preparation  as 
any.  It  may  be  made  more  elegant  by  adding  some  perfume. 
The  sulphuret  of  potassium  may  be  used  in  the  following : 

R.  Potass,  sulphurat., )  ..         • .  , 

Zinci  sulphat.,         J  '  '       «'«' ' 

Aquas  rosse,  5  iv ;     120  M. 

This  preparation  is  commonly  spoken  of  as  "  Lotio  alba," 
and  is  one  of  the  most  useful  of  the  compounds  of  sulphur. 
It  is  to  be  applied  every  day  after  being  well  shaken. 

Vleminck's  solution  is  an  active  preparation  in  causing 
the  old  skin  to  exfoliate.     It  is  composed  of — 


M. 


R  •  Calcis, 

3 ss ; 

15 

Sulph.  sublim., 

3j; 

30 

Aqua?  destil., 

3x; 

300 

Cook  to  ^  vj.  and  filter. 

66  DISEASES   OF    THE    SKIN. 

After  this  has  been  left  on  a  few  hours,  it  must  be  washed 
off  and  a  soothing  ointment,  such  as  ungt.  zinci  oxid.,  or 
ungt.  aquae  rosae,  applied.  It  is  most  useful  in  acne  of  the 
back. 

Mercurial  preparations  may  be  used  to  more  advantage 
in  some  cases  than  those  of  sulphur.  It  must  be  borne  in 
mind  that  a  mercurial  must  never  be  applied  to  the  skin 
until  all  traces  of  sulphur  are  removed,  or  vice  versa, 
because  if  the  precaution  is  forgotten,  the  black  sulphide  of 
mercury  will  be  formed,  which  will  give  the  skin  the  appear- 
ance of  being  sown  with  powder-grains.  A  lotion  of  corro- 
sive sublimate,  1  in  1000  to  2000,  may  be  mopped  on  once  or 
twice  a  day.  Or  an  ointment  of  the  protiodide,  as  recom- 
mended by  Duhring,  may  be  used  : 

R.  Hydrarg.  protiodid.,  gr.  v-xv  ;  II 

Hydrarg.  amnion.,  gr.  x-xxx ;  2 

Ungt.  simplicis,  ^j ;  30 1         M. 

Lassar1  recommends  the  following  paste  : 

R .  /3-naphthol,  10  parts. 

Sulphur  precip.,  50     " 

Vaseline,         \  25     u  M 

feapo  vmdis,  J 

This  is  to  be  spread  upon  the  skin  to  the  thickness  of  the 
back  of  a  knife-blade,  and  left  on  for  fifteen  or  twenty 
minutes.  It  is  then  to  be  wiped  off  with  a  soft  cloth,  and 
the  skin  powdered  with  talc.  The  skin  becomes  inflamed, 
turns  brown,  and  peels  off.  The  application  is  to  be  re- 
peated every  day  until  the  skin  does  peel  off.  Desquama- 
tion can  be  hastened  by  the  application  of  Lassar's  paste 
with  two  per  cent  of  salicylic  acid. 

Resorcin  has  been  commended,  used  in  twenty  per  cent, 
strength.  Ichthyol,  the  ammonio- sulphate,  is  recommended 
by  Unna  for  acne.  As  much  as  fifteen  grains  of  it  is  to  be 
taken  by  the  mouth  during  the  day.  A  mild  corrosive  sub- 
limate wash  is  to  be  applied  to  the  face  until  the  patient  goes 
to  bed,  and  then  a  ten  per  cent,  aqueous  solution,  or  paste 
of  ichthyol,  is  to  be  kept  on  till  morning.     Startin2  has  em- 

1  Therap.  Monatsnft.,  1887,  No.  1. 

2  Lancet,  1889,  i.  934. 


ACNE.  67 

ployed  local  steam  baths  by  means  of  a  steam  atomizer,  with 
success.  The  steaming  should  be  kept  up  for  twenty  or  thirty 
minutes,  and  tincture  of  benzoin  used  in  the  medicine  cup. 

The  foregoing  remedies  are  all  specially  adapted  to  more 
or  less  sluggish  cases,  the  type  met  with  in  the  great 
majority  of  instances.  In  very  recent  and  quite  inflamma- 
tory cases,  besides  the  administration  of  laxatives  and  the 
regulation  of  the  diet,  the  patient  should  be  directed  to 
bathe  the  face  in  hot  water  either  with  or  without  the  addi- 
tion of  borax  (5ij  to  Oj),  and  apply  a  soothing  ointment. 

Bathing  of  the  face  with  hot  water  before  the  application 
of  any  lotion  or  ointment  should  be  advised.  In  indurated 
acne,  where  cutaneous  abscesses  have  formed,  and  the  lesions 
are  discrete,  each  abscess  will  have  to  be  opened  up  with  a 
lance,  the  contents  of  the  abscess  discharged,  and  carbolic 
acid,  either  pure  or  diluted,  introduced,  by  means  of  a  little 
cotton  around  the  end  of  a  bit  of  wood,  into  the  abscess 
cavity,  so  as  to  destroy  the  lining  membrane. 

Individual  acne  lesions  can  sometimes  be  aborted  by  touch- 
ing them  with  pure  carbolic  acid,  or  acid  nitrate  of  mercury. 

Prognosis.  By  persistent  effort,  and  careful  regulation 
of  all  the  bodily  functions,  a  great  improvement  can  be 
effected,  one  fairly  deserving  of  the  name  of  cure.  But  noth- 
ing can  prevent  the  occasional  appearance  of  a  few  acne 
lesions  until  the  period  of  life  in  which  acne  usually  occurs 
is  passed.  There  are  some  rare  cases  in  which  we  can  do 
nothing,  because  we  are  unable  to  remove  the  underlying 
cause. 

Acne  Albida.     See  Milium. 

Acne  Artificialis.  By  this  term  is  meant  an  inflam- 
mation of  the  sebaceous  glands  and  hair  follicles  caused  by 
drugs  either  applied  locally  or  acting  from  within.  It  has 
three  principal  varieties,  namely,  tar  acne,  bromie  acne, 
and  iodic  acne,  and  should  be  regarded  rather  as  a  derma- 
titis  medicamentosa  than  as  an  acne.  Tar  produces  acne- 
like lesions  with  black  points  when  applied  locally  to  some 
susceptible  skins.  As  a  rule,  papules  are  more  abundant 
than  pustules,  but  abscesses  and  furuncles  may  form.  These 
lesions  are  not  confined  to  the  usual  locations  for  acne,  are 


68  DISEASES   OF    THE    SKIN. 

particularly  abundant  on  the  extensor  surface  of  the  arms, 
and  are  recognizable  by  their  central  black  points,  and  by 
the  fact  that  the  patient  is  using  tar.  For  its  cure  air  that 
is  necessary  is  to  stop  the  use  of  the  tar,  and  to  sooth  the 
inflamed  skin.  None  of  these  acnes  is  a  true  acne. 
Bromic  and  iodic  acne  will  be  spoken  of  under  Drug  erup- 
tions. Derivatives  of  tar,  chrysarobin,  and  pyrogallol  may 
also  produce  similar  acne-like  lesions  when  applied  ex- 
ternally. 

Acne  Atrophica  is  a  term  applied  to  the  scars  left  by 
acne,  and  to.  acne  frontalis.  The  first  needs  no  description. 
The  other  will  be  found  further  on. 

Acne  Cachecticorum  is  rather  to  be  regarded  as  a 
scrofuloderma  than  an  acne,  as  it  probably  has  little  to  do 
with  the  sebaceous  glands.  It  occurs  in  broken  down  or 
scrofulous  subjects,  and  is  particularly  prone  to  appear 
upon  the  extremities.  It  takes  the  form  of  small,  con- 
gested, or  dark-red,  sluggish  papules  and  papulo-pustules 
that  run  a  slow  course,  break  down,  perhaps  ulcerate,  and 
leave  small  depressed  cicatrices.  Occurring  on  the  fingers, 
these  will  often  be  congested  and  clubbed.  It  is  one  of  the 
rare  forms  of  disease  and  requires  tonic  remedies  such  as 
cod-liver  oil  and  iron  for  its  cure. 

Acne  Cornea.     See  Psorospermosis  follicularis. 

Acne  Fluente.     See  Seborrhoea  oleosa. 

Acne  Frontalis.  Synonyms :  Acne  rodens,  a.  ulcer- 
euse,  a.  atrophique,  a.  arthritique,  a.  miliare  scrofuleuse,  a. 
varioliformis  of  the  Germans,  a.  necrotica,  a.  pilaris, 
lupoid  acne. 

Acne  frontalis  is  the  name  given  by  Boeck  to  an  acne- 
form  lesion  that  occurs  in  adults  on  the  forehead  along  the 
line  of  the  hair.  It  is  also  met  with  on  the  cheeks  and 
nose,  and  some  lesions  may  be  on  the  scalp.  It  has  been 
described  as  occurring  upon  the  trunk,  sternal  region,  and 
back.  The  eruption  consists  of  pinhead-  to  lentil-sized, 
reddish-brown,  hard  papules,  on  which  form  flaccid  pustules 
that  soon  dry  into  a  brown  crust.  If  on  hairy  regions  the 
crust  may  be  pierced  by  a  hair.     Some  papules  have  an 


ACROCHORDON.  69 

inflammatory  halo  around  them.  The  crust  adheres  very 
closely,  and  seems  as  if  sunk  into  the  papule.  If  removed 
a  loss  of  substance  is  revealed.  It  is  possible  to  press  out 
a  drop  of  pus  from  under  old  lesions  just  about  ripe  enough 
to  lose  their  crusts.  When  the  crust  falls  of  itself  it  leaves 
a  brownish- red  cicatrix  that  gradually  grows  white.  Some- 
times the  lesions  are  present  in  large  numbers,  and  as  each 
one  runs  a  slow  course,  lesions  in  all  stages  of  development 
will  be  found. 

This  is  a  rare  form  of  disease,  and  its  etiology  and  path- 
ology are  still  undetermined.  It  bears  a  decided  resem- 
blance to  syphilis  m  some  of  its  forms.  It  is  probable  that 
some  of  the  cases  that  have  yielded  to  mercurial  ointments 
were  syphilitic. 

Treatment.  In  treatment  sulphur  ointment  or  a  mer- 
curial will  probably  give  the  best  result. 

Acne  Hypertrophica.     See  Rosacea. 

Acne  Keloidienne.     See  Dermatitis  papillaris  capillitii. 

Acne  Mentagra.     See  Sycosis. 

Acne  Miliaris.     See  Milium. 

Acne  Rodens.     See  Acne  frontalis. 

Acne  Rosacea.     See  Rosacea. 

Acne  Scrofulosorum.     See  Acne  cachecticorum. 

Acne  Sebacea.     See  Seborrhoea. 

Acne  Syphilitica.     See  Pustular  syphiloderm. 

Acne  Tuberculoide,  or  Tuberculeuse  Ombiliquee.  See 
Molluscum  contagiosum. 

Acne  Varioliformis.  See  Molluscum  contagiosum  and 
Acne  frontalis. 

Acrochordon  (A2k-ro-ko2rd'-o2n).  See  Molluscum  pen- 
dulum. The  term  is  also  applied  to  large  or  small 
polypoid  prominences  produced  by  an  overgrowth  of  the 
endothelium  of  the  sebaceous  glands.  These  occur  in 
elderly  people  upon  the  eyelids,  neck,  and  throat.  They 
may  attain  the  size  of  hazel-nuts,  and  look  like  overgrown 
milia.  The  treatment  consists  in  removing  them  by  liga- 
ture or  scissors. 


70  DISEASES    OF    THE    SKIN. 

Acrodynia  (A^-ro-drn'-P-a3)  is  a  disease  closely  allied 
to  pellagra  in  its  symptoms,  that  has  been  observed  chiefly 
amongst  the  French  and  Belgian  soldiers,  and  is  probably 
due  to  some  defect  in  food  supplies.  It  begins  with  gastro- 
intestinal irritation  to  which  certain  neuroses  soon  add 
themselves,  such  as  formication,  hyperesthesia  and  anaes- 
thesia. An  erythema  of  the  hands  and  feet,  and  may  be 
of  the  whole  body,  followed  by  brown  or  black  pigamenta- 
tion,  is  the  cutaneous  element  of  the  disease.  Recovery 
usually  takes  place,  though  death  may  occur  from  diarrhoea. 

Addison's  Keloid.     See  Morphcea. 

Adenoma  (A2d-e2n-orma3).  These  are  glandular  tumors, 
and  are  due  to  a  proliferation  of  the  lining  cells  of  either 
the  sebaceous  or  sweat  glands.  There  are  therefore  two 
varieties  :  A.  sebaceum,  and  A.  sudoriferum.  Though  met 
with  in  persons  of  mature  years  it  is  not  improbable  that 
they  are  congenital  defects.  They  form  solid  tumors  from 
pinhead  to  egg  size  or  larger.  They  may  remain  stationary 
or  grow  ;  may  disappear  spontaneously,  ulcerate,  form  cysts, 
or  undergo  hyaline,  colloid,  or  fatty  degeneration.  While 
usually  benign,  they  may  become  malignant.  They  tend  to 
relapse  after  extirpation. 

The  sebaceous  form  is  encountered  most  often  on  the 
face,  about  the  nose  and  mouth ;  less  frequently  upon  the 
scalp,  but  may  occur  anywhere.  Their  color  varies  from 
pale  yellow  to  red,  when  they  will  have  fine  telangiectases 
over  them.  They  occur  most  often  in  females,  are  generally 
multiple,  often  with  an  uneven  surface,  and  seated  deep  in 
the  skin. 

The  sudoriferous  variety  occurs  as  dirty  grayish-white 
tumors,  sometimes  in  groups,  with  uneven,  often  knobby 
surface.  They  are  rare  lesions  of  the  skin,  difficult  of 
diagnosis,  and  require  extirpation  or  total  destruction  for 
their  cure. 

Ainhum  is  a  disease  most  frequently  seen  in  the  negro 
race,  though  a  number  of  cases  have  been  reported  from 
India.  It  is  seen  in  men  more  often  than  women,  and 
several  members  of  the  same  family  have  been  known  to  be 


ALOPECIA.  71 

affected  by  it.  The  little  toe,  of  one  or  both  feet,  is  the  one 
usually  diseased,  though  the  other  toes  do  not  always 
escape.  It  begins  as  a  furrow  on  the  inner  and  lower  side 
of  the  proximal  end  of  the  toe,  which  gradually  extends 
outward  and  upward  so  as  to  encircle  the  whole  toe  at  its 
juncture  with  the  foot.  In  the  meantime  the  toe  becomes 
enlarged,  separates  from  its  next  neighbor,  and  rotates 
outward.  When  fully  developed  the  toe  wobbles  about  so 
that  it  interferes  with  walking.  The  whole  process  is  un- 
attended with  ulceration  except  accidentally  caused,  and 
after  the  disease  has  lasted  a  long  time.  When  it  sets  in 
the  toe  falls  off.  There  is  little  pain  experienced  till  near 
the  end  of  the  disease.  It  takes  from  one  to  ten  years  for 
the  full  development  of  the  disease.  The  cause  is  unknown. 
The  process  is  one  of  progressive  degeneration  and  destruc- 
tion of  all  the  elements  of  the  toe ;  skin,  muscles,  bone. 
Amputation  is  required  for  the  cure,  and  healing  takes 
place  rapidly. 

Albinism.     See  Leucoderma. 

Aleppo  Boil,  Aleppo  bouton,  or  Aleppo  evil,  is  an  ill-de- 
fined furuncular  disease  occurring  in  Syria  and  the  Levant. 

Algidite  Progressive.     See  Sclerema  neonatorum. 

Algor  Progressivus.     See  Sclerema  neonatorum. 

Alopecia  (A^-o-pe'sh^-a3).  Synonyms  :  Calvities  ;  (Fr.) 
Alopecie;  (Ger.)  Kahlheit;  (Ital.)  Calvezza ;  (Sp.)  Calvez; 
Baldness. 

By  alopecia  is  meant  a  partial  or  general  loss  of  the  hair, 
so  as  to  produce  a  noticeable  thinning  or  a  bare  spot. 
There  are  four  main  varieties,  namely,  Alopecia  adnata; 
Alopecia  senilis ;  Alopecia  prematura  or  presenilis ;  and 
Alopecia  areata. 

Alopecia  Adnata  is  congenital  baldness,  and  is  a  rare 
affection. 

Symptoms.  The  newborn  child  is  covered  with  long 
dark  hair  which  soon  falls  to  give  place  to  fine  lanugo 
hairs ;  or  this  change  has  taken  place  before  birth,  the  usual 
course  of  events,  and  at  birth  lanugo  hairs  only  are  present. 
In  alopecia  adnata  there  is  not  the  slighest  trace  even  of 


72  DISEASES   OF    THE    SKIN. 

lanugo  hairs  either  on  the  scalp  or  eyebrows.  In  some 
cases  the  baldness  is  not  so  complete.  Most  cases,  after 
months  or  years,  recover  either  altogether  or  partially,  but 
in  some  cases  the  hair  never  grows.  In  pronounced  cases  de- 
layed dentition  or  deficiency  of  the  teeth  have  been  observed. 

Etiology.  The  cause  of  the  disease  is  arrest  of  the  de- 
velopment of  the  hair,  probably  due  to  an  error  in  innerva- 
tion.    It  is  said  to  be  hereditary  in  some  families. 

Tkeatment.  The  treatment  is  mainly  an  expectant  one. 
The  nutrition  of  the  child  should  be  looked  after,  and  the 
scalp  kept  in  a  healthy  condition.  If  this  expectant  plan 
does  not  satisfy  the  child's  attendants,  some  of  the  stimulat- 
ing hair  washes,  as  in  alopecia  presenilis,  may  be  prescribed 
for  the  moral  effect  upon  them. 

Alopecia  Senilis  is  baldness  occurring  in  advancing 
years.  Any  loss  of  hair  commencing  about  the  forty-fifth 
year  and  without  any  apparent  cause  may  be  placed  under 
this  heading.  Graying  of  the  hair  may  have  preceded  it 
for  several  years  or  may  be  coincident  with  it.  Or  the 
hair  may  fall  without  becoming  gray.  The  hair  fall 
having  once  begun  is  progressive,  though  its  rate  of  progress 
may  be  slow  or  fast.  It  usually  shows  itself  first  upon  the 
vertex  of  the  head,  forming  the  tonsure,  which  slowly  in- 
creases in  size,  and,  moving  forward,  renders  the  whole  top 
of  the  head  bald.  Or  it  may  begin  anteriorly  and  move 
backward.  Or  the  hair  on  the  whole  top  of  the  head  may 
become  thinned  at  once.  Rarely  are  the  temporal  and  occi- 
pital regions  bald,  and  an  island  or  tuft  of  hair  is  sometimes 
preserved  for  a  long  time  in  the  middle  frontal  region. 
The  hair  fall  is  always  symmetrical,  and  the  bare  scalp  is 
smooth,  oily,  shiny,  and  appears  as  if  stretched.  Not  only 
does  the  hair  fall  from  the  scalp,  but  it  may  fall  from  the 
axillae  and  pubic  region ;  these  manifestations  I  believe  to 
be  more  common  in  women  than  men.  Very  rarely  does 
the  beard  fall. 

Etiology.  The  cause  of  this  form  of  baldness  is  a  pro- 
gressive atrophy  of  the  scalp.  Men  are  far  more  prone  to 
the  disease  than  are  women. 

Treatment.     As  to  the  treatment,  we  can  do  nothing. 


ALOPECIA.  73 

Prophylaxis,  as  described  under  Alopecia  prematura,  will 
delay  its  onset. 

Alopecia  Prematura  is  baldness  occurring  before  middle 
life.     It  may  be  idiopathic  or  symptomatic. 

Alopecia  'prematura  idiopathiea  arises  without  any  evi- 
dent disease  of  the  scalp  or  disorder  of  the  general  health. 
It  usually  begins  in  early  life,  between  twenty-five  and 
thirty-five ;  it  may  begin  as  early  as  the  eighteenth  year. 
Its  general  course  is  the  same  as  the  senile  form  of  alopecia. 
Very  often  the  upper  parts  of  the  temples  are  earliest 
affected,  the  hair  line  receding.  In  those  who  part  the  hair 
in  the  middle,  the  thinning  of  the  hair  about  the  part  may 
be  the  first  thing  to  attract  attention.  The  process  of  the 
hair  fall  is  one  of  progressive  thinning  of  the  individual 
hairs  at  first,  and  then  of  the  whole  quantity  of  hair,  so 
that  strong  hairs  give  place  to  lanugo  hairs,  and  these  in  turn 
fall  and  leave  bald  places.  At  the  same  time  a  progressive 
tightening  of  the  scalp  upon  the  skull  will  be  observable  in 
some  cases,  the  scalp  having  lost  that  cushion  of  fat  that  is 
under  it  in  early  life.  The  hair  fall  having  begun  is  pro- 
gressive, though  years  may  elapse  before  there  is  absolute 
baldness.  The  tonsure  may  not  enlarge  for  a  long  time, 
and  then  increase  rapidly  in  size. 

Etiology.  The  main  cause  of  this  form  of  baldness  is 
heredity.  Fathers  and  sons  for  generations  may  grow  bald 
early,  or  the  inherited  peculiarity  may  have  to  be  traced  to 
the  grandparents  or  some  collateral  line.  Not  all  the 
children  of  one  family  in  which  baldness  is  hereditary  are 
bald,  but  it  will  manifest  itself  in  two  or  three  of  the  chil- 
dren. According  to  Pincus,1  inheritance  and  chronic  eczema 
or  an  impetiginous  eruption  on  the  scalp  in  the  years  pre- 
ceding puberty  are  the  only  predisposing  causes  of  bald- 
ness. Insufficient  or  improper  care  of  the  scalp ;  daily 
sousing  of  the  hair  with  water,  combined  with  improper 
drying  of  the  hair  afterward ;  sweating  of  the  head,  either 
spontaneously  or  on  account  of  the  wearing  of  unventilated 
or  hot  head-coverings ;   constant  mental   strain,  either  on 

1  Yirchow's  Archiv.,  1867,  xli.  322. 
4 


74  DISEASES    OF    THE    SKIN. 

account  of  intellectual  work  or  of  worry ;  the  wearing  of 
stiff,  unyielding  hats ;  gout ;  and  dissipation,  are  all  put 
forth  by  reputable  observers  as  causes  of  premature  baldness. 

That  women  are  less  often  bald  than  men  probably  de- 
pends upon  several  factors :  The  fatty  cushion  beneath 
their  scalps  is  longer  preserved  than  in  men  ;  they  give  more 
attention  to  the  care  of  the  hair  and  less  often  wet  it ;  and 
their  hats  are  soft,  ventilated,  and  fit  loosely. 

Treatment.  We  can  do  more  for  this  form  of  baldness 
by  prophylaxis  than  by  attempts  at  making  the  hair  that 
has  fallen  out  grow  in  again.  Prophylaxis  should  begin  at 
the  beginning  of  life,  and  should  be  continuous.  This  is  of 
special  importance  in  the  care  of  children  in  families  prone 
to  early  loss  of  hair. 

The  hygiene  of  the  scalp  is  the  chief  part  of  the  prophy- 
lactic treatment.  Beginning  at  infancy,  the  scalp  should 
be  gently  cleansed  of  the  vernix  caseosa  and  other  extra- 
neous substances  that  have  gathered  on  it  during  the  process 
of  parturition.  This  should  be  done  by  the  gentle  use  of 
soap  and  water  after  rubbing  in  a  little  sweet  almond  or 
other  bland  oil.  No  force  should  be  used,  and  after  the 
scalp  is  washed  it  should  be  patted  dry  with  a  soft  warm 
cloth,  and  a  little  oil  or  vaseline  smeared  over  it.  After 
the  first  washing  it  should  be  oiled  daily  and  washed  every 
second  day.  When  the  hair  begins  to  grow  a  soft  brush 
alone  should  be  used  to  arrange  it,  and  the  daily  oiling 
may  be  stopped  unless  sebaceous  matter  accumulates  in 
cakes,  in  which  event  the  oiling  should  be  continued. 
Sometimes  it  is  well  to  add  a  little  sulphur  to  the  oil  or 
vaseline,  but  in  most  cases  it  is  unnecessary.  The  slightest 
indication  of  disease  of  the  scalp  should  be  promptly  and 
properly  dealt  with.  A  child's  hair  should  be  cut  short, 
not  cropped  close  to  the  head.  After  a  girl  has  reached  her 
eighth  or  ninth  year,  the  hair  should  be  allowed  to  grow. 

The  hair  and  scalp  do  not  need  to  be  washed  more  than 
once  in  two  or  three  weeks,  and  for  this  purpose  any  good 
soap  will  do,  with  plenty  of  water  to  wash  out  the  soapsuds. 
Borax  with  water  will  clean  the  scalp  nicely,  but  its  con- 
tinuous use  is  injurious.     The  yolk  of  three  eggs  beaten  up 


ALOPECIA.  75 

with  lime-water  makes  an  elegant  shampoo.  The  daily  sousing 
of  the  head  in  water  should  be  prohibited.  Deep  brushing 
of  the  hair  with  a  long-bristled  brush  of  sufficient  stiffness 
to  warm,  but  not  scratch  the  scalp,  is  the  best  agent  we  have 
for  stimulating  the  scalp.  The  brushing  should  be  done 
daily  and  systematically. 

Pomades  and  hair  washes  should  be  avoided  unless  there 
is  some  evident  disease  of  the  scalp.  Women  should  be 
cautioned  against  pulling  their  hair  into  artificial  and  con- 
strained positions.  Most  important  of  all  is  it  that  a  suf- 
ficient amount  of  outdoor  exercise  should  be  taken  to  aid  in 
keeping  the  patient  in  good  general  condition. 

When  the  hair  has  begun  to  fall  it  is  important  that  the 
hygiene  of  the  scalp  should  be  begun,  if  not  already  prac- 
tised. We  can  do  more  for  our  cases  in  this  way  than  by 
any  other  method. 

Many  remedies  have  been  advised  for  the  curative  treat- 
ment of  baldness.  Pilocarpine,  in  hypodermic  injections  or 
in  ointment  form,  has  been  warmly  commended.  Lassar1 
prescribes  it  as  follows  : 

R.  Hydrochlorate  of  pilocarpine,  gr.  xxx;  2| 

Vaseline,  £v ;  20  j 

Lanolin,  ^ij;  60  j 

Oil  of  lavender,  gtt.  xxv  M. 

He  also  advises  oil  of  turpentine,  equal  parts  with  an 
indifferent  oil  or  alcohol.  It  is  my  experience  that  most  of 
these  cases  do  better  with  oily  than  with  alcoholic  prepara- 
tions. Gallic  acid,  3  per  cent.,  in  an  oily  excipient ;  tar ; 
galvanism  ;  massage ;  tincture  of  cantharides  (5j-oj) ',  tinc- 
ture of  nux  vomica  (5j— Sj)  ;  and  a  lot  of  other  irritants  and 
essential  oils,  have  their  advocates. 

Peognosis.  But  the  prognosis  of  this  form  of  baldness  is 
bad,  and  especially  so  if  the  disease  is  hereditary  and  the 
patient  is  more  than  thirty  years  of  age.  It  is  better  with 
women  than  with  men,  as  they  will  give  more  time  to  the 
care  of  their  scalps,  and  show  less  tendency  to  alopecia. 

Alopecia   prematura  symptomatica  is  premature    bald- 

1  Therap.  Monatsheft,  1888,  No.  12. 


76  DISEASES    OF    THE    SKIN. 

ness  in  which  there  is  some  evident  disease  of  the  scalp,  or 
disorder  of  the  general  nutrition  of  the  body,  to  account  for 
it.  It  has  four  varieties  :  Alopecia  furfuracea  seu  pity- 
rodes ;  A.  syphilitica ;  Defluvium  capillorum  ;  and  A.  fol- 
licularis. 

Alopecia  Furfuracea  seu  Pityrodes  is  the  form  most 
frequently  met  with,  and  the  one  in  which  we  can  often 
obtain  good  results  by  treatment. 

Symptoms.  In  it  we  have  an  evident  disease  of  the  scalp 
to  deal  with — that  is,  dandruff.  By  this  we  mean  either  a 
seborrhoea  with  fatty  crusts,  or  else  a  pityriasis  with  more 
or  less  abundant  scaling.  Unna  regards  both  conditions  as 
being  simply  different  forms  of  one  disease  that  he  calls 
eczema  seborrhoicum. 

Alopecia  pityrodes  has  two  stages :  The  first  one  lasts 
from  two  to  seven  years  or  more,  and  is  attended  by  a 
greater  or  less  amount  of  dandruff  and  by  dryness  of  the 
hair.  Then  comes  the  second  stage,  when  the  hair  falls 
more  or  less  rapidly.  Its  course  may  be  the  same  as  that 
of  the  two  previously  described  forms  of  baldness,  though 
more  commonly  the  whole  top  of  the  head  is  affected  at 
once,  the  hair  becoming  progressively  thinner  in  diameter 
and  less  in  amount  until  baldness  results.  As  the  baldness 
increases  the  dandruff  lessens.  The  disease  is  one  of  early 
life  in  a  large  number  of  cases,  often  occurring  between  the 
twentieth  and  thirtieth  year,  and  affects  both  sexes. 

Etiology.  The  cause  of  the  hair  fall  is  the  dandruff.  By 
this  it  is  not  meant  that  everyone  who  has  dandruff  will 
become  bald.  Everyone's  experience  is  against  that.  But 
it  is  true  that  in  certain  persons  when,  on  account  of  some 
error  in  the  nutrition  of  the  sebaceous  glands,  they  become 
diseased,  the  hair  follicles  sympathize  with  them,  and  after 
a  time  the  hair  production  ceases.  Of  late,  the  opinion  is 
gaining  ground  that  alopecia  pityrodes  is  contagious,  and 
the  experiments  of  Lassar  and  Bishop1  would  seem  to  prove 
this.  They  succeeded  in  producing  typical  alopecia  pity- 
rodes in  guinea-pigs  by  rubbing  into  their  backs  a  pomade 

1  Monatshefte  f.  prakt.  Dermat.,  1882,  i.  131. 


ALOPECIA.  77 

composed  of  the  scales  taken  from  the  head  of  a  student  who 
was  afflicted  with  the  same  disease.  A  number  of  observers 
have  reported  from  time  to  time  the  finding  of  a  parasite  in 
this  disease,  but  as  yet  no  one  microorganism  can  be  demon- 
stated  as  positively  at  the  bottom  of  the  trouble. 

Treatment.  The  treatment  of  this  form  of  baldness  must 
be  addressed  to  the  cure  of  the  seborrhoea  or  pityriasis  that 
causes  the  loss  of  hair.  Prophylaxis  is  here  again  more 
important  than  the  use  of  remedies  for  promoting  the  growth 
of  the  hair.  The  treatment  of  seborrhoea  and  pityriasis 
will  be  considered  under  their  respective  headings,  and  need 
not  be  here  detailed.  My  belief  is  that  oily  applications 
are  better  than  those  containing  alcohol.  The  mistake  is 
frequently  made  of  prescribing  tincture  of  cantharides  or 
other  irritant  because  the  hair  falls.  Of  course,  these 
things,  in  an  already  more  or  less  inflamed  scalp,  only  do 
harm.  If  we  can  succeed  in  curing  the  seborrhoea,  the  hair 
will  take  care  of  itself.  If  the  case  comes  to  us  before  abso- 
lute baldness  is  established  we  can  feel  pretty  confident  that 
we  can  stop,  or  at  least  delay,  the  fall  of  the  hair. 

Lassar's  plan  of  treatment  has  gained  great  currency, 
and  is  as  follows  :  The  scalp  is  to  be  vigorously  washed  each 
day  with  a  tar  soap  that  forms  plenty  of  suds.  The  soap- 
suds are  to  be  washed  out  with  warm,  followed  by  cold 
water,  the  scalp  dried  and  anointed  with  equal  parts  of  a  half 
per  cent,  solution  of  bichloride  of  mercury,  glycerin,  and 
cologne  water.  This  is  to  be  dried  out  by  applying  a  half  per 
cent,  solution  of /3-naphthol  in  absolute  alcohol.  Finally, 
an  oil  made  up  of 


& .  Ac.  salicylici,  3  iv ;         16 

Tincture  of  benzoin,  gr.  xl ;        3 

Neat's-foot  oil,  g  iij  ;      100 


M. 


is  to  be  applied.  The  procedure  is  to  be  kept  up  for  six  to 
eight  weeks.  I  have  found  few  patients  who  would  persist 
in  it,  and  in  these  I  have  seen  little  good  result.  For 
women  it  is  impracticable. 

Resorcin  has  been  commended.     It  may  be  prescribed 
as  follows : 


78  DISEASES    OF    THE    SKIN. 

R .  Resorcin  pura,                               gr.  xv ;  3 

01.  ricini,                                         %  ss ;  6 

Spts.  vini  rect,  ad  %] ;  100 

Bals.  Peruv.,                                   gtt.  ij.  M. 

Tar  is  a  good  remedy,  but  it  is  objectionable  on  account 
of  its  odor  and  color.  /3-naphthol,  in  5  to  10  per  cent, 
strength,  and  hydrate  of  chloral  in  about  the  same  strength, 
may  be  tried.  When  there  is  absolute  baldness,  it  is  ques- 
able  if  anything  will  make  the  hair  grow. 

Alopecia  Syphilitica  may  be  an  early  or  late  manifesta- 
tion of  syphilis ;  it  occurs  both  in  benign  and  malignant 
cases,  and  manifests  itself  as  a  more  or  less  general  and 
temporary  hair  fall,  or  as  a  localized,  destructive,  and  per- 
manent one. 

Symptoms.  The  former  variety  occurs  early  in  the  dis- 
ease, and  is  a  thinning  of  the  hair  in  irregularly  shaped 
patches  scattered  over  the  scalp,  giving  to  it  an  appearance 
similar  to  what  would  be  produced  by  cutting  the  hair  care- 
lessly with  a  dull  pair  of  shears.  In  rare  cases  we  may 
have  a  general  loss  of  hair  from  all  hairy  regions.  The 
broken  arch  of  the  eyebrow  is  always  suggestive  of  syphilis. 
There  may  be  some  seborrhcea  with  this  form  of  alopecia. 

Localized  baldness  is  one  of  the  later  manifestations  of 
syphilis,  and  is  always  preceded  by  a  destructive  disease  of 
the  scalp.  The  bald  spots  will  vary  in  size  with  the  extent 
of  the  destructive  process,  which  may  be  one  of  absorption 
or  ulceration. 

Diagnosis.  The  diagnosis  of  syphilitic  alopecia  is  made 
by  observing  the  irregular  shape  of  the  patches,  and  that 
they  are  not  completely  bald ;  and  by  the  occurrence  of  the 
broken  arch  of  the  eyebrow.  These  should  arouse  suspicion, 
when  other  symptoms  of  the  disease  will  be  found.  It  most 
resembles  alopecia  areata,  but  in  this  disease  the  patches  are 
perfectly  circular  or  oval,  and  entirely  bald. 

The  baldness  due  to  destructive  forms  of  syphilis  can  be 
confounded  only  with  that  of  favus.  In  the  latter  disease, 
the  scalp  preserves  a  reddish  color  for  a  long  time,  and  then 
assumes  an  atrophic,  smooth,  cicatricial  look  which  is  char- 
acteristic of  it.     The  history  of  the  two  cases  is  very  dif- 


ALOPECIA.  79 

ferent,  as  in  favus  we  do  not  have  ulceration,  and  we  do 
have  cupped,  sulphur-yellow  crusts.  Favus  is  also  more 
widespread  and  disseminated  than  is  late  syphilis  of  the  scalp. 

Treatment.  The  treatment  of  this  form  of  baldness  is 
that  of  the  underlying  disease.  A  mercurial  ointment  or 
an  oil  containing  the  bichloride  may  aid  in  hastening  the 
new  growth  of  the  hair  in  the  early  form  of  baldness.  The 
late  form  may  be  lessened  by  active  constitutional  and  local 
treatment,  according  to  the  general  principles  laid  down  for 
the  management  of  syphilis. 

The  variety  called  Defluvium  Capillorum  is  that  sudden 
and  general  fall  and  manifest  thinning  of  the  hair  which 
comes  on  during  or  after  some  severe  illness,  such  as  parturi- 
tion, fevers,  mercurialism,  and  various  cachexise. 

Symptoms.  Rarely  does  it  produce  complete  baldness. 
The  fall  is  usually  rapid,  and  takes  place  during  convales- 
cence or  after  recovery,  rather  than  during  the  course  of  the 
disease.     Seborrhoea  may  or  may  not  be  present. 

Etiology.  The  cause  of  the  hair  fall  is  the  profound  dis- 
turbance of  the  nutrition  of  the  body,  in  which  the  hair 
sympathizes. 

Treatment.  The  treatment  is  rather  to  be  addressed  to 
the  patient  than  to  the  hair.  If  we  can  succeed  in  building 
up  the  patient's  strength,  the  hair  will  take  care  of  itself. 
Local  treanment  is  the  same  as  in  alopecia  pityrodes. 

Alopecia  Follicularis  is  baldness  due  to  some  disease 
of  the  scalp  that  either  destroys  the  hair  follicles  or  impairs 
the  proper  performance  of  their  function.  A  history  of  the 
causative  disease  may  be  obtained,  or  the  disease  itself  will 
be  present.  Impetigo,  long- continued  sycosis,  inflammatory 
diseases  such  as  erysipelas,  parasitic  diseases  such  as  favus 
and  ringworm,  and  destructive  new  growths  such  as  syphilis 
and  lupus,  all  may  cause  alopecia  follicularis. 

The  etiology,  diagnosis,  prognosis,  and  treatment  of  this 
form  of  baldness  is  the  same  as  the  disease  that  gives  rise  to 
it,  for  which  we  must  refer  to  the  proper  sections. 

Alopecia  Areata.  Synonyms :  Area  celsi ;  Area  occi- 
dental diffluens,  seu  serpens,  seu  tyria ;  Alopecia  circum- 


80 


DISEASES    OF    THE    SKIN. 


scripta ;  Porrigo  seu  tinea  decalvans ;  Vitiligo  capitis ; 
Ophiasis  ;  Phy to- alopecia  ;  (Fr.)  Teigne  pelade  ;  Pelade  ; 
(Ger.)  Die  kreisfleckige  Kahlheit ;  Circumscribed  baldness. 
This  form  of  baldness  usually  begins  suddenly,  the  patient 
discovering  by  accident,  or  being  told  by  someone,  that  he 
has  a  bald  spot.  Sometimes,  on  waking  in  the  morning,  the 
patient  is  astonished  to  find  loose  hairs  in  his  bed  and,  on 
looking  in  the  glass,  to  see  that  he  has  a  bald  patch  on  his 

Fig.  8. 


Alopecia  areata. 

head.  In  some  cases  the  hair  fall  may  have  been  preceded  for 
days  or  weeks  by  neuralgic  pains  in  the  head.  In  most  people 
there  are  no  premonitory  symptoms,  and  apart  from  the  bald 
spots  no  discomfort  on  the  part  of  the  patient,  nor  cutaneous 
lesions.  The  neuralgia  may  continue  after  the  hair  fall,  or 
it  may  cease.  There  may  be  but  one  bald  patch  or  there 
may  be  a  dozen  patches.  A  patch  may  be  as  small  as  a 
three  cent  silver  piece  or  as  large  as  a  silver  dollar.  If 
larger — and  the  whole  head  may  be  completely  bereft  of  hair 
— the  patch  is  formed  by  the  coalescence  of  several  smaller 
ones.  A  patch  may  attain  its  full  size  at  once,  or  it  may 
slowly  enlarge,  spreading  at  the  periphery.     The  patches 


ALOPECIA.  81 

are  more  or  less  perfectly  oval  or  circular  in  shape,  and 
sharply  defined  against  the  surrounding  hair.  Patches 
formed  by  the  coalescence  of  other  patches  lose  the  oval 
outline,  and  may  have  a  scalloped  border.  The  color  is 
usually  that  of  the  normal  scalp ;  it  may  be  pale  or  hyper- 
semic.  The  patch  is  perfectly  bare  and  smooth,  without 
scales,  as  a  rule.  Sometimes  it  is  dotted  over  with  short, 
broken  hairs,  old  roots  that  soon  fall  out.  Sometimes  it  looks 
as  if  it  were  depressed,  an  appearance  due  to  falling  out  of 
the  hair  roots.  Any  or  all  the  hairy  regions  of  the  body 
may  be  affected,  the  patient  sometimes  being  entirely  denuded 
of  hair.  Most  often  it  is  the  scalp  that  suffers,  especially 
the  temporal  and  occipital  regions.  Around  the  border  of 
a  recent  patch  the  hair  is  loosened  so  that  it  may  be  readily 
extracted.  The  sensibility  of  the  skin  may  be  diminished. 
Generally  it  is  preserved. 

The  course  of  the  disease  is  chronic,  with  a  strong  ten- 
dency to  spontaneous  recovery  in  anywhere  from  three 
months  to  several  years.  Recovery  is  heralded  by  the 
growth  of  a  fine  down  upon  the  bald  patch.  This  will  fall 
out  and  be  replaced  by  lanugo  hairs  that  in  their  turn  will 
fall  out  to  be  replaced  by  stronger  hairs,  until  normal  hairs 
will  grow  at  last,  though  these  at  first  may  be  white.  Some 
cases  relapse  year  after  year ;  in  some  cases  the  hair  never 
grows  beyond  the  lanugo  stage ;  and  some  cases  remain 
permanently  bald. 

Etiology.  The  subjects  of  the  disease  may  be  in  appar- 
ently perfect  health,  but  not  infrequently  they  are  of  very 
nervous  temperament,  exhausted  by  overwork  or  nervous 
strain,  or  out  of  health  in  some  way.  Both  sexes  are 
affected,  the  male  sex  rather  more  than  the  female.  It 
occurs  very  often  in  children.  Thus  Crocker,  who  has  a 
large  experience  with  children,  met  with  it  in  children 
under  twelve  years  old  thirty-seven  times  out  of  eighty-three 
cases.  The  youngest  case  reported  was  at  two  years  of  age, 
and  cases  have  been  seen  as  late  as  in  the  sixtieth  year.  It 
is  rather  more  frequent  among  the  poor  than  among  the 
well-to-do.  It  is  more  frequent  in  some  countries  than  in 
others.     Thus  Crocker's  tables  show  that  in  London  it  forms 

4* 


82  DISEASES    OF    THE    SKIN. 

two  per  cent,  of  all  skin  cases ;  Bulkley's  tables  show  but  a 
little  more  than  one-half  of  one  per  cent,  in  New  York. 

The  disputed  points  in  the  etiology  of  alopecia  areata  are 
its  contagiousness,  and  whether  it  is  a  neurosis  or  a  parasitic 
disease.  At  the  present  time  it  is  impossible  to  decide  with 
absolute  certainty  which  of  the  contending  parties  is  right. 
Most  instances  of  contagion  have  been  reported  by  French 
observers  whose  diagnostic  skill  we  can  hardly  call  in  ques- 
tion. They  have  reported  instances  in  which  a  large  number 
of  cases  have  appeared  in  barracks  or  schools  and  from  there 
spread  to  neighboring  towns.  In  England,  similar  apparent 
epidemics  have  been  reported,  but  as  a  fungus  indistinguish- 
able from  the  trichophyton  fungus  was  found  in  the  sur- 
rounding hairs,  they  were  doubtless  instances  of  bald  ring- 
worm. It  is  possible  that  the  French  epidemics  were  of 
similar  character.  Certainly  the  body  of  experience  is 
against  the  contagiousness  of  the  disease.  Besnier  and 
Doyon,1  who  believe  firmly  that  the  disease  is  contagious, 
think  that  it  is  transmitted  most  often  by  means  of  the 
barber's  utensils,  and  that  it  is  impossible  in  a  great  number 
of  cases  to  trace  the  contagion. 

As  to  the  parasitic  origin  of  the  hair  fall,  it  is  as  yet  not 
proven.  A  goodly  number  of  skilled  microscopists  have 
described  the  fungus,  but  they  do  not  agree  amongst  them- 
selves, and  so  we  are  justified  as  regarding  the  question  as 
unsettled. 

This  leaves  only  the  neurotic  theory,  and  by  the  majority 
of  dermatologists  the  disease  is  believed  to  be  a  tropho- 
neurosis. It  has  been  known  to  follow  blows  or  injuries  to 
the  head,  moral  or  mental  shock,  operation  on  the  neck,  and 
experimentally  by  injury  to  or  extirpation  of  the  second 
cervical  ganglion  in  cats. 

Pathology.  Though  hairs  taken  from  the  margin  of  an 
advancing  area  show  atrophic  changes,  there  is  nothing  dis- 
tinctive about  such  changes.  The  most  exhaustive  study  of 
the  disease  of  recent  date  is  that  by  A.  R.  Robinson.2     He 

1  Path,  et  Trait,  des  Mai.  de  la  Peau :  Kaposi.  French  edition,  Paris, 
1891. 

2  Monatshefte  f.  prakt.  Dermal,  1888,  vii.  409. 


ALOPECIA.  83 

found  evidences  of  inflammation,  and  some  round-cell  infil- 
tration confined  principally  to  the  perivascular  region.  In 
recent  cases  there  was  a  coagulation  of  lymph  in  many 
lymphatics,  and  of  fibrin  in  a  few  of  the  large  and  small 
arteries,  with,  in  old  cases,  a  thickening  of  their  walls.  In 
recent  cases  the  hair  follicles  were  either  without  hair,  or 
contained  a  lanugo  hair  or  a  hair  just  about  to  fall.  The 
hair-roots,  where  present,  showed  atrophic  changes.  In 
advanced  cases  the  sebaceous  glands  were  degenerated  or 
had  entirely  disappeared.  In  the  worst  cases  there  was 
complete  atrophy  of  the  hair  follicles  and  of  the  subcuta- 
neous fatty  tissue.  He  also  describes  the  presence  of  various 
cocci  in  the  lymph  spaces  of  the  corium  and  the  walls  of  a  few 
of  the  vessels,  which  he  regards  as  the  cause  of  the  disease. 

Diagnosis.  A  typical  case  of  alopecia  areata  is  so  pecu- 
liar that  there  is  little  danger  of  mistaking  it  for  anything 
else.  It  differs  from  trichophytosis  capitis  in  its  sudden 
onset,  its  perfectly  bare,  smooth,  non-scaly  surface,  without 
broken,  split,  and  gnawed-off  hairs,  and  in  the  absence  of 
the  trichophyton  fungus  from  the  hair  and  scales  taken  from 
the  neighboring  parts.  In  bald  ringworm  patches,  which 
resemble  alopecia  areata,  the  fungus  will  be  found  in  the 
neighboring  hair,  or  some  characteristic  "stumps"  will  be 
found  on  the  scalp.  In  adults,  ringworm  of  the  scalp  is 
very  rare.  It  differs  from  favus  in  the  absence  of  cupped 
crusts  at  any  time  in  its  course,  in  the  scalp  not  presenting 
that  cicatricial  appearance  always  met  with  in  favic  bald- 
ness, and  in  complete  absence  of  fungus  growth. 

The  baldness  due  to  syphilis  may  resemble  that  of  alopecia 
areata,  but  other  symptoms  of  syphilis  will  be  present,  and 
there  will  never  be  a  history  of  the  formation  of  well-defined 
oval  or  circular  areas.  Lupous  erythematosus  at  times  affects 
the  scalp,  and  produces  circumscribed  bald  areas ;  but  these 
are  not  oval  or  round,  and  the  skin  is  red  and  scaly,  and 
evidently  cicatrized.  The  alopecies  innominees  of  Besnier 
is  extremely  difficult  to  diagnose  from  alopecia  areata.  It 
differs  in  not  forming  regular  oval  or  round  bald  areas,  but 
rather  irregular  ones,  with  clumps  of  hair  at  their  borders ; 
in  having  a  cicatricial  appearance ;  and  in  presenting,  at 


84:  DISEASES    OF    THE    SKIN. 

first,  at  least,  some  evidences  of  dermatitis  or  folliculitis. 
This  type  of  baldness  has  not  yet  become  well  recognized. 

Treatment.  In  a  disease  that  is  essentially  self-limited, 
it  is  hard  to  estimate  how  much  good  our  remedies  do.  One 
duty  we  have  without  peradventure,  and  that  is,  to  look  after 
the  general  condition  of  the  patient.  A  large  number  of  the 
cases  require  a  stimulating  and  tonic  treatment — iron,  quinia, 
strychnia,  arsenic,  cod-liver  oil,  or  hypophosphites.  Chil- 
dren should  be  allowed  to  run  free  and  taken  out  of  school. 
Our  hardest  task  will  be  to  manage  those  nervous  patients 
who  are  ever  a  trouble  to  us. 

As  far  as  local  treatment  is  concerned,  it  may  be  summed 
up  in  two  words :  patience  and  stimulation.  As  many  of 
our  parasiticides  are  stimulating  to  the  skin,  they  may  be 
used  with  benefit,  whether  we  believe  in  the  parasitic  cause 
of  the  disease  or  not. 

The  stronger  water  of  ammonia  dabbed  on  to  the  scalp 
by  means  of  a  swab,  care  being  taken  to  guard  the  eyes,  will 
be  beneficial  in  some  cases.  It  is  remarkable  how  little  re- 
action this  powerful  remedy  will  cause  in  alopecia  areata. 
Pilocarpine,  in  hypodermic  injections,  or  in  ointment  form, 
is  at  times  beneficial.  Sulphur  ointment  well  rubbed  in ; 
painting  the  scalp  with  acetic  acid  until  it  whitens,  and  then 
sponging  off  with  cold  water,  and  repeating  every  three  or 
four  days  ;  chrysarobin,  fifteen  or  twenty  grains  to  the  ounce, 
well  rubbed  into  the  scalp  once  a  day;  carbolic  acid  (95  per 
cent.)  applied  every  two  weeks  or  so  to  small  areas  at  a  time; 
the  bichloride  of  mercury,  two  to  four  grains  to  the  ounce 
in  alcohol,  or  oleum  pini  sylvestris ;  the  oleate  of  mercury, 
in  the  strength  of  2  to  10  per  cent. ;  blistering  with  can- 
tharides ;  or  33J  per  cent,  of  iodine  in  collodion,  and  gal- 
vanism, have  one  and  all  been  followed  by  the  return  of  the 
hair. 

Moty1  reports  good  results  from  hypodermic  injections  of 
bichloride  of  mercury,  injecting  five  or  six  drops  of  an 
aqueous  solution  (1  :  500)  into  many  places  about  each 
patch.     In  a  later  number  of  the  same  journal  (p.  864)  he 

1  Ann.  Derm,  et  Syph.,  1891,  ii.  406. 


ANGIOMA    PIGMENTOSUM.  85 

announced  that  he  then  used  a  4  per  cent,  solution  of  the 
mercury,  with  a  2  per  cent,  solution  of  cocaine ;  that  he 
made  but  a  single- drop  injection  in  a  medium-sized  patch, 
and  four  to  five  injections  about  a  large  patch  and  at  its 
periphery.  Pauses  of  four  days  were  taken  between  the 
injections,  and  a  cure  is  expected  after  the  fourth  series. 

It  is  advisable  to  pluck  the  loose  hair  from  around  the 
patch  for  a  zone  of  perhaps  an  eighth  or  a  quarter  of  an 
inch.  Every  few  days  slight  traction  is  to  be  made  on  the 
hairs  surrounding  the  patch,  and  all  the  loose  ones  pulled. 
Massage  is  also  useful. 

Peognosis.  Even  if  left  to  itself,  the  chances  are  that 
the  hair  will  grow  in  again  This  good  prognosis  should  be 
guarded  when  the  patient  is  past  middle  life,  and  in  those 
malignant  cases  in  which  there  is  complete  baldness  that  has 
lasted  several  years. 

Alopecia  Circumscripta.     See  A.  areata. 

Alopecie  Innominee.     See  Folliculitis  decalvans. 

Alphos.     See  Psoriasis. 

Anaesthesia  (A2n-e2s-therzi2-a3)  is  a  loss  of  sensation  in 
the  skin  which  occurs  in  a  number  of  diseases  of  the  nervous 
system,  notably  in  hysterical  affections.  It  may  be  general, 
or  partial,  or  affect  but  one-half  of  the  body.  There  may 
be  loss  of  sensibility  to  pain  while  the  tactile  sense  is  pre- 
served {analgesia),  or  intense  pain  with  loss  of  ordinary 
sensibility  (ancesthesia  dolorosa).  There  are  many  sub- 
stances which  locally  applied  will  cause  anaesthesia,  such  as 
carbolic  acid,  cocaine,  aconite :  and  many  others  which  will 
abolish  sensation  when  taken  internally.  The  subject 
belongs  to  the  domain  of  the  neurologist. 

Anatomical  Tubercle.     See  Tuberculosis  verrucosa  cutis. 

Angeioma  (A^-ji-o'ma3)  or  Angioma.  An  angioma  is  a 
tumor  or  new  growth  made  up  of  bloodvessels  or  lymphatics. 
It  is  usually  congenital.  For  convenience  the  vascular 
angiomata  will  be  described  under  Naevus,  and  the  others 
under  Lymphangioma. 

Angioma  Pigmentosum  et  Atrophicum  is  the  name  pro- 


86  DISEASES    OF    THE    SKIN. 

posed  by  R.  W.  Taylor  for  the  xeroderma  of  Kaposi,  and 
is  described  in  this  book  under  Atrophoderma  pigmentosum, 
which  see. 

Angioses.  "  Disorders  of  the  cutaneous  vascular  appa- 
ratus which  embrace  the  common  eifects  of  engorgement, 
ischsemia,  transudation,  and  inflammation."1 

Angio-keratoma2  is  the  name  given  by  Pringle  to  a 
peculiar  disease  of  the  skin  of  the  hands,  feet,  and  ears,  that 
has  been  called  telangiectatic  warts  or  verrues  telangi- 
ectasiques. 

Symptoms.  It  follows  chilblains,  and  affects  the  dorsal 
aspects  of  the  hands  and  feet.  The  eruption  consists  in 
tiny,  almost  imperceptible  pink  points,  that  do  not  dis- 
appear on  pressure ;  of  pin-point  to  pin-head  darker  spots 
that  can  be  made  to  almost  disappear  on  pressure,  leaving 
a  deep-red  capillary  loop  in  the  centre ;  and  of  clustered 
telangiectatic  points  forming  small  irregularly  shaped, 
slightly  elevated  groups.  These  groups  may  be  as  large  as 
a  split-pea  or  bean  ;  they  may  project  for  half  a  line  above 
the  surface ;  are  hard,  rough,  warty-looking,  and  of  dull 
purplish-brown  color.  Pressure  upon  them  brings  out  the 
telangiectatic  character  of  the  growths.  When  pricked 
with  a  needle  free  hemorrhage  takes  place.  The  eruption 
is  symmetrical  as  a  rule,  and  usually  affects  more  than  one 
member  of  a  family,  and  they  are  young  adults.  There 
are  no  subjective  symptoms  It  will  thus  be  seen  that  in 
many  points  this  disease  bears  a  close  resemblance  to 
atrophoderma  pigmentosum. 

Treatment.  The  treatment  that  proved  most  beneficial 
was  by  electrolysis. 

Anhidrosis  ( A2n-hi2d-ro'-si2s)  or  Anidrosis  ( A2n-i2d-ro'si2s). 
By  this  is  meant  an  affection  of  the  sweat  glandular  ap- 
paratus attended  by  a  diminution  or  more  or  less  complete 
suspension  of  its  functions.  It  is  a  symptom  rather  than 
a  disease.  It  may  be  local  or  general ;  temporary  or  per- 
manent ;  symptomatic,  as  in  fevers  and  diabetes ;  congenital, 

1  Bronson :  Journ.  Cutan.  and  Gen.-urin.  Dis.,  1887,  v.  371. 

2  Brit.  Journ.  Dermat.,  1891,  iii.  237. 


ATROPHIA    CUTIS. 


87 


as  in  xeroderma ;  or  neurotic.  Some  people  never  sweat 
preceptibly.  In  certain  skin  diseases,  such  as  psoriasis, 
scleroderma,  squamous  eczema,  and  ichthyosis  the  affected 
areas  do  not  sweat.  Its  treatment  is  tonic  by  exercise  and 
bathing.  In  symptomatic  cases  we  must  strive  to  remove 
the  underlying  cause.  For  congenital  cases  we  can  do 
nothing. 

Anonychia  (A2n-o2n  i2k'-i2-a3)  means  congenital  absence 
of  the  nail. 

Anthrax  (A2n-thra2x).  See  Carbuncle  and  Pustula 
maligna. 

Area  Celsi.     See  Alopecia  areata. 

Argyria  ( A3r-j  i2r-i2/a3)  is  the  blue  or  black  discoloration  of 
the  skin  and  mucous  membranes,  due  to  the  deposition  of 
particles  of  silver  in  the  rete,  sweat  glands,  and  about  the 
hair  follicles,  where  it  turns  black  by  exposure  to  the  sun- 
light. It  used  to  be  seen  more  often  than  now,  wThen  silver 
salts  were  used  in  the  treatment  of  epilepsy.  It  is  a 
permanent  staining. 

Arthritide  Pseudo-exanthematique.   See  Pityriasis  rosea. 

Asteatosis  (A2s-te-a3-tor-si2s),  an  absence  of  sebaceous  mat- 
ter.    See  Xeroderma. 

Atheroma  (A2th-e2r-or-ma3).     See  Sebaceous  Cyst. 

Atrophia  Cutis  or  Atrophoderma.  Atrophy  of  the  skin 
may  be  quantitative  or  qualitative ;  idiopathic  or  sympto- 
matic ;  diffused  or  circumscribed.  Crocker1  gives  this  use- 
ful table : 

Juvenilis 


Atrophoderma 
Idiopathicoi. 


Diffusum 


Senilis 


Atrophoderma 
Symptomaticum. 


Circumscriptum 
(striae  et  maculae) 

Xeuriticum 

(glossy  skin) 

Morborum  cutis 


Pigmentosum. 

Albidum. 

Quantitativum. 

QualitatiYum. 
f  Traumaticum. 
t  Xon-traurnaticum. 

f  Traumaticum. 
\  iSon-trauniaticum. 

Scleroderma. 

Seborrhoea. 

Lupus. 

Syphilis. 

Favus,  etc. 


Diseases  of  the  Skin,  Lond.  and  Phila.,  1888. 


88 


DISEASES    OF    THE    SKIN. 


The  symptomatic  atrophies  due  to  other  diseases  will  be 
spoken  of  under  their  proper  headings.  The  other  forms 
of  atrophy  will  be  considered  here. 

Atrophoderma  Pigmentosum.  Synonyms :  Xeroderma 
pigmentosum   (Kaposi) ;    Angioma    pigmentosum    et   atro- 


Fm.  9. 


Atrophoderma  pigmentosum.     (After  Taylor.) 


phicum  (Taylor) ;  Dermatosis  Kaposi  (Vidal) ;  Liodermia 
essentialis  cum  melanosi  et  telangiectasia  (Neisser);  Mel- 
anosis lenticularis  progressiva  (Pick) ;  Lentigo  maligna 
(Piifard) ;  Epitheliomatose  pigmentaire  (Besnier).  This  is 
a  very  rare  disease  of  the  skin  first  described  by  Kaposi  in 
1870  under  the  name  of  xeroderma,  to  which  he  subse- 
quently added  the  adjective  pigmentosum.  Only  some 
fifty-six  cases  have  been  reported.  It  is  a  congenital  dis- 
ease ;  almost  all  cases  begin  before  the  second  year  of  life. 


ATROPHODERMA    PIGMENTOSUM.  89 

Symptoms.  It  affects  the  parts  most  exposed  to  the  air: 
the  face,  neck,  chest,  and  back  down  to  the  level  of  the 
clavicles,  or  even  the  third  rib,  the  backs  of  the  hands,  fore- 
arms, and  upper  arms.  The  hands,  face,  and  neck  are  most 
markedly  diseased,  while  a  few  cases  have  occurred  upon 
the  legs  and  backs  of  the  feet.  It  begins  with  erythematous 
patches  like  those  produced  by  sunburn.  After  a  time 
brown  or  black  freckle-like  spots  form  upon  the  erythem- 
atous ones.  They  are  from  pin-head  to  bean  size,  and  round 
or  irregularly  shaped.  The  pigmented  spot  in  time  gives 
place  to  a  white  atrophic  one,  and  the  skin  becomes  too 
small  for  the  underlying  parts,  so  that  it  appears  drawn,  and 
in  some  places  bound  down.  A  fully  developed  case  pre- 
sents a  vast  number  of  lentiginous  spots,  interspersed  with 
white  atrophic  spots  and  stellate  and  striated  telangiectases. 
After  a  time,  on  account  of  the  atrophy  of  the  skin,  we 
find  ectropium,  thinned  alse  nasi,  and  contracted  nasal  and 
oral  orifices.  There  may  be  white  atrophic  spots  on  the 
mucous  membrane  of  the  lips.  Conjunctivitis  generally 
supervenes  upon  the  ectropium  and  the  discharge  from  the 
eyes  sets  up  ulcerations  which  in  their  turn  give  rise  to 
other  ulcerations.  Warty  growths  at  last  appear,  and 
these  are  prone  to  take  on  malignant  action  and  be  con- 
verted into  epitheliomas,  and  the  patient  dies  at  an  early 
age  from  marasmus.  At  first,  however,  there  is  no  dis- 
turbance of  the  health. 

Etiology.  The  etiology  of  the  disease  is  obscure.  It  is 
supposed  by  some  to  have  its  starting-point  in  irritation  of 
the  skin  by  the  sun  or  other  irritant.  Many  of  the  cases 
begin  in  the  summer.  It  is  supposed  by  others  to  be  a 
tropho-neurosis.  It  is  found  in  both  sexes  about  equally, 
but  is  peculiar  in  affecting  several  members  of  the  same 
family  and  of  the  same  sex.  It  is  not  hereditary.  In  a 
few  of  the  cases  there  was  a  history  of  cancer. 

Diagnosis.  The  disease  is  to  be  differentiated  from  sclero- 
derma by  the  peculiarity  of  its  being  limited  to  exposed 
parts,  by  lacking  stony  hardness,  by  occurring  early  in  life, 
and  by  the  general  picture  of  pigmented  and  atrophic  spots 
and    telangiectases   being   intermingled.      It    differs    from 


90  DISEASES    OF    THE    SKIN. 

urticaria  pigmentosa  in  not  itching,  and  not  occurring  upon 
the  trunk,  and  in  having  telangiectases  and  warty  or 
epitheliomatous  growths. 

Treatment.  Nothing  has  yet  been  found  to  stop  the 
progress  of  the  disease.  The  conjunctivitis  is  to  be  cared 
for,  the  ulcerations  on  the  face  healed  as  rapidly  as  possible, 
and  the  warty  growths  and  epitheliomatous  nodules  de- 
stroyed at  an  early  date  so  as  to  prevent  the  development 
of  epitheliomatous  or  carcinomatous  ulcers.  A  saturated 
solution  of  boric  acid  will  do  much  for  the  eyes ;  the  ulcers 
may  be  treated  with  iodoform  or  aristol  powder,  or  a  dilute 
ammoniate  of  mercury  ointment ;  while  the  warty  growths 
should  be  scraped  off  with  the  sharp  spoon. 

Atrophoderma  Albidum  is  the  name  used  by  Crocker 
for  a  second  form  of  the  xeroderma  pigmentosum  of 
Kaposi,  which  is  described  by  the  latter  as  beginning  in 
childhood  ;  affecting  most  frequently  the  lower  extremities, 
and  less  often  the  forearms  and  hands  ;  and  characterized 
by  thinness  of  the  skin  which  in  some  places  is  stretched 
and  cannot  be  readily  taken  up  into  folds.  The  color  of  the 
skin  is  pale  and  white  with  a  delicate  rosy  shimmer  in  places  ; 
and  here  and  there  its  epidermis  peels  off  in  asbestos-like 
lamellae.     The  treatment  is  simply  protective. 

Atrophoderma  Senilis  is  a  true  atrophy  of  the  skin  that 
takes  place  in  consequence  of  advancing  years.  Other 
degenerative  changes  are  also  present,  as  a  rule.  It  may 
be  partial  or  general.  The  skin  looks  wrinkled ;  it  is  thrown 
into  folds  ;  is  dry  and  sometimes  scaly,  and  is  often  of  darker 
color  than  normal.  By  pinching  up  the  skin  the  thinness 
of  it  is  readily  appreciated.  With  the  atrophy  of  the  skin 
there  is  likewise  loss  of  the  subcutaneous  fat ;  pruritus  ;  and 
verruca  senilis.     Treatment  is  out  of  the  question. 

Atrophoderma  Idiopathica  Diffusa.  Diffused  idiopa- 
thic atrophy  of  the  skin  is  a  very  rare  affection.  It  may 
be  congenital,  or  acquired;  general  or  partial.  The  subcu- 
taneous tissue  disappears,  so  that  the  skin  lies  close  to  the 
underlying  parts.  It  is  thin,  pale,  stretched,  easily  mova- 
ble over  underlying  parts,  and  allows  the  bloodvessels  to 


ATROPHODERMA    STRIATUM.  91 

show  through.  In  some  cases  thick  scaly  plates  form,  while 
in  others  these  are  wanting,  and  there  is  only  slight  scaling. 
The  elasticity  of  the  skin  is  lost,  so  that  if  it  is  pinched  up 
into  folds  these  slowly  flatten  out.  In  some  cases  the  skin 
seems  too  small  for  the  body,  which,  on  the  face,  gives  rise 
to  ectropion  and  other  deformities.  The  sensibility  of  the 
skin  may  not  be  diminished.  The  patients  are  susceptible 
to  cold.  Ulcers  are  prone  to  form  upon  slight  injuries. 
The  hair  is  destroyed.  The  disease  is  probably  a  tropho- 
neurosis.    One  case  was  ascribed  to  exposure  to  cold.1 

Hardaway2  reported  two  cases  occurring  in  a  brother  and 
sister ;  and  Ohmann-Dumesnil3  has  met  with  a  case  of 
atrophy  of  the  skin  and  muscles  of  the  right  arm  apparently 
following  an  injury  to  the  radial  nerve  by  means  of  a  burn 
on  the  hand. 

One  variety  of  diffused  idiopathic  atrophy  of  the  skin  is 
that  called  hemiatrophia  facialis  progressiva,  in  which 
only  one-half  of  the  face  is  affected,  and  the  skin  becomes 
thinned  and  shrunken  so  that  it  lies  close  to  the  bones. 

Under  this  heading  may  also  be  placed  the  glossy  skin  of 
Paget,  Weir  Mitchell,  and  others.  It  commonly  affects  the 
fingers,  less  often  the  extremities,  and  follows  upon  disease 
or  injury  of  nerves.  The  fingers  become  dry,  red,  or  mot- 
tled, look  glazed  or  as  if  varnished,  and  are  shrunken. 
The  natural  lines  of  the  skin  disappear,  and  the  nails  fall 
off.  If  parts  covered  with  hair  are  affected,  the  hair  falls. 
The  tendency  is  to  spontaneous  recovery. 

Atrophoderma  Striatum  et  Maculatum.  By  this  is 
meant  circumscribed  atrophic  streaks  or  spots.  They  may 
be  idiopathic  or  symptomatic.  The  idiopathic  form  is  far 
more  rare  than  the  symptomatic  form. 

Symptoms.  The  idiopathic  streaks  are  met  with  most 
often  about  the  thighs,  buttocks,  and  lower  anterior  part  of 
the  abdomen.  They  are  one  or  two  lines  wide,  slightly 
curved,  and  from  one  to  several  inches  long.  There  are 
usually  several  present,  and  then  they  are  arranged  parallel 

1  Pospelow :  Ann.  Derm,  et  Syph.,  1886,  vii.  505. 

2  Trans.  Amer.  Derm.  Association,  1884. 

3  Alienist  and  Neurologist,  July,  1890. 


92  DISEASES    OF    THE    SKIN. 

to  one  another  and  run  in  an  oblique  direction.  The 
macules  are  isolated,  from  pin-head  to  finger-nail  size  or 
larger,  occur  most  frequently  on  the  lower  part  of  the 
trunk,  but  may  occur  as  high  up  as  the  neck,  and  are  less 
common  than  the  streaks.  Both  forms  of  lesion  are  de- 
pressed below  the  surface  of  the  skin,  and  of  a  pearly  or 
bluish- white  color,  and  have  a  glistening,  scar-like  appear- 
ance. They  are  not  primary  atrophies,  but  succeed  to  an 
erythematous  hypertrophic  lesion,  in  this  greatly  resem- 
bling morphcea.  They  give  rise  to  no  inconvenience,  and 
are  accidentally  discovered.  They  usually  are  permanent, 
though  they  may  become  less  pronounced  in  time. 

Etiology.  Their  etiology  is  obscure.  By  many  they  are 
regarded  as  tropho-neuroses.  Shepherd1  has  recently  re- 
ported cases  of  atrophic  spots  and  lines  following  fevers. 

Symptomatic  lines  and  macules  are  very  common,  and 
are  caused  by  the  stretching  or  rupture  of  the  more  super- 
ficial bundles  of  white  and  elastic  fibrous  tissue  of  the  skin. 
If  the  fibres  are  ruptured  the  striae  will  be  most  pronounced, 
and  there  will  be  little  left  of  the  skin  but  the  epidermis 
and  a  thin  fibrous  membrane.2  This  form  of  atrophy  of  the 
skin  is  seen  upon  the  abdomen  of  pregnant  women  (linece 
albicantes),  and  on  the  breasts  of  nursing  women.  In  fact, 
anything  that  greatly  distends  the  skin  may  give  rise  to 
them,  such  as  abdominal  ascites,  ovarian  or  other  tumors. 

Treatment.  The  treatment  of  these  cases  is  purely 
expectant.  Both  the  idiopathic  and  symptomatic  atrophies 
may  grow  less  pronounced  in  time. 

Atrophia  Pilorum  Propria.  Atrophy  of  the  hair  exists 
under  two  forms,  namely,  Fragilitas  crinium,  and  Trichor- 
rhexis nodosa.  In  both  forms  the  hair-shaft  is  easily  fria- 
ble and  splits  or  breaks  of  itself,  or  by  the  slightest  traction. 

Fragilitas  Crinium.  This  disease  has  been  called  scis- 
sura  piloru??i,  and  has  for  its  distinguishing  features  split- 
ting of  the  hair.  The  cleft  is  usually  at  the  free  extremity, 
and  at  times  runs  some  distance  up  the  shaft.     The  split 

1  Trans.  Amer.  Derm.  Association,  1890,  p.  23. 

2  Taylor,  E.  W. :  N.  Y.  Med.  Journ.,  1886,  xliii.  p.  1. 


ATROPHIA    PILORUM    PROPRIA.  93 

hairs  are  either  scattered  here  and  there  through  the  other- 
wise normal  hair,  or  all  the  hairs  of  the  part  are  split. 
The  disease  occurs  most  often  upon  the  scalp,  the  beard 
being  the  place  next  most  frequently  affected.  It  is  a  com- 
mon occurrence  in  the  long  hair  of  women.  The  shaft  may 
be  split  into  two  or  more  fibrillse,  and  these  spread  out  from 
each  other  simply,  or  curve  up  upon  themselves.  The 
cleft  may  also  occur  in  the  middle  of  the  shaft,  or  at  its 
exit  from  the  follicle,  and  in  the  latter  case  the  shaft  will  be 
split  throughout  its  entire  length,  the  segments  either  sepa- 
rating or  holding  together.  Duhring1  has  reported  a  case 
occurring  in  the  beard  in  which  the  hair  began  to  split 
within  the  bulb.  Besides  the  splitting,  the  hair  may  show 
no  other  abnormality,  but  it  is  generally  more  dry  and 
brittle  than  normal,  and  may  be  irregular  and  uneven  in  its 
contour.     The  bulb  of  the  hair  may  be  normal  or  atrophied. 

Etiology.  The  cause  of  the  idiopathic  fragilitas  crinium 
is  yet  undetermined.  The  disease  is,  without  doubt,  due  to 
some  interference  with  the  nutrition  of  the  hair,  probably 
a  yet  undetermined  tropho-neurosis. 

Treatment.  When  occurring  only  at  the  free  end  of 
long  hairs,  they  should  be  cut  above  the  cleft.  In  all  cases 
the  scalp  should  be  kept  in  good  condition,  as  directed  under 
Alopecia  prematura.  If  the  disease  occur  in  the  beard, 
shaving  would  at  least  remove  the  deformity,  and  possibly 
cure  the  disease. 

Trichorrhexis  Nodosa.  Synonyms  :  Trichoclasia ;  Tri- 
choptylose  ;   Clastothrix. 

Symptoms.  The  disease  generally  affects  exclusively  the 
hair  of  the  beard  and  moustache,  and  here  it  reaches  its 
highest  development.  Very  infrequently  it  is  found  in  the 
hairs  of  the  pubic  region,  and  still  more  rarely  in  the  head- 
hair.  Raymond2  says  that  he  has  found  it  on  the  labia 
majora  in  40  per  cent,  of  all  women  he  has  examined,  and 
specially  in  fat  women  with  intertrigo.  He  has  found  it 
also  on  scrotal  hairs.     It  consists  of  one  or  more  whitish  or 

1  Amer.  Journ.  Med.  Sci.,  July,  1878,  p.  88. 

2  Ann.  Demi,  et  Syph.,  1891,  ii.  p.  568. 


94  DISEASES    OF    THE    SKIN. 

grayish  shiny  transparent  nodular  swellings  occurring  along 
the  shaft  of  the  hair.  In  people  with  red  hair  the  color  may 
be  black.  The  number  of  nodes  that  may  be  present  is 
from  one  to  five ;  and  their  size  will  vary  with  the  diameter 
of  the  hair.  The  nodes,  according  to  S.  Kohn,1  occur 
usually  in  the  upper  third  of  the  hair.  These  nodes  give 
to  the  hair  an  appearance  not  unlike  that  produced  by  the 
presence  of  the  nits  of  pediculi.  The  hair  is  exceedingly 
brittle  and  fractures  upon  slight  traction,  or  spontaneously, 
the  fracture  taking  place  through  a  node,  and  the  hair  fibres 
separating  like  the  hairs  of  a  brush.  When  many  hairs  in 
the  beard  are  thus  broken,  their  frayed-out  ends  make  the 
beard  look  as  if  it  were  singed.  Sometimes  the  hair  fibres 
splinter  about  the  node,  but  the  two  ends  do  not  separate, 
and  this  gives  an  appearance  like  as  if  two  small  paint- 
brushes were  pushed  together.  Sometimes  the  hair  pre- 
sents an  irregular  contour,  and  looks  as  if  frayed  along  its 
entire  length.  While  the  fracture  is  usually  transverse,  if 
there  should  be  an  excessive  amount  of  medulla  present  in 
the  node,  it  may  be  longitudinal.  The  hairs  themselves  are 
usually  firmly  fixed  in  the  follicles. 

Etiology.  The  cause  of  the  disease  is  obscure.  It  is 
probably  a  tropho-neurosis  interfering  in  some  way  with  the 
proper  nutrition  of  the  hair.  It  does  not  seem  to  depend 
upon  any  diathesis,  nervous  or  otherwise.  Anderson2  has 
reported  a  case  of  hereditary  trichorrhexis  nodosa,  the 
disease  in  his  patient  being  congenital  or  nearly  so. 

The  cause  of  the  splitting  of  the  hair  is  ascribed  by  some 
investigators  to  a  degeneration  of  the  medulla,  a  conse- 
quent rapid  accumulation  of  cells  at  one  point  which  event- 
ually bursts  open  the  hair  sheath.  Pye-Smith3  regards  it  as 
due  to  a  gradual  drying  of  the  cortical  substance,  and  a 
consequent  loss  of  coherence  of  its  constituent  fibre-cells, 
followed  by  the  breaking  up  into  a  granular  material  and 
swelling  of  the  cells  of  the  medulla,  till  the  rupture  of  the 

1  Vierteljahr.  f.  Derm.  u.  Syph.,  1881,  viii.  581. 

2  Lancet,  1883,  ii.  140. 

3  Trans.  Path.  Soc.,  Lond.,  1879,  xxx.  439. 


ATKOPHIA    PILOKUM    PROPRIA.  95 

cortex  is  complete,  there  being  nothing  left  to  hold  the  hair 
together. 

By  some  it  is  regarded  as  purely  mechanical,  due  to  the 
habit  of  the  patient  of  handling  the  beard. 

The  microscopical  examination  of  the  affected  hair  shows 
that  in  the  early  stage  of  development  of  the  disease  there  is 
is  simply  a  spindle-formed  thickening  in  the  continuity  of  the 
shaft  of  the  hair,  and  a  swelling  of  the  medulla,  while  the 
cuticle  is  still  intact.  Later  the  cuticle  becomes  cleft,  and 
the  cleavage  extends  on  all  sides  of  the  node  till  the  brush- 
like appearance  is  produced  by  spreading  of  the  separate 
fibres.  At  the  same  time  with  the  cleaving  of  the  cuticle,  the 
medulla  undergoes  degenerative  changes,  and  either  slowly 
disappears  or  else,  according  to  Pye-Smith,  oozes  out  between 
the  separated  fibres  as  a  finely  granular  material.  There 
is  either  no  marked  change  in  the  appearance  of  the  hair- 
root,  or  it  is  slightly  atrophied.  Air-globules  are  only  very 
occasionally  found  in  or  about  the  nodes. 

Treatment.  The  treatment  of  the  disease  is  very  unsatis- 
factory. Continued  shaving  probably  offers  the  best  hopes  of 
any  plan.  All  sorts  of  applications  have  been  made  to  the 
affected  parts,  generally  of  a  stimulating  character,  particu- 
larly various  forms  of  mercurials,  but  without  curative 
effect.  Gamberini,  in  his  work  on  the  hair,  recommends 
either  bathing  the  part  with  a  lotion  composed  as  follows : 

R.  Potass,  subcarb.,  ^iijj  8 1 

Alcohol,  dil.,  gv;  100         M. 

or  inunctions  of  tannic  acid  or  oil  of  cade. 
Schwimmer  advises  that  an  ointment  of 


K 


Zinci  oxid., 

gr.  vij  ; 

115 

Sulphur,  loti, 

gr.  xv ; 

3 

Ung.  simp., 

^iiss ; 

30 

M. 


be  rubbed  in  morning  and  evening. 

Besnier  finds  it  useful  to  pluck  the  diseased  hairs  and  to 
apply  to  the  newly  formed  hairs  tincture  of  cantharides,  pure 
or  diluted. 


96  DISEASES    OF    THE    SKIN. 

Atrophia  Unguium.  Atrophy  of  the  nails  occurs  as  a 
symptom  of  very  many  diseases  of  the  skin,  such  as  lichen 
ruber  acuminatus,  pityriasis  rubra,  psoriasis,  and  syphilis  ; 
or  it  may  be  caused  by  the  invasion  of  the  nail  bed  by  para- 
sites, as  in  favus  and  ringworm.  It  may  also  occur  like 
defluvium  capillorutn  as  a  sequence  to  some  grave  acute 
illness  such  as  typhus  fever  or  scarlatina,  or  some  cachexia, 
such  as  diabetes.  The  nails  may  be  congenitally  absent  or 
deficient,  or  become  so  without  apparent  cause.  Injuries, 
and  certain  chemicals,  will  cause  the  nails'  to  atrophy  and 
fall.  Atrophy  is  shown  by  white  spots  in  the  nails,  by 
transverse  white  lines,  by  longitudinal  or  transverse  furrows, 
by  a  worm-eaten  appearance,  or  by  a  general  thinning  and 
breaking  away  of  the  nail  plate. 

Treatment.  The  treatment  is  most  unsatisfactory.  If 
the  cause  can  be  discovered  and  removed,  the  nails  will 
recover.  In  many  cases  all  we  can  do  is  to  protect  the  nail 
by  rubber  cots,  or  by  the  use  of  wax  or  other  protective. 
Ointments  of  lead,  zinc,  or  mercury,  may  be  rubbed  in. 
The  persistent  use  of  sulphur  ointment,  combined  with  the 
administration  of  nerve  tonics,  will  prove  beneficial  in  those 
cases  apparently  dependent  upon  nerve  disturbance. 

Aussatz.     See  Leprosy. 

Autographism.     See  Urticaria  factitia. 

Arzneiexantheme.     See  Dermatitis  medicamentosa. 

Baker's  Itch.     See  Eczema. 

Baldness.     See  Alopecia. 

Barbadoes  Leg.     See  Elephantiasis. 

Barber's  Itch.     See  Trichophytosis  barbae. 

Bartfinne  or  Bartflechte.     See  Sycosis. 

Biskra  Bouton  or  Biskrabeule.     See  Aleppo  boil. 

Blasenausschlag.     See  Pemphigus. 

Blutfleckenkrankheit.     See  Purpura. 

Blutgeschwiir  or  Blutschwar.     See  Furunculus. 

Blutschweiss.     See  Haematidrosis. 

Boil.     See  Furunculus. 


BROMIDROSIS.  97 

Bouton.     See  Acne. 
Bouton  d'Amboine.     See  Yaws. 
Brandrose  is  a  phlegmonous  erysipelas. 
Brandschwar.     See  Carbuncle. 
Bricklayer's  Itch.     See  Eczema. 

Bromidrosis  (Brom-i2d-rorsi2s).  Synonym  :  Osmidrosis. 
This  word  means  stinking  sweat,  which,  though  not  elegant, 
is  expressive.  It  most  often  affects  the  feet,  and  then  is 
associated  with  hyperidrosis.  It  may  be  general,  as  in  the 
negro  race.  The  odor  is  not  necessarily  repulsive,  a  few 
cases  having  been  reported  in  which  it  was  that  of  violets. 
The  axillae  are,  next  to  the  feet,  the  most  common  site  of  the 
trouble.  The  odors  of  different  fevers  and  cachexiae  are 
usually  classed  under  this  heading,  though  they  do  not 
properly  belong  here. 

Strictly  speaking  bromidrosis  should  include  those  rare 
cases  alone  in'which  the  sweat,  when  secreted,  has  a  dis- 
tinctive odor.  Usually  the  odor  in  bromidrosis  is  not  in 
the  sweat,  but  in  the  products  of  decomposition,  the  fatty 
acids,  and  the  like.  When  the  feet  are  the  parts  affected 
they  will  be  found  to  be  of  a  pinkish  color  about  the  soles 
and  between  the  toes,  or  the  skin  will  look  sodden  and 
grayish.  When  the  hyperidrosis  is  well  marked,  and  it 
commonly  is,  the  feet  may  be  so  tender  as  to  interfere  with 
locomotion.  The  stench  from  a  pronounced  case  is  such 
that  it  is  almost  impossible  to  stay  near  the  subject  of  the 
disease. 

Etiology.  The  cause  of  general  bromidrosis  is  either 
inherent  in  the  race,  or  unknown.  Most  of  the  cases,  apart 
from  the  racial  ones,  have  been  in  hysterics.  In  the  usual 
form  of  the  disease  it  is  due  to  decomposition  of  the  sweat 
in  the  stockings,  shoes,  or  clothing  of  the  individual. 
When  the  part  is  uncovered  and  kept  clean  there  is  no  odor. 
Thin  has  described  a  parasite,  that  he  has  named  bacterium 
foetidum,  as  the  cause  of  the  disease.  It  has  been  supposed 
that  this  bacterium  can  live  only  in  an  alkaline  medium. 
The  sweat  is  acid,  and  therefore  on  most  feet  it  does  no 
harm  ;  but  when  hyperidrosis  macerates  the  epidermis  and 

5 


98  DISEASES    OF    THE    SKIN. 

allows   of  the  escape  of  serum,  the  acidity  of  the  sweat  is 
neutralized,  and  the  bacterium  flourishes. 

Treatment.  The  treatment  of  the  general  cases  is  of  no 
effect.  Of  the  local  cases  the  hyperidrosis  is  to  be  overcome, 
as  will  be  described  in  its  proper  place.  The  special  treat- 
ment directed  to  the  cure  of  the  odor  is  to  wash  the  feet  with 
soap  and  water  two  or  three  times  a  day,  to  put  on  a  clean 
pair  of  stockings  every  morning,  to  ventilate  the  shoes 
thoroughly,  and  to  dust  the  feet,  between  the  toes,  the 
stockings,  and  the  inside  of  the  shoes  with  boric  acid.  Thin 
recommends  the  wearing  of  cork  inside  soles,  which  are  to 
be  soaked  in  a  saturated  solution  of  boric  acid  and  dried, 
before  using.     Another  useful  powder  is  : 


R .  Ac.  salicylici,  gjss-iij  ;      5-10 

Pulv.  alum  exsic.  vel  \        z  . . .  -.  nA 

Pulv.  lycopodii,  j        5nj;  iUU 


M. 


to  be  applied  in  the  same  way,  twice  a  day.  This  will  cause 
the  skin  to  exfoliate,  when  the  treatment  may  be  stopped. 

Bucnemia  Tropica.     See  Elephantiasis. 

Cacotrophia  Folliculorum.     See  Keratosis  pilaris. 

Calculi,  Cutaneous.     See  Milium. 

Callositas  (Ka2l-loV-i2t-a2s).  Synonyms:  Callosity;  Cal- 
lus; Tylosis;  Tyloma;  (Fr.)  Durillon.  This  is  familiar  to 
all  as  the  callus  skin  of  the  hands  met  with  in  oarsmen, 
blacksmiths,  and  in  those  who  follow  other  manual  occupa- 
tions, and  is  a  hypertrophy  of  the  epidermis  consequent 
upon  intermittent  pressure  of  the  skin  against  the  under- 
lying bone.  Constant  pressure  will  cause  atrophy.  The 
same  thickenings  of  the  skin  are  found  upon  the  soles  also, 
due  to  going  barefoot  or  wearing  improperly  fitting  shoes. 
In  fact  they  may  develop  anywhere  under  proper  conditions. 

Besides  this  acquired  form,  cases  of  congenital  tyloma 
have  been  met  with.  Unna1  has  reported  five  cases  of  this 
rare  disease  in  one  family,  and  has  proposed  for  it  the  name 
of keratoma  palmare  et  plantare  her  edit  arium.  Other  cases 
have  been  described  under  the  name  of  ichthyosis  palmar  is  et 

1  Vierteljahr.  f.  Derm.  u.  Syph.,  1882,  x.  p.  231. 


CANCROIDE.  99 

plantaris.  Besnier  and  Doyon  place  this  under  the  congenital 
and  hereditary  form  of  Jceratodermie  symetrique  des  extrem- 
ites.  They  describe  a  second  form  that  develops  in  second 
childhood  in  which  the  callosities  are  surrounded  by  an 
erythematous  zone,  and  interfere  with  walking  and  grasping. 
Their  development  is  probably  due  to  some  central  neurosis, 
A  third  variety,  also  due  to  a  tropho-neurosis,  exhibits 
numerous  islands  of  callosities  of  the  hands  and  feet  out 
of  all  proportion  to  the  pressure.  At  times  callosities  will 
develop  without  any  apparent  cause,  and  may  involve  either 
the  feet  or  hands  or  both.  In  all  forms  Ave  have  a  hyper- 
trophy of  the  corneous  layer  of  the  skin,  and  the  formation 
of  more  or  less  smooth  and  thickened  plates  of  skin  which 
are  of  more  or  less  gray  color. 

Treatment.  No  treatment  is  necessary  for  the  acquired 
forms.  Cessation  from  using  the  hands  will  be  followed  in 
course  of  time  by  the  disappearance  of  the  callus.  To 
hasten  their  removal,  or  to  cause  it  in  the  congenital  or 
spontaneous  forms,  we  may  use  maceration  with  rubber  cloth 
continuously  applied  to  the  part,  or  a  plaster  of  salicylic 
acid,  or  a  solution  of  salicylic  acid  ten  to  twenty  per  cent,  in 
ether  or  collodion.  The  action  of  these  remedies  will  be 
aided  by  previously  paring  down  the  part  with  a  sharp  knife. 

Rosen1  recommends  dampening  the  part  with  a  saturated 
solution  of  boric  acid,  and  covering  it  with  a  thick  layer  of 
salicylic  acid  in  crystals,  over  which  is  placed  a  four-folded 
layer  of  borated  lint,  and  then  a  thick  piece  of  gutta-percha, 
the  whole  being  confined  by  a  bandage.  After  five  days 
this  is  to  be  removed,  when  the  growth  may  be  raised  easily 
from  its  bed,  and  there  will  be  soft  skin  underneath. 

Callus.     See  Callositas. 

Calvez     ^ 

Calvezza  >        •  See  Alopecia. 

CalvitiesJ  (Ka2l-vi2s'h'i2-ez). 

Cancer.     See  Carcinoma  and  Epithelioma. 

Cancroide.     See  Epithelioma. 

1  Miinchen.  med.  Woch.,  Feb.  28,  1888. 


100  DISEASES    OF    THE    SKIN. 

Canities  (Ka2n-i2/shi2-ez).  Synonyms:  Trichonosis  cana; 
Trichonosis  discolor;  Poliothrix ;  Poliosis;  Trichonosis 
poliosis ;  Trichosis  poliosis ;  Spilosis  poliosis ;  Poliotes  ; 
Grayness  of  the  hair ;  Whiteness  of  the  hair ;  Blanching  of 
the  hair ;  Atrophy  of  the  hair  pigment. 

Grayness  or  whiteness  of  the  hair  may  be  congenital  or 
acquired ;  the  latter  is  by  far  the  most  common.  The 
whiteness  is  either  partial  or  complete. 

Congenital  canities  usually  occurs  in  the  form  of  tufts, 
sometimes  in  round  patches,  the  more  or  less  pure  white 
hair  showing  conspicuously  amongst  the  normal-colored 
mass.  When  the  whiteness  is  general,  we  have  albinism 
which  is  associated  with  a  deficiency  of  pigment  in  the 
whole  body.     Cases  of  congenital  canities  are  rare. 

Acquired  canities  may  be  premature  or  senile.  Most 
often  grayness  does  not  begin  before  the  thirty-fifth  or 
fortieth  year.  If  it  occurs  before  this  age,  it  may  be  con- 
sidered as  premature ;  and  when  after  this  age,  as  senile. 
Premature  canities  is  by  no  means  uncommon,  many  per- 
sons becoming  gray  between  the  twentieth  and  twenty-fifth 
year.  The  hair  which,  as  a  rule,  first  whitens  is  that  of 
the  temples ;  then  follows,  with  more  or  less  rapidity,  that 
of  the  vertex  and  whole  head.  Sometimes  the  beard  first 
turns  gray,  but  usually  it  changes  color  after  the  hair  of 
the  scalp.  The  last  hair  to  become  gray  is  that  of  the 
axillae  and  pubis.  When  the  graying  is  due  to  some  pass- 
ing cause,  as  anxiety  or  some  diseased  state,  the  process 
may  cease  completely  upon  removal  of  the  cause.  Usually 
the  whiteness  is  "permanent.  As  a  rule,  there  is  no  change 
in  the  color  of  the  scalp,  though  in  some  cases  gray  tufts 
are  found  upon  pale-yellow  patches  of  scalp.  As  in  alopecia, 
so  in  canities,  men  are  more  frequently  affected  than 
women. 

The  hair  in  canities  is  usually  unchanged  except  in  color, 
but  it  may  be  drier  and  stiffer  than  normal.  Canities  may 
exist  for  years  without  alopecia.  According  to  Landois, 
incipient  baldness  usually  follows  senile  canities  in  from 
one  to  five  years. 

The  hair  turns  gray  first  at  its  root.     The  color  at  first 


CANITIES.  101 

is  gray  on  account  of  the  mixture  of  the  normal  color  with 
the  whiteness  due  to  the  absence  of  pigment.  Gradually, 
the  white  parts  gain  the  ascendant,  and  the  whole  hair  is 
blanched,  becoming  finally  of  a  yellowish  or  snowy  white- 
ness. The  darker  the  hair  is  originally  the  more  it  is  prone 
to  turn  gray. 

Sudden  change  of  color  of  the  hair  from  its  normal 
hue  to  perfect  white  has  been  too  well  authenticated  to  allow 
of  a  doubt  as  to  its  occurrence,  though  it  has  been  denied 
by  good  authorities,  who  have  questioned  the  correctness  of 
the  observations  reported, 

Ringed  hair  is  an  anomalous  variety  of  blanching  of  the 
hair  in  which  the  affected  hairs  are  marked  by  alternate 
rings,  one  being  that  of  the  normal  color,  and  the  next 
white.  The  occurrence  of  this  disease  is  very  rare,  and  but 
few  cases  have  been  reported. 

The  hair  has  been  known  to  lose  its  color  under  varying 
circumstances.  Thus  Wallenberg1  reports  a  case  in  which, 
after  an  attack  of  scarlatina,  the  patient's  brown  hair  was 
entirely  lost  and  replaced  by  a  growth  of  white  hair.  Pro- 
longed residence  in  a  cold  climate,  with  much  exposure, 
will  cause  the  hair  to  turn  gray.  Sometimes  the  hair  will 
change  its  color  with  the  season,  becoming  gray  in  winter 
and  darker  in  summer.  On  the  other  hand,  Cottle2  gives 
prolonged  residence  in  hot  climates,  with  much  exposure,  as 
a  cause  of  canities.  Albinoes,  we  know,  are  most  frequent 
in  the  negro  races,  which  inhabit  the  hot  countries. 

Etiology  and  Pathology.  Senile  canities  and  many 
cases  of  the  premature  form  are  due  to  an  obscure  change 
in  the  nutrition  of  the  hair  papillae  which  interferes  with 
the  production  of  pigment.  Whatever  the  nature  of  the 
change  may  be,  only  this  function  of  the  papillae  seems  to 
be  interfered  with,  as  the  hair-forming  function  is  in  full 
activity,  judging  from  the  fact  that  the  hair  in  many  cases  is 
in  full  vigor.  In  cases  of  sudden  blanching  of  the  hair,  the 
change   of  color  is   dependent  upon  the   formation   of  air 

1  Arch.  f.  Derm,  und  Syph.,  1876,  Heft  1. 

2  The  Hair  in  Health  and  Disease.     London,  1877. 


102  DISEASES   OF    THE    SKIN. 

bubbles  between  the  hair  cells  of  the  cortical  substance,  the 
presence  of  the  air  rendering  the  cortical  substance  opaque, 
so  that  the  color  of  the  pigment  is  obscured.  If  one  of 
these  hairs  is  placed  in  hot  water,  ether,  or  turpentine,  the 
air  bubbles  will  be  driven  out,  and  the  hair  will  reassume 
its  normal  color.  There  are  various  agents  which  act  as 
active  or  exciting  causes  of  canities.  Age  is  one  of  the 
most  prominent  of  these.  Heredity  exerts  marked  influence 
upon  the  blanching  of  the  hair,  most  of  the  members  of 
certain  families  turning  gray  at  an  early  period  of  life. 
Neuralgia  of  the  fifth  nerve,  dyspepsia  of  various  forms, 
sudden  fear  or  nervous  shock  (producing  sudden  blanching 
of  the  hair),  abundant  and  frequent  hemorrhage,  excesses 
of  all  kinds,  chronic  debilitating  diseases  (as  syphilis, 
malaria,  and  phthisis),  local  diseases  or  injuries  to  the 
scalp,  as  wounds,  favus,  repeated  epilation,  prolonged  shav- 
ing, and  the  like,  have  been  given  by  various  writers  as 
causes  of  canities.  Schwimmer  regards  it  as  being  prin- 
cipally a  tropho-neurosis,  and  finds  in  the  occurrence  of 
grayness  in  the  course  of  neuralgia  a  strong  argument  for 
his  theory. 

Treatment.  We  cannot  restore  the  color  to  gray  hairs. 
In  some  cases  of  canities  occurring  in  the  course  of  neural- 
gias, if  we  can  cure  the  neuralgia,  the  color  will  gradually 
return  to  the  hair. 

Besnier  and  Doyon  suggest  the  use  of  acetic  acid  as  a 
promoter  of  pigmentation,  as  they  have  seen  numerous  cases 
of  its  use  in  Alopecia  areata  being  followed  by  the  growth 
of  hyperpigmented  hair. 

All  that  can  be  done  for  canities  is  to  artifically  restore 
the  color  by  means  of  hair  dyes ;  and  their  use  is  to  be 
deprecated.  Happily  the  custom  of  dyeing  the  hair  is  falling 
out  of  fashion. 

Carbuncle  (Ka3rb'-u3n-kl).  Synonyms  :  Anthrax  ;*  Car- 
bunculus;  (Grer.)  Brandschwar. 

1  Anthrax,  a  term  that  is  often  applied  to  carbuncle,  should  be  used 
rather  for  malignant  pustule,  or  the  local  manifestation  of  splenic 
fever. 


CARBUNCLE.  103 

A  phlegmonous  inflammation  of  the  skin  and  subcuta- 
neous tissue,  attended  with  sloughing. 

Symptoms.  The  disease  begins  as  an  innocent-looking 
papule  which,  however,  is  far  more  painful,  both  subjec- 
tively and  objectively,  than  an  ordinary  papule  would  be. 
Within  twenty- four  hours  it  becomes  larger,  more  painful, 
slightly  raised,  and  reddened,  and  is  generally  accompanied 
by  a  good  deal  of  constitutional  disturbance,  such  as  chills, 
fever,  and  nervous  irritation.  All  the  symptoms  increase 
in  severity,  the  inflammation  extends  laterally  and  vertically, 
the  swelling  becomes  darker  in  color,  the  pain  more  intense 
and  lancinating,  and  the  constitutional  disturbance  may  be 
so  severe  that  the  patient  is  compelled  to  go  to  bed.  Within 
ten  days  or  perhaps  longer,  the  swelling  has  reached  its 
height.  It  may  be  two  or  three  inches  wide,  with  a  brawny 
base  that  is  more  or  less  sharply  defined,  of  irregular  shape, 
and  firm  to  the  touch.  Now  it  begins  to  soften,  not  like  a 
boil  with  a  central  point,  but  by  the  formation  of  a  number 
of  pea-sized  purulent  points,  through  which  sanious  pus 
exudes,  giving  to  the  surface  a  cribriform  appearance. 
Sloughing  takes  place  through  the  openings,  that  gradually 
enlarge,  so  that  at  last  there  results  an  irregular,  deep,  ex- 
cavated ulcer  with  firm,  sharply  cut,  everted  edges.  This 
gradually  fills  up,  heals,  and  leaves  a  scar.  With  the  dis- 
charge of  the  slough  the  patient  gradually  recovers  his 
health,  but  in  some  cases,  especially  in  already  debilitated 
or  in  elderly  people,  the  disease  runs  a  fatal  course  and 
they  die  of  exhaustion  or  pyaemia,  or  the  disease  runs  into 
a  typhoid  condition  preceding  death.  In  some  cases  the 
resulting  ulceration  is  very  large,  with  a  corresponding 
amount  of  general  disturbance  of  the  system.  Dry  gangrene 
may  take  place. 

The  disease  is  rare  in  children  and  most  common  in  mid- 
dle and  old  age.  Men  suffer  more  often  than  women.  The 
location  of  the  disease  is  most  often  the  upper  dorsal  region, 
back,  buttocks,  and  forearms,  though  it  may  occur  any- 
where. It  is  usually  single.  The  duration  of  the  whole 
process  is  four  to  six  weeks. 

Etiology.     The  causes  of  the  disease  are  verv  much  the 


104  DISEASES   OF    THE    SKIN. 

same  as  those  of  boils.  While  carbuncle  is  most  apt  to 
occur  in  those  who  are  not  in  good  health,  it  does  occur  at 
times  in  apparently  robust  subjects.  Diabetics  are  frequent 
subjects;  gout  and  uraemia  have  been  considered  as  predis- 
posing causes.  The  frequent  location  of  the  disease  about 
the  shoulders  and  on  the  back  of  the  neck  suggests  pressure 
as  a  determining  cause.  Of  course,  the  claim  of  microorgan- 
isms as  the  exciting  cause  of  the  disease  finds  many  ardent 
advocates. 

Pathology.  To  Warren,1  of  Boston,  we  owe  one  of  the 
most  thorough  studies  of  the  pathology  of  carbuncle.  He 
declares  it  to  be  a  spreading  phlegmonous  inflammation  of 
the  subcutaneous  cellular  tissue.  The  inflammatory  cells 
cluster  in  and  about  the  columnse  adiposse,  and  push  out 
latterly  from  them,  infiltrating  the  skin.  They  reach  the 
surface  by  mounting  up  along  the  hair  follicles  and  erector 
pili  muscles. 

Diagnosis.  Carbuncle  differs  from  furuncle  in  being 
single ;  in  its  brawny  base ;  in  its  greater  painfulness  and 
constitutional  disturbance ;  in  its  flatter  shape  and  larger  size ; 
and  especially  in  its  opening  at  many  points  and  presenting 
a  cribriform  surface  rather  than  a  central  core  and  a  crater- 
shaped  opening.  Its  circumscribed  shape,  its  lancinating 
pain,  and  its  multiple  sieve-like  openings  distinguish  it  from 
diffuse  phlegmonous  inflammation  of  the  skin. 

Teeatment.  As  the  disease  is  an  exhausting  one,  the 
patient's  strength  is  to  be  supported  from  the  start,  and  his 
nutrition  kept  up  by  a  generous  diet.  Fresh  air  by  good 
ventilation  must  be  secured.  If  the  pain  is  excessive,  opium 
or  morphine  is  indicated,  especially  to  procure  sleep.  Iron 
is  a  valuable  remedy  all  the  way  through,  and  quinine  or 
antipyrin  if  the  fever  is  marked.  Alcohol  should  be  given 
if  suppuration  is  free,  especially  if  there  are  any  signs  of 
exhaustion. 

The  local  treatment  has  come  of  late  years  to  be  by  the 
use  of  carbolic  acid,  and  this  gives  such  good  results  as  to 
leave' little  to  be  desired.     The   crucial  incision  formerly 

1  Boston  Med.  and  Surg.  Journ.,  1881,  civ.  5. 


CARCINOMA.  105 

practised  is  now  considered  by  most  modern  authorities  as 
harmful,  though  it  certainly  gives  relief  for  the  time  by 
removing  tension.  In  like  manner  the  old-time  method  of 
poulticing  is  condemned,  though  it  too  contributes  to  the 
comfort  of  the  sufferer.  For  ordinary  carbuncles  the  most 
efficient  treatment  is  to  inject  them  with  a  five  or  ten  per 
cent,  solution  of  carbolic  acid  in  olive  oil  or  glycerin,  by 
means  of  an  ordinary  hypodermatic  syringe.  When  there 
are  already  sloughing  points  it  is  well  to  push  into  each  of 
them  a  little  cotton,  wound  on  the  end  of  a  wooden  tooth- 
pick and  dipped  in  carbolic  acid  either  pure  or  in  one  to 
four  solution.  The  procedures  are  painful  for  a  moment. 
The  mass  must  then  be  covered  with  lint  soaked  in  a  weak 
solution  of  carbolic  acid.  It  is  possible  to  abort  some  cases 
by  touching  them  with  pure  carbolic  acid.  Eade,1  to  whom 
we  owe  this  plan  of  treatment  with  carbolic  acid,  says  that  it 
is  possible  to  abort  cases  in  the  papular  stage  by  continuous 
soaking  with  a  solution  of  a  mild  antiseptic,  such  as  boric 
or  salicylic  acid. 

Canquoin's  paste,  and  a  solution  of  chloride  of  zinc,  1  to 
50,  have  been  recommended  for  use  in  the  same  way  as  the 
carbolic  acid. 

Extensive  carbuncles  are  to  be  treated  on  surgical  princi- 
ples, by  excision  or  erosion  with  the  curette.  The  resulting 
raw  surface,  as  well  as  that  of  ordinary  carbuncles,  is  to  be 
dressed  antiseptically  with  iodoform,  iodol,  or  aristol  in 
powder. 

Carcinoma  (Ka^-sr^n-o'ma3).  Epithelioma  is  the  form  of 
cancer  that  most  frequently  is  met  with  in  the  skin.  It  will 
be  described  under  its  proper  heading.  Carcinoma  of  the 
scirrhus  variety  rarely  attacks  the  skin,  but  when  it  does  it 
may  be  primary  or  secondary.  Most  commonly  it  is 
secondary  to  the  same  disease  of  the  breast  or  internal 
organs.  It  may  follow  extirpation  of  the  primary  deposit, 
and  then  is  prone  to  begin  in  the  scar.  Two  varieties  are 
described,  namely :  Carcinoma  lenticulare,  and  Carcinoma 
tuberosum. 

1  Lancet,  May  19, 1888. 
5* 


106  DISEASES    OF    THE    SKIN. 

Carcinoma  Lenticulare  generally  appears  on  the  chest  in 
the  neighborhood  of  the  breast.  It  appears  in  the  form  of 
smooth,  firm,  glistening,  dull,  or  brownish-red  or  pinkish 
nodules  raised  above  the  surface  and  discrete  at  first.  In 
size  the  nodules  vary  from  that  of  a  pea  to  that  of  a  bean. 
After  a  time  the  nodules  run  together  and  form  a  thick, 
indurated  mass,  which  may  involve  so  much  of  the  chest  as 
to  interfere  with  breathing.  This  is  the  cancer  en  cuirasse 
of  Velpeau.  Now  the  neighboring  lymphatic  glands  are 
involved,  and  the  arm  of  the  same  side  becomes  swollen  and 
useless.  In  a  short  time  the  nodules  and  the  mass  break 
down  and  ulcerate,  and  the  patient  soon  dies  of  exhaustion. 

Carcinoma  Tuberosum  is  still  more  rare.  It  may  occur 
anywhere,  but  is  most  frequently  seen  upon  the  face  and 
hands.  It  takes  the  form  of  disseminated,  flat  or  elevated, 
round  or  oval  tubercles  or  nodules,  seated  deeply  in  the  skin 
and  subcutaneous  tissues.  These  are  of  a  dull-red,  viola- 
ceous, or  brownish-red  color.  They  do  not  tend  to  run 
together,  but  they  break  down  and  ulcerate,  and  the  patient 
dies  just  as  in  the  lenticular  variety.  It  usually  appears  in 
old  people. 

In  both  forms  there  may  or  may  not  be  lancinating  pains, 
or  there  may  be  simply  itching.  In  both,  metastasis  may 
take  plnce. 

Carcinoma  Melanodes  is  described  by  most  authors  as  a 
third  form  of  carcinoma,  but  Robinson,  Crocker,  and  Brocq 
regard  it  as  melanotic  sarcoma,  which  see. 

Diagnosis.  The  diagnosis  of  carcinoma  is  not  difficult 
when  one  is  aware  that  there  is  such  a  disease,  and  knows 
that  in  a  given  case  there  has  been,  or  is,  a  carcinoma  else- 
where. The  mode  of  evolution  of  the  lesions,  the  involve- 
ment of  the  lymphatic  glands,  and  the  lancinating  pains  all 
point  toward  carcinoma  as  against  a  tubercular  syphilide, 
lupus,  or  leprosy. 

Treatment.  The  treatment  of  this  form  of  carcinoma 
is  the  same  as  of  other  forms,  and  quite  as  unsatisfactory. 

Causalgia  (KaVaTjP-a3).  Neuralgia  with  a  sense  of 
severe  burning  pain. 


CHLOASMA.  107 

Chair  du  poule.     See  Cutis  anserina. 

Chancre.     See  Syphilis,  initial  lesion  of. 

Chap.  Usually  a  mild  form  of  eczema  attended  with 
superficial  cracking.  It  is  generally  due  to  exposure  to 
cold,  and  affects  exposed  parts,  as  the  backs  of  the  hands 
and  the  lips.  Thorough  drying  of  the  hands  after  washing 
and  keeping  them  covered  from  the  air  will  prevent  its 
occurrence  on  the  hands.  Avoiding  wetting  the  lips,  and 
making  some  greasy  protecting  application,  will  prevent  the 
lips  from  being  affected. 

Charbon.     See  Carbuncle. 

Cheiro-pompholyx.     See  Pompholyx. 

Chelis  and  Cheloide.     See  Keloid. 

Chilblain.     See  Dermatitis  congelationis. 

Chloasma  (Klo-aVinaa).  Synonyms :  (Fr.)  Chloasme, 
Panne  hepatique,  Taches  hepatiques,  Chaleur  du  foie, 
Masque;  (Ger.)  Pigmentflecken,  Leberfleck ;  (Ital.)  Mac- 
chie  epatiche ;  (Eng.)  Liver  spot,  Moth  patch,  Mask. 

A  pigmentary  disease  of  the  skin,  characterized  by  the 
formation  of  yellowish,  browish,  or  blackish  patches  of 
various  sizes  and  shapes. 

Symptoms.  In  this  disease  the  only  alteration  of  the 
skin  is  its  color.  The  disease  consists  in  a  deposit  of  pig- 
ment in  the  rete  mucosum,  and  occurs  in  the  form  of  cir- 
cumscribed or  diffused  patches  of  yellowish  to  black  discolor- 
ation. When  the  color  is  black  it  is  called  melasma  or 
melanoderma.  The  size  of  the  patches  varies  greatly  from 
a  small  spot  up  to  a  general  bronzing  of  the  skin. 

The  disease  may  be  primary  or  secondary,  idiopathic  or 
symptomatic.  The  idiopathic  forms  are  most  often  sec- 
ondary to  some  irritation.  Thus  it  occurs  with  or  in  con- 
sequence of  irritants  applied  to  the  skin,  whether  blisters  or 
even  sinapisms ;  prolonged  scratching  on  account  of  some 
pruriginous  disease,  such  as  prurigo,  pruritus  cutaneous, 
chronic  urticaria,  scabies,  or  pediculosis ;  exposure  to  the 
sun's  rays  or  high  winds,  or  even  to  heat,  as  of  the  furnace 
in  iron-wTorkers,  and  then  on  exposed  parts.  These  all  cause 
more  or  less  hyperseniia  of  the  skin,  and  besides  the  deposit 


108  DISEASES    OF    THE    SKIN. 

of  the  pigment  there  is  more  or  less  discoloration  from  the 
changes  taking  place  in  the  extravasated  blood.  Allied  to 
these  causes  and  acting  in  the  same  way  is  the  discoloration 
of  the  skin  of  the  legs  met  with  about  old  varicose  ulcers, 
and  sometimes  without  the  ulcers  when  there  are  marked 
varicosities. 

The  symptomatic  form  may  likewise  be  primary  or 
secondary.  It  is  primary  in  that  most  common  form 
of  all  that  is  known  as  Chloasma  uterinum,  or  the  mask, 
a  form  of  hyper-pigmentation  of  the  skin  of  the  face 
that  occurs  during  pregnancy,  or  with  uterine  irritation, 
and  that  is  not  met  with  after  the  menopause.  It  usually 
takes  the  shape  of  a  diffused  brownish,  light  or  dark  dis- 
coloration of  the  forehead  alone,  or  also  about  the  mouth 
and  cheeks.  Usually  it  only  extends  across  the  forehead 
and  down  the  temples,  and  is  either  a  continuous  or  inter- 
rupted patch  with  sharply  defined  borders.  Under  the 
same  conditions,  there  takes  place  a  deepening  of  the  color 
about  the  nipples  and  along  the  linea  alba.  The  darkening 
of  the  color  under  the  eyes  of  menstruating  women  is  largely 
due  to  vascular  congestion,  and  little  if  at  all  to  chloasma. 
After  a  time  in  some  women  true  chloasma  does  occur  there. 

Primary  pigmentation  also  occurs  in  certain  cachexia, 
such  as  Addison's  disease,  tubercular  leprosy  in  Europeans, 
abdominal  tuberculosis,  cirrhosis  of  the  liver,  cancer  of  the 
stomach,  malaria,  and  multiple  melanotic  sarcoma.  There 
is  also  an  earthy  look  to  the  skin  in  secondary  syphilis,  as 
well  as  in  congenital  syphilis.  Primary  chloasma  is  also 
seen  as  the  result  of  the  ingestion  of  arsenic.  Argyria  is 
not  a  chloasma  strictly  speaking. 

Secondary  symptomatic  chloasma  is  seen  as  the  sequela 
of  syphiloderma,  and  of  lichen  ruber  planus ;  these  derma- 
toses disappearing  to  leave  behind  them  for  a  greater  or  less 
length  of  time  hyper-pigmented  spots.  This  may  occur  after 
other  diseases  of  the  skin,  but  is  usually  more  fugitive.  It 
is  also  seen  in  senile  atrophy  of  the  skin.  There  is  hyper- 
pigmentation  about  the  patches  of  leucoderma  and  in  sclero- 
derma. There  is  also  a  pigmentary  syphilide  met  with 
upon  the  neck  in  women. 


CHLOASMA.  109 

Etiology.  The  cause  of  chloasma  is  undetermined  in 
most  cases.  A  late  theory  of  the  pigmentation  following 
exposure  to  the  sun  is  that  it  is  due  to  the  action  of  the 
chemical  rays  of  the  sun  upon  the  constituents  of  the  blood. 
We  know  also  that  in  some  cases  of  hyper-pigmentation  the 
color  is  due  to  changes  taking  place  in  the  coloring  matter 
of  the  extravasated  blood.  That  there  is  a  relation  between 
chloasma  uterinum  and  the  uterus,  we  know,  because  the 
chloasma  usually  clears  away  either  after  parturition,  the  cure 
of  the  uterine  disorder,  or  the  attainment  of  the  menopause. 

Diagnosis.  The  diagnosis  is  usually  easy.  Discolora- 
tions  caused  by  artificial  means  can  be  washed  off.  Chromo- 
phytosis  is  scaly  and  can  be  scraped  off  with  the  nail. 
Chromidrosis  is  very  rare  and  can  be  washed  off  with 
chloroform  or  ether. 

Treatment.  The  treatment  of  chloasma  is  very  unsatis- 
factory. While  it  is  possible  to  remove  the  color,  it  is  very 
prone  to  return.  Acetic  acid  touched  on  in  spots  will 
reduce  the  color  and  sometimes  remove  it.  The  same  may 
be  said  of  other  acids,  care  being  used  not  to  cause  too 
great  destruction  of  the  skin  by  the  stronger  ones.  The 
bichloride  of  mercury  in  1  to  2  per  cent,  solution  may  be 
used  for  the  purpose,  applied  repeatedly  or  else  kept  on 
continuously  for  three  or  four  hours.  Hardaway  warns 
against  its  use.  Salicylic  acid,  10  to  15  per  cent.,  in  oint- 
ment, paste,  or  plaster,  or  in  saturated  solution  in  alcohol, 
may  do  well.  Unna  has  recommended  washing  the  part 
with  alcohol,  and  applying  a  mercurial  plaster  made  with 
the  ammoniate  of  mercury  over  night.  The  next  day  this 
is  to  be  removed  and  the  following  ointment  applied  : 


R .  Bismuthi  subnit.,  1       -  -    _ .  « 

Kaolini,  7      ^   3JSS; 

Vaselini,  ^vj  ad     ^jss;     30 


M. 


Brocq  advises  a  mercurial  plaster  during  the  night,  bath- 
ing morning  and  evening  with  a  3  to  5  per  cent,  solution  of 
bichloride  of  mercury,  and  wearing  during  the  day  oxide  of 
zinc  or  bismuth  ointment. 

The  peroxide  of  hydrogen  will  cause  a  temporary  dis- 


110  DISEASES    OF    THE    SKIN". 

appearance  of  the  pigmentation.     In  all  cases  where  there 
is  an  underlying  cause  attention  must  be  given  first  to  it. 

Chorioblastosis  is  any  anomaly  of  growth  of  the  corium 
and  subcutaneous  connective  tissue.     (Auspitz.) 
Chorionitis.     See  Scleroderma. 

Chromidrosis  (Krom-i2d-rosri2s).  Synonyms  :  Ephidrosis 
tincta;  Stearrhoea  or  Seborrhoea  nigricans;  Pityriasis  ni- 
gricans ;  (Fr.)  Cyanopathie  cutanee,  Melastearrhee. 

This  is  a  condition  of  the  body  in  which  the  sweat  has  an 
abnormal  color.  Usually  it  affects  only  limited  regions, 
especially  the  lower  eyelids.  The  color  is  most  commonly 
blue  or  blue-black.  The  subjects  are  most  often  hysterical 
women,  and  many  of  the  cases  are  feigned. 

Besides  the  lower  eyelids  the  upper  ones  may  be  affected. 
Next  in  frequency  it  is  on  some  other  part  of  the  face  where 
the  colored  sweat  forms,  but  it  may  occur  on  any  portion  of 
the  body.  Besides  the  blue  or  black  color,  cases  of  yellow, 
green,  brown,  or  even  rosy  color  have  been  reported.  A 
few  men  have  exhibited  the  phenomenon.  Hoffmann1  re- 
ports a  case  of  blue  sweat  of  the  scrotum  of  a  man  seventy- 
two  years  old ;  and  White2  has  met  with  a  case  of  yellow 
sweat  in  a  man  twenty  years  old.  R.  W.  Taylor  saw  one 
case  of  apparently  blue  sweat  that  occurred  in  a  man  taking 
iodide  of  potassium,  and  was  due  to  a  reaction  between  the 
starch  of  his  shirt  and  the  iodine  contained  in  the  sweat. 
Constipation  and  nervous  derangements  are  often  found  in 
the  cases,  and  the  chromidrosis  has  been  noted  to  growT  worse 
with  increased  constipation,  and  become  better  when  that 
condition  is  removed ;  to  be  more  pronounced  at  menstrual 
periods,  and  to  break  out  suddenly  under  emotional  excite- 
ment. The  skin  may  present  no  appearance  of  change  ex- 
cept the  discoloration,  or  it  may  have  an  evident  deposit 
upon  it.  In  either  case  the  color  can  be  removed  by  wiping 
with  a  little  oil,  or  scraped  off  partially  with  the  finger-nail. 

Etiology.  The  cause  of  the  disease  is  obscure.  It  has 
been  thought  to  be  due  to  the  presence  of  colorless  indican 

1  Wien.  med.  Wochenschr.,  1873,  xxiii.  291. 

2  Journ.  Cutan.  and  Ven.  Dis.,  1884,  ii.  293. 


CHROMOPHYTOSIS.  Ill 

in  the  sweat,  which  becomes  blue  by  oxidation.  This 
accounts  for  a  few  cases  at  least. 

Diagnosis.  The  diagnosis  is  easy,  because  the  discolora- 
tion can  be  readily  removed  by  an  oiled  cloth,  while  that  of 
chromophytosis  does  not  so  readily  come  off,  and  that  of 
chloasma  does  not  yield  at  all.  Moreover,  neither  of  these 
two  last  conditions  exhibits  a  blue  color. 

Treatment.  The  disease  requires  stimulation  in  its 
treatment,  and  good  results  have  been  reported  from  the 
use  of  the  following : 1 


.  Ac.  borici, 

gr.  x; 

Ac.  salicylici, 

gr.  xv ; 

1 

Ungt.  aquse  rosse, 

3j; 

30 

M. 

The  red  sweat  that  occurs  in  the  axillae  more  especially, 
and  elsewhere  occasionally,  is  not  a  true  chromidrosis,  but 
is  due  to  the  growth  of  bacteria  (micrococcus  prodigiosus) 
upon  the  hair,  as  may  readily  be  demonstrated  under  the 
microscope.  The  bacteria  is  sometimes  present  so  abun- 
dantly as  to  encrust  the  hair.  The  same  bacteria  grown  on 
culture  media  are  colorless,  and  it  is  supposed  that  the 
action  of  the  sweat  upon  them  determines  their  color.  At 
times  not  only  are  the  hair  and  skin  stained  red,  but  also 
the  underclothing  is  deeply  dyed. 

A  mild  parasiticide  ointment  or  oil  with  the  use  of  soap 
and  water,  or  a  simple  borax  solution,  will  cure  the  disease 
just  as  in  chromidrosis. 

Grreen  sweat  has  been  seen  in  workers  in  copper.  Yellow 
sweat  has  been  found  associated  with  bacteria  and  without 
them. 

Chromophytosis2  (Krom-o-fit-os'-iV).  Synonyms:  Pityri- 
asis versicolor  ;  Tinea  versicolor  ;  Chloasma  ;  Mycosis  micro- 
sporina ;  (Ger.)  Kleien  Flechte ;  (Fr.)  Pityriasis  parasitaire. 

A  vegetable  parasitic  disease,  characterized  by  brown  or 
cafe-au-lait  colored,  variously  shaped  and  sized  patches  that 
occur  chiefly  upon  the  trunk. 

1  Van  Harlingen  :  Handbook  of  Skin  Diseases. 

2  The  name  of  chromophytosis  was  proposed  for  this  disease  by  Dr. 
F.  P.  Foster,  and  has  been  well  received  in  New  York,  as  it  quite 
accurately'defines  the  disease. 


112  DISEASES    OF    THE   SKIN. 

This  disease  is  far  more  common  than  statistical  tables 
show  it  to  be,  as  it  causes  so  little  trouble  that  many  people 
never  think  of  applying  for  relief.  It  begins  as  a  small 
yellowish  point,  which  rapidly  grows  into  a  split-pea-sized 
lesion.  Many  new  lesions  appear,  and  these  coalescing, 
patches  form  which  may  be  so  large  as  to  occupy  a  great 
part  of  the  chest  or  back.  At  first,  when  of  small  size,  the 
patches  are  circular  in  shape,  but  as  they  grow  larger  they 
lose  all  definiteness  of  shape,  though  their  edges  are  always 
sharply  marked  and  sometimes  raised.  Annular  patches 
sometimes  form,  and  at  other  times  there  will  be  many  more 
or  less  circular  patches  of  sound  skin  in  the  midst  of  the 
diffused  patch.  The  color  is  usually  fawn  or  cafe-au-lait ;  it 
may  be  brown,  or  even  black.  The  latter  is  reported  only 
from  tropical  countries.  In  warm  weather  and  in  those  who 
sweat  profusely  it  is  no  uncommon  thing  to  see  the  eruption 
present  a  pinkish  hue,  due  to  hyperemia  of  the  skin.  The 
edge  of  the  patch  may  be  somewhat  raised,  but  the  surface 
is  not  generally  above  that  of  the  skin.  It  presents  various 
appearances.  At  times  it  is  smooth  and  feels  greasy ;  at 
times  it  is  dry  and  covered  with  fine  branny  scales ;  while 
at  times  it  looks  rough,  and  viewed  from  the  proper  light  it 
presents  an  appearance  resembling  that  of  ichthyosis  of  mild 
grade.  These  appearances  are  dependent  upon  the  amount 
of  sweating,  which,  if  profuse,  will  remove  the  scales,  espe- 
cially if  the  clothing  rubs  upon  the  skin.  The  greasy  feel 
is  imparted  by  the  oily  sebaceous  matter  always  marked  in 
the  region  of  the  sternum,  where  chromophytosis  most  often 
is  located.  Whatever  may  be  the  apparent  condition  of  the 
surface,  scraping  with  the  nail  will  remove  a  good  part  of 
the  disease,  showing  that  it  is  located  in  the  upper  layers  of 
the  epidermis.  These  patches  are  located  chiefly  upon  the 
anterior  surface  of  the  chest  and  upon  the  abdomen.  The 
back  is  also  quite  often  affected,  but  not  so  markedly  as  the 
chest.  In  very  extended  cases  the  arms  and  legs  may  show 
the  disease,  and  a  few  cases  have  been  reported  as  occurring 
upon  the  face.  The  rule  is  that  the  uncovered  parts  of  the 
body  are  spared,  and  exceptions  to  this  are  very  rare.  It 
is  not  symmetrical,  The  number  of  patches  varies  from  a 
few  to  hundreds. 


CHROMOPHYTOSIS.  113 

The  only  subjective  symptom  is  itching,  and  this  is  often 
absent,  and  seldom  so  bad  as  to  cause  the  patient  to  seek 
relief  on  that  account.  Patients  desire  to  be  treated  on 
account  of  the  deformity,  not  the  discomfort,  of  the  disease. 

Etiology.  The  cause  of  the  disease  is  the  lodgment  and 
growth  in  the  corneous  layer  of  the  skin  of  a  vegetable 
parasite,  the  microspor on  furfur.  Like  all  other  parasites 
of  its  class,  this  one  is  incapable  of  growth  on  every  skin, 
but  does  nourish  especially  upon  the  skin  of  one  who  sweats 
freely.  That  consumptives  were  thought  to  be  especially 
prone  to  the  disease  is  due  to  the  fact  that  their  chests  are 
exposed  to  the  physician  more  often  than  are  those  of  any 
other  class  of  patients.  The  disease  is  contagious,  but  its 
contagion  is  of  low  grade,  and  it  is  not  common  for  it  to 
take  place  even  in  such  intimate  relations  as  obtain  between 
husband  and  wife.  Adults  from  twenty  to  forty  years  of 
age  are  the  most  common  subjects,  though  children  have 
had  the  disease.  According  to  Besnier  and  Doyon  the  dis- 
ease is  never  seen  in  very  old  people.  It  occurs  in  all  coun- 
tries, but  most  often  in  hot  climates.  It  attacks  all  classes 
and  conditions  of  men,  and  shows  no  particular  discrimina- 
tion in  regard  to  sex.  Its  growth  is  interrupted  by  malarial 
paroxysms,  and  it  peels  off  with  the  desquamation  of 
scarlatina  and  measles. 

Pathology.  The  microspor  on  furfur  is  one  of  the  most 
readily  demonstrated  of  parasites.  Place  a  few  scales  upon 
the  slide,  add  a  drop  or  two  of  liquor  potassae,  tease  out  the 
material  a  little,  put  on  the  cover-glass,  and  even  with  a  low 
power  the  picture  here  represented  will  be  seen  (Fig.  10). 
It  consists  of  heaps  of  conidra,  which  are  larger  than  those 
of  ringworm,  with  any  quantity  of  interlacing  mycelia  run- 
ning between  them.  Free  conidia  are  scattered  about  in  the 
field.    The  fungus  grows  in  the  upper  layers  of  the  epidermis. 

Diagnosis.  If  one  remembers  the  characteristic  feat- 
ures of  the  disease,  yellow  or  cafe-au-lait,  scaly  patches, 
that  can  be  partly  scraped  away  and  are  located  chiefly 
upon  the  chest,  little  difficulty  can  arise  in  diagnosis.  An 
appeal  to  the  microscope  will  decide  any  doubtful  question. 
Chloasma  is  not  scaly,  and  cannot  be  scraped  off  from  the 


114 


DISEASES    OF    THE    SKIN. 


skin.  Leucoderma  is  an  absence  of  pigment  with  a  hyper- 
pigmentation  about  it  that  comes  up  to  the  white  spot  with 
a  concave  border,  and  is  not  scaly.  A  fading  erythematous 
syphilide  occurs  not  in  patches,  but  in  isolated  round  macules 
that  are  neither  scaly  nor  itchy,  that  are  usually  most 
numerous  over  the  abdomen  and  sides  of  the  chest,  and 
that  are  very  often  found  as  a  disseminated  eruption  occur- 
ring upon  the  face  as  well  as  the  trunk.  JErythrasma  is 
not  so  scaly,  and  occurs  only  in  or  about  the  joints.  Its 
parasite  is  much  smaller  than  that  of  chromophytosis. 


Fig.  10. 


Treatment.  Anything  that  will  cause  the  removal  of 
the  upper  layers  of  the  epidermis  will  cure  chromophytosis 
when  present  only  to  slight  degree.  But  it  is  best  for 
safety  to  use  a  parasiticide.  One  of  the  pleasantest  ways 
of  curing  the  disease  is  to  have  the  patient  scrub  his  skin 
thoroughly  with  soap  and  water,  preferably  soft-soap,  and 
then  dab  on,  twice  a  day,  a  solution  of  hyposulphite  of  soda, 
one  drachm  to  the  ounce.     Sulphurous  acid,  pure  or  dilute, 


CLAVUS.  115 

is  a  prompt  remedy.  Vleminckx's  solution,  one  to  three  or 
six  parts  of  water ;  bichloride  of  mercury,  two  or  three 
grains  to  the  ounce;  sulphur  ointment  rubbed  in  thoroughly ; 
and  tincture  of  veratrum  viride,  are  efficacious.  The  danger 
of  systemic  poisoning  by  either  the  bichloride  of  mercury 
or  the  veratrum  viride  should  deter  us  from  using  these 
remedies  in  extensive  cases.     Unna l  recommends  : 

R .  Tinct.  rhei  aquosa?,  |  a_  M 

Brocq  gives  the  following : 


13c.  Acid,  salicylici, 

2-3    parts. 

Sulphur,  precip., 

10-15      " 

Lanolini, 

70 

Vaselini, 

18 

M. 

Chrysarobin,  naphthol,  boric  acid,  and  resorcin,  all  are 
good.  If  the  disease  is  very  limited,  it  can  be  surely  and 
speedily  destroyed  by  painting  the  spot  with  tincture  of 
iodine. 

There  is  only  one  point  to  be  borne  in  mind  in  using  any 
of  these  remedies,  and  that  is  that  they  must  be  thoroughly 
used,  and  continued  for  a  time  even  after  the  last  trace  of 
the  fungus  seems  to  have  been  removed.  If  one  spore  is 
left  behind,  the  disease  is  liable  to  return.  Relapses  are 
common,  as  the  patient's  skin  is  susceptible  to  the  lodgment 
of  the  fungus. 

Cingulum.     See  Zoster. 

Clastothrix.     See  Trichorrhexis  nodosa. 

Clavus  (Kla'vu3s).  Synonyms:  (Fr.)  Cor;  (Ger.)  Leich- 
dorn,  Huhnerauge ;   Corn. 

Symptoms.  Corns  are  hyperplas  ias  of  the  corneous  lay- 
ers of  the  skin  due  to  pressure,  and  differing  from  calluses 
in  having  a  central  core  that  grows  down  toward  the  corium. 
They  occur  usually  upon  the  toes,  either  over  prominent 
joints,  where  they  form  hard  corns,  or  between  the  toes, 
where,  on  account  of  being  kept  moist,  they  form  soft  corns. 

1  Vierteljahrschr.  Derm.  u.  Syph.,  1880,  vii.  166. 


116  DISEASES    OF    THE    SKIN. 

They  are  usually  conical  in  shape  and  slightly  projecting. 
Unless  pared  down  they  become  painful  by  being  pressed 
into  the  cutis.  They  are  sometimes  spontaneously  painful 
on  the  approach  of  wet  weather  on  account  of  their  being 
hygroscopic.  They  may  suppurate.  They  may  occur  upon 
the  hands ;  I  have  seen  several  cases  in  tennis-players. 

Treatment.  The  best  treatment  for  corns  is  to  wear 
well-fitting  boots  or  shoes,  which  must  not  be  too  large  or 
too  small.  The  corn  may  be  removed  by  the  use  of  a  sali- 
cylic acid  plaster,  or  by  Vigier's  preparation,  now  sold  in 
all  the  shops  under  the  name  of  Hebra's  Corn  Remedy, 
which  is  composed  of — 


Ac.  salicylici, 

gr.  xv. 

Ext.  cannabis  indica?, 

gr.  viij. 

Alcoholis, 

Wxv. 

Etheris, 

Ttlxl. 

Collodion  flex., 

mjxxv 

M. 

which  is  to  be  painted  on  three  times  a  day  for  a  week ; 
then  the  feet  are  to  be  soaked  in  hot  water,  and  the  corn 
picked  out.  They  may  also  be  cut  out,  but  the  operation 
is  at  times  dangerous,  especially  in  old  people.  Crocker 
recommends  for  soft  corns  careful  daily  ablution  with  soap 
and  water,  painting  on  them  spirits  of  camphor  at  night, 
and  wearing  wool  between  the  toes  during  the  day.  But 
unless  well-made  boots  are  worn,  the  corns  will  be  sure  to 
return.  Corns  on  the  hands  may  be  removed  with  salicylic 
acid,  or  scraped  out  with  the  dermal  curette. 

Cnidosis.     See  Urticaria. 

Colloid  degeneration  of  the  skin.  Synonyms :  Colloid 
milium  ;  (Ger.)  Hyalom  der  Haut ;  (Fr.)  Hyalome  cutane. 

Symptoms.  This  is  a  very  rare  disease  of  the  skin  that 
occurs  most  often  on  the  upper  part  of  the  face  in  the  form 
of  disseminated  or  grouped,  discrete,  transparent,  shining, 
rounded,  lemon-yellow  elevations  of  the  skin.  Though  they 
look  as  though  they  were  vesicles,  they  do  not  contain  fluid, 
and  when  pricked  give  exit  to  only  a  small  amount  of 
gelatinous  substance  and  a  drop  or  two  of  blood.  They 
are  resistant  to  the  touch.     The  course  of  the  disease  is 


COMEDO.  117 

slow.  It  is  capable  of  spontaneous  disappearance  by  ab- 
sorption or  inflammation,  leaving  an  ill-defined  mark  on  the 
skin.  It  affects  both  sexes.  The  youngest  patient  so  far 
reported  was  fifteen  years  old.  There  are  no  subjective 
symptoms,  and  the  general  health  is  good. 

Diagnosis.  It  differs  from  xanthoma  in  the  transpa- 
rency and  shining  appearance  of  the  lesions  and  in  their 
lemon-yellow  color.  In  xanthoma  the  lesions  are  soft  and  of 
a  duller  yellow.     They  may  be  removed  with  the  curette. 

Comedo  (Ko2mre2d-o).  Synonyms:  Acne  punctata,  Acne 
follicularis  ;  (Fr.)  Oomedon,  Acne  punctuee,  Tanne  ;  (Grer.) 
Mitesser,  Hautwiirmer ;   Grubs,  Fleshworms,  Blackheads. 

A  comedo  is  a  collection  of  inspissated  sebaceous  matter 
retained  in  a  pilo-sebaceous  gland,  whose  mouth  is  closed 
by  a  black- topped  plug  of  extraneous  matter,  and  appears 
as  a  pin-point  to  a  pin-head,  slightly  elevated,  conical  papule 
in  the  skin. 

Symptoms.  Comedones  are  met  with  most  often  upon 
the  face,  ears,  back,  and  shoulders,  and  occasionally,  but 
much  more  rarely,  on  other  parts  of  the  body.  Wherever 
met  with  they  present  the  characteristics  indicated  in  the 
definition  just  given.  They  are  unaccompanied  by  inflam- 
matory symptoms.  Just  as  soon  as  inflammation  is  caused 
by  their  presence,  they  are  converted  into  acne  lesions — a 
change  that  they  very  commonly  undergo.  Usually  they 
are  scattered  about  irregularly ;  sometimes  they  are  grouped 
in  certain  regions.  They  are  single  lesions  in  the  vast 
majority  of  cases,  and  being  pressed  between  the  thumb- 
nails they  are  readily  expressed  in  the  form  of  a  filiform  or 
worm-like  mass  that  may  be  a  half-inch  or  more  in  length, 
and  has  a  black  head,  that  obtains  for  them  the  popular 
name  of  "  fleshworms."  Very  exceptionally  they  are 
double,  lateral  pressure  squeezing  out  a  filiform  mass  with  a 
black  head  at  both  ends,  if  such  an  expression  is  allowable. 
There  may  be  but  few,  or  there  may  be  hundreds  of  them 
so  that  the  face  looks  as  if  full  of  grains  of  gunpowder. 
The  largest  are  found  in  the  ears  and  on  the  back.  They 
give  rise  to  no  subjective  symptoms.  Seborrhoea  oleosa  is 
frequently  a  marked  complication. 


118  DISEASES   OF    THE    SKIN. 

In  children  they  are  more  apt  to  be  grouped,  and,  ac- 
cording to  Crocker,  to  appear  on  the  foreheads  and  occiputs 
of  boys,  the  temples  in  girls,  and  the  cheeks  in  infants. 
The  scalp,  too,  is  in  them  the  seat  of  the  disease.  Acne 
may  follow  them. 

Etiology.  All  that  has  been  said  as  to  the  causes  of 
acne  applies  with  equal  force  to  comedones,  and  need  not 
be  repeated  here.  We  would  only  add  that  Unna  does  not 
accept  the  commonly  received  doctrine  that  the  black  head 
and  the  clogging  of  the  follicle  are  largely  due  to  extra- 
neous matter,  but  teaches1  that  they  are  due  to  the  corneous 
layer  of  the  skin  being  abnormally  firm,  and  preventing 
the  escape  of  the  follicle  contents  by  growing  over  its  mouth. 
The  black  color  he  believes  to  be  analogous  to  the  coloration 
of  horns  in  cattle.  He  calls  attention  to  the  fact  that 
comedones  are  more  frequent  in  chlorotic  girls  than  in  coal- 
heavers. 

It  is  quite  certain  that  many  cases  of  comedones  are 
directly  due  to  dirt  or  other  foreign  matters  stopping  up  the 
follicles.  This  is  supposed  to  be  especially  the  case  in 
children.  Colcott  Fox2  says  that  in  them  the  comedones  are 
found  most  often  in  the  spring-time,  and  disappear  in  the 
winter.  The  youngest  case  in  a  child  is  one  at  twelve 
months.3 

Pathology.  The  pathology  of  the  affection  is  the  same 
as  that  of  acne  without  the  evidence  of  inflammation.  The 
demodex  folliculorum,  a  harmless  parasite,  is  very  often 
found  in  the  plugs  of  sebaceous  matter.  This  is  long  and 
worm-like,  with  a  head ;  a  thorax  with  four  pairs  of  short, 
conical,  three-jointed  feet,  with  minute  claw-like  extremities, 
and  a  long  tail-like  abdomen,  which  tapers  off  into  a  blunt 
and  rounded  point.     (Fig.  11.) 

Von  During4  has  endeavored  to  show  that  the  double 
comedo  is  always  an  acquired  formation,  and  is  the  result 

1  Virchow's  Archiv,  1880,  lxxxii.  175. 

2  Lancet,  1888,  i.  665. 

3  Crocker :  Lancet,  1884,  i.  704. 

4  Monatshefte  f.  p.  Dermat.,  1888,  vii.  401. 


COMEDO 


119 


of  a  destructive  process  between  the  ducts  of  two  neighbor- 
ing glands,  so  that  the  two  ducts  become  one,  and  that  the 
destructive  process  has  affected  only  one  gland,  while  the 
other  one  is  still  active  enough  to  produce  the  comedo 
plug. 

Fig.  11. 


Demodex  folliculorum.     (After  KUchknmeister.) 


Diagnosis.  There  is  little  difficulty  in  recognizing  the 
disorder.  Powder  grains  in  the  skin  are  under  the  skin, 
and  cannot  be  squeezed  out. 

Treatment.  The  same  constitutional  conditions  being 
met  with  in  comedones  as  in  acne,  we  need  not  repeat  here 
what  was  said  there  in  regard  to  their  general  treatment. 

The  local  treatment  consists  in  pressing  out  the  come- 
dones, and  stimulating  the  skin  to  a  more  healthy  action. 
There  is  little  use  in  doing  the  first  without  the  second,  as 


120 


DISEASES    OF    THE    SKIN 


the  comedo  would  be  sure  to  re-form.  The  comedones  come 
out  most  readily  after  the  free  use  of  soap  and  warm  water. 
Then  they  may  be  pressed  out  between  the  thumb-nails,  or 
by  means  of  an  old  watch-key,  whose  sharp  edges  have  been 
worn  down ;  or  by  means  of  either  of  the  comedo-pressers 
of  PifFard  (Fig.  12),  or  the  comedo-scoop  of  Fox  (Fig.  13). 
With    some   practice   they   may  be  removed   by   pressing 


PifFard's  comedo-extractors. 

the  back  side  of  a  small  dermal  curette  against  one  side  of 
the  follicle  mouth,  and  making  a  quick  turn  of  the  end 
about  them.  Violent  attempts  at  removal  should  not  be 
made,  as  they  may  cause  inflammation  on  account  of 
too  much  irritation.  If  the  comedo  does  not  come  out 
readily,  wait  until  another  time. 

Fig.  13. 


Fox's  comedo-seoop. 


Frictions  with  green  or  soft  soap  and  water  are  excellent 
as  a  stimulating  remedy,  care  being  taken  not  to  set  up  too 
much  reaction.     Hardaway  recommends  : 


R .  Saponis  olivas  preparat.,  \ 
Alcoholis,  J 

Aquae  rosse, 


aa 


16 
100 


M. 


To  be  rubbed  in  with  a  piece  of  dampened  flannel  every 
night.    He  regards  the  use  of  sulphur  preparations  as  tend- 


CORNU    CUTANEUM.  121 

ing  to  cause  comedones,  and  hence  objectionable.  Alcoholic 
and  astringent  lotions,  of  boric  acid,  alum,  or  zinc,  are 
useful.  Unna  in  the  paper  already  cited  directs  that  the 
following — 

K  •  Kaolin,  4  parts. 

Glycerin,  3      " 

Aceti,  2     "        M. 

be  applied  every  night  with  the  eyes  closed.  Sulphur  and 
most  of  the  preparations  given  under  Acne  have  their  advo- 
cates here. 

The  best  prophylactic  measure  is  the  daily  washing  of 
the  face  with  soap  and  water. 

Condyloma.     See  Verruca  and  Syphilis. 

Congelatio.     See  Dermatitis  calorica. 

Corn.     See  Clavus. 

Cornu  Cutaneum  vel  Humanum.  Synonyms :  (Fr.) 
Corne  de  la  peau  ;  (Ger.)  Hauthorn  ;   Cutaneous  horn. 

This  is  a  rare  disease  of  the  skin,  in  which  there  grows 
a  horn-like  excrescence  resembling,  often  in  a  most 
striking  manner,  an  animal's  horn.  These  vary  greatly  as 
to  size.  They  may  attain  the  length  of  a  foot  and  a  diameter 
of  fourteen  inches  at  the  base,  and  are  usually  single,  but  may 
be  multiple.  They  may  be  straight,  but  usually  are  bent 
or  twisted;  they  may  be  laminated,  striated,  or  fibrillated; 
they  may  be  yellowish,  dirty  gray,  green,  brown,  or  black ; 
they  are  solid  and  hard,  but  not  smooth  and  shining  like 
animals'  horns  often  are ;  and  they  have  rounded  or  truncated 
ends.  They  are  not  painful  unless  pressed  on.  When  torn 
or  knocked  off  they  expose  a  raw  and  bleeding  surface. 
Sometimes  they  fall  spontaneously,  or  as  the  result  of  some 
inflammatory  process.  Most  of  them  occur  upon  the  head, 
nose,  face,  or  scalp.  They  may  occur  elsewhere,  as  upon 
the  extremities,  or  male  genitals.  Their  bases  may  become 
the  site  of  epithelioma. 

There  is  little  known  about  their  etiology.  They  may 
occur  at  any  age  and  in  either  sex. 

Treatment.    The  treatment  consists  in  tearing  them  off, 

6 


122  DISEASES    OF    THE    SKIN. 

under  an  anaesthetic  if  large,  curetting  the  base,  and  apply- 
ing a  caustic  agent,  such  as  a  zinc  paste  or  pyrogallic 
acid. 

Couperose.     See  Rosacea. 

Crasses  Parasitaires.     See  Chromophytosis. 

Crusta  Lactea.     See  Eczema. 

Cutis  Anserina,  or  Goose-flesh,  is  that  condition  of  the 
skin  in  which,  on  account  of  the  action  of  cold  causing  a 
contraction  of  the  arrectores  pilorum  muscles  and  elevation  of 
the  hair  follicles,  it  feels  rough,  and  looks  as  if  studded  over 
with  minute  papules.  It  is  a  fugitive  affair,  therein  differ- 
ing from  keratosis  pilaris,  which,  though  resembling  it,  is 
constant. 

Cutis  Pendula.     See  Dermatolysis. 

Cutis  Tensa  Chronica.     See  Scleroderma. 

Cutis  Unctuosa.     See  Seborrhcea. 

Cyanosis  (Si-a2n-osri2s)  is  a  bluish  coloration  of  the  skin 
from  defective  aeration  of  the  blood,  either  temporary,  as  in 
asphyxia,  collapse,  etc.,  or  permanent,  as  in  the  subject  of 
some  malformation  of  the  heart,  especially  persistent  patency 
of  the  foramen  ovale.1 

Cysticercus  Cellulosae  Cutis.  At  times  the  larvae  of  the 
tapeworm  become  lodged  in  the  subcutaneous  tissues,  and 
produce  movable,  painless,  round  or  oval,  pea-  or  cherry- 
sized  tumors,  with  the  skin  raised  over  them.  They  are 
smooth,  firm,  and  elastic.  The  larger  ones  may  feel  like 
wens.  After  about  eight  months  (Cobbold)  the  animals  die, 
and  the  tumors  shrivel  up  and  become  hard  nodules,  or  they 
may  be  absorbed.  They  simulate  gummas,  lipomas,  sar- 
comas, carcinomas,  and  sebaceous  cysts.  In  a  doubtful 
case  excision  or  puncture  of  one  of  the  tumors  will  show  us 
under  the  microscope  either  one  of  the  larvae  curled  up  in 
its  shell,  as  it  were,  or  the  hooklets  in  the  fluid  that 
escapes. 

Cysto-adenoma  is  an  adenoma  containing  cysts. 

1  Foster's  Encyclopaedic  Medical  Dictionary. 


DERMATALGIA.  123 

Dandriff  or  Dandruff.     See  Seborrhoea. 

Dartre  Farineuses,  Furfuracees,  or  Volantes.  Old  terms 
for  Pityriasis  and  Eczema. 

Dartre  Rongeante.     See  Lupus  vulgaris. 

Dartrous  Diathesis.  This  term,  though  still  used  by 
French  writers,  is  of  very  indefinite  meaning,  and  has  been 
dropped  by  their  latest  author,  Brocq,  Dunglison  defines 
it  as  "  a  peculiar  state  of  health,  which  renders  its  subject 
liable  to  general  eruptions  of  different  forms,  which  are 
always  met  with  in  the  young,  are  symmetrical,  and  con- 
trolled by  arsenic."  It  is  supposed  to  be  the  underlying 
cause  of  eczema,  herpes,  seborrhoea,  psoriasis,  and  not  a  few 
other  diseases. 

Decrepitude  Infantile.     See  Sclerema  neonatorum. 

Defluvium  Capillorum.     See  Alopecia. 

Defcedatio  Unguium.     See  Nails,  degeneration  of. 

Delhi  Boil.     See  Aleppo  boil. 

Dermalgia.     See  Dermatalgia. 

Dermatalgia  .(Du5rm-a2t-a2l'ji2-a3).  Synonyms:  (Fr.) 
Dermalgie  ;  (Ger.)  Hautschmerz,  Hautuervenschmerz  ;  Neu- 
ralgia or  rheumatism  of  the  skin. 

By  this  term  is  meant  spontaneous  pain  in  the  skin,  with- 
out any  appreciable  alteration  of  the  same.  The  pain  is 
variously  described  by  patients,  as  boring,  pricking,  or 
burning ;  or  numbness  or  coldness  may  be  complained  of. 
It  is  constant  or  intermittent  in  character,  and  sometimes  so 
severe  as  to  be  agonizing.  It  is  generally  sharply  located 
to  a  certain  place,  but  it  may  be  general.  The  hairy  parts 
are  those  most  often  affected,  as  the  scalp.  The  legs  and 
back,  palms  and  soles,  are  also  not  infrequently  involved,  as 
may  be  any  part.  Hypersesthesia  or  anaesthesia  may  be 
present  at  the  same  time.  Deep  pressure  may  or  may  not 
relieve  it.     It  disappears  of  itself  after  weeks  or  months. 

Etiology  It  is  a  neurosis  that  may  be  idiopathic  or 
symptomatic.  The  idiopathic  form  is  rare,  and  its  etiology 
obscure.    The  symptomatic  form  occurs  in  locomotor  ataxia, 


124  DISEASES    OF    THE    SKIN". 

rheumatism,  syphilis,  malaria,  diabetes,  hysteria,  and  chlo- 
rosis. According  to  Hyde  it  may  be  a  sign  of  the  approach- 
ing menopause.     The  majority  of  its  subjects  are  women. 

Diagnosis.  Dermatalgia  differs  from  neuralgia  in  being 
more  superficial  and  in  being  accompanied  by  hyperesthesia. 
It  differs  from  hyperesthesia  by  being  a  spontaneous  pain, 
while  the  latter  is  pain  only  upon  contact. 

Treatment.  If  we  can  remove  the  underlying  cause  we 
shall  cure  the  trouble,  so  our  remedies  should  be  first  ad- 
dressed to  it.  Unfortunately,  for  some  of  the  diseases  of 
which  dermatalgia  is  a  symptom  we  can  do  little.  In  any 
case,  the  patient  demands  some  local  treatment  to  relieve 
the  pain.  In  the  way  of  internal  remedies  we  can  use 
salicylate  of  soda,  quinine,  antipyrin,  phenacetine,  some 
form  of  opium,  hyoscyamus,  valerian,  and  other  like  drugs. 
Externally,  relief  may  be  obtained  by  galvanism,  blistering, 
a  mustard  leaf  over  the  centre  from  which  emanates  the 
nerve  (Crocker),  hot  or  cold  water  in  a  rubber  water-bag, 
either  alone  or  alternately ;  rubbing  in  Squibb's  oleate  of 
mercury  or  morphine,  menthol  pencil,  chloroform  liniment, 
tincture  of  aconite,  and  the  like. 

Dermatite  Exfoliatrice  Generalisee.  See  Dermatitis  ex- 
foliativa. 

Dermatitis  (Du5rm-a2t-i,-ti2s).  This  word  means  simply 
inflammation  of  the  skin,  and  would,  therefore,  cover  all 
diseases  of  the  skin  that  are  of  inflammatory  nature.  But 
it  is  applied  to  those  diseases  of  the  integument  that  are 
simple  inflammations,  and  due  to  the  action  of  external 
irritants.  They  are  all  marked  by  redness,  swelling,  and 
heat.  The  name  dermatitis,  with  a  qualifying  adjective,  is 
also  applied  to  diseases  other  than  those  in  this  section,  as 
will  be  seen  further  on. 

Dermatitis  Calorica  is  the  inflammation  of  the  skin  pro- 
duced by  heat  or  cold,  and  divides  itself  naturally  into  two 
divisions,  viz :  D.  ambustionis  and  D.  congelationis. 

Dermatitis  ambustionis  is  the  effect  of  heat  upon  the 
skin,  the  source  of  the  same  being  either  natural,  as  from 
the  sun,  or  artificial.     According  to  the  intensity  and  pro- 


DERMATITIS.  125 

longed  action  of  the  heat  and  the  resistance  of  the  skin  will 
be  the  damage  inflicted  on  the  skin.  A  slight  degree  of 
heat  gives  rise  to  a  passing  erythema.  Burns  are  due  to  a 
greater  amount  of  heat,  and  are  described  for  convenience 
as  being  of  three  degrees.  In  the  first  degree  the  skin  is 
reddened,  hot,  and  somewhat  swollen  ;  in  the  second,  the 
damage  is  greater,  and  we  have  the  production  of  vesicles 
and  bullae ;  and  in  the  third,  there  is  complete  destruction 
of  the  skin,  followed  by  gangrene.  Extensive  burns  may  be 
dangerous  to  life  even  if  not  of  very  high  degree,  and  burns 
involving  one-half  the  cutaneous  surface  are  generally  fatal. 
The  cause  of  death  in  such  cases  is  uncertain.  The  latest 
theory,  as  put  forth  by  Lustgarten,1  is  that  it  is  due  to  a 
toxine  developed  by  the  lodgment  of  microorganisms  of 
putrefaction  upon  the  eschar,  probably  a  ptomaine  similar 
to  muscarin.  Some  of  the  other  theories  are  nerve-shock, 
ulcerations  of  digestive  tract,  nephritis,  decomposition  of  the 
red  blood-globules ;  but  no  one  of  these  is  satisfactory  in  all 
cases. 

Treatment.  The  treatment  of  burns  commonly  falls 
into  the  hands  of  the  surgeons.  In  simple  burns  Carron 
oil,  consisting  of  equal  parts  of  linseed  oil  and  lime-water, 
to  which  may  be  added  5  per  cent,  of  carbolic  acid,  applied 
by  means  of  saturating  absorbent  cotton  in  it,  and  then  cover- 
ing it  with  impermeable  rubber  tissue,  forms  an  admirable 
dressing  that  may  be  left  on  for  several  days,  if  care  is  taken 
to  thoroughly  disinfect  the  part  before  applying  it.  If  this 
is  not  at  hand,  the  part  should  be  dusted  thickly  with  flour 
or  corn-starch  until  it  is  procured.  Or  the  burns  may  be 
covered  with  a  varnish  of  linseed  oil  and  wax,  containing  5 
per  cent,  of  salicylic  acid.  Or  they  may  be  powdered  with 
bicarbonate  of  soda  or  any  of  the  antiseptic  powders.  Deep 
and  extensive  burns  must  be  treated  on  surgical  and  strictly 
antiseptic  principles.  Lustgarten,  in  the  paper  referred  to, 
recommends  the  administration  of  atropine  as  a  physiological 
antagonist  to  the  ptomaine,  the  removal  of  necrotic  portions 
of  skin,  and  dressing  the  wound  with  carbonate  of  mag- 

1  Med,  Bee.,  1891,  xl.  152, 


126  DISEASES    OF    THE    SKIN. 

nesia,  1  part,  and  oleum  rusci,  2  parts.  All  cases  of  any 
magnitude  demand  absolute  rest  in  bed.  The  continuous 
water-bath  of  Hebra  is  excellent  where  it  can  be  had. 

Dermatitis  congelationis  or  "  frostbite "  is  the  action 
of  cold  upon  the  skin.  Like  heat,  cold  produces  varying 
degrees  of  damage  to  the  skin;  if  not  very  intense,  the  effect 
is  an  erythema — "erythema  pernio,"  "chilblain" — which 
is  passing.  These  are  seen  upon  the  hands,  feet,  and  face 
as  bluish  or  purplish-red,  circumscribed  patches,  which  are 
cool  to  the  touch,  but  are  accompanied  by  a  feeling  of  heat, 
smarting,  or  burning,  both  while  forming  and  when  the 
parts  again  become  warmed.  To  those  predisposed  to  chil- 
blains, dampness  accompanied  by  only  very  moderately  cool 
temperature  is  sufficient  to  produce  them.  Hutchinson 
speaks  of  the  chilblain  diathesis  to  indicate  the  condition 
found  in  these  people.  Their  circulation  is  poor,  and  they 
are  anaemic.  Greater  degrees  of  cold  or  longer  exposure 
may  produce  bullae  and  vesicles,  or  gangrene,  either  on 
account  of  prolonged  anaemia  or  inflammatory  reaction  from 
too  sudden  warming.  Fingers,  toes,  nose,  or  ears  may  be 
lost  in  consequence,  mortification  setting  in.  Death  may 
result  from  septicaemia. 

Treatment.  The  best  preventive  treatment  of  chilblains 
is  the  wearing  of  warm  woollen  coverings  to  the  affected 
parts,  and  endeavoring  to  improve  the  general  health  of  the 
patient  and  to  quicken  his  circulation.  To  the  latter  end 
we  may  use  warm  foot-baths,  containing  salt,  at  night,  fol- 
lowed by  frictions  with  alcohol.  When  they  occur  stimula- 
tion is  necessary,  for  which  we  may  use  iodine,  either  in 
tincture  or  ointment ;  or  equal  parts  of  camphor  and  bella- 
donna liniment ;  or — 

R.  01.  cajiputi,  \  ..  8| 

Liq.  ammon.  fort.,  J  °  J  ' 

Sapo.  liniment,  co.,  ^iij ;     100 1         M. 

or  simple  frictions.  Care  should  be  taken  in  severe  frost- 
bites not  to  allow  the  parts  to  become  warm  too  rapidly, 
and  nothing  is  better  than  rubbing  them  with  snow,  if  that 
can  be  obtained,  while  the  patient  js  kept  in  a  cool  room. 


Dermatitis.  127 

When  sloughing  or  ulceration  is  begun  it  must  be  treated 
on  surgical  principles. 

Dermatitis  Traumatica.  This  term  is  used  to  comprise 
all  inflammations  of  the  skin  that  are  due  to  traumatic 
influences,  such  as  blows,  rubbing,  and  the  like.  It  pre- 
sents the  usual  signs  of  inflammation  to  a  greater  or  less 
extent,  according  to  the  degree  of  traumatism  and  the  sus- 
ceptibility  of  the  individual  skin.  The  irritation  of  the 
skin,  due  to  scratching,  is  a  common  instance  of  this  form 
of  dermatitis.  Under  certain  circumstances  it  easily  de- 
velops into  an  eczema.  The  chafing  of  the  skin  met  with 
in  horseback-riding,  in  those  unaccustomed  to  the  exercise, 
is  another  common  instance. 

Treatment.  The  treatment  of  this  form  of  dermatitis 
should  be  soothing,  such  as  by  the  free  use  of  dusting  pow- 
ders, alkaline  lotions,  or  mild  ointments,  such  as  that  of  the 
oxide  of  zinc.  Unna1  recommends  for  the  prevention  of  the 
dermatitis  due  to  horseback-riding,  that  the  parts  should 
be  smeared  over  with  a  weak  resorcin  or  ichthyol  ointment. 

Dermatitis  Venenata.  Redness,  swelling,  and  heat,  fol- 
lowed or  attended  by  the  formation  of  a  vast  number  of 
small,  closely  crowded  together  vesicles  that  may  remain 
isolated  or  run  together  and  form  bullae,  are  the  symptoms 
that  constitute  this  form  of  dermatitis,  the  cause  of  which 
is  always  some  sort  of  irritant  applied  to  the  skin.  The 
irritant  is  usually  of  a  chemical  nature,  and  quite  commonly 
is  derived  from  plants.  The  most  frequent  cause  is  contact 
of  the  susceptible  skin  with  the  leaves  of  the  rhus  toxico- 
dendron, the  poison-ivy,  and  the  rhus  venenata,  the  poison- 
sumach,  and  the  rhus  diversiloba,  the  poison-oak.  Dr. 
James  C.  White,2  of  Boston,  has  written  a  most  complete 
and  learned  wTork  on  the  subject,  and  it  is  to  this  that  the 
reader  is  referred  for  a  more  detailed  account  of  the  disease 
than  can  be  here  given.  The  mildest  degree  of  irritation 
is  an  erythema.  Commonly  the  action  is  more  marked. 
The  patient  first  experiences  a  little  burning  or  itching,  and 

1  Monatshefte  f.  prakt.  Dermat.,  1888,  No.  21. 

2  Dermatitis  Venenata,  Boston,  1887. 


128 


DISEASES    OF    THE    SKIN. 


attention  being  drawn  to  the  part  it  is  found  to  be  reddened 
and  swollen.  In  some  cases  we  may  have  wheals.  In  a  few 
hours  papules,  and  then  vesicles,  will  form,  and  perhaps 
bullse.  The  swelling  may  be  intense,  so  as,  on  the  face,  to 
completely  close  the  eyes.     I  have  seen  it  so  great  on  the 

Fig.  14. 


Dermatitis  venenata  from  poison-ivy.1 

scrotum  as  to  give  the  appearance  of  an  immense  hydrocele. 
The  vesicles  may  be  present  in  a  countless  multitude.  The 
acute  developing  symptoms  may  last  several  days,  and 
then  gradually  subside.  The  vesicle  contents  either  dry 
up    or   discharge   upon   the   skin.      The  parts    crust,  the 

1  From  a  photograph  by  Dr.  H.  W.  Blanc,  of  New  Orleans. 


DERMATITIS.  129 

swelling  and  redness  slowly  disappear,  and  the  skin  once 
more  becomes  normal.  The  cause  of  the  trouble  is  supposed 
to  be  toxicodendric  acid.  The  parts  most  usually  affected 
are  the  hands  and  face  in  both  sexes,  the  penis  in  the  male 
and  the  breasts  in  the  female ;  that  is,  those  parts  that  come 
in  direct  contact  with  the  poison,  or  to  which  it  is  most  lia- 
ble to  be  conveyed  by  the  hands.  In  some  rare  cases,  and 
in  extremely  sensitive  individuals,  the  whole  body  may  be 
affected,  and  there  may  be  grave  constitutional  disturbances. 
These  bad  cases  are  met  with  in  children  whose  legs  are  un- 
covered. Most  persons,  perhaps,  are  not  susceptible  to  the 
poison.  Some  few  are  so  susceptible  that  even  having  the 
wind  blow  on  them  from  over  one  of  the  plants  will  set  up 
the  dermatitis. 

It  is  probably  not  true  that  the  dermatitis  will  relapse 
after  an  interval  of  time,  but  it  has  been  observed  that  an 
eczema  may  follow  the  dermatitis,  and  that  this  may  show  a 
certain  amount  of  periodicity  in  its  outbreaks.  White  says 
that  while  the  poison  may  be  most  active  in  the  flowering 
season,  it  is  sufficiently  active  at  all  seasons,  and  that  the 
poison  resides  not  only  in  the  leaves  but  also  in  the  wood, 
bark,  and  fruit.  The  disease  is  not  contagious  after  the 
parts  have  been  well  washed. 

Diagnosis.  The  eruption  differs  from  that  of  eczema  by 
seeking  the  inner  sides  of  the  fingers,  the  hands,  face, 
breasts,  and  genitals ;  by  the  greater  amount  of  swelling 
that  commonly  attends  it ;  by  the  vast  number  of  crowded 
together,  "  lurid  "  vesicles  ;  and  by  the  occasional  occur- 
rence of  the  eruption  in  its  early  stage  in  streaks,  sugges- 
tive of  striking  against  the  plant.  A  history  of  having 
been  in  the  country  will  sometimes  be  an  aid  in  diagnosis. 

Treatment.  The  disease  is  a  self-limited  one.  It  is, 
therefore,  natural  that  there  are  many  "  sure  cures  "  for  it, 
and  nearly  every  section  of  the  country  has  some  popular 
remedy.  Lime-water,  that  can  be  procured  anywhere,  will 
afford  relief  as  promptly  as  anything.  The  parts  are  to  be 
kept  constantly  covered  with  lint  or  absorbent  cotton  con- 
tinuously saturated  with  it.  At  night  we  cannot  use  this  if 
the  patient  sleeps,  as  the  cotton  or  the  lint  dries.     So  it  is 

6* 


130  DISEASES    OF    THE    SKIN. 

better  at  this  time  to  use  some  simple  ointment,  as  cold  cream, 
oxide  of  zinc,  or  diachylon  diluted  one-half.  This  treatment 
commends  itself  on  account  of  its  efficacy,  cheapness,  safety, 
and  accessibility.  White  recommends  black  wash  (calomel, 
5j  ;  aq.  calcis,  Oj),  applied  for  half  an  hour  at  a  time,  two 
or  three  times  a  day.  He  cautions  against  the  danger  of 
using  it  in  extensive  cases.    As  a  substitute  for  it  he  gives : 


R.  Zinci  oxid.,  3iv;       16 

Ac.  carbol.,  gj ;  4 

Aq.  calcis,  Oj ;       500 


M. 


Sugar  of  lead  in  solution  is  a  well-known  remedy,  and 
efficacious,  but  dangerous.     Morrow1  recommends  : 

Be.  Sodii  hyposulphitis,  ,^j  ;  25! 

Glycerini,  5ss;  12 

Aquae,  ad     J  viij ;  200  M. 

S.  Kept  constantly  applied. 

After  the  acute  stage  has  passed  the  case  should  be  treated 
like  an  eczema.  If  the  constitutional  disturbance  is  marked, 
the  patient  should  be  cared  for  upon  general  medical  prin- 
ciples. 

While  the  poison-oak,  or  ivy,  causes  the  symptoms  most 
often  spoken  of  as  dermatitis  venenata,  there  are  a  number 
of  other  plants  that  will  produce  like,  if  not  as  severe,  symp- 
toms. Of  the  commoner  ones  we  find  the  oleander,  Jack-in- 
pulpit,  skunk  cabbage,  bitter  orange,  May-apple,  arnica, 
burdock,  golden  rod,  and  common  daisy.  But  space  will 
not  allow  of  a  complete  list  of  these.  Goa  powder  and  its 
derivative,  chrysarobin,  produce  a  marked  dermatitis  in  addi- 
tion to  their  mahogany-staining  of  the  skin.  The  action  of 
croton  oil,  mustard,  stinging  nettle,  and  oil  of  turpentine  is 
well  known.  Tar  may  excite  a  general  dermatitis  or  an 
acne-like  inflammation  of  the  follicles  called  "tar  acne," 
the  follicles  of  the  skin  being  stopped  up  and  their  mouths 
filled  with  a  black  plug  of  tar.  A  somewhat  similar  eruption 
is  seen  in  workers  in  flax  and  paraffin. 

A  great  number  of  chemicals  produce  dermatitis  of  vary- 
ing degree.     Pyrogallic  acid  produces  burning  and  inflam- 

1  Journ.  Cutan.  and  Yen.  Dis.,  June,  1886. 


DERMATITIS    EPIDEMICA.  131 

mation,  and  covers  the  part  with  a  black  coating  on  account 
of  its  oxidation.  Not  only  does  it  destroy  diseased  tissues, 
but  it  may  cause  sloughing  of  the  sound  skin.  Chloro- 
form will  blister  if  prevented  from  evaporation.  This  pecu- 
liarity is  sometimes  employed  for  vesication.  The  strong 
acids  destroy  the  skin,  as  also  arsenic.  Sulphur,  iodine, 
iodoform,  creolin,  mercurial  preparations,  chloride  of  zinc, 
bichromate  of  potash,  and  potassa  cause  varying  degrees  of 
dermatitis.  Electricity  will  redden  and  inflame  the  skin, 
and  not  a  few  cases  of  dermatitis  have  resulted  from  wear- 
ing clothing  dyed  with  aniline  dyes. 

Dermatitis  Contusiformis.     See  Erythema  nodosum. 

Dermatitis  Epidemica.  Under  this  name  Savill1  has  re- 
ported the  occurence,  in  Paddington  Infirmary,  of  a  num- 
ber of  cases  of  an  apparently  contagious  disease  of  the  skin, 
that  began  either  as  a  discrete  papular  eruption,  or  as  ery- 
thematous blotches  like  erythema  nodosum  or  papulosum, 
or  as  small,  flat  papules  enlarging  at  the  periphery  and 
spreading  like  ringworm.  This  stage  lasted  three  to  eight 
days.  It  was  followed  by  the  second  stage,  which  was  one 
of  exudation  or  desquamation,  and  lasted  three  to  eight 
weeks.  However  the  disease  began,  the  lesions  soon  ran  to- 
gether and  formed  a  crimson  surface  of  thickened  and  indu- 
ated  skin,  continually  shedding  its  cuticle  in  scales  or  flakes 
of  various  sizes,  sometimes  mingled  with  drier  exudation. 
In  the  second  stage  it  assumed  either  a  moist  type  like 
eczema  madidans,  or  a  dry  one  like  pityriasis  rubra.  About 
two-thirds  of  the  cases  were  of  the  moist  variety,  and  almost 
all  at  some  period  showed  slight  moisture,  either  in  the 
flexures  of  the  joints  or  behind  the  ears.  Continuous  ex- 
foliation was  present  in  all  the  cases. 

The  third  stage  was  one  of  subsidence.  By  degrees  the 
inflammation  lessened,  leaving  an  indurated,  thickened  skin, 
with  polished  brown  appearance,  which  was  sometimes  raw, 
or  parchment-like,  smooth  and  shiny,  or  cracked,  or  pur- 
puric, especially  in  aged  people. 

The  disease  began  most  often  in  the  skin-folds  of  the  face 

1  Brit.  Journ.  Dermat.,  1892,  iv.  35. 


132  DISEASES    OF    THE    SKIN. 

and  upper  extremities,  and  involved  either  the  whole  body 
or  limited  areas.  It  generally  spread  by  continuity.  The 
hair  and  nails  were  all  shed. 

The  constitutional  symptoms  were  anorexia  and  prostra- 
tion. There  was  either  no  change  in  the  body  temperature 
or  a  slight  rise  in  the  evening  during  the  height  of  the  dis- 
ease. Itching  and  burning  were  marked,  and  there  was 
considerable  suffering  experienced  in  those  cases  in  which 
the  epidermis  was  shed.  Relapses  were  frequent.  Albu- 
minuria was  found  in  half  of  the  cases,  and  death  occurred 
in  about  twelve  and  four-fifths  of  the  cases. 

More  men  than  women  were  attacked,  and  advanced  age 
predisposed  to  it.  A  specific  microorganism  is  thought  to 
have  been  found  in  it. 

It  seems  to  me  that  these  cases  were  but  dermatitis  ex- 
foliativa, as  we  understand  it  in  this  country,  instances  of 
the  contagion  of  which  I  have  once  met  with.  Its  proper 
place  has  not  been  determined  as  yet. 

Dermatitis  Exfoliativa.  Synonyms :  Pityriasis  rubra 
(Devergie  and  Hebra) ;  Eczema  foliaceum  seu  exfoliativum  ; 
(Fr.)  Dermatite  exfoliatrice  ou  exfoliative  generalised,  Herpe- 
tides  exfoliatives,  Erythrodermies  exfoliantes. 

An  inflammatory  disease  of  the  skin  involving  the  whole 
cutaneous  surface,  and  characterized  by  redness,  dryness, 
and  abundant  desquamation. 

The  terms  dermatitis  exfoliativa  and  pityriasis  rubra  are 
used  interchangeably  by  most  authorities  of  the  present  time. 
If  one  reads  the  description  of  pityriasis  rubra,  as  given 
by  Hebra,  and  of  dermatitis  exfoliativa,  as  given  by  Wil- 
son, he  will  find  that  the  chief  difference  between  them  is 
in  prognosis,  the  first  being  spoken  of  as  uniformly  fatal, 
and  the  second  as  tending  to  recovery  in  many  instances. 
Further,  there  are  not  a  few  cases  of  general  exfoliating 
dermatitis  that  follow  psoriasis,  eczema,  pemphigus  folia- 
ceus,  and  lichen  ruber,  that  present  symptoms  identical 
with  those  of  dermatitis  exfoliativa,  without  antecedent 
disease.  It  seems  justifiable,  therefore,  to  divide  derma- 
titis exfoliativa  into  two  varieties,  namely,  a  primary  and  a 
secondary. 


DERMATITIS    EXFOLIATIVA.  133 

1.  Primary  Dermatitis  exfoliativa  or  Pityriasis  rubra  of 
Hebra. 

Symptoms.  This  disease  begins  as  one  or  more  erythe- 
matous patches  in  the  folds  of  the  joints,  upon  the  upper  part 
of  the  chest,  or  elsewhere,  and  these  patches  gradually  en- 
large. At  the  same  time  new  patches  develop,  and  increas- 
ing in  size  join  the  original  ones.  In  this  way  the  whole 
surface  may  become  red  within  three  days,  or  a  month  or 
more  may  elapse  before  the  whole  surface  is  implicated. 
The  palms  and  soles  may  be  unaffected  for  days  or  weeks. 
The  skin  is  dry,  and  of  a  bright  red  at  first,  without  thick- 
ening and  infiltration,  the  redness  lessening  and  leaving  a 
yellow  stain  on  pressure.  In  a  few  days,  say  from  six  to 
twelve,  scaling  begins,  and  the  skin  becomes  of  a  darker- 
red  ;  it  may  even  become  violaceous.  The  scales  may  be 
large,  thin,  grayish,  attached  at  their  upper  border,  and 
loose  elsewhere,  being  turned  up  at  their  edges.  They  may 
be  small  and  adherent  in  the  centre.  The  amount  of  scaling 
is  so  great  that  handfuls  of  scales  may  be  gathered.  After 
a  few  weeks  the  epidermis  is  raised  and  shed  from  the  hands 
and  soles  in  the  form  of  a  continuous  sheet,  sometimes  form- 
ing a  complete  cast  of  the  part.  The  disease  is  chronic,  and 
the  scaling  constant,  though  marked  with  exacerbations. 
After  lasting  some  time,  there  is  a  certain  amount  of  infil- 
tration of  the  skin,  and  it  seems  to  grow  too  small  for  the 
body,  and  looks  stretched  and  shiny  in  places.  Thus  are 
produced  ectropion  and  a  puckered  condition  of  the  mouth. 
We  may  also  find  cracking  about  the  joints  and  moisture 
in  these  regions.  Furuncles,  bullae,  or  pustules  may  com- 
plicate matters.  The  hair  may  be  shed  from  all  parts,  and 
the  nails  become  raised  from  their  beds  and  shed.  The 
mucous  membranes  participate  in  the  disturbance,  the  tongue 
becomes  markedly  red,  the  lips  cracked,  and  the  nasal  secre- 
tions are  increased.  With  the  ectropion  there  is  conjunc- 
tivitis. 

The  disease  begins,  in  some  cases,  with  a  chill,  followed 
by  a  fever,  that  may  rise  to  104°  F.  Fever  is  present  in 
allcases  during  the  early  period,  and  may  continue  through- 
out.    It  is  sometimes  continuous,  with  evening  exacerba- 


134  DISEASES    OF    THE    SKIN. 

tions ;  at  other  times  it  is  only  at  night.  Diarrhoea  often 
is  met  with,  and  there  may  be  vomiting,  albuminuria,  and 
pulmonary  congestion.  The  patient  complains  of  a  feeling 
of  chilliness,  and  of  pain,  tenderness,  stinging,  burning,  or 
tingling  of  the  skin.  There  is  usually  no  itching.  The  sensi- 
bility of  the  skin  is  preserved,  and  the  secretion  of  sweat  may 
be  normal,  or  lessened,  or  increased.  The  duration  is  very 
variable.  Recovery  may  take  place  in  six  months  or  a 
year,  or  the  course  may  be  chronic,  the  patient  dying  either 
in  a  few  months  or  after  years  by  a  gradual  marasmus,  though 
the  end  is  usually  hastened  by  pulmonary  complications. 

Cases  of  localized  dermatitis  exfoliativa  have  been  re- 
ported, but  they  are  rare.  The  tendency  is  for  the  disease 
to  become  general,  though  it  may  take  years  to  do  so.  Cases 
of  a  recurrent  type  have  been  met  with. 

Etiology.  We  know  very  little  about  the  causes  of  the 
disease.  It  is  a  disease  of  adults,  and  more  common  in  men 
than  in  women.  It  may  occur  in  children.  It  has  been 
thought  to  be  predisposed  to  by  alcoholism,  gout,  and  rheu- 
matism. There  may  be  a  history  of  scaling  skin  diseases 
in  the  family.  At  present  we  cannot  speak  with  any  cer- 
tainty as  to  its  etiology. 

2.  Secondary  Dermatitis  exfoliativa.  A  condition  of 
the  skin  exactly  resembling  the  primary  form  is  seen  from 
time  to  time  to  follow  upon  or  develop  from  a  psoriasis, 
eczema,  pemphigus  foliaceus,  and  lichen  ruber.  I  have 
seen  one  case  follow  lichen  planus.  The  too  vigorous  use 
of  chrysarobin  has  been  known  to  be  followed  by  it.  These 
cases  differ  from  the  primary  form  only  in  their  antecedent 
skin  disease.  Once  developed  they  run  the  same  course  as 
the  primary  form,  either  becoming  well  quickly,  or  falling 
into  a  chronic  state  from  which  recovery  may  or  may  not 
take  place.  The  prognosis  is,  however,  much  better  in  the 
secondary  than  in  the  primary  form. 

Pathology.  Histological  examination  shows  that  the 
disease  is  a  dermatitis,  quite  superficial  at  first,  but  when  it 
has  lasted  some  time  the  whole  depth  of  the  skin  is  involved, 
and  eventually  there  is  new  connective-tissue  formation,  which 
subsequently  undergoes  cicatricial  contraction,  with  abundant 


DERMATITIS    EXFOLIATIVA.  135 

pigmentation,  hyperplasia  of  the  elastic  fibre  bundles,  and 
obliteration  of  the  skin  appendages.     (Crocker.) 

Diagnosis.  When  the  features  of  the  disease,  as  laid 
down  in  the  definition,  are  remembered,  there  should  be  no 
difficulty  in  recognizing  it.  No  other  disease  involves  the 
whole  surface  in  a  uniform  dry  and  scaling  redness.  It  dif- 
fers from  psoriasis  in  being  universal,  in  an  entire  absence 
of  thick,  silvery- white  scales,  and  in  leaving  a  smooth,  red 
surface  when  its  papery  scales  are  removed.  Should  it  be 
secondary  to  a  psoriasis,  there  will  be  no  difficulty  in  ob- 
taining a  history  of  that  disease.  It  differs  from  eczema  in 
being  a  dry  disease,  with  little  infiltration,  in  its  large  papery 
scales,  and  in  itching  but  slightly.  Eczema  may  be  almost 
universal,  but  some  places  are  apt  to  be  spared ;  there 
is  always  moisture  of  a  sticky  sort  present  somewhere,  or  a 
history  of  the  same ;  its  scales  are  small,  and  its  itching  in- 
tense. It  differs  from  pemphigus  foliaeeus  in  an  absence 
of  flaccid  bullae.  It  differs  from  lichen  ruber  in  an  entire 
absence  of  papules,  and  in  the  whole  course  of  the  disease. 
All  these  diseases  may  be  general,  but  it  is  exceedingly  rare 
for  them  to  become  universal,  and  it  is  always  possible  to 
obtain  a  history  of  their  having  been  present  at  some  time 
in  a  case  of  secondary  dermatitis  exfoliativa.  It  is  hardly 
likely  that  scarlatina  could  be  confounded  with  dermatitis. 
A  few  days'  watching  would  in  any  event  decide  the  ques- 
tion. 

Treatment.  The  results  of  treatment  of  this  disease 
leave  much  to  be  desired.  Many  internal  and  external 
remedies  have  been  tried,  but  they  all  are  of  very  uncertain 
value.  There  is  no  doubt  but  that  the  patient  is  most 
comfortable  when  the  skin  is  well  oiled,  and  vaseline  of 
good  quality  answers  well  for  this  purpose.  The  general 
health  is  to  be  watched  over,  iron  and  quinine  administered, 
and  care  exercised  to  preserve  the  strength  by  judicious 
feeding  without  stimulation.  Diuretics  may  be  given  with 
the  idea  of  relieving  the  congestion  of  the  skin.  Carbolic 
acid  has  been  recommended,  but  in  my  hands  proved  worse 
than  useless  in  one  case.  Pilocarpine,  or  jaborandi,  is  rec- 
ommended by  Hardaway  in  acute  cases.     Arsenic  should 


136  .    DISEASES    OF    THE    SKIN. 

not  be  given  till  late  in  the  disease,  if  at  all.  Crocker  recom- 
mends enveloping  the  body  in  calamine  lotion,  and  bicar- 
bonate of  potash  is  given  every  four  hours  in  twenty-grain 
doses,  with  twelve  grains  of  citric  acid  and  three  to  five 
grains  of  quinine,  the  whole  taken  while  effervescing.  Sher- 
well  has  reported  several  cases  cured  by  the  continuous  use 
of  linseed  oil,  both  internally  and  externally.  The  patient 
is  to  chew  or  take  in  milk  several  ounces  of  flaxseed  in 
twenty-four  hours.  He  is  to  be  kept  in  bed  with  a  rubber 
sheet  under  him,  and  to  be  saturated,  as  it  were,  in  crude 
linseed  oil.  If  the  oil  is  not  used  abundantly  it  is  worse 
than  useless. 

Dermatitis  Exfoliativa  Neonatorum  is  a  disease  of  new- 
born children,  first  described  by  Ritter  von  Rittershain,1 
and  said  by  him  to  be  quite  often  seen  in  the  foundling  asy- 
lums of  Prague. 

Symptoms.  It  begins  at  the  mouth  as  an  erythema,  and 
thence  spreads  to  the  trunk  and  extremities.  Then  the 
epidermis  raises  itself  from  the  cutis,  rumples,  and  sponta- 
neously exfoliates  in  large  folds,  leaving  a  dry  skin,  or  there 
may  be  exudation  under  the  epidermis.  It  lasts  seven  to 
eight  days,  and  begins  usually  between  the  second  and  fifth 
wreek  of  life.  Relapses  may  occur.  There  is  no  fever,  nor 
digestive  disturbances.  Furuncles,  abscesses,  or  phlegmonous 
infiltration,  with  gangrenous  destruction,  may  follow.  Re- 
covery takes  place  in  about  half  the  cases.  It  is  supposed 
to  be  a  pysemic  condition  of  the  skin.  Other  cases  have 
been  reported. 

Treatment.  Alkaline  lotions  will  prove  beneficial  in  the 
early  stage.  Later,  a  protecting  ointment,  such  as  that  of 
oxide  of  zinc,  or  simple  vaseline,  followed  by  corn-starch, 
will  be  indicated. 

Dermatite  Exfoliative  Aigue  Benigne.  See  Erythema 
scarlatiniforme. 

Dermatitis  Gangrenosa  or  Sphaceloderma.  Gangrene 
of  the  skin  may  be  due  to  a  great  variety  of  causes.     Many 

1  Archiv.  f.  Kinderheilkunde,  1880,  i.  53. 


DERMATITIS    GANGRENOSA.  137 

cases  are  due  to  purely  local  causes,  such  as  burns,  bruises, 
compression,  chemical  action,  and  the  like.  It  is  seen  in 
the  course  of  diabetes,  albuminuria,  and  some  cardiac  dis- 
eases ;  with  degenerative  changes  taking  place  in  the  vascular 
walls  of  arteries,  or  plugging  of  their  lumen ;  and  in  con- 
nection with  other  skin  diseases,  as  carbuncle.  Besides  these 
we  have  a  group  of  little-understood  cases  of  gangrene,  due, 
apparently,  to  nervous  influences,  and  occurring  in  connection 
with  diseases  of  the  nervous  system.  These  may  occur  any- 
where, and  may  be  superficial  or  deep.  They  behave  like 
surgical  gangrene,and  are  to  be  treated  on  the  same  principles. 
It  is  always  to  be  borne  in  mind  that  gangrene  occurring  in 
hysterical  women  is  apt  to  be  self-imposed.  If  such  cases 
are  carefully  noted,  it  will  be  observed  that  the  spots  appear 
where  they  can  be  most  readily  reached  by  the  patient's 
right  hand,  or  left,  if  she  be  left-handed.  A  case  of  that 
sort  was  recently  seen  by  me,  which  rapidly  became  well  as 
soon  as  I  told  the  girl  that  she  knew  the  cause  of  the  trouble 
as  well  as  I  did,  and  need  have  no  more  of  it  unless  she 
wished. 

There  are  two  forms  of  cutaneous  gangrene  that  have  re- 
ceived special  names  that  must  be  noticed  here.  They  are  : 
1.  Symmetrical  gangrene  or  Raynaud's  disease;  and,  2. 
Dermatitis  gangrenosa  infantum. 

1.  Symmetrical  G-angrene.  This  was  first  described  by 
Maurice  Raynaud,1  and  since  then  has  been  observed  by 
others,  although  it  is  a  very  rare  disease.  It  most  often 
attacks  the  second  and  third  phalanges  of  the  fingers  and 
toes ;  next  most  frequently  the  nose  and  ears ;  but  any  part 
may  be  attacked.  The  parts  become  pale  and  hard,  and 
then  swell.  They  feel  numb,  but  the  patient  may  experi- 
ence darting  or  stabbing  pains  in  them.  After  a  time,  hours 
or  weeks,  they  become  black,  a  line  of  demarcation  forms, 
and  separation  of  the  affected  skin  takes  place.  The  process 
may  stop  short  of  the  complete  destruction  of  the  part,  and 
recovery  may  take  place,  though  relapses  are  liable  to  occur. 
The  disease  is  symmetrical.     It  may  involve  all  four  ex- 

1  These  de  Paris,  1862. 


138  DISEASES    OF    THE    SKIN. 

treuiities,  but  usually  only  two  are  affected.     Bullae  may 
form.     The  nails  may  fall. 

Etiology.  Men  are  more  often  affected  than  women. 
People  of  all  ages  are  liable  to  it.  Exposure  to  cold  seems 
to  be  a  causative  factor,  and  not  a  few  of  its  victims  have 
been  subject  to  chilblains  or  other  symptoms  of  poor  circu- 
lation. The  malarial  cachexia  and  the  gouty  habit  have 
been  supposed  to  be  predisposing  causes.  It  is  probably  of 
neurotic  origin. 

Treatment.  The  internal  treatment  that  has  done  best 
has  been  the  administration  of  quinine  and  belladonna. 
Locally,  galvanism  may  be  tried,  as  it  has  done  good.  Cold 
applications  are  said  to  be  better  than  hot.  If  gangrene 
has  occurred  it  must  be  treated  on  surgical  principles. 

Prognosis.  The  outlook  is  not  good.  Death  may  result 
in  those  who  are  not  robust.  Even  if  one  attack  is  recov- 
ered from,  another  is  apt  to  occur. 

2.  Dermatitis  G-angrcenosa  Infantum  (Crocker).  Syno- 
nyms :  Varicella  gangraenosa  (Hutchinson) :  Pemphigus 
gangraenosus  (Stokes) ;  Rupia  escharotica  (Fagge) ;  Ecthyma 
infantile  gangreneux  (Pineau) ;  Gangrenes  multiples  ca- 
chectiques  de  la  peau ;  Ecthyma  terebrant  de  l'enfance 
(Baudouin). 

Under  these  names  has  been  described  a  disease  of  the 
skin  that  occurs  most  often  after  varicella,  but  may  occur 
after  other  diseases  of  the  skin  in  children.  It  consists 
essentially  in  the  formation  of  deep  or  superficial  round  or 
oval  ulcerations  beneath  a  black  slough,  and  following  upon 
a  varicella  or  other  pustule.  The  lesion  when  fully  formed 
may  be  one  inch  or  more  in  diameter,  and  three-quarters  of 
an  inch  deep.  The  wider  the  slough,  the  deeper  is  the 
ulcer.  Around  the  slough  is  a  red  areola.  Crocker  says 
that  if  the  gangrene  occurs  while  the  varicella  is  still 
present,  it  begins  on  the  head  or  upper  part  of  the  body, 
and  then  looks  like  a  vaccination  pustule ;  while  if  it  begins 
late  in  the  course  of  the  disease,  the  lesions  will  be  located 
on  the  lower  half  of  the  body,  especially  the  buttocks  and 
thighs.  In  the  latter  cases  the  affected  parts  are  riddled 
with  ulcers  of  all  sizes,  shapes,  and  depths.     If  several 


DERMATITIS     HERPETIFORMIS  139 

ulcers  run  together,  very  large  and  irregular  ones  may  form. 
If  the  lesions  are  extensive  or  numerous,  they  may  cause 
death  very  frequently  by  pulmonary  complications. 

Etiology.  Infants  and  young  children  under  three  years 
of  age  are  those  affected  by  this  disease,  and  most  of  them 
are  girls.  Debilitating  diseases,  such  as  congenital  syphilis, 
tuberculosis,  and  scrofula  so  called,  predispose  to  the  dis- 
ease. In  my  service  at  the  Infants'  Hospital  on  Randall's 
Island  cases  of  this  sort  are  not  infrequent.  In  an  epidemic 
of  varicella,  occurring  in  1890,  two  cases  were  met  with, 
one  quite  extensive  upon  the  upper  part  of  the  back.  The 
children  received  in  the  institution  are  from  the  lowest  dregs 
of.  our  population,  and  the  disease  seems  to  be  a  product  of 
several  dyscrasic  conditions  plus  a  possible  microbic  in- 
fection. 

Treatment.  The  cases  are  to  be  managed  upon  general 
principles.  Tonics,  fresh  air,  good  food,  and  hygienic 
surroundings,  and  remedies  addressed  as  far  as  may  be  to 
the  underlying  constitutional  condition  are  the  best  means 
for  combating  the  disease.  Crocker  recommends  quinine 
and  sulpho-carbolate  of  soda,  five  grains  every  three  hours. 
Locally,  the  Randall's  Island  cases  were  treated  with  iodo- 
form and  antiseptic  dressings.  Aristol  would  probably 
answer  well. 

Prognosis.  The  prognosis  is  not  good  in  bad  cases. 
Death  is  apt  to  result  from  lung  complications,  or  pyaemic 
infection. 

Dermatitis  Herpetiformis.  This  name  was  first  suggested 
by  Duhring,1  of  Philadelphia,  for  a  composite  disease  which 
is  characterized  by  great  multiformity,  marked  grouping 
of  the  lesions ;  by  pruritus  of  varying  intensity  ;  by  chron- 
icity  of  course ;  and  by  a  strong  tendency  to  relapse. 
Under  it  he  includes  the  herpes  impetiginiformis  of  Hebra, 
the  hydroa  of  Bazin  and  Tilbury  Fox,  the  herpes  phlyctse- 
nodes  of  Gibert,  the  herpes  gestationis  of  Bulkley,  pem- 
phigus pruriginosus  and  circinatus,  pemphigus  a  petites  bulle, 
hydroa    bulleux,    and   the   herpes    circinatus    of    Wilson. 

1  Journ.  Anier.  Med.  Assoc,  1884,  iii.  225. 


140  DISEASES    OF    THE    SKIN. 

Though  the  name  has  been  adopted  by  many,  the  exact 
status  of  the  disease  has  not  been  settled.  I  shall  give 
Duhring's  account  of  the  disease,  space  not  allowing  of  a 
discussion  of  the  subject. 

Symptoms.  In  severe  cases  there  may  be  prodromata 
for  several  days  preceding  the  outbreak,  such  as  malaise, 
constipation,  fever,  chills,  sensations  of  heat  or  cold,  or 
these  alternating,  and  itching.  In  mild  cases  these  are 
absent.  The  onset  of  the  disease  may  be  gradual  or  sudden 
— the  latter  not  infrequently.  It  may  be  diffused  over  the 
greater  part  of  the  general  surface,  or  it  may  be  in  localized 
patches.  Itching  and  burning,  which  is  severe,  precedes  or 
accompanies  the  outbreak.  It  may  begin  as  an  erythema- 
tous, vesicular,  bullous,  pustular,  or  papular  eruption,  or 
by  a  combination  of  two  or  more  of  these,  the  multiformity 
being  a  characteristic.  It  shows  a  tendency  for  one  variety 
of  lesion  to  pass  over  into  another,  either  during  the  attack 
or  at  some  relapse.  The  relapses  occur  at  intervals  of 
weeks  or  months.  All  regions  are  invaded,  the  course  is 
essentially  chronic,  and  in  pronounced  old  cases  the  skin  is 
excoriated  and  pigmented.  The  mucous  membranes  may 
be  involved. 

Dermatitis  herpetiformis  erythematosa.  This  form  is 
usually  of  urticarial  or  erythema-multiforme  type,  and  occurs 
either  in  patches  or  diffused.  The  circumscribed  patches 
may  coalesce  and  form  larger  patches  with  marginate  out- 
line. The  color  varies  with  the  age  of  the  lesion,  becoming 
darker  with  age.  There  may  be  maculo-papules,  flat  in- 
filtrations, or  vesico-papules.  It  may  continue  in  this  way 
for  days  or  weeks,  but  usually  it  changes  to  the  multiform 
type.     There  is  pruritus. 

Dermatitis  herpetiformis  vesiculosa.  This  is  the  form 
most  usually  met  with.  The  vesicles  are  from  pin-head  to 
pea-sized,  flat  or  raised,  irregular  or  stellate  in  shape,  glis- 
tening, pale-yellow  or  pearly,  firm,  tensely  distended,  and 
without  areola.  There  may  be  papules,  papulo-vesicles, 
vesico-pustules,  and  sometimes  bullae.  The  lesions  are  dis- 
seminated, but  aggregated  into  clusters  of  two,  three,  or 
more,  or  may  form  groups  as  large  as  a  silver  dollar.     If 


DERMATITIS    HERPETIFORMIS.  141 

the  vesicles  are  near  together,  they  tend  to  run  together 
and  form  blebs,  which  are  raised  and  surrounded  by  a  pale 
or  distinct  red  areola,  and  of  a  puckered  or  drawn-up 
appearance.  The  eruption  is  usually  profuse.  All  regions 
are  affected.  Severe  itching  and  sometimes  burning  lasts 
until  the  vesicles  are  broken,  which  may  not  be  for  several 
days.  Sometimes  there  is  a  good  deal  of  constitutional  dis- 
turbance.    This  is  Fox's  hydroa  herpetiforme. 

Dermatitis  herpetiformis  bullosa.  In  this  form  we  have 
more  or  less  typical  bulla?  filled  with  cloudy  or  serous  fluid, 
from  pea-  to  cherry-sized,  irregular  or  angular  in  outline, 
and  with  or  without  an  inflammatory  base.  They  occur  in 
groups,  with  red  and  puckered  skin  between,  and  more  or 
less  vesicles  and  pustules  disseminated  over  the  skin.  All 
parts  of  the  body  are  affected.  They  come  out  in  crops  at 
intervals,  rupture  in  two  or  three  days,  and  crust  over. 
This  is  Fox's  hydroa  bulleux. 

Dermatitis  herpetiformis  pustulosa.  This  form  is  less 
clearly  defined  than  the  vesicular  form,  because  vesicles, 
vesico  pustules,  and  bullae  often  occur  at  the  same  time. 
The  pustules  are  acuminated,  round  or  flat,  tense  or  flaccid, 
and  vary  in  size  from  a  pin-point  to  a  twenty-five  cent 
piece.  The  large  pustules  generally  have  an  areola.  They 
tend  to  flatten,  spread,  and  dry  in  the  centre,  and  to  group. 
On  the  trunk  we  may  find  a  central  pustule  surrounded  by 
a  variable  number  of  small  pustules.  They  are  opaque,  and 
whitish  or  yellowish.  There  may  be  slight  hemorrhagic 
exudation  into  them.  They  are  slow  of  development,  an 
attack  lasting  from  two  to  four  weeks.  There  is  more 
marked  constitutional  disturbance  than  in  the  other  forms. 
It  is  accompanied  by  heat,  pricking,  and  itching.  It  some- 
times precedes,  follows,  or  alternates  with  the  other  forms. 

Dermatitis  herpetiformis  papulosa.  This  is  the  rarest 
variety  of  all,  and  consists  in  small  or  large,  irregularly 
shaped,  firm,  reddish  or  violaceous  papules  in  disseminated 
groups,  the  papules  being  usually  excoriated  on  account  of 
the  scratching  to  relieve  the  severe  itching.  Ill-defined 
papulo-vesicles  are  also  present. 

Dermatitis   herpetiformis  multiforme  is  simply  a  com- 


142  DISEASES    OF    THE    SKIN". 

bination  of  all  the  former  varieties,  with  the  type  changing 
from  time  to  time. 

Etiology.  The  disease  occurs  in  both  sexes,  and  is  sup- 
posed to  be  a  tropho -neurosis.  Little  is  known  as  to  its 
causes.  It  occurs  quite  independently  of  pregnancy,  and  in 
one  case  became  better  during  the  same.  Another  case  was 
aggravated  during  pregnancy  and  by  irregular  menstrua- 
tion. One  case  seemed  to  arise  from  a  nervous  shock.  By 
Bazin  the  gouty  diathesis  was  considered  to  be  a  predis- 
posing cause  of  hydroa,  and  hence  possibly  of  dermatitis 
herpetiformis.  It  is  probable  that  future  investigations  will 
throw  some  light  on  the  origin  of  this  disease. 

Diagnosis.  The  disease  must  be  differentiated  from 
erythema  multiforme,  eczema,  and  pemphigus.  It  differs 
from  erythema  multiforme  by  not  occurring  markedly  upon 
the  backs  of  the  hands,  wrists,  forearms,  and  feet ;  by  its 
more  intense  itching,  instead  of  the  burning  of  erythema ; 
by  its  chronicity  and  greater  tendency  to  relapse ;  and  by 
its  obstinacy  to  treatment.  If  the  case  is  watched  for  a 
time,  the  character  of  the  eruption  will  be  seen  to  change. 

The  vesicular  form  of  dermatitis  herpetiformis  differs 
from  vesicular  eczema  in  having  larger  vesicles  of  angular 
or  stellate  outline,  and  with  no  disposition  to  rupture ;  in 
the  grouping  of  these  vesicles  in  small  clusters ;  in  its  her- 
petic character;  more  intense  itching;  greater  constitutional 
disturbance  ;  and  greater  obstinacy  to  treatment. 

The  papular  form  differs  from  papular  eczema  in  the 
irregularity  of  the  size  and  form  of  the  papules ;  their 
strong  disposition  to  group;  their  slow  evolution;  their 
appearance  in  crops  with  free  intervals ;  the  chronicity  of 
its  course;  and  obstinacy  to  treatment. 

It  differs  from  herpes  iris  by  being  a  general  eruption, 
and  by  not  having  the  groups  of  vesicles  arranged  in  circles 
about  a  central  vesicle. 

It  differs  from  pemphigus  by  the  grouping  of  its  lesions, 
by  their  more  inflammatory,  herpetic  aspect,  and  by  the 
occurrence  of  vesicles  and  pustules  at  the  same  time  with 
the  bullae.  If  only  bullae  are  present,  the  diagnosis  is 
difficult. 


DERMATITIS    HERPETIFORMIS.  143 

Impetigo  herpetiformis  is  always  and  only  pustular,  and 
never  has  erythematous  patches,  vesicles,  or  bullae.  It  de- 
velops by  new  lesions  springing  up  in  a  circular  manner 
about  the  old  ones.  It  is  unattended  by  pruritus,  and  is  a 
grave  disease,  often  ending  fatally. 

A  well-marked  case  of  dermatitis  herpetiformis  with 
erythematous  patches,  grouped  vesicles,  pustules,  and  bullae 
of  stellate  form,  intensely  pruritic  and  with  a  myriad  of 
excoriations,  is  so  characteristic  as  to  admit  of  no  doubt  in 
diagnosis. 

Pathology.  But  little  has  yet  been  done  in  the  study 
of  the  pathology  of  dermatitis  herpetiformis,  but  we  have  a 
careful  study  of  herpetiform  hydroa  by  Elliott,1  which  is 
considered  by  Duhring  as  one  variety  of  the  disease  under 
consideration.  He  shows  that  the  vesicles  originate  in  the 
epithelium  of  the  sweat  ducts,  several  being  implicated  at 
the  same  time,  and  that  the  ordinary  signs  of  inflammation 
are  present.  He  believes  that  the  inflammation  is  second- 
ary, and  is  seated  in  the  papillary  layer  of  the  corium. 
Degenerated  nerve  fibres  are  found,  and  the  disease  is  be- 
lieved to  be  due  to  trophic  nerve  disturbance. 

Treatment.  This  disease  is  one  of  the  most  rebellious 
to  treatment.  Hygienic  measures,  fresh  air,  proper  and 
restricte  1  diet,  abstinence  from  all  alcoholics,  and  relief 
from  all  nervous  disturbances  must  be  secured  as  far  as  may 
be.  Nerve  tonics  may  be  given,  such  as  arsenic,  strych- 
nine, cod-liver  oil,  hypophosphites,  and  quinine ;  alkaline 
diuretics,  belladonna  in  full  doses,  laxatives,  all  may  be 
tried.  Duhring2  places  little  faith  in  any  of  them.  Locally, 
Duhring  has  found  the  best  treatment  to  be  sulphur  oint- 
ment containing  two  drachms  of  sulphur  to  the  ounce,  having 
it  well  rubbed  in  with  vigorous  friction  as  in  scabies.  The 
frictions  should  be  continued  for  an  hour  at  a  time.  This 
plan  is  not  suitable  for  the  erythematous  variety.  In  one 
marked  case  this  treatment  gave  most  satisfactory  results  in 
my  hands.     Other  authorities  recommend  alkaline  and  bran 

1  N.  Y.  Med.  Journ.,  1887,  xlv.  449. 

2  Trans.  Amer.  Derm,  Assoc.,  Xew  York,  1890. 


144  DISEASES    OF    THE    SKIN. 

baths,  dusting  on  starch  powder  with  zinc,  Lassar's  paste, 
resorcin  ointment,  liquor  carbonis  detergens  in  water,  5\j  to 
Sviij  ;  calamine  lotion,  liquor  picis  alkalinus,  tar  ointment, 
solutions  of  carbolic  acid,  5j  to  5j,  dabbed  on.  All  these 
will  afford  a  certain  measure  of  relief,  but  the  disease  is  apt 
to  laugh  at  our  efforts  to  drive  it  out. 

Prognosis.  The  duration  of  the  disease  is  indefinite. 
Some  mild  cases  may  recover  in  a  short  time,  never  to  re- 
lapse. The  course  of  the  disease  is  essentially  chronic ;  it 
may  last  for  many  years ;  it  shows  a  strong  tendency  to  re- 
lapse at  longer  or  shorter  intervals  ;  and,  as  a  rule,  does  not 
materially  affect  the  patient's  health. 

Dermatitis,  Malignant  Papillary.  See  Paget's  Disease 
of  the  Nipples. 

Dermatitis  Medicamentosa.  By  this  is  meant  inflamma- 
tion of  the  skin  due  to  the  ingestion  of  drugs  or  to  their 
absorption.  There  are  a  great  number  of  drugs  that  may 
cause  eruptions  upon  the  skin  in  susceptible  individuals. 
These  effects  are  seen  but  rarely  with  some  drugs,  and  quite 
constantly  with  others.  The  modus  operandi  of  drugs  in 
producing  eruptions  is  probably  not  the  same  in  all  cases. 
Some,  doubtless,  act  by  irritating  the  skin  while  circulating 
in  the  blood ;  some  while  being  excreted  by  the  glandular 
apparatus  ;  while  most  of  them  do  so  by  direct  or  reflex 
excitation  of  the  vasomotor  nerves.  Idiosyncrasy  is  marked 
in  all  of  them.  Erythema  is  the  principal  feature  of  nearly 
all  drug  eruptions,  to  which  may  be  added  vesiculation  or 
pustulation.  Two  drugs,  bromine  and  iodine,  produce  pus- 
tular eruptions  in  nearly  all  cases  where  ingested.  All 
drug  eruptions  appear  with  more  or  less  suddenness,  and 
disappear  quite  promptly  when  the  drug  is  stopped.  They 
are  symmetrical  and  general  in  distribution  as  a  rule.  They 
may  be  universal  or  localized.  The  cause  of  all  doubtful 
eruptions  of  an  erythematous  type  should  always  be  sought 
for  in  the  ingestion  of  some  drug.  As  a  rule,  little  if  any 
treatment  is  required  for  this  form  of  dermatitis  apart  from 
stopping  the  drug.  Sometimes  the  system  becomes  accus- 
tomed to  a  drug,  and  after  a  time  does  not  react  unfavorably 


DERMATITIS    MEDICAMENTOSA.  145 

to  it  if  its  administration  is  persisted  in.  With  most  drugs 
this  is  not  the  case. 

Dr.  P.  A.  Morrow1  has  written  an  excellent  work  on  the 
subject  of  drug  eruptions,  and,  with  the  author's  kind  permis- 
sion, upon  this  I  have  largely  drawn  in  the  preparation  of 
this  section.  To  it  the  reader  is  referred  for  fuller  informa- 
tion on  the  subject.  Here  no  more  than  a  skeleton  account 
can  be  given. 

Acids :  Benzoic  acid  may  produce  an  eruption  of  urti- 
caria, maculo-papules,  or  erythema.  Boric  acid  may  cause 
an  erythematous,  psoriatic,  or  erythemato-bullous  erup- 
tion. The  psoriatic  form  is  unique.  Carbolic  acid  causes 
an  erythema  that  may  be  scarlatinous  in  character,  Nitric 
acid,  in  rare  cases,  gives  rise  to  a  pustular  eruption.  Sali- 
cylic acid  produces  erythematous,  urticarial,  vesicular,  bul- 
lous, petechial,  or  purpuric  manifestations.  Tannic  acid 
caused  an  erythema  in  one  case. 

Aconite  gives  rise  to  itching,  vesicular,  pustular,  or  bul- 
lous lesions. 

Amygdala  amara  causes  erythema. 

Antimony  causes  an  urticarial  or  vesiculo-pustular  erup- 
tion. 

Antipyrin  gives  rise  to  an  erythema,  consisting  of  small, 
irregularly  circular,  slightly  elevated  patches,  which  may  be 
discrete  or  confluent,  and  is  at  times  followed  by  desquama- 
tion Profuse  sweating  and  itching  may  accompany  it,  and 
it  affects  the  chest,  abdomen,  back,  and  extremities,  specially 
their  extensor  surfaces.  It  may  be  measly  in  character  or 
purpuric.     It  has  also  given  rise  to  a  bullous  eruption. 

Arsenic  causes  erythema  of  scarlatina  type,  papules,  pete- 
chise,  urticaria,  vesicles,  pustules,  and  an  erysipelatous 
eruption.  Itching  may  attend  some  of  these  eruptions,  and 
grayish  or  brownish  discolorations  of  the  skin  have  followed 
prolonged  ingestion  of  the  drug. 

Belladonna  produces  a  scarlatinal  eruption  with  or  with- 
out vesicles  and  pruritus.  As  the  fauces  are  often  reddened 
the  resemblance  to  scarlatina  is  striking.     It  will  clear  up 

1  Drug  Eruptions.     Win.  Wood  &  Co.,  Xew  York,  1887. 

7 


146  DISEASES    OF    THE    SKIN". 

in  twenty-four  hours,  and  the  eruption  is  patchy,  not  punc- 
tate. Moreover,  there  are  none  of  the  prodroma  of  scarla- 
tina, nor  the  strawberry  tongue.  The  pupils  may  be 
dilated. 

Bromine,  in  combination  with  potassium,  ammonium,  and 
other  salts,  produces  the  well-known  "bromic  acne"  so 
commonly  seen  in  the  treatment  of  epilepsy.  It  is  an  out- 
break of  dark-red  inflammatory  papules,  papulo-pustules, 
and  cutaneous  abscesses  that  bear  a  close  resemblance  to 
acne,  and,  like  it,  often  leave  scars.  It  differs  from  acne  in 
having  a  predilection  for  hairy  parts,  a  wider  distribution, 
and  in  occurring  at  all  ages.  This  is  the  most  common 
form  of  bromine  eruption,  but  erythematous,  urticarial, 
papular,  ulcerative,  verrucose,  vesicular,  and  bullous  erup- 
tions have  been  met  with.  It  would  be  desirable  to  prevent 
these  eruptions,  but  thus  far  there  is  nothing  that  will  do  so 
with  certainty  but  stopping  the  administration  of  the  drug. 
Arsenic,  or  sulphide  of  calcium,  or  aromatic  spirits  of 
ammonia  may  be  tried. 

Calx  sulphurata  gives  rise  to  vesicles,  pustules,  and 
furuncles  ;  rarely  to  petechia. 

Cannabis  indica  caused  a  vesicular  eruption  in  one  case. 

Cantharides  and  capsicum  give  rise  to  erythematous  and 
papular  lesions. 

Chloral  produces  erythematous,  papular,  urticarial,  vesic- 
ular, and  petechial  eruptions. 

Cinchona  and  quinine  produce  all  the  primary  lesions  of 
the  skin,  though  most  frequently  an  erythema  of  scarlatina 
type,  attended  by  congestion  of  the  fauces  and  followed  by 
desquamation. 

Conium  has  an  erysipelatous  eruption  as  well  as  an 
erythematous  one. 

Copaiba  and  cubebs.  Their  most  common  eruption  is  an 
erythema  which  is  often  of  a  scarlatina  type,  but  may 
resemble  measles,  and  may  be  followed  by  desquamation. 
Outbreaks  of  urticaria,  vesicles,  bullae,  or  petechia  may 
occur.  Pruritus  may  be  present.  The  odor  of  the  drug 
may  usually  be  detected  in  the  breath. 


DEKMATITIS    MEDICAMENTOSA.  147 

Digitalis  produces  an  erythema  of  an  erysipelatous,  papu- 
lar, or  urticarial  character. 

Ergot,  quite  apart  from  the  condition  of  ergotism,  may 
cause  vesicles,  pustules,  furuncles,  and  petechiae. 

Ferrum  is  said  to  produce  an  acne. 

Hydrargyrum  gives  rise  to  a  scarlatiniform  eruption, 
followed  by  desquamation,  as  well  as  urticaria,  herpes, 
impetigo,  purpura,  furuncles,  and  ulcers. 

Hyoscyamus  produces  an  itching  erythematous  eruption, 
with  more  or  less  oedema  and  wheals.  Purpura  has  also 
followed  its  use. 

Iodine  and  its  compounds,  like  bromine,  gives  rise  to  a 
upon  the  face,  back,  and  upper  part  of  the  chest  and  arms, 
but  pustular  or  papulo-pustular,  acneiform  eruption,  usually 
often  general.  This  is  the  most  typical  form  of  eruption, 
but  an  erythema  limited  to  the  face  and  chest,  or  general, 
an  urticaria,  a  vesicular  erythema  or  an  eczema-like  erup- 
tion, a  bullous  form  resembling  pemphigus,  as  well  as  car- 
buncular,  petechial,  and  nodular  eruptions,  may  occur. 
Sometimes  there  will  be  more  than  one  type  present.  It  is 
supposed  that  iodic  eruptions  occur  more  often  in  cases  in 
which  the  kidneys  are  more  or  less  inactive.  They  some- 
times follow  the  administration  of  very  small  doses.  It  is 
thought  that  the  iodide  of  sodium  is  less  apt  to  cause  cuta- 
neous disturbances  than  are  the  other  salts  of  iodine.  At 
times  the  system  becomes  accustomed  to  the  drug,  or  the 
kidneys  acting  more  freely  relieve  the  skin.  The  trouble 
may  be  relieved  or,  to  a  large  extent,  obviated  by  administer- 
ing the  salt  largely  diluted  in  vichy  or  seltzer  water,  or  giving 
it  in  milk.  The  free  use  of  alkaline  diuretics  will  relieve 
the  skin.  Arsenic  has  also  been  commended,  but  does  no 
better  here  than  in  the  bromine  eruptions. 

Ipecac  in  one  case  caused  burning  heat  with  an  erysipe- 
latous eruption. 

Nux  vomica  and  strychnine  have  given  rise  to  a  scarlatina- 
like erythema  and  a  miliary  eruption. 

Oleum  morrhuae  may  cause  an  eczematous  eruption  or  an 
acne. 

Opium  causes  itching  and  an  erythema  resembling  scar- 


148 


DISEASES    OF    THE    SKIN. 


latina  or  measles  in  character,  which,  though  often  widely 
distributed,  is  not  infrequently  limited  to  certain  regions. 

Morphine  may  cause  urticaria,  ulcers,  a  papular,  vesicular, 
or  pustular  eruption. 

Phosphorus  causes  bullous  eruptions,  and  also  purpura. 

Pix  liquida  produces  an  erythema. 

Potassii  chloras,  in  two  instances,  has  caused  a  papular 
erythema. 

Santoninum  produces  an  urticaria  or  a  vesicular  eruption. 

Stramonium  gives  rise  to  an  itching  or  burning  scarlat- 
inoid erythema,  a  petechial  eruption,  or  an  erysipelatoid 
inflammation. 

Sulphonal  produces  a  scarlatiniform  erythema. 

Sulphur  causes  dark  discoloration  of  the  skin,  and  an 
eczematous,  pustular,  furuncular,  or  papular  exanthem. 

Tansy  has  caused  a  varioliform  eruption. 

Veratria  gives  rise  to  an  erythematous  eruption. 

Dermatitis  Papillaris  Capillitii.  Synonyms  :  Dermatitis 
papillomatosa  capillitii ;  Framboesia ;  Sycosis  framboesia 
(Hebra) ;  Sycosis  capillitii  (Rayer) ;  Mycosis  framboesiodes, 
or  Acne  keloidique,  or  Pian  ruboide  (Alibert) ;  Acne  keloid. 

Fig.  15. 


Symptoms.  This  is  one  of  the  rare  diseases  of  the  skin. 
It  begins  as  an  eruption  of  small-sized  papules  upon  the 
back  of  the  neck  at  the  margin  of  the  hair.     They  are  of 


DERMATOLYSIS.  149 

the  color  of  the  skin,  or  slightly  red  with  an  inflammatory 
halo ;  exceedingly  hard  and  firm ;  and  when  pricked  they 
give  vent  to  a  little  bloody  serous  fluid.  Increasing  slowly 
in  number  and  crowding  together  they  form  raspberry-like 
elevations  with  uneven  lobulated  surfaces.  Gradually,  the 
disease  spreads  laterally  and  also  upward  upon  the  hairy 
scalp,  even  reaching  the  vertex  after  months  and  years. 
After  a  time  the  masses  may  soften  a  little  and  contain  pus. 
At  times  they  secrete  a  foul-smelling  fluid,  and  crust.  Gradu- 
ally they  become  sclerosed  and  keloidal.  Pustules  may 
form  on  the  hairy  scalp,  and  little  tufts  of  hair  protrude  out 
of  them.  When  they  become  keloidal  they  may  be  bald  or 
tufted  with  hair.  Hairs  plucked  from  the  growths  are  some- 
times normal,  and  sometimes  atrophied.  There  may  be 
pain  or  tenderness,  or  there  may  be  no  subjective  symptoms. 

Etiology.  Both  men  and  women  are  affected,  and  the 
disease  may  begin  at  any  age.  The  etiology  is  obscure.  It 
has  been  suggested  that  they  may  be  due  to  the  rubbing  of  the 
shirt  collar. 

Diagnosis.  If  the  charateristics  of  the  disease  are  re- 
membered there  should  be  no  difficulty  in  diagnosis.  In 
sycosis  we  have  no  hard  tumors,  and  the  single  hairs  are 
surrounded  by  pustules.  Warts  are  not  so  hard,  do  not 
tend  to  increase  in  size,  and  do  not  become  keloidal. 

Treatment.  The  best  treatment  is  to  scrape  away  the 
small  ones  with  the  curette  and  excise  the  larger  ones. 
After  either  operation  the  base  must  be  cauterized.  They 
may  be  removed  with  the  galvano-cautery. 

Prognosis.  So  far  as  reported  the  growths  are  benign, 
and  have  no  effect  upon  the  health  of  the  patient.  They 
are  progressive,  and  show  no  tendency  to  spontaneous  re- 
covery. They  are  obstinate  to  treatment  and  prone  to 
relapse. 

Dermatolysis  (Du5rm-a2t-oW-si2s).  Synonyms:  Chalasto- 
dermia ;   Cutis  pendula  ;  Pachydermatocele. 

This  term  is  applied  to  two  entirely  different  diseases  of 
the  skin.  In  one  we  have  folds  of  loose  thickened  skin  and 
subcutaneous  tissue  that  sometimes  form  huge  masses  hang- 


150  DISEASES    OF    THE    SKIN". 

ing  down  from  the  side  of  the  face,  trunk,  or  any  part  of 
the  body.  The  skin  is  soft  and  does  not  appear  altered,  ex- 
cepting that  it  is  pigmented  to  a  certain  extent.  This  form 
is  really  a  species  of  fibroma.  True  dermatolysis  is  a  yet 
more  rare  affection,  in  which,  owing  to  some  defect  in  the 
attachments  of  the  skin,  it  can  be  pulled  away  from  the 
body  like  the  skin  of  a  cat.  The  "  Elastic-skin  Man  "  is  an 
instance  of  this.  There  have  been  several  of  these  freaks. 
The  one  mentioned  could  pull  the  skin  from  his  chest  up  to 
his  eyes.  The  condition  is  congenital,  but  can  be  increased 
by  cultivation. 

Treatment.  The  treatment  of  the  first  variety  is  by 
excision  before  it  becomes  too  large. 

Dermatomycosis.  A  disease  of  the  skin  due  to  a  vege- 
table parasite. 

Dermatosclerosis.     See  Scleroderma. 

Dermatosis  Kaposi.     See  Atrophoderma  pigmentosum. 

Desquamative  Scarlatiniform  Erythema.  See  Dermatitis 
exfoliativa. 

Diabetide  (De-a3-ba-ted)  is  a  French  term  for  a  local 
lesion  occurring  as  a  manifestation  of  diabetes  mellitus.  Ac- 
cording to  Brocq  they  may  be  divided  into  two  great  classes  : 
1.  Those  in  direct  relation  to  alterations  in  the  general 
economy,  such  as  pruritus,  chronic  papular  urticaria,  acne 
cachecticorum,  erythema,  lichen,  eczema,  herpes  ecthyma, 
furuncle,  carbuncle,  xanthelasma,  gangrene.  2.  Derma- 
toses due  directly  to  the  contact  of  the  secretions  of  the 
body  charged  with  sugar,  and  more  especially  the  eczema  of 
the  genitals,  caused  by  contact  with  the  urine. 

Kaposi1  has  described  a  bullo-serpiginous  gangrene  of  dia- 
betics, which  begins  by  a  disseminated  eruption  of  bullae  upon 
the  extremities.  The  bullae  dry  up  in  the  centre  into  a  black 
crust,  while  at  the  periphery  there  is  a  ring  of  fluid  pushing 
up  the  epidermis.  When  the  crust  is  removed  sphacelated 
skin  is   exposed,  which   separates  and  leaves  a  red,  granu- 

1  Wien.  med.  Presse,  1883. 


ECTHYMA.  151 

lating  surface.     The  penis  is  a  favorite  site  for  this  form  of 
gangrene.    It  must  be  treated  on  general  surgical  principles. 

Distichiasis  (Di2s-ti2k-i2-a'si2s.)  This  is  a  congenital  or 
acquired  condition  of  the  cilia,  in  which  they  grow  in  two 
distinct  rows,  the  inner  row  being  directed  inward  so  as  to 
scrape  the  cornea.  According  to  Michel,  generally  the 
outer  third  of  the  upper  lid  is  affected  alone,  the  deformity 
is  symmetrical  and  bilateral,  and  of  embryonic  origin.  Elec- 
trolysis offers  the  best  method  of  relief.  These  cases  belong 
to  the  ophthalmic  surgeon. 

Dracontiasis.     See  Guinea-worm  disease. 

Durillon.     See  Callositas. 

Dysidrosis.     See  Pompholyx. 

Ecchymomata  and  Ecchymoses.      See  Purpura. 

Ecdermoptosis  (Huguier).     See  Molluscum  epitheliale. 

Ecthyma  (E^-thi'ma3).  Synonyms  :  Furunculi  atonici*; 
Phlyzacia  agria  :  (Ger.)  Eiterpusteln  ;  (Fr.)  Furoncles  aton- 
iques  ;  (Ital.)  Rogna  grossa. 

A  cutaneous  eruption  of  deep-seated  pustules,  with  hard, 
elevated,  reddened  bases,  attended  by  the  formation  of  thick, 
greenish,  or  dark-colored  crusts,  and  followed  either  by  cica- 
trices or  dark  pigmented  spots. 

Symptoms.  Though  the  existence  of  this  disease  as  a 
separate  entity  is  denied  by  many  authorities,  and  relegated 
to  the  domain  of  eczema,  it  presents  certain  well-defined 
symptoms  that  entitle  it  to  be  regarded  as  a  distinct  disease. 
It  consists  in  the  outbreak  of  one  or  more  round,  flat  pus- 
tules, whose  covers  are  not  fully  distended,  and  which  have 
an  inflammatory  areola.  In  size  they  vary  from  a  split-pea 
to  a  finger-nail,  or  larger.  At  first  they  are  white  or  yellow. 
Subsequently  they  may  or  may  not  become  reddish  from 
the  admixture  of  blood.  They  may  dry  up,  forming  a 
crust  which,  on  falling,  leaves  a  healthy  surface.  Or  they 
may  rupture  spontaneously  or  be  broken,  and  form  a  thick, 
greenish  or  blackish  crust,  under  which  is  a  raw  or  super- 
ficially ulcerated  surface,  which  on  healing  leaves  a  pig- 
mented   or  slightly   cicatricial  spot.     In  subjects  in    bad 


152  DISEASES    OF    THE    SKIN. 

hygienic  surroundings  quite  deep  ulcers  may  result.  These 
pustules  are  usually  discrete,  but  they  may  group.  They 
are  both  painful  and  tender.  Any  part  of  the  body  may 
"be  affected,  but  they  are  most  often  seen  on  the  ex- 
tremities, especially  the  legs  where  the  hair  is  coarse,  the 
shoulders,  and  the  back.  The  course  of  the  disease  may 
be  acute,  each  pustule  lasting  five  or  ten  days,  and  the 
whole  disease  lasting  about  two  weeks,  but  generally  it  is 
chronic  and  kept  up  by  the  outbreak  of  fresh  crops.  There 
is  more  or  less  itching.  It  is  not  contagious,  but  it  is  auto- 
inoculable.  Febrile  symptoms  may  accompany  or  precede 
the  outbreak  of  the  disease,  but  as  a  rule  they  are  absent. 

Etiology.  Dirt,  want,  bad  hygienic  surroundings,  the 
strumous  diathesis,  or  a  broken-down  cachectic  condition 
brought  on  by  intemperance  or  dissipation,  all  predispose 
to  the  disease.  It  is  quite  often  seen  in  the  genus  "  tramp/' 
Crocker  believes  that  it  is  but  a  form  of  impetigo  contagiosa. 
It  follows,  not  infrequently,  upon  scratching  on  account  of 
pediculi  and  scabies.  It  is  most  often  seen  in  adults,  and 
is  rare  in  children.  Like  in  all  other  purulent  diseases,  pus 
cocci  are  found  in  the  pus,  and  are  regarded  by  many  as  the 
cause  of  the  disease. 

Diagnosis.  Ecthyma  differs  from  eczema  in  having  much 
larger  pustules,  which  are  discrete  and  not  confluent,  in  the 
marked  areola  about  the  pustules,  and  in  the  absence  of  all 
other  signs  of  eczema.  It  differs  from  impetigo  contagiosa  in 
its  pustules  being  deeper  ;  in  their  location  upon  the  extremi- 
ties rather  than  upon  the  face  and  hands ;  in  not  having 
that  flabby,  bullous  look  of  a  burn  of  the  second  degree,  so 
common  to  impetigo ;  in  having  thick  greenish  or  blackish 
crusts,  and  not  straw-colored  stuck-on  crusts ;  in  occurring 
in  more  or  less  debilitated  adults  and  not  in  otherwise 
healthy  children,  and  in  being  non-contagious.  From  im- 
petigo it  differs  principally  in  its  being  a  deeper  and  more 
inflammatory  process,  and  in  occurring  in  debilitated  subjects. 
It  resembles  the  large,  flat,  pustular  syphiloderm,  but  its 
crusts  are  not  heaped  up  into  oyster-shell-like  masses,  as  in 
syphilis,  and  when  they  are  removed  they  leave  a  more  super- 
ficial, and  not  so  punched-out  an  ulcer.    There  is  more  pain 


ECZEMA.  153 

and  itching  in  ecthyma,  and  an  entire  absence  of  other 
symptoms  or  history  of  syphilis. 

Treatment.  The  first  thing  to  be  done  in  these  cases 
is  to  obtain  cleanliness,  proper  hygienic  surroundings,  and 
complete  abstinence  from  alcoholics.  If  there  is  general 
debility  tonics  must  be  given  and  the  dietary  improved. 
Locally,  all  crusts  must  be  removed  with  soap  and  water, 
the  lesions  dressed  with  an  ointment  containing  some  anti 
septic  such  as — 

R .  Hydrarg.  ammon.,  J)j ;  5|5 

Ungt.  zinci  oxidi,  Jj ;  301         M. 

and  the  part  enveloped  in  a  rubber  bandage,  where  such  is 
applicable.  An  ointment  or  oil  containing  five  or  ten 
grains  of  salicylic  acid  to  the  ounce  will  also  answer  well. 
If  ulcerations  have  formed  they  should  be  treated  as  will  be 
indicated  under  Ulcer. 

Eczema  (E^'-zeWa3).  Synonyms :  (Fr.)  Dartre  vive, 
ouhumide,  eczema;  (Ger.)  Ekzem,  Hitzblatterchen,  Flechte, 
nassende  Flechte,  Salzfluss ;  Salt  rheum,  Tetter,  Humid 
tetter,  Scall,  Scald,  Heat  eruption. 

A  non-contagious,  inflammatory  disease  of  the  skin, 
sometimes  acute,  more  often  chronic,  attended  with  itching, 
desquamation  or  loss  of  the  cuticle,  and  usually  with  the 
exudation  of  serous  or  sero-purulent  fluid  either  beneath 
the  cuticle  or  upon  the  denuded  surfaces.  It  may  present 
erythema,  papules,  vesicles,  or  pustules,  and  its  lesions 
show  a  decided  disposition  to  run  together  and  form  in- 
filtrated patches. 

Symptoms.  This  is  a  most  protean  disease.  It  has  been 
well  said  that  if  a  student  learns  to  recognize  and  treat 
syphilis  and  eczema,  he  has  possession  of  the  key  to  the 
whole  of  dermatology.  There  are  six  prominent  symptoms 
of  the  disease : 

1.  Redness. 

2.  Itching. 

3.  Infiltration. 

4.  Tendency  to  moisture. 

5.  Crusting  or  scaling. 

7* 


154  DISEASES    OF    THE    SKIN. 

6.   Cracking  of  the  skin. 

In  every  case  there  will  be  four  or  five  of  these  symptoms; 
or  perhaps  all  of  them. 

Eczema  begins  suddenly,  and  most  often  without  any 
constitutional  disturbance.  Should  slight  fever  and  malaise 
be  present  they  are  accidental,  or  an  expression  of  that 
condition  of  the  system  that  predisposes  to  the  disease,  and 
not  part  of  the  disease  itself.  Very  often  the  first  thing 
that  attracts  the  patient's  attention  is  itching,  and  when  he 
examines  the  skin  he  finds  it  reddened  and  either  scaly,  or 
covered  with  papules,  vesicles,  or  pustules,  or  moist. 

The  tendency  of  eczema  in  all  forms  is  to  form  patches, 
and  these  are  infiltrated  to  greater  or  less  extent ;  ill  de- 
fined ;  shade  off  imperceptibly  into  the  surrounding  skin  so 
that  it  is  hard  to  say.  where  they  end,  and  with  outlying 
lesions  about  the  patches  ;  irregular  in  shape ;  of  all  sizes, 
sometimes  involving  nearly  the  whole  cutaneous  surface; 
sometimes  swollen ;  and  of  dark-red  color,  sometimes  with  a 
shade  of  yellow.  Beginning  by  a  few  lesions  the  disease 
increases  more  or  less  rapidly  in  extent.  It  may  clear  away 
after  a  short  time,  or  it  may  last  weeks  or  months,  or  be- 
come chronic,  showing  little  tendency  to  recovery.  There 
is  no  constant  rule  as  to  the  course  of  the  disease,  though 
many  cases  occur  and  recur  at  certain  seasons  of  the  year ; 
it  may  be  in  the  summer,  spring,  autumn,  or  winter.  Any 
or  all  parts  of  the  skin  may  be  affected,  but  it  has  a  pre- 
dilection for  the  flexures  of  the  joints,  the  face,  the  scalp, 
and  the  sulcus  behind  the  ear.  There  may  be  but  a  single 
patch  or  many  of  them.  It  commonly  affects  both  sides  of 
the  body,  but  with  no  marked  symmetry. 

The  subjective  symptoms  are  itching,  burning,  and  a 
feeling  of  heat  and  tension.  Of  these,  the  most  constant  is 
itching,  which  is  present  in  all  cases  and  is  often  so  great  as 
to  cause  the  patient  to  excoriate  the  skin  by  scratching. 
It  is  subject  to  exacerbations  and  remissions.  The  latter 
may  be  complete  or  incomplete.  Burning  and  tension  are  ex- 
perienced for  the  most  part  only  at  the  beginning  of  the  attack 
or  during  some  exacerbation  of  a  subacute  or  chronic  case. 

The  old  definition  of  the  disease  was  that  it  is  a  vesicular 


ECZEMA.  155 

one.  It  is  well  to  disabuse  the  mind  of  this  impression  at 
the  start,  as  there  is  a  form  of  the  disease  that  is  dry 
throughout :  the  erythematous  form.  There  are  five  vari- 
eties of  eczema,  known  as  the  erythematous,  papular,  vesic- 
ular, pustular,  and  squamous.  Eczema  madidans  is  but  a 
convenient  term  to  describe  a  very  moist  eczema.  Eczema 
rimosum  or  rhagadiforme  is  but  an  eczema  in  which  the 
skin  cracks  about  the  joints.  Unna  has  recently  introduced 
the  term  eczema  seborrhoicum,  which,  though  it  has  not  yet 
taken  a  secure  place  in  the  family,  has  won  so  much  notice 
that  it  merits  a  special  description. 

Before  discussing  each  of  these  varieties  by  itself,  it  is 
necessary  to  understand  that  no  one  of  them,  excepting 
perhaps  eczema  erythematosum,  is  clear-cut  and  unchang- 
ing. On  the  contrary,  the  disease  may  begin  as  a  papular 
erythema;  upon  the  papules  vesicles  may  form  which  will 
run  together  and  soon  break  down  of  themselves  and  form 
a  weeping  patch ;  the  subsequent  lesions  may  then  be  pus- 
tules, and  the  final  stage  through  which  all  varieties  pass 
before  recovery  is  the  squamous.  Now  we  are  ready  to 
study  each  variety  by  itself. 

Eczema  erythematosum  is  most  often  encountered  upon 
the  face  of  an  adult,  though  it  may  occur  elsewhere  and  in 
children.  Beginning  as  one  or  more  ill-defined  red  patches, 
it  soon  forms  a  continuous  patch  by  the  coalescence  of  the 
smaller  ones.  Sometimes  the  whole  face  is  involved,  sometimes 
there  are  several  patches.  The  inflammation  is  often  attended 
by  oedema  to  such  an  extent  that  the  eyes  are  nearly  closed 
if  the  disease  is  in  their  neighborhood.  The  patient  experi- 
ences great  discomfort  on  account  of  the  burning  and  stiffness 
of  the  skin.  The  skin  feels  harsh,  dry,  and  thickened;  it  is 
swollen ;  its  color  is  bright  or  dull-red ;  and  there  is  a  slight 
amount  of  small  adherent  scales.  If  it  occurs  on  contiguous 
folds  of  skin  there  may  be  moisture.  Upon  the  face  vesicles 
may  develop,  but  this  is  exceptional.  After  lasting  for  a 
time  the  symptoms  may  subside,  and  recovery  takes  place, 
the  patches  fading  away  altogether  and  not  in  the  centre. 
It  may  assume  a  chronic  form  and  last  for  years. 

Eczema  papulosum.     This  is  the  lichen  simplex  of  the 


156  DISEASES    OF    THE    SKIN. 

old  writers.  It  consists  in  an  eruption  of  pin-point  to 
pin-head,  bright  or  dull-red,  acuminate,  discrete,  grouped,  or 
perhaps  confluent  papules.  Very  frequently  the  papules 
are  capped  by  vesicles.  The  papules  may  remain  discrete 
throughout  their  course  with  an  occasional  small  confluent 
patch  to  betray  the  nature  of  the  disease.  This  is  one  of 
the  most  itchy  varieties  of  this  pruriginous  disease,  and  the 
scratching  consequent  upon  it  produces  excoriations,  and 
breaking  down  the  vesicles  and  papules  gives  exit  to  the 
serum  and  converts  the  patch  into  a  moist  one.  This 
variety  is  located  preferably  on  the  extensor  aspects  of  the 
limbs.  The  life  of  the  individual  papule  is  comparatively 
long — days  or  weeks.     It  is  often  obstinate  to  treatment. 

Eczema  vesiculosum  is  the  most  common  and  most  char- 
acteristic variety,  and  consists  in  an  eruption  of  pin-point 
to  pin-head,  rounded  or  acuminate  vesicles  that  appear  upon 
a  reddened  surface  in  immense  numbers.  Prickling  and 
tingling  precede  the  outbreak ;  intense  itching,  and  more  or 
less  swelling  attend  it.  The  vesicles  group,  and  perhaps 
coalesce,  and  soon  rupture  of  themselves,  and  discharge  a 
clear,  sticky,  mucilaginous  fluid  that  possesses  the  quality 
of  stiffening  and  staining  linen,  and  dries  into  a  light-yel- 
lowish crust.  The  vesicles  rupture  so  early  that  it  is  rare 
for  the  physician  to  see  a  case  with  the  vesicles  intact. 
New  vesicles  form  about  the  patch,  and  break  down  ;  the 
discharge  continues  from  the  sites  of  the  vesicles,  and  the 
crust  continuously  forms  A  raw  surface  is  exposed  when 
the  crusts  are  removed.  Sometimes,  on  account  of  the  crust 
being  prevented  from  forming  on  account  of  friction,  there 
is  a  weeping  surface  which  has  been  called  eczema  madidans 
or  rubrum.  Eventually  the  discharge  ceases,  the  hypergemia 
lessens,  scaling  takes  place,  and  after  a  time  the  skin  re- 
turns to  its  normal  condition.  This  variety  of  eczema  seeks 
the  soft  parts  of  the  skin,  the  flexures  of  the  joints,  the 
flexor  surfaces  of  the  limbs,  and  behind  the  ears.  It  may 
involve  the  whole  or  nearly  the  whole  cutaneous  surface. 
After  it  has  lasted  a  little  while  in  a  part,  the  skin  is  evi- 
dently thickened.  With  it  papules  and  pustules  very  gen- 
erally are  found. 


ECZEMA.  157 

Eczema  pustulosum.  Under  this  head  many  authors, 
notably  the  Vienna  school,  place  all  cases  of  impetigo. 
Like  the  pustular  syphilide,  this  variety  of  eczema  occurs 
in  more  or  less  broken-down,  cachectic,  delicate,  or  strumous 
subjects.  It  is  the  most  common  form  of  eczema  met  with 
in  children,  and  in  them  occurs  by  preference  on  the  face 
and  head.  The  eruption  consists  of  small  pustules  that 
may  start  as  pustules  or  develop  from  vesicles.  They  are 
present  in  large  numbers,  and  tend  to  break  down  and  form 
patches  covered  with  greenish  crusts.  If  blood  is  drawn 
by  scratching,  the  crust  will  be  blackish.  They  are  some- 
what larger  than  the  characteristic  vesicles,  and  have  a 
fondness  for  hairy  parts,  though  any  part  of  the  body  may 
be  affected.  This  and  the  previous  variety  often  merge  into 
each  other.  It  is  not  so  itchy  as  the  other  forms.  It  may 
change  into  an  eczema  madidans,  and  it  passes  through  the 
squamous  stage  on  the  way  to  recovery. 

Eczema  squamosum  is  the  final  stage  through  which 
most  cases  pass  on  their  way  to  recovery.  In  it  the  skin  is 
dry,  red,  and  covered  with  thin,  papery,  flat,  large  or  small 
scales.  It  is  a  condition  of  the  skin  in  which  the  formation 
of  its  corneous  layer  falls  short  of  perfection.  The  disease 
may  continue  in  this  condition  for  an  indefinite  time,  a 
chronic  eczema,  with  occasional  exacerbations.  Then  it 
may  pass  away  entirely  and  the  skin  become  quite  well ; 
or  some  local  injury  may  cause  an  acute  outbreak  of  eczema. 
The  skin  in  this  variety  is  more  or  less  thickened,  and  deep 
cracks  are  liable  to  form  about  the  joints,  because  the  infil- 
tration of  the  skin  interferes  with  its  elasticity,  and  it  breaks 
instead  of  stretching.  While  the  patches  are  usually  ill 
defined,  in  some  cases  they  will  be  round  and  with  well- 
marked  borders. 

Eczema  may  be  acute  or  chronic — terms  that  apply  not 
to  the  length  of  time  that  the  disease  has  lasted,  but  to  the 
symptoms  it  presents.  It  predisposes  to  ulceration  upon 
the  legs  when  combined  with  varicose  veins,  and  then  is 
named  eczema  varicosum.  This  must  not  be  confounded 
with  a  somewhat  similarly  sounding  name,  eczema  verru- 
cosum,  which  is  a  rare  variety,  in  which  the  skin  takes  on 


158  DISEASES    OF    THE    SKIN. 

a  warty  appearance  on  account  of  a  hypertrophy  of  the 
papillae. 

Etiology.  Like  its  symptoms,  its  causes  are  numerous. 
It  may  arise  from  purely  local  causes,  but  even  then  it  is 
probable  that  we  should  assume,  in  most  cases,  a  predispo- 
sition on  the  part  of  the  skin.  Thus,  we  have  eczemas  of 
the  hands  in  washerwomen.  Perhaps  for  a  score  of  years 
they  had  washed  in  the  same  water  and  with  the  same  soap 
without  eczema.  Then  under  the  same  local  conditions,  but 
with  some  unknown  internal  constitutional  state,  an  eczema 
breaks  out.  Of  external  irritants  we  have  the  sun,  water, 
intense  artificial  heat,  acids,  alkalies,  traumatism,  rubbing 
of  opposed  surfaces  or  chafing  by  the  clothing,  parasites; 
in  fact,  just  the  same  things  as  will  cause  a  dermatitis,  only 
now  the  action  goes  further,  and  a  catarrhal  condition  of 
the  skin  results.  Cold  has  an  undoubted  influence  on  the 
skin,  and  eczema  is  more  common  in  winter  than  in  summer, 
and  is  generally  aggravated  by  extremely  low  temperature, 
even  when  the  patient  keeps  in  the  house.  It  has  been 
observed  that  children  with  eczema  grow  worse  when  it  is 
cold  and  a  high  wind  is  blowing,  even  though  they  are  not 
exposed  directly  to  these  conditions.  Vaccination  may  act 
as  a  local  cause. 

Of  the  internal  or  predisposing  causes,  perhaps  the  most 
common  and  active  is  some  digestive  or  intestinal  disturb- 
ance— it  may  be  dyspepsia  or  mal-assimilation,  or  derange- 
ment of  the  liver,  or  constipation.  At  other  times  the 
kidneys  are  at  fault.  Diabetes  and  Bright's  disease  both 
predispose  to  eczema.  Chlorosis  and  anaemia,  uterine  dis- 
orders and  the  menopause,  and  the  strumous  diathesis,  are 
at  times  active  factors.  Derangements  of  the  nervous  system 
are  exciting  causes ;  now  and  again  we  will  meet  with  cases 
which  appear  suddenly  after  some  nervous  shock.  Rheuma- 
tism and  gout  and  varicose  veins  are  other  predisposing 
causes.  To  most  of  these  internal  causes  some  external  cause 
must  be  added  before  the  eczema  appears. 

The  French  school  of  dermatology  has  long  held  to  its 
theory  of  diathesis,  and  has  taught  that  the  dartrous  dia- 
thesis is  the  cause  of  eczema.     Outside  of  France  little  is 


ECZEMA.  159 

known  about  diathesis.  A  vulnerability  of  the  skin  is 
necessary  for  the  production  of  an  eczema,  and  many 
patients  may  fairly  be  regarded  as  eczematous,  just  as  others 
may  be  spoken  of  as  gouty  or  rheumatic  or  psoriatic.  This 
peculiarity  or  tendency  of  the  skin  may  be  inherited,  and 
in  so  far  eczema  may  be  regarded  as  hereditary. 

The  disease  attacks  all  ages,  conditions,  races,  and  both 
sexes,  and  is  the  dermatosis  we  are  most  often  called  upon 
to  treat.  It  is  especially  common  in  children.  In  Bulk- 
ley's  tables,  out  of  3000  cases,  676  occurred  under  five 
years  of  age,  and  of  these  520  were  in  children  under  three 
years.  Of  the  remaining  cases  1234  were  between  the  ages 
of  twenty  and  fifty,  and  were  divided  about  equally  in  each 
decade.     About  one-third  of  all  skin  diseases  are  eczema. 

These  many  etiological  factors  indicate  that  it  is  probable 
that  our  present  eczema  is  a  too  composite  disease,  and  it  is 
for  this  reason  that  attempts  are  constantly  made  to  take 
away  certain  members  of  the  family  and  form  them  into 
separate  diseases.  Unna  and  others  have  asserted  of  late 
that  a  parasite,  yet  undiscovered,  is  the  cause  of  one  variety 
of  eczema,  his  Eczema  seborrhoicum.  Unna  further  teaches 
that  there  are  two  other  varieties  of  the  disease,  one  due  to 
reflex  nervous  irritation,  such  as  is  seen  during  dentition  of 
infants,  and  one  dependent  upon  the  tubercular  diathesis. 

Pathology.  Eczema  is  a  catarrhal  inflammation  of  the 
skin,  analogous  to  that  of  the  mucous  membrane,  which  has 
its  seat  principally  in  the  papillary  layer  of  the  skin  and  in 
the  rete.  This  superficial  location  of  the  disease  is  the 
reason  why  the  skin  is  left  unmarked  after  the  disease  has 
been  recovered  from.  Atropho-neurosis  is  supposed  by  many 
to  be  the  cause  of  the  disease  when  not  due  to  local  irri- 
tants, and  Crocker  quotes  Marcacci  as  having  found 
changes  in  the  sympathetic  in  a  fatal  case  of  universal 
eczema. 

Diagnosis.  If  the  six  prominent  symptoms  of  eczema 
are  remembered,  namely,  redness,  itching,  infiltration  or 
thickening,  exudation  or  tendency  to  moisture,  crusting  or 
scaling,  and  cracking,  they  will  be  of  great  aid  in  diagnosis. 
To  them  should  be  added  the  tendency  the  disease  evinces 


160  DISEASES    OF    THE    SKIN. 

to  locate  in  the  folds  of  the  joints,  between  apposed  surfaces 
of  skin  and  behind  the  ears,  and  the  peculiar  mucilaginous 
quality  of  the  exudate,  which  stiffens  and  stains  linen  and 
glues  the  hair  together.  Fortunately,  a  diagnosis  of  eczema 
will  fit  one  out  of  every  three  cases.  Here  will  be  given 
the  general  diagnosis,  reserving  for  the  sections  on  regional 
eczema  the  diagnosis  of  special  forms  where  necessary. 

Dermatitis  is  often  distinguished  with  difficulty  from 
eczema,  and  frequently  runs  over  into  it.  As  a  rule,  it  runs 
a  more  rapid  course,  its  vesicles  are  longer  preserved,  bullae 
are  apt  to  form,  there  is  burning  rather  than  itching,  and  it 
heals  readily  on  removal  of  the  cause. 

Dermatitis  exfoliativa  is,  when  fully  developed,  a  uni- 
versal eruption,  while  eczema  is  very  rarely  so.  It  is  also 
dry,  and  has  abundant  large  scales,  while  eczema  will  ex- 
hibit moisture  somewhere,  and  does  not  scale  so  abundantly. 
For  further  points  in  diagnosis,  see  under  Dermatitis  ex- 
foliativa. 

Erysipelas  is  attended  by  fever  and  marked  constitutional 
disturbances,  has  a  sharply  defined  border,  advances  steadily 
at  its  margin,  and  forms  a  swollen,  deep-red  patch  upon 
which  large  vesicles  and  bullae  form.  The  margin  of  eczema 
is  ill-defined,  fading  off  into  the  surrounding  skin ;  its  vesi- 
cles are  pin-point  to  pin-head  size,  and  there  is  little  or  no 
constitutional  disturbance.  Eczema  has  a  dry,  rough  sur- 
face in  the  erythematous  form,  while  erysipelas  has  at  first 
a  smooth  and  shining  one. 

Erythema  burns  rather  than  itches ;  its  redness  can  be 
entirely  squeezed  out  by  pressure,  leaving  a  whitish  spot, 
and  returns  promptly  when  the  pressure  is  removed.  It  lacks 
the  itching,  exudation,  scaling  or  crusting,  and  cracking  of 
eczema,  and  is  prone  to  appear  upon  the  backs  of  the  hands 
and  wrists,  and  is  symmetrical. 

Herpes  febr His  resembles  eczema  only  in  having  vesicles 
upon  a  red  surface.  It  occurs  usually  in  a  single  patch 
upon  the  face ;  its  vesicles  are  discrete,  and  show  no  ten- 
dency to  run  together ;  its  course  is  short,  and  it  pains  or 
burns,  but  does  not  itch. 

Zoster  occurs  in  the  form  of  a  number  of  herpetic  patches 


ECZEMA.  161 

following  the  course  of  a  nerve,  and  occupying  only  one  side 
of  the  body — symptoms  that  are  entirely  foreign  to  eczema. 

Impetigo  contagiosa  occurs  for  the  most  part  upon  the 
face,  hands,  and  exposed  parts.  Its  pustules  are  large,  flat, 
and  discrete,  not  small  and  conglomerate.  Its  crusts  are 
thin  and  stuck  on,  not  greenish  and  thick,  as  in  eczema.  It 
is  a  vesico-pustular  disease,  and  often  presents  large  vesicles 
or  bullae  that  look  like  burns  of  the  second  degree. 

Lichen  ruber  and  Pemphigus  foliaceus  do  bear  some 
resemblance  to  eczema  erythematosum  when  generalized. 
But  the  history  of  these  two  is  quite  different  from  that  of 
eczema. 

Phthiriasis  or  pediculosis  shows  parallel  scratch-marks 
over  the  shoulders  and  excoriations  about  the  waist  and  on 
the  limbs  where  the  seams  of  the  clothing  come.  If  on  the 
head,  the  lesions  will  be  on  the  occiput,  and  nits  will  be 
found  on  the  hair  of  that  region,  or  of  the  temples.  The 
eruption  to  which  they  give  rise  is  an  eczema,  but  the  cause 
of  it  is  evident. 

Pruritus  cutaneous  has  no  lesions,  properly  speaking, 
and  the  excoriations  met  with  are  not  in  patches,  but  scat- 
tered all  over  the  body  at  intervals  and  irregularly.  The 
itching  is  more  paroxysmal  than  it  is  in  eczema,  and  the 
itching  is  the  only  symptom  that  it  has  in  common  with 
eczema. 

Psoriasis,  when  occurring  in  typical  round  or  oval 
sharply  defined  patches,  with  silvery  scales,  offers  no  diffi- 
culty in  diagnosis  from  a  typical  eczema.  From  circum- 
scribed eczema,  that  occurs  occasionally,  it  may  be  diag- 
nosticated by  the  color — of  a  brighter  red ;  by  the  scaling, 
that  is  whiter,  thicker,  and  more  laminated,  and  by  finding 
characteristic  patches  either  of  the  one  or  the  other  disease 
elsewhere  on  the  body.  When  psoriasis  occurs  in  large  areas 
it  is  diagnosticated  from  squamous  eczema  by  its  sharply 
defined  border ;  its  marginate  form ;  its  brighter  red ;  its 
more  abundant,  thicker  and  whiter  scales ;  its  fondness  for 
the  extensor  surfaces  of  the  limbs,  while  eczema  seeks  the 
flexor  aspects  and  the  flexures  of  the  joints ;  its  uniform 
character  and  constant  dryness,  against  the  polymorphous 


162  DISEASES    OF    THE    SKIN. 

character  of  eczema  and  its  moisture ;  and  its  history  of  fre- 
quent relapses,  always  of  the  same  sort  and  always  on  the 
elbows  and  knees. 

Rosacea  occupies  the  middle  third  of  the  face  from  above 
downward,  attacking  the  forehead,  nose,  and  chin,  while 
eczema  affects  the  whole  or  part  of  the  face,  but  never  occurs 
on  these  limited  regions  alone  ;  it  burns  rather  than  itches; 
it  shows  telangiectases,  and  its  redness  and  occasional  dis- 
crete, sluggish,  superficial  pustules  are  very  different  from 
either  the  dry,  harsh,  scaly  redness  of  an  erythematous 
eczema,  or  the  crusted  surface  of  a  pustular  eczema. 

Scabies  may  be  diagnosed  from  eczema  by  its  location 
upon  the  anterior  surface  of  the  wrists,  between  the  fingers, 
and  upon  the  abdomen  and  buttocks  of  both  sexes,  and 
upon  the  nipples  and  breasts  of  women,  and  the  penis  of 
men.  In  children  the  feet  are  often  affected.  The  pres- 
ence of  cuniculi  is  diagnostic,  but  they  are  hard  to  find  in 
some  cases.  Of  course,  the  eruption  in  scabies  is  an  eczema, 
but  it  is  important  to  recognize,  where  possible,  the  cause  of 
an  eczema  in  order  to  cure  it. 

Syphilis,  like  eczema,  is  a  protean  disease,  but  it  does  not 
itch,  and  that  is  an  important  point  in  differential  diagnosis. 
It  is  true  that  occasionally  a  papular  syphilide  does  itch,  but 
the  occurrence  is  so  rare  that  it  need  not  here  be  taken  into 
account.  The  early  syphilides  are  general  eruptions,  whether 
macular,  papular,  or  pustular,  and  the  efflorescences  never 
form  patches,  though  they  may  show  more  or  less  grouping. 
When  the  other  symptoms  of  syphilis  are  present,  such  as 
the  initial  lesion,  mucous  patches,  and  alopecia,  there  can 
be  no  difficulty.  It  is  the  later  manifestations  of  the  dis- 
ease that  offer  difficulties  in  diagnosis,  and  especially  the 
grouped  papular  lesions  that  occur  on  the  palms  in  the  form 
of  scaly  patches.  In  some  cases  a  diagnosis  is  impossible. 
The  most  suggestive  symptom  of  syphilis  is  the  occurrence 
of  the  disease  upon  one  hand  alone.  The  patch  will  have 
a  wavy  outline  ;  will  be  scaly,  but  not  moist  or  crusted  ;  will 
often  show  healthy  skin  in  the  middle ;  and  there  are  apt  to 
be  isolated,  scaly,  dark-red  papules  somewhere  in  the  neigh- 


ECZEMA.  163 

borhood.     The  finding  of  scars  of  old  lesions,  or  some  other 
evidence  of  syphilis,  will  aid  us. 

Urticaria,  when  it  has  induced  itching  and  been  scratched, 
looks  like  an  eczema.  We  recognize  it  by  the  finding  of 
wheals,  or  the  history  of  them,  and  by  the  isolated,  scattered 
distribution  of  the  excoriations  and  papules.  Some  cases  of 
papular  urticaria  can  only  be  diagnosticated  after  prolonged 
watching. 

Treatment.  While  not  a  few  cases  of  eczema  arise  from 
purely  local  causes,  and  require  only  external  treatment,  in 
most  cases  the  patient  is  not  in  good  condition,  and  he  needs 
treatment  quite  apart  from  his  skin  disease.  It  is  well  for 
us  to  begin  our  treatment  of  a  case  by  regarding  it  as  one 
of  a  sick  man  rather  than  of  a  sick  skin.  The  better  prac- 
titioner of  medicine  a  man  is,  the  better  his  chances  of  curing 
his  case  will  be.  It  is  not  the  part  of  the  writer  on  matters 
dermatological  to  instruct  his  readers  in  general  medicine, 
and  here  I  can  give  only  an  outline  of  the  treatment  proper 
to  be  followed. 

If  the  patient  is  anaemic  we  should  administer  iron,  and 
see  that  he  has  plenty  of  fresh  air  and  a  sufficient  amount 
of  exercise.  If  he  is  run  down,  and  especially  if  he  is  of 
a  strumous  habit,  cod-liver  oil  will  be  indicated.  To  the 
nervous  patient,  strychnine,  hypophosphites,  and  other 
nerve  tonics  should  be  administered.  The  dyspeptic  needs 
mineral  acids,  nux  vomica,  pepsine,  or  bismuth  and  soda, 
according  to  the  different  form  the  trouble  takes.  Those 
suffering  from  uterine  diseases  need  the  treatment  best 
suited  to  their  case.  The  gouty  and  rheumatic  will  be  bene- 
fited by  alkalies,  such  as  the  acetate  of  potash  or  the  phos- 
phate of  sodium.  Colchicum  will  be  useful  in  gouty  cases. 
In  fact,  there  is  no  specific  for  eczema,  and  each  case  should 
be  studied  and  treated  for  itself. 

But  nearly  every  case  requires  attention  to  the  diet  and 
exercise,  and  to  the  proper  action  of  the  bowels  and  kidneys. 
The  diet  is  of  special  importance.     Piffard1  has  found  that 

1  Materia  Medica  and  Therapeutics  of  the  Skin.    Wm.  Wood  &  Co., 
N.  Y.,  1881. 


164  DISEASES    OF    THE    SKIN". 

56  per  cent,  of  his  cases  of  eczema  have  been  carnivorous — 
that  is,  eating  meat  three  times  a  day  and  but  little  bread 
and  vegetables;  40  per  cent,  omnivorous,  and  but  4  per 
cent,  herbivorous.  Many  of  the  cases  eat  too  much  and 
exercise  too  little.  Many  suffer  from  distress  of  stomach 
after  eating  certain  articles  Some  eat  too  little,  and  that 
of  improper  sort.  The  indications  for  treatment  are  there- 
fore obvious.  The  greatest  difficulty  to  contend  with  is  the 
objection  most  people  have  to  dieting  of  any  sort. 

In  an  acute  eczema  of  any  considerable  extent  it  is  always 
best  to  put  the  patient  on  a  restricted  and  simple  diet,  and 
of  these,  where  milk  is  well  borne,  a  milk  diet  is  the  best. 
Some  two  quarts  of  milk  may  be  taken  during  the  day  in 
divided  doses,  with  dry  toast  or  toasted  crackers.  After  a 
few  days  a  more  liberal  diet  may  be  allowed,  as  in  subacute 
and  chronic  eczema. 

In  subacute  and  chronic  eczema  meat  should  be  taken 
but  once  a  day,  and  should  be  beef,  mutton,  or  chicken, 
and  these  should  be  eaten  in  the  middle  of  the  day  when 
possible.  Breakfast  and  supper  should  be  very  simple,  of 
crackers  and  milk,  bread  and  milk,  or  some  of  the  grains 
well  cooked,  and  eaten  without  sugar.  Fish  may  be  allowed, 
but  not  those  with  dark  meat  or  oily.  An  occasional  egg 
may  be  eaten  in  the  morning,  but  not  every  day.  No  pastry, 
cake,  or  confectionery  should  be  allowed.  Apart  from  abso- 
lute simplicity  the  patient's  taste  may  be  consulted,  care 
being  taken  to  avoid  anything  that  he  knows  will  disagree 
with  him.  It  is  a  good  rule  to  tell  the  patient  that  he  may 
eat  what  he  likes,  but  not  of  more  than  two  dishes  at  a 
meal.  It  is  unlikely  that  he  will  then  overeat.  Those  who 
eat  too  little  for  any  reason  should  be  directed  to  take  that 
little  more  often  during  the  day.  The  dyspeptic  should 
drink  a  cup  of  hot  water  about  a  half-hour  before  meals. 
In  these  cases  it  is  sometimes  necessary  for  a  time  to  resort 
to  kumyss  or  matzoon,  and  artificially  digested  foods,  but 
the  sooner  he  can  return  with  comfort  to  a  more  natural 
diet  the  better.  Fried  and  warmed-up  meats  should  be 
avoided  in  all  cases.  Fruits  fully  ripe  or  stewed  can  as  a 
rule  be  liberally  partaken  of. 


ECZEMA.  165 

All  alcoholic  drinks  must  be  absolutely  forbidden.  Malt 
liquors  are  specially  obnoxious  to  all  irritable  skins.  Tea, 
coffee,  and  chocolate  are  best  let  alone.  Coffee,  one  small 
cup,  may  be  allowed  for  breakfast ;  or  cocoa,  which  is  better, 
if  made  with  a  good  deal  of  milk.  Water  should  be  drunk 
regularly,  and  it  is  not  unlikely  that  much  of  the  benefit 
derived  from  visiting  foreign  spas  is  on  account  of  the  regu- 
lar drinking  of  water.  A  good  rule  is  for  the  patient  to 
drink  a  glass  of  water  before  meals,  while  dressing,  a  glass 
of  water  or  other  fluid  at  each  meal,  a  glass  of  water  about 
two  hours  after  meals,  and  before  going  to  bed.  If  pre- 
ferred, bottled  table  waters  may  be  used.  Vichy  water 
may  be  substituted  for  plain  water  once  or  twice  a  day. 
Tobacco  is  harmful  in  some  cases. 

Enforcement  of  these  dietary  laws  will  in  many  cases  over- 
come constipation.  It  is  best  not  to  resort  to  medicines  to 
procure  a  good  daily  movement  of  the  bowels,  if  it  can  be 
avoided.  Kneading  of  the  bowels  when  in  a  recumbent  posi- 
tion will  often  stand  us  in  good  stead,  the  bowels  being 
steadily  and  deeply  rubbed  with  the  heel  of  the  hand,  starting 
in  the  right  groin,  and  following  the  course  of  the  large  in- 
testine upward,  across,  and  downward.  The  habit  of  going 
to  stool  at  a  regular  hour  of  the  day  should  be  formed,  and 
it  should  be  seen  to  that  the  bowels  act  promptly.  If  we 
must  needs  give  medicine,  the  tablet  triturates  of  aloin, 
belladonna,  and  nux  vomica ;  the  pill  of  iron  and  aloes ; 
the  extract  of  cascara  sagrada,  with  or  without  nux  vomica, 
which  may  be  administered  in  capsules  to  avoid  the  dis- 
agreeable taste  ;   Startin's  mixture — 

R 


Magnesii  sulphatis, 

3vJ-3>s; 

20-30 

Ferri  sulphatis, 

3J; 

3 

Ac.  sulphur,  dil., 

3y; 

6 

Syr.  pruni  virgin., 

fj; 

24 

Aquae, 

ad  Jiv; 

100 

M. 

Sig.    A  teaspoonful  through  a  tube,  after  meals. 

or  any  other  serviceable  remedy  may  be  given.  Hardaway 
recommends  the  phosphate  of  sodium,  a  teaspoonful  in  hot 
water  before  breakfast,  or  three  times  a  day,  for  lithsemic 
patients  who  are  constipated.     This  is  an  excellent  laxative 


166  DISEASES    OF    THE    SKIN. 

for  children,  a  little  of  it  being  put  into  their  milk,  to  which 
it  gives  a  hardly  noticeable  salty  taste. 

Exercise  in  the  open  air  is  as  necessary  for  our  eczema- 
tous  patients  as  for  any  other  class.  It  should  not  be  taken 
so  as  to  cause  over-fatigue.  Patients  with  eczema  on  the 
face  and  hands,  or  with  a  tendency  thereto,  should  always 
wear  gloves  during  the  cold  seasons,  and  should  always 
protect  the  skin  of  their  faces  by  a  little  powder  or  vaseline 
before  going  out  into  the  cold  or  storm  of  wind  or  rain. 

Though  there  is  no  specific  for  eczema,  there  are  certain 
drugs  that  have  acted  favorably  upon  the  disease  in  the 
hands  of  some  observers.  Arsenic  has  come  down  from 
old  with  a  reputation  for  curing  eczema,  and  is  largely  pre- 
scribed. It  had  best  be  let  alone.  It  is  only  of  benefit  in 
chronic  scaling  cases,  and  only  in  a  few  of  them.  It  may 
be  used  in  the  form  of  Fowler's  solution  (Liq.  potassii 
arsenitis),  giving  from  2  to  5  minims ;  or  as  arsenious  acid, 
in  tablet  triturates,  either  with  or  without  pepper,  dose  ^ 
to  -g1^-  grain.  The  wine  of  antimony  in  5-minim  doses,  three 
times  a  day,  has  been  warmly  commended.  Phosphorus, 
TFo"  t°  2V  gram>  either  in  pill  or  in  oil,  has  been  found 
useful  in  long-standing  eczema.  Piffard  speaks  well  of  an 
infusion  of  viola  tricolor  in  acute  or  chronic  eczema  capitis, 
specially  in  lymphatic  children.  It  is  made  by  putting  one 
or  two  drachms  of  the  herb  into  a  bowl,  pouring  a  pint  of 
hot  water  over  it,  and  covering  with  a  plate.  When  cool, 
it  is  to  be  taken  in  divided  doses  during  the  day.  After  a 
few  days  it  generally  aggravates  the  disease,  a  good  thing 
to  accomplish  in  chronic  cases.  It  is  then  to  be  discontinued 
for  a  few  days  or  a  week.  In  acute  cases  the  dose  should 
be  quite  small.  Turpentine,  the  spirits,  is  recommended 
by  Crocker  in  obstinate  cases.  It  is  given  in  an  emulsion 
with  mucilage,  three  times  a  day,  after  meals :  the  dose 
being  10  minims  at  first,  and  then,  if  tolerated,  increased 
by  5-minim  doses  up  to  20  or  30  minims.  While  it  is 
being  taken,  not  less  than  a  quart  of  barley-water  should 
be  drunk,  and  the  last  dose  should  be  taken  not  later  than 
six  o'clock  in  the  evening.  The  same  author  recommends 
counter -irritation  over  the  spine,  the  nape  of  the  neck  for 


ECZEMA.  167 

eczema  of  the  upper  half  of  the  body,  and  over  the  last 
dorsal  and  first  lumbar  vertebrae  for  the  lower  half.  Dry 
heat,  a  mustard-leaf,  or  liquor  epispasticus,  may  be  used. 
I  have  seen  most  excellent  effects  from  this  plan.  The 
spinal  ice-bag  sometimes  accomplishes  the  same  result. 

In  acute  eczema,  if  taken  early,  sharp  catharsis  will 
sometimes  tend  to  lessen  the  severity  of  the  attack  by  re- 
ducing the  congestion  of  the  skin.  In  chronic  eczema,  even 
without  evident  renal  derangement,  the  acetate  of  potash  in 
15-grain  doses  will  prove  useful.  The  itching  may  be  so 
severe  in  some  cases  that  even  our  local  remedies  may  not 
allay  it,  and  it  may  seem  necessary  to  give  some  medicine 
to  procure  sleep.  Never  use  opium.  The  bromides,  chloral, 
or  phenacetine  may  be  given.  Bulkley  recommends  tincture 
of  gelsemium,  of  which  ten  drops  are  to  be  given,  and  re- 
peated and  increased  every  half-hour  till  relief  is  obtained, 
or  constitutional  symptoms  of  languor,  tranquillity,  dizzi- 
ness, impairment  of  vision,  and  drooping  of  the  lids,  are 
produced.  Quinine,  in  J-grain  to  15-grain  dose  given  at 
bed-time,  is  commended  by  some  for  the  same  purpose. 

Local  Treatment.  In  all  cases,  whether  due  to  purely 
local  causes  or  a  combination  of  these  and  some  general 
cause,  local  treatment  is  of  the  greatest  importance.  The 
books  teem  with  prescriptions  which  have  been  found  effi- 
cacious, and  some  of  them  contain  so  many  ingredients  that 
it  is  hard  to  determine  with  exactness  to  what  the  good  is 
due.  After  all,  the  matter  is  very  simple,  and  if  the  prin- 
ciples are  mastered,  little  difficulty  will  be  found  in  accom- 
plishing the  desired  end.  In  acute  cases  employ  soothing 
remedies ;  in  subacute  cases  use  astringent  and  slightly 
stimulating  remedies ;  in  chronic  cases  stimulate ;  in  all 
cases  protect  the  skin  from  external  irritation.  It  is  better 
to  learn  how  to  use  a  few  remedies  and  to  know  what  to 
expect  from  them  than  to  try  every  new  method  that  appears 
in  the  medical  press. 

It  is  a  good  broad  rule  that  water  should  not  be  used  on 
an  eczematous  skin,  as  it  removes  the  newly  formed  epi- 
dermis and  exposes  the  tender  skin  to  the  air.  In  all  but 
chronic  cases  it  should  be  used  sparingly,  and  only  to  re- 


168  DISEASES    OF    THE     SKIN". 

move  dirt,  or  crusts,  or  scales,  and  the  skin  should  be  at 
once  covered  with  some  protecting  powder  or  ointment.  If 
water  is  used,  it  should  be  either  rain  or  boiled  water,  or 
water  with  a  little  soda,  one  drachm  to  the  basinful,  or  bran 
in  it. 

In  acute  eczema  lime-water,  liquor  plumbi  subacetatis 
dil.,  lead  and  opium  wTash,  or  solutions  of  borax  or  soda, 
one  or  two  drachms  to  the  pint,  may  be  sopped  on  three  or 
four  times  a  day,  dusted  over  with  corn  starch,  bismuth, 
lycopodium,  kaolin,  or  French  chalk,  and  covered  with  light, 
old  linen  or  muslin.  All  these  will  allay  the  itching,  but  if 
this  is  especially  severe  the  following  may  be  used  : 


Be.  Camphori, 
Zinci  oxidi, 
Amyli, 

Startin  recommends  the  following : 


3ss; 

3\j; 
3^; 

3 
15 
30 

5ss; 

6 

?  fr ; 

2 

3  vij ; 

12 
100 

M. 


& .  Zinci  oxidi, 

Pulv.  calamine  prep., 

Glycerini, 

Liq.  calcis,  ^  vij ;     100         M. 

As  soon  as  the  early  and  most  acute  stage  is  passed,  a 
protecting  and  soothing  ointment  is  to  be  used,  and  of  these 
no  one  is  safer  than  the  standard  benzoated  oxide  of  zinc 
ointment  that  usually  can  be  obtained  anywhere.  The 
cucumber  ointment  is  also  soothing.  If  the  case  be  one  in 
which  there  is  much  discharge,  as  in  pustular,  vesicular,  and 
weeping  eczemas,  Lassar's  paste  is  better  than  the  oxide  of 
zinc  ointment,  as  being  a  paste  it  allows  the  discharge  to 
percolate  through  it.     It  is  made  as  follows  : 


H.z™di,|  u    3ij;        15 

Vaselini,  ad     ^ss;         30 


M. 


The  addition  of  10  or  15  grains  of  salicylic  acid  to  the 
ounce  increases  its  anti-pruritic  quality.  The  only  difficulty 
is  that  it  takes  time  and  muscle  to  make,  and  but  few  drug- 
gists make  it  well.  See  that  in  it,  as  in  all  other  ointments, 
there  are  no  gritty  particles  left.     All  ointments  must  be 


ECZEMA.  169 

smooth,  or  they  do  harm  rather  than  good.  In  using  oint- 
ments in  eczema  they  should  be  evenly  spread  upon  cheese- 
cloth folded  four  times,  or  upon  old  linen  or  muslin,  in  a 
layer  as  thick  as  the  back  of  a  table-knife,  applied  to  the 
affected  part  and  bound  down  snugly  with  a  bandage.  They 
should  be  changed  twice  a  day,  or  more  often  if  the  dis- 
charges are  profuse. 

Painting  a  limited  moist  patch  of  eczema  with  a  solution 
of  nitrate  of  silver,  3  to  10  grains  to  the  ounce,  is  often  a 
most  prompt  method  of  curing  the  disease. 

In  subacute  eczema  these  same  ointments  may  be  used 
for  a  time.  The  diachylon  ointment  will  sometimes  prove 
beneficial.  Most  cases  that  we  are  called  upon  to  treat  are 
in  or  near  to  the  subacute  stage,  as  the  acute  stage  soon 
passes  off.  It  is  always  advisable  to  begin  treatment  not 
too  boldly.  If  our  protecting  and  astringent  remedies  do 
not  cure  the  case  after  a  fair  trial,  then  we  must  add  stimu- 
lants, and  of  these  one  of  the  most  reliable  is  tar,  adding  it 
at  first  in  the  proportion  of  about  fifteen  drops  of  the  oil  of 
cade  to  the  ounce  of  ointment  base,  such  as  oxide  of  zinc 
ointment. 

In  chronic  squamous  eczema  we  need  stimulation  to  whip 
up  the  circulation,  to  produce  absorption  of  the  infiltration 
of  the  skin,  and  to  promote  a  return  to  health.  Here  tar 
is  one  of  our  most  reliable  remedies,  and  it  can  be  used  in 
various  strengths  and  ways.  We  may  use  the  oil  of  cade, 
oleum  cadini,  the  oil  of  birch,  oleum  rusci,  or  pix  liquida. 
There  is  some  doubt  and  difficulty  about  obtaining  genuine 
oleum  rusci,  which  is  largely  used  by  tanners  in  the  prepa- 
ration of  Russia  leather.  The  oil  of  cade  is  most  used.  Some 
prefer  this  ointment : 


R.  01.  cadini,  3ss-j;l       aa    2-4 

Zinci  oxidi,  3ss-j  ;  / 

Unguenti  aquae  rosse,  ^j ;  30 


M. 


Or  the  cade  may  be  added  to  the  oxide  of  zinc  ointment  in 
the  proportion  of  a  drachm  to  the  ounce.  Or  pix  liquida 
may  be  substituted  in  about  double  the  strength. 

Another  most  excellent  way  of  using  tar,  and  preferable 


170  DISEASES    OF    THE    SKIN. 

to  the  latter  because  not  so  liable  to  stain  the  clothing,  is 
that  proposed  by  Pick,  namely :  To  make  a  strong  tincture 
of  tar,  using  40  parts  of  pix  liquida  to  20  parts  of  alcohol. 
To  paint  the  part  every  night  with  three  coats  of  this 
tincture,  letting  each  coat  dry  on  before  another  is  applied. 
Then  cover  with  oxide  of  zinc  ointment;  the  ointment  being 
changed  morning  and  night. 

Bulkley  in  some  cases  recommends  tar  in  what  he  names 
liquor  picis  alkalinus,  which  is  made  as  follows : 


R 


Picis  liquid*, 

.lij; 

25 

Potass,  causticae, 

,lj; 

12 

Aquse, 

3v; 

ad     100 

M. 


Dissolve  the  potash  in  the  water  and  add  slowly  to  the  tar 
in  a  mortar  with  friction.  This  is  to  be  used  diluted  twenty 
or  more  times  with  water,  and  followed  by  oxide  of  zinc 
ointment. 

In  some  very  chronic,  thickened  eczemas  the  tar  may  be 
rubbed  in  pure.  If  the  eczema  is  very  extensive,  the  tar 
may  be  used  in  olive  oil  or  cotton-seed  oil  and  smeared  over 
the  body.  In  some  cases  the  tar  will  give  rise  to  systemic 
poisoning,  the  urine  will  become  black,  and  the  patient  will 
suffer  from  headache,  oppression,  nausea,  vomiting,  and 
diarrhoea,  and  the  pulse  will  become  frequent.  Of  course, 
under  these  circumstances  the  tar  must  be  stopped. 

Sulphur  is,  next  to  tar,  one  of  our  best  stimulating  reme- 
dies in  squamous  eczema.  It  is  not  so  reliable,  as  it  is  more 
uncertain  in  its  effects.  It  finds  its  best  use  in  circumscribed 
patches,  and  may  be  used  in  vaseline  or  simple  ointment  in 
the  strength  of  one  or  two  drachms  to  the  ounce.  In  some 
skins  it  produces  a  good  deal  of  dermatitis. 

Green  soap  is  often  of  the  greatest  service  in  chronic 
eczema.  It  is  to  be  used  in  the  following  way  :  Take  either 
the  green  soap  or  Bagoe's  prepared  olive  soap,  warm  Avater, 
and  oxide  of  zinc  ointment  spread  on  muslin  or  linen. 
Dip  a  piece  of  flannel  in  the  soap  and  then  in  the  water, 
and  then  with  it  scrub  the  part  vigorously  until  all  the 
scales  are  removed  and  the  skin  looks  somewhat  raw. 
Now  wash  off  all  the  soap  with  plenty  of  water,  dab  the 


ECZEMA.  171 

part  dry  with  a  soft  towel,  immediately  cover  with  the  oint- 
ment, and  apply  a  bandage.  The  soap  is  to  be  used  once  a 
day  and  the  ointment  changed  twice  a  day. 

Caustic  potash,.  15  grains  to  1  drachm  to  the  ounce;  or 
salicylic  acid,  10  to  15  per  cent.,  in  ether,  may  be  used  to 
reduce  very  much  thickened  patches.  Nitrate  of  silver,  10 
to  15  grains  to  the  ounce,  may  also  be  used. 

Unguent.  Jiydrarg.  ammoniat.,  diluted  to  half  its  strength, 
is  of  use  in  chronic  eczema  of  limited  area. 

Ichthyol  and  resorcin  are  two  of  the  more  recent  addi- 
tions to  our  armamentarium.  The  former  has  a  more  dis- 
agreeable odor  than  tar,  and  Crocker  says  of  it :  "  We  do 
not  want  more  of  such-  remedies,  as  tar  fills  that  place  so 
well ;  what  is  required  are  remedies  which  do  not  stain  nor 
smell."  Resorcin  in  from  2  to  5  per  cent,  strength  is  a 
good  stimulating  application. 

For  the  reduction  of  infiltration  and  removing  the  scales 
in  a  chronic  eczema  nothing  is  better  for  a  time  than  sheet 
rubber  applied  to  the  part  and  bound  down  with  a  roller 
bandage.  The  rubber  should  be  removed  once  a  clay, 
sponged  off  with  soda  and  water,  and  reapplied.  The  relief 
to  the  itching  procured  by  this  means  is  sometimes  surpris- 
ing. As  soon  as  the  infiltration  is  reduced  we  should  resort 
to  our  tar  remedies  for  completion  of  the  cure. 

Many  attempts  have  been  made  to  find  a  substitute  for 
greasy  or  oily  applications  in  the  treatment  of  skin  diseases. 
Thus  we  have  the  plaster  mulls  of  Unna,  in  which  a  plaster 
mass  is  incorporated  with  the  mulls.  Many  speak  loudly  in 
tbeir  praise.  Then  collodion  and  traumaticine  have  been 
used,  and  answer  well,  the  tar,  salicylic  acid,  or  what  not, 
being  dissolved  or  held  in  suspension.  In  this  way  chrys- 
arobin  may  be  used  on  limited  patches  of  chronic  eczema. 
Gelatin  preparations  have  been  introduced,  but  they  take 
so  long  to  dry  as  a  rule  that  they  have  not  become  popular 
in  this  country.  Bassorin  paste  and  plasment  have  been 
recently  brought  out,  and  promise  well.  Medicated  soaps 
have  their  advocates.  I  have  had  no  experience  with 
them. 

Massage  sometimes  does  good   service   in    reducing  in- 


172  DISEASES    OF    THE    SKIN. 

filtration,  the  part  being  stroked  upward   in  the  course  of 
the  circulation. 

Baths  are  not  usually  advisable  in  eczema,  and  are  ap- 
plicable only  to  chronic  cases.  Good  results  have  been 
reported  from  some  sulphur  baths.  Residence  at  the  sea- 
side generally  proves  bad  for  eczematous  patients,  but  it 
may  be  a  good  thing  for  some  run-down  patients,  the  tonic 
effect  of  the  sea- air  out-balancing  the  evil  effect  of  the  damp- 
ness. Soda,  borax,  or  bran  baths  will  prove  grateful  in 
some  cases.     Bulkley  orders  the  following  : 

R .  Potass,  carbonat.,  ^  iv  ; 

Sodii  carbonat.,  ^  iij  ; 

Boracis  pulveris,  J  ij ;  M. 

Add  to  thirty-gallon  bath  with  half  a  pound  of  starch. 

We  must  now  consider  Regional  Eczema. 

Eczema  Ani,  as  usually  met  with,  is  of  the  squamous, 
thickened  variety  with  Assuring.  It  usually  extends  up  the 
whole  internatal  fold.  It  gives  rise  to  great  pain  in  defeca- 
tion and  to  much  itching  at  all  times.  The  discharge  from 
this  form,  as  well  as  from  eczema  of  the  genitals,  is  frequently 
offensive.  Excessive  use  of  tobacco  predisposes  to  this 
variety  of  eczema,  probably  on  account  of  the  nervous  irri- 
tation inducing  itching,  for  the  relief  of  which  the  patient 
scratches  and  produces  the  eczema. 

In  treatment  the  first  thing  is  to  stop  the  use  of  tobacco, 
a  hard  task,  as  the  patient  is  ofttimes  incredulous  of  its  effi- 
cacy. Horseback  riding  and  much  walking  will  sometimes 
have  to  be  stopped,  as  they  may  aggravate  the  trouble.  If 
hemorrhoids  or  fissures  of  the  mucous  membrane  are  present, 
as  they  quite  frequently  are,  they  must  be  cured  in  order  to 
obtain  a  permanent  cure  of  the  eczema.  The  bowels  must  be 
kept  easy  by  laxatives  so  that  one  soft  movement  may  be  had 
each  day.  Liver  derangements  must  be  corrected  to  prevent 
portal  congestion,  and  dieting  will  be  of  service.  The  nates 
must  be  separated  by  folds  of  lint,  and  the  parts  kept 
scrupulously  clean,  though  water  should  be  used  as  sparingly 
as  possible.  The  itching  may  be  relieved  by  sopping  on 
hot  water,  dabbing  the  part  dry,  and  making  the  chosen 


ECZEMA.  173 

application.  Tar  or  diachylon  ointment  may  be  used,  all 
covered  in  with  a  dusting-powder.  Usually  the  drier  the 
parts  can  be  kept  the  better.  Painting  a  limited  surface  with 
salicylic  acid,  10  to  15  grains  in  an  ounce  of  flexible  collo- 
dion, is  often  followed  by  the  happiest  results.  Painting  with 
nitrate  of  silver,  10  to  15  grains  to  the  ounce,  is  sometimes 
advisable.  Here,  too,  if  there  is  much  thickening,  wearing 
rubber  cloth  for  a  few  days  will  greatly  hasten  the  cure. 
A  well  applied  T-bandage  is  the  best  way  of  keeping  dress- 
ings in  place. 

Eczema  Aurium.  Eczema  may  affect  both  the  ear  itself, 
and  the  inside  of  the  auditory  canal.  When  the  ear  is 
acutely  affected  it  is  swollen  at  times  so  much  as  to  stand 
out  from  the  head.  In  acute  eczema  of  the  external  audi- 
tory canal,  which  is  secondary  to  that  of  the  auricle,  the 
swelling  may  be  so  great  as  to  cause  dulness,  if  not  loss  of 
hearing.  Of  eczema  of  the  outer  part  of  the  ear  nothing 
special  need  be  said  excepting  that  the  dressings  must  be 
exactly  applied  to  all  the  little  furrows  of  the  ear,  and  it 
must  be  seen  to  that  a  pledget  of  lint  is  placed  in  the  fur- 
row behind  the  ear  so  that  it  is  separated  from  the  side  of 
the  head,  that  in  sleeping  the  two  surfaces  of  skin  do  not 
come  into  contact.  Painting  this  part  of  the  ear  with  a 
solution  of  nitrate  of  silver,  ten  grains  to  the  ounce,  will 
sometimes  aid  greatly  in  converting  a  moist  eczema  into  a 
squamous  one.  During  the  day  a  cure  will  be  hastened  by 
having  the  ear  covered  with  a  linen  bag  made  in  the  fashion 
of  an  ear-muff.  Eczema  of  the  auditory  canal  is  sometimes 
very  annoying  on  account  of  the  excessive  itching,  or  on 
account  of  an  accumulation  of  scales  dulling  the  hearing. 
For  this  condition  an  ointment  of  tannin,  one  drachm  to  the 
ounce  ;  a  solution  of  nitrate  of  silver,  five  to  twenty  grains  to 
the  ounce ;  either  of  these  is  to  be  applied  thoroughly  by 
means  of  absorbent  cotton  on  a  probe,  the  ear  being  properly 
lighted  by  means  of  a  head-mirror,  and  the  operator  having  the 
requisite  skill.  Otherwise  the  tannic  acid  ointment  or  one 
of  oxide  of  zinc,  or  the  diachylon  ointment,  may  be  applied 
on  pledgets  of  lint  rolled  up  to  fit  the  orifice.  The  insuffla- 
tion of  boric  acid  will  sometimes  be  better  yet.     The  ear 


174  DISEASES    OF    THE    SKIN". 

should  not  be  syringed  out  often,  and  when  it  is  necessary 
to  do  it  a  solution  of  borax  or  soda  should  be  used. 

Eczema  Barbae  is  scarcely  ever  confined  to  the  bearded 
portion  of  the  face,  but  it  generally  runs  over  on  to  the 
bordering  skin,  and  is  often  but  a  part  of  eczema  of  the 
face.  It  has  practically  the  same  symptoms  as  has  eczema 
capitis.  It  needs  to  be  diagnosticated  from  ringworm  and 
sycosis,  which  see.  In  treatment,  shaving,  or  cutting  the 
hair  close,  which  is  better,  should  be  practised  so  that 
remedies  may  be  closely  applied.  Plucking  the  hair  from 
the  pustules  is  to  be  recommended.  Its  further  treatment  is 
the  same  as  that  of  Eczema  capitis.  It  is  an  obstinate  form 
of  eczema,  prone  to  relapses. 

Eczema  Capitis.  The  scalp  is  very  commonly  the  seat  of 
eczema  either  by  itself  or  in  connection  with  eczema  else- 
where. It  has  received  various  names,  such  as  crusta  lactea  ; 
porrigo  ;  melitagra  ;  scalled  head  ;  milk  crust ;  or  vesicular 
or  running  scall.  While  any  variety  of  eczema  may  occur 
on  the  scalp,  the  vesicular  is  very  rarely  seen,  and  the  most 
common  is  the  pustular,  and  the  final  stage,  the  squamous. 
In  the  acute  stage  the  scalp  may  be  swollen  and  boggy,  and 
moist,  with  the  hair  stuck  together.  Usually  we  find  the 
scalp  crusted  with  a  yellowish  serous  crust,  but  more  com- 
monly with  a  greenish  or  blackish  purulent  crust,  while  the 
scalp  is  swollen  but  little.  In  some  cases  of  pustular  eczema 
there  will  be  discrete,  rather  larger  pustules  scattered 
through  the  hair,  besides  moist  and  crusted  patches.  The 
hair  is  always  matted  together,  and  the  odor  from  the  scalp 
unpleasant.    If  the  crusts  are  removed  they  will  soon  re-form. 

In  both  the  erythematous  and  squamous  forms  the  scalp 
is  red  and  scaly.  In  the  latter  variety  there  is  apt  to  be 
more  or  less  thickening  of  the  scalp,  and  in  very  severe 
cases  the  scalp  may  be  cracked.  Not  infrequently  there 
will  be  squamous  patches  in  some  places  and  moist  and 
crusted  patches  in  other  places. 

With  eczema  of  the  scalp  there  is  almost  always  eczema 
behind  the  ears.  The  cervical  glands  are  very  often  swol- 
len, especially  in  children,  but  they  need  give  no  anxiety, 
as  they  very  rarely  suppurate.     In  the  chronic  form  there 


ECZEMA.  175 

may  be  loss  of  hair,  especially  in  children,  when  it  is  some- 
times mechanically  rubbed  off  from  the  occiput.  It  is  never 
permanently  lost.  All  forms  are  itchy,  the  pustular  form 
least  so.  The  patient  may  complain  of  a  "  drawn  "  feeling 
of  the  scalp.  As  in  all  inflammatory  diseases  of  the  scalp 
there  is  over-activity  of  the  sebaceous  glands,  and  the  crusts 
will  contain  a  certain  amount  of  fat.  In  chronic  cases  there 
may  be,  on  the  other  hand,  a  deficiency  of  fat.  Pediculi 
are  often  found  on  the  hair.  The  disease  may  affect  the 
whole  scalp  or  only  a  portion  of  it,  and  may  run  an  acute 
or  chronic  course. 

Etiology.  The  exciting  causes  of  eczema  capitis  are  all 
irritants  to  the  scalp.  Sometimes  it  is  well  meant  but  badly 
directed  efforts  at  cleanliness,  especially  in  children.  Comb- 
ing with  a  fine-toothed  comb,  too  vigorous  use  of  soap  and 
water,  the  use  of  a  too  stiff  brush,  are  some  of  these. 
Pediculi  are  very  often  the  cause — not  the  pediculi  them- 
selves, but  the  scratching  to  relieve  the  itching  produced  by 
them.  An  eczema  of  the  occiput  should  always  suggest 
their  presence,  and  search  then  will  generally  reveal  the 
pediculi  or  their  nits  upon  the  hair.  Sometimes  remedies 
used  to  kill  the  lice  will  set  up  an  eczema,  such  as  strong 
mercurial  ointments.  In  most  cases  eczema  of  the  scalp  is 
but  a  part  of  a  more  or  less  general  eczema  and  due  to  the 
same  causes. 

Diagnosis.  The  disease  must  be  differentiated  from 
pityriasis  capitis,  ringworm,  erysipelas,  lupus  erythematosus, 
a  dermatitis,  psoriasis,  seborrhcea,  favus,  pediculosis,  and 
syphilis.     See  under  these  diseases. 

Treatment.  The  treatment  of  the  disease  is  along  the 
same  lines  as  is  that  of  the  disease  in  general.  On  the 
scalp  it  is  always  best  to  use  our  remedies  either  in 
vaseline  or  oil,  as  preparations  of  lard  make  a  disagree- 
able mess  with  the  hair.  Nor  should  a  thick  ointment  ever 
be  used,  excepting  perhaps  in  children  before  their  hair 
is  grown,  or  on  bald  heads.  If  there  are  crusts  on  the 
scalp  they  must  be  removed  before  any  local  treatment  is 
used.  This  may  be  done  best  by  soaking  them  with  oil  for 
twelve  or  twenty-four  hours,  and  then  washing  them  away 


176  DISEASES    OF    THE    SKIN. 

with  soap  and  water.  Plenty  of  oil  must  be  used,  and  it  is 
well  to  tie  the  head  up  in  a  towel  over  night.  A  woman's  or 
half-grown  girl's  hair  should  never  be  cut  in  order  to  treat  the 
scalp.  In  applying  remedies  to  the  scalp,  afier  the  acute  stage, 
they  should  be  worked  in  and  not  merely  smeared  over  it. 

In  acute  eczema  equal  parts  of  lime-water  and  sweet  or 
almond  oil,  with  or  without  one  per  cent,  of  carbolic  acid, 
forms  a  good  application. 

In  subacute  and  chronic  eczema  of  the  scalp,  tar,  especially 
the  oil  of  cade,  is  our  most  reliable  remedy.  It  must  be 
remembered  that  it  can  be  used  much  earlier  on  the  scalp 
than  elsewhere,  and  most  cases  will  improve  under  it  as 
soon  as  the  acute  stage  is  passed.  It  may  be  begun  in  the 
strength  of  twenty  drops  to  the  ounce  of  oil,  and  increased 
to  one  or  two  drachms  to  the  ounce.  Many  people  object 
to  the  odor  of  the  tar.     We  can  substitute  for  it : 


Or, 


K .  Hydrarg.  ammon.,  gr.  xx ;  1 15 

Vaselini,  %y,  30 1       M. 

R.  Ac.  salicylici,  gr.  xx-xxx  ;  1.5—2] 

01.  olivaj,  |j ;  30!       M. 


The  oil  of  cajuput  in  five  to  ten  per  cent,  strength  may 
be  tried.     Neither  of  which  is  as  good  as  tar. 

If  the  disease  is  in  a  chronic  condition  shampooing  with 
green  soap  or  its  tincture,  followed  by  some  oily,  not  very 
stimulating  application,  will  prove  curative.  In  this  condi- 
tion it  is  sometimes  best  to  exhibit  the  tar  in  an  alcoholic 
solution.  Rcsorcin  in  three  to  ten  per  cent,  strength  may 
be  used  cautiously  in  this  way.  If  the  scalp  is  cracked  and 
thickened,  great  and  prompt  amelioration  will  be  secured  by 
having  the  patient  wear  a  close-fitting  cap  of  rubber. 

Eczema  Crurum.  Eczema  of  the  legs  acquires  its  pecu- 
liarities from  the  fact  that  the  circulation  of  the  parts  is  less 
active  than  it  is  in  the  upper  portions  of  the  body,  on  ac- 
count of  the  action  of  gravity  upon  the  returning  venous 
blood.  It  usually  is  seen  as  an  eczema  madidans,  though 
any  form  may  be  present.  Varicose  veins,  either  super- 
ficial or  deep,  predispose  to  it.     Pigmentation  of  more  or 


ECZEMA.  177 

less  dark-brown  color  follows  or  accompanies  it,  if  of  any 
chronicity,  and  occasionally  purpuric  spots  will  be  scattered 
about  the  chronic  patch.  In  treatment  nothing  special 
need  be  said  except  that  it  is  always  advisable  to  have  the 
legs  bandaged  snugly  from  toes  to  knee,  and  that  the  best 
results  will  be  attained  when  the  bandaging  is  done  by  the 
doctor  or  a  trained  nurse. 

Eczema  Genitalium  often  causes  a  great  deal  of  discom- 
fort on  account  of  the  excessive  itching  that  accompanies  it. 
It  affects  the  scrotum  most  commonly,  which  in  some  cases 
will  be  greatly  thickened  and  feel  like  leather.  The  skin 
of  the  penis  also  suffers  at  times  as  well  as  the  glans.  In 
women,  both  the  lesser  and  the  greater  lips  of  the  vulva 
may  be  affected,  and  show  excoriations  and  thickening,  as 
well  as  the  entrance  to  the  vagina.  All  forms  of  eczema 
may  be  encountered  in  the  genital  region.  In  chronic  eczema 
of  the  penis  the  organ  becomes  greatly  enlarged  both  later- 
ally and  longitudinally,  on  account  of  the  thickening  of  the 
skin.  The  disease  may  be  confined  to  the  genitals  or  extend 
to  the  thighs,  or  the  anal  region.  The  presence  of  diabetes 
should  always  be  suspected  in  a  case  of  this  kind,  and  the 
urine  should  be  examined  for  sugar.  Leucorrhcea  is  a 
common  cause  of  the  disease  in  women. 

Treatment.  In  the  treatment  of  eczema  of  the  genitals, 
apart  from  that  due  to  general  conditions  and  specially  to  the 
diabetes,  it  is  essential  that  men  should  wear  a  well-fitting  sus- 
pensory bandage,  inside  of  which  the  dressing  may  be  placed. 
The  itching  may  be  greatly  relieved  in  all  forms  by  directing 
the  patient  to  sit  over  a  vessel  containing  hot  water  and  to  sop 
the  water  up  on  the  parts.  The  skin  should  be  mopped  dry, 
the  oxide  of  zinc  ointment,  diachylon  ointment,  or  Lassar's 
paste  immediately  applied,  and  the  suspensory  bandage  ad- 
justed. Carbolic  acid,  one  or  two  drachms  to  the  ounce  of 
glycerin  and  water,  may  also  be  used,  lightly  dabbed  on,  for 
the  purpose  of  allaying  the  itching.  It  should  be  followed 
by  either  of  the  above  ointments.  For  chronic,  thickened 
eczema  wearing  sheet  rubber  inside  of  the  suspensory  ban- 
dage will  give  positive  and  immediate  relief,  and  greatly 
reduce  the  thickening.    After  a  few  days  it  is  well  to  follow 

8* 


178  DISEASES    OF    THE    SKIN. 

it  with  a  tar  or  resorcin  ointment.  In  some  cases  nothing 
will  do  so  well  as  the  application  of  nitrate  of  silver,  as 
already  indicated.  The  spirits  of  nitrous  ether  may  be 
used  as  an  excipient  of  this.  Hardaway  speaks  highly  of 
rubbing  the  scrotum  with  a  solution  of  salicylic  acid  in 
alcohol,  one  drachm  to  the  ounce,  and  following  this  with  a 
boric  acid  or  diachylon  ointment. 

Women  should  use  a  T-bandage  instead  of  the  suspensory. 
Otherwise  the  treatment  is  the  same.  In  them  I  have  seen 
the  nitrate  of  silver  treatment  do  remarkably  well. 

Eczema  Intertrigo  occurs  wherever  folds  of  skin  come 
into  contact,  and  requires  that  the  parts  should  be  kept 
separate  and  as  dry  as  possible  by  means  of  a  dusting- 
powder,  or  by  placing  a  piece  of  old  linen  or  cheese-cloth, 
spread  with  the  appropriate  ointment,  between  the  apposed 
folds  of  skin.  For  a  dusting-powder  we  may  use  either 
corn  starch  alone  or  with  bismuth,  or  zinc  oxide.  Lyco- 
podium  is  also  an  excellent  powder.  The  disease  often  re- 
sembles an  erythema,  but  inasmuch  as  both  diseases  are 
amenable  to  the  same  treatment,  absolute  accuracy  of  diag- 
nosis is  not  essential.  Kaposi  has  seen  gangrenous  and 
diphtheritic  inflammation  begin  in  an  intertriginous  eczema. 

Eczema  Labiorum  is  usually  due  to  a  nasal  catarrh,  and 
can  be  cured  only  when  the  cause  is  removed.  Eczema  may 
occur  all  about  the  mouth  in  an  orbicular  manner.  Many 
people  suffer  from  chapped  lips,  especially  in  winter.  This 
is  an  eczema  of  the  vermilion  border.  For  this  little  can 
be  done  except  to  caution  the  patient  against  moistening  the 
lips.  Greasing  the  lips  every  night  with  camphor-ice  or  the 
like  keeps  them  in  good  condition.  Glycerin  agrees  well 
with  some  skins,  and  is  harmful  to  others.  Cracks  may  be 
touched  with  the  nitrate  of  silver  stick,  and  the  lip  painted 
with  compound  tincture  of  benzoin. 

Eczema  Mammarum  et  Mammellarum.  One  of  the  most 
annoying  accidents  to  befall  a  nursing  woman  is  eczema 
of  the  nipples.  They  become  excoriated  and  fissured,  the 
cracks  sometimes  extending  to  the  base  of  the  nipple.  At 
times  a  drop  of  pus  can  be  squeezed  from  the  bottom  of  the 


ECZEMA.  179 

crack.  They  are  exquisitely  sensitive,  and  every  time  the 
baby  takes  hold  the  woman  suffers  agony.  The  moisture 
from  the  child's  mouth  and  the  decomposing  milk  left  on 
the  nipple  aggravate  the  trouble.  Mastitis  may  complicate 
matters.  In  the  intervals  of  nursing  the  nipple  scabs  over. 
Either  one  or  both  nipples  may  be  affected.  The  disease 
may  extend  on  to  the  breasts,  or  the  breasts  may  be  affected 
independently  of  the  nipples.  Women  with  pendulous  and 
heavy  breasts  frequently  suffer  with  a  moist  eczema  in  the 
sulcus  beneath  them.  Apart  from  this  nothing  special  need 
be  said  about  eczema  of  the  breasts.  There  is  one  disease 
of  the  breasts,  called  Paget's  disease  of  the  nipple,  which 
at  first  very  closely  resembles  eczema,  and  it  is  a  question 
whether  it  is  carcinomatous  all  the  way  through,  or  an 
eczema  developing  into  a  carcinoma.  (See  Paget's  Disease 
for  diagnosis.) 

Treatment.  It  is  often  possible  to  cure  eczema  of  the 
nipples  even  while  the  child  nurses.  Sometimes  it  will  be 
necessary  to  wean  the  child.  Women  during  the  latter 
months  of  pregnancy  should  handle  their  nipples  every  day 
and  bathe  them  with  whiskey  or  alcohol,  to  which  may  be 
added  20  or  30  grains  of  borax  to  the  ounce.  This  will  do 
much  to  prevent  future  trouble.  The  nursing  having  begun, 
the  nipples  should  be  carefully  washed  off  and  dried  with  a 
soft  handkerchief,  and  dressed  with  oxide  of  zinc  or  diachylon 
ointment,  should  eczema  show  itself.  Of  course,  the  oint- 
ment should  be  removed  before  the  infant  is  put  to  the 
breast,  and  this  should  be  done  with  as  little  water  and  as 
much  gentleness  as  possible.  If  there  are  cracks  the  child 
should  nurse  through  a  rubber  nipple,  and  when  it  lets  go 
the  nipple  should  be  dried  and  painted  with  compound 
tincture  of  benzoin,  or  the  solution  of  nitrate  of  silver 
already  spoken  of.  It  is  also  advised  to  touch  the  cracks 
with  the  nitrate  of  silver  stick.  This  is  very  painful,  and 
of  little  use  as  long  as  the  infiltration  of  the  nipple  that 
causes  them  continues.  The  nipples  may  be  washed  with  a 
borax  solution  and  covered  with  an  ointment  of  borax.  It 
is  always  advisable  to  use  nothing  that  is  poisonous  in  the 


180  DISEASES    OF    THE    SKIN. 

dressings.     Hardaway  recommends  the  following  for  eczema 
under  the  breasts : 

R.  Thymol,  gr.  j. 

Pulv.  zinci  oleat.,  ^j.  M. 

Eczema  Manuum.  Eczema  of  the  hands  has  been  called 
"washerwoman's  itch,"  "grocer's  itch,"  "bricklayer's  itch," 
and  various  other  itches.  It  is  in  many  cases  a  trade 
eczema,  caused  by  strong  alkaline  soaps,  or  contact  with 
sugar,  mortar,  or  other  irritant.  It  may  arise  independently 
of  any  of  these  trade  causes,  or  it  may  be  part  of  a  general 
eczema.  The  acute  forms,  as  they  occur  upon  the  backs  of 
the  hands,  do  not  differ  from  the  same  on  other  parts  of  the 
body,  and  the  same  may  be  said  of  the  chronic  forms.  The 
palms  are  seldom  primarily  affected,  but  secondarily  to 
eczema  of  the  wrists  or  fingers.  The  epidermis  of  the 
palms,  as  well  as  that  of  the  inside  of  the  fingers,  is  thicker 
than  that  of  the  other  parts  of  the  body,  excepting  the  soles 
of  the  feet,  and  so  the  vesicles  do  not  rupture  readily,  but 
are  seen  like  little,  more  or  less  translucent  grains  under 
the  skin.  When  they  rupture,  the  skin  is  left  more  or  less 
ragged  and  worm-eaten.  The  skin  over  all  the  joints  is 
liable  to  crack  and  form  painful  fissures.  Chronic  eczema 
of  the  palms  prevents  free  movement  of  them  on  account 
of  the  thickening  and  the  painful  cracking.  The  skin  is 
reddened  and  covered  with  large  adherent  scales.  Itching 
is  intense  at  times.  The  whole  palm  may  be  affected,  or 
the  disease  may  form  limited  areas,  as  upon  the  center  of 
the  palm,  over  the  thenar  eminence,  and  upon  the  finger- 
ends.  This  form  of  eczema  is  often  difficult  of  diagnosis 
from  the  squamous  syphilide.  The  occurrence  of  the  lesions 
upon  one  hand  alone  should  rouse  suspicion  of  syphilis, 
especially  if  little  or  no  itching  is  complained  of. 

Treatment.  It  is  one  of  the  most  obstinate  of  eczemas 
to  treat,  and  when  of  chronic  form  requires  active  stimula- 
tion by  means  of  tar;  salicylic  acid;  the  soap  and  salve  treat- 
ment ;  rubbing  in  5  to  10  per  cent,  of  the  oleate  of  mercury  ; 
or  painting  with  caustic  potash.  The  constant  wearing  of 
rubber  gloves  is  excellent  for  the  purpose  of  softening  the 


ECZEMA.  181 

skin  and  preparing  it  for  other  remedies.  It  is  best  to  buy 
the  canvas-lined  gloves,  turn  them  inside  out,  and  wear  the 
rubber  next  the  skin.  The  hands  must  be  kept  out  of 
water.  Where  this  cannot  be  done,  great  care  must  be  used 
in  drying  them.  It  is  well  to  have  the  patient  dry  on  two 
towels  or  before  the  fire,  and  then  either  to  thrust  the  hands 
in  a  box  of  corn- starch  powder  or  flour,  or  preferably  to 
apply  the  proper  dressings. 

Eczema  Narium  is  often,  if  not  always,  associated  with  a 
chronic  rhinitis.  It  is  very  obstinate.  Crusts  form  on  the 
inside  of  the  nose,  are  picked  off,  re-form,  and  after  a  time 
ulcers  result  from  the  constant  irritation.  Sometimes  in 
adults  the  disease  locates  itself  about  the  hair  follicles,  and 
is  very  annoying.  It  is  a  not  uncommon  point  of  de- 
parture for  recurrent  attacks  of  facial  erysipelas.  If  long 
continued  it  gives  rise  to  a  thickening  of  the  upper  lip. 
Furuncles  sometimes  complicate  matters.' 

In  the  treatment  of  these  cases  the  first  attention  must 
be  given  to  the  cure  of  the  rhinitis.  Then  all  crusts  must 
be  removed  by  soaking  with  oil.  For  the  eczema  we  may 
use : 

R .  Glycerole  plumbi  subacetat,  \ 

Ungt.  aquse  rosse,  J  1 '     '         M. 

as  recommended  by  HardaAvay. 

Herzog1  recommends  the  yellow  oxide  of  mercury  oint- 
ment, or  equal  parts  of  ungt.  plumbi  and  vaseline,  spread 
on  lint  and  accurately  applied  to  the  diseased  part.  Urma 
rolls  his  zinc  and  red  precipitate  ointment  muslin  into  a 
pledget  and  introduces  it  into  the  nose.  In  obstinate  cases 
about  the  hairs,  epilation  by  electrolysis  may  have  to  be 
performed. 

Eczema  Palpebrarum  is  usually  of  an  erythematous  char- 
acter, and  occurs  as  part  of  the  same  disease  elseAvhere. 
Eczema  of  the  cilise,  also  called  blepharitis  ciliaris,  is 
always  pustular.  The  edges  of  the  lids  are  swollen,  rounded, 
and  more  or  less  thickly  strewn  with  pustules  or  crusts. 

1  Archiv  f.  Kinderheilk.,  1887,  p.  211. 


182  DISEASES    OF    THE     SKIN. 

The  lids  stick  together  on  waking  in  the  morning.  In  the 
squamous  form  the  edges  of  the  lids  are  merely  red  and 
scaly.  It  is  almost  always  symmetrical,  occurs  usually  in 
strumous  subjects,  and  is  due  to  conjunctivitis. 

Treatment.  The  lids  should  be  anointed  before  going 
to  sleep  in  order  to  prevent  their  sticking  together.  I  have 
always  found  the  following  ointment,  as  given  by  my  friend, 
Prof.  D.  Webster,  of  the  New  York  Polyclinic,  most  excellent : 

R.  Ac.  salicylici,  gr.  x ;  18 

Ungt.  hydrarg.  oxid.  rubra,  £j  ;  5 

Ungt.  aquae  rosse,  3vj;        30,         M. 

An  ointment  composed  of — 

Jjt .  Hydrarg.  oxid.  flav.,  gr.  ij-viij  ; 

Vaselini,  %] ;  M. 

is  recommended  by  Hardaway.  Resorcin,  3  grains ;  cold 
cream,  2J  drachms,  is  editorially  commended  in  the  Mo- 
natshefte  f.  prakt.  Dermat,  1888,  vii.  1057.  Whatever  is 
used,  we  must  be  sure  that  any  substance  entering  into  it 
is  in  an  impalpable  powder,  so  as  to  avoid  the  possibility  of 
getting  anything  gritty  into  the  eye.  Epilation  may  be 
necessary  in  some  cases. 

Eczema  Pedum.  Eczema  of  the  soles  of  the  feet,  though 
not  so  common  as  that  of  the  palms,  presents  the  same 
symptoms  and  calls  for  the  same  treatment.  The  greatest 
difficulty  will  be  encountered  in  dressing  the  toes  properly. 
For  this  the  ointment  should  be  spread  upon  a  long  and 
narrow  strip  of  lint,  the  centre  of  the  strip  placed  against 
the  big  toe,  and  the  strip  wound  in  and  out  between  the 
toes.  A  piece  of  rubber  sheeting  cut  to  fit  the  sole  and 
bound  down  with  a  bandage  takes  the  place  of  the  rubber 
glove. 

Eczema  Unguium.  Eczema  may  affect  the  nail  fold 
alone,  and  the  nail  may  be  scarcely  diseased,  or  the  matrix 
and  bed  may  be  diseased,  when  the  nail  will  lose  its  lustre, 
and  become  rough,  uneven,  striated,  and  atrophied.  The 
nail  may  be  depressed  in  the  centre  and  turned  up  at  the 


ECZEMA.  183 

end  with  an  accumulation  of  scales  under  its  free  border. 
Usually  eczema  of  the  nails  occurs  as  a  part  of  a  general 
eczema,  but  it  may  occur  as  an  independent  disease. 

It  is  best  treated  by  means  of  cots  made  of  rubber.  It 
must  be  remembered  that  an  ointment  can  never  be  used 
when  rubber  is,  as  it  rots  it.  If  the  time  has  come,  for  an 
ointment,  linen  or  leather  cots  must  be  substituted  for  the 
rubber  ones. 

Universal  Eczema  is  uncommon,  and  when  it  does  occur 
it  is  usually  of  the  erythematous  or  squamous  variety,  with 
a  tendency  to  cracking  about  the  creases  of  the  joints  and 
skin,  exudation,  scaling,  and  itching.  These  symptoms  will 
serve  to  distinguish  it  from  dermatitis  exfoliativa,  to  which 
it  bears  a  strong  resemblance.  Constitutional  disturbances, 
such  as  fever  and  chills,  loss  of  appetite,  and  digestive  dis- 
orders are  not  uncommon  in  these  truly  pitiable  cases, 
Furunculosis  is  apt  to  complicate  matters.  The  patients  are 
slow  in  recovering,  and  are  apt  to  be  a  good  deal  pulled 
down  by  the  disease. 

Treatment.  These  patients  should  be  put  to  bed  and 
the  underlying  cause  searched  for,  and  if  possible  removed. 
They  are  best  treated  locally  by  lotions,  oils,  or  vaseline. 
The  ordinary  Carron  oil,  equal  parts  of  linseed  oil  and  lime- 
water  ;  cotton-seed  oil  with  carbolic  acid,  1  part  of  acid  to  60 
of  oil ;  or  simply  smearing  the  body  with  vaseline  and  powder- 
ing on  corn  starch,  will  each  relieve.  Salicylic  acid  in  oil,  1 
in  30  will  also  allay  the  discomfort.  Alkaline  baths,  warm, 
and  followed  by  one  of  the  above,  after  tapping  the  skin  gently 
dry,  will  also  relieve,  but  the  bath  should  not  be  used  more 
than  once  a  day.  Its  temperature  should  be  about  98°  F. ; 
it  should  last  ten  or  fifteen  minutes.  Bulkley  recommends 
anointing  the  skin  before  drying  it,  with — 

$ .  Acid,  carbolici,  Bj-3y;         3-16] 

Glycerite  amyli,  ^iv;  100 1     M. 

applying  it  freely.  The  best  way  of  drying  the  skin  is  to 
envelop  the  patient  in  a  warm  sheet,  and  pat  the  skin  dry. 
As  the  intensity  of  the  eczema  lessens,  the  frequency  of  the 


184  DISEASES    OF    THE     SKIN. 

baths  must  be  reduced.     It  will  gradually  cease  from  being 
universal,  and  become  localized  in  patches. 

Eczema  Infantile  presents  certain  peculiarities  that  war- 
rant its  being  considered  as  a  special  form  of  eczema.  It 
is  very  prone  to  be  of  the  pustular  variety,  following  the 
rule  that  in  delicate  or  debilitated  subjects  an  eruption  upon 
the  skin  is  apt  to  be  pustular.  While  in  adults  eczema  of 
the  face  is  usually  erythematous,  in  infants  it  is  nearly 
always  pustular.  In  them  it  is  quite  common,  if  not  the 
rule,  to  have  several  regions  affected  at  once,  such  as  the 
scalp,  the  face,  and  the  region  of  the  crotch.  In  them, 
also,  we  have  eczema  madidans  in  these  regions.  While  in 
adults  that  form  of  eczema  is  most  frequently  seen  upon  the 
legs,  in  infants  it  is  quite  exceptional.  Eczema  of  the  scalp 
in  infants  presents  itself  as  a  thick  crust  formed  of  purulent 
matter,  epithelial  debris,  and  sebaceous  matter.  This  is 
called  "  milk  crust."  When  the  crust  is  raised  the  scalp 
will  be  found  to  be  thickened,  swollen,  boggy,  and  moist, 
with  a  purulent  secretion.  The  whole  scalp  maybe  affected, 
or  only  the  vertex.  With  it  there  will  nearly  always  be  a 
moist  surface  behind  the  ears,  even  though  the  face  may  be 
comparatively  or  absolutely  free.  The  lymphatic  glands 
will  be  swollen,  but  they  seldom  suppurate.  When  the  face 
is  affected  it  will  sometimes  be  studded  over  with  holes, 
superficial  ulcerations,  which,  however,  never  leave  scars. 
This  appearance  is  seen  very  rarely  in  adults.  It  is  often 
striking  to  note  that  the  skin  about  the  mouth  and  nose, 
and  below  the  eyes,  is  in  perfect  health,  though  pale,  while 
all  the  rest  of  the  face  may  be  involved  in  the  most  intense 
inflammation.  The  creases  of  the  neck,  the  flexures  of  the 
joints,  and  the  region  of  the  genitals  usually  show  an  erythe- 
matous or  a  moist  intertriginous  eczema.  At  times  the  whole 
body  will  be  affected  with  a  general,  but  very  rarely  with  a 
universal  eczema.  While  the  pustular  and  intertriginous 
forms  of  eczema  are  the  most  common,  we  may  have  all 
forms  present  at  one  time,  and  of  them,  the  papular  is  most 
frequently  met  with.  Itching  is  usually  severe,  keeping  the 
little  patient  awake  at  night,  and  the  tearing  made  by  the 


ECZEMA.  185 

nails  to  relieve  the  itching  gives  rise  to  immense  excoria- 
tions, especially  of  the  face. 

Etiology.  There  are  several  causes  tending  to  eczema  in 
infants.  Their  skin  is  vulnerable  to  all  irritants.  When 
we  consider  that  the  child  is  born  into  the  cold  world  sud- 
denly, and  launched  there  out  of  a  warm  atmosphere,  in 
which  it  was  surrounded  by  an  alkaline  fluid,  covered  over 
with  a  fatty  coating,  and  safe  from  the  action  of  the  atmos- 
pheric air,  we  can  but  wonder  that  its  skin  escapes  as  well 
as  it  does.  More  than  one-third  of  the  cases  of  eczema  oc- 
curring before  the  fifth  year  of  life  occur  in  the  first  year. 
Add  to  the  vulnerability  of  the  skin  the  overzealous  care 
commonly  bestowed  upon  it  for  a  few  months  after  birth, 
and  we  have  a  good  explanation  for  its  frequence.  Bad 
diet  has  much  to  do  with  its  production.  The  vast  majority 
of  the  little  sufferers  are  nursed  too  often  if  at  the  breast, 
"  every  time  they  cry  "  being  the  rule ;  or  fed  too  frequently 
or  improperly,  "  everything  that  is  going"  being  again  the 
rule.  Inattention  to  the  condition  of  the  diapers  is  another 
active  cause  of  the  eczema  about  the  genitals.  Teething  is, 
without  doubt,  an  exciting  cause,  a  fresh  outbreak  of  eczema 
marking  the  eruption  of  a  new  tooth.  Want  of  self-control 
in  scratching  is  an  aggravating  circumstance.  The  frequent 
disturbances  of  digestion,  so  common  at  this  period  of  life, 
predispose  the  infant's  skin  to  eczema  with  rather  more 
force  than  does  the  same  disease  in  adults.  Fat  babies  are 
frequent  subjects  of  eczema,  especially  of  the  intertriginous 
varieties. 

Treatment.  The  treatment  of  eczema  infantile  is  along; 
the  same  lines  as  that  of  eczema  in  adults.  Special  stress 
must  be  laid  upon  the  feeding  of  infants,  and  strict  rules 
must  be  laid  down  for  the  parents'  guidance.  The  condition 
of  the  breast  milk  must  be  inquired  into,  as  it  is  often  of 
too  poor  quality  to  nourish  the  child.  Women  will  some- 
times nurse  their  children  far  too  long,  with  the  idea  of 
preventing  conception.  It  is  also  very  necessary  to  insist 
upon  the  child  wearing  a  mask  in  eczema  of  the  face  and 
scalp.  This  may  be  made  of  light  flannel  or  linen,  a  piece 
of  the  stuff  being  shaped  somewhat  after  the  shape  of  the 


186  DISEASES    OF    THE     SKIN. 

face,  with  holes  cut  out  for  the  nose,  eyes,  and  mouth.  A 
skull-cap  is  to  be  made,  on  to  which  the  mask  maybe  sewed, 
or  pinned  with  safety-pins.  The  ointment  is  to  be  spread 
upon  lint  or  cheese-cloth- — a  strip  for  the  forehead,  one  for 
the  chin,  and  one  for  each  cheek.  These  are  to  be  laid 
upon  the  face,  and  then  the  mask  put  over  them,  fastened 
to  the  skull-cap,  and  tied  behind  the  head  by  two  strings 
from  its  lower  corners.  It  is  astonishing  what  relief  this 
affords  to  the  itching,  and  how  much  more  rapidly  the  case 
improves.  The  itching  of  the  skin  may  be  relieved  by  ap- 
propriate dressings,  but  if  not  it  may  become  necessary  to 
put  the  child  in  a  home-made  straight-jacket,  by  putting  it 
in  a  pillow-case  and  sewing  up  the  same  between  the  arms 
and  body.  This  is  an  extreme  measure  and  should  not  be 
lightly  adopted.  In  eczema  of  the  crotch  great  care  must  be 
given  to  changing  the  napkins  as  soon  as  soiled.  Fresh, 
clean  ones  must  be  put  on,  not  those  that  have  been  dried 
without  being  washed.  Dr.  George  H.  Fox  has  called  at- 
tention to  a  tight  prepuce  as  a  cause  of  eczema  in  male 
children.  The  urine  dribbles  away,  so  that  a  few  drops  wet 
the  clean  diapers,  and  thus  keep  up  the  trouble.  In  such 
cases  judicious  stretching  of  the  prepuce  may  obviate  the 
necessity  for  circumcision.  Water  must  be  kept  from  the 
skin  in  all  cases. 

Internally,  calomel  in  tablet  triturates,  one-tenth  grain 
three  times  a  day  for  three  days,  will  give  us  good  aid  in 
many  cases,  even  though  the  bowels  are  not  constipated. 
Care  must  be  taken  not  to  produce  too  frequent  and  loose 
movements  of  the  bowels.  Other  medication  will  be  neces- 
sary, according  to  the  nature  of  the  case.  Cod-liver  oil  will 
often  cure  a  case  which  has  been  very  obstinate. 

Prognosis.  We  can  give  assurances  of  curing  eczema  so 
far  as  the  attack  with  which  the  patient  comes  to  us  is  con- 
cerned. We  can  give  no  positive  assurances  that  the  disease 
will  not  return.  The  cure  of  the  attack  requires  patience, 
careful  study  of  the  case,  and  the  intelligent  use  of  remedies. 
But  there  are  some  cases  that  are  exceedingly  rebellious.  We 
have  to  accept  the  fact  that  some  people  are  "  eczematous," 
and  that   they  cannot  be   permanently  cured   unless  they 


ECZEMA    SEBORRHOICUM.  187 

are  regenerated.  We  should  cure  our  cases  as  rapidly  as 
we  can,  and  not  take  refuge  in  the  excuse  of  the  incompetent 
man,  and  tell  the  patient  that  it  is  dangerous  to  cure  it. 

Eczema  Marginatum.     See  Trichophytosis. 

Eczema  Seborrhoicum.  Unna  read  a  paper  upon  this 
disease  in  the  Dermatological  Section  of  the  Ninth  Inter- 
national Medical  Congress  at  Washington  in  1887,  and  pub- 
lished some  papers  upon  the  same  subject  in  foreign  journals 
at  about  the  same  time.  From  his  first-mentioned  paper1  I 
shall  quote  largely  in  this  section.  He  does  not  believe 
that  there  is  such  a  disease  as  seborrhcea  sicca,  and  employs 
the  caption  of  this  section  as  a  substitute  for  the  same. 

Symptoms.  He  teaches  that  the  starting-point  of  almost 
all  seborrheal  eczemas  is  the  scalp ;  more  rarely  the  margin 
of  the  eyelids,  the  axillae,  bend  of  the  elbows,  or  cruro-scrotal 
fold.  Upon  the  head  it  exists  mostly  as  an  affection  that  is 
scarcely  noticeable  at  its  onset,  and  it  is  only  after  months 
or  years  that  a  sudden  increase,  loss  of  hair,  an  unusual 
amount  of  scaliness  or  collection  of  crusts,  severe  itching, 
or,  finally,  a  circumscribed  moist  spot,  or  an  evident  eczema, 
leads  the  patient  to  consult  a  physician.  The  hair  during 
the  early  stage  is  abnormally  dry.  A  progressive  alopecia 
pityrodes  may  show  itself,  the  scaliness  decreasing  with  the 
loss  of  the  hair  to  make  way  for  a  hyperidrosis  oleosa.  Or 
the  scaling  and  crusting  may  increase,  a  corona  seborrhoica 
may  form  along  the  hair  line,  and  the  affection  may  extend 
upon  the  temples,  over  the  ears  to  the  neck,  or  on  to  the 
nose  and  cheeks.  Or  the  catarrhal  symptoms  may  be  pro- 
nounced, and  a  moist  eczema  affect  the  scalp  and  ears,  and, 
in  children,  the  cheeks  and  forehead. 

.  Next  to  the  head,  the  sternum  is  a  favorite  site  for  the 
eruption,  where  it  most  Commonly  assumes  the  crusted  form, 
and  most  rarely  the  moist  form.  The  crusted  form  is  in 
round  or  oval  spots  the  size  of  the  finger-nail ;  these  group 
and  partly  coalesce,  forming  patches  the  size  of  a  silver  half- 
dollar,  having  a  scalloped  border.  The  color  is  yellow,  with 
a  delicate  red  border.    These  may  clear  up  somewhat  in  the 

1  Journ.  Cutan.  and  Gen.-urin.  Dis.,  1887,  v.  440. 


188  DISEASES    OF    THE    SKIN. 

centre  and  form  circles,  or  break  and  form  bow-shaped 
figures  with  the  convexity  outward. 

In  the  axillae  we  meet  most  commonly  with  the  moist 
form,  and  here  it  shows  a  tendency  to  spread  with  rapidity 
upon  the  thorax.  From  the  shoulders  it  spreads  down 
upon  the  arms  almost  always  in  the  crusted  form,  and 
shows  a  predilection  for  the  flexor  surface.  The  backs  of 
the  hands  and  fingers  are  often  affected  with  a  moist  eczema, 
the  trunk  and  arms  escaping. 

Upon  the  palms  and  soles  we  find  little  heaped-up  masses 
of  scales  corresponding  to  individual  coiled  glands  and  re- 
sembling psoriasis  guttata.  Later  the  epidermis  peels  off, 
but  there  is  never  any  moisture.  The  crusted  form  gen- 
erally appears  in  rings  or  serpiginous  patches  on  the  trunk, 
buttocks,  and  hips.  The  cruro- scrotal  fold  and  the  approxi- 
mating surfaces  of  the  thigh  and  scrotum  are  favorite  loca- 
tions for  the  disease,  probably  forming  here  many  of  the 
so-called  cases  of  eczema  marginatum.  The  thigh  and 
extensor  surface  of  the  knee  are  but  little  affected,  while 
the  popliteal  space  and  the  leg  often  are,  either  in  the  large 
papular  or  the  thick-crusted  form. 

Upon  the  bearded  portion  of  the  face,  when  the  beard  is 
worn,  we  find  either  a  diffused  pityriasis,  or  circumscribed, 
reddened,  itchy  patches.  Upon  the  face  of  women  and  the 
unbearded  portions  of  the  face  in  men  we  have  circum- 
scribed, scaly,  yellowish  or  yellowish-gray,  slightly  elevated 
patches,  mostly  on  the  forehead,  cheeks,  and  naso-labial 
fold.  There  may  also  be  red  papules,  free  from  scales  or 
with  fine  yellow  ones,  with  redness  of  the  skin  between 
the  papules.  The  face  is  the  favorite  location  for  a  moist 
seborrheal  eczema,  in  children  especially. 

Diagnosis.  The  diagnostic  points  from  psoriasis  are  : 
1.  The  spreading  of  the  affection  from  above  downward, 
mostly  in  the  middle  line  of  the  body,  and  the  stationary 
character  of  the  lesions.  2.  The  history  of  a  previous 
seborrheal  affection.  3.  The  fatty  and  crumbling  character 
of  the  scales,  and  the  yellowish  color.  4.  The  configuration 
of  the  separate  lesions,  the  thickened  papules  spontaneously 
flattening  out  in  the  middle   or  one  side;    the  red  color 


ELEPHANTIASIS.  189 

changing  to  yellow  ;  and  the  scaly  surface  becoming  smooth, 
to  suddenly  break  out  again  at  the  margin  in  a  raised,  red, 
scale-covered,  bow-formed  wall. 

Treatment.  The  best  remedy  for  the  moist  form  is 
sulphur,  and  for  the  scaly  and  crusted  forms,  chrysarobin, 
pyrogallol,  and  resorcin.  It  is  always  necessary  to  direct 
special  attention  to  the  scalp  and  eyelids,  as  these  are  the 
foci  from  which  the  disease  spreads.  For  the  disease  upon 
the  back  of  the  hand,  it  is  recommended  that  the  affected 
part  be  covered  with  a  thin  layer  of  lint  soaked  in  the  fol- 
lowing solution  diluted  one-half: 

R .  Resorcin,  ~l  n  A        , 

rn         .  '  >  aa     10  parts, 

(jrlycerm,  J  L 

Alcohol,  dil.,  180     "  M. 

and  over  this  a  large  piece  of  gutta-percha  tissue  is  to  be 
bound.  This  is  to  be  used  at  night,  and  during  the  day  it 
is  to  be  kept  dressed  with  a  zinc-oxide  paste  with  or  without 
tar,  sulphur,  or  resorcin. 

It  must  be  added  that  a  parasitic  origin  has  been  assumed 
for  this  disease,  the  parasite  being  yet  undiscovered.  On 
this  ground  a  contagious  element  has  been  assumed.  It 
will  be  seen  on  consulting  the  section  on  seborrhcea  that 
the  greater  part  of  seborrhoeal  eczema  is  but  seborrhcea. 
Further  investigation  of  the  subject  will  doubtless  elucidate 
many  uncertainties  regarding  it. 

Elephantiasis  (E2l-e2-fa2nt-i2-a'-si2s).  Synonyms :  Bar- 
badoes  leg;  Cochin-China  leg;  Glandular  disease  of  Barba- 
does  ;  Sarcocele  of  the  Egyptians ;  Tropical  big-leg  ;  Buc- 
nemia  tropica  ;  Morbus  elephas  ;  Pachydermia  ;  Spargosis  ; 
Phlegmasia  Malabarica ;  Hernia  carnosa ;  Elephantiasis 
Indica  seu  Arabum. 

A  chronic  endemic  or  sporadic  disease  of  the  skin,  char- 
acterized by  hyperplasia  of  the  skin  and  subcutaneous 
tissues,  due  to  a  stoppage  of  the  lymphatics,  affecting  chiefly 
the  lower  extremities,  and  marked  by  enormous  enlargement 
of  the  affected  part. 


190 


DISEASES    OF    THE    SKIN. 


Symptoms.  In  certain  tropical  regions,  such  as  India, 
China,  Japan,  Egypt,  Arabia,  the  West  Indies,  and  South 
America,  the  disease  is  endemic,  but  sporadic  cases  occur  in 
all  parts  of  the  world.  The  symptoms  of  the  two  forms 
differ  only  in  that  in  the  endemic  variety  there  is  usually 
what   is    called    aelephantoid    fever,"    with   lumbar   pain, 

Fig.  16. 


Elephantiasis.     (After  Taylor.) 

nausea,  and  vomiting,  and  followed  by  sweating.  The  fever 
is  of  high  grade,  and  bears  a  striking  resemblance  to  mala- 
rial pyrexia.  In  sporadic  cases  the  characteristic  fever  is 
wanting,  though  usually  there  is  some  constitutional  dis- 
turbance preceding  the  local  symptoms.  In  other  instances 
the  fever  is  altogether  wanting. 


ELEPHANTIASIS.  191 

Locally  the  affected  part  is  apparently  attacked  by  ery- 
sipelas, or  a  deep  dermatitis,  phlebitis,  or  lymphangitis  ;  it 
becomes  greatly  reddened  and  swollen;  and  there  may 
or  may  not  be  a  clear  or  milky  discharge  from  the  skin, 
and  an  eruption  of  vesicles.  After  a  time  these  symptoms 
subside,  but  the  part  does  not  return  to  its  normal  size,  and 
there  is  some  pitting  of  the  skin  on  pressure.  After  a  few 
months  there  is  a  repetition  of  the  attack,  and  the  part  is 
left  still  more  enlarged.  And  so  the  case  progresses  with 
varying  periods  of  quiescence,  and  recurrent  erysipelatous 
attacks,  each  one  leaving  the  part  more  thickened  than  be- 
fore, until  it  attains  enormous  proportions.  The  normal 
contour  of  the  part  is  lost;  the  folds  of  the  skin  are  ob- 
literated ;  and  the  surface  is  smooth  and  shiny.  Now  no 
impression  can  be  made  upon  the  swelling  by  pressure  of 
the  finger.  Ulcerations  are  apt  to  occur,  and  some  cases 
show  varicose  lymphatics  which  are  tender  and  painful,  and 
may  rupture  of  themselves  or  by  accident  and  discharge  a 
clear  or  milky  chylous  coagulable  fluid.  The  escape  of  this 
fluid  saps  the  patient's  strength. 

The  parts  most  frequently  affected  are  the  legs,  usually 
one,  but  may  be  both;  and  next  to  them,  the  male  or  female 
genitals.  It  occurs  also  on  the  arms,  face,  ears,  female  breast, 
and  tongue.  When  the  leg  is  the  seat  of  the  disease  it  becomes 
so  large  as  to  interfere  with  locomotion  and  compel  the 
sufferer  to  take  to  his  bed.  The  suface  of  the  limb  may  be 
smooth  ;  or  uneven  on  account  of  the  varicose  lymphatics  ; 
or  warty  on  account  of  enlargement  of  the  papillae.  The 
foot  and  leg  may  melt  into  each  other,  as  it  were,  all  trace 
of  an  ankle- being  lost.  Wherever  there  are  two  surfaces  in 
contact,  there  is  apt  to  be  a  decomposition  of  the  sweat, 
sebaceous  matter,  and  epithelium,  giving  rise  to  a  foul  odor 
like,  but  worse  than,  that  of  an  ordinary  intertrigo.  The 
lymphatic  glands  in  the  groin  are  enlarged.  Eczema  may 
develop  with  its  attendant  itching.  The  appearance  of  this 
elephantine  leg  gave  the  name  to  the  disease.  When  the 
scrotum  is  the  affected  part,  vomiting  often  occurs  in  the 
febrile  attacks,  as  well  as  pain  in  the  groins  along  the 
spermatic  cord  and  in  the  testicles.    Hydrocele  may  develop, 


192  DISEASES    OF    THE    SKIN". 

and  the  abdominal  rings,  over-stretched  by  the  swollen 
cords,  may  give  opportunity  to  the  formation  of  hernia 
upon  the  subsidence  of  the  acute  symptoms.  The  scrotum 
may  become  so  large  as  to  reach  the  ground  when  the  pa- 
tient is  standing,  and  one  case  has  been  reported  in  which 
it  weighed  one  hundred  and  ten  pounds.  One  form  of  the 
affection  is  called  "  lymph  scrotum  or  nsevoid  elephantiasis," 
on  account  of  the  marked  dilatation  of  the  lymphatics. 

There  are  all  degrees  of  thickening  of  the  skin  and  sub- 
cutaneous tissues,  but  the  recurrent  attacks  of  erysipelas, 
and  the  progressive  enlargement,  are  characteristic  of  all. 
The  bones  may  become  enlarged.  This  is  a  very  rare 
affection,  which  is  called  "  acromegalia."  In  the  Lancet  of 
June  11,  1887,  several  cases  are  reported,  one  of  which 
was  on  exhibition  in  a  travelling  show  as  the  "  Elephant 
man."     In  his  case  the  head  attained  massive  proportions. 

Etiology.  The  disease  occurs  in  both  sexes  and  in  all 
ages,  but  is  most  common  in  men  of  middle  life  and  in  the 
dark-skinned  races.  Moncorvo1  reports  a  case  in  an  infant 
four  months  old,  and  speaks  of  a  case  in  one  fifteen  days  old. 
He  believes  that  it  may  develop  in  utero.  Floras2  reports  a 
case  beginning  at  birth  and  remaining  stationary  for  fifteen 
years,  when  it  took  on  the  typical  course  of  the  disease.  It 
is  particularly  prevalent  in  damp,  malarious  parts  of  the  sea- 
coast.  It  is  not  supposed  to  be  hereditary,  though  in 
countries  in  which  it  is  endemic  several  members  of  the 
same  family  may  be  affected  by  it.  Leprosy  and  elephan- 
tiasis have  been  accidentally  associated.  Exposure  to  cold, 
phlegmasia  dolens,  cellulitis,  ulcers,  lupus,  repeated  attacks 
of  eczema  or  erysipelas,  posture,  as  the  hanging  down  of  a 
limb  on  account  of  rheumatism,  may  give  rise  to  the  disease. 
In  fact,  any  disease  of  the  skin  that  is  attended  by  repeated 
inflammatory  outbreaks  favors  the  occurrence  of  elephanti- 
asis. The  filaria  sanguinis  hominis  has  been  claimed  to  be 
the  cause  of  the  endemic  form  of  the  disease.  It  is  not  found 
in  every  case,  and  is  rarely  encountered  in  sporadic  cases. 

1  Rev.  mens,  des  Mai.  de  l'Enfance,  1886,  iv.  101. 

2  Archiv.  klin.  Chirurgie,  1888,  xxxvii.  598. 


ELEPHANTIASIS.  193 

Pathology.  Anything  that  will  occlude  the  lymphatic 
channels  may  cause  the  disease.  In  endemic  cases  it  is  the 
ova  of  the  filaria  that  does  this.  In  sporadic  cases  the 
several  etiological  factors  play  the  same  part.  However 
caused,  the  result  is  an  enormous  hypertrophy  of  the  sub- 
cutaneous tissues  from  increase  of  fibrous  tissue  in  various 
stages  of  development.  The  corium  is  also  increased  in 
thickness,  and  there  is  proliferation  of  the  epidermis,  en- 
largement of  bloodvessels,  lymphatics,  and  nerves.  In  ad- 
vanced cases  the  muscles  undergo  fibro-fatty  changes,  and 
the  bones  become  enlarged  (Crocker). 

Treatment.  The  best  thing  for  a  patient  with  endemic 
elephantiasis  to  do  is  to  go  to  a  more  healthful  climate.  The 
treatment  of  the  patient  during  the  exacerbations  is  purely 
symptomatic,  with  fomentations,  quinine,  iron,  and  the  like. 
Various  measures  for  the  cure  of  the  disease  have  been  pro- 
posed, but  none  are  perfectly  satisfactory.  Of  course,  the 
scrotal  tumor  may  be  cut  off.  The  leg  has  been  ampu- 
tated at  the  hip,  a  dangerous  operation.  Unfortunately  the 
other  leg  has  become  diseased  soon  after  the  one  has  been 
cut  off.  Ligature  of  the  femoral  artery  has  been  performed, 
but  the  result  has  not  been  satisfactory.  Compression  by 
means  of  a  Martin's  rubber  bandage,  or  the  ordinary  roller 
bandage,  will  afford  relief.  When  it  is  left  off  for  a  time, 
enlargement  will  again  take  place.  It,  of  course,  cannot  be 
used  while  inflammation  is  present.  Bentley1  has  reported 
the  cure  of  a  case  by  the  daily  inunction  of  a  half-drachm 
of  mercurial  ointment  twice  daily,  and  the  application  of  a 
firm  bandage  for  fourteen  days.  After  that  the  inunctions 
were  made  once  a  day.  Internally  he  gave  iodide  of  potash 
alone,  or  in  this  formula  : 


R .  Potass,  iodid.,                                  ^  ij ;  1 

Potass,  chlor.,                                   3j ;  1 

Sol.  hydrarg.  perchlor.,                 %  ss ;  6 

Inf.  chiretta,  ad  ^  viij  ;  100 

Sig.    %  ss  three  times  a  day. 


M. 


Galvanism  has  produced  alleviation,  if  not  cure,  in  some 
cases.     Hardaway  has  seen  great  amelioration  in  one  case 


1  Lancet,  1878,  i,  785. 
9 


194  DISEASES    OF    THE    SKIN". 

by  the  use  of  Squire's  glycerole  of  the  subacetate  of  lead. 
Massage  is  beneficial. 

Prognosis.  Unless  exhausted  by  the  loss  of  lymph  the 
disease  may  last  indefinitely  without  deterioration  of  the 
health.  Death  may  result  from  pyaemia  or  thrombosis. 
The  patient  often  dies  from  some  intercurrent  affection. 

Elephantiasis  Grecorum.     See  Leprosy. 

Emphysema  of  the  skin  is  a  rare  accident.  It  usually 
affects  the  upper  chest  and  neck,  and  is  due  to  a  rupture  of 
the  pulmonary  alveoli  on  account  of  vomiting  or  paroxysmal 
coughing,  and  the  air  making  its  way  under  the  skin.  The 
affected  part  looks  swollen,  feels  cushiony,  and  gives  a  deli- 
cate crackling  sound  on  palpation.  There  will  be  a  history 
of  the  sudden  occurrence  of  the  swelling  after  coughing  or 
vomiting,  and  probably  more  or  less  dyspnoea  will  be  expe- 
rienced. The  air  slowly  escapes,  and  the  parts  return  to 
their  normal  condition. 

Endemic  Verrugas.     See  Favus. 

Endothelcarcinoma.     See  Carcinoma. 

Endurcissement  du  Tissu  Cellulaire.  See  Sclerema 
neonatorum. 

Engelures.     See  Dermatitis  calorica. 

Ephelides.     See  Lentigo. 

Ephidrosis.     See  Hyperidrosis. 

Ephidrosis  Cruenta.     See  Haematidrosis. 

Epidermolysis  (E^-i^du^rm-o^'-P-s^s).  Synonyms :  Acan- 
tolysis  bullosa  (Goldscheide  and  Joseph) ;  Dermatitis  bullosa 
(Valentine).  This  is  a  rare  disease,  or  rather  peculiarity  of 
the  skin,  in  which  bullae  arise  upon  the  slightest  pressure. 
The  disease  shows  itself  in  infancy,  and  occurs  especially 
upon  the  hands  and  feet.  The  tendency  to  the  formation  of 
bullae  lessens  toward  middle  life.  The  lesions  begin  as  a 
red  spot,  which  is  itchy.  The  bulla  begins  to  form  about 
two  hours  afterward,  and  keeps  on  enlarging  for  two  or 
three  days.  It  then  gradually  decreases,  dries  into  a  scale, 
which  falls,  leaving  healthy  skin.  If  the  bulla  is  broken,  it 
discharges  a  yellow,  slightly  sticky  fluid,  and  leaves  a  sup- 


EPITHELIOMA.  195 

purating  base.    The  disease  is  hereditary  in  certain  families, 
and  is  most  pronounced  in  summer-time. 

Epithelialkrebs.     See  Epithelioma. 

Epitheliom  Kystique  Benin.  See  Adenoma  of  sweat 
glands. 

Epithelioma  (E2p-i2-thel-i2-o'ma3).  Synonyms  :  (Fr.)  Epi- 
theliome  cancro'ide  ;  (Ger.)  Epithelialkrebs  ;  Cancroid,  Skin 
cancer,  Epithelial  cancer,  Noli  me  tangere. 

Epithelioma  is  a  chronic,  progressive,  malignant  new 
growth  in  the  skin  or  mucous  membrane,  which  is  char- 
acterized by  the  formation  of  ulcers  with  raised,  hard  waxy 
edges,  and  by  a  strong  tendency  to  return  in  the  scar  after 
apparent  removal  by  knife  or  caustic. 

Symptoms.  Epithelioma  always  begins  in  a  most  inno- 
cent manner,  and  may  be  present  for  months  or  years  be- 
fore the  patient  dreams  that  he  has  a  serious  disease.  It 
may  occur  upon  the  skin  alone,  or  upon  the  mucous  mem- 
brane alone,  or  upon  both  the  skin  and  mucous  membrane 
at  their  line  of  juncture.  Epitheliomas  occurring  upon  the 
tongue,  larynx,  or  uterus  do  not  concern  us  here,  as  they 
belong  to  the  domain  of  surgery.  The  starting-point  of  the 
disease  may  be  a  crack  or  an  abraded  scaly  spot,  as  on  the 
lip ;  a  small,  flat,  scaly,  sebaceous  patch ;  a  white,  pearly- 
looking,  hard  nodule ;  a  senile  or  other  wart  or  papilloma ; 
a  pigmentary  mole ;  a  cicatrix  ;  an  adenoma;  a  chronic  or 
lupous  ulcer ;  a  psoriatic  patch,  or  some  other  new  growth  in 
the  skin.  Some  of  these  lesions  may  have  been  present  for 
many  years,  as,  for  instance,  a  mole.  Some  appear  but  a 
short  time  before  they  frankly  declare  their  nature,  such  as 
the  waxy  nodule.  However  it  may  begin,  after  a  varying 
time  ulceration  occurs,  the  disease  spreads  at  its  edges,  and 
the  ulceration  grows  deeper  and  deeper,  eating  its  way 
through  skin,  muscles,  and  bone  in  the  infiltrating  form,  or 
creeping  over  the  surface  in  the  most  superficial  form.  The 
lymphatic  glands  may  be  involved  early  in  the  course  of  the 
disease,  or  not  for  many  years.  Eventually  they  become 
swollen,  hard,  break  down,  and  ulcerate,  assuming  the  ap- 
pearance of  an  epitheliomatous  ulcer.     A  typical  epitheli- 


196  DISEASES    OF    THE    SKIN. 

omatous  'ulcer  is  irregular  in  shape,  with  raised,  hard,  waxy- 
looking,  rounded  or  everted  edges,  over  which,  quite  com- 
monly, course  dilated  bloodvessels ;  the  floor  is  uneven, 
bleeds  easily  when  touched,  and  is  covered  by  a  brownish 
crust,  or  a  sanious,  purulent  secretion.  Epithelomas  are 
usually  single  lesions,  but  they  may  be  multiple.  Some 
years  ago  there  was  a  patient  in  Dr.  George  H.  Fox's  ser- 
vice at  the  New  York  Skin  and  Cancer  Hospital,  who  had 
scores  of  epithelomas  developing  from  large,  waxy,  reddish 
nodules  scattered  all  over  his  face.  Sometimes  a  single  epi- 
thelioma attains  vast  dimensions,  involving  the  whole  of  one 
side  of  the  face,  scalp,  and  neck  in  one  huge  excavated  ulcer. 
Sometimes  before  the  characteristic  ulceration  develops  the 
new  growth  may  take  the  form  of  a  single  enlarged  papilla, 
or  a  group  of  them.  In  some  cases  it  may  have  a  cauli- 
flower-like appearance,  spreading  out  from  a  more  or  less 
narrow  base.  Fissures  are  apt  to  form  between  the  papilla, 
and  then  there  is  usually  an  offensive  discharge.  This  is 
called  the  papillary  form.  The  most  typical  case  of  the 
cauliflower  form  that  I  have  seen  was  on  the  vulva. 

Subjective  symptoms  are  absent  in  many  cases  at  first, 
but  in  the  deep,  infiltrating  form  pain  of  a  lancinating  char- 
acter is  present.  This  often  is  so  severe  that  the  sufferer  is 
robbed  of  his  sleep.  Sometimes  there  is  no  pain,  and  the 
patient  experiences  only  the  discomfort  incident  to  the 
ulceration. 

The  course  of  the  disease  is  always  chronic.  Different 
cases  show  different  degrees  of  malignancy.  Some  will 
prove  fatal  in  four  years  or  less  ;  some  will  last  indefinitely. 
There  is  no  tendency  to  recovery,  though  at  times  a  partial 
attempt  at  healing  will  be  made.  I  have  watched  one  super- 
ficial epithelioma  in  an  old  Irishwoman,  in  Prof.  E.  B. 
Bronson's  service  at  the  New  York  Polyclinic,  creep  over 
the  skin  of  the  face,  healing  up  in  the  older  parts  while 
spreading  ahead.  She  refused  active  interference.  While 
all  epitheliomas  show  a  strong  tendency  to  return  after 
operation  and  in  the  scar  left  by  it,  in  some  cases  this  ten- 
dency is  much  more  marked  than  in  others.  Death  results 
from  exhaustion. 


EPITHELIOMA.  197 

While  epithelioma  may  occur  upon  any  part  of  the  body, 
it  is  more  frequently  located  upon  the  lower  lip,  where  it 
occurs,  according  to  Paget,  in  50  per  cent,  of  the  cases. 
The  next  most  common  location  is  the  face.  Indeed,  Thiersch 
met  with  it  here  in  seventy-eight  out  of  one  hundred  and 
two  cases.  The  external  genital  organs  of  both  sexes,  and 
the  anal  region,  more  rarely,  are  other  common  sites.  The 
upper  lip  is  very  rarely  affected.  A  favorite  location  upon 
the  face  is  upon  the  side  of  the  nose  and  near  the  inner 
canthus  of  the  eye.  Here  it  is  very  apt  to  pass  over  on  to 
the  eyelids,  and  destroy  them.  Not  infrequently  it  begins 
upon  the  eyelid  itself. 

It  is  customary  to  describe  a  number  of  forms  of  epi- 
thelioma, but  it  seems  to  me  much  better,  especially  for  a 
student,  not  to  encumber  his  mind  with  too  many  names. 
The  superficial,  deep-seated  or  infiltrated,  and  the  papillary 
forms  have  already  been  mentioned.  The  chimney-sweep's 
cancer  is  an  epithelioma  of  the  scrotum,  met  with  in  par- 
affin-workers and  chimney-sweeps.  The  rodent  ulcer 
used  to  be  described  as  a  special  form  of  disease,  but  it  is 
now  considered  to  be  an  epithelioma.  Clinically,  it  is  sup- 
posed to  be  characterized  by  occurring  on  the  skin  of  the 
upper  half  of  the  face,  but  running  a  slower  and  painless 
course  by  not  involving  the  lymphatics,  and  by  perpendicu- 
lar rather  than  lateral  extension. 

Etiology.  The  cause  of  epithelioma  is  often  obscure. 
We  know  that  repeated  irritation  of  a  part  is  often  followed 
by  its  advent.  Smoking  short  clay  pipes  is  not  uncom- 
monly followed  by  epithelioma  of  the  lip ;  a  ragged  tooth 
accounts  for  many  an  epithelioma  of  the  tongue ;  the  wear- 
ing of  spectacles  or  eye-glasses  has  in  some  cases  apparently 
caused  the  new  growth  upon  the  nose ;  constant  picking  or 
inadequate  attempts  at  the  removal  of  warts  and  scaly  spots 
would  seem  to  account  for  epithelioma  of  the  face ;  and  the 
scratching  to  relieve  the  pruritus  of  the  anus  may  play  the 
same  part  in  producing  the  disease  about  the  anus.  This 
constant  irritation  would  explain  the  appearance  of  epi- 
thelioma in  paraffin-workers  and  chimney-sweeps,  in  chronic 
ulcers,  psoriasis,  old  cicatiices,  and  the  like.     A  congenital 


198  DISEASES    OF    THE    SKIN. 

or  acquired  phimosis  and  the  repeated  inflammation  due  to 
decomposing  smegma  are  the  forerunners  of  the  disease 
upon  the  penis.  Age  is  the  most  pronounced  predisposing 
cause.  The  disease  is  rare  under  thirty  years  of  age,  and 
increases  in  frequency  beyond  that  period.  Heredity  has 
some  influence,  though  Lewis  has  found  that  it  is  not  so 
well  marked  as  it  is  frequently  assumed  to  be.  Males  are 
more  often  affected  than  females.  It  seems  to  have  a  pre- 
dilection for  all  neoplastic  growths.  The  latest  theory, 
unproven,  is  that  of  Darier  and  Wickham,  who  think  that 
it  is  parasitic  and  due  to  psorosperms.  (See  section  on 
that  subject.) 

Pathology.  Crocker  sums  up  the  pathology  of  the 
affection  as  follows :  "  The  essence  of  the  epitheliomatous 
process  is  the  development  of  epithelium,  and  its  infiltration 
into  the  deeper  tissues  where  it  does  not  normally  exist,  and 
where  its  presence  produces  irritation  and  consequent  in- 
flammatory changes."  "  Cell  nests,  consisting  of  horny 
transformed  cells  in  the  centre,  and  of  laminae  of  flattened 
epithelium  externally,  are  characteristic  of  the  disease,  but 
are  not  present  in  every  case,  nor  is  their  presence  always 
necessary  for  a  diagnosis."     (Robinson.) 

Diagnosis.  The  disease  must  be  differentiated  from 
lupus,  syphilis,  papilloma,  and  seborrhoeal  warts.  From 
lupus  it  differs  in  an  entire  absence  of  brownish  lupus 
tubercles ;  in  beginning  late  in  life,  as  a  rule,  while  lupus 
begins  in  early  life;  by  its  comparatively  more  rapid  course; 
its  lancinating  pain;  the  involvement  of  the  lymphatic 
glands;  the  deep  ulceration;  the  waxy,  raised,  hard  margin; 
and  the  development  of  the  cancerous  cachexia.  From 
syphilis  it  differs  in  having  a  single  and  not  a  multiple 
lesion ;  in  its  slower  course ;  in  its  showing  no  tendency  to 
recovery ;  in  its  not  responding  to  internal  treatment ;  in 
its  painfulness ;  and  in  its  waxy,  raised,  hard  margin.  From 
papilloma  and  seborrhoeal  warts  there  are  no  positive  diag- 
nostic marks  of  distinction.  Either  of  the  two  diseases 
appearing  late  in  life,  or  showing  symptoms  of  activity  at 
that  time,  should  rouse  our  suspicions. 

Treatment.     Complete  and  radical  destruction  of  the 


EPITHELIOMA. 


199 


disease  is  the  only  thing  to  be  done  in  the  treatment  of 
epithelioma.  As  a  prophylactic  measure  it  is  well  to  de- 
stroy all  suspicious  warts  appearing  after  middle  life,  and 
to  apply  appropriate  treatment  to  seborrhoeal  patches  occur- 
ring at  the  same  period.  Superficial  caustics  should  never 
be  used  to  an  epithelioma,  as  they  only  encourage  their 
growth.  The  radical  treatment  will  differ  with  the  point  of 
view,  all  surgeons  inclining  to  the  knife,  while  dermatolo- 
gists advocate  the  curette  or  powerfully  destructive  caustics. 
If  the  knife  is  used  it  must  cut  out  a  wide  margin  beyond 
the  growth.  Extirpation  is  especially  applicable  and  the 
most  appropriate  treatment  of  epithelioma  of  the  lip  and 
penis.  In  the  latter  the  organ  must  be  amputated  above  the 
ulcer,  if  that  has  attained  any  size,  and  the  inguinal  glands 
likewise  taken  out.  In  all  cases  in  Avhich  the  lymphatic 
glands  have  become  involved  they  should  be  taken  out. 

To  all  superficial  epitheliomas  and  to  many  of  the  in- 
filtrating variety  Schwimmer's  plan  of  treatment  will  be 
applicable,  and  will  prove  curative.  The  growth  is  to  be 
scraped  out  thoroughly  with  the  dermal  curette  (Fig.  17); 

Fig.  17. 


The  dermal  curette. 


the  diseased  tissues  will  give  way  readily ;  the  bleeding  is 
to  be  stopped  by  pressure ;  and  a  pyrogallic  acid  ointment 
of  33  J  per  cent,  strength  is  to  be  applied  for  from  four  to  six 
days.  Care  should  be  taken  that  it  be  applied  exactly  to 
the  growth,  for  though  it  exerts  its  greatest  action  upon  the 
diseased  tissues,  it  also  acts  upon  the  sound  skin.  This 
ointment  will  produce  a  black  crust  over  the  growth,  on 
account  of  oxidation  of  the  acid,  and  will  cause  a  free  dis- 


200  DISEASES    OF    THE    SKIN. 

charge  from  the  scraped  surface  during  a  few  days.  The 
discharge  becomes  less  by  degrees.  After  the  end  of  four 
or  six  days  the  black  crust  is  to  be  removed  by  covering  it 
with  carbolized  vaseline  for  twenty-four  or  forty-eight 
hours.  Last  of  all  mercurial  plaster  is  to  be  applied, 
under  which  the  part  will  heal.  This  method  has  produced 
most  satisfactory  results  in  my  hands,  and  is .  not  particu- 
larly painful  if  cocaine  is  used  hypodermically  before  the 
scraping. 

Arsenic  holds  the  first  place  among  caustics.  Marsden's 
paste,  composed  of  equal  parts  of  arsenious  acid  and  gum 
acacia  rubbed  together  and  mixed  into  a  paste  with  water 
just  before  using,  is  perhaps  the  most  often  used.  It  is 
dreadfully  painful  and  often  causes  great  oedema.  It  should 
be  applied  accurately  to  the  affected  part  on  linen,  and  left 
on  for  twelve  to  twenty-four  hours,  according  to  the  patient's 
endurance.  Poultices  are  to  be  applied  after  the  paste,  and 
kept  on  continuously  till  the  slough  separates.  If  the 
growth  has  not  been  destroyed,  the  process  may  be  repeated. 
Lewis1  has  had  good  results  from  using  Bougard's  paste,  as 
follows : 

R .  Wheat  flour,  \  -  -         aa 

Starch,  |  aa         0U 

Arsenic,  1 


Cinnabar,  1  .  _  K 

Sal.  ammoniac,  J 

Corrosive  sublimate, 

Solution  chloride  of  zinc  @,  52°,  245 


50 


M. 


The  first  six  ingredients  are  separately  ground  to  a  fine 
powder  and  mixed  in  a  mortar.  Then  the  solution  of  the 
zinc  is  slowly  added  while  the  mass  is  stirred.  It  is  to  be 
kept  covered  in  an  earthen  jar.  A  portion  is  to  be  applied 
accurately  to  the  part  and  kept  on  for  thirty  hours,  and 
followed  by  a  poultice.  Lactic  acid  is  another  powerful 
caustic,  to  be  applied  by  mixing  it  with  an  equal  part  of  finely 
powdered  silica  and  spreading  it  upon  gum-paper.  It  is  kept 
on  for  twelve  hours  and  renewed  twenty-four  hours  afterward. 

1  Journ.  Cutan.  and  Gen.-urin.  Dis.,  1890,  viii.  70. 


EQUINIA.  201 

Hardaway  prefers  to  apply  the  syrupy  acid  by  means  of 
absorbent  cotton  for  ten  or  fifteen  minutes,  and  then  wash 
off  the  excess  of  acid  with  water.     This  is  done  daily. 

The  thermo-  or  galvano-cautery  may  also  be  used.  Re- 
sorcin  has  its  advocates,  as  has  caustic  potash,  chloride  of 
zinc,  and  the  nitrate  of  silver.  These  may  be  of  service 
where,  for  any  reason,  a  more  radical  operation  is  not 
admissible.  The  chlorate  of  potassium  in  saturated  solu- 
tion has  in  some  hands  done  good.  Fuchsin  and  methyl-blue, 
either  injected  under  the  skin  or  locally  applied,  will  some- 
times seem  to  stay  the  progress  of  an  epithelioma. 

There  are  some  cases  that  are  too  advanced  for  any  active 
interference,  and  the  palliative  remedies  only  are  permissible. 

Prognosis.  The  prognosis  of  epithelioma  as  to  life  is 
fairly  good.  While,  as  already  said,  there  are  some  cases 
that  are  rapidly  fatal,  many  do  not  seem  to  have  any  effect 
on  the  patient's  health  for  years.  The  prognosis  as  to  cure 
is  always  doubtful.  Some  cases,  whether  excised  or  de- 
stroyed by  other  means,  will  return  after  a  time. 

Epithelioma  Contagiosum.     See  Molluscum. 

Epitheliomatose  Pigmentaire.  See  Atrophoderma  pig- 
mentosum. 

Equinia  (E2k-wiV-i2-a3).  Synonyms :  Glanders  ;  Farcy ; 
(Fr.)  Morve  ;  (Ger.)  Rotz. 

A  contagious,  specific  disease,  with  general  and  local 
symptoms,  derived  from  the  horse. 

This  is  a  rare  disease  in  the  human  race,  and  runs  an  acute, 
subacute,  or  chronic  course.  It  is  derived  by  inoculation,  and 
its  symptoms  show  themselves  in  from  three  days  to  six 
weeks  after  it.  Its  constitutional  symptoms  are  fever,  pros- 
tration, constipation,  and  rheumatic  pains,  with  the  subse- 
quent development  of  a  typhoid  condition  in  which  the 
patient  dies.  The  objective  symptoms  are  a  profuse  puru- 
lent or  sanious  nasal  discharge ;  chancroidal  ulceration  at 
the  site  of  entrance  of  the  poison ;  phlegmonous  inflamma- 
tion of  the  affected  part ;  adenitis ;  and  a  cutaneous  efflo- 
rescence. The  latter  is  at  first  disseminated  red  macules 
developing   into  yellow  papules,   upon  which  variola-like 

9* 


202  DISEASES    OF    THE    SKIN. 

pustules  and  bullae  may  form.  These  may  coalesce  into 
superficial  ulcerations  and  gangrenous  patches.  Infiltration 
of  the  subcutaneous  tissues  may  occur  and  deep  sloughs 
may  form.  There  may  be  a  general  adenitis,  and  the  glands 
may  break  down  and  form  ulcerating  cavities.  The  whole 
skin  may  be  involved  in  these  destructive  processes. 

Treatment.  Treatment  is  usually  unavailing,  and  is 
on  general  principles.  The  prognosis  is  bad.  The  more 
acute  the  symptoms  the  worse  the  outlook. 

Erbgrind.     See  Favus. 

Erysipelas  (E2r-i2-si2p'e2l-a2s).  Synonyms  :  (Fr.)  La  rose, 
Feu  sacre  ;  (Ger.)  Rothlauf,  Rose,  Hautrose,  Wundrose ; 
(It.)  Risipola ;   St.  Anthony's  fire,  Wildfire,  Rose. 

An  inflammatory  disease  of  the  skin  or  the  adjacent 
mucous  membranes,  attended  always  with  redness  and  swell- 
ing, and  often  with  vesicles,  bulla?,  pustules,  diffuse  sup- 
puration, and  gangrene ;  and  characterized  by  a  tendency 
to  spread  at  the  periphery  and  by  fever.     (Foster.) 

Symptoms.  Though  the  most  modern  pathology  teaches 
that  erysipelas  always  originates  in  or  about  a  lesion  of  the 
skin  or  mucous  membrane,  and  is  therefore  allied  if  not 
identical  with  the  same  disease  as  met  with  in  surgical  and 
lying-in  wards,  so-called  surgical  erysipelas  will  not  be  con- 
sidered here.  The  outbreak  of  the  disease  is  usually  pre- 
ceded for  a  day  or  so  with  malaise,  and  the  attack  is  often 
ushered  in  with  a  chill,  pyrexia,  and  vomiting.  The  fever 
is  present  throughout  the  whole  course  of  the  disease,  ex- 
cepting in  the  most  mild  type,  when  it  may  soon  subside. 
The  thermometric  range  is  from  101°  to  105.5°  F.  There 
will  be  other  signs  of  constitutional  disturbance,  such  as  a 
coated  tongue,  a  quickened  pulse,  either  full,  soft,  and  com- 
pressible, or,  in  bad  cases,  small  and  weak ;  headache, 
drowsiness,  or,  in  bad  cases,  delirium ;  and  sometimes  albu- 
min is  found  in  the  urine. 

The  most  frequent  location  of  the  disease,  as  far  as  we 
now  are  concerned,  is  the  head  and  face,  though  it  may 
occur  anywhere  on  the  body.  The  eruption  begins  usually 
as  a  single  patch,  which  is  at  once  rosy  red,  swollen,  sharply 
defined,  irregularly  shaped,  hot  to  the  touch,  and,  at  first, 


EKYSIPELAS.  203 

with  a  smooth,  glazed  surface.  The  patch  enlarges,  creep- 
ing with  more  or  less  rapidity  over  the  surface,  always  pre- 
serving its  sharp,  ofttimes  indented  border  that  is  raised 
toward  the  sound  skin ;  it  becomes  of  a  darker  hue,  some- 
times livid ;  and  very  commonly,  though  not  uniformly, 
vesicles  or  even  blebs  form  on  it.  These  latter  may  become 
purulent,  and  breaking,  discharge  their  contents  upon  the 
surface,  which  dries  into  crusts.  As  the  process  extends, 
the  central  portion  becomes  flattened  and  less  red.  Some- 
times new  patches  may  appear,  and  coalesce  with  the 
original  patch.  Sometimes,  while  spreading  peripherally, 
there  may  be  a  recrudescence  in  the  older  parts.  The  area 
of  the  disease  may  be  limited  or  may  include  the  whole 
body.  Arery  often  it  seems  to  be  checked  by  the  line  of 
the  hair,  whether  of  the  whiskers  or  scalp.  Not  uncom- 
monly it  invades  the  hairy  parts,  involving  one-half  or  the 
whole  of  the  scalp  and  extending  down  upon  the  neck. 
Then  the  patient's  appearance  is  indeed  deplorable.  His 
lips  are  swollen  and  livid,  his  eyelids  are  swollen  so  that  the 
eyes  cannot  be  opened,  and  his  head  seems  enormously  en- 
larged. At  times  there  may  be  a  lighting  up  of  the  disease 
on  a  distant  part  of  the  body,  as  on  the  arm  with  erysipelas 
of  the  face.  The  lymphatics  and  the  lymphatic  glands  are 
involved.  The  former  often  show  themselves  as  red  streaks. 
The  glands  may  suppurate,  and  gangrene  of  the  skin  may 
declare  itself.  All  grades  of  inflammation  may  be  reached. 
Sometimes  the  disease  is  but  slight,  sometimes  very  severe, 
the  constitutional  symptoms  keeping  pace  with  the  severity 
of  the  local  symptoms.  The  duration  of  the  disease  may  be 
six  or  seven  days,  or  two  or  three  weeks.  The  patient  is 
always  more  or  less  prostrated  by  it,  though  many  of  the 
cases  we  see  are  ambulant  cases. 

The  subjective  symptoms  are  burning,  tingling,  itching, 
and  tension.  The  parts  are  often  tender,  and  may  be  spon- 
taneously painful. 

The  disease  quite  commonly  begins  about  the  nose,  and 
may  invade  the  mouth.  Occasionally  it  spreads  rapidly 
over  the  surface  as  an  advancing,  broad,  rosy  red,  raised 
line.  Sometimes  recurrent  attacks  occur  at  short  intervals ; 
generally  the  disease  does  not  recur.     When  the  scalp  is 


204  DISEASES    OF    THE    SKIN. 

invaded,  the  hair  commonly  falls  during  convalescence. 
Sometimes  some  lesion  of  the  skin  may  be  found  as  the 
starting-point  of  the  inflammation,  or  perhaps  some  lesion 
of  the  mucous  membrane  of  the  nose,  mouth,  or  ear.  In 
the  recurrent  attacks  the  nose  is  quite  commonly  the  pec- 
cant member.  But  in  a  very  large  proportion  of  cases  no 
lesion  at  all  will  be  discoverable.  When  the  disease  sub- 
sides the  skin  desquamates,  and  returns  at  last  to  the 
normal  condition. 

Erysipelas  occurring  upon  the  trunk  or  extremities  pre- 
sents pretty  much  the  same  symptoms  as  when  occurring 
upon  the  face. 

Etiology.  It  is  now  generally  accepted  that  the  disease 
is  infectious  and  caused  by  a  specific  microorganism  that 
was  described  by  Fehleisen.1  This  gains  access  to  the  body 
through  some  lesion  of  continuity  of  the  skin,  however 
minute  that  may  be.  As  in  many  of  the  supposed  bacterial 
diseases,  so  in  this  one,  it  is  probable  that  the  patient  must 
be  in  the  proper  condition  of  health,  or  rather  ill-health,  for 
the  lodgment  of  the  cocci.  It  is  more  frequent  in  women 
than  in  men ;  and  in  winter,  than  in  summer.  Intemper- 
ance, Bright's  disease,  parturition,  and  a  lowered  state  of 
nutrition  predispose  to  it.  While  the  contagiousness  of 
surgical  erysipelas  is  well  known,  and  commonly  observed, 
it  is  rare  to  meet  a  case  of  facial  erysipelas  traceable  directly 
to  contagion.  The  possibility  of  the  occurrence  of  the  dis- 
ease without  infection  by  the  microorganism  may  still  be 
entertained.  It  has  been  thought  to  arise  from  taking  cold, 
or  to  begin  in  some  circumscribed  purulent  deposit. 

There  is  nothing  specific  about  the  pathological  anatomy 
of  the  disease. 

Diagnosis.  If  the  clinical  features  of  the  disease  are 
kept  in  mind,  the  sharply  defined,  swollen,  red  patch,  ad- 
vancing with  more  or  less  steadiness  over  the  surface,  the 
process  being  preceded  by  a  chill  and  accompanied  by 
marked  constitutional  disturbance,  there  is  little  danger  of 
mistaking  it.  It  may,  however,  be  mistaken  for  an  erythe- 
matous eczema,  an  erythema,  or  urticaria.     In  eczema  the 

1  Deutsche  Zeitschrift  fur  Chirurgie,  1882,  xvi.  391. 


ERYSIPELAS.  205 

parts  are  not  so  swollen ;  the  margin  of  the  patch  fades  into 
the  surrounding  skin  ;  the  color  is  not  so  brilliant ;  the  sur- 
face is  rougher  and  more  scaly ;  there  is  decided  itching, 
and  a  lack  of  constitutional  disturbance  of  any  magnitude. 
Erythema  lacks  the  constitutional  symptoms  of  erysipelas  ; 
the  redness  fades  completely  away  under  pressure,  without 
leaving  a  yellowish  stain,  and  springs  back  promptly  when 
the  pressure  is  removed  ;  it  does  not  creep  over  the  skin  ;  and 
it  is  of  short  duration.  In  urticaria  there  will  usually  be  well- 
marked  wheals  or  a  history  of  them  ;  great  itching ;  no 
tenderness ;  a  short  course  ;  a  history  or  evidence  of  diges- 
tive disturbance ;  and  an  absence  of  marked  constitutional 
disturbance. 

Treatment.  The  great  variety  of  remedies  that  have 
been  vaunted  for  the  cure  of  erysipelas  evidences  the  fact 
that  most  cases  recover  of  themselves.  There  are  not  a 
few  competent  observers  who  are  sceptical  of  the  real  efficacy 
of  any  treatment.  As  the  disease  tends  to  lower  the  vitality 
of  the  patient  we  should  strive  to  support  his  strength  by  a 
most  nutritious  diet,  and  by  alcoholic  stimulants  in  adynamic 
cases.  The  internal  medication  will  be  symptomatic  to  a  large 
extent,  by  means  of  aconite,  quinine,  antipyrin,  phenacetine, 
and  the  like.  The  tincture  of  the  chloride  of  iron,  in  twenty 
to  sixty  minim  doses  every  two  or  three  hours,  is  regarded 
by  many  as  a  specific,  and  should  be  given  in  all  but  the 
slightest  cases.  Jaborandi  by  the  mouth,  or  pilocarpine, 
one-sixth  to  one-quarter  grain  hypodermic-ally,  have  their 
advocates,  but  must  not  be  thought  of  in  debilitated  subjects. 

The  local  treatment  is  very  important.  The  lead  and 
opium  wash  is  an  old  remedy  and  has  proved  useful  in  very 
many  cases.  It  may  be  used  hot  or  cold,  whichever  is 
most  agreeable  to  the  patient.  Dry  heat  will  also  relieve 
the  discomfort  of  the  patient.  Resorcin  in  watery  solution 
of  2  or  3  per  cent,  strength  seems  at  times  to  cut  short  the 
disease.  Duckworth1  commends  chalk  ointment  made  of 
equal  parts  of  melted  lard  and  chalk,  with  or  without  a 
half-drachm  of  pure  carbolic  acid  to  the  ounce.  This  is  to 
be  smeared  on  thickly  and  covered  with  plain  or  boric  lint. 

1  Practitioner,  January,  1887. 


206  DISEASES    OF    THE    SKIN. 

White-lead  paint  has  done  well  in  some  hands.  White1 
expects  to  cure  his  cases  of  ordinary  facial  erysipelas  by 
keeping  the  part  constantly  covered  with  cloths  saturated 
in  the  following : 

R .  Ac.  carbolici,  3  j  ;         4 

Alcohol.,  ")  -       r\  orn 

Aqua,       }  aa     0ss5     250  •  M. 

It  may  be  used  every  alternate  hour.  Carbolic  acid 
may  also  be  used  in  oil,  10  per  cent,  strength,  and  rubbed 
in  every  hour.     Piffard  recommends  the  external  use  of: 

H .  Tinct.  belladonna,  1  part. 

Glycerini,  1     " 

Aqua,  8  parts.       M. 

Shoemaker  is  fond  of  the  ointment  of  the  oleate  of  bis- 
muth. Ichthyol,  equal  parts  with  vaseline,  or  as  a  paint 
with  collodion,  may  be  used. 

The  treatment  by  scarifications  about  the  patch,  the  in- 
cisions being  made  diagonally,  partly  in  the  sound  and  partly 
in  the  diseased  skin,  and  then  covered  with  gauze  wet  with 
a  solution  of  bichloride  of  mercury,  1  in  1000,  has  of  late 
been  highly  praised  by  many  men.  This  is  known  as  the 
Kraske-Riedel  method,  and  should  be  always  thought  of  in 
grave  cases.  Woelfler2  recommends  compression  of  the 
border  line  by  adhesive  plaster  strips. 

Prognosis.  Many  cases  of  erysipelas  recover  of  them- 
selves in  a  few  days.  The  prognosis  may  be  said  to  be 
good  in  most  cases.  But  even  in  those  that  begin  as  mild 
ones,  we  should  be  on  the  watch  for  grave  symptoms. 
When  the  scalp  is  affected  the  prognosis  is  more  grave  than 
when  the  face  alone  is  the  seat  of  the  disease.  When  the 
patient  is  the  subject  of  chronic  alcoholism,  or  Bright's  dis- 
ease, or  is  in  the  puerperal  state,  the  prognosis  is  bad. 

Erysipeloid  is  a  term  employed  by  Rosenbach  to  desig- 
nate an  erysipelatous  eruption  unattended  by  constitutional 
symptoms.     It  is  an  infectious  disease  originating  in  a  wound 

1  Trans.  Amer.  Derm.  Assoc,  1890. 

2  Wiener  klin.  Wochenschr.,  1889,  Nos.  23  and  25. 


ERYTHEMA. 


207 


from  contact  with  some  dead,  putrefying  animal  substance,  and 
chiefly  affecting  cooks,  butchers,  fishmongers,  and  the  like. 
It  occurs  mostly  on  the  fingers,  and  spreads  from  the  point 
of  inoculation  as  a  dark-red,  often  livid  swelling  with  a 
sharp  border.  As  it  travels  over  the  surface  the  central 
portion  undergoes  involution,  and  thus  circles  may  be  formed. 
It  stops  spontaneously  after  one  to  three  weeks'  duration. 
A  salicylic  acid  or  other  antiseptic  ointment  may  be  used  in 
treatment. 

Erythanthema  (E2r-i2-tha2nrthe2ma3)  is  a  term  employed 
by  Auspitz  to  designate  a  class  of  cutaneous  efflorescences 
which  have  in  common  a  basis  of  erythema.     (Foster.) 

Erythema  (E2r-i2-therma3).  Synonyms  :  Dermatitis  ery- 
thematosa, Erysipelas  suffusum ;  (Fr.)  Erytheme,  Dartre 
erythemo'ide;  (Ger.)  Erythem,  Hautrothe ;  Rose  rash. 

An  inflammatory  hyperemia  of  the  skin  attended  with 
redness  of  the  surface,  and  usually  only  slight  or  imper- 
septible  exudation,  and  with  little  or  no  disturbance  of  the 
epidermis.     (Foster.) 

There  are  many  forms  of  erythema,  but  they  may  all  be 
classed  under  one  of  two  main  varieties,  namely  :  Erythema 
hyperaemicum,  and  Erythema  exudativum.  I  shall  follow 
Crocker's  classification,  as  it  is  a  practical  one.  It  is  a 
question  whether  erythema  should  be  regarded  as  a  disease 
or  a  symptom. 


f  i. 


Erythema  - 


E.  hypersemicum  \ 


I 


Due  to  external 
causes 


Due  to  internal 
causes 


E.  exudativum 


E.  multiforme 
E.  seu  Herpes  iris 
E.  nodosum 
k  E.  gangrenosum 


f  E.  simplex. 

J  E.  pernio. 

-J  E.  intertrigo. 

j  E.  lreve. 

[  E.  paratrimma. 

{  E.  fugax. 

j  E.  urticans. 

I  E.  roseola. 

^  E.  scarlatiniforine. 


Symptoms.  Erythema  Hypercemicwm.  This  form  of 
erythema  is  characterized  by  simple  redness  without  swell- 
ing, and  usually  is  not  followed  by  desquamation.     This 


208  DISEASES    OF    THE    SKIN 

shows  that  it  is  due  simply  to  a  localized  hyperemia  with- 
out inflammation.  It  is  always  of  short  duration.  The 
redness  disappears  under  pressure,  but  springs  back  again 
as  soon  as  the  pressure  is  removed.  It  occurs  both  in  cir- 
cumscribed patches  of  large  or  small  size,  or  diffused  over 
large  areas.  Subjective  symptoms  are  often  hardly  notice- 
able. There  may  be  some  burning  and  tenderness,  but 
there  is  never  decided  itching.  The  patient  may  rub  his 
skin  gently,  but  never  scratches  violently.  There  may  be 
slight  constitutional  symptoms  with  fever  of  mild  grade, 
or  some  digestive  disturbance,  but  these  are  not  properly 
symptoms  of  the  erythema,  but  rather  of  the  underlying 
disease  of  which  the  eruption  is  but  an  accidental  expres- 
sion. For  instance,  two  people  may  eat  the  same  thing. 
In  both  there  may  be  digestive  disturbances.  But  one  will 
have  an  erythema  and  the  other  will  escape. 

Etiology.  This  form  of  erythema  may  arise  either  from 
external  or  internal  causes.  Those  arising  from  external 
causes  are  localized,  while  those  due  to  internal  causes  are 
general.  Both  are  angioneuroses,  and  predisposed  to  by  an 
inborn  susceptibility,  that  is  idiosyncrasy,  of  the  patient. 

In  the  first  group  we  have  Erythema  simplex,  due  to 
the  rubbing  of  the  clothing,  the  effect  of  heat  or  cold,  as  of 
the  sun  or  wind,  and  of  various  vegetable  or  chemical  irri- 
tants. Many  of  these  simple  erythemas  we  have  already 
described  under  the  caption  of  Dermatitis  venenata,  which 
see.  They  are  usually  localized,  and  for  treatment  require 
only  the  removal  of  the  irritating  cause,  and  the  application 
of  a  simple  dusting-powder  or  ointment. 

Erythema  Pernio  has  been  described  under  Dermatitis 
calorica,  which  see. 

Erythema  Intertrigo,  or  simply  Intertrigo,  is  an  erythema 
occurring  between  two  folds  of  skin.  It  is  most  commonly 
seen  in  fat  infants  in  the  folds  of  the  skin  of  the  neck  and 
joints.  It  is  also  encountered  in  adults  who  are  corpulent,  and 
is  often  a  very  annoying  trouble  to  women,  where  it  fre- 
quently occurs  underneath  the  hanging  breasts.  It  also 
occurs  in  adults  between  the  scrotum  and  inside  of  the 
thighs,  under  the  prepuce,  in  the  furrows  alongside  of  the 


ERYTHEMA.  209 

vulva,  in  the  joints,  and  all  other  skin  creases.  It  is  caused 
by  the  friction  in  walking  and  favored  by  heat  and  moisture. 
It  is  therefore  more  common  in  warm  weather.  If  not  at 
once  and  properly  attended  to,  the  decomposition  of  the 
sweat  and  sebaceous  matters  will  aggravate  it ;  and  the 
irritation  being  continued,  an  eczema  will  start  up.  It  is, 
in  infants,  very  common  about  the  inside  of  the  thighs, 
where  the  wet  napkins  cause  and  aggravate  it.  It  is  very 
often  accompanied  by  a  disagreeable,  cheesy  odor,  and, 
contrary  to  what  obtains  in  other  erythemas,  there  is  exuda- 
tion upon  the  skin  in  some  cases. 

Diagnosis.  The  diagnosis  from  eczema  is  very  often 
difficult.  Indeed,  they  run  into  each  other  so  imperceptibly 
at  times  that  it  is  difficult  to  tell  where  erythema  leaves  off 
and  eczema  begins.  But  eczema  itches  more  than  erythema, 
it  tends  to  spread  further  beyond  the  affected  part,  and  its 
exudation  is  not  only  sticky,  but  also  stains  and  stiffens 
linen.  The  location  in  the  skin-folds  should  suggest  an 
erythema.  Happily,  the  differentiation  is  a  matter  of  no 
great  importance  as  the  same  treatment  is  applicable  to 
both. 

In  infantile  syphilis  we  frequently  have  an  eruption  upon 
the  buttocks  and  inside  of  the  thighs  that  bears  a  decided 
resemblance  to  intertrigo.  Here  a  correct  diagnosis  is  of 
great  importance.  In  syphilis  the  redness  commonly  ex- 
tends down  the  whole  inside  of  the  legs  to  the  feet  and 
soles,  it  is  of  a  darker  color,  and  there  will  be  other  symp- 
toms of  the  disease,  such  as  snuffles,  large  or  small  papules 
to  the  outside  of  the  red  patch,  mucous  patches,  and  the 
like.  In  infants'  asylums,  where  a  great  number  of  debili- 
tated as  well  as  syphilitic  children  are  received,  opportuni- 
ties for  the  differentiation  between  syphilis  and  intertrigo 
frequently  occur. 

Treatment.  The  treatment  of  intertrigo  is  simple.  The 
opposing  surfaces  of  skin  must  be  separated  by  pieces  of 
lint,  the  furrows  must  be  kept  perfectly  clean,  and  dusting- 
powders  of  starch,  talc,  lycopodium,  and  the  like  must  be 
freely  used.  To  these  powders  oxide  of  zinc,  boric  acid,  or 
Other  astringents  may  be  added.     Hardaway  recommends  : 


210  DISEASES    OF    THE    SKIN. 

R.  Thymol,    _  gr.  j. 

Pulv.  zinci  oleat.,  ^j.  M. 

As  a  rule,  powders  answer  better  than  ointments,  though 
Lassar's  paste,  as  given  under  Eczema,  may  be  used.  The 
treatment  of  intertrigo  in  infants  is  to  be  managed  in  the 
same  way  as  eczema.     (See  under  Eczema  infantile.) 

Erythema  Lceve  is  an  obsolete  term,  which  was  employed 
to  indicate  the  redness  seen  on  oedematous  limbs.  Let  it 
rest. 

Erythema  Paratrimma  belongs  to  the  same  category,  only 
here  it  was  the  redness  over  bony  prominences,  as  that  pre- 
ceding a  bed-sore. 

We  have  now  to  consider  the  second  group  of  erythema 
hypersemicum,  those  which  are  due  to  internal  causes.  Here 
might  be  placed  all  the  erythemata,  as  well  as  the  drug 
eruptions.  But  the  first  of  these  belong  to  the  domain  of 
general  medicine,  and  the  last  will  be  found  under  Derma- 
titis medicamentosa. 

Erythema  Fugax  is,  as  its  name  indicates,  a  fugitive  ery- 
thema, as  it  were  a  prolonged  blush.  It  is  seen  most  often 
in  children  with  some  digestive  disturbance,  and  its  chosen 
location  is  the  face.  It  lasts  for  a  few  moments  or  hours, 
and  is  seldom  seen  by  the  physician,  although  he  will  be 
told,  not  infrequently,  by  patients  that  they  are  annoyed 
by  a  flushing  of  the  face  after  eating,  exposure  to  cold, 
or  mental  emotion.  It  is  to  be  managed  like  Urticaria, 
which  see. 

Erythema  Urticans  is  simply  the  first  stage  of  urticaria. 
The  term  should  be  dropped. 

Erythema  Roseola,  or  simply  roseola.  While  children 
are  more  subject  to  this  form  of  erythema  than  adults  are, 
it  may  occur  in  the  latter.  Most  commonly  it  affects  the 
whole  body,  but  it  may  be  localized.  As  it  is  due  in  most, 
if  not  all,  cases  to  digestive  disorders  or  other  constitutional 
disturbance,  it  is  usually  ushered  in  with  rise  of  tempera- 
ture, which  may  be  pretty  sharp,  103°  or  104°  F.,  furred 
tongue,  restlessness,  and  the  like.  Soon  the  eruption  ap- 
pears, which  may  be  a  blotchy  redness,  or  in  faintly  marked 
papules,  or  in  rings,  or  gyrate  figures.     The  eruption  lasts 


ERYTHEMA.  211 

a  few  hours  only,  or,  coming  and  going  in  different  places, 
it  may  be  prolonged  for  a  few  days.  Besides  digestive  dis- 
orders, gout,  changes  of  temperature,  and  the  seasons  of 
spring  and  autumn  have  been  assigned  as  causes. 

Diagnosis.  In  itself  it  is  a  matter  of  little  moment,  but 
as  it  resembles  scarlet  fever,  rotheln,  and  measles,  its  diag- 
nosis is  important.  It  differs  from  scarlatina  in  not  having 
such  severe  constitutional  symptoms ;  in  an  absence  of  the 
strawberry  tongue,  swollen,  reddened  fauces,  and  enlarged 
glands;  in  the  rash  coming  out  all  over  the  body  without 
following  any  regular  course  of  development  from  the  neck 
downward ;  in  the  eruption  being  blotchy  or  papular,  and 
not  a  diffused  redness.  After  watching  the  case  for  a  day 
the  diagnosis  will  be  evident  by  the  clearing  away  of  the 
disease  wholly  or  partially.  It  differs  from  measles  in  an 
entire  absence  of  catarrhal  symptoms,  and  in  its  eruption 
not  being  crescentic,  as  well  as  in  the  irregularity  of  its 
course,  the  mildness  of  its  symptoms,  and  the  brightness  of 
its  color.  It  bears  most  resemblance  to  rotheln,  and  prob- 
ably the  two  are  often  confounded.  If  there  is  a  clear  his- 
tory of  contagion,  or  more  than  one  member  of  the  family 
affected  at  the  same  time,  the  diagnosis  of  rotheln  is  at  once 
established.  Rotheln  is  more  pronounced  on  the  extremi- 
ties, and  the  lesions  are  of  a  more  stable  character.  In  case 
of  doubt  as  to  diagnosis  of  roseola  the  patient  should  be 
regarded  as  having  a  contagious  disease,  isolated  and  care- 
fully watched. 

Treatment.  Little  need  be  done  for  the  patient  but  to 
give  a  laxative,  and  to  relieve  symptoms. 

Erythema  Neonatorum  makes  its  appearance  in  the  first 
few  days  of  life,  and  is  thought  to  be  due  to  the  influence 
of  external  and  unusual  irritants  acting  upon  the  tender 
skin  of  a  newborn  child.  "  The  eruption  consists  of  very 
minute  red  papules,  seated  upon  a  hypersemic  base,  which 
can  be  made  to  lose  their  color  upon  pressure.  The  lesions 
are  most  pronounced  upon  the  back  and  breast,  and  fade  away 
in  a  few  days  with  slight  desquamation  of  the  most  con- 
gested spots.  The  mucous  membranes  are  unaffected,  and 
there  is  no  evidence  of  systemic  reaction,"     (Hardaway.) 


212  DISEASES    OF    THE    SKIN. 

Erythema  Scarlatiniforme.  A  scarlatina-like  erythema 
follows  the  ingestion  of  a  number  of  drugs,  and  has  been 
frequently  mentioned  in  the  section  on  Dermatitis  medica- 
mentosa. The  French  authors  describe  a  scarlatiniform 
erythema  under  the  name  of  Erythemes  scarlatiniformes 
recidivantes,  which,  according  to  Besnier,1  who  has  pub- 
lished an  excellent  study  of  the  affection,  was  first  described 
by  Fereol  in  1876  at  the  Societe  Medicale  de  Hopitaux  de 
Paris.  The  disease  is  marked  by  redness,  desquamation, 
and  relapses.  Its  outbreak  may  or  may  not  be  preceded 
for  one  or  two  days  by  malaise  and  slight  febrile  movement. 
It  begins  on  the  trunk  and  invades  the  whole  surface  in  a 
few  hours  or  in  two  days.  It  is  a  diffused,  uniform,  in- 
tense, scarlatinal,  or  sombre-red  eruption.  There  may  be 
slight  differences  in  the  shade, or  the  redness  maybe  punctate, 
or  some  pin-head  vesicles  may  develop  upon  it.  Sometimes 
the  eruption  is  limited  to  a  certain  portion  of  the  body  ; 
sometimes  the  eruption  is  general,  but  not  universal,  normal 
islands  of  skin  being  found  in  the  general  redness.  It 
comes  out  in  patches  that  run  together.  There  is  generally 
redness  of  the  mucous  membrane  of  the  mouth  and  fauces. 
There  is  no  thickening  of  the  skin  nor  infiltration  of  mucous 
membranes.  The  skin  burns,  and  there  may  be  slight  itch- 
ing. Exfoliation  of  the  skin  begins  almost  as  soon  as  the 
eruption  is  out,  commencing  at  the  point  of  invasion.  The 
desquamation  is  general,  and  may  be  furfuraceous,  or  abun- 
dant and  in  large  plaques.  Upon  the  scalp  it  is  furfuraceous. 
The  whole  process  may  take  but  one  or  two  days,  or  it  may 
be  prolonged  for  a  month  or  six  weeks.  The  hair  and  nails 
may  be  shed.  The  tongue  is  furred  and  may  desquamate, 
but  never  presents  the  papillae  of  scarlatina.  After  the 
beginning  of  the  attack  there  is  usually  no  fever,  and  the 
appetite  is  preserved.  There  may  be  albuminuria  during 
the  attack.  The  relapses,  which  are  apt  to  occur  after  in- 
tervals of  days,  months,  or  years,  are  less  pronounced,  and 
the  patient's  health  is  good  in  the  interim. 

Etiology.     The  cause  of  the  disease  is  very  often  ob- 

1  Annal.  de  Derm,  et  de  Syph.,  1890,  i.  1. 


ERYTHEMA    EXUDATIVUM.  213 

scure.  The  first  attack  has  been  observed  to  follow  ex- 
posure to  cold,  the  application  of  mercurial  ointment,  or 
the  action  of  other  irritant.  But  it  is  difficult  to  explain 
why  from  such  causes  relapses  should  occur.  Besnier 
thinks  that  in  some  cases  the  cause  is  a  poison  developed 
within  the  individual.  In  this  way  he  would  explain  some 
of  the  erythemas  developing  during  an  acute  urethritis, 
which  some  observers  claim  may  arise  quite  independent  of 
the  taking  of  copaiba.  Scarlatiniform  erythemas  occur 
occasionally  in  septicemic  conditions,  in  typhus  fever,  in 
malaria  of  children,  in  sewer-gas  poisoning,  and  in  various 
other  conditions. 

Diagnosis.  Brocq  considers  scarlatiniform  erythema  as 
one  form  of  dermatitis  exfoliativa,  but  it  is  distinguished 
from  it  by  an  absence  of  evening  rise  of  temperature,  by 
having  no  permanent  effect  upon  the  health,  by  running 
a  shorter  course,  and  by  the  skin  not  being  dry,  contracted, 
and  shrivelled.  It  differs  from  scarlatina  in  the  mildness 
of  its  constitutional  symptoms ;  by  the  course  of  the  erup- 
tion ;  by  the  absence  of  tumefaction  of  the  fauces,  and  the 
strawberry  tongue ;  by  the  early  desquamation ;  by  not 
being  contagious  ;  and  by  its  tendency  to  relapse.  If  there  is 
any  doubt  as  to  the  diagnosis  the  patient  should  be  isolated. 
It  differs  from  erythematous  eczema  in  an  entire  absence 
both  of  thickening  and  moisture;  in  being  less  itchy;  and 
in  its  rapid  course. 

Treatment.     The  treatment  is  purely  symptomatic. 

Erythema  Exudativum,  the  second  variety  of  erythema, 
differs  from  erythema  hypersemicum  in  the  presence  of  an 
exudation  into,  not  on,  the  skin  so  that  the  patches  are 
raised  above  the  level  of  the  skin  ;  and  in  never  involving 
the  whole  surface,  but  always  occurring  in  circumscribed 
patches.  The  two  varieties  are  alike  in  that  the  redness 
disappears  under  pressure  to  return  at  once  when  the  pres- 
sure is  removed.  It  is  probable  that  erythema  nodosum  is 
really  but  a  part  of  erythema  multiforme,  as  the  two  forms 
may  be  present  at  one  time.  But  it  is  usually  described 
apart,  and  although  this  may  not  be  strictly  accurate,  it  is 
convenient. 


214  DISEASES    OF    THE    SKIN. 

Erythema  (Exudativum)  Multiforme,  as  its  name  indi- 
cates, is  very  multiform  in  its  efflorescences.  For  a  day  or 
a  few  days  before  they  appear  there  is  some  constitutional 
disturbance.  This  may  be  nothing  more  than  slight  malaise, 
the  patient  not  feeling  as  well  as  usual.  From  these  in- 
definite symptoms,  there  are  all  grades  up  to  fever  of  104°  F., 
headache,  gastric  disturbances,  and  severe  muscular  and 
articular  pains  like  rheumatism.  According  to  Besnier  and 
Doyon  an  erythema  of  the  pharynx,  or  a  pharyngitis, 
laryngitis,  or  bronchitis,  often  precede  or  accompany  the 
outbreak  of  the  eruption  upon  the  skin.  The  eruption  is 
most  constantly  seen  upon  the  backs  of  the  hands  and  feet, 
and  here  it  commonly  begins,  though  this  is  denied  by 
PolotebnofF,  to  whom  we  are  indebted  for  a  most  exhaustive 
and  able  study  of  erythema.1  It  also  appears  on  the  trunk 
and  extremities  more  or  less  generally,  coming  out  in  crops, 
and  preserving  a  rough  symmetry.  Sometimes  it  may  re- 
main confined  to  a  single  region,  as  the  backs  of  the  hands. 
Sometimes  it  occurs  on  the  mucous  membranes,  as  of  the 
mouth  and  eyes.  It  is  usually  most  marked  and  abundant 
about  the  joints  should  they  have  exhibited  rheumatic  pains. 
It  is  rare  not  to  find  lesions  upon  the  backs  of  the  hands. 
With  the  appearance  of  the  eruption  there  is  a  subsidence 
of  the  constitutional  symptoms,  though  in  many  cases  the 
patients  are  more  or  less  definitely  ill  during  the  whole 
course  of  the  disease. 

The  eruption  commences  as  a  group  of  deep-red  papules, 
from  pin-head  to  pea  size,  conical  or  rounded,  and  this  is 
called  Erythema  papulatum.  The  eruption  may  continue 
as  such ;  or  the  papules  may  coalesce  and  form  elevated 
patches,  sharply  marked  against  the  sound  skin ;  or  they 
may  enlarge  to  the  size  of  tubercles,  thus  forming  erythema 
tuberculatum.  If  they  still  continue  to  enlarge,  they  be- 
come depressed  in  the  centre,  and  ring-shaped,  the  periphery 
being  deep-red  while  the  centre  is  purplish.  This  is  called 
erythema  circinatum  or  annulare.  Sometimes  it  happens 
that  the  ring  still  enlarges  by  successive  exudations,  and 
then  we  will  have  ring  within  ring,  the  outer  one  pink,  the 

1  Zur  Lelire  von  den  Erytlienien.    Hamburg,  1887. 


EKYTHEMA    EXUDATIVUM.  215 

next  red,  the  next  purplish,  thus  forming  an  iris-like  play  of 
colors  that  has  been  termed  erythema  iris.  Two  rings  near 
each  other  and  enlarging  will  after  a  time  meet  at  the 
peripheries,  the  points  of  contact  will  melt  into  each  other 
and  disappear,  and  then  we  will  have  a  large  patch  with  a 
figure-of-eight  or  scalloped,  raised  border  and  a  flattened 
centre.  This  is  called  erythema  marginatum.  It  may 
travel  over  a  large  part  of  the  trunk  or  the  circumference 
of  a  limb,  leaving  a  fawn-colored  pigmentation,  which  soon 
fades.  Or  two  rings  meet,  and  each  breaks,  and  only  a 
gyrate  line  is  formed,  to  which  the  name  of  erythema  gyratum 
is  applied.  Sometimes,  though  rarely,  the  exudation  is  so 
abundant  that  the  epidermis  is  raised  in  the  form  of  vesicles 
or  bullae.  This  is  erythema  bullosum.  Hemorrhage  may 
take  place  into  the  bullae. 

It  is  uncommon  to  find  all  these  forms  present  at  the 
same  time,  nor  must  it  be  understood  that  one  form  neces- 
sarily evolves  into  the  other.  The  evolution  may  stop  at 
any  point.  Most  often  this  is  at  the  papular  stage.  Never- 
theless, more  than  one  form  is  usually  to  be  seen,  so  that  the 
term  multiform  is  merited.  Crocker  says  that  in  children 
multiformity  is  less  the  rule,  the  constitutional  symp- 
toms are  more  pronounced,  and  if  vesiculation  occur,  the 
vesicles  are  more  prone  to  become  purulent  and  leave 
scars. 

The  duration  of  the  disease  is  from  two  to  four  weeks, 
but  may  be  extended  by  a  succession  of  outbreaks  for 
months  or  years.  The  eruption  is  attended  with  burning, 
rather  than  itching,  and  sometimes  by  a  feeling  of  tension. 
Slight  pigmentation  may  be  left,  but  it  is  transitory.  Des- 
quamation may  follow  the  eruption,  but  is  not  common. 
In  some  patients  there  is  a  decided  tendency  to  relapse  at 
irregular  intervals  for  years.  In  Prof.  Geo.  Henry  Fox's 
service  at  the  Vanderbilt  Clinic  I  have  seen  a  boy  with  a 
relapsing  bullous  erythema  of  the  face  and  ears  that  had 
appeared  at  intervals  during  ten  years.  The  bullae  were  of 
large  size,  fully  distended,  and  of  irregular  shape.  They 
left  depressed,  pigmented  cicatrices  in  some  places.  Similar 
cases  have  been  reported  by  others,  as,  for  instance,  by 
Hardaway,  who  saw  one  case  with  relapses  for  four  years ; 


216  DISEASES    OF    THE    SKIN. 

and  T.  C.  Fox,  who  saw  two  cases  with  a  duratian  of  sixteen 
years  in  each  case. 

As  complications  of  erythema  multiforme,  and  especially 
of  erythema  nodosum,  have  been  reported  endo-  and  peri- 
carditis, meningitis,  pleurisy,  pneumonia,  and  the  like,  but 
it  is  better  to  regard  these  diseases  not  as  complicating  the 
erythema,  but  as  the  primary  diseases  of  which  the  ery- 
thema is  a  phenomenon. 

Erythema  Iris.  This  very  rare  disease  was  formerly  re- 
garded as  a  herpes,  and  is  described  in  most  text-books  as 
herpes  iris.  Its  other  synonyms  are  hydroa,  herpes  circin- 
atus,  and  hydroa  vesiculeux.  The  opinion  has  been  gain- 
ing ground  that  it  is  only  a  form  of  erythema,  and  it  is 
placed  in  the  group  of  erythema  multiforme  by  Crocker 
and  by  Hardaway.  It  is  seen  sometimes  along  with  other 
manifestations  of  erythema  multiforme,  or  with  herpes, 
though  it  usually  occurs  alone.  It  is  located  most  often 
upon  the  backs  of  the  hands  and  feet,  and  upon  the  arms 
and  legs,  but  it  may  occur  anywhere  upon  the  skin  as  well 
as  the  mucous  membranes.  I  have  seen  one  case  upon  the 
buttocks  as  well  as  upon  the  elbows.  According  to  Crocker 
there  are  two  varieties  of  the  disease,  one  with  a  central 
vesicle  or  a  purplish  depression  surrounded  by  one  or  more 
whitish  rings  slightly  raised  up  by  effused  fluid ;  the  other 
with  a  central  bulla  with  one  or  more  rings  of  more  or  less 
discrete  vesicles  round  it.  Of  these  two  the  first  is  the 
most  frequent. 

The  first  variety  begins  as  a  small  erythematous  papule 
upon  which  a  pinhead- sized  conical  vesicle  forms  in  about 
twelve  hours.  The  vesicle  grows  larger  and  flattens,  but 
preserves  a  red  areola.  When  about  a  quarter  of  an  inch  in 
diameter  the  fluid  is  absorbed  in  the  centre,  leaving  a  pur- 
plish depression  ;  or  only  a  ring  of  absorption  occurs,  so  that 
there  will  remain  a  vesicle  in  the  centre  with  a  purplish 
zone  about  it,  and  then  a  raised  white  ring,  and  around 
all  a  narrow,  pink  areola.  This  play  of  colors  gives  the 
name  of  iris.  The  patch  may  reach  the  diameter  of  half 
an  inch,  and  then  undergo  involution ;  or  several  patches 
may  unite  and  form  patches  of  one  inch  or  more  in  diam- 


ERYTHEMA    EXUDATIVUM.  217 

meter,  and  hemorrhage  may  take  place  into  the  bullae  that 
may  form. 

In  the  second  variety,  which  is  the  hydroa  vesiculeux 
bulleux  of  Bazin,  round  a  central  bulla  a  ring  of  split-pea- 
sized  vesicles  forms,  the  vesicles  being  either  discrete  or 
touching.  A  second  or  a  third  ring  of  vesicles  may  form 
outside  of  these,  the  skin  between  them  being  of  a  purplish 
tint.  The  bullae  and  vesicles  may  leave  scars.  Crusting  also 
takes  place  from  the  breaking  or  drying  of  the  vesicles. 

The  lesions  of  both  varieties  are  more  or  less  symmetri- 
cal, though  a  patch  may  develop  on  one  side  several  days 
before  the  other.  The  duration  is  from  three  to  four 
weeks  or  longer.  Relapses  are  common.  Burning  is  usually 
pronounced,  and  there  may  be  some  itching.  From  this 
description  it  will  be  seen  that  the  so-called  herpes  iris  is 
really  an  erythema. 

Erythema  Nodosum,  also  called  dermatitis  contusiforme, 
and  Erythema  noueux  (Fr.),  is  more  common  than  erythema 
iris,  but  not  nearly  so  common  as  erythema  multiforme. 
It  is,  probably,  really  but  a  variety  of  erythema  multi- 
forme, as  it  may  occur  as  a  part  of  that  disorder.  In  the 
vast  majority  of  cases  it  occurs  alone.  Its  prodromal 
symptoms  are  substantially  the  same  as  those  of  erythema 
multiforme,  but  its  rheumatic  pains  are  more  pronounced 
and  always  present.  There  is  also  tenderness  and  pain 
over  the  tibiae.  After  a  few  days  of  prodromata,  round 
or,  more  often,  oval,  bright  or  rosy  red  swellings  appear 
over  the  tibiae,  with  their  long  axis  vertical.  These  are  from 
nut  to  egg-sized ;  raised ;  their  borders  merge  gradually  into 
the  surrounding  skin ;  they  are  painful  and  often  ex- 
quisitely tender ;  firm  at  first  but  may  be  semi-fluctuating 
afterward ;  and  their  color  darkens  to  a  dark  red,  then 
purple,  and  in  undergoing  absorption  they  present  the  ap- 
pearance of  a  black- and-blue  spot  from  a  bruise.  The  color 
at  first  disappears  under  pressure,  to  spring  back  when  the 
pressure  is  removed.  The  changes  of  color  subsequently 
seen  are  due  to  the  gradual  absorption  of  the  coloring  mat- 
ters of  the  blood  deposited  in  the  tissues.  There  are  not 
usually  more  than  a  dozen  lesions,  generally  less.     They 

10 


218  DISEASES    OF    THE    SKIN. 

are  most  frequently  located  over  the  tibiae,  but  may  occur 
as  well  upon  the  arms,  scapulae,  thighs,  and  mucous  mem- 
branes. They  are  roughly  symmetrical.  The  duration  of 
the  disease  is,  like  that  of  other  erythemas,  two  to  four 
weeks. 

Etiology.  The  causes  of  erythema  exudativum  are  not 
fully  determined.  It  occurs  more  commonly  in  women  than 
in  men,  and  in  young  adults  rather  than  in  old  people. 
Erythema  nodosum  is  said  to  be  most  frequent  in  children. 
It  is  most  frequent  in  the  spring  and  autumn,  seasons  in 
which  dampness  and  cold  winds  prevail,  and  sudden  changes 
of  temperature  are  common.  The  papular  erythema  is  very 
often  seen  in  recently  arrived  immigrants.  Rheumatism 
has  a  well-marked  causal  relation  to  erythema  nodosum, 
and,  it  may  be,  to  the  other  forms.  Syphilis  seems  to  be 
an  etiological  factor  of  some  weight  in  the  production  of 
erythema  nodosum.  Some  years  ago  I  saw  in  the  service 
of  Professor  E.  B.  Bronson  in  the  New  York  Polyclinic  a 
well-marked  instance  of  this  in  the  course  of  recent  syphilis 
in  a  woman.  Many  cases  seem  to  be  due  to  systemic  poison- 
ing either  by  some  infectious  disease  or  by  auto-infection. 
It  is  seen  with  cholera,  influenza,  and  the  exanthemata; 
with  indigestion,  pregnancy,  parturition,  menstrual  disturb- 
ances, kidney  diseases,  and  various  other  internal  or  systemic 
disorders.  Sometimes  the  disease  seems  to  be  a  pure  angio- 
neurosis.  Cases  of  erythema  multiforme  recurring  with 
recurring  attacks  of  gonorrhoea  have  been  reported.  These 
appear  as  reflex  angioneuroses  without  the  ingestion  of 
balsamics  in  the  treatment  of  the  urethritis.  Cases  of 
erythema  multiforme  not  infrequently  follow  the  ingestion 
of  drugs ;  at  least  they  are  almost  identical  with  it  in 
appearance.  Sometimes,  according  to  PolotabnofF,  it  seems 
to  be  an  abortive  form  of  prevailing  epidemics.  Cases 
certainly  should  be  watched  carefully  in  connection  with 
other  symptoms,  as  they  may  be  but  part  of  the  prodromata 
of  some  grave  disorder.  I  have  seen  one  case  in  which  a 
well-marked  erythema  multiforme  preceded  for  about  ten 
days  the  outbreak  of  typhoid  fever ;  the  erythema  then 
disappearing  and  the  characteristic  typhoid  eruption  coming 


ERYTHEMA    EXUDATIVUM.  219 

in  due  course.  Many  of  the  subjects  of  erythema  are  de- 
bilitated. Individual  predisposition  probably  plays  an  im- 
portant role  in  the  etiology  of  some  cases,  especially  in  the 
relapsing  ones. 

Pathology.  All  forms  of  the  disease  show  not  only 
hyperemia,  but  also  inflammatory  effusion  both  of  fluid  and 
leucocytes.  Upon  the  amount  of  this  fluid  depends  the 
character  of  the  lesion.  If  small  in  amount  it  will  simply 
push  up  the  epidermis  into  a  papule  or  tubercle ;  if  of 
larger  amount  we  will  have  vesicles  and  bullae.  There  is 
also  an  escape  of  the  coloring  matter  of  the  blood  into  the 
tissues.     (Crocker.) 

Diagnosis.  If  the  characteristics  of  erythema  multi- 
forme are  borne  in  mind,  little  difficulty  in  diagnosis  will 
arise.  These  are  the  sudden  occurrence  of  raised,  bright 
or  rosy-red  lesions,  located  by  preference  upon  the  backs  of 
the  hands  and  feet ;  and  the  color  that  fades  away  entirely 
under  pressure  to  return  again  when  pressure  is  removed, 
and  in  disappearing  leaves  stains.  It  most  resembles 
urticaria,  but  differs  from  it  in  having  more  stable  lesions 
of  more  varied  shape ;  in  absence  of  wheals ;  in  occur- 
ring particularly  on  the  backs  of  the  hands  and  feet ;  and 
in  burning  rather  than  itching.  The  papular  form  dif- 
fers from  jiapular  eczema  in  its  chosen  locations ;  in  its 
burning  rather  than  itching  ;  in  its  papules  being  larger 
and  never  developing  vesicles  nor  forming  patches ;  in  an 
absence  of  thickening  of  the  skin  ;  in  disappearing  com- 
pletely under  pressure ;  in  tending  to  get  well  without 
treatment ;  and  in  leaving  stains.  The  nodes  of  erythema 
nodosum  differ  from  those  of  sy2)liilis  in  occurring  suddenly 
and  not  gradually.  In  syphilis  the  redness  does  not  occur 
until  after  the  node  has  existed  for  some  time,  and  the 
nodes  are  not  tender  nor  developed  symmetrically.  More- 
over there  would  be  other  evidences  of  syphilis. 

Treatment.  There  is  nothing  that  will  lessen  the  dura- 
tion of  the  disease,  though  Villemin1  maintains  that  iodide 
of  potassium,  in  doses  of  at  least  thirty  grains  a  day,  is 

1  Gaz.  hebdom.,  May  24,  1886. 


220  DISEASES    OF    THE    SKIN. 

almost  a  specific,  and  will  abort  relapses.  The  experience 
of  Besnier  and  others  has  not  been  in  accord  with  that  of 
Villemin.  The  treatment  is  mainly  symptomatic,  and  di- 
rected to  relieving  the  constipation,  regulating  the  diet,  aiding 
digestion,  ameliorating  rheumatism,  or  toning  up  the  system. 
In  obstinate  cases  the  patient  had  best  be  kept  in  bed. 
Locally  any  alkaline  lotion  will  afford  relief,  such  as 


Or, 


R.  Pulv.  calamin.  prep.,  ^ij;  4 

Zinci  oxid.,  3ss;  3 

Liq  calcis,  %  ij ;       100 


M. 


Be.  Liquor  plunibi  subacetat is,  Tltxv  ;        3| 

Aqua?,  3j ;         100|         M. 


Or,  lead  and  opium  wash. 

Sometimes  a  simple  dusting-powder  will  do  as  well.  In 
erythema  nodosum  the  patient  should  be  kept  in  bed,  and 
often  the  lotion  is  more  agreeable  to  the  patient  when  used 
warm.  Salicylic  acid  or  salicylate  of  soda  internally  may 
afford  relief  to  the  sometimes  intense  pains.  Regulation 
and  simplification  of  the  diet,  and  the  administration  of 
diuretics  or  tonics,  according  to  the  nature  of  the  case,  will 
do  good  in  the  disease  as  seen  in  immigrants. 

Erythema  Centrifuge.     See  Lupus  erythematosus. 

Erythema  Gangrenosum,  though  described  as  a  disease 
is  probably  always  a  feigned  eruption,  and  needs  no  de- 
scription here. 

Erythema  Mamelonne.     See  Erythema  roseola. 

Erythema  Papuleux  Desquamatif  (Vidal).  See  Pityriasis 
maculata  et  circinata. 

Erythema  Noueux.     See  Erythema  nodosum. 

Erythrasma  (E"2r-i2-thra2z-ma3).  A  contagious  parasitic 
disease  of  the  skin?  occurring  especially  in  the  groins  and 
axillae  in  the  form  of  sharply  defined,  brownish-red,  desqua- 
mating patches,  bordered  by  a  fringe  of  broken  and  partly 
detached  epidermis.     (Foster.) 

This  affection  of  the  skin  is  very  rarely  seen  in  this  coun- 
try. This  may  be  because  it  gives  no  trouble  to  the  patient, 
and  therefore  he  does  not  apply  to  the  physician.     It  begins 


ERYTHRASMA.  221 

as  a  little  yellowish  point  that  soon  becomes  a  lentil-sizecl 
macule,  and  grows  into  a  patch  the  size  of  a  silver  dollar  or 
the  hand.  Several  patches  join  together  so  that  large  sur- 
faces may  be  involved.  The  patches  are  oval  or  disc-shaped. 
They  are  located  in  the  situations  where  intertrigo  is  liable 
to  occur,  such  as  the  axillae,  groins,  and  where  the  scrotum 
comes  in  contact  with  the  thighs.  The  latter  situation  is 
declared  by  Besnier  to  be  nearly  always  the  original  site  of 
the  disease.  From  these  favorite  locations  the  disease  may 
spread  to  the  chest,  abdomen,  or  thighs.  Besnier1  met 
with  a  case  involving  the  thigh  down  to  the  knee.  The  color 
of  the  patches  is  orange,  red,  yelloAvish,  or  brownish,  or,  in 
the  folds  of  the  skin,  pale  red.  Their  outline  is  sometimes 
marked  by  a  raising  of  the  epidermis.  Their  surface  is 
dull-looking,  and  feels  less  smooth  than  normal.  They  are 
quite  tenacious,  cannot  be  readily  rubbed  off,  and  show  little 
tendency  to  spontaneous  recovery.  There  may  be  slight 
itching,  and  a  very  little  delicate  scaling. 

Etiology.  The  disease  occurs  most  often  in  men,  and 
never  in  children.  It  is  due  to  a  parasite  called  the  micro- 
sporon  minutissimum  which  is  described  by  Balzer2  as  con- 
sisting of  long,  wavy  mycelia,  that  are  rarely  branched; 
and  of  very  fine  spores.  High  powers  of  the  microscope 
are  necessary  to  see  them.  They  are  located  exclusively  in 
the  corneous  layer  of  the  skin.  He  regards  them  as  a 
common  form  of  parasite  that  produces  the  disease  only  in 
some  people  on  account  of  the  peculiar  fermentation  of 
their  skin  secretions. 

Diagnosis.  The  disease  resembles  both  chromophytosis, 
eczema  marginatum,  and  chloasma.  It  differs  from 
chromophytosis  by  the  darkness  of  its  color ;  by  the  ab- 
sence of  distinct  rather  large  scales  that  can  be  lifted  by  the 
nail;  by  its  location,  sparing  the  trunk,  except  by  exten- 
sion ;  and  by  the  character  of  the  microscopical  appearances. 
From  eczema  marginatum  it  is  distinguished  by  an  absence 
of  all    inflammatory    symptoms,   by  not    being    more   pro- 

1  Journ.  de  Med.  et  de  Chirurg.  prat.,  1883,  liv.  351. 

2  Annal.  Derm,  et  Syph.,  1884,  v.  597. 


222  DISEASES    OF    THE    SKIN. 

nounced  at  the  periphery  than  at  the  centre,  and  by  the 
microscopical  appearances.  From  chloasma  it  differs  by 
being  a  parasitic  and  not  a  pigmentary  disease,  and  by  the 
change  it  causes  in  the  feel  and  texture  of  the  skin,  and  by 
the  effect  of  treatment. 

Treatment.  It  is  curable  by  the  same  means  as  is 
chromophytosis,  namely  by  the  tincture  of  iodine  ;  pyro- 
gallol ;  chrysarobin ;  bichloride  of  mercury ;  or  sulphur. 
It  is  more  obstinate  than  is  chromophytosis,  and  quite  as 
prone  to  relapse  unless  thoroughly  eradicated. 

Erythromelalgia  (E2r/i2-thro-me2l-a2l/gi2-a3)  is  a  nervous 
disease  characterized  by  the  appearance  of  a  persistent  patcli 
of  congestion,  often  on  the  sole  of  the  foot,  attended  with 
swelling  and  pain.     (Foster.) 

Esthiomene  (E2s-te-o-me2n).  This  is  a  disease  of  the 
ano-vulvar  region  that  was  described  by  Huguier,1  and  about 
which  there  is  a  good  deal  of  uncertainty.  It  has  been 
variously  considered  as  a  form  of  lupus,  syphilis,  elephantia- 
sis, and  epithelioma.  "  It  is  characterized  by  a  leaden  or 
violaceous  hue  of  the  parts,  and  their  simultaneous  altera- 
tion of  shape,  induration,  thickening,  ulceration,  destruc- 
tion, hypertrophy,  and  infiltration,  so  that  the  orifices  and 
canals  of  the  vulvo-anal  region  may  be  at  the  same  time 
ulcerated,  enlarged,  and  constricted,  and  its  grooves  and 
cutaneous  and  mucous  folds  exaggerated,  thickened,  and  the 
seat  of  more  or  less  extensive  and  deep  ulcerations  and 
cicatrices;  without  pain,  without  directly  threatening  life, 
and  for  a  long  time  without  affecting  the  constitution. 
(Foster.) 

Exanthematous  Fevers.  These  concern  us  as  dermatolo- 
gists only  in  the  matter  of  diagnosis.  They  are  chiefly 
liable  to  be  mistaken  for  different  forms  of  erythema  hyper- 
semicum,  and  their  diiferentiation  from  these  has  been  already 
considered.  (See  Erythema.)  Besides  this,  measles  must 
be  differentiated  from  the  erythematous  syphilide ;  variola 
from  papulo-pustular  syphilide  and  acne;  scarlatina  from 

1  Mem.  de  l'Acad.  de  Med.  I860,  p.  507. 


favus.  223 

erythematous  eczema  ;  and  varicella  from  vesicular  eczema 
and  impetigo  contagiosa.  Consideration  of  the  constitu- 
tional symptoms  and  the  course  of  the  disease  in  question 
should  leave  little  doubt  as  to  diagnosis,  and  in  any  event 
watching  the  case  for  a  day  or  so  will  decide  it  positively. 
See  also  Morbilli,  Scarlatina,  Rotheln,  etc. 

Farcy.     See  Equinia. 

Favus  (Fa3/vu3s).  Synonyms :  Porrigo  lupinosa,  seu 
favosa,  seu  lavalis,  seu  scutulata ;  Porrigophyta ;  Tinea 
favosa,  seu  vera,  seu  ficosa,  seu  lupinosa,  seu  maligna ;  Tri- 
chomykosis  or  Dermatomycosis  favosa  ;  (Fr.)  Teigne  faveuse, 
teigne  du  pauvre  ;  (Ger.)  Erbgrind  ;  Crusted  or  honey-comb 
ringworm,  Scall  head,  True  porrigo. 

A  contagious  vegetable  parasitic  disease  due  to  the 
Acliorion  Schoenleinii,  and  characterized  by  the  presence  of 
discrete  or  confluent,  circular,  pale  sulphur-yellow  cupped 
crusts,  or  by  asbestos-like  masses  of  grayish  friable  crusts ; 
by  loss  of  hair  producing  irregularly-shaped,  disseminated, 
red,  bald  patches ;  by  permanent  atrophy  of  the  scalp ;  and 
by  running  a  chronic  course. 

Symptoms.  Favus  affects  both  the  scalp  and  the  non- 
hairy  skin  as  well  as  the  nails  and  mucous  membrane.  We 
will  first  describe  it  as  it  affects  the  scalp.  It  begins  either 
as  one  or  more  scaly  erythematous  spots ;  or  as  minute  yel- 
lowish puncta  ;  or  as  a  group  of  vesicles  smaller  than  those 
met  with  in  ringworm.  These  develop  into  small  sulphur- 
yellow  cupped  crusts  about  the  hairs.  When  the  case  is 
seen  by  the  physician  the  early  stage  is  usually  passed,  and 
he  will  find  that  the  hair  is  dry  and  lustreless,  and  has  fallen 
out  in  places,  leaving  irregularly- shaped  bald  patches,  of  all 
sizes,  and  of  pronounced  red  color.  Upon  both  the  bald 
patches  and  the  parts  still  covered  with  hair  the  sulphur- 
yellow  cup  or  saucer-shaped  crusts  will  be  found,  with  raised 
or  rounded  edges,  and  with  one  or  several  hairs  growing  out 
of  the  middle  of  them.  There  will  be  also  more  or  less 
scaling,  and,  if  the  disease  be  of  some  age,  thick  mortar-like 
crusts  of  grayish  color.  In  some  cases  when  first  seen  it 
may  be  impossible  to  find  the  characteristic  crusts,  scutula 


224  DISEASES    OF    THE    SKIN 

Fig.  18. 


Case  of  favus  of  hand  showing  scutula.     Side  view. 


Fig.  19. 


Favus  of  hand,  front  view. 


favus.  225 

as  they  are  called,  they  being  obscured  by  the  mortar-like 
masses.  In  some  cases  the  scutula  are  wanting;.  If  we 
approach  near  enough  to  the  patient  we  will  appreciate  a 
peculiar  odor  variously  described  as  that  of  mice,  straw,  or 
of  a  menagerie. 

The  crusts,  scutula,  or  favi  are  situated  about  the  hair 
follicles.  They  are  from  pin-head  to  split-pea  size,  accord- 
ing to  age.  At  first  they  are  covered  with  a  thin  layer  of 
epidermis,  but  later  the  edges  are  free.  When  they  are 
picked  off  they  leave  a  moist  depression  which  soon  fills  up, 
or  a  pustule,  or  an  atrophied  spot.  The  color  is  pale  or 
sulphur-yellow,  or,  if  of  long  standing,  it  may  be  a  dirty  or 
greenish-yellow.  The  crusts  are  discrete  and  disseminated 
or  grouped  ;  sometimes  they  coalesce ;  they  are  firm  to  the 
touch,  and  when  crushed  between  the  fingers  impart  a  feeling 
of  crumbling  like  mortar.  There  is  a  slight  zone  of  redness 
about  them.  Though  they  may  not  be  seen  at  the  first 
examination,  if  the  scalp  is  cleaned  off  and  left  to  itself  they 
will  form  in  the  course  of  two  or  three  weeks.  The  bald- 
ness is  rarely  in  well-defined  shapes.  The  patches  may  be 
few  in  number,  or  so  numerous  that  the  hair  occurs  only  in 
islands.  At  first  their  color  is  inflammatorv  red ;  later 
they  become  white  and  atrophic  in  appearance.  The  bald- 
ness is  permanent.  The  hair  is  dry  from  the  first ;  later  it 
becomes  brittle  and  split  longitudinally;  but  it  is  never  so 
easily  broken  as  in  ringworm,  and  can  easily  be  pulled  out 
with  its  roots.  There  is  itching  of  the  scalp.  That  is  the 
only  subjective  symptom.  Pustulation  does  not  belong  to 
the  disease,  but  may  be  an  accidental  complication.  Other 
complications  that  may  arise  are  pediculosis,  eczema,  and 
enlargement  of  the  cervical  glands. 

Occurring  upon  non-hairy  parts  it  undergoes  materially 
the  same  development  and  forms  the  characteristic  cups. 
Sometimes  it  will  take  the  circular  form  of  a  ringworm  with 
the  development  of  vesicles,  and  resemble  it  very  closely 
only  that  the  cups  will  be  sure  to  develop  somewhere.  (Figs. 
18  and  19.)  The  scutula  develop  around  the  lanugo  hairs. 
On  the  non-hairy  parts  the  disease  is  easier  of  cure  than  on 
the  scalp,  and  is  not  so  apt  to  leave  scars.     In  a  single  case? 

10* 


226 


DISEASES    OF    THE    SKIN". 


that  of  Kaposi,  the  favic  fungus  was  found  implanted  upon 
the  mucous  membrane  of  the  stomach.  The  nails  may  be 
affected,  either  in  the  form  of  onychitis  beginning  at  the 
side  of  the  nail  hardly  distinguishable  from  the  same  dis- 
ease developed  from  common  causes ;  or  in  having  a  scutu- 
lum  develop  in  the  nail-bed  and  showing  through  the  nail. 
This  is  rare.  The  occurrence  of  favus  upon  the  head  will 
give  a  clue  to  the  origin  of  the  onychitis. 

Etiology.  The  disease  is  due  to  the  implanation  and 
growth  of  the  Aclwrion  Schoenleinii  primarily  in  the  scalp 
and  secondarily  in  the  hair.  It  is  contagious,  but  not  so 
much  so  as  is  ringworm.  It  used  to  be  rare  in  this  city  but 
on  account  of  its  being  constantly  imported  from  Europe 
the  disease  is  on  the  increase,  and  cases  are  beginning  to 
occur  in  native  Americans.  Its  course  is  very  chronic,  and 
it  shows  less  tendency  than  ringworm  does  to  spontaneous 
recovery  about  the  time  of  puberty,  though  children  are 
more  commonly  affected  than  are  adults.  It  has  been 
asserted  that  the  strumous  diathesis  predisposes  to  favus, 
but  this  is  doubtful.  Like  all  other  parasites  it  requires  a 
certain  soil  upon  which  to  grow,  and  does  not  affect  all  skins. 
It  is  a  disease  common  in  mice,  and  may  occur  in  rabbits, 
dogs,  cats,  and  fowls,  and  be  a  source  of  contagion  for  the 
human  race. 

Fig.  20. 


V 

Achorion  Schoenleinii.     (After  Kaposi.) 

Pathology.     The  cups  are  composed  almost  wholly  of 
the  fungus,  which  consists  of  flat,  narrow,  branching,  and 


FAVUS. 


227 


inosculating  mycelial  threads  -g-J-^-th  of  an  inch  in  diameter, 
and  of  pale  gray  color;  and  of  small  spores  of  round,  oval, 
flask,  or  dumb-bell  shape,  and  of  a  pale  greenish  color. 
(Figs.  20,  21.)     The  spores  gain  access  to  the  skin  by  the 


Fig.  21. 


Achorion  Schoenleinii  in  hair  shaft  and  follicle.     (After  Kaposi.) 

orifices  of  the  hair  follicles,  and,  after  remaining  there  undis- 
turbed, begin  to  grow  in  the  upper  part  of  the  hair  sac,  and 
between  the  superficial  layers  of  the  epidermis,  and  subse- 
quently invade  the  hair,  growing  in  its  cortical  substance. 
The  cup  may  be  formed  either  by  the  sinking  in  of  the  more 


228  DISEASES    OF    THE    SKIN. 

central  portion  of  the  mass,  or  on  account  of  the  central 
portion  being  attached  to  the  hair  so  firmly  that  it  cannot 
so  readily  give  way  and  bow  out  under  the  pressure  of  the 
growing  fungus  as  do  the  parts  further  away  from  the  hair. 
The  atrophy  of  the  skin  is  largely  due  to  the  pressure  of  the 
growing  fungus,  which  is  powerful  enough  to  destroy  the 
cranial  bones  of  mice ;  and  in  part  to  the  inflammation  of 
the  skin  produced  by  the  presence  of  the  fungus. 

The  question  of  the  unity  or  non-unity  of  the  fungus  of 
favus  is  still  unsettled.  Several  fungi,  Quincke  says  three, 
seem  capable  of  producing  the  clinical  picture  of  the  dis- 
ease. Other  competent  bacteriologists  hold  that  the  appa- 
rently diverse  fungi  are  either  different  stages  of  develop- 
ment of  the  same  fungus  or  due  to  different  culture  media. 
It  is  distinct  from  the  trichophyton  fungus. 

Diagnosis.  Most  cases  of  favus  are  easy  of  diagnosis  : 
the  sulphur-yellow  cupped  crusts  ;  the  asbestos-like  grayish 
masses ;  the  red,  atrophic  bald  spots  ;  and  the  peculiar  odor 
being  so  well  marked.  Ringworm  has  none  of  these  fea- 
tures. Moreover,  it  occurs  in  the  form  of  circular,  circum- 
scribed, only  partially  bald  patches  covered  with  grayish 
scales  in  moderate  amount;  has  characteristic  nibbled-off 
"stumps"  of  hair;  and  under  the  microscope  we  find  the 
spores  less  abundant,  smaller,  and  more  uniformly  round 
than  in  favus.  It  must  be  confessed,  however,  that  without 
the  clinical  features  of  one  or  the  other  disease,  none  but  a 
most  expert  microscopist  could  make  the  diagnosis  by  the 
microscope  alone.  In  eczema  baldness  is  very  rare,  and  we 
will  usually  find  a  characteristic  patch  of  the  disease  behind 
the  ear  ;  its  crusts  are  greenish  and  tenacious,  not  gray  and 
friable ;  the  hair  is  matted  by  the  sticky  exudation  ;  and  if 
discrete  impetigo  lesions  are  present  they  will  contain  pus, 
and  not  be  solid  like  the  favus  crust.  Leaving  the  scalp 
alone  for  a  time  will  decide  the  matter,  as  scutula  will  be 
sure  to  form  if  the  disease  is  favus.  Seborrhoea  causes  a 
general  thinning  of  the  hair,  the  scalp  is  not  atrophic,  there 
are  no  scutula,  and  no  achorion  in  the  hair  and  scalp.  Lupus 
erythematosus  resembles  favus  only  in  producing  atrophic  red 
spots.     There  will  usually  be  patches  of  the  disease  else- 


favus.  229 

where,  and  its  whole  course  is  different.  Psoriasis  does 
not  cause  atrophic  bald  spots,  and  never  occurs  on  the  scalp 
alone.  Alopecia  areata  presents  more  or  less  circular  bald 
areas,  but  these  are  white,  smooth,  and  of  normal  texture, 
and  there  is  no  fungous  growth  in  the  hair.  Alopecia  from 
syphilis  in  its  early  stage  resembles  favus  more  closely  than 
any  other  disease  of  the  scalp.  But  it  occurs  primarily  at 
a  later  age  than  does  favus,  it  comes  on  more  suddenly, 
there  is  no  history  of  crusts,  and  there  will  be  other  evidences 
of  syphilis  on  the  body,  and  (especially  in  women)  the  broken 
arch  of  the  eye-brows. 

Treatment.  In  the  treatment  of  the  disease  we  need 
three  weapons — patience,  perseverance,  and  parasiticides. 
Before  using  the  last  we  should  always  epilate,  pulling  the 
hair  out  systematically  from  day  to  day  so  that  eventually 
all  the  hair  of  the  scalp  is  plucked.     To  do  this  we  may  use 

Fig.  22. 


Piffard's  epilating  iorceps. 

the  epilating  forceps  (Fig.  22) ;  or  Kaposi's  method  of 
grasping  the  hair  between  the  thumb  and  a  spatula  or  piece 
of  stiff  cardboard  held  firmly  in  the  hand;  or,  in  dispensary 
practice,  we  may  employ  epilating  sticks,  made,  according  to 
Bulkley,  of — 

R-  Cerse  flavse,  .^iij- 

Laccse  in  tabulis  ^iv. 

Picis  burgundies?,  %  x. 

Gummi  damar.  Sjss.  M. 

These  ingredients  are  to  be  melted  together,  and  then 
moulded  into  sticks  of  a  half-inch  or  more  in  diameter. 
They  are  to  be  used  by  melting  the  end,  and  when  warm 
applying  it  to  the  hair  with  a  sort  of  boring  motion.  When 
cold  they  are  to  be  suddenly  twisted  off,  when,  of  course, 
they  will  bring  many  hairs  with  them.  The  "  calotte,"  or 
pitch- cap,  used  to  be  used  for  this  purpose,  but  was  given 


230  DISEASES    OF    THE    SKIN. 

up  because  it  caused  the  death  of  several  patients.  Kaposi's 
method  is  the  best  of  all.  If  the  head  is  greatly  crusted, 
the  crusts  should  be  cleaned  off  by  means  of  soaking  the 
scalp  with  oil  for  a  day  or  two,  and  then  washing  with  soap 
and  water.  For  an  oil  we  can  use  sweet  oil,  sweet  almond 
oil,  or  cotton-seed  oil  with  three  per  cent,  of  carbolic  or  sali- 
cylic acid.  The  use  of  these  oils  should  be  continued 
throughout  the  whole  course  of  the  disease  to  prevent  the 
spread  of  the  fungus  upon  the  scalp  of  the  patient,  and  to 
other  people's  scalps.  After  the  first  washing  we  should 
allow  the  scalp  to  go  unwashed  for  a  week  or  more  at  a  time, 
so  as  to  permit  of  the  full  action  of  the  parasiticide. 

After  the  cleansing  and  the  epilation,  the  parasiticide 
must  be  rubbed  and  worked  into  the  scalp.  Of  these  there 
are  many  from  which  to  choose.  Sulphur  ointment  is  one 
of  the  best,  if  properly  and  persistently  used.  Other  oint- 
ments are  thymol,  naphthol,  resorcin,  and  pyrogallol  in  5 
to  10  per  cent,  strengths,  and  those  of  the  ammoniate  or 
yellow  sulphate  of  mercury.  Or  solutions  may  be  employed, 
as  bichloride  of  mercury,  two  grains  to  the  ounce  of  ether 
or  alcohol ;  the  oleate  of  mercury  or  copper,  10  to  20  per 
cent. ;  tar ;  oil  of  cade ;  creasote  in  ether  or  alcohol ;  sul- 
phurous acid  in  full  strength  ;  or  salicylic  acid,  five  per 
cent,  in  oil.  Hydronaphthol  plaster  does  good  service  in 
favus  used  according  to  the  method  described  under  Tricho- 
phytosis, which  see.  Peroni1  recommends  spraying  the  head 
with  acetic  acid  used  in  an  atomizer,  after  covering  any  ex- 
coriated points  with  diachylon  ointment  on  a  piece  of  cloth. 
At  first  the  scalp  feels  cold.  Hyperemia  follows,  which 
last  about  forty-eight  hours,  and  disappears  leaving  slight 
desquamation.  When  the  hyperemia  lessens,  the  acid  is  to 
be  again  used.  When  there  are  no  excoriations  the  head  is 
to  be  washed  every  morning  and  evening  with  water  and 
corrosive  sublimate  soap.  Busquet2  recommends  sopping  on 
daily  a  solution  of 

R.  Essence  of  cinnamon,  10 1 

Spts.  ether,  sulph.,  30 1        M. 

1  Annal.  Derm,  et  Svph.,  1891,  ii.  797. 

2  Ibid.,  1892,  ii._269. 


FAVUS.  231 

Besnier  and  Doyon1  recommend  as  a  preparatory  treat- 
ment for  favus  that  the  hair  be  cut  from  off  and  around  all 
the  patches,  and  the  whole  head  then  covered  for  two  or 
three  hours  with  equal  parts  of  soft-soap  and  lard.  This 
is  to  be  washed  off  with  warm  water,  and  the  head  to  be 
kept  covered  during  the  night  with  a  cap  of  rubber  or  other 
impermeable  cloth.  The  next  morning  the  head  is  to  be 
washed  perfectly  clean,  bathed  with  a  solution  of  boric  acid 
(25  to  1000),  and  covered  with  borated  lint  soaked  in  the 
following  solution  : 


R 


Sodii  salicylati, 

25 

Sodii  bicarbonati, 

10 

Aqua?, 

1000 

M. 


Over  all  comes  the  impermeable  cap.  After  a  few  days 
the  dermatitis  will  disappear  and  the  scalp  will  be  clean,  and 
then  epilation  must  be  practised,  the  hairs  being  pulled  not 
only  from  the  patches  but  for  about  a  half-inch  about  them. 
Epilation  is  to  be  repeated  every  week  until  no  longer  any 
trace  of  redness  about  the  hairs  exists,  and  the  head  is  to  be 
kept  covered  with  the  impermeable  cap.  Every  evening  the 
whole  head  is  to  be  rubbed  with  an  antiparasitic  ointment 
such  as : 

R .  Bals.  Peruv.  vel 

01.  cadini,  2  to    5  parts. 

Ac.salicyl.,)    u  ±         g     „ 

Kesorcm.,     J 

Sulph.  precip.,  5  to  15     " 

Lanolini,     ") 

Yaselini,      >-    aa  p.  a\  ad  100  parts. 

Adepis,       J  M, 

Every  morning  the  whole  scalp  is  washed  with  tar  soap, 
and  each  favic  patch  is  soaked  with  the  following  : 

R.  Alcoholis  (90  per  cent.),  100  parts. 

Ac.  acetic,  (crystals),  j  to  1  part. 
Ac.  boric,  2  parts 

Chloroformi,  5     "        M. 

Then  each  patch  is  to  be  accurately  covered  with  mercu- 
rial plaster. 

1  French  ed.  Kaposi's  Mai.  de  la  Peau.     Paris,  1S91. 


232  DISEASES    OF    THE    SKIN. 

Favus  of  the  non-hairy  parts  of  the  body  usually  yields 
readily  to  the  removal  of  the  crust  and  the  use  of  a  parasiti- 
cide. 

Favus  of  the  nail  may  be  treated  by  the  constant  applica- 
tion of  a  mercurial,  resorcin,  or  hydronaphthol  plaster.  If 
the  disease  is  limited  to  one  or  two  points  they  may  be  cut 
down  upon  and  the  remedy  applied  directly.  Sometimes  it 
may  be  necessary  to  remove  the  whole  nail. 

After  a  case  of  favus  has  been  faithfully  treated  for  a  num- 
ber of  weeks  and  looks  as  if  it  were  well,  it  should  be  let 
alone  and  watched  carefully  for  a  long  time.  Any  red 
point  that  appears  is  evidence  that  the  disease  is  cropping  up 
again,  and  should  be  immediately  attacked. 

Prognosis.  The  prognosis  is  good,  provided  the  case  is 
faithfully  and  energetically  treated.  Relapses  will  surely 
occur  if  any  of  the  fungus  remains  in  the  scalp.  A  cure 
takes  months  or  years  to  effect.  Favus  of  the  nail  is  spe- 
cially rebellious  to  treatment,  and  may  cause  permanent 
destruction  of  the  nail. 

Feuergurtel,     See  Zoster. 
Feuermal.     See  Naevus. 

Fibroma  (Fi-bro'ma3).  Synonyms  :  Fibroma  molluscum ; 
Molluscum  fibrosum ;  Molluscum  simplex ;  Molluscum 
pendulum. 

Fibromata  are  soft  tumors  of  the  skin  that  are  composed 
of  a  hyperplasia  of  the  connective  tissue  as  well  as  the 
subcutaneous  tissue,  and  occur  in  various  shapes,  colors, 
and  sizes.  The  most  commonly  encountered  form  of 
fibroma  is  molluscum  fibrosum.  These  may  be  of  the 
color  of  the  skin,  or  pinkish,  or  even  brownish,  or  brown- 
ish-red ;  most  commonly  they  are  of  normal  color.  They 
may  be  rounded,  flattened,  sessile,  or  pedunculated,  but 
always  raised  above  the  level  of  the  skin.  They  may 
hang  down  like  polypi.  The  skin  over  them  feels  soft 
and  of  normal  texture,  or  it  may  be  thickened,  or  atro- 
phied. A  hair  sometimes  grows  from  them.  There  may 
be  but  one  or  two  present,  or  there  may  be  hundreds 
of  them  so  that  the  body  is  strewn  over  from  head  to  foot 


FIBROMA. 


233 


with  the  variously  shaped  tumors.  The  trunk  is  the  most 
common  location  for  fibromata,  but  they  may  occur  on  all 
parts  and  involve  even  the  mucous  membranes.  (Fig.  23.) 
They  give  rise  to  no  inconvenience  except  on  account  of 


Fig.  23. 


Multiple  fibromata.1 

their  size,  which  sometimes  may  be  that  oi  a  child's  head. 
Their  usual  size  is  from  that  of  a  cherry  to  that  of  a  walnut. 
Many  of  them  show  a  slow  growth,  while  many  are  station- 
ary, and  some  may  involute.  Comedones  of  large  size  may 
accidentally  form  in  some  fibromata.     The  larger  ones  may 

1  From  a  photograph  of  a  case  of  Dr.  E.  T.  Tappey,  of  Detroit. 


234  DISEASES    OF    THE    SKIN. 

ulcerate.  All  of  them  feel  soft,  while  the  larger  ones  may 
be  elastic  to  the  touch.  When  they  hang  down  in  the  forms 
of  large  skin-folds  which  have  undergone  hypertrophy,  the 
term  fibroma  pendulum  is  applied  to  them.  Dermatolysis 
(which  see)  has  been  considered  as  a  form  of  fibroma.  Ac- 
cording to  some  authorities  fibrous  moles  and  soft  warts  are 
but  forms  of  fibroma. 

Etiology.  Fibromata  usually  appear  in  childhood, 
though  they  may  not  do  so  until  later  in  life.  They  are 
sometimes  hereditary.  They  tend  to  increase  with  advan- 
cing age — that  is,  they  are  not  so  large  or  numerous  in  chil- 
dren as  in  adults.  Hebra  taught  that  these  children  were 
stunted  both  physically  and  mentally,  but  this  is  not  always 
true.  By  some  authorities  they  are  regarded  as  related  to 
neuro  fibromata. 

Diagnosis.  Molluscum  fibroma  differs  from  molluscum 
contagiosum  by  not  having  a  central  depression,  and  by 
being  of  the  normal  color  of  the  skin.  They  are  also  usually 
far  more  numerous.  From  fatty  tumors  they  differ  in  not 
being  tabulated,  and  in  being  pedunculated,  and  less  flat. 
Sebaceous  cysts  are  not  so  numerous,  and  their  contents 
can  be  squeezed  out  to  large  extent,  while  fibromata  are 
solid. 

Treatment.  They  may  be  snipped  off  with  scissors  or 
tied  off  with  ligature  if  pedunculated.  If  non-pedunculated 
they  may  be  destroyed  by  electrotysis,  or  excised.  If  of 
large  size  they  must  be  excised.  The  galvano-cautery  may 
be  used  to  destroy  any  form. 

Fibroma  Fungoides.     See  Mycosis  fungoide. 

Fibroma  Lipomatodes.   *  See  Xanthoma. 

Fibroma  Molluscum.     See  Fibroma. 

Fibromyoma.     See  Myoma. 

Figwart.     See  Verruca 

Filaria  Sanguinis  Hominis.     See  Elephantiasis. 

Filaria  Medinensis.     See  Guinea  worm. 

Finnen,     See  Acne. 

Fischschuppenausschlag.     See  Ichthyosis. 


FOLLICULITIS    DECALVANS.  235 

Fish-skin  Disease.     See  Ichthyosis. 

Flachenkatarrh  der  Haut.     See  Eczema, 

Flachenkrebs.     See  Epithelioma. 

Fleckenmal.     See  Nsevus  pigmentosus. 

Flechten.  May  mean  Herpes,  or  (nassende)  Eczema,  or 
(fressende)  Lupus. 

Fluxus  Sebaceus.     See  Seborrhcea. 

Folliculitis  Barbae.     See  Sycosis. 

Folliculitis  Decalvans.  Under  the  name  of folliculites  et 
perifolliculites  decalvantes  ac/minees,  Brocq  has  described 
a  form  of  inflammation  of  the  hair  follicle  closely  allied  to 
sycosis  to  which  Besnier  has  given  the  name  of  aloj^ecies 
cicatricielles  innominees.  It  is  characterized  by  an  inflam- 
matory process,  which  results  in  complete  destruction  of  the 
hair  papillae,  and  the  formation  of  cicatricial  tissue ;  and  by 
a  tendency  for  its  lesions  to  aggregate  themselves  in  groups. 
Besnier1  reported  a  case  of  this  in  1889.  He  says  that  it 
is  the  same  thing  that  has  been  called  acne  lupoide  and 
folliculite  epilante.  In  the  case  reported  the  disease  affected 
all  the  posterior  part  of  the  scalp,  which  was  sown  over 
with  disseminated  patches  of  baldness  of  unequal  size, 
irregular  shape,  and  serpiginous  They  were  depressed  in 
the  centre,  which  was  smooth,  polished,  thinned,  cicatricial, 
and  completely  bald.  Their  borders  were  not  well  defined, 
but  merged  into  the  islands  of  healthy  hair.  The  scalp 
between  the  borders  and  the  centre  of  the  patches  was  bald, 
of  variegated  redness  with  some  hairs  broken  off  at  the  sur- 
face of  the  scalp.  In  the  funnel-shaped  openings  of  the 
hair  follicles  there  were  little  superficial  collections  of  pus. 
Some  of  the  patches  were  torn  by  scratching,  and  others 
looked  precisely  like  those  of  alopecia  areata,  Avithout  signs 
of  inflammation.  All  treatment  seemed  to  be  in  vain,  and 
the  scalp  bore  only  the  mildest  applications. 

Another  variety  of  folliculitis  decalvans  is  that  described  by 
Quinquaud.  It  affects  most  often  the  scalp  hair,  more  rarely 
that  of  the  beard,  pubes,  and  axillary  region.     It  produces 

1  Annal.  Derm,  et  Syph.,  1889,  x.  104. 


236  DISEASES    OF    THE    SKIN. 

irregularly  shaped  areas  of  baldness,  which  are  quite  smooth, 
polished,  pale,  atrophic-looking,  and  presenting  at  some 
points  slight  redness.  The  areas  are  disseminated,  about  the 
size  of  a  franc-piece,  separated  by  islands  of  healthy  hair. 
The  bald  spots  are  slightly  depressed.  At  the  peripheries 
of  the  patches  or  in  the  islands  of  healthy  hair  between 
them,  will  be  found  pin-head,  discrete  pustules  about  the 
hairs.  The  latter  are  easily  plucked  or  fall  spontaneously. 
Or  we  find  simply,  punctiform,  isolated  red  spots  which 
may  or  may  not  be  scaly ;  or  a  reel,  elevated,  inflamed 
follicle.  The  fall  of  neighboring  hairs  produces  the  bald 
patches.  The  disease  is  very  chronic  and  marked  by  a 
series  of  outbreaks.  A  micrococcus  has  been  found  in  prob- 
able causative  connection  with  the  disease. 

Treatment.  The  treatment  found  to  be  most  efficacious 
is  to  clean  the  scalp  with  soap  and  water ;  to  paint  the  dis- 
eased patches  and  their  vicinage  with  the  tincture  of  iodine ; 
and  to  bathe  the  same  every  morning  Avith  the  following : 

15 


R .  Hydrarg.  biniod., 

gr-  .1 ; 

Hydrarg.  bichlor., 

gr.  iv ; 

1 

Alcohol., 

^ss; 

GO 

Aquoe  destil., 

ad     ^  iv ; 

500 

M. 

This  will  check  the  disease,  but  the  baldness  is  irremedi- 
able.    (Brocq.) 

Folliculitis  Rubra.     See  Keratosis  pilaris. 
Fragilitas  Crinium.     Sec  Atrophia  pilorum  propria. 
Frambcesia.     See  Yaws. 
Freckles.     See  Lentigo. 
Frieselausschlag.     See  Miliaria. 

Fungous  Foot  of  India.  Synonyms :  Madura  foot ; 
Mycetoma ;  Podelcoma ;  Ulcus  grave ;  Tubercular  disease 
of  the  foot. 

This  is  a  disease  that  is  endemic  in  certain  parts  of  India, 
but  has  been  met  with  in  this  country.  Though  usually 
affecting  the  foot  and  leg,  it  is  seen  occasionally  on  the 
hands,  shoulders,  and  scrotum.  According  to  Crocker 
there  are  two  varieties,  the  pale  and  the  black,  the  latter 


FURUNCULUS.  237 

being  the  most  common.  It  may  begin  with  slight  conges- 
tion of  the  affected  part ;  or  as  a  local  induration,  either 
superficial  or  deeply  seated,  of  some  part  of  the  foot,  which 
is  firmer,  larger,  more  diffused  and  less  painful  than  a  boil. 
When  this  is  opened  it  discharges  pus  at  first,  later  granules 
like  poppy  seeds,  or  mulberry-like  masses  are  mingled  with 
the  discharge.  Or  it  may  begin  as  a  blackish  or  bluish 
mottled  discoloration  like  tatoo  puncta.  The  progress  of 
the  disease  is  slow,  but  in  the  course  of  a  few  years  the  foot 
becomes  swollen  and  distorted,  the  arch  being  broken,  the 
toes  being  over- extended,  and  the  sole  convex  from  behind 
forward.  It  becomes  dotted  over  with  the  raised  orifices 
of  sinuses  extending  deep  down  into  the  tissues,  and  giving 
vent  to  the  above-described  discharge. 

It  is  more  common  in  males  than  in  females,  and  rare 
before  puberty.  It  does  not  occur  in  Europeans.  Its  origin 
is  obscure,  though  it  is  supposed  to  be  due  to  a  fungus. 
Surgical  interference  is  the  only  hope  for  a  cure. 

Furunculus  (Fu^ruVku^-uV).  Synonyms  :  (Fr.)  Fur- 
oncle,  Clou  ;  (Ger.)  Blutschwar ;  Furuncle  or  Boil. 

An  acute  circumscribed  phlegmonous  inflammation  round 
a  skin  gland  or  follicle,  characterized  by  one  or  more  round, 
more  or  less  acuminated,  firm,  painful  formations,  and 
usually  terminating  by  necrosis  and  suppuration.     (Foster.) 

Symptoms.  This  is  a  common  and  familiar  disease  of 
the  skin.  Its  most  frequent  locations  are  the  back  of  the 
neck,  face,  forearms,  buttocks,  and  legs,  though  it  may 
occur  anywhere.  It  begins  as  a  small,  round,  red,  painful 
spot,  which,  in  two  or  three  days,  enlarges  to  attain  the 
size  of  a  split-pea  or  silver  quarter-  or  half-dollar.  It  is 
now  raised  above  the  surface,  hard,  of  a  dark-red  color  at 
the  centre  with  the  redness  fading  awTay  into  the  sound  skin, 
more  or  less  pyramidal  in  shape,  exquisitely  tender  to  the 
touch,  and  with  a  most  agonizing  throbbing  pain.  Its  centre 
soon  becomes  yellow,  indicating  the  point  at  which  sup- 
puration has  taken  place,  and  where  it  will  open.  From 
the  opening  comes  the  "  core,"  a  greenish-gray  or  whitish 
pultaceous  mass  mixed  with  pus  and  blood.     With  the  es- 


238  DISEASES    OF    THE    SKIN. 

cape  of  this,  all  the  symptoms  subside  and  the  cavity  fills 
up  by  granulation,  leaving  more  or  less  of  a  scar.  The 
course  of  the  individual  boil  is  from  seven  to  ten  or  fifteen 
days.  At  times  suppuration  does  not  take  place,  but  the 
mass  undergoes  resolution.  This  is  the  so-called  "  blind 
boil." 

There  may  be  but  one  boil,  or  there  may  be  hundreds  of 
them.  They  come  out  in  crops  of  from  two  to  half  a  dozen 
at  a  time.  If  very  numerous,  or  of  large  size,  they  give 
rise  to  constitutional  disturbance.  They  may  continue  to 
form  for  weeks,  months,  or  even  years  if  left  untreated. 
This  is  what  is  called  furuneulosis. 

Boils  are  always  isolated.  They  may  be  confined  to  one 
spot,  or  come  out  in  a  number  of  regions  at  the  same  time. 
There  may  be  sympathetic  enlargement  of  the  neighboring 
lymphatics.  If  the  disease  is  extensive  the  patient  presents 
a  truly  pitiable  condition. 

If  a  boil  starts  from  a  sweat  gland  it  resembles  that 
which  originates  in  a  sebaceous  gland,  except,  according  to 
Crocker,  it  has  no  mattery  head  and  is  somewhat  less  in- 
durated. This  form  of  boil  is  called  "  hydro-adenitis  "  by 
Verneuil  and  Bazin.  It  is  of  the  size  of  a  pea,  and  is  most 
often  met  with  in  the  axillae,  about  the  anus  and  perineum, 
near  the  nipples,  and  may  form  anywhere  where  there  are 
sweat  glands,  excepting  on  the  soles  of  the  feet. 

Boils  may  occur  in  the  external  auditory  canal  in  con- 
junction with  the  disease  elsewhere.  They  are  exceedingly 
painful,  and  produce  deafness.  One  or  both  ears  may  be 
affected,  but  usually  it  is  only  one  ear.  They  may  set  up 
inflammation  of  the  entire  canal  and  tympanum ;  one  case 
of  this  sort  has  ended  fatally.  If  the  furuncle  is  situated 
in  the  posterior  wall  of  the  canal,  or  a  general  inflammation 
has  been  set  up,  considerable  redness  and  tumefaction  over 
the  mastoid  region  may  occur.     (Dr.  A.  Rupp.1) 

Etiology.  In  this  bacteriological  age  the  cause  of  fu- 
runcles is  believed  to  be  the  entrance  into  the  skin  of  the 
staphylococcus  pyogenes  aureus  et  albus.    It  would  certainly 

1  Personally  communicated. 


FUKUNCULUS.  239 

seem  that  local  infection  does  play  a  part  in  the  production 
of  crops  of  boils  occurring  in  one  region,  and  the  doctrine 
of  local  infection  finds  further  support  in  the  results  of 
treatment  by  antiseptics.  It  must  be  remembered  that  these 
micrococci  are  widely  distributed,  having  been  found  in  dish- 
water, in  the  superficial  layers  of  decayed  vegetable  matter, 
in  the  swaddling-clothes  of  healthy  infants,  in  the  dirt 
under  the  finger-nails,  and  in  numerous  other  places.  Like 
other  parasites,  these  require  some  peculiarity  of  soil  for 
their  growth,  or  at  least  an  opportunity  for  gaining  entrance 
to  the  glandular  apparatus  of  the  skin.  The  soil  is  afforded 
in  lowered  vitality  of  the  skin,  and  thus  we  find  boils  in 
diabetes  mellitus,  after  specific  fevers,  in  anaemia,  lithsemia, 
uraemia,  and  septicaemia ;  and  as  a  complication  of  other 
skin  diseases,  such  as  eczema,  prurigo,  and  scabies.  In  many 
cases  no  disorder  of  the  general  health  can  be  discovered. 
The  second  condition  is  fulfilled  by  local  injury  to  the  skin, 
such  as  friction  or  pressure,  or  scratching.  It  is  probable 
that  they  are  contagious,  as  they  are  certainly  auto- 
inoculable,  and  can  be  produced  by  inoculation  of  pure  cul- 
tures of  the  micrococcus.  The  popular  notion  of  their 
origin  from  too  good  living  is  only  another  way  of  saying 
that  they  occur  in  individuals  not  in  perfect  health. 

Pathology.  The  inflammation  begins  in  the  corium  and 
deeper  tissues  in  or  about  the  hair  follicles  or  glands  of  the 
skin.  "  The  mechanism  of  the  process  is  supposed  by  some 
to  be  that  the  vessels  around  the  gland  or  follicle  become 
blocked,  producing  its  death,  and  inflammation  is  then  set 
up  round  the  necrosed  tissue  to  get  rid  of  it  by  suppuration." 
(Crocker.) 

Diagnosis.  The  disease  is  so  common  that  there  is  no 
need  for  detailing  the  diagnosis.  For  the  diagnosis  from 
carbuncle,  see  under  that  word. 

Treatment.  In  most  cases  there  is  no  need  of  internal 
treatment.  If  the  patient  is  out  of  health  in  any  way  we 
should  endeavor  to  help  him  back  to  his  normal  condition. 
In  furunculosis  we  should  always  bear  in  mind  the  proba- 
bility of  there  being  diabetes  mellitus  at  the  bottom  of  the 
mischief,  seek  for  it,  and  do  our  best  to  cure  the  patient  if 


240  DISEASES    OF    THE    SKIN". 

we  find  evidence  of  it.  As  a  rule,  tonics  are  called  for. 
There  are  many  drugs  recommended  for  the  treatment  of 
boils,  apart  from  constitutional  conditions.  Of  these,  sulphide 
of  calcium  is  one  of  the  most  popular,  one-tenth  of  a  grain 
being  given  every  two  or  three  hours,  or  a  fourth-  to  a  half- 
grain  three  or  four  times  a  day.  Piffard  speaks  well  of  the 
compound  syrup  of  the  hypophosphites,  a  dessertspoonful 
three  times  a  day.  Hardy  recommends  tar- water  up  to  a 
quart  a  day.  The  sulphite  or  hyposulphite  of  sodium  in 
fifteen-  to  twenty-grain  dose  three  times  a  day,  is  also  well 
spoken  of.  Yeast  is  a  homely  but  efficient  remedy,  either  a 
half-wineglassful  being  taken  night  and  morning  or  a  like 
quantity  in  divided  doses,  or  one  of  Fleischmann's  yeast 
cakes  being  eaten  during  the  day.  Le  Gendre,1  believing 
that  boils  may  arise  from  the  absorption  of  imperfect  prod- 
ucts of  digestion,  advises  the  disinfection  of  the  intestinal 
tract  by  the  use  of  the  following  powder  : 


Be .  0-Naphthol 

Bismuth,  sal  icylat.,  \-  aa     gr.  ivss; 

Magnesia  carb., 


30 

M. 


which  is  to  be  given  every  four  hours. 

The  local  treatment  of  boils  is  important  and  efficient. 
They  should  not  be  poulticed,  as,  being  due  to  a  fungus,  the 
heat  and  moisture  only  facilitate  the  growth  of  the  same, 
and  the  production  of  new  boils.  That  new  boils  are  apt  to 
spring  up  about  a  poulticed  boil  is  a  common  experience. 
"Hands  off"  is  the  rule  for  young  boils,  nor  should  old 
ones  be  squeezed.  We  should  endeavor  to  abort  the  de- 
velopment of  a  boil.  To  do  this  there  are  various  approved 
methods,  but  the  one  most  highly  commended  is  the  use  of 
carbolic  acid.  This  may  be  either  by  touching  them  with 
pure  carbolic  acid  ;  injecting  them  with  a  few  drops  of  a  two 
per  cent,  solution  ;  or  spraying  them  with  the  same  solution 
for  fifteen  minutes  at  a  time  eight  times  during  the  day,  and 
keeping  them  covered  with  carbolized  dressings  in  the  mean- 
time. Mercury  may  be  used  instead  of  carbolic  acid,  the 
boil  beingkept  covered  with  emplastrum  hydrarg.  with  a  little 

1  Union  Med.,  1888,  xlv.  98. 


FURUNCULUS.  '  241 

hole  cut  in  the  plaster  to  correspond  to  the  centre  of  the 
boil ;  or  an  ointment  of  the  nitrate  or  red  oxide  may  be  used. 
Painting  with  iodine  is  also  commended  ;  as  well  as  keeping 
them  covered  with  a  saturated  solution  of  boric  acid,  or  an 
eight  or  ten  per  cent,  plaster  or  ointment  of  salicylic  acid. 
Hardaway  speaks  highly  of  Unna's  carbolic  acid  and  mer- 
cury mull  plaster.  Electrolysis  to  destroy  the  follicle  is 
spoken  of  by  the  same  authority. 

When  aborting  is  out  of  the  question,  it  is  a  good  plan 
to  thrust  a  little  pure  carbolic  acid  into  the  central  opening. 
It  hurts  for  a  few  minutes  only,  and  is  promptly  curative. 
The  boil  should  then  be  dressed  with  carbolized  vaseline  or 
a  boric  acid  ointment.  Or  it  may  be  opened  and  dressed 
with  iodoform,  or  aristol,  as  the  odor  of  the  former  is  objec- 
tionable. Here  too  the  mull  plaster  of  carbolic  acid  and 
mercury  may  be  used.  Instead  of  the  pure  carbolic  acid, 
Crocker  advises  the  glycerole  of  carbolic  acid  of  the  British 
Pharmacopoeia. 

Furuncles  of  the  ear.  My  friend  Dr.  A.  Rupp,  aural 
surgeon  to  the  New  York  Eye  and  Ear  Infirmary,  has 
kindly  advised  me  on  this  head  as  follows  :  If  the  auditory 
canal  be  filled  or  unclean,  it  must  be  syringed  out  with  a  two 
to  five  per  cent,  solution  of  carbolic  acid  followed  by  a  solu- 
tion of  bicarbonate  of  soda  as  hot  as  can  be  comfortably 
borne. 

The  canal  is  to  be  dried  with  absorbent  cotton,  and  if  the 
membrana  tympani  is  intact,  filled  with — 


R .  Hydrarg.  biclilor.,  gr.  v. 

Glycerini,  \  ..    z- 

Alcoholis,  J  ^J  ' 


30 


M. 


which  is  to  remain  in  some  minutes,  and  then  the  excess  is 
allowed  to  drain  off.  The  canal  is  lightly  closed  with 
borated  or  salicylated  absorbent  cotton.  If  the  membrana 
tympani  is  deficient,  the  whole  canal  is  to  be  filled  with 
powdered  boric  acid,  and  the  orifice  closed  as  before.  In 
either  case  the  cotton  is  to  be  changed  when  soiled.  When 
furuncles  are  at  the  inner  end  of  the  canal  near  the  mem- 
brana tympani,  a  leech  or  two  in  front  and  a  little  above  the 

11 


242  DISEASES    OF     THE     SKIN. 

tragus  will  afford   mucli  relief.     It  is  unnecessary  to  incise 
the  furuncles  except  where  pus  has  formed  and  has  no  outlet. 

Furunculus  Orientalis.     See  Aleppo  boil. 

Gale.     See  Scabies. 

Gangrene  of  the  Skin.     See  Dermatitis  gangrenosa. 

Gansehaut.     See  Cutis  anserina. 

Gefassmaler.     See  Nsevus  vasculosus. 

Geromorphisme  Cutane  is  the  name  chosen  by  Drs. 
Souques  and  Charcot1  to  designate  an  affection  producing 
changes  in  the  skin  of  a  girl  eleven  years  of  age  so  that  she 
looked  like  an  old  woman.  The  expression  of  the  face  sug- 
gested that  due  to  facial  paralysis.  The  skin  hung  in  loose 
folds  and  was  flabby  like  the  skin  sometimes  seen  in  very 
old  people.  Apart  from  loss  of  natural  consistence  and 
elasticity  there  was  no  change  in  the  skin.  If  lifted  up, 
twisted  or  folded  in  any  way,  it  returned  very  slowly  to  its 
normal  position ;  and  it  was  abnormally  movable  over  the 
subcutaneous  tissues,  in  these  things  suggesting  that  form  of 
dermatolysis  called  "  elastic  skin."  There  were  no  changes 
in  the  hair,  nails,  or  teeth.  There  was  no  assignable  cause 
for  the  condition,  which  was  preserved  unaltered  during  an 
interval  of  ten  years  from  the  first  to  the  last  time  that  the 
doctors  saw  the  case. 

Geschwulst  is  the  German  for  tumor. 

Geschwiire.     See  Ulcers. 

Gesichtsatrophie.     See  Hemiatrophia  facialis. 

Glanders.     See  Equinia. 

Glanzhaut.     See  Atrophoderma  idiopathica. 

Glossy  Skin.     See  Atrophoderma  idiopathica. 

Gneis.     See  Seborrhcea  sicca. 

Gommes  Scrofuleuses.     See  Scrofuloderma. 

Goose-flesh.     See  Cutis  anserina. 

Granulationsgeschwulste  (Grer.).  Connective-tissue  new 
growths. 

1  Nouvelle  Iconographie  de  la  Salpetriere. 


H^MATIDROSIS.  243 

Granuloma  Fungoides.     See  Mycosis  fungo'ides. 

Greisenhaftigheit  der  Kinder.  See  Sclerema  neona- 
torum. 

Grocers'  Itch  is  eczema  of  the  hand. 

Grutum.     See  Milium. 

Grutzgeschwulst.     See  Atheroma. 

Guinea-worm  Disease  or  Dracontiasis  is  met  with  en- 
demically  in  tropical  climates.  It  is  caused  by  the  larvae  of 
the  Guinea-worm,  or  filaria  medinensis,  being  swallowed,  and 
developing  in  the  body.  The  female  makes  its  way  into  the 
muscles,  and  within  nine  to  twelve  months  gives  rise  to  the 
symptoms  of  the  disease.  The  male  probably  dies  and  is 
passed  out  of  the  body.  The  symptoms  of  the  disease  are  a 
small  tumor  under  the  skin  that  feels  like  a  coil  of  soft 
string;  the  appearance  of  a  pea-  to  filbert-sized  vesicle  upon 
this  when  the  animal  is  about  to  escape ;  tension,  pain,  and 
itching;  in  severe  cases  inflammation,  purulent  discharge, 
hectic  fever,  and  perhaps  delirium.  The  worm  is  either 
gradually  wholly  extruded  after  the  vesicle  breaks,  or  a 
new  tumor  forms  after  a  part  has  escaped,  and  this  after  a 
time  breaks,  and  the  rest  of  the  worm  comes  away.  There 
may  be  only  one  worm  or  a  legion  of  them.  They  are 
located  most  often  in  the  foot,  but  may  be  found  anywhere. 

Treatment.  The  treatment  of  the  disease  is  to  remove 
the  worm,  which  is  done  by  winding  it  carefully  around  a 
stick  when  the  head  is  protruded,  giving  a  turn  or  two  every 
day  until  the  worm  is  extracted.  Tincture  of  assafoetida  in 
doses  of  one  or  two  drachms  three  times  a  day  kills  the 
worm,  before  extraction. 

Gumma.     See  Syphilis. 

Gune.     See  Tinea  imbricata. 

Gurtelkrankheit.     See  Zoster. 

Gutta  Rosea.     See  Rosacea. 

Haarmenschen.     See  Hypertrichosis. 

Haematidrosis(He2m-a2t-i2-dro/si2s)  or  Haemidrosis(He2m- 
i2  dror-si2s)  is  a  rare  disease  of  the  sweat  glands  in  which,  on 
account  of  an  effusion  of  blood  into  the  coils  and  their  ducts 


244  DISEASES    OF    THE    SKIN. 

by  diapedesis  from  the  surrounding  vascular  plexus,  blood  is 
discharged  upon  the  skin  along  with  the  sweat.  The  sub- 
jects are  apt  to  be  hysterical  young  women,  though  the 
affection  has  been  seen  in  newborn  children.  It  is  in  some 
cases  vicarious  menstruation.  The  points  of  election  are  the 
face,  ear,  umbilicus,  hands  and  feet.  Ephidrosis  cruenta 
and  bleeding  stigmata  are  other  names  for  the  curious  malady. 
The  treatment  should  be  directed  to  the  condition  of  the 
individual. 

Hsemorrhcea  Petechialis.     See  Purpura. 
Hautfinne.     See  Acne. 
Hauthorn.     See  Cornu  cutaneum. 
Hautgries.     See  Milium. 
Hautkrebs.     See  Epithelioma. 
Hautsclerem.     See  Scleroderma. 
Hemorrhagic  Cutanee.     See  Purpura. 

Herpes  (Hu5r-pez).  An  acute  inflammatory  disease  of 
the  skin  characterized  by  an  eruption  of  one  or  more  groups 
of  vesicles  upon  reddened  bases. 

There  are  two  main  varieties  of  the  disease :  one  occur- 
ring upon  the  face,  herpes  facialis  ;  and  one  occurring  upon 
the  genitals,  herpes  pro  genitalis. 

Symptoms.  Herpes  facialis,  also  called  herpes  febrilis, 
herpes  labialis,  hydroa  febrilis,  fever  blister  or  cold  sore, 
usually  occurs  upon  the  lower  part  of  the  face,  about  the 
mouth  (Fig.  24).  There  is  commonly  some  slight  disturb- 
ance of  the  general  economy,  not  as  part  of  the  disease, 
but  as  the  cause  of  it.  The  patient  first  notices  more  or  less 
marked  burning,  stinging,  or  itching  in  the  part,  and  perhaps 
at  the  same  time  erythematous  papules  may  form.  After  a 
few  hours  a  number  of  pinhead-  to  pea-sized,  clear,  fully  dis- 
tended vesicles  will  appear  upon  an  erythematous  base. 
Perhaps  the  herpetic  patch  may  appear  suddenly  without 
antecedent  erythema.  There  is  usually  not  more  than  one 
or  two  patches  of  small  size.  There  may  be  a  score  or  more 
of  them,  and  they  may  be  of  large  size.  The  patches  are 
always  irregular  in  shape.     There  may  be  but  two  or  three 


HERPES. 


245 


vesicles  in  a  group,  or  there  may  be  a  dozen  of  them. 
Thev  do  not  tend  to  break  down  of  themselves,  but  after  a 
few  days  dry  up  into  a  crust  which  falls  and  leaves  a  red 
spot  that  soon  disappears.  Sometimes  the  vesicles  may 
coalesce  into  bullae.     The  duration  of  the  disease  is  about 


Fig.  24. 


Herpes  febrilis. 


eight  or  ten  days.  The  most  common  location  is  upon  the 
upper  lip,  but  it  may  be  anywhere  upon  the  face,  and  not 
uncommonly  bilateral.  The  mucous  membrane  of  the 
mouth  may  also  be  involved,  but  here,  owing  to  the  heat 
and  moisture,  the  vesicles  are  seldom  seen,  as  they  break 
down  and  leave  excoriated  points.     There  is  a  strong  tend- 


246  DISEASES    OF    THE    SKIN. 

ency   for   the    disease  to  recur  with  the  recurrence  of  the 
exciting  cause. 

Etiology.  It  is  still  an  undetermined  question  whether 
herpes  facialis  is  a  zoster  or  not.  By  most  authorities  it  is 
considered  to  be  an  independent  disease ;  by  a  few  it  is 
thought  to  be  an  incomplete  zoster.  It  is  known  to  occur 
with  catarrhal  inflammations  of  mucous  membranes,  such  as 
a  coryza  or  a  bronchitis;  with  digestive  derangements,  as  gas- 
tritis or  enteritis ;  with  various  febrile  diseases,  such  as 
pneumonia,  and  the  fevers  in  general,  and  it  is  very  often 
seen  in  women  as  a  herald  of  the  menstrual  epoch,  occur- 
ring with  great  regularity  for  years.  It  arises  sometimes 
on  account  of  an  injury  to  the  terminal  ends  of  the  nerves, 
and  as  such  injuries  are  liable  to  occur  in  the  tender  mucous 
membrane  of  the  lips,  this  may  be  an  explanation  of  its 
frequency  about  the  mouth.  Infection  has  been  invoked 
by  a  few  observers  as  a  cause,  but  this  is  not  proven.  It  is 
evidently  a  neurosis.  Sometimes  it  occurs  coincidently  with 
herpes  progenitalis,  or  with  zoster. 

Diagnosis.  It  must  be  diagnosticated  from  zoster,  and 
from  vesicular  eczema.  From  zoster  it  differs  in  not  occurring 
in  a  series  of  groups  scattered  along  the  course  of  distribu- 
tion of  the  trigeminus;  and  in  frequently  being  bilateral. 
Generally  speaking  there  is  more  marked  neuralgia  in 
zoster,  though  in  some  cases  this  is  wanting.  From  eczema 
it  differs  in  the  large  size  of  its  vesicles,  in  their  showing 
no  tendency  to  break  down,  in  being  less  pruriginous,  in 
running  a  regular  course  and  rapidly  recovering  by  the 
simple  drying  up  of  the  vesicles. 

Treatment.  Left  to  itself  the  disease  will  speedily  get 
well,  and  really  requires  no  treatment  beyond  protection 
with  flexible  collodion,  or  any  indifferent  soothing  lotion  or 
ointment.  We  are  often  asked  if  we  cannot  prevent  or 
abort  the  disease  when  due  to  the  menstrual  flux.  Women 
know  well  that  the  application  of  spirits  of  camphor  will 
sometimes  do  this.  Hardaway  recommends  rubbing  the 
part  with  borax.  Or  one  of  the  alcoholic  solutions  recom- 
mended by  Leloir  for  this  purpose  in  herpes  progenitalis 
may  be  used,  namely,  either  2  per  cent,  resorcin,  1  per  cent. 


HERPES.  247 

thymol,  3  per  cent,  menthol,  or  2  per  cent,  tannin  frequently 
applied. 

Herpes  pro  genitalis.  This  has  been  called  herpes  pre- 
putials, but  as  it  occurs  in  women  as  well  as  men  and  on 
other  places  than  the  prepuce,  that  name  is  obviously  incor- 
rect. 

Symptoms.  The  eruption  is  preceded  and  accompanied 
by  burning  and  itching,  and  the  vesicles  occur  in  groups 
upon  an  erythematous  base.  If  on  the  prepuce,  that  part 
is  sometimes  swollen.  The  vesicles  are  at  first  clear  with 
serous  contents,  and  if  on  moist  locations,  as  under  the  pre- 
puce or  about  the  mucous  membranes  of  the  female  geni- 
tals, they  soon  break  down  and  leave  tiny  excoriations. 
There  may  be  but  one  or  several  patches  of  herpes.  The 
disease  runs  a  course  of  eight  or  ten  days  and  gets  well  of 
itself,  unless  irritated  under  the  mistaken  idea  of  its  being 
a  chancroid. 

According  to  Bergh,1  who  has  made  a  careful  study  of  the 
disease,  in  women  the  groups  usually  contain  five  to  eight 
pin-head  to  hemp-seed  vesicles,  but  may  have  twenty  to 
thirty-five  millet  to  popy  seed  sized  vesicles.  Around  each 
group  is  a  reddish  areola.  The  vesicles  are  isolated,  and 
seldom  confluent.  Itching  is  apt  to  precede  their  outbreak. 
There  may  also  be  slight  tenderness  or  swelling  of  the 
neighboring  glands.  In  both  sexes  the  patches  may  be 
unilateral,  bilateral,  or  median.  In  men  it  occurs  most 
frequently  on  the  inner  surface  of  the  prepuce,  then  on  its 
outer  surface,  the  sulcus,  glans,  meatus,  sheath  of  the  penis, 
and  rarely  in  the  meatus.  In  women,  Bergh  found  it  most 
often  on  the  labia  majora,  then  the  labia  minora,  and  ano- 
genital  region ;  seldom  on  the  clitoris  or  in  the  vestibule ; 
very  rarely  on  the  cervix  uteri.  Unna2  gives  the  order  of 
frequency  as  labia  minora,  clitoris,  labia  majora,  introitus 
vaginae  et  carunculae  myrtiformes,  perineum,  anal  region, 
genito-crural  fold,  mons  veneris,  and  mucous  membrane  of 
anus  and  vagina.     The  disease  has  a  tendency  to  relapse, 

1  Monatshefte  f.  prakt  Derrnat ,  1890,  x.  1. 

2  Journ.  Cutan.  and  Ven   Dis .,  1883-4,  i.  321. 


248  DISEASES    OF    THE    SKIN. 

in  men  with  each  coitus,  in  women  with  each  menstrual 
period.  It  is  very  common  in  women  to  have  herpes  of  the 
face  at  the  same  time,  and  this  has  been  noted  in  men. 

Etiology.  The  cause  of  the  disease  is  congestion  of  the 
genital  region.  Thus  in  men  it  is  frequently  seen  two  or 
three  days  after  each  coitus;  or  accompanying  a  gonor- 
rhoea or  chancre  (soft  sore).  A  long  prepuce  seems  to  pre- 
dispose to  it.  In  women  it  comes  in  80  per  cent,  of  the 
cases  with  menstruation  (Bergh),  and  in  them  it  does  not 
seem  to  have  any  marked  relation  to  the  sexual  act.  It  is 
also  seen  in  connection  with  pregnancy  and  the  puerperal 
state.  It  is  a  not  infrequent  disease.  Greenough1  met 
with  it  in  men  in  about  17  per  cent,  of  all  venereal  cases  in 
private  practice.  In  women  there  are  no  statistics  from 
private  practice,  and,  indeed,  it  is  in  this  country  but  rarely 
reported.  Both  Bergh  and  Unna,  however,  met  with  it 
very  frequently  in  public  prostitutes  in  St.  Petersburg  and 
Hamburg. 

Diagnosis.  The  disease  of  itself  is  of  little  moment, 
but  is  of  great  consequence  viewed  from  a  diagnostic  stand- 
point on  account  of  its  liability  to  be  taken  for  chancre  (soft 
sore),  or  for  the  initial  lesion  of  syphilis.  This  can  hardly 
occur  if  the  vesicles  are  seen,  but  when  they  are  no  longer 
present  some  difficulty  may  arise.  From  chancre  the 
superficial  character  of  the  lesion  points  toward  herpes.  In 
case  of  doubt  the  use  of  a  simple  dusting-powder  for  a  day 
or  two  will  clear  up  the  difficulty,  because  the  chancre  will 
continue  to  enlarge  while  the  herpes  will  become  well. 
Auto-inoculation  will  afford  positive  evidence.  From  the 
inital  lesion  of  syphilis  herpes  differs  in  the  absence  of  all 
induration  of  its  base,  and  in  the  inflammatory  character  of 
the  lesion.  Here  again  a  short  wait  will  clear  up  the  diag- 
nosis. 

Treatment.  Herpes  progeni talis  will  usually  promptly 
disappear  by  the  use  of  a  dusting  powder  of  bismuth,  or 
oxide  of  zinc  and  starch  ;  or  by  covering  it  with  a  piece  of 
lint  soaked  in  an  astringent  solution,  such  as  a  weak  lotion 

1  Archiv.  Dermat.,  1881,  vii.  1. 


HERPETIDE.  249 

of  liquor  plumbi  subacetatis.  If  suppuration  has  occurred 
on  account  of  bad  treatment,  and  the  glands  are  enlarged  or 
tender,  the  patient  had  best  be  put  in  bed.  Circumcision 
has  been  recommended  to  prevent  recurrences,  but  is  of 
doubtful  effiacy.  It  is  well  to  have  the  patient  wash  the 
parts  daily,  and  after  coitus.  Marriage  and  fidelity  to  the 
wife  are  good  means  of  curing  a  relapsing  herpes.  Astrin- 
gent washes  are  useful  in  both  sexes.  If  the  "  habit "  of 
herpes  progenitalis,  as  it  may  be  termed,  has  been  formed, 
careful  hygienic  and  general  treatment  may  be  necessary  for 
a  cure.  Leloir's  directions,  as  given  under  herpes  facialis, 
may  be  tried  for  aborting  the  disease. 

Herpes  Circinatus  is  either  erythema  iris  or  trichophy- 
tosis corporis. 

Herpes  Circinatus  Bullosus  was  the  name  given  by  Wilson 
to  what  has  since  been  called  Herpes  gestationis. 

Herpes  Cretace.     See  Lupus  erythematosus. 

Herpes  Esthiomenes.     See  Lupus  vulgaris. 

Herpes  Gestationis  is  regarded  as  being  a  dermatitis  her- 
petiformis occurring  during  and  provoked  by  pregnancy. 
It  is  prone  to  relapse  with  each  succeeding  pregnancy ;  and 
slowly  subsides  after  delivery.  Apart  from  its  etiological 
relation,  it  corresponds  closely  to  dermatitis  herpetiformis, 
which  see. 

Herpes  Imbrique.     See  Trichophytosis  corporis. 

Herpes  Parasitaires.     See  Trichophytosis  corporis. 

Herpes  Iris.     See  Erythema  Iris. 

Herpes  Phlyctaenoides.     See  Zoster. 

Herpes  Tonsurans,  seu  Tonsurant.  See  Trichophytosis 
capitis. 

Herpes  Tonsurans  Muculosus.     See  Pityriasis  rosea. 
Herpes  Zoster.     See  Zoster. 

Herpetide  Maligne  Exfoliative.  See  Dermatitis  ex- 
foliativa. 

Herpetide  (E2r-pa-ted).  This  is  a  class  of  skin  disease 
which  depend  upon  what  the  French  writers  call  the  her- 

11* 


250  DISEASES    OF    THE    SKIN. 

petic  diathesis.  The  affections  in  this  class  are  marked  by 
long  duration  ;  obstinacy  to  treatment ;  tendency  to  relapse  ; 
and  more  or  less  pain  and  discomfort.  Under  it  are  included 
eczema,  the  lichens,  psoriasis,  and  prurigo. 

Hirsuties.     See  Hypertrichosis. 

Homines  Pilosi.     See  Hypertrichosis. 

Homines  Sylvestris.     See  Hypertrichosis. 

Honey-comb  Ringworm.     See  Favus. 

Horn.     See  Cornua  cutaneum. 

Hiihnerauge.     See  Clavus. 

Hydradenomes  Eruptifs.     See  Adenoma  of  sweat  glands. 

Hydroa  (Hi-dro'-a3)  is  practically  dermatitis  herpetiformis. 
It  is  an  old  term  recently  revived,  aud  is  of  uncertain  sig- 
nificance. By  some  it  is  used  to  designate  eruptions  that 
are  midway  between  erythema  multiforme  and  pemphigus. 
As  dermatitis  herpetiformis  certainly  comprises  what  has 
been  described  as  hydroa,  I  shall  consider  the  latter  no  fur- 
ther. All  the  different  forms  of  hydroa,  such  as  H.  vaccini- 
forme of  Bazin ;  H.  vesiculeux,  etc.,  may  well  be  dropped 
from  our  nomenclature. 

Hydroa  Bulleux.     See  Erythema  iris. 

Hydro-adenitis.     See  Furunculus  of  sweat  glands. 

Hygroma  Cysticum  Colli  Congenitum.  See  Lymphan- 
gioma. 

Hyperesthesia  (Hip-u5r-e2s-the'-zi2-a3).  This  is  that 
condition  of  the  skin  in  which  pain  is  experienced  on  the 
slightest  contact  even  of  a  current  of  air,  in  this  differing 
from  dermatalgia,  where  the  pain  is  spontaneous.  It  is  a 
neurotic  disease  and  is  met  with  most  commonly  as  a  symp- 
tom of  other  diseases,  such  as  non-tuberculated  leprosy, 
hydrophobia,  and  hysteria.  Idiopathic  cases  are  met  with, 
though  rarely.  The  hyperesthesia  may  be  general  or 
localized,  unilateral  or  symmetrical. 

The  treatment  is  in  most  cases  that  of  the  disease  of 
which  it  is  but  a  symptom.     Barbillion1  cured  one  case  of 

1  Progres  Med.,  1885,  i.  375. 


HYPERIDROSIS.  251 

the  idiopathic  variety  by  blisters,  and  two  cases  by  congela- 
tion by  means  of  methyl  chloride.  It  is  probable  that  cata- 
phoresis  by  cocaine  after  the  method  of  Peterson  might  be 
beneficial.  This  is  done  by  means  of  discs  of  filter-paper 
soaked  in  cocaine,  and  placed  on  a  specially  made  electrode 
attached  to  the  positive  pole  of  a  galvanic  battery.  The 
sponge  electrode  attached  to  the  negative  pole  is  placed 
indifferently  on  the  skin,  and  a  current  of  some  five  milliam- 
peres,  if  the  patient  can  bear  so  much,  is  allowed  to  pass  for 
fifteen  or  twenty  minutes.  I  have  found,  by  experimenting 
on  myself,  that  lasting  anaesthesia  is  produced,  though  some 
pain  must  be  endured  before  it  is  attained. 

Hyperidrosis  (Hip-u5r-i2d-ro'si2s).  Synonyms  :  Ephidro- 
sis  ;  Idrosis  ;  Sudatoria ;  Polyidrosis  ;  Excessive  Sweating. 

A  functional  disorder  of  the  sweat  glands  characterized  by 
an  excessive  flow  of  sweat. 

Symptoms.  Hyperidrosis  may  be  general  or  localized; 
unilateral  or  symmetrical ;  in  large  or  small  amount.  The 
cases  of  general  sweating  occur  most  often  symptomatically 
in  the  course  of  general  diseases  such  as  phthisis,  malaria, 
and  rheumatism,  and  do  not  concern  us  now.  Some  cases 
occur  idiopathically.  Such  patients  are  usually  fat.  The 
hyperidrosis  may  be  constant  or  at  intervals,  being  excited 
by  the  slightest  irritation  of  the  nervous  system,  or  by  mus- 
cular exertion.  The  outburst  of  the  sweat  is  generally  pre- 
ceded by  a  prickling  sensation.  It  is  apt  to  be  accompanied 
by  prickly  heat  (lichen  tropicus). 

We  are  called  upon  as  dermatologists  to  treat  localized 
sweating  more  often  than  the  just  described  variety,  and  those 
cases  occur  most  commonly  upon  the  palms  and  soles,  in  the 
axillae,  about  the  genitals,  and  on  the  face  and  scalp.  The 
excessive  flow  of  sweat  may  be  constant,  but  it  is  usually 
paroxysmal,  and  often  under  the  influence  of  the  emotions. 
It  is  usually  more  pronounced  in  warm  than  in  cold 
weather.  Eat  people  are  more  prone  to  it  than  are  those 
who  are  thin ;  anaemic  and  delicate  people  rather  than  the 
robust.  In  some  cases  there  may  be  a  sense  of  tingling  be- 
fore the  flow  occurs.     The  affected  part  may  be  warm  or  cold ; 


252  DISEASES    OF    THE    SKIN. 

if  the  first,  it  is  apt  to  be  somewhat  hypersemic.  Occur- 
ring in  places  that  are  warm  and  covered,  brornidrosis  is  a 
common  accompaniment.     The  disease  may  last  for  years. 

Sweating  palms  usually  feel  cold  and  clammy.  Some- 
times the  amount  of  sweat  is  only  enough  to  keep  them 
more  or  less  constantly  moist ;  sometimes  it  is  so  abundant 
as  to  drop  from  the  hand  and  fingers,  or  even  to  fill  up  the 
upturned  palm  and  run  over  the  edge.  It  spoils  gloves,  and 
interferes  with  many  forms  of  work.  Sweating  soles  are 
soon  followed  by  tender  feet,  the  epidermis  becoming  sodden, 
macerated,  and  removed.  It  interferes  with  walking. 
Sweating  in  the  axillae  spoils  the  clothing,  and  is  only  ren- 
dered worse  by  the  rubber  dress  shields  so  commonly  worn 
by  women.  In  its  paroxysmal  form  it  is  frequently  en- 
countered in  patients  stripped  for  examination  in  public. 
This  form  has  been  aptly  named,  by  the  French,  the  mili- 
tary sweat,  as  it  so  often  is  seen  in  examining  recruits  for 
the  army.  Sweating  about  the  genitals  is  often  accompanied 
by  intertrigo,  which  may  also  occur  in  other  parts  subject  to 
hyperidrosis  where  folds  of  skin  are  in  contact.  Sweating 
of  the  face  is  most  commonly  encountered  upon  the  forehead, 
nose,  and  eyelids,  beads  of  sweat  standing  out  upon  them  or 
running  off  in  little  rivulets.  It  is  here  that  haemidrosis  is 
most  common.  Upon  the  scalp  it  has  been  observed  that 
its  occurrence  is  frequently  followed  by  loss  of  hair. 

Unilateral  sweating  is  occasionally  met  with.  It  may 
affect  half  of  the  forehead  or  face,  or  whole  body.  Upon  the 
forehead  and  face  this  form  of  sweating  occurs  as  an  accom- 
paniment of  migraine  and  limited  to  the  painful  region ;  it 
is  in  paraplegia  that  one-half  of  the  body  alone  is  affected. 

Etiology.  The  disease  is  probably  due  to  a  disturbance 
in  the  sphere  of  the  sympathetic  system.  It  has  followed 
lesions  of  the  cerebro-spinal  nerves.  It  occurs  in  all  classes 
and  conditions  of  men,  and  in  all  ages  and  both  sexes.  In 
some  cases  it  is  hereditary.  Ill  health  seems  to  be  the 
cause  in  many  cases;  it  maybe  anaemia;  chlorosis;  lith- 
aemia ;  hysteria ;  or  general  debility.  In  any  case  it  is 
purely  a  functional  disease  of  the  sweat  glands,  they  being 
structurally  unchanged. 


HYPERIDROSIS.  253 

The  diagnosis  is  so  evident  that  we  need  not  stop  to  dif- 
ferentiate it  systematically. 

Treatment.  The  condition  of  the  patient's  health  is  to 
be  carefully  investigated,  and  tonics,  mineral  acids,  nux 
vomica,  or  other  medicine  ordered  according  to  the  nature 
of  the  case.  If  there  is  no  indication  for  this  plan,  or  it  does 
not  succeed,  recourse  may  be  had  to  belladonna  or  atropia  to 
the  point  of  producing  their  full  physiological  effect ;  or  pilo- 
carpine, -£q  gr.  t.  i.  d. ;  or  agaricin  in  dose  of  ^  grain ;  or 
ergot,  half  a  drachm  of  the  fluid  extract  t.  i.  d.  Crocker 
has  found  a  fall  teaspoon  of  precipitated  sulphur  in  milk 
twice  a  day  the  best  remedy.  If  it  loosens  the  bowels  too 
much  he  prescribes  it  as  follows : 


R  •  Pulv.  cretse  co., 
Pulv.  cinnam.  co., 
Sulph.  precip., 
Sig.  A  teaspoonful  twice  a  day. 


3"j; 

25 

3y; 

15 

3J; 

100 

M, 


The  local  treatment  in  many  cases  is  as  unsatisfactory  as 
the  constitutional  treatment.  There  have  been  many  plans 
proposed.  Local  faradization  is  one  agent.  Very  hot 
water  may  be  sponged  on  for  a  few  minutes;  belladonna 
ointment  or  liniment  may  be  rubbed  in ;  or  we  may  use  some 
astringent  application,  as  of  bismuth,  tannin,  alum,  sulphate 
of  zinc,  borax,  and  the  like,  in  alcohol,  ointment,  or  powder. 
As  a  rule,  ointments  cannot  be  used  on  the  hands  and  face. 
The  strength  of  the  alcoholic  solution  is  1  to  3  per  cent. 
The  most  reliable  of  these  is  probably  a  saturated  solution 
of  boric  acid,  or  a  3  per  cent,  solution  of  salicylic  acid. 
Kaposi  speaks  highly  of  the  good  effect  ot  bathing  the  parts 
with  a  5  per  cent,  solution  of  naphthol  in  alcohol,  and  keep- 
ing them  powdered  with  one  part  of  naphthol  to  one  hundred 
of  starch.  Piffard  recommends  freshly  prepared  silicic 
hydrate,  one  part,  in  ointment  of  rose-water,  nine  parts. 
Sulphate  of  quinine,  5  per  cent,  in  alcohol,  may  be  tried. 
For  sweating  of  the  feet  the  best  means  are  those  given 
under  Bromidrosis,  wThich  see.  Permanganate  of  potash  in 
1  per  cent,  strength  may  be  used.  Unna  recommends 
ichthyol  in  2J  per  cent,  ointment  and  the  use  of  ichthyol 
soap. 


254  DISEASES    OF    THE    SKIN. 

The  prognosis  is  doubtful,  many  cases  proving  very 
rebellious  to  treatment. 

Hypertrichosis1  (Hip-e2r-trik-ho'-si2s).  Synonyms :  Hir- 
suties ;  Trichauxis  ;  Polytrichia  ;  Dasyma ;  Trichosis  hir- 
suties  ;  (Fr.)  Poils  accidentels  ;   Superfluous  hair. 

Symptoms.  Hypertrichosis  is  a  growth  of  hair  that  is 
either  abnormal  in  amount  or  occurs  in  places  where,  nor- 
mally, only  lanugo  hairs  are  present.  It  may  be  general 
or  partial,  congenital  or  acquired.  The  general  form  is  also 
congenital,  but  it  is  never  universal,  as  no  hair  grows  upon 
the  palms  and  soles,  the  backs  of  the  last  phalanges  of  the 
fingers  and  toes,  the  inside  of  the  labia  majora,  the  prepuce, 
and  glans  penis.  Subjects  of  this  malady  are  usually  born 
covered  more  or  less  thickly  with  hair,  which  may  be  light 
or  dark  in  color.  This  continues  growing  longer,  coarser, 
and  darker  till  it  reaches  its  full  development.  As  a  rule, 
the  long  hair  covering  the  body  is  fine,  resembling  more  the 
hair  of  the  head  than  of  the  beard,  as  is  also  the  case  with 
the  hair  on  the  face  of  these  people.  With  this  excessive 
growth  of  hair  there  is  usually  combined  a  deficiency  of 
teeth,  specially  marked  in  the  upper  jaw.  Subjects  of  this 
malady  are  called  homines  pilosi  and  are  met  with  in  all 
quarters  of  the  world. 

Of  partial  congenital  hypertrichosis  we  have  an  immense 
number  of  examples.  This  condition  is  apt  to  be  of  the 
nature  of  nsevus.  The  distinction  between  a  localized 
hypertrichosis  and  a  nsevus  is  made  mostly  upon  the  color  of 
the  underlying  skin.  In  the  former  case  the  skin  is  per- 
fectly normal,  while  in  the  latter  it  is  pigmented  and  may  be 
otherwise  altered.  Thus  we  have  in  the  Lancet  of  1869,  ii. 
276,  an  account  of  a  Mexican  woman  who  had  a  nsevus  pilosus 
extending,  like  a  pair  of  bathing  trousers,  from  the  umbilicus 
anteriorly  and  the  sixth  dorsal  vertebra  posteriorly,  to  about 
half-way  down  the  thighs,  covering  the  buttocks.  Dr. 
Cummin2  mentions  the  case  of  a  lady  who  was  noted  for  the 

1  Jackson,  G.  T.,  "  Superfluous  Hair,"  Med.  Record,  May  23, 1885,  is 
the  basis  of  this  section. 

2  London  Medical  Gazette,  1836,  xix.  263. 


HYPERTRICHOSIS.  255 

beauty  of  her  face,  whose  body  from  breast  to  knee  was 
covered  with  a  profusion  of  black,  thick,  bristly  hair.  Wal- 
deyer1  reports  the  case  of  a  girl  nine  years  of  age,  who  had 
a  lock  of  hair  running  from  the  first  to  the  fourth  lumbar 
vertebra,  and  a  smaller  one  from  the  third  to  the  fourth  cer- 
vical vertebra.  These  localized  and  partial  cases  of  hyper- 
trichosis are  most  frequently  met  with  in  the  sacral  or 
lumbar  region,  and  not  infrequently  are  associated  with 
spina  bifida. 

Partial  acquired  hypertrichosis  is  more  common  than  is 
the  congenital  variety,  and  takes  the  form  either  of  an  ex- 
cessive growth  of  hair  in  regions  where  it  is  usually  found, 
or  of  the  development  of  hair  in  regions  usually  hairless  or 
only  provided  with  downy  or  lanugo  hair,  or  of  the  develop- 
ment of  pubertal  hair  at  an  early  age. 

The  following  cases  are  instances  of  excessive  growth  and 
precocious  development.  Chowne2  speaks  of  a  boy,  eight 
years  of  age,  who  had  the  whiskers  of  a  man.  Beigel3  has 
seen  a  six-year  old  girl  with  pudenda  like  a  twenty-year 
old  woman,  both  in  shape  and  hair.  As  cases  of  excessive 
growth,  the  following  may  be  mentioned  :  Leonard4  men- 
tions the  case  of  a  man  in  his  neighborhood  whose  beard 
measured  seven  feet  six  and  a  half  inches  in  length.  Other 
instances  of  excessive  length  of  beard  are  met  with  in  medi- 
cal literature.5  Many  men  have  an  excess  of  hair  upon  the 
chest  and  shoulders.  Hair  is  generally  better  developed 
upon  the  forearm  than  upon  the  upper  arm,  and  upon  the 
legs  than  upon  the  thighs.  As  men  grow  old  they  are  apt 
to  have  long  hair  grow  from  the  nostrils  and  the  ears. 
These  are  instances  of  the  growth  of  strong  hair  where 
normally  only  lanugo  hairs  are  present. 

The  growth  of  the  beard  in  women  is  the  form  of  hy  per- 
trichosis  which  concerns  us  most,  as  it  is  the  deformity  which 
we  will  be  called  upon  to  cure.     As  women  grow  old,  espe- 

1  Atlas  der  menschl.  u.  thierisch.  Haare.     Lahr,  1884. 

2  Lancet,  1852,  i  421. 

5  Virchow's  Archiv,  1868,  xliv.  418. 

*  The  Hair :  its  Diseases  and  Treatment      Detroit,  1881. 

5  Jackson  :  Diseases  of  the  Hair  and  Scalp.     ISew  York,  1887. 


256  DISEASES    OF    THE    SKIN. 

cially  after  they  have  passed  through  the  climacteric  period 
of  middle  life,  a  slight  mustache  or  a  few  straggling  dark 
hairs  on  other  parts  of  the  face  often  appear.  These  growths 
seldom  annoy  them  much,  as  they  are  accepted  as  evidences 
of  advancing  years.  The  case  is  very  different  when  a 
young  woman  is  afflicted  with  a  beard,  and  most  of  the 
patients  who  apply  for  relief  from  their  facial  hair  are  between 
twenty  and  thirty-five  years  old.  The  hair  generally  begins 
to  grow  so  as  to  be  noticeable  at  about  the  eighteenth  year  of 
age.  To  get  rid  of  the  trouble  the  tweezers  are  first  resorted 
to ;  then  depilatories  are  tried ;  sometimes  burning  is  at- 
tempted, and  as  a  final  refuge  the  razor  is  used.  All  the 
time  the  hair  grows  coarser  and  more  abundant.  Some  of 
these  women  shun  company,  keep  themselves  shut  up  all  day, 
their  health  deteriorates,  and  constantly  brooding  over  their 
misfortune,  they  are  prone  to  become  hypochondriacal  and 
melancholic.  The  amount  of  hair  presented  by  these  cases 
varies.  Perhaps  the  commonest  growth  is  a  mustache  alone. 
In  most  of  my  cases  the  hair  has  grown  thickest  and  coarsest 
under  the  chin  and  upon  the  front  of  the  throat.  It  is  rare, 
even  in  the  best-developed  cases,  to  have  much  hair  under 
the  lower  lip.  Sometimes  the  growth  is  as  complete,  as 
heavy,  and  as  coarse  as  is  met  with  in  men.  The  skin  of 
many  cases  is  coarse,  muddy,  greasy,  and  studded  with  acne. 
From  time  to  time  cases  of  transitory  hypertrichosis 
have  been  reported.  This  has  been  noticed  during  the 
treatment  of  a  fractured  limb,  the  hair  being  much  more 
prominent  upon  the  part  that  has  been  kept  quiet  and  warm. 
In  some  of  these  cases  the  increase  is  probably  more  apparent 
than  real,  the  hair  not  having  been  rubbed  off  by  friction. 
Likewise,  after  injury  to  nerves  the  hair  sometimes  becomes 
hypertrophied,  only  to  fall  out  after  recovery.  Continued 
irritation  of  a  part,  as  by  blisters,  may  stimulate  hair 
growth  which  may  or  may  not  be  transitory.  The  most 
interesting  of  this  group  of  cases  is  that  comprising  those 
of  hirsuties  occurring  during  pregnancy,  and  disappearing 
again  after  some  months.  Wilson  reported  a  case  of  delayed 
appearance  of  menstruation  in  which  hair  grew  upon  the 


HYPERTRICHOSIS.  257 

face.      After  the   menstrual  function    was  established,  the 
hair  ceased  to  grow  and  gradually  disappeared. 

The  cause  of  hypertrichosis  is  very  obscure  in  some  of 
its  forms,  while  in  other  varieties  we  can  more  readily  dis- 
cover it.  In  general  congenital  hirsuties  heredity  plays  an 
important  part.  But  hereditary  tendencies  will  not  explain 
the  first  appearance  of  these  congenital  cases.  Virchow  en- 
deavored to  account  for  them  upon  the  theory  of  nervous 
influence,  founded  upon  the  fact  that  in  the  Kostroma  people 
the  lack  of  development  of  the  teeth  and  jaws  was  in  the  same 
zone  as  the  over-development  of  the  hair  on  the  forehead,  nose, 
cheek,  and  ears ;  these  regions  all  being  supplied  by  branches 
of  the  trigeminus  or  fifth  cranial  nerve.  (Jnna's  theory  of 
congenital  hypertrichosis  is  that  it  is  due  to  a  persistence 
of  the  foetal  or  primitive  hair ;  the  change  of  type  between 
the  primitive  and  permanent  hair  not  taking  place. 

The  cause  of  acquired  hirsuties  is,  in  some  cases,  not  far 
to  seek.  Heat  and  moisture  will  apparently  increase  the 
growth  of  hair,  just  as  they  favor  the  growth  of  vegetable 
life.  Thus  the  hair  has  grown  luxuriantly  under  the  stimu- 
lation of  poultices,  and  on  the  limbs  when  confined  in  a 
fracture-box.  To  these  factors  must  be  added  an  increase 
of  the  flow  of  blood  to  the  part.  Increase  of  the  flow  of 
blood  will  stimulate  hair  growth  independently  of  heat  and 
moisture.  At  least  Prentiss'  case  of  hair  growing  more 
luxuriantly  and  coarser  under  the  use  of  pilocarpine,  which 
causes  hyperemia  of  the  skin,  would  seem  to  indicate  this. 
Hypertrichosis  following  injury  to  nerves  is  probably  de- 
pendent upon  vasomotor  disturbances.  The  growth  of  hair 
upon  exposed  parts,  as  upon  the  arms  and  chest  of  laboring 
men,  sailors,  and  the  like,  is  due  to  the  local  irritation  of  the 
sun  and  wind. 

Now  we  come  to  the  more  obscure  cause  of  facial  hirsu- 
ties in  women.  To  account  for  this,  numerous  hypotheses 
have  been  formed.  Probably  the  one  most  generally 
accepted  is  that  it  is  in  some  way  connected  with  derange- 
ment of  the  uterus  and  appendages.  Because  in  some 
bearded  women  there  has  been  some  evident  derangement 
of  the  sexual  organs,  it  has  been  affirmed  that  some  similar 


258 


DISEASES    OF    THE    SKIN. 


derangement  is  present  in  all.  This  is  on  a  par  with  the 
too  loosely  accepted  idea  that  too  free  use  of  alcohol  is  the 
only  cause  of  rosacea.  In  the  cases  I  have  met  with,  the 
majority  were  as  free  from  uterine  trouble  as  the  rest  of  their 
sex.  While  it  is  true  that  some  of  these  women  are  of  mas- 
culine build,  and  have  a  masculine  voice,  most  of  them  do 
not  exhibit  these  characteristics.  In  some  cases,  however, 
there  does  seem  to  be  some  relation  between  the  reproduc- 
tive organs  and  the  growth  of  the  beard.  Heredity  is  often 
well  marked.  It  is  improbable  that  attempts  at  destroying 
the  fine  hair  causes  the  development  of  the  coarse  hair.  It 
is  more  likely  that  it  only  hastens  its  growth. 

An  interesting  study  of  the  relation  between  hirsuties  in 
women  and  insanity  was  made  by  Hamilton.1  He  regards 
hair  growth  on  the  face  in  women  as  the  inevitable  result  of 
the  over-active  and  continuous  exercise  of  the  uterine  and 
ovarian  functions.  He  believes  it  to  be  of  neuropathic 
origin,  connected  with  disorders  of  the  fifth  cranial  nerve ; 
and  that  when  it  occurs  upon  the  face  of  an  insane  person 
it  is  indicative  of  an  unfavorable  form  of  insanity,  especially 
if  the  subject  had  not  reached  middle  life. 

We  may  sum  up  the  evidence  on  the  etiology  of  facial 
hirsuties  in  this  way :  While  at  times  there  appears  to  be  a 
relation  between  the  uterine,  or  more  properly,  the  menstrual 
function,  and  the  growth  of  hair  on  the  face,  shown  by  a 
decrease  or  deficiency  of  the  first,  and  an  increase  of  the 
second,  still  in  the  majority  of  cases  no  such  relation  is 
discoverable,  and  it  must  be  viewed  as  a  deformity  or  freak 
of  Nature. 

Treatment.  For  general  hypertrichosis  we  can  practi- 
cally do  nothing.  This,  not  because  we  cannot  destroy  hair 
so  that  it  will  not  grow  again,  but  because  of  the  great 
amount  of  time  it  would  take  to  destroy  it. 

The  only  form  of  hirsuties  which  urgently  calls  for  relief 
is  that  occurring  upon  the  face  in  women.  In  1879  Dr. 
Michel,  of  St.  Louis,  devised  the  method  of  removing  the 
hairs  in  trichiasis  by  means  of  electrolysis,  which  was  taken 


1  The  Medical  Eecord,  1881,  xix.  281. 


HYPERTRICHOSIS.  259 

up  by  Dr.  Harclaway,  of  the  same  city,  for  the  removal  of 
superfluous  hair.  The  question  is  often  asked :  "Is  the 
removal,  by  this  method,  permanent?  "  This  question  may 
be  answered,  "  It  is,  without  a  shadow  of  a  doubt."  The 
object  being  to  destroy  the  papilla,  and  that  being  very 
small  and  often  placed  at  an  unexpected  angle  to  the  sur- 
face of  the  skin,  it  is  not  possible  always  to  accomplish  this 
at  the  first  attempt.  But  with  patience  and  the  necessary 
skill,  it  will  finally  be  permanently  destroyed.  At  times, 
after  the  dark  coarse  hairs  have  been  removed,  there  will  be 
found  a  number  of  finer  and  lighter  hairs.  This  appear- 
ance is  due  partly  to  the  uncovering  of  these  hairs,  and 
partly,  it  may  be,  to  lanugo  hairs  becoming  stronger  under 
the  stimulation  of  the  operation.  In  most  cases,  with 
proper  care  and  the  use  of  a  fine  needle,  the  amount  of  scar- 
ring will  be  very  slight,  amounting  to  nothing  more  than  fine 
punctate  cicatricial  spots.  In  some  peculiarly  irritable  skins 
it  is  very  difficult  to  prevent  the  formation  of  plainly  visible 
scars.  If  the  proper  conditions  are  not  observed,  the  oper- 
ator must  expect  to  produce  a  good  deal  of  disfigurement. 

The  amount  of  pain  experienced  by  the  patient  will  vary 
greatly.  Certain  parts  of  the  face  are  far  more  sensitive 
than  others.  On  the  whole,  the  pain  does  not  amount  to 
much.  After  a  time  the  skin  seems  to  become  tolerant  of 
the  action  of  the  current  and  the  patient  no  longer  com- 
plains. Hyper-pigmentation  may  be  produced  by  the  oper- 
ation. This  is  a  very  rare  complication,  and  is  only  men- 
tioned by  way  of  warning. 

Fig.  25. 


Epilating  forceps. 

The  instruments  needed  for  the  operation  are  a  good 
twenty-cell  zinc-carbon  (galvanic)  battery,  a  sponge  electrode, 
a  proper  needle-holder,  a  fine  needle,  a  pair  of  epilating  for- 
ceps, and,  if  the  operator's  eyes  are  not  good,  a  lens  of  low 


260  DISEASES    OF    T&E    SKIN". 

power.  Any  sponge  electrode  will  answer.  There  are 
various  patterns  of  needle-holders,  any  one  of  which  may 
be  used.  It  should  be  long  enough  to  be  held  with  ease, 
and  not  too  long  to  be  readily  manipulated.  The  most 
essential  instrument  is  the  needle.  Hardaway  recommends 
a  needle  made  of  iridium  and  platinum.  He  claims  that  it 
will  follow  the  direction  of  the  hair  follicle,  and  more  surely 
hit  the  papilla  than  will  a  steel  needle.  I  have  had  most 
satisfactory  results  with  a  jeweller's  instrument  called  a 
44  steel  broach."  These  come  in  many  grades  ;  those  known 
as  Nos.  5  and  7  are  serviceable  ones.  A  lens  is  generally 
not  needed.  Dr.  Piffard  has  invented  a  needle-holder  with 
lens  attachment,  which  he  has  found  useful.  A  galvan- 
ometer is  not  essential,  but  very  desirable. 

A  good  light  is  necessary  for  the  operation,  and  a  cloudy 
day  is  a  bad  one  for  working.  An  operating  or  reclining 
chair  is  a  comfort,  and  the  patient  should  be  so  placed  that 
the  part  to  be  operated  on  is  on  a  level  with  the  operator's 
eye.  The  operation  is  done  in  the  following  manner :  The 
patient,  being  in  position,  is  to  be  given  the  sponge  elec- 
trode attached  to  the  positive  pole  of  the  battery,  and  told 
to  hold  it  in  one  hand.  The  hair  to  be  extracted  is  then 
seized  with  the  forceps,  and  put  slightly  on  the  stretch  in 
the  direction  in  which  it  naturally  grows.  The  needle, 
attached  to  the  negative  pole,  is  then  inserted  parallel  with 
the  hair  and  into  the  follicle.  One  soon  learns  to  know 
whether  the  follicle  is  entered  or  not  by  the  sense  of  touch. 
When  the  follicle  is  entered  the  needle  glides  along 
smoothly  ;  when  it  is  not  entered  a  sense  of  resistance  is 
communicated  to  the  fingers  as  the  skin  is  punctured.  The 
depth  to  which  the  needle  is  to  be  thrust  will  vary  with  the 
case.  Roughly  speaking,  it  is  from  y1^  to  ^  of  an  inch. 
The  needle  being  inserted,  the  patient  is  told  to  place  the 
palm  of  the  disengaged  hand  over  the  sponge  electrode.  In 
a  few  moments  there  will  be  frothing  about  the  needle,  and 
in  from  half  a  minute  to  a  minute  or  more,  the  hair  will 
come  away  upon  the  very  slightest  traction.  The  hand  is 
to  be  removed  from  the  sponge  before  the  needle  is  taken 
out. 


ICHTHYOSIS.  261 

The  hair  must  not  be  pulled  on  with  any  force,  for  the 
ease  with  which  it  leaves  the  follicle  is  a  guarantee  of  the 
completeness  of  the  operation.  The  hairs  must  not  be 
extracted  in  close  proximity,  because  the  inflammatory  action 
thus  set  up  will  lead  to  more  or  less  deep  ulceration  and  sub- 
sequent prominent  scars.  It  is  best  only  to  extract  the 
coarser  hair  and  to  leave  the  lanugo  hairs  alone.  The 
strength  of  the  current  to  be  used  will  depend  upon  the 
quality  of  the  patient's  skin  and  the  recentness  of  the  filling 
of  the  battery.  Eight  cells  are  the  fewest  I  have  used  and 
fifteen  the  greatest  number.  More  exactly,  a  current 
strength  of  J  to  1 J  milliamperes. 

The  patient  should  be  directed  to  bathe  the  face  in  hot 
water  and  to  anoint  it  with  cold  cream  several  times  during 
the  day  following  the  operation. 

Hypohidrosis.     See  Anidrosis. 
Hystricismus.     See  Ichthyosis. 

Ichthyosis  (I2k-thi2-o'si2s).  Synonyms :  Xeroderma ; 
Xeroderma  ichthyoides ;  Ichthyosis  vera,  seu  congenita ; 
Sauriasis;  (Fr.)  Ichthyose  ;  (Grer.)  Fischschuppenausschlag ; 
Fish-skin  disease. 

Ichthyosis  is  a  congenital,  general  or  partial,  chronic 
disease  of  the  skin,  characterized  by  dryness,  harshness,  and 
scaling  of  the'  skin,  and  sometimes  by  the  development  of 
warty -looking  growths. 

Symptoms.  Though  the  disease  is  congenital  it  usually 
does  not  show  itself  until  after  the  second  month,  and  some- 
times not  until  the  second  year.  There  are  four  varieties 
of  the  disease,  namely :  xeroderma,  ichthyosis  simplex, 
ichthyosis  hystrix,  and  ichthyosis  congenita. 

Xeroderma  is  the  mildest  grade  of  the  disease.  The  skin 
is  dry,  harsh,  slightly  scaly,  grayish  or  dirty-looking,  and 
its  natural  lines  are  more  pronounced  than  usual.  Upon 
the  extensor  surfaces  of  the  limbs  it  is  particularly  marked, 
and  here  too  it  is  accompanied  by  keratosis  pilaris  It  is 
most  annoving  to  voung  women  who  want  to  wear  short- 
sleeved  dresses.  It  is  doubtless  far  more  common  than 
statistics  show,  as  it  very  often  is  very  slight  in  amount. 


262 


DISEASES    OF    THE    SKIN. 


Ichthyosis  simplex.  This  is  a  more  severe  grade  of  the 
disease  in  which  the  skin  is  dry,  harsh,  and  scaly,  and  also 
divided  off  into  small  diamond-shaped  or  polygonal  figures. 
(Fig.  26.)     While   the  whole    cutaneous   surface   may  be 


Fig.  26. 


Ichthyosis. 

involved,  the  disease  is  usually  most  pronounced  upon  the 
extensor  surfaces  of  the  legs  and  arms,  and  the  face,  scalp, 
palms,  and  soles  are  often  spared.  The  skin  about  the  ex- 
tensor surfaces  of  the  elbows  and  knees  is  generally  thrown 


ICHTHYOSIS.  263 

into  well-marked  folds,  while  the  flexor  surfaces  of  the  same 
joints  are  unaffected,  the  skin  in  these  situations  being  soft 
and  natural.  While  upon  the  extremities  the  disease  is 
well  developed,  upon  the  trunk  it  may  assume  more  of  the 
xerodermatous  form.  When  the  face  and  scalp  are  affected 
they  are  simply  very  scaly,  while  on  the  palms  and  soles 
we  have  accentuation  of  the  normal  lines.  In  a  typical  case 
the  skin,  especially  of  the  extremities,  will  be  grayish, 
greenish,  or  blackish-green  in  color,  dry,  and  the  little 
polygonal  plates  will  be  attached  in  their  centres  and  turned 
up  slightly  at  their  edges,  so  that  they  appear  depressed  in 
the  centre.  The  amount  of  loose  scaling  is  sometimes 
abundant,  but  usually  moderate  in  amount.  The  hair,  if 
the  scalp  is  involved,  is  dry.  The  nails  are  often  pitted. 
Ectropion  may  result  in  those  rare  cases  in  which  the  disease 
affects  the  face  severely.  Itching  is  often  complained  of, 
and  eczema  may  complicate  matters.  There  is  a  marked 
absence  of  perspiration,  and  lessened  sebaceous  secretion ; 
and  the  patients  are  sensitive  to  cold.  The  disease  is 
usually  worse  in  cold  weather. 

Ichthyosis  hystrix  is  one  of  the  rarest  forms  of  the  dis- 
ease. It  is  never  general,  but  confined  to  a  limited  area, 
or  to  a  number  of  areas.  It  is  often  unilateral,  and  at 
times  seems  to  follow  the  course  of  a  nerve  in  its  distribu- 
tion. It  occurs  in  the  form  of  horny  papillary  growths, 
that  may  be  isolated  and  pinpoint-sized;  or  massed  together 
into  elevated,  warty,  dark-green  plates,  traversed  by  deep 
lines  ;  or  arranged  in  long  lines  of  parallel  rows.  When  in 
the  last  form  it  has  been  called  nerve  nsevus,  ngevus  verru- 
cosus, neuropathic  papilloma,  papilloma  neuroticum,  and 
the  like.  Ichthyosis  hystrix  may  be  present  alone,  the  rest 
of  the  skin  being  normal,  or  it  may  occur  as  a  part  of 
ichthyosis  simplex. 

Ichthyosis  congenita  is  the  most  rare  form  of  the  disease. 
It  is  also  called  Keratoma  follicularis,  Keratosis  diffusa,  seu 
epidermica,  seu  intra-uterina,  and  the  u  Harlequin  foetus." 
It  is  considered  by  some  to  be  a  general  seborrhoea  It  is 
present  at  birth,  the  skin  being  covered  with  fatty  epidermic 
plates  cracked  in  all  directions  and  arranged  transversely  to 


264  DISEASES    OF    THE    SKIN. 

the  axis  of  the  body.  The  fissures  may  extend  into  the 
corium.  The  eyes  are  held  partly  open,  or  there  may  be 
ectropion  ;  the  lips  cannot  be  moved  ;  and  the  feet  are  con- 
tracted and  deformed.  The  color  is  yellowish-white  or 
grayish.  The  scrotum  and  penis  may  not  be  involved. 
These  infants  are  either  born  dead  or  survive  birth  but  a 
short  time. 

There  are  also  cases  of  ichthyosis  intra-uterina  in  which, 
after  the  removal  of  the  vernix  caseosa,  the  skin  looks  red, 
glazed,  and  dry,  and  then  soon  assumes  the  characteristics 
of  ichthyosis  simplex. 

With  the  exception  of  ichthyosis  congenita,  the  disease 
does  not  show  itself  until  some  months  after  birth,  but  by 
the  second  year  it  has  made  its  appearance.  As  a  rule,  it 
increases  in  severity  as  the  patient  grows  older  until  adult 
age,  when  it  usually  remains  stationary,  or  perhaps  improves 
a  little.  It  is  a  chronic  disease  and  shows  no  tendency  to 
get  well.  It  does  not  seem  to  affect  the  patient's  health, 
and  it  should  be  regarded  rather  as  a  deformity  than  a  dis- 
ease. Occasionally  mental  weakness  and  other  congenital 
defects  have  been  noticed. 

Etiology.  We  know  of  no  cause  for  the  disease  beyond 
heredity,  which  may  be  direct,  skip  a  generation,  or  be 
through  a  lateral  branch.  Many  cases  occur  without  mani- 
fest heredity.  It  attacks  both  sexes  about  equally.  It  shows 
a  tendency  to  occur  in  only  one  sex  in  certain  families, 
while  in  other  families  both  sexes  are  equally  affected. 
It  is  a  congenital  defect  in  the  development  of  the  skin  with 
a  disturbance  of  the  functions  of  perspiration  and  sebaceous 
secretion. 

Diagnosis.  The  disease  is  so  unique  that  if  its  charac- 
teristics are  remembered  there  can  be  no  difficulty  in  diag- 
nosis. There  is  no  other  disease  commencing  in  infancy 
that  at  all  corresponds  to  ichthyosis  simplex.  Xeroderma 
may  resemble  a  mild  grade  of  squamous  eczema,  but  has 
not  its  history.  Sometimes  we  meet  with  a  dry  skin  that 
is  not  ichthyosis,  but  it  is  only  a  passing  state  and  has  not 
existed  from  infancy.  Ichthyosis  hystrix  may  resemble 
common  warts,  and  sometimes  the  latter  may  be  present, 


IMPETIGO.  265 

but  differs  from  them  in  its  color  and  distribution.  Ichthy- 
osis congenita  differs  from  seborrhoea  in  not  being  removable 
by  soaking  in  oil ;  and  by  proving  fatal. 

Treatment.  The  treatment  is  largely  palliative.  The 
free  use  of  Russian  baths  or  of  prolonged  warm  baths,  simple 
or  with  soda,  and  washing  with  soap,  followed  by  inunctions 
of  vaseline,  glycerin,  lanolin,  or  oil,  such  as  cocoa  butter,  will 
keep  the  skin  supple.  Kaposi  recommends  a  5  per  cent, 
naphthol  ointment,  or  a  2  per  cent,  solution  in  spiritus  sapo. 
viridis,  or  cod-liver  oil,  in  conjunction  with  naphthol  soap. 
Andeer1  recommends  a  3  to  20  per  cent,  ointment  of  resorcin 
well  rubbed  in,  and  covered  with  a  bandage,  and  claims  a 
cure  in  eight  days.  Sulphur  ointment  has  also  been  recom- 
mended. Whatever  is  used  must  be  persisted  in.  Ichthy- 
osis hystrix  may  be  removed  by  curetting,  or  by  salicylic 
acid  plaster,  20  per  cent,  strength ;  or  by  the  same  drug  in 
alcohol  or  collodion,  a  drachm  to  the  ounce. 

Besnier  recommends  as  adjuvants  to  the  local  treatment, 
regular  gymnastic  exercise,  and  the  internal  administration 
of  cod-liver  oil. 

Prognosis.  The  prognosis  is  good  as  to  life,  bad  as  to 
cure.  Thus  far  it  has  proved  incurable  in  the  hands  of 
most  physicians.  All  one  can  hope  to  accomplish  is  to 
render  the  patient  comfortable  and  fit  to  mingle  with  his 
kind  by  repeated  courses  of  emollient  baths.  Ichthyosis 
congenita  is  fatal  in  a  few  days,  if  the  child  is  not  born 
dead,  as  is  usually  the  case. 

Ichthyosis  Follicularis.     See  Keratosis  follicularis. 
Ichthyosis  Sebacea.     See  Seborrhoea  sicca. 
Idrosis.     See  Hyperidrosis. 
Ignis  Sacer.     See  Zoster. 

Impetigo  (Pm-peH-i'go)  is  a  name  applied  at  one  time 
to  all  pustular  eruptions.  At  the  present  time  there  are 
but  three  varieties  described,  namely  :  Impetigo  or  impetigo 
simplex  ;  Impetigo  contagiosa ;  and  Impetigo  herpetiformis. 
The  right  of  the  first  named  variety  to  be  recognized  as  a 

1  Monatshefte  f.  prakt.  Dermat,  1884,  iii.  365. 
12 


266  DISEASES    OF    THE    SKIN. 

distinct  affection  is  denied  by  systematic  writers  of  all 
nations  but  our  own.  Our  own  writers  largely  follow  Duhr- 
ing  in  their  description  of  the  disease,  and  as  soon  as  they 
vary  from  his  description,  it  seems  to  me  that,  instead  of 
simple  impetigo,  they  describe  the  contagious  form.  I  shall 
here  follow  Duhring. 

Symptoms.  Impetigo  simplex.  The  appearance  of  the 
disease  may  or  may  not  be  preceded  by  loss  of  appetite, 
constipation,  or  malaise.  The  eruption  consists  of  one  to  a 
dozen  or  more  pustules  that  are  pustules  from  the  beginning. 
They  are  split-pea  to  finger-nail  in  size ;  rounded  :  and  raised 
above  the  surface  of  the  skin.  They  have  thick  walls,  a 
more  or  less  marked  areola,  little  surrounding  infiltration, 
and  no  central  depression.  Their  color  is  yellowish  or 
whitish.  They  manifest  no  disposition  to  rupture,  are  dis- 
crete and  disseminated,  and  do  not  incline  to  coalesce. 
While  they  may  occur  anywhere  they  are  seated  by  prefer- 
ence on  the  face,  hands,  feet,  and  lower  extremities.  Itching 
and  burning  are  absent,  as  a  rule.  The  course  of  the  dis- 
ease is  acute,  its  duration  being  several  weeks.  The  pustules 
gradually  undergo  absorption  and  dry  into  a  crust,  or  they 
may  be  ruptured  by  external  injury.  The  crust  when  it 
falls  leaves  a  reddish  base  without  pigmentation  or  scar. 
It  is  not  contagious,  and  occurs  mostly  in  children. 

Such  is  the  disease  as  described  by  Duhring,  It  will  be 
seen  by  reading  the  next  section  that  it  bears  a  strong  re- 
semblance to  impetigo  contagiosa. 

Impetigo  Contagiosa.  Synonyms :  Porrigo  contagiosa ; 
Impetigo  parasitica. 

An  acute,  inflammatory,  contagious  disease,  occurring 
especially  on  the  face,  hands,  and  exposed  parts,  and  char- 
acterized by  the  appearance  of  vesico-pustules  and  bulla?. 

Symptoms.  By  Tilbury  Fox,  who  first  described  the 
disease,  and  others  who  followed  him,  its  onset  is  said  to  be 
marked  by  slight  febrile  disturbances.  These  are  very 
slight,  and  I  have  not  satisfied  myself  as  to  their  occurrence 
in  the  many  cases  that  I  have  seen,  except  incidentally  as 
part  of  some  digestive  disorder  that  may  be  present.  The 
eruption  consists  of  vesico-pustules  that  come  out  in  crops. 


IMPETIGO.  267 

They  are  of  various  sizes,  but  average  that  of  a  split-pea. 
They  are  at  first  surrounded,  in  well-marked  cases,  with  a 
red  halo,  which  soon  fades.  They  tend  to  increase  slowly 
in  size,  and  sometimes  assume  grotesque  shapes.  They  are 
not  fully  distended,  but  flaccid,  and  not  infrequently  upon 
the  hands  will  bear  a  strong  resemblance  to  a  burn  of  the 
second  degree.  If  the  covers  of  the  vesicles  or  small  bullae 
are  not  disturbed,  their  contents  in  a  few  days  will  dry  up, 
and  the  vesico-pustule  will  change  into  a  straw-yellow 
granular  crust,  which  is  placed  superficially  upon  the  skin 
with  its  edge  somewhat  detached,  and,  it  may  be,  turned  up. 
In  fact,  it  looks  "stuck  on."  When  the  crust  is  removed 
or  falls  of  itself,  there  is  exposed  an  erythematous  spot, 
which  in  a  short  time  will  disappear  and  leave  no  trace  of 
its  existence.  If  the  vesicles  are  torn  by  scratching,  or  if 
by  any  other  means  their  covers  are  removed,  we  shall  find 
very  superficial  losses  of  substance — a  moist  surface  covered 
with  a  slight  purulent  secretion.  Even  this  disappears  and 
leaves  no  trace,  passing  through  the  erythematous  stage  in 
its  course  to  recovery.  Such  are  the  appearances  presented 
in  the  majority  of  cases. 

Besides  this  usual  and  typical  form  we  meet  with  another 
and  rarer  variety,  in  which,  instead  of  vesi co-pustules,  there 
are  large  bullae.  These  may  be  several  inches  in  their  long 
diameter,  are  of  irregular  oval  shape,  not  fully  distended 
with  fluid,  and  sometimes  show  a  slight  depression  in  their 
centres.  Their  contents  are  at  first  serous,  but  soon  become 
sero-purulent.  They  seem  to  be  longer  preserved  than  the 
vesicles,  but  otherwise  run  the  same  course.  At  first  they 
have  a  slight  zone  of  redness  about  them,  but  this  soon  dis- 
appears. They  either  are  formed  by  two  or  more  vesico- 
pustules  running  together,  or  spring  up  of  themselves. 
They  may  attain  their  full  size  at  once,  or  increase  slowly. 
Rarely  do  they  exist  alone  ;  generally  the  typical  vesico- 
pustules  will  be  found  in  their  neighborhood  or  elsewhere 
on  the  body.  It  is  the  bullous  form  that  is  liable  to  be  mis- 
taken for  pemphigus. 

Impetigo  contagiosa  is  located  principally  upon  the  face, 
most  often  on  the  chin,  and  on  the  hands ;  it  may  also  occur 


268  DISEASES    OF    THE    SKIN". 

upon  the  scalp,  legs,  and  trunk,  especially  in  infants.  Ac- 
cording to  my  experience,  the  bullous  form  is  most  often 
seen  upon  the  trunk.  The  lesions  of  both  varieties  are  dis- 
crete ;  exceptionally  two  or  more  may  run  together.  They 
are  superficial,  and  rarely  very  numerous.  The  bullous 
lesions  are  generally  widely  separated  from  one  another. 
The  disease  does  not  run  any  definite  course,  and  may  last 
several  weeks  ;  a  slight  amount  of  itching  is  sometimes 
present. 

Etiology.  It  is,  as  its  name  indicates,  very  contagious, 
and  often  occurs  in  epidemics.  When  one  case  is  met  with 
in  dispensary  service,  several  more  may  be  expected  in 
children  of  the  same  family  or  neighborhood.  It  is  readily 
inoculable  both  on  the  subject  of  the  disease  and  on  others. 
Not  unfrequently  we  see  a  mother  or  other  attendant  of  a 
child  with  the  characteristic  lesions  of  impetigo  contagiosa 
upon  the  arms,  derived  from  carrying  the  child  suffering 
with  the  same  disorder.  What  the  contagious  element  may 
be  is  not  yet  determined  with  certainty,  though  various 
investigators  have  described  several  parasites  as  the  cause  of 
the  disease.  We  know  that  all  pus  is  under  certain  circum- 
stances inoculable,  and  hence  it  has  been  maintained  that 
there  is  no  such  disease,  properly  speaking,  as  contagious 
impetigo.  But  when  we  succeed  in  inoculating  from  an 
ordinary  impetigo  pustule,  we  produce  an  ordinary  impetigo 
pustule,  not  the  characteristic  vesico-pustule  of  impetigo 
contagiosa.  It  has  been  stated  by  some  authorities  that  the 
disease  is  due  to  lice  on  the  head.  In  some  cases  phtheiria- 
sis  capitis  may  be  present,  because  both  diseases  occur  with 
special  frequence  in  children  of  the  poor.  In  my  own 
experience,  in  most  cases  no  such  relationship  could  be 
traced.  A  number  of  cases  have  been  reported  of  the  occur- 
rence of  contagious  impetigo  shortly  after  the  fall  of  vaccine 
crusts,  and  thus  has  been  suggested  the  possible  connection 
between  impetigo  and  vaccinia.  It  is  more  frequent  in  the 
warm  months  than  in  the  cold.  Children  furnish  the  vast 
majority  of  the  cases. 

Diagnosis.  Impetigo  contagiosa  is  diagnosticated  by 
the  presence  of  discrete,  partially  distended  vesico-pustules, 


IMPETIGO.  269 

which  are  located  upon  the  exposed  parts — head,  face,  and 
hands — in  most  cases  ;  these  are  sometimes  grouped,  run 
an  acute  course,  and  dry  up  into  straw-yellow  "  stuck-on" 
crusts.  It  is  sometimes  preceded  by  slight  constitutional 
disturbances,  and  accompanied  by  a  slight  amount  of  itching. 
It  must  be  differentiated  from  simple  impetigo,  pustular 
eczema,  varicella,  scabies,  pemphigus,  and  possibly  ecthyma. 

The  lesions  of  simple  impetigo  are  pustules  from  the  start, 
while  those  of  impetigo  contagiosa  are  first  vesicles  and  then 
vesico-pustules.  The  pustules  of  impetigo  are  prominently 
raised,  and  run  no  definite  course.  The  vesico-pustules  of 
impetigo  contagiosa  are  flattened,  and  run  a  rather  definite 
course.  The  crusts  of  impetigo  are  generally  greenish, 
while  those  of  the  contagious  form  are  yellowish.  Impetigo 
is  not  so  readily  inoculable  as  impetigo  contagiosa,  and  is 
much  more  widely  disseminated,  as  a  rule.  Simple  impetigo 
is  a  deeper  process  than  the  contagious  form. 

Pustular  eczema  is  itchy ;  its  pustules  tend  to  break 
down  quickly,  run  together,  and  form  large  patches,  which 
soon  become  covered  with  a  greenish  or  blackish  crust. 
These  phenomena  are  entirely  foreign  to  impetigo  con- 
tagiosa. Eczema  does  not  present  vesico-pustules  nor  bullae, 
as  a  rule,  and  shows  slight  tendency  to  spontaneous  re- 
covery. Varicella  is  an  acute  contagious  disease,  with  con- 
stitutional symptoms  in  most  cases.  Its  vesicles  are  smaller 
than  those  of  impetigo  contagiosa,  and  they  run  a  definite 
course  peculiar  to  themselves.  They  are  widely  distributed 
over  the  whole  surface,  usually  appear  first  on  the  trunk, 
sometimes  occur  on  the  fauces,  and  not  infrequently  leave 
pitted  scars.  Contagious  impetigo  is  in  most  cases  limited 
to  the  exposed  parts,  it  never  occurs  upon  the  fauces,  and 
its  lesions  leave  no  trace.  The  crusts  of  varicella  are  small, 
while  those  of  contagious  impetigo  are  large. 

The  diagnosis  from  scabies  offers  little  difficulty.  In 
fact,  the  location  of  both  diseases  upon  the  back  of  the 
hands  is  their  strongest  point  of  resemblance.  When  we 
bear  in  mind  that  scabies  is  very  itchy,  that  it  occurs 
usually  as  a  copious  eruption  upon  the  hands,  wrists,  and 
forearms,  about  the  umbilicus,  on  the  nipples  of  females  and 


270 


DISEASES    OF    THE    SKIN. 


the  genitals  of  males  ;  that  scratched  papules  and  pustular 
lesions  are  more  characteristic  of  it  than  vesicles,  and  that 
it  presents  the  pathognomonic  furrows,  we  should  not  con- 
found it  with  impetigo  contagiosa,  which  has  none  of  these 
symptoms.  Further,  impetigo  will,  in  almost  all  cases,  occur 
upon  the  face  at  the  same  time  with  the  hands,  and  that 
location  is  very  rarely  attacked  by  the  itch  mite. 

The  diagnosis  from  pemphigus  is  by  no  means  always 
easy.  The  occurrence  of  the  bullous  form  of  contagious 
impetigo  is  so  rare  that  it  is  no  wonder  it  is  mistaken  for 
pemphigus.  Indeed,  it  is  probable  that  not  a  few  of  the 
cases  reported  as  acute  pemphigus  in  children,  which  pos- 
sessed apparent  contagious  qualities,  were  instances  of  this 
bullous  form  of  impetigo.  The  diagnosis  between  the  two 
diseases  can  scarcely  be  made  with  certainty  by  the  appear- 
ances of  the  bullae  alone ;  we  must  also  take  into  considera- 
tion the  general  course  of  the  disease.  The  differential 
diagnosis  may  be  given  as  follows  : 


Pemphigus. 

1.  Occurs  chiefly  in  adults. 

2.  No  source  of  contagion  can  be 

found. 

3.  No   particular   sites    of     pref- 

erence ;  if  anything,  it  is 
most  frequent  on  the  ex- 
tremities. 

4.  Chronic  in  its  course  ;  marked 

by  frequent  relapses ;  may 
return  from  year  to  year. 

5.  Bullae  are  fully  distended  with 

a  clear  fluid,  so  that  their 
covers  appear  tense.  They 
often  spring  up  out  of  the 
sound  skin  without  areola. 


6.  Lesions  often  occur   in    great 

numbers,  so  as  to  cover  the 
whole  body,  and  at  times  are 
pruriginous. 

7.  Disease  obstinate  to  treatment, 

and  prognosis  usually  grave. 


Impetigo  Contagiosa. 
(Bullous  form). 

1.  Occurs  chiefly  in  children. 

2.  A    source    of    contagion    can 

usually  be  found. 

3.  Met  with  most  often  upon  the 

trunk ;  sometimes  it  may 
occur  on  the  face,  hands,  or 
extremities. 

4.  Acute    in     its    course,    rarely 

lasting  more  than  a  few 
weeks. 

5.  Bullae  not  fully  distended,  but 

flaccid,  and  contain  sero- 
purulent  fluid.  They  may 
have  a  well-marked  red  halo 
while  slowly  attaining  their 
full  size.  Characteristic 
vesi co-pustules  are  generally 
present  elsewhere  at  the 
same  time. 

6.  Lesions,   few  in   number,    do 

not  involve  the  whole  body, 
and  itch  but  little,  if  at  all. 

7.  Disease  yields  readily  to  treat- 

ment; prognosis  uniformly 
good. 


IMPETIGO    HERPETIFORMIS.  271 

Ecthyma  should  not  be  mistaken  for  impetigo  contagiosa. 
It  occurs  in  broken-down  subjects,  affects  by  preference  the 
lower  extremities,  is  seen  most  often  in  adults,  and  its  lesions 
are  deep  pustules,  which  are  highly  inflammatory  and  pain- 
ful. It  is  non-contagious,  and  inoculable  with  difficulty. 
These  symptoms  will  sufficiently  distinguish  the  two  dis- 
eases. 

Prognosis.  The  prognosis  of  impetigo  contagiosa  is 
always  good ;  so  readily  is  it  cured  that  the  patients  seldom 
present  themselves  a  third  time  at  the  dispensary. 

Treatment.  The  treatment  of  the  usual  form  is  to 
direct  the  affected  parts  to  be  scrubbed  with  warm  Avater 
and  soap,  and  covered  with  a  5  per  cent,  carbolized  vaseline, 
or  with  oxide  of  zinc  ointment  with  carbolic  acid  in  the  same 
strength,  or  with  the  ointment  of  the  ammoniate  of  mercury 
diluted  to  half  its  strength.  If  there  is  a  good  deal  of  crust- 
ing, the  crusts  may  readily  be  removed  by  soaking  them 
with  oil  or  hot  water,  after  which  the  applications  men- 
tioned may  be  made,  or  a  very  mild  mercurial  ointment 
used.  In  the  bullous  form  it  is  well  to  prick  the  bullae  at 
their  most  dependent  part,  and  let  the  fluid  escape,  after 
which  the  lesions  may  be  treated  as  just  indicated. 

Impetigo  Granulata.     See  Pediculosis. 

Impetigo  Herpetiformis.  This  disease  was  first  described 
by  Hebra1  in  1872. 

In  this  country  it  is  exceedingly  rare,  only  one  case 
having  been  reported.  We  owe  to  Hebra  and  Kaposi 
nearly  all  we  know  about  the  disease,  and  it  is  from  Kaposi2 
that  the  account  here  given  is  taken. 

The  disease  begins  with  an  eruption  of  pustules  in  the 
genito- crural  region,  about  the  umbilicus,  on  the  breasts, 
and  in  the  axillae ;  later  upon  various  other  locations.  The 
pustules  are  crowded  together,  grouped,  pinhead-size,  with 
at  first  opaque,  and  later  greenish-yellow  contents.  They 
dry  into  a  dirty-brown  crust,  while  immediately  around 
them  new  pustules  appear  in  double  or  threefold   circles, 

1  Wiener  med.  Wochenschrift,  1872,  No.  48. 

2  Pathologie  unci  Therapie  der  Hautkrankheiten. 


272  DISEASES    OF    THE    SKIN. 

by  the  drying  of  which  the  crust  is  enlarged.  The  disease 
spreads  by  the  growth  of  the  individual  groups  and  by  the 
coalescence  of  neighboring  ones.  Underneath  the  crusts 
the  skin  appears  red  and  covered  with  new  epidermis ;  or 
deprived  of  epidermis,  moist,  infiltrated,  and  smooth;  or 
papillary,  but  never  ulcerated.  Within  three  or  four  months 
nearly  the  whole  skin  is  involved,  swollen,  hot,  covered  with 
crusts,  showing  torn  and  excoriated  places  with  here  and 
there  circles  of  pustules.  The  mucous  membrane  of  the 
tongue  may  show  circumscribed,  gray  patches.  There  is  a 
continuous  remittent  fever,  and  each  outbreak  of  pustules  is 
marked  by  chills,  higher  fever,  and  dry  tongue.  Nearly 
all  cases  prove  fatal.  The  disease  has  affected  almost  ex- 
clusively pregnant  women,  only  one  man  having  been  re- 
ported with  the  malady.  Delivery  has  not  stopped  the 
course  of  the  disease.     It  is  probably  of  septic  origin. 

Diagnosis.  The  disease  is  held  by  Kaposi  to  differ 
from  dermatitis  herpetiformis  in  being  only  pustular ;  in 
its  peculiar  location  and  manner  of  spreading ;  in  the  ab- 
sence of  itching ;  in  the  severe  constitutional  symptoms  ; 
and  in  its  lethal  ending. 

Treatment.  No  treatment  has  proved  successful.  We 
can  only  do  our  best  to  nourish  the  patient ;  and  by  means 
of  baths,  dusting-powders,  or  alkaline  lotions  render  her  as 
comfortable  as  possible. 

Induratio  Telae  Cellulosse  Neonatorum.  See  Sclerema 
neonatorum. 

Inflammatory  Fungoid  Neoplasm.    See  Mycosis  fungoide. 

Intertrigo.     See  Erythema  intertrigo. 

Iodine  Acne.     See  Dermatitis  medicamentosa. 

Itch.     See  Scabies. 

Juckblattern.     See  Prurigo. 

Kahlheit.     See  Alopecia. 

Kelis.     See  Keloid. 

Keloid  (Kel'oid).  Synonyms :  Kelis ;  (Fr.)  Cancer 
tubereux,  Cheloide ;  (Ger.)  Knollenkrebs. 

A  connective-tissue  new-growth  in  the  skin,  occurring 


KELOID. 


273 


most  commonly  upon  the  chest ;  characterized  by  hardness, 
by  a  pinkish  color,  and  by  sending  off  prolongations  in  all 
directions.  (Fig.  27.) 

Symptoms.     It  is  usual  to  divide  keloids  into  two  varie- 
ties, one  of  which  is  called  the  true  or  spontaneous  keloid, 


Fig.  27. 


Keloid.     (After  Taylor.) 

and  the  other  the  false  or  secondary  keloid  the  result  of 
injuries.  Of  late  the  opinion  is  gaining  ground  that  no 
such  distinction  can  be  made.  As  most  commonly  met  with 
it  consists  in  a  single,  firm,  hard,  pinkish,  freely  movable, 
oval   or  elongated,  elevated  tumor  upon  the  upper  half  of 

12* 


274  DISEASES    OF    THE    SKIN. 

the  sternum,  from  which  claw-like  processes  are  given  off  in 
all  directions.  While  there  may  be  but  one  tumor,  the 
lesions  may  be  multiple,  there  being  either  one  large  and 
several  small  ones  upon  the  chest,  or  many  scattered  over 
the  body.  They  begin  as  small,  pinkish  elevations  and 
gradually  enlarge  until  they  attain  a  certain  size,  when  they 
may  remain  stationary,  or  else  slowly  grow.  They  assume 
all  sorts  of  shapes  and  sizes.  Sometimes  they  have  an 
even  surface,  sometimes  they  are  nodular.  They  may  be 
quite  small,  or  they  may  be  so  large  as  to  run  nearly  half- 
way across  the  chest  Then  the  appearance  is  as  if  the 
skin  were  drawn  up  into  the  tumor.  The  epidermis  is 
smooth  over  them,  and  the  pink  color  is  due  to  the  dilated 
bloodvessels.  Sometimes  the  color  is  white.  Though  they 
are  rarely  met  with  on  the  face  in  the  white  races,  they  are 
very  common  upon  the  face  of  negroes.  They  are  often 
attended  by  a  good  deal  of  pain,  or  pruritus,  or  pricking 
sensations. 

Besides  this  form  of  keloid,  that  may  or  may  not  be  spon- 
taneous, we  have  the  evident  scar  keloid  that  occurs  over  the 
site  of  an  injury  to  the  skin.  These  have  followed  syphilides 
that  have  destroyed  the  skin,  variola  pustules,  psoriasis,  a 
blister,  or  acne.1  They  may  be  limited  to  the  site  of  the 
previous  lesion,  or  spread  beyond  it.  This  form  of  keloid  is 
very  often  seen  on  the  face  of  the  male  negro  who  shaves, 
the  cheeks  and  chin  being  studded  over  with  small,  hard, 
white  elevations.  The  hypertropliied  scar  resembles  keloid, 
but  never  spreads  beyond  the  limits  of  the  injury,  has  no 
claw-like  processes,  is  not  so  pinkish,  nor  so  permanent. 

Etiology.  We  know  scarcely  anything  as  to  the  cause 
of  keloid,  and  can  only  beg  the  question  by  saying  that  it 
is  a  predisposition  on  the  part  of  the  skin.  It  is  probable 
that  some  minute  injury  precedes  the  tumor.  The  negro 
race  is  peculiarly  prone  to  the  disease.  Sex  is  without 
influence,  and  it  may  occur  at  any  age,  though  rare  before 
puberty  and  in  old  age. 

Treatment.     As  a  rule  it  is  safest  to  leave  the  growths 

1  Purdon :  Joura.  Cutan.  and  Ven.  Dis.,  1882-3,  i.  203. 


KERATOSIS    FOLLICULARIS.  275 

alone.  Cutting  them  out  is  often  disappointing  in  its  results, 
as  the  growth  is  apt  to  return.  Multiple  scarifications  fol- 
lowed by  the  application  of  acetic  acid  have  been  successful. 
Leloir  and  Vidal1  recommend  following  multiple  scarifica- 
tions with  a  boric  acid  dressing.  The  next  day  mercurial 
plaster  is  to  be  applied,  and  changed  every  morning  and 
evening.  Perseverance  in  this  method,  they  say,  may  result 
in  a  cure.  Compression  by  means  of  an  elastic  bandage  has 
been  recommended.  Hardaway  has  succeeded  in  removing 
one  keloid  and  two  hypertrophied  scars  by  means  of  electro- 
lysis, and  Brocq  has  commended  the  method.  A  stout 
needle  must  be  used  and  multiple  punctures  made  in  all 
directions,  and  in  the  tissues  for  a  space  beyond  the  tumor. 
Andeer2  recommends  resorcin  and  a  bandage.  Hypoder- 
matic injections  of  morphia,  or  the  application  of  belladonna 
ointment,  may  be  necessary  to  relieve  pain. 

Prognosis.  It  is  possible  for  keloids  to  undergo  spon- 
taneous involution.  This  is  especially  the  case  in  the  scar 
keloid  following  syphilis.     Usually  this  cannot  be  expected. 

Keloid  of  Addison.     See  Morphoea. 

Keloid  of  Alibert.     See  Keloid. 

Keratodermies  Palmaires  et  Plantaires.     See  Callositas. 

Keratoma  Palmaris  et  Plantaris.     See  Callositas. 

Keratosis  Circumscripta.     See  Ichthyosis. 

Keratosis  Diffusa  seu  Epidermica.  See  Ichthyosis  con- 
genita. 

Keratosis  Follicularis  (Ke2r-a2t-os'i2s  fo2l-i2kV-la3ris). 
This  is  a  rare  affection  of  the  skin  to  which  especial  atten- 
tion has  of  late  been  given.  It  is  probably  the  same  as  was 
described  by  Guibout  by  the  name  of  acne  sebacee  cornee, 
and  by  Lesser  as  ichthyosis  follicularis.  The  French  have 
named  it  psorospermose  folliculaire  vegetante,  but  as  this 
title  was  given  it  by  Darier  and  Thibault  in  1889  under 
the  idea  that  it  was  due  to  psorosperms,  a  pathological  basis 

1  Annal.  Derm,  et  Sypli ,  1890,  No.  3. 

2  Centralbl.  f.  med.  Wissenscliaft,  1888,  xxvi.,  785. 


276  DISEASES    OF    THE    SKIN. 

that  is  not  yet  proven,  and  as  Morrow1  had  already  reported 
a  case  in  1886,  with  the  title  of  keratosis  follicularis,  and 
White2  another  in  1889,  under  the  same  title,  it  seems  to 
me  best  to  retain  their  title. 

Symptoms.     The  disease  affects  nearly  the  whole  cuta- 
neous surface,  though  both  in  Morrow's  and  White's  cases 
the  palms  and  soles  were  free.     The  parts  most  affected  are 
the  scalp,  face,  sternum,  flanks,  and  groins.     The  eruption 
begins  as  pinhead-sized  papules,  which  are  firm  and  of  the 
color  of  the  skin.     As   they   increase  in  size  they  become 
hyperaemic  ;  still  growing,  they  become  hemispherical  or  flat- 
tened, with  smooth  or  polished,  dense  adherent  coverings  of 
nail-like  consistence,  and  varying  in  color  from  dull  red  to 
purplish,  dusky  red,  brown,  and  brownish  black.     Some  of 
them  are  excoriated  by  scratching  and  bear  hemorrhagic 
crusts.     These  lesions  are  discrete,  and  the  skin  about  them 
normal.     They  are  located  in  the  hair  follicles.     In  places 
the  lesions  run  together  and  form  elevated  areas  with  uneven 
surfaces  and  covered  by  thick  yellowish  or  brownish,  flat- 
tened  horny    concretions;    or   there  may  be   brownish   or 
blackish    plates.     The   patches   feel   rough    and  somewhat 
greasy.     Here  and  there  will  be  found  papillomatous  excres- 
cences ;  or  enormously  dilated  follicular  openings  filled  by 
comedo-like,  firm,   slightly  projecting   concretions  forming 
hemispherical  elevations,  which  when  expressed  are  found 
to  be  hard  and  perfectly  dry,  leaving  the  follicle   mouth 
patulous.      The  nails   are  coarse,   slightly   thickened,   and 
jagged  at  their  free  edges.     Boeck3  says  that  they  are  often 
the  seat  of  a  marked  hyperkeratosis  without  a  trace  of  the 
disease  itself  anywhere  in  their  neighborhood.     The  hard 
palate   in  White's  case  showed  some  follicular  elevations. 
Pruritus  is  marked  in  some  cases.     A  fetid  odor  is  given 
off  from  the  patient. 

Upon  the  scalp  the  disease  appears  for  a  long  time  as  a 
seborrhoea  sicca,  but  later  the  same  elevations  about  the 

1  Journ.  Cutan.  and  Ven.  Dis.,  1886,  iv.  257. 

2  Journ.  Cutan.  and  Gen.-urin.  Dis,  1889,  vii.  201. 

3  Archiv.  f.  Derm,  und  Syph.,  1891,  xxiii.  857. 


KERATOSIS    FOLLICULARIS,  277 

hairs  can  be  made  out  as  are  seen  upon  the  general  integu- 
ment. Upon  the  backs  of  the  hands  and  fingers  the  erup- 
tion presents  the  appearance  of  simple  papillary  growths, 
little  pale-white,  slightly  raised,  confluent  and  adherent 
masses.  Upon  the  palms  and  soles,  instead  of  elevations,  we 
find  punctate  depressions,  and  perhaps  a  hyperkeratosis. 

The  course  of  the  disease  is  a  progressive  one  by  the 
springing  up  of  new  lesions.  It  develops  symmetrically.  It 
seems  to  have  no  damaging  effect  on  the  health.  It  affects 
specially  the  scalp,  axillae,  inguinal  region,  abdomen  below 
the  umbilicus,  backs  of  the  hands  and  feet,  and  the  wrists. 

Etiology.  We  know  nothing  positive  about  the  etiology 
of  this  rare  affection.  White  met  with  it  in  a  father  and 
daughter,  and  that  would  suggest  the  idea  of  heredity. 

The  psorosperm  of  Darier  is  regarded  by  some  as  simply 
a  changed  epithelial  cell,  and  of  no  importance  as  an  etio- 
logical factor.  Darier  and  many  other  competent  observers 
hold  that  it  is  a  true  parasite,  and  the  cause  of  the  disease. 
The  disease  may  begin  at  any  age,  cases  having  been  reported 
as  commencing  in  the  first  weeks  of  life,  in  the  sixth,  six- 
teenth, twenty-second,  twenty-seventh,  and  thirty-sixth  year. 

Pathology.  Bowen,  who  made  a  careful  examination  of 
White's  first  case,  says  that  u  the  disease  is  a  keratosis  of  the 
epithelial  lining  of  the  mouths  of  the  follicles,  which,  by 
extension  downward,  gradually  produces  pouch-like  depres- 
sions in  the  corium.  The  capacity  for  corneous  metamor- 
phosis is  so  great  that  the  central  portion  becomes  a  firm 
horn,  which,  by  production  of  horny  matter  from  below,  is 
gradually  pushed  out  above  the  surface  of  the  skin.  There 
was  no  proof  that  the  sebaceous  glands  were  affected  by  the 
horny  change."  Robinson  found  in  Morrow's  case  that  the 
changes  occurred  principally  in  the  sebaceous  glands.  But 
the  disease  has  not  yet  been  sufficiently  studied  to  warrant 
positive  statements.  The  psorosperm  is  described  as  a  sin- 
gle-celled organism,  which  is  round,  generally  encysted,  and 
contained  in  the  epithelial  cell. 

Diagnosis.     The  disease,  according  to  Lustgarten,1  dif- 

1  Journ.  Cutan.  and  Gen.-urin.  Dis.,  1891,  ix.  7. 


278  DISEASES    OF    THE    SKIN". 

fers  from  pityriasis  rubra  pilaris  in  lacking  the  constant 
and  early  involvement  of  the  palms  and  soles,  and  the 
extensive,  diffused,  scaly  dermatitis  of  the  face,  neck,  and 
other  parts. 

Treatment.  The  proper  treatment  is  yet  undeter- 
mined. It  might  be  well  to  try  the  methods  found  useful  in 
ichthyosis. 

Keratosis  Pigmentosa.     See  Verruca  senilis. 

Keratosis  Pilaris  (K.  Pil-a'riY).  Synonyms :  Lichen 
pilaris  ;  Pityriasis  pilaris  ;  Ichthosis  seu  hyperkeratosis  follic- 
ularis  ;  Cacotrophia  folliculorum ;  (Fr.)  Xerodermic  pilaire, 
Ichthyose  anserine  des  scrofuleux. 

Symptoms.  As  its  name  indicates,  this  is  a  disorder  of 
cornification.  It  is  characterized  by  a  heaping  up  of  the 
corneous  cells  about  the  mouths  of  the  hair  follicles  in  the 
form  of  small  conical,  whitish  or  grayish  elevations.  Be- 
tween them  the  texture  of  the  skin  is  normal ;  its  color 
may  be  unchanged  or  rosy,  or  of  a  grayish  or  brownish 
shade.  It  occurs  chiefly  upon  the  extensor  surfaces  of  the 
limbs,  especially  upon  the  upper  arm  and  thigh,  but  may 
occur  anywhere.  The  appearance  of  the  affected  part  re- 
sembles cutis  anserina,  being  dotted  over  with  little  pinhead 
to  small-pea-sized  papules,  each  one  of  which  is  either 
pierced  by  a  hair  or  has  a  black  dot  at  its  summit  indicat- 
ing the  mouth  of  the  hair  follicle.  The  papules  are  often 
scaly.  The  hair  is  either  normal,  broken  off,  or  only  to  be 
found  by  opening  the  papule,  when  it  will  be  seen  curled  up 
inside  of  it.  The  skin  feels  dry  and  harsh.  There  may 
be  slight  pruritus.  Pityriasis  capitis  may  be  present  at  the 
same  time.  As  the  disease  is  attended  by  but  slight,  if  any, 
subjective  symptoms  it  is  often  overlooked.  It  is  a  chronic 
affection  in  most  cases. 

Brocq  describes  a  Keratosis  pilaris  of  the  face  beginning  as 
minute  scaly  papules  about  the  hairs,  which  crowd  together 
to  form  patches  and  give  a  rosy  or  red  tint  to  the  skin. 
After  a  time  the  disease  seems  to  destrov  the  follicle,  and 
we  find  depressed  scars  arranged  in  rows  or  scattered  about 
on  the  red  patch.     This  bears  some  resemblance  to  lupus 


KERION.  279 

erythematosus,  and  is  the  ulerythema  ophryogenes  of  Taenzer. 
Besnier  describes  a  somewhat  similar  condition  as  occurring 
upon  the  extremities. 

Etiology.  The  disease  is  sometimes  congenital  and  often 
forms  a  part  of  ichthyosis.  It  is  most  common  in  women, 
and  in  those  who  do  not  bathe  frequently,  or  in  whom  there 
is  cutaneous  inactivity. 

Diagnosis.  It  differs  from  cutis  anserina  in  being  a 
permanent  condition ;  from  the  miliary  papular  sypliilide 
in  being  whitish,  grayish,  or  blackish,  and  not  dark-red  or 
raw-ham  color,  and  in  being  removable  by  soap  and  water. 
Lichen  scrofulosorum  occurs  in  strumous  subjects  and  in 
well-marked  circular  or  crescentic  patches,  which  is  foreign 
to  keratosis.  Papular  eczema  differs  in  being  very  itchy 
and  in  having  red  inflammatory  lesions.  Ichthyosis  is  a 
general  affection  of  congenital  origin,  and  with  peculiar 
markings  of  the  skin,  not  being  limited  to  the  hair  follicles. 

Treatment.  The  vigorous  use  of  green  soap  and  water 
in  an  alkaline  bath,  followed  by  oil  or  vaseline,  will  remove 
the  evidences  of  the  disease.  Vapor  or  Russian  baths  may 
be  used  for  the  same  purpose.  As  the  affection  is  allied  to 
ichthyosis  it  may  be  treated  on  the  same  plan,  a  new  course 
of  bathing  being  taken  with  each  relapse. 

Keratosis  Senilis.     See  Verruca  senilis. 

Kerion  (Ke'-ri2-o'n).  Synonyms  :  Trichomykosis  capil- 
litii ;  Tinea  kerion  ;  Kerion  Celsi. 

Symptoms.  This  is  a  more  or  less  chronic  inflammation  of 
the  scalp  or  beard  that  most  often  is  a  form  of  ringworm  ;  but 
it  may  be  produced  quite  independently  of  that  disease.  The 
affected  part  becomes  red,  cedematous,  swollen,  and  boggy, 
and  may  assume  a  purplish  color.  Its  surface  is  glazed, 
uneven,  and  studded  with  a  number  of  yellowish  suppurat- 
ing points,  or  with  foramina  out  of  which  oozes  a  sticky, 
viscid,  gelatinous,  transparent  fluid.  Sometimes  suppura- 
tion may  occur  attended  with  a  sero-purulent  discharge. 
The  swelling  is  round  or  oval  in  shape,  and  varies  in  size ; 
it  may  be  but  one  or  two  inches  in  diameter  or  as  large  as 
a  turkey's  egg.     The  pustules  form  about  the  hair  in  the 


280  DISEASES    OF    THE    SKIN". 

early  stage ;  later  the  hairs  fall  and  the  discharge  takes 
place  from  the  openings  of  the  hair  follicles.  If  the  tumor  is 
opened  a  thick  viscid  material  is  discharged.  If  the  disease 
occurs  with  ringworm,  the  hair  will  be  broken  off.  Per- 
manent baldness  may  result  if  the  inflammation  is  intense. 
There  is  more  or  less  pain  and  tenderness,  and  at  times 
itching  and  burning.  The  posterior  cervical  glands  may  be 
enlarged. 

Etiology.  The  disease  is  comparatively  rare.  It  occurs 
chiefly  in  children  of  poor  constitution.  It  is  most  com- 
monly due  to  the  trichophyton  fungus  passing  deep  down 
into  the  hair  follicles,  but  may  be  caused  by  the  application 
of  irritants  to  the  scalp,  or  follow  eczema,  favus,  or  sycosis 
of  that  part. 

Diagnosis.  Kerion  must  be  diagnosticated  from  abscess, 
a  papilloma,  a  gumma,  and  a  sebaceous  cyst.  An  abscess  is 
not  preceded  by  ringworm,  has  no  history  of  an  irritant 
applied  to  the  scalp,  and  may  arise  without  any  antecedent 
disease  of  the  scalp  ;  it  is  more  painful ;  it  is  often  accom- 
panied by  a  sensation  of  throbbing,  by  chilliness,  fever,  and 
general  malaise;  when  fully  formed  there  is  fluctuation,  and 
when  opened  it  gives  exit  to  pus.  These  symptoms  are  not 
met  with  in  kerion.  A  papilloma  is  non-inflammatory, 
firm  to  the  touch,  and  is  unaccompanied  by  a  discharge.  A 
gumma  is  usually  accompanied  by  other  signs  of  syphilis, 
and  tends  to  break  down  and  ulcerate.  A  sebaceous  cyst  is 
slow  in  its  growth,  the  skin  over  it  is  normal,  there  is  no  dis- 
charge, and  when  opened  it  gives  vent  to  a  cheesy  mass.  A 
fatty  tumor  is  a  chronic,  elastic,  freely  movable  swelling, 
with  normal  skin  over  it. 

Treatment.  In  treating  a  case  epilation  should  be  per- 
formed in  order  to  save  the  hair  and  give  exit  to  the  dis- 
charge. If  some  irritant  application  is  the  cause,  that 
should  be  discontinued,  and  hot-water  dressings,  antiseptic 
solutions,  or  mild  emollient  applications  employed.  If  the 
cause  is  ringworm  the  remedies  proper  for  that  disease 
should  at  once  be  used.  What  they  are  will  be  found  under 
Trichophytosis  capitis. 


Kleienflechte.     See  Chromophytosis. 


•LENTIGO.  281 

Kohlenbeule.     See  Carbuncle. 
Kopskurv.     See  Favus. 
Knollenkrebs.     See  Keloid. 
Kratze.     See  Scabies. 

Kraurosis  (Kra*-ro'-si2s)  Vulvae  is  a  name  proposed  by 
Breisky1  for  a  form  of  atropby  of  tbe  skin  of  the  external 
genitals  of  women.  The  disease  has  its  seat  in  the  vestibule, 
the  labia  minora  with  the  frenulum  and  praeputium  clitoridis, 
the  inner  surfaces  of  the  labia  majora  up  to  the  posterior 
commissure,  and  the  contiguous  skin  of  the  perineum.  It 
gives  rise  to  the  appearance  of  a  defect  in  the  development 
of  the  normal  folds  of  the  vulva.  At  times  the  labia  minora 
and  the  praeputium  clitoridis  are  apparently  wanting.  The 
affected  skin  is  white  and  dry,  the  epidermis  is  often  thick- 
ened, and  telangiectasic  vessels  are  visible.  Stenosis  of  the 
vulvar  entrance  may  result,  and  thus  obstruction  be  offered 
both  to  coitus  and  parturition.  The  cause  is  obscure  ;  pos- 
sibly a  long-continued  blennorrhea,  or  a  congenital  defect, 
or  a  process  analogous  to  leucoplakia  buccalis.  Treatment 
is  of  no  effect.2 

Krebs  is  the  German  for  cancer. 
Kupferfinne.     See  Rosacea. 
Kupfriges  Gesicht.     See  Rosacea. 
Kupferrose.     See  Rosacea. 
Land  Scurvy.     See  Purpura  hemorrhagica. 
Lausesucht.     See  Pediculosis. 
Leichdorn.     See  Clavus. 
Leiomyoma  Cutis.     See  Myoma. 

Lentigo  (Le2nt-i'go).  Synonyms:  Ephelides ;  (Ger.) 
Sommersprossen,  Linsenflecke ;  Freckles. 

Freckles  are  properly  a  species  of  chloasma.  They  occur 
as  light  to  dark  brown  or  even  black  macules,  and  are 
usually  located  upon  exposed  parts,  especially  the  face  and 

1  Zeitschrift  f.  Heilkunde,  1885. 

2  Janovsky :  Monatshefte  f.  prakt.  Dermat,  1888,  vii.  951. 


282  D I  SEA'S  IS  S    OF    TIT-E    SK1X. 

backs  of  the  hands.  In  size  they  vary  from  a  pinhead  to 
a  split-pea.  They  give  rise  to  no  subjective  symptoms. 
They  usually  do  not  appear  before  the  eighth  year  of  life, 
but  congenital  cases  have  been  reported.  These  should 
rather  be  classed  among  the  pigmentary  nsevi.  A  division 
is  sometimes  made  between  those  which  are  permanent  and 
occur  upon  unexposed  places,  and  those  which  occur  in 
summer  to  disappear  in  winter.  To  the  former  the  name 
lentigo  is  given,  and  to  the  latter  ephelides.  The  distinc- 
tion is  not  worth  preserving.  As  old  age  is  approached, 
freckles  no  longer  form,  and  the  old  ones  are  apt  to  dis- 
appear. 

Etiology.  The  cause  of  freckles  is  probably  an  inborn 
peculiarity  of  the  skin.  It  has  been  advanced  as  a  theory 
of  their  production  that  they  are  due  to  the  chemical  action 
of  the  sun's  rays  upon  the  blood.  Blonds  are  more  prone 
to  them  than  are  brunettes.  Many  people  never  freckle. 
Symptomatically  they  occur  as  part  of  atrophoderma  pig- 
mentosum. 

Pathology.  Freckles  are  but  circumscribed  deposits  of 
pigment.  Cohn1  has  endeavored  to  show  that  lentigines 
differ  from  ephelides  in  being  discrete,  slightly  elevated,  and 
having  their  pigment  in  all  the  layers  of  the  epidermis,  as 
well  as  in  the  cutis,  and  in  being  associated  with  changes  in 
the  bloodvessels  of  the  cutis ;  while  ephelides  are  crowded 
together,  their  pigment  is  only  in  the  basal  layer  of  the 
epidermis,  and  there  are  no  changes  in  the  bloodvessels. 

Treatment.  The  treatment  of  freckles  is  the  same  as 
that  of  chloasma.  The  only  prevention  is  to  protect  the 
skin  from  the  action  of  the  sunlight.  Hardaway  recom- 
mends the  following  : 

R .  Hydrarg.  amnion.,     \  ~         .  4! 

Bismuthi  subnitrat,  J  ' '      ^J  ' 

Ungt.  aq.  roste,  3J  ;         30  M. 

He  also  speaks  highly  of  electrolysis  for  the  removal  of 
very  black  freckles.     There  is  hardly  any  use  in  endeavor- 

1  Monatshefte  f.  prakt.  Dermat.,  1891,  xii.  119. 


LEPRA 


283 


in2  to  cure  freckles  occurring  from  the  action  of  the  sun,  as 
they  depart  of  themselves. 

Leontiasis.     See  Leprosy. 

Lepothrix.     See  Tinea  nodosa. 

Lepra  (Le2p'ras).     Synonyms  :  Elephantiasis  Grnecorum  ; 

Fig.  28. 


Tubercular  and  anaesthetic  leprosy.1 


1  From  a  photograph  kindlv  loaned  me  bv  Dr.  P.  A.  Morrow,  of  New 
York. 


284  DISEASES    OF    THE    SKIN. 

Leontiasis ;  Satyriasis  ;  Lepra  Arabum ;  (Fr.)  La  Lepre ; 
(Ger.)  Der  Aussatz  ;  (Norweg.)  Spedalskhed  ;  Leprosy. 

A  chronic,  endemic,  constitutional  disease  due  to  infection 
by  a  specific  bacillus ;  characterized  by  anaesthesia,  erythe- 
matous patches,  tubercles,  ulcerations,  atrophies,  and  de- 
formities according  to  the  structures  most  affected ;  and 
ending  in  death.  (Fig.  28.) 

Symptoms  It  is  usual  to  describe  three  forms  of  leprosy 
— the  tubercular,  the  anaesthetic,  and  the  mixed.  This  is 
convenient  for  clinical  purposes,  though  not  absolutely  cor- 
rect, as  even  in  the  nearly  pure  tubercular  form  there  is 
more  or  less  anaesthesia.  All  forms  exist  in  all  endemic 
regions,  but  now  one  and  now  another  form  predominates. 
The  tubercular  form  is  the  one  most  common  in  cold 
countries,  the  anaesthetic  in  hot  countries.  Morrow,1  how- 
ever, found  that  in  the  Sandwich  Islands  the  tubercular 
form  constituted  one-half  of  the  cases,  while  the  anaesthetic 
form  formed  but  one-third  of  them. 

Tubercular  leprosy.  Sometimes  this  form  appears  sud- 
denly without  prodromata,  but  usually  for  days,  weeks,  or 
months  before  the  disease  frankly  declares  itself  the  patient 
is  out  of  health.  He  feels  indefinitely  ill,  depressed,  and 
listless ;  he  has  dyspepsia  and  diarrhoea  ;  he  is  weak,  chilly, 
and  suffers  from  profuse  sweating.  There  may  be  nose- 
bleed. Then  a  remittent  fever  of  malarial  type  appears. 
This  fever  may  occur  without  the  other  prodromata,  and 
may  recur  with  each  new  outbreak  of  tubercles.  After  a 
time  an  erythematous  eruption  appears  upon  the  face,  ears, 
the  forearms,  and  thighs.  It  consists  of  purplish  or 
mahogany-red,  slightly  raised,  hyperaesthetic,  smooth,  shiny 
patches,  of  one  or  several  inches  in  diameter,  usually  of  oval 
form.  The  eruption  may  fade  entirely  away,  to  again  ap- 
pear with  a  fresh  outbreak  of  fever.  After  some  three  to 
six  months  of  the  exanthem  the  tubercles  appear,  either 
upon  the  sites  of  the  previous  lesions,  or  quite  indepen- 
dently of  them.  They  begin  as  pinhead-sized  pink  papules 
that  enlarge  to  split-pea  or  even  to  hen's-egg  size,  yellowish- 

1  New  York  Med.  Journ.,  1889,  1,  85. 


LEPRA.  285 

brown  tubercles.  If  a  number  of  these  run  together  large 
infiltrated  patches  are  formed  of  irregular  shape  and  nodular 
surface.  Then  infiltrations  may  also  arise  by  an  increased 
deposit  of  leprous  material  in  the  macules,  for  the  macules 
themselves  are  formed  of  leprous  material  and  are  not  sim- 
ply erythematous  lesions.  Sometimes  the  infiltrated  patches 
that  arise  from  the  macules  may  assume  ring  shapes,  by 
clearing  up  in  the  centres.  The  tubercles  are  completely 
anaesthetic.  They  may  come  anywhere,  but  are  most  com- 
monly seen  in  the  eyebrows,  lobes  of  the  ears,  the  face  gen- 
erally, upon  the  extremities,  breasts,  scrotum,  and  penis. 
The  scalp  is  said  never  to  be  affected.  The  mucous  mem- 
branes of  the  mouth,  nose,  larynx,  trachea,  uterus,  and 
vagina  are  also  involved,  as  may  be  the  conjunctivae.  The 
tubercles  may  undergo  spontaneous  involution  in  one  place, 
while  fresh  outbreaks  of  them  occur  in  other  places.  Or 
they  may  soften  and  break  down  and  form  leprous  ulcers, 
which  are  indolent,  sharply  defined,  and  glazed  over  with  a 
mucous  discharge  of  peculiar  odor.  These  may  attain  enor- 
mous dimensions,  becoming  serpiginous  and  phagedenic. 
When  these  ulcers  go  deep,  as  they  may  do  on  the  lower 
extremities  especially,  there  may  take  place  spontaneous 
amputation  of  the  fingers,  toes,  or  whole  members.  This  is 
one  form  of  mutilating  leprosy,  which  is  most  frequently 
encountered  in  the  anaesthetic  form  of  the  disease.  Or  the 
tubercles  may,  on  disappearing,  leave  atrophic  spots.  Their 
development  and  involution  are  always  slow.  The  appear- 
ance of  a  well-developed  case  is  striking.  The  face  is  de- 
formed by  the  tubercles  and  assumes  the  "leonine''  expres- 
sion on  account  of  the  thickening  of  the  eyebrows  causing 
them  to  protrude  so  that  the  eyes  are  sunken  and  have  a 
stern  expression.  The  immense  lobes  of  the  ears  hang 
down.  The  lips  protrude  and  are  often  everted.  Tubercles 
stud  the  face.  The  forearms  are  enlarged  and  knobby. 
The  hands  are  deformed.  There  is  very  commonly  a  dis- 
charge from  the  nose,  a  disagreeable  odor  from  the  mouth, 
and  the  sense  of  smell  is  lost.  The  eyesight  is  often  lost, 
the  voice  is  cracked  and  croaking.  The  lymphatic  glands 
are   often    swollen.      Happily,    both   in   men   and  women 


286  DISEASES    OF    THE    SKIN". 

sterility  is  the  rule.  There  is  commonly  atrophy  of  the 
testicles  and  loss  of  sexual  power  in  men.  The  disease  is 
steadily  progressive,  and  death  occurs  in  eight  years,  on  an 
average,  though  the  disease  may  last  for  many  years. 
Crocker  says  40  per  cent,  die  of  the  disease  itself,  40  per 
cent,  die  from  renal  or  lung  complications,  and  the  rest  from 
diarrhoea,  anaemia,  or  general  marasmus. 

Anoesthetic  leprosy  announces  its  onset  not  by  febrile 
symptoms,  but  by  shooting,  lancinating  pains  in  the  chief 
nerve  trunks,  as  the  ulnar,  median,  peroneal,  and  saphenous. 
There  are  also  pain  and  tenderness  in  various  places,  and  a 
state  of  general  hyperesthesia.  There  may  also  be  symp- 
toms of  general  malaise  and  digestive  disturbances.  A 
frequent  early  symptom  is  a  vesicular  or  bullous  eruption 
upon  the  fingers  and  toes,  with  at  first  serous,  then  purulent 
contents.  These  may  burst  and  leave  a  white,  shining  anaes- 
thetic spot,  or  an  ulceration  that  heals  with  an  anaesthetic 
cicatrix.  Numbness  soon  follows  the  hyperaesthetic  state. 
The  patient  cannot  grasp  things  firmly,  and  the  consequent 
unskilfulness  of  his  actions  may  be  the  first  thing  to  attract 
his  attention.  This  shows  muscular  weakness  as  well  as 
numbness. 

After  some  months  of  these  prodromal  symptoms  an  erup- 
tion of  macules  similar  to  those  of  the  tubercular  variety 
appear  upon  the  extremities,  face,  and  back.  They  are 
isolated,  of  oval  shape,  hardly  raised  above  the  surface,  and 
of  a  pale  yellow  to  reddish-brown  color.  These  often  enlarge 
peripherally  and  clear  up  or  become  atrophic  in  the  centre. 
Sometimes  instead  of  being  oval  they  will  take  the  form  of 
wide  streaks  or  of  gyrate  figures.  They  are  often  hyperaes- 
thetic  when  newly  formed,  but  always  perfectly  anaesthetic 
when  they  have  become  atrophic,  and  even  before  that  in 
cases  that  have  lasted  some  little  time.  The  large  nerve 
trunks,  as  that  of  the  ulnar,  are  at  first  hyperaesthetic,  but 
later  are  anaesthetic  and  can  be  felt  like  a  whip- cord,  and 
rolled  about  under  the  finger  without  giving  rise  to  pain. 
Anaesthetic  areas  will  be  found  independently  of  the  macules, 
and  in  old  cases  a  rather  general  anaesthesia  develops  so  that 
the  patient  burns  himself  without  noticing  it.     The  ances- 


LEPRA.  287 

thetic  areas  are  subject  to  change  from  time  to  time.  Soli- 
tary bullae  appear  from  time  to  time  as  well  as  urticaria-like 
lesions.  Marked  atrophy  of  the  muscles  of  the  hands  and 
feet  occurs,  and  paralysis  of  the  extensor  muscles  of  the 
second  and  third  phalangeal  joints.  Wasted  interossei 
muscles,  and  permanent  flexion  of  the  last  phalanges  of  the 
fingers  give  as  characteristic  an  expression  to  the  hand  in 
this  form  of  leprosy,  as  the  tubercles  do  to  the  facial  expres- 
sion of  the  tubercular  form.  After  some  ten  years  or  so, 
during  which  the  greater  part  of  the  cutaneous  surfaces  may 
have  become  studded  over  with  white,  wrinkled,  hairless, 
atrophic  spots,  the  permanent  stage  is  reached.  During 
these  years  painless  amputation  of  many  of  the  joints  may 
have  occurred  by  a  process  of  dry  gangrene  (Lepra  muti- 
lans). Erysipelas  may  occur.  The  nails  and  hair  are  shed. 
Sleeplessness  may  prove  a  distressing  symptom.  Loss  of 
sexual  power,  and  sterility,  are  manifest.  This  form  lasts 
much  longer  than  the  tubercular  form,  fifteen  years  being  an 
average  duration.  Sometimes  a  fair  degree  of  health  is 
preserved  for  a  much  greater  length  of  time.  In  most  all 
cases  more  or  less  hebetude  of  mind  is  marked,  becoming 
more  pronounced  with  the  duration  of  the  disease. 

The  mixed  form  is  a  combination  of  the  symptoms 
of  the  two  former  varieties,  and  perhaps  is  the  one  most 
commonly  met  with  in  this  country.  Indeed,  it  is  the  rule 
that  all  tubercular  cases  present  certain  symptoms  of  the 
anaesthetic  form,  and  vice  versa,  the  variety  being  named 
from  the  prevailing  lesion. 

Etiology.  Up  to  within  a  few  years  various  agencies 
were  regarded  as  causes  of  leprosy,  such  as  residence  by  the 
sea-shore,  eating  of  putrid  fish,  heredity  ;  but  in  the  light 
of  our  present  knowledge  there  is  but  one  cause,  and  that  is 
contagion.  The  limits  of  this  book  forbid  full  discussion  of 
this  interesting  topic,  but  an  incontrovertible  argument  for 
this  view  is  found  in  the  spread  of  the  disease  in  the  Sand- 
wich Islands,  where,  within  a  few  years  of  its  introduction,  it 
has  decimated  the  community.  For  further  evidence  upon 
this  point  the  reader  is  referred  to  the  excellent  papers  by 
Dr.  P.    A.   Morrow  which   have  appeared   in  a  number  of 


288  DISEASES    OF    THE    SKIN. 

American  medical  journals  during  1890.  The  contagious- 
ness of  the  disease  is  a  strong  plea  for  the  segregation  of  the 
lepers  within  our  own  country. 

Leprosy  is  seen  in  both  sexes,  though  the  male  sex  is 
rather  more  often  affected.  It  is  rare  in  children,  and  is 
never  seen  in  infants  ;  a  strong  argument  against  heredity. 
Its  incubation  stage  is  very  long,  reaching  over  a  period  of 
years.  It  occurs  in  all  countries  and  climates,  but  is  endemic 
in  certain  regions.  Sporadic  cases  have  been  reported,  but 
careful  investigation  would  doubtless  show  that  they  have 
been  exposed  to  contagion.  Vaccination  has  often  been  a 
carrier  of  contagion. 

Pathology.  Constantly  accumulating  evidence  points  to 
the  bacillus  leproe  as  the  disease-carrier.  This  has  been 
found  in  the  tubercles,  the  infiltrations,  the  lymphatic 
glands,  nerves,  spleen,  liver,  walls  of  the  bloodvessels,  hair 
follicles,  and  sebaceous  glands.  It  was  discovered  by  Han- 
sen in  1874,  and  since  then  has  been  studied  by  many 
pathologists.  "  They  are  straight  or  very  slightly  curved 
rods,  5  qVo"  °f  an  *ncn  *n  length,  and  may  have  knob-shaped 
expansions  at  their  ends  or  in  their  length,  due  to  the  pres- 
ence of  two  to  five  spores"  (Crocker).  Inoculation  experi- 
ments have  often  resulted  negatively,  but  some  positive  ones 
sufficiently  prove  the  claim  for  the  bacilli  as  propagators  of 
the  disease. 

Diagnosis.  In  a  fully  developed  case  little  difficulty  in 
diagnosis  can  arise.  Sometimes  lepra  will  need  to  be  differ- 
entiated from  erythema  multiforme ;  syphilis  ;  lupus ;  and 
morphoea.  The  presence  of  anaesthesia  in  any  doubtful  case 
will  establish  the  diagnosis  of  leprosy.  Besides  this,  erythema 
runs  a  more  acute  course ;  syphilis  of  the  tubercular  form 
presents  redder  tubercles,  which  ulcerate  more  readily,  are 
grouped,  and  a  history  of  syphilis  is  usually  attainable ;  the 
lupus  tubercles  are  small,  of  apple-jelly  color,  soft,  do  not 
produce  thickening  of  the  eyebrows  and  nodular  lobulation 
of  the  ears,  and  group  themselves  in  patches  in  which  cica- 
tricial tissue  will  be  found  ;  morphoea  has  a  lardaceous 
appearance  with  a  violaceous  border. 


LEPRA.  289 

Treatment.  The  best  chance  for  recovery  from  leprosy 
is  removal  to  a  region  in  which  the  disease  is  not  endemic. 
This,  with  attention  to  hygiene,  and  a  general  tonic  treat- 
ment, will  do  a  great  deal  toward  a  cure.  Of  internal 
remedies,  chaulmoogra  oil  holds  the  first  rank,  with  an  in- 
itial dose  of  three  minims  three  times  a  day,  and  then  gradu- 
ally increased  to  as  high  a  dose  as  the  patient  will  stand. 
Nausea,  vomiting,  and  diarrhoea  show  when  this  is  reached. 
Fox1  has  cured  one  patient  by  giving  nux  vomica  or  strych- 
nia up  to  full  constitutional  effects,  and  then  administering 
chaulmoogra  oil  continuously.  Gurjun  oil  is  also  highly 
commended  in  an  emulsion  of  one  part  of  the  oil  and  three 
parts  of  lime-water,  of  which  the  dose  is  half  an  ounce  morn- 
ing and  night. 

Unna  claims  to  have  cured  one  case  with  sulpho-ichthyo- 
late  of  sodium,  from  six  to  forty-five  grains  a  day,  but  others 
who  have  tried  it  have  not  had  the  same  success.  Salicy- 
late of  soda,  thirty  grains  every  four  hours  till  two  drachms 
are  taken ;  salol  in  full  doses ;  thymol,  forty-five  to  sixty 
grains  a  day ;  carbolic  acid  up  to  fifteen  grains  a  day ;  are 
advocated  by  Lutz,  Besnier,  and  others.  The  general 
health  of  the  patient  should  receive  attention,  and  symptoms 
treated  as  they  arise. 

Externally  the  chaulmoogra  or  gurjun  oil  may  be  rubbed 
in.  The  ulcers  are  to  be  treated  upon  the  usual  surgical 
principles.  Unna2  recommends  rubbing  into  all  the  lesions 
but  those  on  the  hands  and  face,  the  following : 

R .  Chiysarobin,  \ 
Ichthyol,        j 


Ac  salicyLj  2 

Ungt.  simpl.,  100 


M. 


On  the  face  and  hands,  he  substitutes  pyrogallol  for  the 
chrysarobin.  To  counteract  the  bad  effects  of  the  drugs,  he 
administers  thirty  drops  of  dilute  hydrochloric  acid  during 
the  day.  For  women  and  children  he  substitutes  resorcin 
for  the  chrysarobin.     To    old  nodes,   after  protecting  the 

1  Post-Graduate,  1885-6,  i.  143. 

2  Journ.  Cutan.  and  Gen.-urin.  Dis.,  1887,  v.  381. 

13 


290  DISEASES    OF    THE    SKIN. 

surrounding  skin,  he  applies  during  five  to  seven  days  a 
plaster  mull  containing  twenty  to  forty  parts  of  salicylic 
acid  and  forty  parts  of  creasote.  Roake1  advocates  excision 
of  the  tubercles,  followed  by  the  application  of  pure  carbolic 
acid.  The  thermo-  or  electro- cautery  may  be  used  to  the 
same  end.     Segregation  is  the  only  preventive  measure. 

Prognosis.  The  prognosis  is  bad,  the  disease  steadily 
progressing  to  a  fatal  termination  unless  the  patient  can  be 
removed  from  the  endemic  region.  If  he  can  be  removed, 
there  is  a  chance  of  staying  the  disease.  In  some  instances 
the  disease,  even  where  the  patient  does  not  change  his 
residence,  pauses  in  its  course  for  a  long  time  ;  but  it  will 
eventually  again  become  active. 

Lepra  Alphos.      See  Psoriasis. 

Lepra  Arabum.     See  Elephantiasis. 

Lepre  Vulgaire.     See  Psoriasis. 

Leprosy.     See  Lepra. 

Leucasmus.     See  Leucoderma. 

Leucoderma  (Lu'^ko-du^rnV).  Synonyms  :  Vitiligo  ; 
Leucasmus  ;  Leucopathia ;  Achroma  ;  Piebald  skin. 

An  acquired  loss  of  pigment  of  the  skin  characterized  by 
the  formation  of  symmetrical  white  patches  with  convex 
borders  surrounded  by  an  area  of  hyper-pigmentation. 

Symptoms.  This  is  an  acquired  anomaly  of  pigmenta- 
tion, the  opposite  to  chloasma.  It  is  akin  to  albinismus, 
only  that  the  latter  is  a  congenital  condition.  It  consists 
in  the  disappearance  of  the  pigment  of  the  skin  in  circum- 
scribed round  or  oval  patches  so  that  white  areas  are  formed 
(Fig.  29).  At  the  same  time  there  is  an  accumulation  of  pig- 
ment around  the  areas  so  that  there  is  a  process  of  apigmen- 
tation  and  hyper-pigmentation.  The  size  of  the  patches 
varies  greatly.  They  may  be  no  larger  than  a  ten-cent 
piece,  or  of  immense  size.  The  disease  most  commonly 
begins  upon  the  neck,  face,  or  backs  of  the  hands,  but  may 
begin  anywhere.  It  is  chronic.  It  may  progress  so  as 
eventually  to  involve  the  whole  body  ;  or  it  may  become 

1  Brit.  Med.  Journ.,  1888,  i.  1214. 


LEUCODERMA. 


291 


stationary ;  or,  in   rare   cases,  the  skin  may  become  pig- 
mented again.     It    is  a  symmetrical  disease   in  nearly  all 


Fig.  29. 


Leucoderma.     (After  Hyde.) 

cases.     The  general  health   is  unaffected,  and  there  is  no 
change  in  the  sensibility  of  the  patches.     In  some  cases  the 


292  DISEASES    OF    THE    SKIN. 

white  parts  are  unusually  sensitive  to  exposure  to  the  sun. 
When  the  scalp  or  hairy  regions  are  affected  the  hair  turns 
white.  The  disease  is  most  evident  in  the  summer  on 
account  of  the  increased  pigmentation  that  normally  occurs 
in  the  sound  skin  at  this  season. 

Etiology.  The  cause  of  the  disease  is  obscure.  All  we 
can  now  say  is  that  it  is  probably  a  disturbance  of  innerva- 
tion. It  is  uncommon  for  it  to  occur  before  the  tenth  year 
of  life,  though  it  may  do  so.  Adults  are  most  frequently 
affected.  Both  sexes  are  subject  to  it.  It  is  more  common 
in  the  warm  than  in  the  cold  countries,  and  is  particularly 
common  in  negroes.  Exposure  to  the  sun  and  cold  seem  to 
be  excitants  in  some  cases.  It  has  followed  typhoid  fever, 
scarlatina,  and  malarial  fever.  Wood1  says  that  when  mulat- 
toes  contract  syphilis  they  become  several  shades  lighter  all 
over  the  body.  Symptomatically  it  is  seen  with  morphoea, 
Addison's  disease,  and  alopecia  areata.  There  is  also  a 
syphilitic  leucoderma.  I  have  had  one  case  in  a  young 
man  of  eighteen  years,  who  began  to  smoke  tobacco  when 
he  was  six  years  of  age,  and  had  continued  to  do  so.  He 
seemed  to  be  in  the  best  of  health. 

Diagnosis.  There  is  little  difficulty  in  diagnosis,  as  there 
is  no  other  disease  in  which  the  only  symptoms  are  a  loss 
of  pigment  with  surrounding  pigmentation.  In  morphoea 
the  patch  may  be  raised,  and  the  skin  is  changed  in  texture, 
and  there  is  apt  to  be  a  lilac  ring  about  it.  In  chloasma  the 
patch  itself  is  dark  with  a  convex  border,  while  in  leuco- 
derma the  border  of  the  pigmentation  is  concave.  The 
concave  border  of  the  pigmentation  will  also  distinguish 
the  disease  from  chromophytosis,  which  too  is  scaly.  The 
normal  sensation  of  the  patches  distinguishes  them  from 
leprosy,  in  which  the  patches  are  anaesthetic. 

Treatment.  Unfortunately  there  is  hardly  anything 
that  can  be  done  in  the  way  of  treatment.  Galvanism  or 
faradism  may  be  tried,  and  nerve  tonics  given.  We  must 
content  ourselves  with  making  the  patches  less  evident  by 
removing  the  pigment  from  about  them  by  the  means  given 

1  Journ.  Cutan.  and  Ven.  Dis.,  1883,  i.  274. 


LEUKOPLAKIA.  293 

under  chloasma.  Or  we  can  stain  the  patches  so  that  they 
shall  be  less  white,  as  by  the  use  of  walnut  juice.  Besnier 
and  Doyon  believe  that  they  have  cured  cases  in  young  sub- 
jects by  the  prolonged  use  of  bromide  of  potassium  inter- 
nally, and  saline  or  bromo-iodide  baths  externally,  with  or 
without  injections  of  pilocarpine. 

Leukaethiopes,  a  name  applied  to  negro  albinoes. 

Leucokeratose.     See  Leucoplakia. 

Leucopathia.     See  Leucoderma. 

Leucopathia  Unguium.  This  affection  of  the  nails  is  de- 
scribed by  Morison.1  It  consists  of  white  spots  in  the  nail 
which  begin  in  the  lunula  and  gradually  approach  the  free 
end  of  the  nail  as  it  grows  forward.  Sometimes  these  take 
the  form  of  stripes  or  lines.  The  nail  substance  is  other- 
wise unaltered.  The  spots  are  due  to  air-spaces  in  the  nail 
substance.  Why  these  occur  we  do  not  know.  Possibly 
there  may  be  a  process  of  fatty  degeneration  of  the  nerve 
cells  and  subsequent  absorption  of  the  fat.  (Taylor.)  Or 
they  may  be  caused  by  pressing  back  the  nail-fold.  They 
are  common  in  the  young  and  coincident  with  white  spots 
in  the  teeth.  (Hutchinson.) 

Leucoplakia  (Lu2-ko-pla'ki2-a3).  This  is  a  rare  affection 
of  the  mucous  membrane  of  the  tongue,  lips,  inside  of  the 
cheeks,  and  vulva,  that  has  been  described  under  the  names  of 
psoriasis  buccalis,  ichthyosis  linguae,  and  tylosis  linguae.  It 
occurs  in  the  form  of  ivory-white  or  bluish- white,  glistening, 
smooth,  irregularly  shaped  patches  upon  the  mucous  mem- 
branes that  maybe  a  little  elevated.  They  may  give  rise  to 
no  discomfort,  or  they  may  interfere  with  chewing  and 
speaking.  They  may  be  fissured.  There  is  sometimes  saliva- 
tion. They  are  caused  by  smoking  or  occur  in  syphilis, 
psoriasis,  lithaemia,  stomachic,  or  intestinal  catarrh,  diabetes, 
and  disturbed  nervous  influences.  Sometimes  they  arise 
without  assignable  cause. 

They  are  obstinate  to  treatment.  It  is  very  essential 
that  tobacco  be  given  up  if  the  patient  has   been  in  the 

1  Joura.  Cutan.  and  Gen.-urin.  Dis.,  1887,  v.  474. 


294  DISEASES    OF     THE     SKIN. 

habit  of  using  it.  It  is  also  necessary  to  address  our 
remedies  to  the  cure  or  relief  of  any  lithsemic  or  diges- 
tive disorder ;  and  to  have  the  teeth  put  and  kept  in  good 
order.  An  anti-syphilitic  treatment  may  be  tried,  but  is 
of  doubtful  value  Sometimes  they  may  be  removed  by 
the  daily  application  of  pure  lactic  acid  ;  or  J-  per  cent,  so- 
lution of  bichloride  of  mercury  ;  or  10  to  30  per  cent, 
solution  of  salicylic  acid  ;  or  1  per  cent,  of  chromic  acid  ;  or 
2  to  10  per  cent,  of  bichromate  of  potash  ;  or  by  galvano 
or  actual  cautery. 

The  prognosis  as  to  cure  is  not  good.  They  not  infre- 
quently take  on  a  cancerous  change. 

Lichen  (Li'ke2n).  This  term  was  formerly  applied  to  all 
papular  diseases,  and  a  host  of  lichens  were  described.  Of 
these,  only  lichen  ruber  acuminatus  and  planus,  and  lichen 
scrofulosorum,  have  survived. 

Lichen  Circinatus.     See  Seborrhcea. 

Lichen  Moniliformis.     See  Lichen  planus. 

Lichen  Pilaris.     See  Keratosis  pilaris. 

Lichen  Ruber.  Though  it  is  many  years  since  Hebra 
first  described  this  disease,  dermatologists  are  still  undecided 
as  to  many  of  its  essential  features,  such  as  whether  lichen 
ruber  planus  is  but  a  form  of  lichen  ruber  acuminatus,  or  a 
disease  sui  generis ;  and  as  to  whether  the  separate  lesion 
of  lichen  ruber  increases  peripherally  or  not.  In  this 
country  the  acuminate  form  of  the  disease  is  very  rare,  only 
twenty-seven  cases  having  been  reported  to  the  American 
Dermatological  Association  for  ten  years  out  of  a  total  of 
123,746.  Some  of  these  have  been  questioned  as  to  the 
possibility  of  their  being  pityriasis  rubra  pilaris.  While  in 
Europe  lichen  planus  is  considered  as  only  a  form  of  lichen 
ruber,  in  this  country  it  is  regarded  by  probably  the  majority 
of  our  dermatologists  as  a  separate  disease,  and  will  be  de- 
scribed as  such  in  this  book.  On  account  of  the  diversity 
in  the  descriptions  of  lichen  ruber  acuminatus,  the  one  here 
given  is  taken  from  Hebra  and  Kaposi  (Lehrbuch  der 
Hautkranklieiten.  1872). 

Lichen  ruber  acuminatus.     Lichen  ruber  acuminatus  is 


LICHEN"    RUBER.  295 

a  chronic  progressive  disease  of  the  skin  marked  by  an 
eruption  of  small,  red,  conical  papules  tipped  with  a  scale. 
These  tend  to  run  together  and  form  lines  or  diffused  red, 
scaly,  infiltrated  patches. 

Symptoms.  The  disease  begins  as  a  discrete  eruption  of 
milletseed-sized  slightly  scaly  papules,  that  cause  but  little 
itching,  and  therefore  are  accompanied  by  but  few  excoria- 
tions. The  papules  may  be  bright  or  brownish  red,  conical, 
hard,  covered  with  an  adherent,  dry,  white  scale,  and  im- 
parting, when  they  are  present  in  a  sufficient  number,  a 
rough  feeling  to  the  touch.  Or  they  may  be  pale  red,  waxy, 
smooth,  rounded,  and  with  a  small,  angular  depression  in 
their  center.  The  first  outbreak  may  be  scattered  about 
the  whole  trunk  and  extremities,  though  somewhat  more 
abundant  on  the  flexor  surfaces  of  the  latter.  Or  it  may 
be  limited  for  a  long  time  to  a  single  region,  such  as  the 
leg,  or  genitals.  After  a  time  the  eruption  becomes  general 
by  the  appearance  of  new  papules  either  at  the  periphery 
of  the  first  patch,  or  between  the  original  papules,  or  irreg- 
ularly over  all.  The  single  papules  never  increase  in  size 
during  their  whole  course.  After  a  time  the  papules  crowd 
together,  and  melt  into  each  other,  and  form  continuous, 
red,  infiltrated  patches  of  various  sizes  and  shapes,  whose 
surfaces  are  like  chagrin  leather  or  covered  with  scales. 

This  is  the  most  common  course.  Sometimes,  however, 
the  new  papules  appear  in  manifold  circular  rows  about  the 
older  ones.  The  older  ones  sink  in,  disappear,  and  leave 
a  darkly  pigmented  depression.  The  thus  formed  patches 
are  usually  on  the  extremities. 

In  a  fully  developed  case  the  skin  is  everywhere  reddened, 
scaly,  and  thickened,  and  the  movements  of  the  joints  are 
greatly  interfered  with  so  that  they  are  held  in  a  semi- 
flexed position.  The  thickening  of  the  skin  is  specially 
marked  on  the  palms,  soles,  fingers,  and  toes,  and  here  rha- 
gades  are  prone  to  form.  The  nails  are  thickened,  uneven, 
brittle,  broken,  opaque,  yellowish-brown ;  or  they  are  only 
represented  by  thin  horny  plates.  The  coarse  hair  of  the 
head,  axillae,  and  pubes  is  unaffected.     (Kaposi,  in  the  third 


296  DISEASES    OF    THE    SKIN. 

edition  of  his  book,  says  that  a  defluvium  capillorum  takes 
place.) 

The  subjective  symptoms  are  itching,  and  a  gradual  pro- 
gressive interference  with  nutrition.  At  first  the  patient 
may  feel  quite  well,  but  when  the  whole  body  is  affected  he 
falls  into  a  general  marasmus,  and  at  last  dies  from  the 
effects  of  the  disease. 

So  far  Hebra.  Subsequent  observers  have  reported  the 
occurrence  of  a  bullous  eruption  in  the  course  of  the 
disease. 

Etiology.  The  cause  of  the  disease  is  obscure.  It 
affects  all  ages  and  conditions,  but  is  most  frequent  in  the 
male  sex — about  two-thirds  of  the  cases.  By  many  the  dis- 
ease is  considered  to  be  a  neurosis. 

Diagnosis.  It  is  needful  to  diagnosticate  the  disease  from 
psoriasis,  eczema,  pityriasis  rubra,  pityriasis  rubra  pilaris, 
and  lichen  ruber  planus.  From  psoriasis  it  differs,  when  in 
the  early  stages,  in  that  its  papules  do  not  enlarge  into  the 
large,  characteristic  psoriatic  papules  and  patches ;  in  the 
later  stages  there  is  less  scaling  than  in  psoriasis  universalis, 
and  more  thickening  of  the  skin ;  and  the  palms  and  soles 
are  far  more  profoundly  diseased.  From  eczema  it  differs 
in  that  its  papules  neither  undergo  involution  nor  change 
into  vesicles.  Moreover,  it  does  not  itch  so  much,  and  there 
is  never  any  moisture.  From  pityriasis  rubra  it  differs  in 
the  greater  thickening  of  the  skin,  and  in  its  scaling,  which 
is  not  in  the  form  of  thin  plates  or  furfuraceous  desquama- 
tion. From  pityriasis  rubra  pilaris  it  differs  in  being  less 
scaly,  in  affecting  the  flexor  surfaces  by  preference,  in  the 
darker  color  of  the  eruption  from  the  first,  in  being  more 
itchy,  and  in  the  profound  constitutional  disturbance. 
From  lichen  planus  it  differs  in  that  it  does  not  have  its 
favorite  locations  upon  the  flexor  surface  of  the  wrists  and 
insides  of  the  knees,  in  having  conical  and  not  flattened 
papules,  in  not  forming  lilac-colored  angular  patches,  and  in 
a  more  frequent  general  involvement  of  the  skin. 

Treatment.  Arsenic,  by  the  mouth  or  hypodermatically, 
is  the  drug  upon  which  most  reliance  is  placed  for  the  cure 
of  this  disease.     The  drug  must  be  pushed  up  to  its  limit  of 


LICHEN    PLANUS.  297 

toleration  and  given  continuously  for  a  long  time,  and  for 
some  weeks  after  the  disappearance  of  the  eruption.  The 
hypodermic  method  is  very  painful.  The  external  treat- 
ment is  by  means  of  tar,  if  not  too  irritating ;  or  we  may 
simply  address  ourselves  to  the  relief  of  the  itching  by  means 
of  carbolic  acid,  one  or  two  drachms  to  the  pint  of  olive  oil 
or  pound  of  vaseline.  Crocker  speaks  well  of  thymol  or 
naphthol,  10  gr.  to  5ij  to  the  ounce  of  vaseline.  Unna's1 
treatment  has  proved  serviceable  in  many  hands.  He 
keeps  the  patient  in  bed  between  woollen  blankets,  and  has 
him  rubbed  every  morning  and  night  with  the  following : 


Be .  Ungt.  zinc.  oxid.  benzoat.,    %  iv  ;  500 

Ac.  carbolici,  9  iy  5  20 

Hydrarg.  bichlor.,  gr.  ij-iv ;      0.5-1 


M. 


For  the  ointment  of  oxide  of  zinc,  diachylon  ointment 
may  be  substituted ;  or  a  mixture  of  oil,  lime-water,  and 
white  bolus  may  be  used  instead.  Where  the  corneous  layer 
is  very  thick,  two  drachms  and  a  half  of  chalk  may  be  sub- 
stituted for  the  bolus. 

Prognosis.  The  course  of  the  disease  is  essentially 
chronic.  Even  when  a  cure  is  effected,  relapses  are  liable  to 
occur.  Hebra  at  first  said  that  all  cases  were  fatal,  but  the 
use  of  arsenic  and  increased  experience  in  the  treatment  of 
the  disease  has  greatly  modified  his  gloomy  prognosis. 

Lichen  (ruber)  Planru3s.  A  chronic  disease  of  the  skin 
characterized  by  the  eruption  of  smooth,  waxy,  angular, 
umbilicated,  red  papules,  that  tend  to  form  scaly,  lilac- 
colored,  elevated  and  infiltrated  patches  specially  upon  the 
flexor  surfaces  of  the  wrists,  and  the  inside  of  the  knees. 

While  the  testimony  from  skilled  observers  is  overwhelming 
that  lichen  planus  papules  may  occur  with  lichen  acumina- 
tum, and  while  some  cases  of  lichen  acuminatus  have  de- 
veloped after  and  together  with  lichen  planus,  still  we  see  so 
many  cases  of  the  latter  occurring  by  itself,  that  it  merits  a 
special  description.  In  this  country  and  in  England  lichen 
planus    is    far    more    frequent    than    is  lichen  acuminatus. 

1  Monatshefte  f.  prakt.  Dermat.,  1882,  i.  5. 
13* 


298  DISEASES    OF    THE    SKIN. 

While  the  latter  occurred  but  27  times  in  123,746  cases,  the 
former  occurred  154  times  in  the  same  number  of  cases, 
according  to  the  statistics  of  the  American  Dermatological 
Association. 

Symptoms.  The  disease  begins  as  an  eruption  of  small, 
purplish-  or  crimson-red,  angular,  flat,  slightly  raised  papules, 
varying  in  size  from  ^  to  -J-  of  an  inch  in  diameter. 
Their  surface  is  smooth  and  shiny,  u  waxy-looking,"  and 
they  have  a  small  depression  in  their  centre.  The  papules 
may  remain  discrete,  and  be  disseminated  over  a  larger  or 
smaller  area ;  or  they  may  arrange  themselves  in  rows,  or 
aggregate  themselves  into  patches,  the  single  papules  dis- 
appearing. The  single  papules  are  not  scaly,  the  patches 
are  slightly  so.  The  patches  may  be  small,  and  if  so  there  is 
apt  to  be  a  well-marked  depression  in  their  centre,  and  their 
shape  is  round  or  oval.  The  larger  patches  have  no  definite 
shape  nor  depression,  but  are  well  defined,  and  elevated. 
The  color  of  the  patches  is  characteristic,  and  may  be  de- 
fined as  lilac.  If  the  color  is  once  seen  it  will  be  an  impor- 
tant aid  in  the  diagnosis  of  future  cases.  Both  the  papules 
and  patches  on  disappearing  leave  behind  pigmented  spots, 
which,  after  a  time,  fade  away.  It  is  still  a  moot  point  as 
to  whether  the  individual  papule  enlarges  peripherally  or  not. 
Like  those  of  psoriasis,  the  papules  of  lichen  planus  may 
appear  upon  scratched  surfaces. 

The  disease  is  most  often  met  with  upon  the  anterior 
surface  of  the  wrists  and  forearms,  and  upon  the  inside 
of  the  knees,  the  former  being  the  favorite  location.  But 
it  may  occur  anywhere,  other  favorite  locations  being  the 
flanks,  lower  part  of  the  abdomen,  and  the  calves,  and  it 
may  involve  a  large  part  of  the  body,  though  it  rarely  be- 
comes general.  When  the  papules  disappear  after  lasting 
many  weeks  they  leave  behind  them  pigmented  depres- 
sions, which  later  may  become  white.  The  mucous  mem- 
branes of  the  lips  and  mouth  are  affected  but  rarely  and 
the  disease  then  appears  as  white  spots  difficult  if  not 
impossible  of  diagnosis,  without  the  occurrence  of  the  typical 
eruption  on  the  integument.  As  a  rule  there  is  more  or 
less  symmetry  shown  in  the  disposition  of  the  efflorescences  ; 


LICHEN    PLANUS. 


299 


and  pruritus,  which  sometimes  is  marked.  The  general 
health  is  often  unaffected,  but,  on  the  other  hand,  many  of 
the  subjects  of  the  disease  are  not  in  perfect  condition  when 


Fig.  30. 


Lichen  ruber  moniliformis.     (After  Taylor.) 

the  disease  begins,  and  not  a  few  others  become  greatly 
broken  down  on  account  of  the  loss  of  sleep  and  continual 
discomfort  caused  by  the  pruritus.  The  course  of  the  dis- 
ease is  chronic,  and  new  outbreaks  are  liable  to  occur.  True 
relapses  are  not  liable  to  occur  when  the  disease  is  once 
cured. 


300  DISEASES    OF    THE    SKIN". 

Kaposi1  has  described  a  unique  form  of  this  dis- 
ease under  the  name  of  lichen  ruber  moniliformis,  in 
which  the  typical  lesions  became  transformed  into  keloidal 
nodes  arranged  in  lines  (Fig.  30).  The  nodes  were  in  some 
places  as  large  as  cherries  with  their  bases  confluent  and  their 
upper  parts  separated  by  furrows.  The  cases  of  this  sort 
that  I  have  seen  in  this  country  occurred  in  what  were 
rather  lichen  ruber  acuminatus  or  pityriasis  rubra  pilaris. 
Unna2  describes  what  he  names  lichen  obtusus,  a  form  of 
papule  midway  between  the  acuminate  and  the  plane.  They 
are  large  and  waxy,  discrete  papules,  often  bluish -white,  not 
scaly,  and  but  slightly  itchy.  A  lichen  verrucosus  and  a 
lichen  hypertrophicus  have  also  been  described.  Pemphi- 
goid eruptions  occasionally  occur  as  part  of  the  disease. 
Crocker  says  that  there  is  an  infantile  form  of  the  disease 
in  which  the  papules  come  out  acutely  in  groups,  acuminate 
at  first,  but  soon  becoming  flat,  angular,  and  red  changing  to 
purple.  It  is  itchy,  and  tends  to  rapid  recovery  in  a  few 
weeks  under  soothing  applications. 

Etiology.  We  know  no  more  about  the  causes  of  lichen 
planus  than  we  do  about  those  of  lichen  acuminatus.  A 
neurotic  element  is  marked  in  many  of  the  cases,  and  cases 
have  been  reported  in  which  the  papules  were  distributed 
along  the  course  of  a  nerve.3  Nervous  exhaustion,  rheu- 
matic sweating,  and  checking  perspiration  are  given  as 
causes.  Its  subjects  are  mostly  adults.  It  is  more  frequent 
in  men  than  in  women. 

Pathology.  u  In  the  plane  form  the  process  appears  to 
be  inflammatory,  beginning  usually  round  a  sweat  duct  in 
the  upper  part  of  the  corium,  with  subsequent  thickening 
of  the  rete  and  enlargement  of  the  papillas  by  down  growth 
of  the  inter-papillary  processes."  (Crocker.)  The  fact  that 
the  mucous  membranes  are  affected  is  brought  forward  as  an 
objection  to  the  view  that  the  process  begins  in  the  sweat 
duct.     Robinson  thinks  that  the  process  begins  as  an  in- 

1  Vierteljahr.  f.  Dermat.  u.  Syph.,  1886,  xiii.  571. 

2  St.  Petersburg,  med.  Wochenschrift,  1884,  i.  447. 

3  Mackenzie :  Brit.  Med.  Journ.,  1884,  ii.  1077. 


LICHEN    POLYMORPHE    CHRONIQUE.  301 

flammation  of  the  papillae  and  upper  part  of  the  coriurn. 
The  form  of  the  papule  is  determined  by  the  shape  of  the 
so-called  "skin  fields." 

Diagnosis.  An  eruption  of  flat,  shiny,  angular,  umbili- 
cated  papules  of  a  lilac  color  situated  on  the  anterior  sur- 
faces of  the  wrists  can  be  nothing  but  lichen  planus.  These 
same  characteristics  are  diagnostic  anywhere  on  the  body, 
and  sufficient  to  diagnosticate  the  disease  from  eczema  and 
psoriasis.  Moreover,  eczema  will  show  a  tendency  to  moist- 
ure, or  the  papules  will  undergo  change ;  and  psoriasis 
will  be  almost  sure  to  have  characteristic  patches  upon  the 
elbows  and  knees,  covered  with  more  abundant  white  and 
ofttimes  thick  scales.  Syphilis  sometimes  bears  a  strono- 
resemblance  to  lichen  planus,  but  itching  is  less  marked,  its 
eruption  is  more  polymorphous,  and  its  color  is  more  that 
of  raw  ham. 

Treatment.  In  the  treatment  of  lichen  planus,  arsenic, 
nerve  tonics,  and  attention  to  the  general  health  as  well  as 
to  the  hygiene  both  of  the  body  and  mind,  are  our  most 
reliable  agents.  Alkaline  diuretics  sometimes  do  well,  as 
the  acetate  of  potash.  Locally,  stimulants  such  as  tar, 
pyrogallol,  and  chrysarobin  will  prove  serviceable.  Unna's 
ointment,  as  given  under  lichen  ruber  acuminatus,  is  proba- 
bly our  most  reliable  application.  In  acute  cases  alkaline 
lotions  will  allay  irritation.  Thymol  and  naphthol  may  be 
tried  as  in  lichen  acuminatus.  In  chronic  cases  Hardaway 
recommends : 


u 

Saponis  olivse  prep., 

3iv; 

100 

Olei  rusci,  \ 
Glycerinae,  J 

aa 

3J; 

25 

01.  rosmarini, 

3jss ; 

4 

Alcoholis, 

ad 

I  viiJ ; 

200 

M. 

well  rubbed  in  with  a  piece  of  flannel.  The  patches  are 
sometimes  favorably  affected  by  mercurial  plaster.  Some 
cases  in  which  the  skin  is  very  irritable  are  best  treated  by 
means  of  prolonged  simple  or  medicated  emollient  baths. 

Prognosis.     The  prognosis  is  generally  favorable,  though 
the  disease  is  often  very  obstinate.  ■ 

Lichen  Polymorphe  Chronique.     See  Prurigo. 


302  DISEASES    OF    THE    SKIN. 

Lichen  Scrofulosorum  (L.  SknyT-ni-os-orVm)  or  Scrofu- 
losus.  A  disease  of  the  skin  occurring  in  strumous  subjects, 
consisting  in  an  eruption  of  small  pale  papules  that  tend  to 
group  in  round  or  halfmoon-shaped  figures  upon  the  ab- 
domen, sides  of  the  chest,  and  flanks. 

Symptoms.  It  occurs  in  the  form  of  pinpoint  to  pinhead- 
sized,  grouped,  conical  papules,  which  may  be  of  the  color  of 
the  skin,  or  pale  red,  or  fawn-colored.  These  papules  occur 
around  the  hair  follicles  and  form  small  round  groups,  or 
circles,  or  segments  of  circles,  upon  the  abdomen,  sides  of 
the  chest,  flanks,  and  neck  in  adults ;  and  upon  the  extremi- 
ties in  children.  They  are  somewhat  scaly,  but  give  rise  to 
no  inconvenience,  so  that  they  are  often  overlooked.  In 
some  cases  the  papules  are  so  numerous  that  the  groups 
lose  their  distinctive  shape,  and  large  surfaces  are  covered, 
giving  the  skin  then  a  dirty-brown  color.  Many  dissemi- 
nated and  discrete  papules  are  scattered  over  the  body  out- 
side of  the  patches.  Acne  pustules  may  form  ;  and  a  brown 
pigmentation  of  the  face  has  been  observed  in  some  cases. 
The  papules  finally  undergo  absorption,  desquamate,  and 
leave  transitory  yellowish  pigmentation.  The  disease  runs 
a  chronic,  slow  course.  Eczema  may  complicate  matters. 
Keratosis  pilaris  is  frequently  well-marked  upon  the  limbs. 

Etiology.  The  great  majority  of  the  subjects  of  this 
disease  present  evidences  of  scrofula.  A  few  are  robust. 
Some  are  phthisical,  especially  the  children.  The  disease 
is  most  common  in  childhood,  and  is  excessively  uncommon 
after  the  twenty-fifth  year  of  life. 

Diagnosis.  The  disease  must  be  diagnosticated  from  pap- 
ular eczema,  the  papular  syphilide,  lichen  ruber,  a  punctate 
psoriasis,  and  keratosis  pilaris.  Eczema  differs  from  it  in 
greater  itching,  in  the  brightness  and  rapid  development  of 
the  papules,  and  in  its  tendency  to  vesiculation  or  moisture. 
The  papular  syphilide  is  of  darker  red  color,  much  larger, 
and  more  polymorphous ;  the  patient's  age  is  greater,  and 
the  history  and  course  of  the  eruption  will  soon  decide  the 
diagnosis.  Lichen  ruber  acuminatum  has  darker  papules, 
which  do  not  group  in  circles  and  segments  of  circles ;  they 
itch,  and  tend  to  involve  the  whole  surface.     The  patients 


LUPUS    ERYTHEMATOSUS.  303 

are  more  often  adults,  and  there  is  a  profound  constitutional 
disturbance.  Psoriasis  itches,  is  abundantly  scaly,  and  its 
papules  soon  enlarge  and  form  characteristic  patches. 
Keratosis  pilaris  affects  the  extensor  surfaces  of  the  limbs 
by  preference,  each  papule  is  plainly  about  a  hair,  and  the 
papules  do  not  group.  A  curled  up  hair  will  often  be  found 
in  the  centre  of  the  papule. 

Treatment.  The  persistent  use  of  cod-liver  oil  both 
internally  and  externally  will  cure  the  disease.  The  syrup 
of  the  iodide  of  iron  may  be  given  with  the  oil.  Good 
hygiene  and  food  are  valuable  adjuncts.  For  the  cod-liver 
oil,  which  is  disagreeable  for  external  use,  other  oils,  such  as 
cocoa  butter,  may  be  used ;  or  vaseline  with  or  without  oil 
of  cade.  Crocker  recommends  the  addition  of  liq.  plumb, 
subacetatis,  nixv,  or  thymol,  5  grains  to  the  ounce  of 
vaseline. 

Lichen  Simplex.     See  Papular  eczema. 

Lichen  Syphiliticus.     See  Papular  syphilide. 

Lichen  Tropicus.     See  Miliaria. 

Lichen  Urticatus.     See  Urticaria. 

Lineae  Albicantes.     See  Atrophoderma. 

Linsenflecken.     See  Lentigo. 

Liodermia  Essentialis.  See  Angioma  pigmentosum  et 
atrophicum. 

Lipoma  is  a  fatty  tumor. 

Lombardian  Leprosy.     See  Pellagra. 

Lousiness.     See  Pediculosis. 

Lues.     See  Syphilis. 

Lupoid  Acne.     See  Acne  frontalis,  and  Lupus  miliaris. 

Lupus  Erythematosus  (Lu'pus  Er2-i2-the2m-a2t-os/u3s). 
Synonyms  :  Seborrhoea  congestiva  ;  Lupus  superficialis  ; 
Lupus  sebaceus ;  Lupus  erythematodes ;  Scrofulide  erythe- 
mateuse,  or  Erytheme  centrifuge  (Fr.) ;  Dermatitis  glandula- 
ris erythematosa  (Morison)  ;   Ulerythema  (L^nna). 

This  is  a  chronic  disease  of  the  skin,  occurring  in  variously 
sized,  slightly  elevated,  scaly,  red  patches  which  show  a 
strong  tendency  to  the  production  of  atrophic  scars. 


304  DISEASES    OF    THE    SKIN. 

Symptoms.  There  are  two  varieties  commonly  described, 
namely,  the  circumscribed  or  discoid,  and  the  diffuse,  or  dis- 
seminated, or  aggregated.  To  these  some  of  the  English 
writers  add  a  third,  the  telangiectic. 

The  circumscribed  or  discoid  form  is  the  one  most  often 
met  with.  It  occurs  generally  on  the  face,  specially  upon 
the  sides  of  the  nose  and  the  cheeks,  the  scalp,  and  the 
ears  ;  more  rarely  upon  the  hands  and  feet ;  and  still  more 
rarely  on  other  parts  of  the  body.  It  begins  by  the 
appearance  of  several  isolated  or  grouped  red  spots  slightly 
elevated,  of  pinhead  to  split-pea  size,  with  a  thin  ad- 
herent scale  upon  them.  Some  of  these  spots  may  be 
depressed  in  the  centre.  When  the  scale  is  removed  there 
will  be  found  upon  its  under  side  a  delicate  projection 
formed  by  a  plug  of  sebaceous  matter  that  dipped  down  into 
the  mouth  of  the  sebaceous  gland.  The  mouth  of  the 
gland  will  be  found  patulous.  These  spots  increase  in  size 
to  form  disc-shaped  figures  of  varying  size ;  neighboring 
ones  will  coalesce,  and  thus  patches  will  be  formed,  also 
covered  with  the  fine  grayish  or  white  adherent  scales. 
Now  when  the  scale  is  raised  a  number  of  the  characteristic 
prolongations  will  be  found  on  its  lower  side.  The  margins 
of  the  patches  are  slightly  raised  but  the  middle  parts 
undergo  involution,  are  lower  than  the  margins,  and  after  a 
time  are  apt  to  assume  a  cicatricial  appearance,  the  skin 
being  atrophied. 

The  scar  tissue  thus  formed  is  thin,  delicate,  and  white, 
never  puckered  or  deforming.  The  color  of  the  patches  is 
red,  but  of  a  peculiar  hue  that  is  characteristic,  and  perhaps 
can  be  best  defined  as  violaceous.  There  is  never  any 
moisture  connected  with  the  disease.  Burning  or  itching 
may  or  may  not  be  present.  The  patches  are  of  indefinite 
duration — months  or  years.  At  times  they  disappear  of 
themselves,  and  do  not  leave  scars,  but  the  rule  is  that  scars 
are  left.  The  extent  of  the  disease  varies  greatly,  as  well  as 
the  shape  of  the  patches.  The  greater  part  of  the  face  may 
be  involved,  or  there  may  be  only  a  single  patch.  Usually 
the  eruption  is  symmetrical.  A  characteristic  location  for 
the  disease  is  upon  the  back  and  sides  of  the  nose  and  the 


LUPUS    ERYTHEMATOSUS.  305 

contiguous  parts  of  the  cheeks,  forming  what  has  been  fanci- 
fully called  a  butterfly,  the  ridge  of  the  nose  representing 
the  back  of  the  animal,  and  the  cheeks  its  wings.  Some- 
times gvrate  figures  are  formed.  The  mucous  membranes 
and  the  vermilion  border  of  the  lips  may  be  affected. 
Occurring  upon  the  scalp  it  leads  to  permanent  loss  of  hair, 
and  the  same  may  be  said  of  it  as  it  occurs  on  other  hairy 
parts.  The  disease  may  become  stationary  after  a  time. 
Relapses  are  liable  to  occur.  The  general  health  is  un- 
affected. 

The  diffuse  or  disseminate  form  is  a  more  acute  process, 
and  exceedingly  rare  in  this  country.  In  it  the  patches 
may  appear  suddenly,  or  slowly  develop.  They  are  from 
pinhead  to  finger-nail  size,  slightly  elevated,  reddish-brown, 
hyperceruic  and  hard  ;  they  are  pale  under  pressure,  and  are 
attended  with  heat  and  burning.  In  this  stage  thev  resemble 
an  urticaria,  or  the  papular  stage  of  eczema.  There  may  be 
twenty  to  a  hundred  or  more  of  them,  crowded  together  upon 
the  face  and  scattered  over  the  bodv.  Manv  of  them  may 
disappear  in  a  few  days  without  leaving  any  trace,  while 
others  will  remain  and  become  characteristic  lupus  erythe- 
matosus patches  with  depressed  cicatrices.  The  individual 
lesions  do  not  increase  in  size,  and  the  patches  are  formed 
by  aggregations  of  single  lesions.  The  eruption  may  be 
accompanied  by  a  high  degree  of  inflammation,  exudation, 
and  crusting,  or  even  by  bullae.  There  may  be  deep,  painful 
subcutaneous  tumors  in  the  joints  and  glands  at  first,  over 
which  characteristic  patches  will  form.  In  some  acute  cases 
the  development  of  the  patches  is  accompanied  by  fever, 
osteocopic  pains,  and  nocturnal  headache.  Or  there  may 
be  a  persistent  inflammation  of  the  face,  erysipelas  perstans, 
which  may  lead  through  a  typhoid  state  to  death.  There 
mav  be  also  swelling  of  the  parotid  glands,  and  of  various 
lymphatic  glands.  In  some  cases  the  disease  bears  a  close 
resemblance  to  chilblain. 

The  telangiectic  form  occurs,  according  to  Crocker,  as  a 
persistent  circumscribed  redness,  which  close  inspection 
shows  to  be  due  to  dilated  vessels,  and  is  commonly  located 
symmetrically  upon  both  cheeks.      Upon  pinching  up  the 


306  DISEASES    OF    THE    SKIN. 

skin  it  will  be  found  to  be  markedly  thickened.     Some  few 
comedones  may  be  present.     There  is  no  desquamation. 

Etiology.  About  two-thirds  of  the  cases  occur  in  women. 
It  seldom  occurs  before  puberty,  though  Kaposi  has  seen  a 
case  in  a  child  of  three  years.  Beyond  these  facts  we  know 
but  little  about  its  etiology.  The  French  regard  it  as  a  scro- 
fulous affection.  Nothing  suggesting  its  relation  to  a  tuber- 
culous process  has  ever  been  found  in  the  skin.  It  is  true 
that  some  few  cases  have  reacted  to  tuberculin  injections,  but 
that  is  no  proof  of  its  tubercular  origin.  On  account  of  not 
a  few  patients  having  other  symptoms  of  a  general  tubercu- 
losis, Besnier  regards  lupus  erythematosus  as  allied  to  lupus 
vulgaris,  as  a  species  of  tuberculosis  of  the  skin.  Crocker 
suggests  a  feeble  circulation,  and  prolonged  exposure  to 
great  cold  or  heat  as  possible  causes.  It  would  also  seem 
that  those  who  are  subjects  of  seborrhcea  are  predisposed  to 
the  disease. 

Pathology.  In  spite  of  much  careful  study  it  is  still 
undetermined  whether  the  disease  is  inflammatory  or  not 
In  the  majority  of  cases  the  disease  begins  about  the  seba- 
ceous glands  and  hair  follicles.  It  may  also  begin  in  the 
sweat  glands,  or  in  any  part  of  the  skin  ;  or  in  the  deeper 
layers  of  the  skin  around  the  vessels  of  the  sweat  or  seba- 
ceous glands.  The  cicatricial  scarring  is  the  result  of 
atrophic  processes. 

Diagnosis.  The  disease  must  be  differentiated  from 
lupus  vulgaris,  eczema,  rosacea,  psoriasis,  and  syphilis.  A 
typical  case  occurring  upon  the  face  in  the  form  of  red 
patches,  with  fine  cicatrices  in  the  centre,  and  covered  with 
a  delicate  white  or  grayish  adherent  scale  from  the  under- 
side of  which  are  a  number  of  projections,  offers  no  difficulty 
in  diagnosis.  Lupus  vulgaris  differs  from  lupus  erythema- 
tosus in  occurring  before  puberty,  in  showing  no  disposition 
to  symmetry,  in  the  presence  of  apple-jelly  tubercles,  in 
being  a  deeper-seated  disease,  and  in  leading  to  far  more 
disfiguring  cicatrices.  Eczema  never  leaves  scars,  is  prone 
to  exudation,  itches,  its  scales  do  not  show  prolongations 
from  the  underside,  and  its  patches  undergo  more  rapid 
and  varied  changes.     Psoriasis  will  be  pretty  sure  to  show 


LUPUS    EKYTHEMATOSUS.  307 

characteristic  patches  covered  with  thick  scales,  and  never 
causes  scarring  or  leads  to  permanent  loss  of  hair.  Rosacea 
is  largely  composed  of  dilated  bloodvessels,  occupies  the 
middle  third  of  the  face,  often  presents  superficial  pustules, 
does  not  leave  scars,  and  is  subject  to  frequent  exacerba- 
tions. In  syphilis  a  history  of  other  lesions  will  be  attain- 
able, there  will  be  more  evident  infiltration,  and  the  course 
of  the  lesions  will  be  more  rapid.  The  disseminate  form  of 
the  disease  would  be  very  difficult  of  diagnosis  at  first,  but 
as  soon  as  characteristic  patches  form,  the  difficulty  would 
be  removed. 

When  lupus  erythematosus  occurs  upon  the  scalp  it 
causes  a  bald  spot  that  may  be  mistaken  for  alopecia  areata, 
but  differs  from  it  in  its  irregular  shape,  in  the  signs  of 
inflammation  in  it,  and  in  the  cicatricial  condition  of  the 
scalp  it  leaves.  A  microscopical  examination  of  the  hairs 
from  about  a  patch  will  decide  as  between  lupus  erythema- 
tosus wndifavus  or  ringworm. 

Treatment.  Little  beyond  the  care  of  the  general  con- 
dition of  the  patient  upon  general  principles  can  be  done 
for  lupus  erythematosus  in  the  way  of  internal  medication. 
McCall  Anderson  advocates  the  use  of  iodide  of  starch, 
made  by  triturating  twenty-four  grains  of  iodine  with  a  little 
water,  and  gradually  adding  one  ounce  of  starch,  rubbing 
them  well  together  until  a  deep-blue  color  of  the  mass  is 
struck.  Of  this  a  heaped  teaspoonful,  increased  gradually, 
may  be  given  three  times  a  day  in  water  or  gruel.  Iodide 
of  potassium  is  also  commended,  as  is  phosphorus. 

Our  main  reliance  is  upon  external  treatment.  Some- 
times in  the  early  stages  alkaline  washes,  such  as  lotions  of 
zinc  or  lead,  may  be  used.     Or  one  composed  of — 

R  •  Zinci  sulpliatis,  )  -  -      _  • 

ti,  )  "     3i; 


Potassii  sulphureti 

Alcohol.,  3  iij  ;         10 

Aqua?  rosae,  ad     %  iv ;       100 


M. 


as  in  acne  and  rosacea.  Green  soap  or  prepared  olive  soap, 
or  its  tincture  may  be  used  in  more  chronic  cases.  This  is 
often  serviceable  for  the  disease,  as  it  attacks  the  eyelids. 
The  affected  parts  are  to  be  well  rubbed  with  it,  using  a  piece 


308 


DISEASES    OF    THE    SKIN. 


of  flannel.  The  process  is  to  be  repeated  every  few  days. 
If  the  reaction  is  too  great,  a  little  oil  or  a  glycerin  lotion 
may  be  applied.  Crocker  advocates  the  addition  of  one 
or  two  drachms  of  the  oil  of  cade  to  the  ounce  of  the 
tincture  of  the  soap.  Carbolic  acid,  pure,  applied  to  the 
patches,  often  acts  admirably.  It  turns  them  white  at  first. 
The  application  is  to  be  repeated  as  soon  as  the  crust 
falls.  Fowler's  solution  applied  externally  is  sometimes 
efficacious,  but  painful.  Pyrogallic  acid,  10  per  cent,  in 
ointment,  sometimes  does  well ;  as  also  chloracetic  acid ; 
oil  of  cade ;  solution  of  naphthol,  1  per  cent. ;  resorcin  3 
to  10  per  cent,  strength  in  solution  or  ointment  ;  tincture  of 
iodine  or  iodide  of  glycerin  ;  caustic  potash,  one  part  to  six 
or  twelve  of  water.  Hydronaphthol  plaster  and  resorcin  plas- 
ters of  10  to  20  per  cent,  strength,  and  mercurial  plaster, 
are  often  excellent  when  persisted  in.  Sulphur  or  ichthyol 
in  ointment  or  paste  do  well  in  some  cases.  All  cases  should 
be  carefully  watched  that  the  reaction  from  our  remedies 
does  not  go  too  far.  If  these  superficial  caustics  do  not 
cure,  resort  may  be  had  to  linear  scarifications,  making  a 
series  of  cross-hatchings,  taking  care  not  to  go  very  deep 
(Fig.  31).     The  bleeding  is  to  be  checked  by  pressure  and 


Fig.  31. 


Scarify  ing-knife. 

the  application  of  carbolic  acid,  two  drachms  to  the  ounce. 
Limited  surfaces  must  be  taken  at  a  time.  Electrolysis  by 
means  of  multiple  punctures  will  sometimes  give  brilliant 
results.  Sometimes  running  the  needle  across  the  patch, 
making  a  number  of  parallel  insertions,  will  have  a  good 
effect.  Ecrasion  with  the  curette,  the  galvano  or  Paquelin 
cautery,  and  strong  escharotics,  such  as  the  acid  nitrate  of 
mercury,  may  have  to  be  used  in  very  obstinate  cases,  but 
not  till  all  other  means  are  exhausted,  as  they  are  apt  to 
leave  deep  scars. 

Prognosis.     The  prognosis  should  be  guarded,   as  the 


LUPUS    VULGARIS.  309 

disease  is  a  most  obstinate  one  and  prone  to  relapses.  A 
cure  may,  however,  be  effected  by  patient  perseverance.  It 
is  wise  always  to  tell  our  patients  that  scars  are  liable  to  be 
left,  not  only  by  the  treatment  employed,  but  by  the  disease 
itself.  The  discoid  form  has  little  effect  upon  the  health  of 
the  patient,  but  the  disseminated  variety  not  infrequently 
ends  fatally. 

Lupus  Exedens.     See  Lupus  vulgaris. 

Lupus  Exfoliativus.     See  Lupus  vulgaris. 

Lupus  Exulcerans.     See  Lupus  vulgaris. 

Lupus  Hypertrophicus.     See  Lupus  vulgaris. 

Lupus  Sclereux.     See  Tuberculosis  verrucosa  cutis. 

Lupus  Sebaceus.     See  Lupus  erythematosus. 

Lupus  Superficialis.     See  Lupus  erythematosus. 

Lupus  Tuberculosus.     See  Lupus  vulgaris. 

Lupus  Verrucosus.     See  Lupus  vulgaris. 

Lupus  Vorax.     See  Lupus  vulgaris. 

Lupus  Vulgaris  (L.  Vu3l-ga-ri2s).  Synonyms  :  Besides 
those  given  above,  which  merely  describe  certain  stages  or 
forms  of  the  disease  and  are  quite  unnecessary  to  be  re- 
membered, we  have :  Noli  me  tangere  ;  Herpes  esthiomenos ; 
(Fr.)  Dartre  rongeante,  Scrofulide  tuberculeuse,  Esthio- 
mene  ;  (Ger.)  Fressende  Flechte. 

This  is  a  chronic  neoplastic  disease  of  the  skin  probably 
due  to  its  invasion  by  the  tubercle  bacillus,  and  character- 
ized by  one  or  more  brownish-red  papules,  tubercles,  or  in- 
filtrated patches,  that  tend  either  to  absorption  or  ulceration, 
and  always  leave  scars. 

Symptoms.  Lupus  vulgaris  usually  begins  in  childhood 
and  upon  the  face  ;  the  cheek  and  nose  being  the  parts  most 
usually  affected.  The  initial  lesion  is  a  dark-red  or  brown 
pinpoint  to  pinhead-  sized  papule,  which  may  be  on  a 
level  with  the  skin,  depressed  below,  or  raised  above  it. 
There  may  be  but  a  single  lesion,  but  more  usually  there 
are  a  few  of  them  either  grouped  or  scattered.  After  a 
time  slightly  scaly  patches  will  form  by  the  coalescence  of 
the  lesions  which  have  enlarged,  into  brownish-red,  semi- 


310  DISEASES    OF    THE    SKIN. 

translucent,  smooth,  shiny  tubercles,  or  by  the  development 
of  new  lesions  between  the  old  ones.  The  size  of  the  patches 
varies  greatly,  but  they  are  always  elevated  above  the  sur- 
face of  the  skin,  of  a  dark-red  color,  and  studded  with  the 
little  brownish-red  papules,  or  so-called  tubercles.  The 
appearance  of  these  tubercles  has  been  likened  by  Hutchin- 
son to  that  of  apple-jelly.  There  may  be  but  one  patch,  or 
the  whole  face  may  be  more  or  less  covered  with  a  number 
of  them.  Symmetry  is  not  a  feature  of  the  disease,  often 
only  one  side  of  the  face  being  affected.  Sometimes  two  or 
more  patches  will  coalesce  at  their  borders,  their  centres  will 
fade  out,  or  rather  become  atrophic,  and  we  will  have  a 
gyrate  patch  creeping  over  the  skin  with  a  well-marked, 
elevated,  red  border.  The  centre  of  all  the  patches  is  lower 
than  the  border,  and  eventually  is  atrophic.  The  course  of 
the  disease  is  slow  and  chronic,  and  the  fate  of  the  patches 
varies  greatly.  For  months  or  years  they  may  remain 
absolutely  quiet,  and  then  show  signs  of  activity  by  new 
lesions  appearing  about  the  edges  of  the  patches  or  in  the 
scar  tissue.  The  patches  may  entirely  disappear,  leaving 
a  fine,  smooth  cicatrix ;  this  is  rare  without  treatment. 
Or  they  may  break  down  and  form  ulcers  which  are  irregu- 
larly rounded  in  shape,  shallow,  with  easily  bleeding  floors, 
and  a  moderate  amount  of  purulent  secretion  that  dries  into 
a  crust.  This  is  the  so-called  lupus  exulcerans  and  is  not 
very  frequent  in  this  country  according  to  my  experience. 
Sometimes  upon  this  ulcerated  surface  papillary  or  warty 
growths  will  spring  up,  the  so-called  lupus  papillomatosus 
or  verrucosus.  Sometimes  the  infiltration  of  the  patch  is 
unusually  great,  and  then  we  have  lupus  hypertrophicus. 
Most  commonly  we  have  a  non-ulcerated,  exceedingly  chronic 
infiltrated  patch  with  areas  of  cicatricial  tissue  scattered 
through  it.  When  the  disease  attacks  the  end  of  the  nose 
it  will  cause  it  to  shrink  up  and  convert  it  into  cicatricial 
tissue.  When  the  ear  is  diseased  it  also  shrinks  up  so  as  to 
be  half  the  size  it  was  originally.  These  changes  are 
due  either  to  ulceration  or  to  the  gradual  absorption  of  the 
lupus  tubercles  that  they  all  undergo. 

While  the  face  is  the  site  of  predilection  of  lupus,  it  may 


LUPUS    VULGARIS.  311 

also  occur  upon  any  part  of  the  skin  of  the  body,  as  well 
as  upon  the  mucous  membranes.  In  this  latter  situation  it 
is  most  often  secondary  to  the  disease  elsewhere,  still  it  is 
often  primary.  Thus  Bender1  found  that  30^  per  cent,  of 
all  his  lupus  cases  began  in  the  nasal  mucous  membrane. 
Pontoppidan  also  found  the  origin  of  the  disease  to  be  the 
nasal  mucous  membrane  in  many  cases.  In  the  nose  it 
frequently  leads  to  perforation  of  the  septum  and  sometimes 
great  deformity  of  the  nose,  but  it  does  not  attack  the 
bones.  All  other  mucous  membranes  may  be  attacked ;  the 
rectum  and  vagina  being  least  often  affected.  The  con- 
junct va3  may  be  involved  primarily  or  secondarily.  Epi- 
thelial cancer  has  developed  in  very  rare  instances  upon  the 
lupoid  tissue  itself,  more  commonly  upon  the  scar  tissue  left 
by  the  lupus.  Whenever  it  develops  as  a  sequela  of  lupus 
its  course  is  much  more  rapid  and  its  prognosis  far  more 
grave  than  is  usually  the  case.  Erysipelas  is  a  not  infre- 
quent complication  of  lupus,  and  is  sometimes  curative  in 
its  action.  Lupus  of  the  extremities  is  often  followed  by 
permanent  deformities  and  disabilities,  and  sometimes  by 
tubercular  lymphangitis.  Implication  of  the  lymphatic 
glands  is  exceptional  in  lupus,  and  then  only  in  advanced 
cases. 

Etiology.  Lupus  has  long  been  regarded  as  a  manifes- 
tation of  scrofula.  It  is  now  pretty  well  demonstrated  that 
it  is  a  tubercular  disease.  It  should  be  placed  under  the 
division  of  tuberculosis  cutis,  but  usage  makes  it  advisable  to 
consider  it  by  itself.  Many  patients  with  lupus  are  plainly 
strumous  ;  many,  55  j9^-  per  cent,  of  SachV  cases,  are  either 
tuberculous  themselves  or  have  a  decided  history  of  the 
occurrence  of  phthisis  in  their  family.  The  phthisical  his- 
tory is  far  less  pronounced  in  this  country  than  it  is  in 
Europe.  It  is  no  uncommon  thing  for  several  members  of 
the  same  family  to  have  lupus.  It  is  probable  that  we 
could  find  a  close  connection  between  lupus  and  infection 
with  the  tuberculous  virus  in  all  cases,  were  it  practicable 
to    do    so.     Another   evidence  of  its    tubercular  origin  is 

1  Yierteljahr.  f.  Derm,  mid  Syph.,  1888,  xv.  891. 

2  Ibid.,  1888,  xiii.  241. 


312  DISEASES    OF    THE    SKIN. 

found  in  the  nearly  uniform  reaction  of  lupus  to  tuberculin. 
Beyond  this  it  is  not  necessary  to  search  for  a  cause.  It 
is  much  more  frequent  in  females  than  in  males,  about  62 
per  cent,  being  in  females  according  to  Block's  and  Sach's 
statistics.  It  begins  in  more  than  half  the  cases  before  the 
fifteenth  year.  It  may  begin  as  early  as  the  second  year. 
It  is  almost  always  a  disease  of  youth. 

Pathology.  The  pathology  of  lupus  has  been  studied 
by  many  competent  investigators.  As  their  results  do  not 
altogether  agree,  this  is  no  place  to  discuss  them.  "  It  is  a 
neoplasm  of  the  granuloma  class,  and  consists  of  a  small 
cell  infiltration  which  begins  in  the  deep  part  of  the  corium, 
and  from  thence  gradually  invades  all  the  other  skin  struc- 
tures," says  Crocker.  The  tubercle  bacillus  is  found  in  the 
tissues,  though  but  sparsely.  Inoculations  have  not  always 
been  successful,  but  in  a  goodly  number  of  cases  the  inocu- 
lations have  been  followed  by  general  tuberculosis,  so  as  to 
warrant  our  belief  in  the  tubercular  nature  of  the  disease. 
It-  has  been  suggested  that  as  the  bacilli  are  present  in  but 
a  small  number,  the  irritation  of  the  tissues  is  due  to  the 
ieucomaines  produced  by  them. 

Diagnosis.  Lupus  is  most  commonly  confounded  with  a 
tubercular  or  gummous  syphilide.  It  may  have  to  be  dif- 
ferentiated sometimes  from  a  scrofuloderm  originating  in  a 
caseous  gland,  from  an  epithelioma,  lupus  erythematosus,  and 
possibly  lepra.  From  syphilis  it  is  diagnosticated  by  the  pres- 
ence of  the  characteristic  apple-jelly  tubercles ;  by  its  slow 
course ;  by  its  history ;  by  the  absence  of  all  other  signs  of 
syphilis  ;  by  its  little  tendency  to  ulceration  ;  by  the  super- 
ficial character  of  its  ulcers  and  their  slight  crusting ;  and 
by  its  sparing  the  bones.  If  there  is  still  any  doubt,  appeal 
may  be  made  to  the  effect  of  treatment  by  means  of  the 
iodide  of  potassium  and  mercury,  which  will  have  no  effect 
upon  the  lupus.  As  the  scrofuloderm  is  another  manifesta- 
tion of  the  tubercular  diathesis  and  amenable  to  the  same 
treatment  as  that  of  lupus,  its  differentiation  is  not  so  im- 
portant. It,  however,  will  begin  about  a  caseous  and  broken- 
down  lymphatic  gland,  will  probably  have  sinuses,  and  no% 
characteristic   tubercles.      An    epithelioma   begins    usually 


LUPUS    VULGARIS*  313 

after  the  thirty-fifth  year ;  has  no  tubercles  ;  and  forms  a 
deep  ulcer  with  raised,  hard,  waxy  edges  crossed  with 
dilated  bloodvessels.  The  diagnosis  from  lupus  erythema- 
tosus is  given  in  the  preceding  section.  Leprosy  presents 
large  tubercles  which  are  anaesthetic,  and  this  at  once 
decides  in  its  favor. 

Treatment.  As  lupus  is  a  tubercular  disease,  and  some- 
times is  followed  by  tuberculosis  of  the  lungs,  care  must  be 
given  to  the  general  health  of  the  patient,  and  he  must  be 
placed  in  the  best  possible  hygienic  surroundings.  His  diet 
should  be  nutritious,  and  cod-liver  oil,  iodine,  and  iron 
should  be  given.  But  external  treatment  is  of  the  greatest 
importance,  and  the  disease  must  be  gotten  rid  of  root  and 
branch.  If  a  single  diseased  cell  remains,  the  disease  is 
sure  to  return.  To  effect  its  destruction  surgical  procedures 
had  best  be  resorted  to.  The  whole  patch  or  patches  may 
be  scraped  out  with  the  dermal  curette,  and  this  followed  by 
a  25  or  30  per  cent,  pyrogallol  ointment  for  a  week  or  ten 
days,  and  that  in  turn  by  the  mercurial  plaster  for  another 
equal  term.  The  pyrogallol  will  cause  free  suppuration  and 
destroy  the  cells  left  behind  by  the  curette.  A  second  or 
third  course  may  be  necessary.  Piffard  prefers  to  touch  the 
base  left  after  curetting  with  the  galvano-cautery  at  a  red 
heat.  The  wound  is  then  to  be  packed  with  absorbent 
cotton.  After  about  ten  to  fourteen  days  the  crust  and 
cotton  will  fall  off  and  leave  a  soft,  smooth,  pliable  cicatrix. 
Multiple  scarifications  have  proved  of  great  use.  They  may 
be  made  with  many-bladed  instruments  constructed  for  the 
purpose,  or  with  a  scalpel,  or  a  knife  shaped  like  a  butcher's 

Fig.  32. 


Scarify  ing-kuife. 

cleaver  (Fig.  32).  They  must  go  deep  enough  to  pene- 
trate all  the  softened  tissue  but  not  to  wTound  the  sound 
parts.     The  resistance   offered  by  the  healthy  tissues  will 

14 


314  DISEASES    OF    THE    SKIN. 

be  sufficient  guide  for  this.     The  scarifications  should  be  so 
made  as  to  divide  the  tissues  into  little  squares,  thus : 


They  may  be  repeated  in  five  or  six  days,  and  need  no  after- 
treatment.  This  is  Vidal's  method.  The  individual  tuber- 
cles may  be  bored  out  with  Morris's  double- screw  instru- 
ment, or  with  dental  burrs  and  hooks  as  proposed  by  Dr. 
George  H.  Fox.  Pure  carbolic  acid  may  be  introduced 
into  the  little  holes  so  left  to  further  insure  the  destruction  of 
the  disease.  The  galvano  or  Paquelin  cautery  may  be 
employed  to  destroy  the  disease.  This  will  require  the 
administration  of  an  anaesthetic,  while  the  former  procedures 
do  not  require  it,  or  at  most  anything  more  than  local 
anaesthesia  by  means  of  cocaine.  Multiple  punctures  by 
means  of  the  galvano-  or  thermo-cautery  at  sombre  red  heat 
at  1  mm.  distance  for  small  patches,  and  linear  scarifications 
with  cautery  knife  for  large  ones,  followed  by  emplast. 
vigo,  and  repeated  once  a  week,  is  Besnier's  method.  Elec- 
trolysis in  multiple  punctures  or  by  passing  the  needle 
through  the  patch,  or  by  means  of  a  flat  metallic  button,  is 
a  useful  mode  of  treatment.  The  current  must  be  3  to  5 
milliamperes,  and  it  must  be  continued  for  five  minutes  when 
the  button  is  used.  Auspitz  recommends  puncturing  the 
patches  in  many  places  with  a  steel  point  dipped  in  carbolic 
acid.     Small  patches  may  be  excised. 

These  surgical  procedures  have  largely  superseded  the 
use  of  caustics,  though  the  latter  are  valuable  and  may  be 
used  where  the  patient  fears  an  operation.  Arsenic  may  be 
employed  in  the  form  of  a  paste  such  as  Hebra's  modifica- 
tion of  Cosme's  Paste : 

R .  Ac.  arsenios.,  gr.  x ;         2 

Hydrarg.  sulphureti  rubri,  3  j  ;  12  50 

Ungt.  aq.  rosse,  ^j ;        100  M. 

which  is  to  be  spread  on  lint  or  linen,  applied  evenly,  and 
bound  down  firmly.  It  is  to  be  left  on  for  twenty-four 
hours,  then  removed  and  reapplied  till  ulceration  is  set  up. 


LYMPHANGIECTASIS.  315 

It  is  painful.  Vienna  paste,  of  equal  parts  of  cautic  potash 
and  unslacked  lime;  or  a  chloride  of  zinc  paste  may  be 
used,  such  as  1  part  of  zinc  to  3  parts  of  starch.  Both  are 
painful.  Many  think  highly  of  boring  into  the  patch  with 
the  solid  nitrate  of  silver  stick.  Salicylic  acid,  10  to  20  per 
cent,  in  plaster  or  plaster  muslin  changed  once  or  twice  a 
day,  is  good.  It  is  well  to  combine  creasote  with  the 
salicylic  acid  in  equal  parts  to  allay  the  pain  caused  by  the 
acid.  The  local  application  of  bichloride  of  mercury  in 
solution  (gr.  j  to  oj)  to  ulcerated  forms,  and  in  ointment 
to  non-ulcerated  forms,  is  commended  by  White  and  others. 
Unna1  recommends  painting  with  pure  carbolic  acid 
for  from  two  to  four  days.  He  has  also  had  good 
results  with  a  salve  muslin  containing  1  per  cent,  of 
bichloride  of  mercury,  20  per  cent,  of  carbolic  acid,  and  36 
per  cent,  of  oxide  of  zinc.  Tuberculin  has  not  proved  as 
valuable  as  it  promised.  Only  very  few  cases  have  been 
reported  as  cured.  The  inconvenience,  depression,  and 
sometimes  fatal  results  from  the  remedy  render  it  an  unfit 
one  for  use. 

Prognosis.  The  prognosis  should  always  be  guarded. 
Relapses  after  any  plan  are  too  often  seen.  A  scar  must 
result  both  from  the  disease  and  its  treatment.  The  possi- 
bility of  the  development  of  a  general  tuberculosis  must  also 
be  borne  in  mind,  although  most  patients  preserve  through- 
out the  course  of  the  disease  a  robust  state  of  health. 

Lupus  Miliaris  or  Lupoid  or  Adenoid  Acne  is  a  rare 
disease  of  the  skin  that  occurs  upon  the  cheeks  in  the 
form  of  discrete,  pinhead-sized,  deep-red,  slightly  raised 
papules,  which  do  not  tend  to  suppurate.  Sometimes  the 
papules  will  disappear,  leaving  a  pit  behind.  The  papules 
must  be  treated  by  very  much  the  same  remedies  as  are 
useful  in  lupus,  such  as  by  salicylic  acid  plaster,  or  acid 

nitrate  of  mercurv. 

«/ 

Lymphadenoma.     See  Mycosis  fungoide. 
Lymphangiectasia   (Li2mf-a2n-ji2-e2krta3-si2s).     Varices  of 
the  dermal  lymphatics  may  be  superficial,  or  deep  ;  and  affect 

1  Monatshefte  f.  prakt.  Derm.,  1891,  xii.  341. 


316  .  DISEASES   OF    THE    SKIN". 

the  trunk,  the  meshes,  or  the  lacunse,  though  most  com- 
monly all  parts  of  the  vessels  are  diseased.  When  they  are 
superficial  they  form  ampullary  swellings  at  the  surface  of 
the  skin,  which  may  be  isolated  or  agglomerated.  In  size 
they  vary  from  the  size  of  a  millet-seed  to  that  of  a  pea,  or 
larger.  In  color  they  vary  with  that  of  the  skin.  They 
break  more  or  less  easily  and  discharge  the  lymphatic  fluid. 
If  deep  they  can  be  more  readily  felt  than  seen,  or  form 
upon  the  surface  of  the  skin  isolated  or  associated  raised 
cords  which  run  a  more  or  less  tortuous  course.  After  a 
time  these  also  break  and  discharge  lymph. 

Hallopeau  and  Goupil1  describe  under  this  title  a  disease 
that  they  believe  to  be  of  tubercular  origin,  and  that  appears 
about  a  bony  prominence  of  the  extremities  as  a  diffuse 
tumefaction,  or  a  cushion-like  elevation  resembling  varicose 
vein  tumors.  They  eventually  open  and  discharge  pure 
lymph,  or  lymph  mixed  with  pus.  Fresh  tumors  arise  in 
the  course  of  the  lymphatics  in  an  ascending  series :  also 
gummy  nodes.  The  affected  limb  is  swollen,  indurated,  and 
of  more  or  less  sombre  red.  The  prognosis  is  grave,  and 
the  proper  treatment  undetermined. 

Lymphangioma  (Li2mf-a2n-ji2-o'ma3),  also  called  Lymph- 
angiectasis,  Lymphangiectodes,  Lupus  Lymphaticus,  and 
Lymphorrhagica  Pachydermia,  is  an  exceedingly  rare 
disease.  It  consists,  according  to  Crocker,  in  a  number  of 
minute,  deep-seated  vesicles,  closely  crowded  together  in 
irregularly  outlined  groups  of  from  one-third  to  one-quarter 
of  an  inch  in  size.  These  groups  are  arranged  irregularly 
with  healthy  skin  between  them,  or  a  few  scattered  vesicles 
in  the  otherwise  healthy  skin.  They  are  usually  confined 
to  a  single  small  area.  The  vesicles  are  deep-seated  with 
thick  walls,  some  of  them  almost  warty-looking.  They  are 
pinpoint  to  hempseed-size,  colorless  or  straw-colored,  or 
pinkish,  and  contain  a  clear  fluid.  Some  have  vascular 
strise  or  tufts  over  them,  others  red  clots,  others  contain  ex- 
travasated  blood. 

They  run  a  chronic,  non-inflammatory  course,  spreading 

1  Ann.  Derm,  et  Syph.,  1890,  i.  957. 


MELASMA.  317 

slowly  at  the  periphery,  and  tending  to  relapse  if  removed. 
Most  of  the  few  cases  have  occurred  in  males  and  began  in 
early  childhood. 

The  disease  is  of  lymphatic  origin,  and  the  main  feature 
is  dilated  lymphatic  vessels. 

The  treatment  consists  in  destruction  by  caustics,  excision, 
or  electrolysis,  but  relapses  are  liable  to  occur. 

A  number  of  other  rare  affections  of  the  lymphatics  have 
been  named  lymphangioma.  The  present  state  of  our 
knowledge  in  regard  to  them  is  by  no  means  exact.  One 
variety  is  named  by  Kaposi 

Lymphangioma  Tuberosum  Multiplex.  This  is  a  still 
more  rare  disease  than  lymphangioma,  and  consisted,  in 
Kaposi's  case,  in  the  appearance  all  over  the  trunk  and  neck 
of  hundreds  of  lentil-sized,  rounded,  brownish-red,  smooth, 
glistening,  disseminated,  flat,  or  elevated  tubercles.  They 
were  firm  and  elastic,  slightly  painful,  and  upon  some  of 
them  were  dilated  bloodvessels.  One  or  two  other  cases  of 
the  same  kind  have  been  reported  by  others. 

Lymphoderma  Perniciosa.     See  Mycosis  fungoides. 

Lymphosarcoma.     See  Sarcoma. 

Maculae  et  Striae  Atrophicae.  See  Atrophoderma  stria- 
tum et  maculacum. 

Maculae  Caeruleae.     See  Pediculosis  corporis. 

Madura  Foot.     See  Fungous  Foot  of  India. 

Madesis  or  Maderosis  is  an  obsolete  term  for  thinning  of 
the  hair. 

Mai  de  la  Rosa.     See  Pellagra. 

Mai  Rosso.     See  Pellagra. 

Maladie  des  Vagabonds.     See  Pediculosis. 

Malignant  Papillary  Dermatitis.     See  Paget's  Disease. 

Malignant  Pustule.     See  Pustula  maligna. 

Masque  de  la  Grossesse.     See  Chloasma. 

Medicinal  Eruptions.     See  Dermatitis  medicamentosa. 

Melanoderma.     See  Chloasma. 

Melasma.     See  Chloasma. 


318  DISEASES    OF    THE    SKIN. 

Melanosarcoma.     See  Sarcoma. 

Melanosis  Lenticularis  Progressiva.  See  Atrophoderma 
pigmentosum. 

Melitagra.     See  Pustular  eczema. 

Mentagra.     See  Sycosis. 

Microsporon  furfur  is  the  parasite  of  chromophytosis, 
which  see. 

Miliaria  (Mi2l-i2-a'ri2-a3).  Synonyms :  Sudamina ; 
Lichen  tropicus  ;  (Ger.)  Frieselauschlag  ;  Prickly  heat. 

This  is  a  disease  of  the  sweat  glands  due  to  excessive 
sweating,  which  may  or  may  not  be  inflammatory,  and  is 
characterized  by  an  eruption  of  discrete  papules,  vesicles, 
or  pustules.  Several  varieties  are  described,  but  it  is 
enough  to  distinguish  two  forms,  namely,  sudamina,  and 
lichen  tropicus. 

Symptoms.  Sudamina,  also  called  miliaria  crystallina, 
is  the  form  that  is  met  with  during  the  course  of  febrile 
diseases,  and  occurs  as  an  eruption  of  an  immense  number 
of  small,  closely  crowded,  but  discrete,  bright,  pearly  vesi- 
cles entirely  without  inflammation  or  subjective  symptoms. 
They  are  most  abundant  on  the  trunk,  especially  upon  its 
anterior  plane,  but  may  occur  anywhere.  After  lasting  a 
few  days  they  are  absorbed  and  disappear  by  drying  up, 
possibly  with  some  scaling. 

Lichen  tropicus  is  very  commonly  seen  in  this  country 
during  warm  weather.  It  may  consist  in  an  eruption  of 
pinpoint,  bright-red  papules  (miliaria  papulosa) ;  or  of  very 
small  vesicles  upon  an  inflamed  skin  (miliaria  rubra)  ;  or  the 
eruption  may  be  a  composite  one  of  papules  interspersed 
with  vesicles  and  pustules.  Whichever  form  it  may  assume 
the  lesions  are  present  in  great  number,  and  closely  crowded 
together,  though  not  aggregated.  It  may  involve  the  whole 
surface,  but  is  most  common  on  covered  parts,  and  specially 
upon  the  trunk.  The  eruption  is  apt  to  become  better  or 
worse  according  to  the  changes  in  the  temperature  of  the 
atmosphere.  The  disease  may  last  in  this  way  throughout 
the  warm  weather.  It  is  no  uncommon  thing  for  furuncles 
to  form,  and  even  cutaneous  abscesses.     Itching,  prickling, 


MILIUM.  319 

and  burning  are  always  annoying  accompaniments.  If  the 
skin  is  much  scratched,  eczema  may  complicate  the  disease. 
The  old  nurse's  "  red  gum,"  the  strophulus  of  older  writers, 
is  a  miliaria.     Kaposi  regards  the  disease  as  an  eczema. 

Etiology.  The  cause  of  sudamina  is  retained  sweat, 
owing,  probably,  to  epithelium  clogging  up  the  sweat  pores 
when  sweating  is  stopped  on  account  of  the  fever.  Lichen 
tropicus  is  due  to  congestion  about  the  sweat  pores  and  irri- 
tion  of  the  skin  when  profuse  sweating  is  induced  by  too 
wrarm  clothing  and  hot  weather.  It  is  also  suggested  that 
checking  a  profuse  sweat  may  cause  it.  It  is  seen  most 
commonly  in  babies  and  fat  people.  It  is  noticeable  in  this 
city  (New  York)  that  the  children  who  live  near  the  river- 
front and  are  a  good  deal  in  the  salt  water  escape  the  dis- 
ease, while  it  is  very  common  in  the  rest  of  the  tenement- 
house  population. 

Diagnosis.  Sudamina  differs  from  vesicular  eczema  by 
its  sudden  occurrence  during  a  febrile  process ;  by  being 
non-inflammatory ;  by  its  vesicles  not  breaking  down  ;  and 
by  not  itching.  Lichen  tropicus  differs  from  eczema  by  the 
minuteness  of  its  papules ;  by  its  sudden  appearance ;  by 
not  forming  patches  which  are  moist ;  by  having  a  high 
atmospheric  temperature  as  an  evident  etiological  factor, 
and  by  the  tingling  rather  than  the  itching  of  the  eruption. 

Tkeatment.  Sudamina  needs  no  treatment,  as  with  the 
subsidence  of  the  fever  it  gets  well  of  itself.  Lichen  tropi- 
cus requires  attention  to  the  diet,  cutting  off  the  meat  in 
children,  and  lessening  its  amount  in  adults.  Cooling 
drinks,  and  the  administration  of  gentle  saline  laxatives  are 
also  advisable.  Locally,  bathing  in  salt  water  or  alkaline 
lotions,  and  subsequent  powdering  of  the  skin,  conjoined 
wTith  wearing  light  clothing,  and  not  using  too  warm  bed- 
covers, will  relieve  and  ofttimes  cure  the  trouble. 

Miliary  Fever,  or  the  sweating  sickness,  is  an  epidemic 
disease  accompanied  by  profuse  sweating  and  miliaria.  The 
epidemics  have  occurred  most  often  in  France. 

Milium  (Mi2l-i2-u3my  Synonyms  :  Grutum  ;  Strophulus 
albidus ;  Acne  albida  ;  Tuberculum  sebaceum, 


320  DISEASES    OF    THE    SKIN. 

Symptoms.  These  are  small  pinhead  to  split-pea  sized, 
firm,  whitish  or  yellowish,  slightly  elevated  papules  that 
occur  usually  upon  the  face.  They  are  spherical  in  shape, 
and  slowly  increase  in  size  up  to  a  certain  point,  when  they 
remain  stationary.  They  give  rise  to  no  subjective  sensa- 
tion. While  their  most  common  site  is  the  face  below  the 
eyes,  they  may  occur  anywhere  on  the  face ;  and  also  upon 
the  penis  and  scrotum.  In  this  latter  situation  they  are 
more  decidedly  yellow  in  color,  flat,  and  often  attain  the 
size  of  a  small  bean.  Along  the  corona  glandis  they  are 
sometimes  very  thickly  strewn.  On  the  genitals  of  women 
their  most  frequent  site  is  the  labia  minora.  There  may  be 
but  one  or  two,  or  a  score  of  them.  Occurring  in  the  eye- 
lids they  are  called  chalazion.  When  they  undergo  calca- 
reous degeneration  (an  infrequent  occurrence),  they  form 
mtaneous  calculi.  Comedones  are  often  present  at  the  same 
time  with  milia.     Any  part  of  the  body  may  be  affected. 

Etiology.  Milia  occur  chiefly  in  infants  and  young 
adults,  and  sometimes  follow  other  diseases  of  the  skin,  such 
as  pemphigus,  erysipelas,  or  those  in  which  destructive  pro- 
cesses have  taken  place  and  cicatrices  formed.  They  are 
often  congenital. 

Pathology.  They  are  supposed  to  be  due  to  retained 
secretion  on  account  of  the  upper  layers  of  the  stratum  cor- 
neum  growing  over  the  openings  of  the  sebaceous  glands, 
or  to  a  non- development  of  the  glands.  Robinson  thinks 
that  some  of  them  are  due  to  "  miscarried  embryonic  epi- 
thelium from  a  hair  follicle  or  from  the  rete,"  while  those 
"  following  pemphigus,  erysipelas,  syphilis,  and  lupus  con- 
sist of  fatty  epithelium  and  cholesterine,  the  epithelium 
being  often  arranged  in  concentric  layers  around  a  central 
fat  nucleus." 

Treatment.  The  treatment  consists  in  pricking  the  top 
of  the  papule  and  pressing  out  its  contents.  To  make  sure 
of  the  destruction  of  the  growth  a  drop  of  carbolic  acid  or 
iodine  may  be  introduced  into  the  cavity  remaining.  Hard- 
away  advocates  electrolysis  as  being  the  speediest  and  best 
treatment. 

Mitesser.     See  Comedo, 


MOLLUSCUM    CONTAGIOSUM. 


321 


Mole.     See  Nsevus. 

Molluscum  Cholesterique.     See  Xanthoma. 

Molluscum  Contagiosum  (Mo'^-lu^k'uSm  ko2n-ta-ji2-osr- 
u3m).  Synonyms :  Molluscum  epitheliale,  seu  sebaceum, 
seu  verrucosum,  seu  sessile ;  Epithelioma  contagiosum ; 
(Fr.)  Acne  varioliforme,  Ecdermoptosis. 

Fig.  33. 


I Hi   Are 


Molluscum.     (After  Allen.) 

Symptoms.  This  is  a  contagious  disease  of  the  skin 
that  occurs  in  most  cases  upon  the  face  and  in  children,  and 
is  characterized  by  the  appearance  of  one  or  more  rounded 
pearly  white  or  pinkish  discrete  tumors,  varying  in  size  from 
a  pinhead  to  large  pea  (Fig.  33).     These  tumors  are  waxy 


322  DISEASES    OF    THE    SKIN. 

or  opaque,  and  on  top  are  slightly  flattened,  and  show  an 
umbilication  or  small  depression,  out  of  which  the  soft  cheesy 
contents  of  the  tumors  can  be  squeezed.  These  tumors  are 
at  first  very  small,  but  gradually  grow  until  they  attain  a  cer- 
tain size,  when  they  may  remain  unchanged  for  an  indefinite 
period,  or  they  may  become  inflamed,  break  down  of  them- 
selves, discharge  their  contents,  and  disappear  either  with- 
out leaving  any  trace  or  with  a  very  slight  scar.  There  are 
not  infrequently  scores  of  these  tumors  to  be  found  on  the 
same  subject.  They  are  commonly  sessile,  but  may  become 
more  or  less  pedunculated.  The  genitalia,  breasts,  and 
scalp  are  affected  next  to  the  face  in  point  of  frequency, 
while  the  tumors  may  occur  anywhere  but  on  the  palms  and 
soles. 

Etiology.  Children  are  far  more  often  affected  than 
adults.  If  adults  show  them  it  will  usually  be  found  that 
they  are  in  attendance  upon  children  who  have  the  dis- 
ease. The  bad  hygienic  conditions  under  which  poor  people 
live  seem  to  predispose  to  the  affection,  as  it  is  rare  to 
meet  with  it  among  the  well-to-do.  There  is  little  doubt 
but  that  the  disease  is  contagious.  Though  inoculation  ex- 
periments have  failed  in  most  instances,  still  there  have 
been  a  few  cases  in  which  they  have  been  successful.  In 
the  spring  of  1891  a  child  with  molluscum  contagiosum 
came  into  my  service  in  the  Randall's  Island  Hospital, 
and  within  a  few  weeks,  no  attempt  being  made  to  destroy 
the  tumors,  there  were  six  cases  in  the  wards. 

Pathology.  The  true  pathological  anatomy  of  these 
growths  has  not  been  settled,  but  the  old  idea  that  they 
spring  from  the  sebaceous  glands  is  no  longer  entertained. 
The  rete  seems  to  be  the  starting-point  of  the  disease.  One 
of  the  most  characteristic  features  of  the  disease  is  the 
so-called  "  molluscum  corpuscle,"  wThich  is  but  a  changed 
epithelial  cell  (Fig.  34).  These  appear,  under  the  micro- 
scope, as  large,  ovoid,  lustrous  bodies,  without  nuclei,  some 
being  either  wholly  or  partly  contained  in  an  epidermic 
envelope,  and  some  being  entirely  uncovered.  Several 
parasites  have  been  declared  to  be  the  cause  of  the  disease 
by  different  investigators,   the  latest  candidates  being  the 


MOLLUSCUM    VERKUCOSUM.  323 

psorosperm  of  Darier  in  1889,  and  the  gregarine  of  Neisser 
in  1888.  Torok1  declares  these  to  be  merely  artificial 
products  of  the  methods  used,  and  is  sure  that  the  disease  is 
not  due  to  a  parasite. 

Fig.  34. 


Molluscum  corpuscles.     (After  Kaposi.) 

Diagnosis.  The  appearance  of  the  disease  is  so  charac- 
teristic as  to  be  diagnostic.  It  is  most  apt  to  be  confused 
with  milium,  but  if  it  is  remembered  that  milia  have  no 
central  depression,  while  mollusca  have,  the  confusion  will 
exist  no  longer.  If  they  are  taken  for  the  vesico-pustule  of 
variola,  a  scarcely  probable  occurrence,  pricking  their  tops 
will  at  once  show  that  they  are  not  pustules,  and  if  they  are 
watched  for  a  day  or  so  it  will  be  found  that  they  remain 
unchanged. 

Treatment.  The  speediest  way  of  getting  rid  of  the 
tumors  is  to  scrape  them  off  with  the  curette.  To  insure 
their  not  returning  it  is  advisable  to  touch  the  base  of  each 
tumor  with  a  drop  of  carbolic  acid,  or  a  stronger  acid.  Or 
it  is  sufficient  to  make  a  small  slit  in  the  top  of  the  tumor 
with  a  scalpel,  and  squeeze  out  the  contents,  and  touch  up 
the  base. 

Molluscum  Epitheliale.     See  Molluscum  contagiosum. 

Mulluscum  Fibrosum.     See  Fibroma. 

Molluscum  Pendulum.     See  Fibroma. 

Molluscum  Sebaceum.     See  Molluscum  contagiosum. 

Molluscum  Verrucosum.     See  Molluscum  contagiosum. 

1  Monatshefte  f.  prakt.  Dermat.,  1890,  x,  149. 


324  DISEASES    OF    THE    SKIN. 

Monilethrix.      See  Nodositas  crinium. 

Morbilli  (Mo^b-Wli).     Synonyms  :  Rubeola ;  measles. 

This  is  one  of  the  contagious  exanthemata,  which  is 
characterized  by  marked  catarrhal  symptoms,  such  as  con- 
junctivitis, coryza,  and  bronchial  inflammation  ;  more  or 
less  fever,  and  constitutional  disturbance ;  and  then,  on 
about  the  third  day,  an  eruption  of  small,  red,  flat  papules 
that  rapidly  enlarge,  and  uniting  with  others  form  mulberry- 
colored  little  patches  often  of  a  crescentic  shape,  with  areas 
of  sound  skin  between.  The  eruption  begins  on  the  face 
and  neck,  spreading  downward,  from  which  it  covers  the 
whole  body  in  about  a  day  and  a  half.  The  fever  begins  to 
decrease  on  the  second  day  of  the  eruption.  The  rash 
begins  to  disappear  by  the  third  or  fourth  day,  and  is 
gone  by  the  ninth  day.  Furfuraceous  desquamation  follows 
the  subsidence  of  the  exanthem.  Sometimes  it  is  so  slight 
as  to  be  hardly  noticeable,  and  it  is  never  so  marked  as  in 
scarlatina. 

Diagnosis.  The  only  dermatoses  with  which  measles  is 
apt  to  be  confounded  are  an  erythema,  and  the  macular 
syphilide.  But  the  catarrhal  symptoms ;  the  regular  pro- 
gression of  the  eruption  from  above  downward  ;  and  the 
crescentic  patchy  arrangement  and  dark  color  of  the  lesions 
are  sufficient  to  differentiate  it.  In  erythema  we  may  have 
some  constitutional  disturbance,  but  it  is  of  short  duration  ; 
the  eruption  is  more  pronounced  on  the  trunk  and  extremi- 
ties, and  shows  no  order  of  progression  ;  the  color  of  the 
eruption  is  a  brighter  red  ;  there  is  an  absence  of  crescentic 
arrangement ;  and  very  often  an  accompanying  urethritis 
will  suggest  the  ingestion  of  some  of  the  balsams  as  a  cause 
of  the  trouble.  The  erythematous  syphilide  affects  the  sides 
of  the  chest  and  the  abdomen  more  than  the  face ;  the  rash 
lasts  for  weeks  after  any  possible  fever  has  passed  ;  its  lesions 
have  no  definite  arrangement  and  come  out  in  successive 
crops,  so  that  at  the  same  time  there  will  be  present  lesions 
of  different  age,  and  staining  of  the  skin  from  those  that 
have  gone. 

Morbus  Elephas.     See  Elephantiasis. 


MORPHCEA.  325 

Morbus  Maculosus  Werlhofii.     See  Purpura. 
Morbus  Pedicularis.     See  Pediculosis. 

Morphoea  (Mo2rf-e'a3).  Synonyms  :  Keloid  of  Addison  ; 
Circumscribed  scleroderma. 

A  chronic,  circumscribed  hardening  of  the  skin,  forming 
an  oval  or  irregularly  shaped,  smooth,  lardaceous,  yellowish 
patch,  looking  as  if  mortised  into  the  skin,  and  tending  to 
spontaneous  recovery. 

Symptoms.  This  is  one  of  the  rarer  forms  of  skin  dis- 
ease, regarded  by  many  as  a  circumscribed  scleroderma.  It 
occurs  either  as  circumscribed,  variously  sized,  oval  or 
irregularly  shaped  patches  ;  or  in  the  form  of  bands.  The 
most  common  is  the  patchy  form.  It  begins  as  a  congested, 
red,  rosy,  or  lilac  macule,  which  enlarges,  pales  in  the  centre, 
becomes  hardened,  and  assumes  the  form  of  a  characteristic 
patch  of  the  disease.  This  patch  looks  like  a  piece  of  old 
ivory  or  of  lard  set  in  the  skin,  being  of  a  yellowish-white  color. 
The  color  may  be  pinkish,  yellow,  brown,  or  even  black.  The 
skin  over  the  patch  is  usually  smooth,  and  easily  pinched 
up.  It  may  be  wrinkled,  or  eroded  in  the  centre.  It  may 
be  level  with  the  surface  of  the  skin,  or  raised  above  it,  or 
sunken  below  it.  Around  it  is  a  lilac  border  due  to  dilated 
vessels.  When  the  patch  is  pinched  between  the  fingers 
it  feels  firm,  like  leather.  There  may  be  but  a  single 
patch,  or  a  number  of  them.  As  a  rule  the  disease  is 
unilateral.  After  a  varying  length  of  time  it  may  disappear 
spontaneously,  although  it  may  remain  for  a  number  of 
years.  There  are  usually  no  subjective  symptoms,  and 
the  disease  remains  unchanged  until  it  disappears.  In 
some  cases  it  enlarges  by  new  patches  developing  at  the 
periphery  of  the  old  one  and  uniting  with  it.  Exception- 
ally there  may  be  some  itching  or  pain,  and  ulceration  may 
occur.  Sensation  is  generally  preserved.  The  band  form 
is  usually  single,  and  may  form  a  depressed  sulcus  or  a 
raised  ridge,  looking  much  like  a  cicatrix.  In  addition  to 
the  bands  there  may  be  atrophic  spots. 

The  most  common  locations  of  morphoea  are  anywhere  on 
the  trunk,  but  specially  on  the  breasts  ;  on   the  head  and 


326  DISEASES    OF    THE    SKIN. 

face  in  the  parts  supplied  by  the  fifth  nerve,  and  on  the 
limbs.  It  is  not  infrequently  associated  with  other  nervous 
phenomena,  and  may  occur  along  the  course  of  a  nerve,  like 
zoster.  Nettleship1  has  reported  a  case  in  the  region  of  the 
first  and  second  divisions  of  the  fifth  nerve  with  paralysis  of 
the  intra-ocular  branches  of  the  third  nerve,  which  in  time 
had  associated  with  it  hemi-atrophy  of  the  whole  of  the  left 
side  of  the  head.  There  is  no  disturbance  of  the  general 
health.  The  secretion  of  sweat  over  the  patches  may  be 
normal,  lessened,  or  absent.  When  the  disease  disappears 
it  may  leave  no  trace  of  itself,  or  it  may  be  followed  by  pig- 
mentation or  even  permanent  atrophy  not  only  of  the  skin 
but  also  of  the  muscles.  A  form  of  leprosy  has  been 
wrongly  named  morphoea. 

Etiology.  The  disease  is  a  neurosis  that  occurs  at  all 
ages  after  the  second  year.  The  victims  of  it  are  often  neu- 
rotic. Prolonged  worry  or  anxiety  seems  to  predispose  to 
it,  and  in  some  cases  external  local  irritation  seems  to  excite 
it.  It  is  said  that  the  band  form  is  most  frequently  seen  in 
children,  and  that  females  are  more  often  affected  than 
males. 

Diagnosis.  Keloid  may  be  mistaken  for  morphoea,  but 
it  has  claw-like  processes ;  is  more  vascular  and  harder ; 
and  lacks  the  old  ivory  color  and  the  lilac  surround- 
ing zone.  Some  forms  of  ancesthetic  leprosy  have  been 
spoken  of  as  morphoea,  but  they  are  markedly  ansesthetic, 
and  this  will  be  sufficient  for  diagnosis.  Leucoderma  is  a 
pigment  change  only,  the  skin  being  otherwise  unchanged. 

Treatment.  Unfortunately  there  is  little  or  nothing  to 
be  done  for  the  disease  beyond  attention  to  the  general 
health  of  the  patient.  Arsenic  may  be  of  some  benefit. 
Galvanism  is  perhaps  the  only  local  means  that  gives  any 
promise  of  benefit,  and  that  is  but  a  feeble  one. 

Prognosis.  We  can  tell  our  patient  that  there  is  a  strong 
probability  that  the  disease  will  be  recovered  from  in  time, 
but  we  should  be  careful  about  giving  a  positive  favorable 
prognosis. 

1  Trans.  Clin.  Soc.  Lond.,  1882-3,  xvi.  199. 


MYCOSIS    FUNGOIDES.  327 

Morpion  is  a  name  for  the  pubic  louse. 

Morvan's  Disease  is  a  disease  of  the  spinal  cord  which 
causes  profound  cutaneous  lesions,  such  as  ulceration,  bullae, 
and  fissures  of  the  palmar  side  of  the  hands  and  fingers,  and 
paronychia  and  necrosis  of  several  phalanges.  It  is  allied 
to,  if  not  identical  with,  syringomyelia. 

Mother's  Mark.     See  Naevus. 

Multiple  Fungoid  Papillomatous  Tumors.  See  Mycosis 
fungoides. 

Myasis  Externa  Dermatosa  is  a  dermatitis  due  to  the 
penetration  of  the  skin  by  certain  forms  of  flies,  which  lay 
their  eggs  under  the  skin.  These  subsequently  hatch  out 
and  give  rise  to  the  dermatitis. 

Mycetoma.     See  Fungous  foot  of  India. 

Mycosis  Fungoides  (Mi-ko'srs  fu'n-goM'dez).  Syno- 
nyms :  Inflammatory  fungoid  neoplasm  ;  Multiple  fungoid 
papillomatous  tumors  ;  Fibroma  fungoides ;  Lymphadenie 
cutanee ;  Granuloma  fungoides  ;  Eczema  hypertrophicum  or 
tuberosum ;  Ulcerative  scrofuloderma  ;  Lymphodermia  per- 
niciosa ;  Sarcomatosis  generalis  ;  Multiple  sarcoma  cutis  ; 
Fungoid  dermatitis  ;  Beerschwamahnliche  multiple  Papillar- 
geschwiilste  der  Haut. 

A  chronic  progressive  disease  of  the  skin,  characterized 
by  the  appearance,  with  or  without  an  antecedent  erythema- 
tous or  eczematous  stage,  of  fungating  tumors,  that  tend  to 
break  down  and  ulcerate.  It  leads,  through  marasmus,  to 
death. 

Symptoms.  The  many  names  that  have  been  applied  to 
this  rare  disease  testify  to  the  uncertainty  of  our  knowledge 
of  its  proper  place  in  the  classification  of  skin  diseases.  It 
assumes  so  many  forms  that  it  is  impossible  in  our  limited 
space  to  give  a  complete  picture  of  the  disease.  In  some 
cases  the  first  thing  noticed  is  what  appears  to  be  a  simple 
eczema,  erythema,  urticaria,  or  psoriasis  in  variously  sized 
patches,  and  accompanied  by  marked  pruritus.  These 
lesions  occur  anywhere,  and  constitute  the  first  stage  of  the 
disease.  After  some  months,  or  two  or  three  years  or  more, 
the  patches  become  raised,  glistening,  and  infiltrated,  more 


328  DISEASES    OF    THE    SKIN. 

deeply  red,  and  pea-sized  papules  form.  These  disappear, 
and  new  ones  form.  This  is  the  second  stage,  and  may  last 
months  or  years.  Then  the  characteristic  tumors  form 
either  by  the  papules  enlarging  and  coalescing,  or  as  tumors 
at  once  rising  out  of  the  sound  skin,  without  antecedent 
erythematous  stage.  The  tumors  are  oval,  hemispherical, 
or  irregular  in  shape,  sharply  defined,  sometimes  slightly 
pedunculated.  They  are  of  bright-red,  bluish-red,  or  dark- 
red  color.  Sometimes  hard  and  elastic,  sometimes  soft  and 
succulent.  The  epidermis  over  them  is  tense,  thin,  and 
glistening.  They  may  be  absorbed  and  disappear,  new  ones 
appearing  ;  or  they  may  become  necrotic  and  ulcerate.  In 
size  they  vary  from  that  of  a  pea  to  that  of  the  fist.  At 
first  they  occur  only  on  the  trunk,  later  they  come  any- 
where, and  involve  even  the  mucous  membrane  of  the 
mouth.  The  itching  and  pain  continue  well  into  the  tumor 
stage,  when  they  lessen.  The  lymphatic  glands  enlarge 
painlessly.  The  hair  falls  from  over  the  tumor.  The  gene- 
ral health  of  the  patient  is  undisturbed  for  a  long  time,  but 
at  last  a  general  marasmus  sets  in  and  the  patient  dies, 
usually  from  an  uncontrollable  diarrhoea  or  some  complica- 
tion on  the  side  of  the  lungs.  There  has  been  but  one  case 
of  recovery  reported. 

Etiology.  The  majority  of  the  cases  have  been  women 
over  thirty  years  old.  The  disease  is  held  not  to  be  con- 
tagious. Blanc1  found  in  one  case  that  there  was  a  marked 
reduction  in  the  white  blood-corpuscles,  their  proportion  to 
red  being  1  to  130,  instead  of  1  to  350  or  500.  This  is 
about  all  that  is  known  of  the  etiology  of  the  disease. 
While  much  study  has  been  given  to  the  pathology  of  the 
affection  there  is  no  agreement  among  pathologists  as  to  the 
essential  nature  of  the  disease. 

Diagnosis.  The  diagnosis  of  the  disease  in  its  early 
erythematous  stage  is  very  difficult,  and  probably  cannot  be 
made  with  certainty.  There  is  something  peculiar  in  the 
sharply  circumscribed  outline,  and  the  chronicity  of  the 
eczematous  patches,  and  an  unusual  location  and  pertinacity 

1  Journ.  Cutan.  and  Gen.-urin.  Dis.,  1888,  vi.  256. 


MYXCEDEMA.  329 

about  the  psoriatic  patches  that  would  suggest  the  possi- 
bility of  mycosis  fungoides.  When  the  tumors  develop,  and 
the  capricious  manner  of  their  coming  and  going  is  observed, 
the  diagnosis  is  more  evident. 

Treatment.  Thus  far  nothing  has  been  found  to  stay 
the  course  of  the  disease,  except  that  Kobner  reports  a 
cure  of  a  case  by  means  of  hypodermic  injections  of  arsenic. 
A  general  tonic  treatment  is  always  indicated.  Locally, 
pyrogallol;  ichthyol ;  mercurial  ointment ;  injections  of  car- 
bolic acid;  resorcin,  and  camphorated  naphthol  have  been 
used  and  may  be  tried.  The  itching  is  most  rebellious 
to  treatment.  The  tumors,  when  not  in  great  numbers, 
may  be  cut  out,  though  the  operation  is  of  doubtful  utility. 
The  ulcerations  that  result  from  breaking  down  of  the 
tumors  must  be  treated  on  surgical  principles. 

Mycosis  Microsporina.     See  Chromophytosis. 

Myoma  (Mi-o'-ma3).  Like  most  of  the  tumors,  so  this 
one  concerns  the  surgeon  more  than  the  dermatologist. 
Myomata  may  be  single  or  multiple.  The  latter  is  very 
rare.  They  are  composed  of  muscular  fibres,  and  vary  in 
size  from  a  split-pea  to  an  orange.  They  are  painful  on 
pressure,  and  sometimes  spontaneously.  They  are  pink,  red, 
or  normal  in  color,  disseminated,  or  aggregated  into  patches, 
though  still  retaining  their  individuality.  The  epidermis 
over  them  is  unchanged.  The  single  tumors  may  be  sessile 
or  pedunculated,  and  may  attain  the  size  of  an  orange. 
They  have  their  seat  most  often  on  the  female  breasts,  and 
on  the  genitalia  of  both  sexes.  If  they  contain  a  good  deal 
of  fibrous  tissue  they  are  called  fibro-myoma  ;  if  they  con- 
tain large  bloodvessels,  they  form  angio -myoma ;  or,  if  the 
lymphatics  are  involved,  we  have  lympliangio-myoma. 
Excision  is  the  only  thing  that  can  be  done  for  them. 

Myoma  Telangiectodes.     See  Myoma  (Angio-myoma). 

Myxoedema  (Mi2x-e2d-e'ma3).  This  is  a  constitutional 
disease  with  cutaneous  symptoms.  The  skin  becomes  waxy 
pale  ;  yellowish ;  shining  in  some  places,  dull  and  earthy- 
looking  in  others ;  it  is  dry,  scaly,  exfoliating  on  the  ex- 
tremities, sometimes  ulcerated,  and  verrucose  on  the  lower 


330  DISEASES    OF    THE    SKIN. 

limbs.  The  fingers  and  toes  are  sometimes  livid.  There  is 
partial  or  general  alopecia,  and  deformity  and  fragility  of  the 
nails.  There  is  a  general  oedematous  swelling  of  the  whole 
integument  as  well  as  of  the  mucous  membranes,  and  this 
oedema  does  not  pit  on  pressure. 

The  disease  affects  women  far  more  often  than  men,  and 
involves  all  parts  of  the  body.  There  is  an  enfeeblement  of 
mind,  and  a  great  lowering  of  the  sense  of  touch,  taste,  and 
smell ;  a  torpidity  of  movement  and  of  the  digestive  func- 
tions. It  ends  fatally  either  by  marasmus,  or  by  complica- 
tions on  the  side  of  the  internal  organs. 

The  diagnosis  in  the  early  stage  is  difficult ;  when  fully 
developed  it  could  hardly  be  taken  for  anything  else.  The 
cause  of  the  disease  is  unknown,  and  its  treatment  in- 
effectual. 

Nsevus  (Ne'virV).     Nsevi  may  be  pigmentary  or  vascular. 

Nsevus  Pigmentosus.  Synonyms  :  Nsevus  spilus  ;  Nae- 
vuspilosus;  Nsevus  verrucosus ;  Naevus  lipomatodes  ;  (Ger.) 
Fleckenmal,  Pigmentmal,  Linsenmal ;  Pigmentary  mole ; 
Mother's  mark. 

A  congenital,  circumscribed  hyperpigmentation  of  the 
skin,  often  accompanied  by  a  growth  of  coarse  hair,  and 
hypertrophy  of  the  connective  and  fatty  tissues. 

Symptoms.  These  growths  are  closely  allied  to  lentigo 
and  chloasma,  as  a  hypertrophy  of  pigment  is  a  prominent 
feature  of  them.  When  they  consist  of  pigment  only,  and 
are  not  raised  above  the  surface  of  the  skin,  they  are  called 
ncevus  spilus.  When  besides  the  pigment  there  is  a  hyper- 
trophy of  the  connective  tissue,  and  they  are  raised  and 
uneven,  the  name  ncevus  verrucosus  is  applied  to  them ;  or 
ncevus  lipomatodes  if  they  are  soft  and  contain  fatty  tissue ;  if 
hair  grows  from  either  form,  then  we  speak  of  ncevus pilosus. 
In  color  they  vary  from  a  light  to  dark  brown  or  black.  In 
size  they  vary  from  a  split-pea  to  an  area  large  enough  to 
cover  the  whole  back.  Most  commonly  they  are  of  small 
size.  They  may  be  located  anywhere,  though  most  often  on 
the  face,  neck,  and  back.  There  may  be  but  one  or  two,  or 
hundreds  of  them.     They  may  have  no  special  distribution, 


JST^VUS    VASCULARIS.  331 

or  they  may  follow  nerve-tracts.  They  may  be  unilateral  or 
bilateral,  and  sometimes  symmetrical.  If  hair  is  in  them  it 
is  coarse  and  stiff,  and  generally  darker  than  that  of  the 
head.  Sometimes  large  hairy  moles  bear  a  strong  resem- 
blance to  the  fur  of  animals.  They  grow  in  proportion  to 
the  growth  of  the  individual,  and  cease  growing  when  he 
has  attained  his  growth.  They  are  usually  congenital,  but 
may  be  acquired,  and  are  liable  to  undergo  malignant  change 
in  advanced  life.  They  give  rise  to  no  subjective  symptoms. 
They  are  permanent  growths.  They  rarely  disappear  of 
themselves. 

Etiology.  To  account  for  the  appearance  of  these  mal- 
formations we  have  only  the  theory  of  nerve  influence,  and 
that  is  by  no  means  satisfactory.  Their  popular  name  of 
mother's  mark  shows  that  the  popular  superstition  agrees 
with  the  scientific  theory.  We  can  simply  regard  them  as 
anomalies. 

Diagnosis.  Moles  differ  from  lentigo  in  being  congeni- 
tal and  permanent,  and  in  a  hypertrophy  of  connective 
tissue  and  a  growth  of  hair  being  connected  with  them. 
The  difference  between  hairy  moles  and  hypertrichosis  is  in 
the  substratum  ;  in  the  latter  the  underlying  skin  is  other- 
wise normal. 

Treatment.  We  can  destroy  these  growths  and  leave 
behind  but  little  scar.  If  there  is  but  a  single  pigmentary 
mole  it  may  be  cut  out.  In  this  case  it  will  leave  a  linear 
scar.  It  is  generally  better  to  destroy  the  growth  by  touch- 
ing it  over  carefully  with  nitric  or  acetic  acid.  This  is  done 
by  stippling,  as  it  were,  making  a  row  of  dots  in  this 
fashion — 


Electrolysis  by  multiple  puncture,  or  by  transfixing  the 
mole  in  various  directions,  is  a  sure  and  speedy  way.  Hairy 
moles  are  best  destroyed  by  electrolysis  as  in  superfluous 
hair,  only  here  a  coarser  needle  must  be  used,  as  we  are 
not  so  particular  about  a  little  scarring. 

Naevus  Vascularis.     Synonyms :  Nasvus  vasculosus  seu 
sanguineus ;     Angioma ;     (Grer.)      Feuermal,     Gefassmal ; 


332  DISEASES    OF    THE    SKIN". 

(Fr.)    Tache   de  feu,  Tache  vasculaire ;  Port-wine    mark ; 
Birth-mark ;   Claret  stain. 

Symptoms.  These  are  composed  mainly  of  vascular  tis- 
sue, and  are  congenital  or  appear  during  the  first  month  of 
life.  They  are  usually  single,  but  may  be  multiple.  They 
vary  greatly  in  size,  shape,  and  color,  but  all  possess  one 
feature  in  common — they  pale  under  pressure.  They  may 
be  pinhead  spots  not  raised  above  the  surface  of  the  skin,  or 
they  may  form  large,  erectile,  elevated,  pulsating  tumors,  or 
they  may  spread  out  so  as  to  involve  a  large  area.  They 
may  be  pink,  bright-red,  dark-red,  or  even  purple  in  color. 
When  on  the  face  they  become  more  pronounced  on  crying, 
coughing,  and  the  like.  They  may  disappear  spontaneously ; 
increase  in  size  during  a  few  months  or  years ;  or,  most 
commonly,  remain  unchanged.  According  to  their  size 
they  have  received  various  names.  The  small,  flat  or  scarcely 
raised  nsevus  composed  of  capillaries  is  called  ncevus  sim- 
plex or  capillary  ngevus.  This  is  the  form  very  often  seen 
in  children.  It  is  not  infrequent  for  it  to  disappear  of  itself 
after  a  while,  either  leaving  no  trace,  or  a  delicate  atrophic 
scar.  When  it  is  so  large  as  to  form  a  patch  as  big  as  the 
hand  or  larger,  it  is  called  ncevus  flammcus  or  port-wine 
mark.  The  surface  of  this  form  is  often  uneven,  and  studded 
with  small,  erectile  vascular  tumors,  or,  may  be,  moles.  The 
large,  erectile,  pulsating  tumors  are  called  ncevus  tuberosus, 
angioma  cavernosum,  venous  ncevus.  They  differ  very  much 
from  the  other  forms  in  appearance  and  formation.  Their 
surface  is  uneven  and  lobulated.  This  form  is  apt  to  in- 
crease in  size,  and  may  attain  enormous  dimensions. 

Ngevi  may  occur  anywhere  on  the  body,  but  are  most  fre- 
quent on  the  head  and  face.  They  may  also  occur  upon  the 
mucous  membranes  primarily  or  secondarily.  The  back, 
nates,  pudenda,  and  lower  limbs  are  said  by  Crocker  to  be  the 
most  common  sites  of  the  cavernous  form.  All  forms  of 
nsevi  made  be  hardly  perceptible  at  birth,  but  become 
gradually  more  evident  afterward. 

Etiology  and  Pathology.  Vascular  nsevi  are  probably 
always  congenital  malformations,  though  their  appearance 
upon  the  skin  may  be  retarded  for  some  time.     The  simple 


N^IVUS    VASCULARIS.  333 

capillary  nsevi,  which  includes  the  port-wine  marks,  are 
simply  an  increase  in  number  and  size  of  the  capillaries. 
In  the  venous  nsevi  we  have  also  a  new  growth  of  connec- 
tive tissue  forming  a  mesh- work,  and  they  are  supplied 
directly  by  an  artery  without  the  interposition  of  capillaries. 
Women  are  more  prone  to  them  than  are  men. 

Diagnosis.  There  can  be  no  difficulty  in  diagnosis, 
excepting  that  a  ncevus  may  be  taken  for  a  telangiectasis. 
This  error  would  be  of  little  consequence,  since  the  latter  is 
simply  an  acquired  nrevus,  and  differs  chiefly  in  having  a 
central  red  point  from  which  the  dilated  capillaries  radiate. 

Treatment.  Electrolysis  is  the  best  means  for  destroy- 
ing the  vast  majority  of  these  growths.  The  best  way  to 
use  it  in  capillary  nrevi  and  port-wine  marks  is  by  making 
multiple  punctures  in  parallel  rows,  perpendicularly  to 
the  skin  and  down  though  its  entire  thickness.  To  ex- 
pedite matters  one  may  use  either  a  circle  of  needles  set  in 
a  handle,  or  a  row  of  three  needles.  Of  course,  the  nega- 
tive pole  is  to  be  connected  with  the  needle- holder,  and 
the  operation  is  to  be  conducted  in  the  same  way  as  in 
removing  superfluous  hair.  By  this  method  it  is  possible 
to  entirely  destroy  small  nsevi,  and  to  very  much  diminish 
the  unsightly  appearance  of  large  port-wine  marks.  As 
electrolysis  necessarily  destroys  the  skin,  we  must  leave  a 
scar.  But  this  is  less  conspicuous  than  the  nsevus,  and  if 
the  operation  is  carefully  done  the  scar  is  soft,  smooth,  and 
pliable.  There  is  also  much  less  danger  of  a  deforming 
scar  from  the  use  of  a  single  needle  than  from  a  group  of 
them.  Therefore  this  method  is  preferable,  though  more 
tedious.  The  punctures  must  not  be  made  close  together ; 
at  least  a  sixteenth  of  an  inch  should  be  left  between 
them.  After  the  na?vus  has  been  carefully  gone  over,  it 
should  be  left  alone  for  a  couple  of  weeks  or  more  for  the 
full  effect  of  the  operation  to  be  seen.  It  can  be  gone  over 
again,  and  another  interval  of  time  allowed,  and  so  on  till 
the  growth  is  destroyed  as  much  as  possible. 

Beside  electrolysis  we  may  use  multiple  scarifications  ob- 
liquely to  the  skin.  Or  we  may  use  the  ethylate  of  sodium 
freshly   prepared  and   applied   to  the  absolutely  dry  skin, 


334  DISEASES    OF    THE    SKIN. 

using  a  brush  or  glass  rod.  To  avoid  scarring,  only  a  small 
part  of  the  naevus  must  be  attacked  at  a  time.  A  crust  will 
form,  which  must  be  left  to  come  away  of  itself.  Fuming 
nitric  acid  or  the  acid  nitrate  of  mercury  may  be  stippled 
over  the  growth.  Or  vaccination  may  be  performed  over 
them.  Or  multiple  punctures  may  be  made  by  means  of  a 
steel  needle  dipped  in  nitric  or  carbolic  acid.  Marshall 
Hall  advocates  breaking  up  the  nsevus  by  introducing  a 
cataract-needle  close  to  the  edge  of  the  growth,  pushing  it 
across  to  the  opposite  side,  then  nearly  withdrawing  it,  and 
again  pushing  it  in  at  a  little  distance  from  the  first 
puncture.  But  electrolysis  is  the  best  and  most  controllable 
method. 

For  cavernous  nsevus  we  may  use  electrolysis  also,  but 
here  we  pass  the  needle  obliquely  into  the  skin  in  the  hope 
of  striking  the  deep  vessels,  It  is  well,  sometimes,  to  pass 
the  needle  from  the  edge  deep  under  the  naevus  and  clear 
through  to  the  other  side,  let  the  current  pass  for  a  half 
minute,  partially  withdraw  the  needle,  and  again  push  it  in 
another  direction.  Some  prefer  introducing  two  needles, 
connected  each  with  one  pole  of  the  battery,  in  opposite 
directions.  A  platinum  or  gold  needle  must  be  used  with 
the  positive  pole.  Excision  may  be  performed,  but  some- 
times this  gives  rise  to  alarming  hemorrhage.  Multiple 
punctures  with  a  red- hot  steel  shoemaker's  awl,  or  the  point 
of  a  Paquelin  or  galvano-cautery  heated  to  a  dull  red,  are 
other  good  methods  of  treatment.  It  has  been  proposed  to 
use  a  metallic  plate  perforated  with  a  number  of  holes  with 
which  to  exercise  strong  pressure  upon  the  mevus  wThile  the 
galvano-cautery  is  introduced  through  the  holes.  Injections 
of  carbolic  acid,  perchloride  of  iron,  alcohol,  and  the  like, 
are  effectual,  but  dangerous  methods.  Setons  are  not  used 
as  much  as  formerly.  Compression  by  an  elastic  bandage 
is  at  times  curative  when  the  nsevi  are  located  over  bony 
prominences. 

As  many  capillary  nsevi  in  children  disappear  in  time  it 
is  advisable  not  to  interfere  with  them  at  once,  contenting 
ourselves  with  painting  them  with  collodion  and  waiting 
until  the  child  is  old  enough  to  desire  their  removal.     Of 


NODOSITES    NON-ERTTHEMATEUSES.         335 

course,  if  they  are  very  unsightly  we  cannot  wait,  nor  should 
we  temporize  with  cavernous  nsevi.  In  children  one  works 
most  comfortably  by  using  an  anaesthetic,  but  it  is  not  abso- 
lutely necessary.  Keloidal  scars  may  be  an  unfortunate 
accident  in  some  cases. 

Prognosis.  The  prognosis  should  be  guarded,  and  the 
cases  carefully  watched.  All  naevi  may  increase  in  size, 
though  very  many  remain  stationary. 

Naevus  Araneus.     See  Telangiectasis. 
Narbengeschwulst.     See  Keloid. 
Narbenkeloid.     See  Keloid. 
Nerven  Naevi.     See  Ichthyosis  hystrix. 
Nesselausschlag.     See  Urticaria. 
Nettlerash.     See  Urticaria. 
Neuralgia  Cutis.     See  Dermatalgia. 

Neuroma  Cutis  is  an  exceedingly  rare  disease  of  which 
but  few  cases  have  been  reported.  Neuromata  are  small, 
flat,  firm  tumors  firmly  imbedded  in  the  skin.  They  are 
painful  spontaneously  and  on  pressure.  The  pain  may  be 
paroxysmal  in  character.  They  are  relievable  by  surgical 
interference  with  the  nerve. 

Neuropathic  Papilloma.     See  Ichthyosis  hystrix. 

Nodosites  Non-erythemateuses  des  Arthritiques.  Brocq 
applies  this  name  to  cutaneous  and  subcutaneous  tumors  that 
he  has  met  with  in  connection  with  the  gouty  diathesis. 
They  are  of  two  varieties.  The  first  one  he  calls  Epheme- 
ral cutaneous  nodules.  They  occur  upon  the  forehead  and 
form  ill-defined  elevations  of  the  skin,  of  small  pea  to  hazel- 
nut size,  and  entirely  painless.  They  are  movable  with  the 
skin,  though  sometimes  they  are  adherent.  They  appear 
first  during  the  night  and  disappear  within  twenty-four 
hours. 

The  second  variety  is  the  subcutaneous  rheumatismal 
nodule.  It  forms  a  small  tumor  resembling  a  gumma. 
The  skin  slides  freely  over  them  in  most  cases.  The  color 
of  the  skin  is  unchanged.  They  are  firm  and  elastic  to  the 
touch.     Generally   they  are  painful  on  pressure,  at  times 


336  DISEASES    OF    THE    SKIN". 

spontaneously.  In  size  they  vary  from  a  pea  to  an  almond, 
and  they  are  sharply  defined.  They  may  remain  for  days 
or  weeks,  when  they  disappear,  leaving  no  trace.  They 
often  come  in  successive  outbreaks.  Their  seat  of  predilec- 
tion is  about  the  joints,  and  upon  the  fibrous  tissues  that 
cover  the  superficial  bones.  They  are  generally  discrete, 
and  often  very  numerous.  Their  appearance  often  coin- 
cides with  symptoms  of  pericarditis  or  pleurisy.  Their 
treatment  is  that  appropriate  to  the  rheumatism  that  seems 
to  be  their  cause,  especially  iodine  and  the  iodides. 

Noli  Me  Tangere.  See  Lupus  vulgaris.  It  has  been 
used  as  a  synonym  for  rodent  ulcer.     (Crocker.) 

Non-parasitic  Sycosis.     See  Sycosis. 

Nodulus  Laqueatus  is  that  condition  of  the  hair  in  which 
it  seems  to  tie  itself  into  knots.  The  hair  is  usually  dry 
and  curly.  It  is  probably  caused  by  handling  of  the  hair, 
and  does  not  occur  spontaneously. 

Norwegian  Itch.     See  Scabies. 

(Edema  Cutis,  Acute  Circumscribed.  It  is  a  question 
whether  this  is  a  form  of  urticaria  or  not.  It  is  certainly 
allied  to  it  in  the  suddenness  of  its  onset ;  in  the  attending 
erythema,  and  digestive  or  other  constitutional  disturbances  ; 
and  in  the  character  of  its  lesions.  It  differs  from  urticaria 
in  being  recurrent  in  the  same  locations ;  in  the  shading  off 
of  the  swellings  into  the  surrounding  skin ;  and  in  being 
unattended  by  itching.  It  is  prone  to  occur  upon  the  face, 
and  there  often  closes  up  one  or  both  eyes  in  an  enormous 
swelling ;  or  the  lips  so  that  the  mouth  cannot  be  opened. 
In  the  present  state  of  our  knowledge  it  is  probably  well 
to  regard  it  as  urticaria  cedematosa.     (See  Urticaria.) 

(Edema  Neonatorum.  This  disease  was  formerly  con- 
founded with  sclerema,  but  quite  recently  has  been  separated 
from  it. 

Symptoms.  It  is  a  rare  disease,  that  begins  upon  the 
legs  within  the  first  three  days  of  life.  The  oedema  spreads 
upward  along  the  thighs,  shows  itself  upon  the  hands, 
then  upon  the  genitals  and  back.  It  is  hard  and  pits  only 
on  deep  pressure.     The  skin  is  of  a  violaceous  red,  or  more 


ONYCHAUXIS.  337 

or  less  intense  yellow,  and  feels  cold.  The  infant  is  coma- 
tose; its  pulse  is  feeble ;  its  breathing  labored;  and  its  cry 
sharp.  A  high  temperature  may  exceptionally  be  present. 
Death  usually  results  on  account  of  some  pulmonary  affec- 
tion, or  from  collapse.     Exceptionally,  recovery  takes  place. 

Etiology.  The  disease  occurs  in  feeble,  ill-nourished 
children,  in  those  prematurely  delivered,  or  exposed  to  poor 
hygienic  surroundings. 

Diagnosis.  It  differs  from  sclerema  in  being  more 
limited  to  certain  localities ;  in  the  skin  being  more  livid 
from  the  first,  and  not  so  hard  ;  in  affecting  the  dependent 
parts  ;  and  in  lacking  the  stiffness  of  the  joints      (Crocker.) 

Treatment.  Though  the  prognosis  is  exceedingly  bad, 
an  attempt  should  be  made  to  nourish  the  child  as  well  as 
possible  by  artificial  feeding ;  it  should  be  wrapped  in 
flannel  and  kept  warm  ;  and  the  limbs  should  be  rubbed 
with  warm  oil,  or  camphorated  alcohol,  in  such  a  way  that 
the  blood  is  forced  toward  the  heart. 

(Eil  de  Perdrix.     A  soft  corn. 

Oligamie.     Anaemia. 

Oligosteatosis.     Deficiency  of  fat  secretion. 

Oligotrichia.     See  Alopecia. 

Onychatrophia.     See  Atrophia  unguium. 

Onychauxis  (02n-i2k-a*x'i2s).  Onychogryphosis  (02n  i2k- 
o-gri2f-or-si2s).  These  are  both  hypertrophies  of  the  nail 
either  in  length,  breadth,  or  thickness  ;  or  in  all  at  the  same 
time.  When  the  growth  is  markedly  forward,  and  the  nail 
is  much  thickened,  it  is  called  onychogryphosis.  The  nail 
in  these  instances  generally  turns  to  one  side  after  reaching 
a  certain  leno-th,  sometimes  so  much  so  that  a  bio-  toe-nail 
may  lie  over  the  second  and  third  toes.  If  the  hyper- 
trophy is  lateral  we  are  apt  to  have  onychia,  ingrowing 
toe-nail.  The  hypertrophied  nail  is  rugous,  but  highly 
polished,  brown,  and  there  is  often  an  accumulation  of 
scales  under  it  which  at  times  °:ive  rise  to  a  bad  odor  from 
decomposition.  The  toe-nails  are  those  most  often  hyper- 
trophied, but  the  finger-nails  may  be  so  affected. 

15 


338  DISEASES    OF    THE    SKIN. 

Etiology.  Badly  fitting  boots  and  neglect  of  proper 
care  of  the  nails  are  causes  of  onychauxis,  and  onychogryph- 
osis.  They  often  arise  without  discoverable  causes.  They 
may  be  due  to  a  congenital  predisposition.  They  very 
often  occur  as  part  of  other  chronic  skin  and  constitutional 
diseases,  such  as  eczema,  psoriasis,  leprosy,  syphilis,  and 
ichthyosis.  The  thickening  may  be  due  to  disease  of  the 
matrix  or  to  a  thickening  of  the  horny  layer  only. 

Treatment.  The  hypertrophied  nail  may  be  removed 
by  mechanical  means  such  as  by  the  file,  saw,  or  knife.  The 
continuous  use  of  salicylic  acid  sometimes  will  cause  the 
thickened  mass  to  fall  off.  The  oleates  of  tin  and  lead  ; 
the  continuous  wearing  of  rubber  cots  ;  and  liquor  potassre, 
are  also  efficacious  in  softening  the  thickened  mass  of  the 
nail.  The  action  of  all  these  agents  is  assisted  by  daily 
removing  the  softened  layers  by  mechanical  means.  When 
the  hypertrophy  is  but  a  part  of  some  other  disease,  it  will 
be  benefited  by  the  same  means  as  will  benefit  the  cause 
from  which  it  arises.  If  it  is  due  to  an  inflammatory  dis- 
ease of  the  nail-bed  or  matrix,  that  must  receive  attention. 
(See  Onychia  and  Paronychia).  After  the  nail  deformity 
has  been  overcome  it  may  return. 

Onychia  (02n-rk'i2-a3)  or  Onychitis  (02n-i2k-i'ti2s).  By 
this  is  meant  acute  inflammation  of  the  matrix  and  nail-bed. 
The  end  of  the  finger  or  toe  is  reddened  and  swollen,  and 
there  is  more  or  less  throbbing  pain.  The  nail  is  lifted  from 
its  bed,  more  or  less  pus  escapes  from  underneath  it,  and  it 
is  eventually  shed.  The  inflammation  often  spreads  to  the 
adjacent  parts  of  the  finger,  and  then  we  have  that  condi- 
tion commonly  called  Cl  whitlow."  When  the  nail  falls,  a 
spongy  nail-bed  is  left,  often  with  exuberant  granulations. 
Under  proper  treatment  a  good  nail  may  be  reproduced, 
though  in  many  cases  either  a  very  much  deformed  one  will 
result  or  one  that  differs  somewhat  in  appearance  from  the 
other  nails.  In  some  cases,  instead  of  this  phlegmonous 
form  we  have  a  dry  inflammation  that  is  known  as  onychia 
sicca.  Here  the  nail  is  discolored,  its  edge  thickened  and 
brittle,  its  surface  rough  and  more  or  less  pitted.  Eventu- 
ally the  nail  is  shed.     This  condition  is  met  with  most  often 


paget's  disease  of  the  nipple.        339 

in  syphilis.     A  chronic  onychia  is  occasionally  seen,  and  is 
one  of  the  causes  of  onychauxis. 

Etiology.  Onychia  is  due  to  traumatism  or  to  some  other 
disease  of  the  skin,  such  as  syphilis,  eczema,  psoriasis,  para- 
sitic diseases,  dermatitis  exfoliativa,  and  the  strumous  state. 

Treatment.  The  treatment  of  onychia  varies  with  the 
stage  of  the  disease  and  with  the  cause.  Occurring  as  part 
of  some  general  disease  of  the  skin,  the  treatment  appro- 
priate to  the  general  disease  will  be  beneficial  to  the  onychia. 
Arising  as  an  independent  disease,  or  resulting  from  trau- 
matism, the  application  of  a  10  to  20  per  cent,  resorcin 
ointment  or  plaster  will  often  abort  the  disease  in  an  early 
stage.  If  the  disease  has  gone  on  to  suppuration,  surgical 
procedures  will  have  to  be  resorted  to,  such  as  splitting  of 
the  nail  or  its  removal  as  a  whole,  and  subsequent  dressing 
with  iodoform,  aristol,  or  a  bichloride  solution. 

Onychomycosis  (02n  rk-o-mi-ko'-srs).  This  term  means 
the  invasion  of  the  nail  by  a  fungus,  such  as  the  trichophyton 
or  favus,  which  see. 

Orticaria.     See  Urticaria. 

Osmidrosis.     See  Bromidrosis. 

Pachydermatocele.     See  Dermatolysis. 

Pachydermia.     See  Elephantiasis. 

Paget's  Disease  of  the  Nipple.  Synonyms  :  Mamillaris 
maligna  ;  Malignant  papillary  dermatitis  ;  Epitheliomatose 
eczematoide  de  la  mamelle  (Besnier). 

Symptoms.  This  is  a  rare  disease  of  the  skin  that  is 
named  after  Paget,  who  first  described  it  in  1874. 1 

It  usually  occurs  in  women  over  forty  years  of  age,  and  at 
first  has  the  appearance  of  an  eczema  madidans ;  that  is,  it 
presents  "  a  florid,  intensely  red,  raw  surface,  very  finely 
granular,  as  if  the  whole  thickness  of  the  epidermis  had  been 
removed.  From  such  a  surface,  on  the  whole  or  greater 
part  of  the  nipple  and  areola,  there  is  always  a  copious, 
clear,  yellowish,  viscid  exudation."  Besnier  believes  that 
its  primary  stage  is  a  keratosis,  which,  under  any  irritation, 

1  St.  Bartholomew's  Hospital  Keports,  vol.  x.  p.  83. 


340  DISEASES    OF    THE    SKIN. 

assumes  an  eczematous  appearance.  The  edge  of  the  patch 
is  sharply  defined  and  slightly  raised.  Sometimes,  instead 
of  the  raw  surface,  we  have  crusting,  or  even  scaling. 
Telangiectases  may  be  seen  here  and  there.  After  months 
or  years  marked  induration  is  manifest,  pinching  up  the 
patch  imparting  the  sensation,  as  described  by  Mr.  Morris, 
of  "a  penny  felt  through  a  cloth."  Burning  or  itching  is 
complained  of,  which  makes  the  disease  the  more  nearly  re- 
semble an  eczema.  But  it  does  not  yield  to  the  ordinary 
treatment  of  eczema,  and  its  border  gradually  extends.  The 
female  breast,  usually  the  right  one,1  is  the  part  most  often 
affected,  and  there  it  always  begins  at  the  nipple,  spreading 
thence  over  the  areola  and  skin.  After  a  few  months,  or  not 
until  twenty  years,  signs  of  scirrhous  cancer  appear.  The 
nipple  becomes  more  and  more  retracted  and  ulcerated. 
Hard  nodules  develop  in  the  raw  surface  or  deep  down  in 
the  skin.  The  mammary  gland  itself  may  become  affected. 
The  cancerous  cachexia  develops  later  with  ganglionic  en- 
largements.    Crocker  has  met  with  it  on  the  scrotum. 

Pathology.  It  is  still  an  open  question  whether  the 
disease  is  malignant  from  the  start,  or,  beginning  as  a  sim- 
ple inflammation,  becomes  malignant,  just  as  we  find  epi- 
thelioma of  the  tongue  developing  upon  a  leucoplakia. 
Darier  and  Wickham  believe  that  the  disease  is  due  to 
psorosperms  (see  Psorospermosis).  But  their  theory  has  not 
been  generally  accepted  as  yet. 

Diagnosis.  Though  very  important,  it  is  exceedingly 
difficult  at  first  to  make  a  positive  diagnosis  of  a  case  of 
Paget's  disease,  from  an  eczema.  Eczema,  of  the  nipple  is 
very  common  during  the  childbearing  period,  while  Paget's 
disease  occurs  most  commonly  after  the  climacteric.  In 
eczema  we  do  not  have,  as  a  rule,  the  raw  granulating  sur- 
face of  Paget's  disease,  while  we  do  have  more  variation  in 
the  course  of  the  disease,  exacerbations  and  seasons  of  ap- 
parent quiescence.  In  eczema  the  patch  is  not  so  sharply 
defined,  and  its  border  is  not  raised;  about  it  there  are  apt 
to  be  outlying  pustules  or  vesicles,  and   there  is  not  the 

1  Wickham :  Maladie  de  Paget,  Paris,  1890. 


PANARIS    NERVEUX.  341 

papyrus-like  induration.  When  the  nipple  becomes  re- 
tracted and  ulcerations  take  place,  together  with  shooting 
pains  and  enlarged  lymphatics,  the  diagnosis  is  easy. 

Treatment.  At  the  beginning,  and  while  the  diagnosis 
is  still  doubtful,  the  usual  remedies  for  eczema  should  be 
tried.  If  these  fail,  as  they  will  if  the  disease  is  not 
eczema,  or  if  the  right  diagnosis  is  arrived  at,  powerful 
caustics  must  be  used,  if  the  disease  is  still  superficial.  We 
may  use,  as  recommended  by  Darier,  a  solution  of  chloride 
of  zinc,  one  in  three,  to  produce  an  exfoliation  of  the  dis- 
eased epidermis,  and  follow  it  with  a  mercurial  plaster, 
alternating  with  iodoform  or  aristol.  Or,  a  zinc  paste  may 
be  kept  on,  spread  thickly  on  lint,  for  four  to  six  hours,  and 
the  slough  poulticed  off  or  allowed  to  separate  under  wet 
boric  lint,  under  oiled  silk,  as  recommended  by  Crocker. 

The  paste  used  in  the  Middlesex  Hospital  is  made  as  fol- 
lows : 

R.  Zinci  ohlorid.,  £>iv;  7  50 

Liq.  opii  sed.,  g  iv ;  7  50 

Amyli,  HJss;  3 

Aquse,  Jj  ,  30  M. 

Ft.  pasta. 

When  there  is  ulceration,  but  not  much  induration,  the 
surface  should  be  thoroughly  curetted  and  dressed  antisep- 
tically.  When  nodules  have  formed  and  there  is  marked 
induration  under  an  ulcerated  surface,  the  whole  diseased 
surface  must  be  freely  excised  or  the  breast  removed  entire. 
If  an  operation  or  the  use  of  caustics  is  unadvisable  for 
any  reason,  relief  to  the  pain  and  discomfort  may  be  had 
by  dressing  with  a  fuchsin  solution  1  per  cent,  strength. 

Panaris  Nerveux  of  Quinquaud  belongs  to  that  group 
of  obscure  diseases  in  which  stand  Morvan's  disease  and 
syringomyelia.  It  is  characterized  by  swelling  of  the  ex- 
tremities, slight  redness,  and  attacks  of  intense  pain,  ter- 
minating in  eight  to  fifteen  daj^s  by  fissure  of  the  finger-end 
and  fall  of  the  nail.  Sometimes  the  skin  of  the  finger-end 
becomes  sclerosed  and  atrophied. 

Brocq  advises  in  its  treatment  the  constant  application  of 


342  DISEASES    OF    THE    SKIN. 

chloroform  liniment,  and  of  irritant  lotions  or  frictions  to 
the  cervical  region  and  along  the  course  of  the  nerves  sup- 
plying the  parts.  Internally,  he  advises  the  valerianate  of 
ammonia  or  of  quinine. 

Panaritium.     See  Paronychia. 

Papilloma  (Pa2p-i2l-lo'ma3).  By  this  term  is  meant  a 
papillary  outgrowth  from  the  skin.  Such  are  common 
warts,  verrucous  eczema,  papillary  excrescences  following 
ulceration,  Kaposi's  dermatitis  papillaris  capillitii,  ichthy- 
osis hystrix,  and  the  like.  The  term  is,  therefore,  of  un- 
certain significance.  Some  authors  have  described  papillo- 
mata  apart  from  the  above  -  designated  diseases,  and 
Hardaway  reports  at  length  a  case  of  general  idiopathic 
papilloma  in  a  seven-months-old  child.  Mental  defects  have 
been  noted  in  some  of  these  cases.  A  muco-purulent  secre- 
tion often  is  present,  welling  up  between  the  papillae.  The 
condition  is  a  rare  one.  Under  the  name  of  papilloma  area 
elevatum  Beigel  has  described  one  of  these  rare  cases. 

Papilloma  Neuroticum.     See  Ichthyosis  hystrix. 

Parasitic  Diseases.  The  diseases  of  the  skin  caused  by 
well-accepted  parasites  may  be  divided  into  two  classes  : 
1.  Those  due  to  vegetable  parasites.  2.  Those  due  to  animal 
parasites. 

Group  1  comprises  favus,  ringworm,  chromophytosis,  ery- 
thrasma,  and  pinta.  These  will  be  found  described  under 
their  proper  headings. 

Group  2  comprises  a  large  variety  of  parasites.  Scabies 
and  pediculosis,  due  respectively  to  the  acarus  and  pedicu- 
lus,  are  described  at  length  in  this  book.  Besides  these  we 
have — 

The  leptics  autumnalis,  harvest-bug,  or  mower's  mite, 
that  bores  its  head  into  the  skin,  causes  great  itching,  and 
induces  violent  scratching  and  consequent  excoriations. 

The  demodex  folliculorum  is  described  in  relation  with 
the  comedo. 

The  pulex  penetrans,  chigoe,  or  jigger,  that  resembles  a 
flea,  but  penetrates  under  the  skin  with  its  head,  sets  up  in- 


PARONYCHIA.  343 

flammation  and,  perhaps,  ulceration  and  gangrene,  and  has 
to  be  dug  out  of  the  skin  with  a  blunt  needle. 

The  pulex  irritansy  or  common  flea,  whose  ravages  are  so 
well  known  as  not  to  require  description. 

The  dmex  lectularius,  or  common  bedbug,  attacks  the 
skin  for  its  food,  punctures  it,  and  at  the  same  time  injects 
an  irritating  fluid  to  increase  the  hyperemia  and  his  food 
supply.  A  wheal,  or  raised  red  spot  with  a  central  punc- 
ture, follows  the  bite,  and  a  purpuric  spot  results.  The  ir- 
ritation is  relieved  by  any  of  the  means  serviceable  in  urti- 
caria. 

Gnats  and  mosquitoes  are  too  familiar  to  all  of  us. 

Ixodes,  or  wood-ticks,  the  filaria  sanguinis  and  filar ia 
medinensis,  the  tcenia  solium,  and  the  echinococcus  all  find 
lodgment  at  times  in  the  human  skin.  These  parasites  do 
not  exhaust  the  list,  but  are  the  principal  ones. 

Parasitare  Bartfinne.     See  Trichophytosis  barbae. 

Parasitic  Mentagra.     See  Trichophytosis  barbae. 

Parasitic  Sycosis.     See  Trichophytosis  barbae. 

Parchment    Skin.     See  Atrophia  cutis. 

Paronychia  (Pa2r-o2n-i2k'-i2-a3).  This  affection  is  popu- 
larly known  as  a  whitlow,  run-around,  or  ingrowing  toe-nail. 
Ingrowing  toe-nail  results  from  the  nail  shoving,  or  being 
shoved  into  the  soft  parts,  either  on  account  of  disease  of 
the  nail  itself,  or  of  ill-fitting  shoes,  or  of  injury.  The  big 
toe-nail,  at  its  inner  or  outer  edge,  is  the  most  common  site 
of  the  disease,  though  any  toe  may  be  affected,  and  even  the 
finger  mav  suffer.  The  furrow,  fold,  and  bed  of  the  nail 
all  become  inflamed,  ulcerated,  and  exquisitely  tender,  dis- 
charging more  or  less  pus.  It  is  said  to  be  more  common 
in  young  people  than  in  old,  and  far  more  frequent  in  men 
than  in  women.  Paronychia  of  either  the  ulcerative  or 
non-ulcerative  form  is  frequently  met  with  in  syphilis. 

Treatment.  Severe  cases  of  paronychia  most  often  find 
their  way  to  the  surgeon's  hands.  In  syphilitic  paronychia 
general  anti-syphilitic  treatment  is  required.  In  the  non-ulcer- 
ative form  mercurial  ointment,  diluted  with  one  or  two  parts 
of  diachylon  ointment,  may  be  used,  or  the  mercurial  plas- 


344  DISEASES    OF    THE    SKIN. 

ter.  In  the  ulcerative  form,  the  parts  should  be  cauterized 
with  nitric  acid  or  a  strong  solution  of  acid  nitrate  of  mer- 
cury, followed  by  water  dressings.  Afterward  the  part 
may  be  dressed  with  iodoform  or  aristol.  Bandaging,  strap- 
ping with  mercurial  plaster,  and  the  use  of  rubber  cots  are 
also  useful  methods  of  treatment. 

In  ingrowing  toe-nail  the  nail  should  be  filed  down  the 
middle,  or,  if  that  does  not  relieve  the  pressure,  it  may  have 
to  be  removed,  in  part  or  entire.  The  insertion  of  borated 
lint  between  the  nail  and  the  nail-fold,  or  using  boric  acid 
in  powder  first  and  some  threads  of  lint  or  a  little  absorbent 
cotton  to  separate  the  parts,  and  strapping  the  toe  with  ad- 
hesive plaster,  will  also  answer  well.  If  ulceration  has  taken 
place,  the  ulcerated  surface  should  be  dressed  with  iodoform 
or  aristol.  If  the  ulceration  should  be  covered  with  exu- 
berant granulations,  they  should  be  touched  with  the  nitrate 
of  silver  stick.  As  a  preventive  of  the  trouble,  wearing 
well-fitting  shoes  and  keeping  the  nails  clean  and  cut  down 
the  middle  are  the  best  means  at  our  command. 

Paxton's  Disease.     See  Tinea  nodosa. 

Pediculosis  (Pe2d-i2k-u2l-or-si2s).  Synonyms :  Phthiri- 
asis  ;  Morbus  pediculare  ;  Pedicularia ;  Lousiness. 

Symptoms.  There  are  three  varieties  of  lice  that  infest 
the  human  species,  namely,  the  pediculus  capitis,  pediculus 
vestimentorum,  and  pediculus  pubis.  Though  they  all  be- 
long to  one  family,  they  differ  among  themselves,  and  have 
distinct  regions  which  they  invade. 

The  pediculus  capitis  infests  the  head  only,  and  of  that 
the  occipital  region  is  the  seat  of  invasion.  From  there  it 
generally  spreads  to  the  parietal  region,  whicli  is  one  of  the 
best  places  in  which  to  seek  for  nits,  and,  maybe,  all  over  the 
scalp.  The  lice  cause  irritation  of  the  scalp  both  by  their 
movements  and  by  the  insertion  of  their  haustellum  into  the 
follicles  of  the  skin  for  feeding  purposes.  The  louse  has  no 
mandibles.  There  is  no  such  thing  as  a  louse-bite.  They 
simply  suck  their  nutriment  by  inserting  their  haustellum 
into  the  follicles  of  the  skin.  The  victim  scratches  to  re- 
lieve  the  itching  and  irritation,  and  this  gives  rise  to   a 


PEDICULOSIS.  345 

dermatitis  of  eczematous  character  with  the  production  of 
large  pustules.  A  fully  developed  and  characteristic  case 
shows  the  hair  in  the  occipital  region  matted  together  with 
a  sticky  secretion  and,  maybe,  blood-crusts,  more  or  less 
eczematous  lesions  and  scattered  pustules  over  the  whole 
scalp,  enlarged  lymphatic  glands  in  the  neck,  and  perhaps 
a  few  small  pustules  on  the  neck  and  face.  When  a  patient 
presents  himself  with  a  pustular  eruption  on  the  neck,  ped- 
iculosis capitis  should  always  be  suspected,  and  search  made 
for  the  pediculi  or  their  nits  upon  the  occipital  and  parietal 
regions.  Very  often  no  pediculi  can  be  found,  but,  if  the 
disease  is  pediculosis,  the  nits  will  be  discovered  in  the 
localities  mentioned. 

The  pediculus  vestimentorum,  or  body-louse,  inhabits  the 
seams  of  the  clothing,  where  it  lays  its  eggs,  and  which  it 
leaves  only  for  the  purpose  of  feeding  upon  the  skin.  It 
inserts  its  haustellum  into  the  follicles  of  the  skin,  and  thus 
produces  a  small  hemorrhagic  spot,  even  with  the  surface  of 
the  skin,  which  is  a  pathognomonic  lesion  of  the  disease. 
This  feeding  gives  rise  to  itching,  and  the  victim  scratches 
to  relieve  it,  thus  producing  a  second  symptom,  excoriations. 
These  have  one  peculiarity,  which  is  that  they  are  very  apt 
to  take  the  form  of  long,  parallel  scratch-marks,  because  the 
patient  digs  into  his  skin  with  all  four  nails  at  once.  More- 
over, as  the  lice  live  by  preference  in  the  shirt-band  at  the 
back  of  the  neck,  these  long  scratch-marks  are  most  often 
seen  over  the  shoulders.  Whenever  they  are  seen  we  should 
suspect  lice.  Excoriations  are  also  seen  on  the  inside  of  the 
limbs  in  locations  corresponding  to  the  seams  of  the  clothing. 
In  certain  individuals,  besides  excoriations  and  hemorrhagic 
specks,  we  will  find  ecthymatous  pustules,  ulcerations,  and, 
in  very  old  cases,  a  great  deal  of  pigmentation,  so  that  the 
skin  appears  as  if  affected  with  a  general  chloasma.  Any 
of  these  symptoms,  hemorrhagic  specks,  excoriations,  and 
itching,  which  is  incessant  in  pronounced  cases,  should  lead 
us  to  suspect  lice,  and  a  careful  search  of  the  seams  of  the 
clothing  will  reveal  them,  unless  the  patient  has  changed 
everything  before  coming  to  us.     It  must  be   remembered 

15* 


346  DISEASES    OF    THE    SKIN. 

that  the  lice  dwell  both  in  the  linen  and  woollen  clothing, 
and,  in  bad  cases,  in  the  bedding  also. 

The  pediculus  pubis,  crab-louse  or  morpion,  has  a  far 
wider  feeding  range  than  the  other  varieties.  Though  its 
favorite  feeding-ground  is  the  pubic  region,  it  may  be  met 
with  upon  the  hair  of  the  abdomen,  chest,  axillae,  beard, 
eyebrows  and  eyelashes.  Itching,  excoriations,  and  eczema- 
tous  lesions  are  -the  symptoms  it  gives  rise  to,  though  the 
disturbance  is  not  so  great  as  that  caused  by  the  other  forms 
of  lice.  It  is  the  least  common  variety.  It  requires  care- 
ful search  and  a  sharp  eye  to  discover  the  vermin  at  times, 
as  they  are  almost  transparent,  and  usually  are  attached  to 
the  hairs  head  downward,  and  close  to  the  skin.  Cobbold 
taught  that  the  pediculus  that  inhabits  the  eyelashes  was  a 
distinct  species,  the  pediculus  palpebrarum  ;  but  by  most 
authorities  the  distinction  is  not  made.  In  some  cases,  in- 
stead of  red  punctate  marks,  we  find  dull  or  slaty  gray,  or 
pale-blue,  lentil  to  split-pea-sized  macules  scattered  over  the 
pubes,  abdomen,  extensor  surface  of  the  arms,  axillae,  and 
inside  of  the  thighs.  These  are  known  as  maeulce  eerulecB, 
or  taches  ombrees.  They  do  not  disappear  on  pressure,  last 
for  a  few  days,  and  then  disappear  of  themselves.  To  give 
rise  to  these  spots  there  must  be  a  predisposition  on  the  part 
of  the  skin.  Most  of  the  few  reported  cases  have  been  in 
debilitated  subjects.  According  to  Duguet,1  the  macules 
are  produced  by  the  emptying  of  the  contents  of  the  salivary 
glands  of  the  louse  beneath  the  human  epidermis. 

Etiology.  All  these  diiferent  varieties  of  pediculosis  are 
due  to  different  varieties  of  lice.  The  head-louse  (Fig-  35)  is 
about  2  mm.  long  and  1  mm.  broad,  with  a  triangular  head 
and  broad  thorax  and  short  legs.  The  body-louse  (Fig.  36) 
is  larger  than  the  head-louse,  being  2  or  3  mm.  long,  with 
a  more  oval  head  and  longer  legs  with  more  developed  claws. 
The  pubic  louse  is  broader  and  flatter  than  either  of  the 
others,  with  rounder  head,  longer,  stronger,  and  more  claw- 
like legs,  resembling  somewhat  a  crab  (Fig.  37).  The  color 
of  the  lice  is  gray  or  white.     They  propagate  with  great 

1  Gaz.  des  Hop.,  1880,  liii.  362. 


PEDICULOSIS. 


347 


rapidity,  the  young  hatching  out  in  six  or  seven  days,  and 
being    capable  within  eighteen    days   of  propagating  their 


Fig.  35. 


Pediculus  capillitii. — Male. 
(After  Kuchenmeister.) 


Fig.  37. 


Fig.  36. 


Pediculus  corporis. 
(After  Kuchenmeister.) 


Pediculus  pubis.     (After  Schmarda.) 


species.  It  has  been  calculated  that  two  female  lice  might 
become  the  grandmothers  of  10,000  lice  in  eight  weeks' 
time.     The  pediculi  deposit  their  eggs  close  to  the  scalp 


348 


DISEASES    OF    THE    SKIN. 


Fig.  38. 


ift 


S 


■a 


and  secrete  a  glue-like  substance  that  sticks  the  ova  to  the 
hair.  There  may  be  but  one  ova  on  a  hair,  or  many  of 
them.  The  distance  of  the  nit  from  the  scalp  shows  the 
length  of  time  that  the  disease  has  existed.  As  it  takes  the 
hair  about  a  month  to  attain  the  length 
of  three-fourths  of  an  inch,  if  we  find 
the  nit  that  distance  from  the  scalp  we 
know  that  it  was  deposited  at  least  one 
month  before.  The  severity  of  the  symp- 
toms to  which  the  lice  give  rise  will 
vary  with  the  individual,  some  people 
being  far  more  susceptible  than  others. 
Infection  takes  place  from  other  people 
or  from  infested  body  or  bed  clothing. 
Women  and  children  are  the  most  fre- 
quent victims  of  pediculosis  capitis ; 
adults,  and  especially  elderly  people,  of 
pediculosis  vestimentorum.  Pediculosis 
pubis  is  most  frequently  obtained  from 
impure  sexual  intercourse,  and  is,  there- 
fore, most  common  in  young  adults. 
Dirt  and  uncleanness  favor  all  forms, 
though  even  the  most  cleanly  may  at 
times  harbor  vermin. 

Diagnosis.  Pediculosis  capitis  needs 
to  be  diagnosticated  from  eczema.  The 
characteristic  location  of  its  lesions  upon 
the  occipital  region  and  nape  of  the  neck, 
with  its  scattered  and  discrete  large  pus- 
tules over  more  or  less  of  the  scalp, 
should  always  suggest  pediculosis  ;  then, 
if  the  lice  or  their  ova  are  found  by 
searching  the  hair,  the  diagnosis  is  es- 
tablished. Nits  here,  as  elsewhere,  are 
diagnosticated  from  epidermic  scales  by 
being  located  upon  the  side  of  the  hair,  while  the  scale 
has  a  hair  passing  through  its  centre  (Fig.  38).  The  nit, 
too,  is  of  a  yellowish  color,  somewhat  pear-shaped,  with 
its  larger  rounded  end  upward,  and  it  adheres  closely  to 


\ 


h 


Ova  of  head-louse 
attached  to  hair.  (Af- 
ter Kaposi.) 


PEDICULOSIS.  849 

the  hair,  so  as  not  to  be  readily  removed.  It  is  not 
always  easy  to  distinguish  pediculosis  vestiuientorum  from 
pruritus  cutaneus,  especially  if  at  the  time  the  patient 
presents  himself  he  has  clean  clothes  on  throughout.  Both 
may  occur  in  elderly  people,  and  both  may  last  a  long  time 
with  no  other  lesion  than  scratch-marks.  In  pruritus  we 
may  find  evidences  of  atrophic  skin  changes;  the  itching  is 
often  paroxysmal,  and  made  worse  by  the  patient  becoming 
overheated.  If  we  find  the  parallel  scratch- marks  over  the 
shoulders  and  the  hemorrhagic  specks,  we  can  make  a  positive 
diagnosis  of  pediculosis.  From  urticaria  pediculosis  vestimen- 
torum  differs  in  having  hemorrhagic  specks  and  in  the  parallel 
scratch-marks.  Urticaria  may  complicate  a  pediculosis. 
Scabies  differs  from  pediculosis  in  appearing  by  preference 
upon  the  anterior  face  of  the  wrists,  upon  the  breasts  in 
women,  upon  the  penis  of  men,  and  about  the  waist-bands 
of  both  sexes.  Its  excoriations  are  not  long,  parallel 
scratch-marks,  but  small  excoriations.  If  the  lice  or  their 
ova  can  be  found  in  any  case  the  diagnosis  of  pediculosis  is 
made  easy.  Dermatitis  herpetiformis  differs  from  pedicu- 
losis in  wanting  the  parallel  scratch-marks  and  in  the  mark- 
edly grouped  character  of  its  lesions.  There  will  often  be 
found  groups  of  vesicles  scattered  about  the  skin.  There 
can  be  no  difficulty  in  diagnosticating  the  pediculosis  pubis. 
Any  itching  there  should  lead  to  an  investigation,  which,  if 
carefully  made,  will  reveal  the  pediculi  or  their  nits. 

Treatment.  The  most  ready  means  of  curing  the  dis- 
ease when  in  the  hairy  regions  is  to  shave  the  hair  off*  and 
make  some  emollient  application  to  the  scalp  to  cure  the 
eczema.  But  this  is  not  advisable,  excepting  in  children 
and  in  men  in  hospitals,  and  is  not  necessary,  The  most 
speedy  and  practicable  method  in  public  practice  is  to  soak 
the  head  or  pubic  region  in  raw  petroleum  or  kerosene,  with 
or  without  diluting  it  with  sweet  oil.  This  may  be  done 
night  and  morning  for  two  days  and  the  parts  then  washed 
with  soap  and  water.  This  will  effectually  kill  all  the  lice, 
and  probably  destroy  the  life  of  the  ova.  The  latter  must  be 
removed  for  fear  that  they  are  not  dead,  and  for  this  pur- 
pose we  may  use  the  fine-toothed  comb  to  the  hair  or  pull 


350  DISEASES    OP    THE    SKIN. 

the  hair  through  a  cloth  saturated  with  vinegar  or  dilute 
acetic  acid,  which  will  soften  the  gluey  attachment  of  the 
nits.  No  attention  is  to  be  paid  to  the  dermatitis  until  after 
the  cause  of  it  is  removed,  when  it  will  rapidly  get  well 
under  any  simple  treatment.  In  private  practice,  an  in- 
fusion of  staphisagria  (larkspur  seeds),  or  a  10  per  cent, 
solution  of  carbolic  acid,  or  a  half  to  one  per  cent,  solution 
of  bichloride  of  mercury,  may  be  substituted  for  the  petro- 
leum. The  bichloride  should  not  be  used  if  there  is  much 
dermatitis.  The  ointment  of  the  ammoniate  of  mercury  is 
efficient,  but,  as  a  rule,  an  ointment  should  not  be  used  on 
hairy  parts.  Blue  ointment  is  a  well-known  remedy  for 
pediculosis  pubis,  but  it  is  apt  to  set  up  a  dermatitis  that  is 
undesirable. 

For  pediculosis  vestimentorum  there  is  no  use  in  making 
any  application  to  the  skin.  The  wToollen  clothes  should  be 
baked  in  a  hot  oven  and  the  underclothing  and  sheets  should 
be  well  boiled.  If  this  cannot  be  done,  or  new  clothes  ob- 
tained, powdered  sulphur  or  staphisagria  may  be  powdered 
in  all  the  seams  of  the  clothing. 

Pelade.     See  Alopecia  areata. 

Peliosis  Rheumatica.     See  Purpura. 

Pelioma  Typhosum.     See  Maculae  caerulese 

Pellagra  (Pe2l'-la3-gra3).  Synonyms  :  Risipola  lombarda ; 
Mai  de  la  rosa ;  Mai  roxo ;  Lombardian  leprosy. 

Symptoms.  But  few  cases  of  this  disease  have  been  re- 
ported in  this  country.  Since  the  number  of  Italians  is 
constantly  increasing  here  it  is  important  for  us  to  be  able 
to  recognize  the  disease.  It  has  prodromal  symptoms  of 
progressive  weakness,  intestinal  catarrh,  lassitude,  giddiness, 
headache,  and  burning  sensations  in  back,  limbs,  hands,  and 
feet.  These  make  their  appearance  in  the  spring,  and 
shortly  after  an  erythema  affects  the  backs  of  the  hands 
down  to  the  articulation  of  the  first  and  second  phalanges, 
the  backs  of  the  wrists  and  forearms  up  to  the  elbow,  the 
backs  of  the  feet,  if  the  person  goes  barefoot,  the  front  of 
the  neck  and  chest  to  the  lower  edge  of  the  first  piece  of  the 
sternum,  and,  in  women  and  children,  the  forehead,  nose, 


PELLAGRA.  351 

and  cheeks — that  is,  all  those  regions  exposed  to  the  sun. 
The  color  is  bright,  dark,  or  livid  red,  and  is  not  a  simple 
erythema,  as  the  color  cannot  be  made  to  completely  disap- 
pear under  pressure.  The  skin  is  often  so  swollen  as  to 
prevent  all  work.  Bullae  may  form  upon  the  affected  parts 
and  be  followed  by  erosions.  In  a  few  weeks  desquamation 
begins,  but  the  skin  continues  discolored  and  thickened  up 
to  July  or  August,  when  a  gradual  decline  of  all  the  symp- 
toms takes  place.  During  the  winter  the  patient  may  appear 
quite  well,  but  a  relapse  is  pretty  sure  to  occur  daring  the 
next  spring,  and  to  recur  each  succeeding  spring  with  ever- 
increasing  severity  of  all  the  symptoms ;  the  patient  emaci- 
ates, loses  strength,  develops  grave  cerebro-spinal  neurosis, 
sinks  into  a  typhoid  state,  and  dies.  The  skin  becomes 
atrophied,  smooth,  shining,  cracked,  or  it  may  be  thickened. 
There  is  loss  of  cutaneous  sensibility  and  the  erythematous 
redness  gradually  extends  over  the  whole  surface  of  the 
body.     The  average  duration  of  the  disease  is  five  years. 

Etiology.  The  disease  is  endemic  in  northern  and 
central  Italy,  especially  in  Lombardy,  Venetia,  and  iEmilia ; 
in  the  southwestern  part  of  France,  and  in  the  north  part 
of  Spain.  It  may  occur  anywhere.  Women  are  most  sub- 
ject to  it,  children  least  so.  It  seems  to  be  a  disease  fos- 
tered by  poverty,  want,  and  bad  hygiene,  and  to  be  induced 
by  an  almost  exclusive  diet  of  decomposed  or  fermented 
maize  or,  possibly,  other  grains.  Some  cases  have  been 
traced  to  the  drinking  of  spirits  made  from  damaged  maize. 
It  is,  therefore,  similar  in  origin  to  ergotism.  It  is  not 
contagious  or  hereditary. 

Diagnosis.  A  suspicion  of  a  case  being  one  of  pellagra 
should  be  aroused  whenever  an  erythema  upon  the  exposed 
parts  is  met  with  in  a  person  coming  from  the  regions  in 
which  the  disease  is  known  to  be  endemic,  especially  if  it 
is  combined  with  more  or  less  lassitude  and  hebetude. 

Treatment.  The  treatment  of  the  disease  is  mainly 
hygienic  and  symptomatic.  Crocker  has  faith  in  the  effi- 
cacy of  arsenic  for  adults,  and  frictions  with  chloride  of 
sodium  solution  in  children. 


352  DISEASES    OF    THE    SKIN. 

Pemphigus  (Pe2m/fi2-gu3s).  Synonyms :  Pompholyx ; 
(Ger.)  Blasenausschlag ;  (Ital.)  Pemfigo. 

A  chronic  disease  of  the  skin  characterized  by  the  erup- 
tion of  successive  crops  of  bullae  upon  the  apparently  sound 
skin  and  with  either  transient  or  no  antecedent  erythema. 

At  one  time  every  bullous  eruption  was  a  pemphigus,  but 
with  more  careful  observation  and  study  a  number  of  bullous 
eruptions  have  been  lifted  out  of  pemphigus,  and  estab- 
lished as  distinct  diseases.  It  is  probable  that  this  process 
of  elimination  will  continue.  In  the  meantime  a  considera- 
ble degree  of  uncertainty  pervades  our  knowledge  of  the 
disease,  both  as  to  its  symptomatology  and  etiology,  and  we 
can  only  stand  and  await  further  developments.  While  in 
this  attitude  we  must  have  some  sort  of  a  chart  to  guide  us, 
and  it  has  been  my  object  to  draw  its  lines  with  as  great 
sharpness  as  possible. 

The  disease  is  a  rare  one  in  this  country,  only  183  cases 
being  reported  in  a  total  of  123,746  cases  in  the  statistical 
tables  of  the  American  Dermatological  Association  from 
1878  to  1887.  My  own  experience  shows  it  to  be  still 
more  rare,  as  I  have  seen  only  two  cases  which  I  was  willing 
to  call  pemphigus  out  of  some  10,000  cases  in  public  and 
private  practice. 

Symptoms.  It  is  usual  to  describe  two  varieties  of  pem- 
phigus, namely  :  pemphigus  vulgaris  and  pemphigus  folia- 
ceus. 

Pemphigus  Vulgaris  may  begin  with  an  outbreak  of 
bullae,  or  there  may  be  more  or  less  constitutional  disturb- 
ance before  their  appearance.  The  latter  condition  is  more 
often  seen  in  debilitated  subjects,  children,  and  old  people, 
and  consists  in  chilliness,  nausea,  and,  perhaps,  a  rise  of  two 
or  three  degrees  of  temperature.  These  constitutional  dis- 
turbances may  occur  before  the  appearance  of  each  crop  of 
bullae.  The  characteristic  eruption  is  an  outbreak  of  two 
or  more  pinhead-sized  vesicles  that  in  a  few  hours  develop 
into  tense,  oval,  hemispherical,  prominently  raised,  fully 
distended  bullae  with  translucent  contents.  The  size  of  the 
bullae  varies ;  it  may  be  but  one-eighth  of  an  inch  in  diam- 
eter, or,  by  the  coalescence  of  several  neighboring  bullae, 


PEMPHIGUS.  353 

large,  irregular  ones  of  two  or  three  inches  in  diameter  may 
be  formed.  One  distinguishing  feature  of  these  bullae  is 
that  they  have  no  areola,  but  spring  up  at  once  from  the 
seemingly  healthy  skin.  Their  contents  soon  becomes  tur- 
bid, or  perhaps  purulent,  and  then  a  slight  inflammatory 
halo  may  form.  The  bullae  do  not  tend  to  rupture  spontane- 
ously, but  to  dry  up,  and  leave  the  dried  cover  as  a  crust.  If 
they  are  ruptured  accidentally,  an  excoriated  place  is  left 
that  heals  more  or  less  readily,  according  to  the  general 
condition  of  the  patient.  Some  pigmentation  may  be  left 
for  a  time  to  mark  the  site  of  the  bullae. 

This  eruption  may  take  place  anywhere,  but  affects  par- 
ticularly the  lower  part  of  the  face,  the  trunk,  and  limbs. 
It  is  usually  bilateral,  and  may  be  roughly  symmetrical. 
The  life  of  the  individual  bulla  is  two  to  eight  days ;  but 
while  one  crop  is  disappearing  a  new  one  forms,  and  the 
duration  of  the  disease  may  thus  be  measured  by  weeks  or 
months.  Sometimes  there  is  an  interval  of  weeks  or  months 
between  the  outbreaks.  In  favorable  cases  a  few  crops 
appear,  and  that  is  all,  the  patient  making  a  good  and  com- 
plete recovery.  In  less  favorable  cases,  or  when  the  eruption 
is  very  extensive,  frequent  relapses  and  many  excoriations 
take  place,  the  patient's  strength  becomes  exhausted  by  the 
constant  drain  upon  his  system  and  loss  of  rest  on  account 
of  the  discomfort  of  his  condition;  he  may  die  in  a  typhoid 
state,  or  of  some  intercurrent  affection.  A  number  of  cases 
of  death  from  the  disease  within  two  or  three  weeks  have 
been  reported,  and  to  these  the  name  of  acute  pemphigus 
is  given.  A  few  authorities  have  reported  acute  bullous 
eruptions  running  their  course  in  three  to  six  weeks  as  acute 
pemphigus.  Many  of  these  cases  were  probably  cases  of 
bullous  erythema,  as  in  many  of  them  a  preceding  ery- 
thema is  noted  in  the  reports  of  the  cases.  Most  cases  run 
a  chronic  course,  extending  over  months  or  years. 

In  rare  instances  a  diphtheritic  membrane  may  form  at  the 
site  of  the  bullae,  or,  instead  of  healing  taking  place,  a  gan- 
grenous process  may  be  set  up,  with  considerable  destruc- 
tion of  tissue,  or  hemorrhage  may  take  place  in  some  of  the 
bullae. 


354 


DISEASES    OF    THE    SKIN 


Neumann  has  described  as  'pemphigus  vegetans  a  bullous 
eruption  in  which  healing  does  not  take  place,  but  the  base 
becomes  covered  with  sprouting  granulations  and  assumes 
an  uneven  surface  marked  by  furrows  and  secreting  a  thin 
fluid.  The  raw  patches  thus  formed  spread  slowly  at  their 
circumference,  and  neighboring  ones  coalesce.  The  disease 
proves  progressive ;  marasmus,  and  finally  death  closes  the 
scene.     Most  of  the  cases  are  in  syphilitics. 

All  the  mucous  membranes  may  be  affected  by  pemphi- 
gus, and  the  excoriations  that  thus  form  in  the  mouth  add 
greatly  to  the  discomfort  of  the  disease.  The  conjuntiva  is 
not  spared,  and  if  attacked  serious  deformity  results. 

'Cases  of  pemphigus  neonatorum  have  been  reported  from 
time  to  time,  and  epidemics  of  it  have  been  described.  These 
are  so  evidently  septic  in  origin  that  they  hardly  admit  of 
being  classified  under  the  heading  of  pemphigus.  Careful 
reading  of  not  a  few  outbreaks  of  contagious  pemphigus 
reported  in  the  German  journals  will  convince  one  who  is 
acquainted  with  the  bullous  form  of  contagious  impetigo 
that  a  mistake  in  diagnosis  had  been  made  by  the  reporter. 
Still,  until  further  evidence  is  forthcoming,  it  is  probably 
advisable  to  allow  that  both  of  these  varieties  of  the  disease 
do  exist.  Pempliigus  pruriginoxu*  is  another  variety  made 
by  writers.  It  fits  in  quite  well  under  Duhring's  dermatitis 
herpetiformis. 

Pemphigus  Foliaceus  differs  considerably  from  pemphigus 
vulgaris.  It  may  begin  as  such  or  it  may  develop  from 
pemphigus  vulgaris.  Behrend1  teaches  that  the  difference 
between  the  two  forms  is  simply  a  matter  of  coherence  be- 
tween the  epidermis  and  corium,  this  being  so  slight  in  pem- 
phigus foliaceus  that  we  have  a  flaccid  bulla  instead  of  the 
tense,  fully  distended  one  of  pemphigus  vulgaris. 

Pemphigus  foliaceus  is  much  the  more  rare  variety  of  the 
disease,  Crocker  giving  its  occurrence  as  one  in  five  thous- 
and cases.  Its  characteristic  lesions  are  flaccid  bullae,  with 
opaque  contents,  that  soon  rupture  and  leave  raw,  moist 
surfaces  with  an  edge  of  ragged  epithelium.     The  fluid  of  the 

1  Vierteljahr.  f.  Dermat.  u.  Syph.,  1879,  vi.  191. 


PEMPHIGUS.  355 

bullae  changes  its  position  with  the  position  of  the  patient, 
always  seeking  the  most  dependent  part,  and  soon  becomes 
purulent.  After  the  disease  has  existed  some  time  the 
patient  emits  a  sickening  odor  on  account  of  the  large 
amount  of  the  raw  surfaces  of  the  ruptured  bullae  that  are 
bathed  with  sero-pus.  Affecting  at  first  only  a  limited 
space,  by  degrees  the  disease  spreads  so  that  the  whole  body 
surface  becomes  red  and  weeping,  looking  like  eczema 
rubrum,  with  crusts  and  areas  of  ragged  epithelium.  The 
palms  and  soles  are  often  spared  on  account  of  the  thickness  of 
their  epidermal  coverings.  When  the  skin  is  thus  generally 
involved  it  is  difficult  to  establish  the  fact  of  the  occurrence 
of  new  bullae.  The  mucous  membranes  of  the  mouth  and 
pharynx  are  affected  in  like  manner,  becoming  converted 
into  raw  patches.  The  hair  falls  out ;  the  nails  become 
thinner,  brittle,  atrophied,  and,  maybe,  drop  off;  and  ectro- 
pion is  apt  to  result  from  contraction  of  the  skin  about  the 
eyes.  The  mucous  membranes  are  also  attacked,  which 
greatly  adds  to  the  patient's  discomfort. 

The  condition  of  the  patient  is  most  deplorable  in  these 
extensive  cases ;  his  skin  is  stiff  and  sore,  and  perhaps 
smarts  ;  and  after  months  or  years  he  succumbs  to  the  drain 
on  his  system,  sinks  into  a  typhoid  state,  and  dies.  During 
the  early  part  of  the  disease  there  may  be  no  constitutional 
disturbance.  But  eventually  death  is  quite  sure  to  result, 
if  not  from  the  disease,  from  some  intercurrent  affection 
against  which  the  patient  is  unable  to  offer  any  resistance. 

Etiology.  We  know  very  little  about  the  causes  of 
pemphigus.  The  tropho-neurotic  theory  of  the  disease 
offers  us  a  cloak  for  our  ignorance,  and  perhaps  is,  after 
all,  the  true  one.  Experiments  have  demonstrated  that 
bullae  can  be  made  to  form  by  operations  on  the  spinal  cord, 
and  observation  has  shown  that  bullae  do  form  in  certain 
spinal  diseases.  Both  sexes  are  equally  subject  to  the  dis- 
ease. Children  are  more  often  affected  than  adults.  The 
septic  origin  of  certain  bullous  eruptions  has  already  been 
spoken  of  under  the  heading  of  pemphigus  neonatorum. 
Bullous  eruptions  are  hereditary  in  some  families,  and  in 
some  subjects  follow  slight  injuries  to  the  skin.     Chilling  of 


356  DISEASES    OF    THE    SKIN. 

the  body  seems  to  have  been  the  exciting  cause  of  some 
cases.  Some  have  advanced  the  theory  that  an  excess  of 
ammonia  in  the  blood  or  defective  kidney  elimination  are 
the  cause  of  the  disease.  Attacks  of  the  disease  have  been 
observed  to  occur  with  each  new  pregnancy  in  some  women. 
Thus  we  see  that  so  far  we  have  only  more  or  less  ingenious 
hypotheses  and  theories  in  answer  to  our  question,  What  are 
the  causes  of  pemphigus? 

Pathology.  "  Most  authors  regard  the  actual  formation 
of  the  bulla  as  due  to  an  inflammation  of  the  papillary 
layer,  with  outpouring  of  fluid  from  the  vessels,  but  Aus- 
pitz  calls  it  an  akantholysis,  or  loosening  of  the  prickle-cell 
layer,  by  the  sudden  escape  of  fluid  from  the  vessels, 
destroying  the  young  prickle  cells  and  lifting  up  the  epider- 
mis as  a  whole.  Any  inflammatory  phenomena,  he  thinks, 
are  secondary  "(Crocker).  Microorganisms  have  been  found 
in  the  fluid  both  of  the  bullae  of  chronic  and  acute  pemphi- 
gus, but  their  connection  with  the  disease  has  not  been 
satisfactorily  demonstrated. 

Diagnosis.  If  we  regard  the  pathognomonic  symptoms 
of  pemphigus  vulgaris  as  fully  distended  bulled  springing  up 
out  of  the  sound  skin  without  any  antecedent  erythema  and 
without  inflammatory  halo,  and  occurring  in  crops  so  as  to 
run  a  chronic  course,  then  little  difficulty  will  arise  in  diag- 
nosis. A  bullous  erythema  lias  bullae  arising  upon  an  ery- 
thematous base  or  with  erythematous  lesions  elsewhere,  and 
runs  a  comparatively  acute  course.  In  bullous  urticaria  the 
bulla  rises  upon  a  wheal.  The  bullous  form  of  impetigo 
contagiosa  will  be  quite  sure  to  present  the  characteristic 
impetigo  pustules  upon  the  hands  or  face,  and  search  will 
probably  discover  some  child  with  impetigo  with  whom  the 
patient  has  come  into  contact.  Varicella  bullosa  occurs 
epidemically,  and  runs  a  short  course. 

Pemphigus  foliaceus  when  in  its  early  stage,  and  affecting 
but  a  small  area,  is  readily  diagnosticated  by  the  occurrence 
of  its  flabby  bullae,  arising  without  antecedent  injury.  After 
it  has  lasted  long  enough  to  involve  a  large  area  it  is  with 
difficulty  diagnosticated  from  eczema  rubrum  and  dermatitis 
exfoliativa.     In  fact  without  the  history  of  the  case  it  is 


PEMPHIGUS.  357 

sometimes  almost  impossible  to  make  the  diagnosis.  It  may 
be  differentiated  from  eczema  rubrum  by  its  crusts  being 
made  less  of  dried  exudation  than  of  epithelium,  by  the 
slighter  amount  of  exudation,  by  the  ragged  look  of  some  part 
of  the  disease,  and  by  careful  watching  for  and  finding  the 
large  flaccid  bullae  which  will  be  sure  to  appear  if  the  case  is 
one  of  pemphigus.  Moreover,  a  universal  eczema  rubrum 
is  very  rare,  and  the  itching  is  more  pronounced.  Derma- 
titis exfoliativa  differs  from  pemphigus  in  the  absence  of 
moisture  and  of  bullae,  and  in  the  thinness  of  the  exfoliated 
epidermis.  Lichen  ruber  acuminatum  is  also  perfectly  dry 
and  presents  characteristic  papules. 

Treatment.  The  drug  upon  which  most  reliance  is 
placed  in  the  treatment  of  this  disease  is  arsenic.  We  may 
use  Fowler's  solution  ;  or  arsenions  acid  in  pill  form,  as  the 
tablet  triturate  with  piperina,  or  the  Asiatic  pill.  Whatever 
form  is  given  it  is  advisable  to  begin  with  small  doses  and 
push  them  gradually  up  until  the  limit  of  tolerance  is  reached, 
or  the  disease  is  controlled.  Unfortunately  it  often  disap- 
points us  in  its  effects.  Attention  to  diet  and  hygiene,  and 
the  general  condition  of  the  patient,  with  the  judicious  use 
of  tonics,  such  as  quinine,  iron,  and  cod-liver  oil,  will  often 
do  as  much,  if  not  more,  than  arsenic  to  cure  the  patient. 

Locally,  dusting  powders  of  oxide  of  zinc,  starch,  lycopo- 
dium,  or  bismuth  in  varying  combinations;  lotions  of  lime- 
water,  borax,  zinc,  liquor  plumbi  subacetatis,  and  the  like, 
prove  helpful  in  allaying  irritation  and  discomfort.  Lassar's 
paste  is  also  a  good  application.  Unna1  recommends  equal 
parts  of  linseed  oil,  lime-water,  oxide  of  zinc,  and  chalk, 
both  to  dry  up  the  bullae  and  prevent  their  return.  Lini- 
mentum  calcis  with  one  minim  of  creasote  to  the  ounce  is 
recommended  by  Hardaway.  The  continuous  warm  bath 
has  afforded  great  relief  in  the  Vienna  hospitals.  The 
bullae  may  be  opened  if  they  are  troublesome.  Alkaline 
and  antiseptic  mouth-washes  will  afford  relief  where  the 
mucous  membranes  are  affected. 

Prognosis.     The   chances    of    recovery   are    uncertain. 

1  Monatshefte  f.  prakt.  Dermat.,  1888,  No.  1. 


358  DISEASES    OF    THE    SKIN. 

While  many  cases  of  pemphigus  vulgaris  recover,  relapses 
are  the  rule,  and  if  the  patient  is  not  strong,  or  the  disease 
has  lasted  a  long  time,  a  guarded  prognosis  should  be  made. 
Hemorrhagic,  diphtheritic  or  fungating  bullae  are  of  bad 
augury.  Pemphigus  vegetans  and  pemphigus  foliaceus  are 
almost  invariably  fatal. 

Perforating  Ulcer  of  the  Foot  is  an  accident  liable  to 
occur  in  those  in  whom  the  nerve  supply  to  the  foot  is  de- 
ficient, as  in  locomotor  ataxia,  syphilis,  leprosy,  and  periph- 
eral neuritis.  The  most  common  location  for  the  ulcer 
is  at  the  metatarso-phalangeal  articulation  of  the  great  or 
little  toe,  or  the  cushion  of  the  great  toe.  It  may  be  only 
on  one  foot,  or  both  feet  may  be  affected.  The  process  is 
slow,  beginning  as  a  proliferation  of  the  epidermis  like  a  corn, 
under  which  suppuration  takes  place,  and  an  ulcer  is  left. 
This  goes  deeper  into  the  tissues  until  a  sinus  forms  that 
reaches  to  the  bone.  The  edges  of  the  ulcer  are  hard. 
Usually  there  is  little  pain,  though  there  may  be  hyperaes- 
thesia  of  the  surrounding  parts.  This  painlessness  distin- 
guishes it  from  a  suppurating  corn.  The  palms  may  be 
affected  in  the  same  way  as  the  soles.  The  disease  is  very 
intractable,  and  must  be  managed  on  surgical  principles, 
amputation  of  the  whole  or  part  of  the  foot  being  required 
in  some  cases.     Death  may  result  from  the  disease. 

Under  the  name  of  "  Hand  and  Foot  Disease"  Hyde  re- 
ports1 three  cases  of  ulcerations  of  the  hands  and  feet  that 
he  regards  as  due  to  tropho-neurotic  disturbances.  In  these 
cases,  with  or  without  functional  disturbances,  such  as 
hyperidrosis  and  coldness  of  the  hands  and  feet,  bromidrosis, 
local  anaesthesias,  vertigo,  faintness,  and  rheumatic  pains, 
there  were  found  various  grades  of  dystrophia  unguium, 
from  roughness  to  onychogryphosis,  tender  and  painful  or 
insensitive  maculations  of  the  hands  and  feet,  pigmentary 
patches  on  the  palms  and  soles  or  the  backs  of  the  hands  or 
feet,  or  both  ;  different  dermatoses,  such  as  erythema,  ec- 
zema, ichthyosis,  local  alopecias,  hypertrichosis,  symmetrical 
tylosis,  with  or  without  spontaneous  exfoliation  or  recur- 

1  Phila.  Med.  News,  1887,  li.  416. 


PERIFOLLICULITIS.  359 

rence.    After  a  time  ulcerations  formed  on  the  hands  or  feet, 
or  on  both  hands  and  feet. 

Periadenitis  Sudoripara.     See  Abscess  of  sweat  glands. 

Perifolliculitis  Suppurees  et  Conglomerees  en  Placards. 
Under  this  lengthy  title  Leloir1  has  described  and  figured  a 
rare  disease  of  the  skin  which  specially  affects  the  backs  of 
the  hands. 

Symptoms.  It  seems  to  commence  as  a  diffused  red 
patch  upon  which  develop  small  pustules, which  itch  slightly, 
or  as  small,  red,  more  or  less  conglomerate,  slightly  itching 
elevations  that  form  patches.  The  patches  however  formed 
are  sharply  defined,  raised  from  2  to  5  millimetres,  round 
or  oval,  flattened,  and  of  red,  vinous,  violaceous,  or  blue 
color.  They  vary  in  size  from  that  of  a  ten-cent  piece  to  a 
silver  dollar,  and  are  often  crusted.  When  the  crust  is  re- 
moved the  exposed  surface  is  smooth  or  mammillated,  but 
never  papillomatous  ;  and  riddled  with  a  number  of  pinpoint 
to  pinhead-size  openings,  corresponding  to  glandular  orifices, 
many  of  which  are  closed  with  a  plug  of  greenish,  dried  pus. 
Besides  these  openings  there  are  a  number  of  greenish 
points  that  are  ready  to  become  such  whenever  the  epider- 
mis over  them  is  removed.  At  a  more  advanced  stage  the 
openings  form  small  pinhead  ulcers.  By  compression  of 
the  patch  these  openings  give  vent  either  to  a  drop  of  pus 
or  serous  fluid,  or  little,  elongated,  vermicelli-like  whitish 
masses.  In  still  more  advanced  cases  the  patches  become 
more  elevated,  fluctuation  manifests  itself,  and  a  sero-pus 
may  be  expressed.  The  patches  are  usually  single,  but  may 
be  multiple.  The  back  of  the  hand  and  wrist  are  the  usual 
locations  of  the  disease,  but  it  may  occur  upon  the  dorsum 
of  the  foot  or  the  outer  side  of  the  thigh,  or  be  disseminated, 
but  chiefly  located  on  the  extremities.  The  course  of  the 
disease  is  acute.  It  is  fully  developed  in  eight  days  ;  it  then 
continues  a  week  or  two  and  disappears  in  about  twelve  days 
more.  If  badly  treated,  it  may  last  longer,  and  be  followed 
by  a  papillary  condition.  It  is  unattended  by  subjective 
symptoms,  except  slight  itching.     It  leaves  either  no  trace 

1  Annal.  de  Derm,  et  Syph.,  1884,  v.  437. 


360  DISEASES    OF    THE    SKIN. 

of  itself,  or  a  delicate  superficial  cicatrix  that  disappears  of 
itself,  or  a  slight  staining  that  soon  fades.  The  hair  is  un- 
affected, though  the  disease  may  involve  its  follicles. 

Pathology.  The  disease  is  a  purulent  inflammation  of 
the  skin  follicles,  specially  of  the  lanugo  hairs,  and  the  pilo- 
sebaceous  follicles  of  regions  deficient  in  true  hairs.  It  is 
possibly  microbic  in  origin. 

Diagnosis.  The  disease  is  diagnosticated  from  tricho- 
phytosis barbce  by  its  more  rapid  course,  and  recovery  under 
simple  treatment ;  by  the  hair  being  unaffected  ;  and  by  the 
absence  of  the  trichophyton  in  the  hair.  Anthrax  differs 
from  it  in  the  more  pronounced  character  of  its  local  and 
general  reaction,  its  central  core,  and  inflammatory  indura- 
tion Tuberculosis  verrucosa  cutis  is  much  slower  in  its 
evolution,  is  serpiginous,  and  does  not  yield  to  simple  treat- 
ment. Eczema  differs  from  it  in  not  having  such  sharply 
marked  borders;  in  wanting  the  characteristic  openings  and 
livid  tint;  and  in  having  more  pronounced  itching,  a 
mucous,  sticky  discharge,  and  a  comparatively  long  duration. 

Treatment.  The  treatment  is  simple  and  consists  in 
squeezing  out  the  pus  once  a  day,  bathing  the  part  for  half 
an  hour  in  warm  carbolized  water  or  a  solution  of  boric 
acid,  and  covering  with  an  antiseptic  dressing.  If  papillae 
have  formed  they  should  be  scraped  off,  and  the  surface 
touched  with  the  nitrate  of  silver.  In  some  obstinate  cases 
it  may  be  necessary  to  scrape  out  the  whole  patch. 

Perionyxis.     See  Paronychia. 

Perleche  (Pe'V-le2sh).  According  to  Brocq  this  is  a  dis- 
ease occurring  in  infants  and  affecting  the  commissures  of 

O  CD 

the  lips.  Their  epithelium  is  pale,  macerated,  desquamat- 
ing, while  the  skin  underneath  is  red  and  slightly  inflamed. 
Sometimes  fissures  will  form  that  are  painful,  and  may 
bleed  when  the  patient  widely  opens  his  mouth.  The  inflam- 
mation may  spread  to  the  neighboring  regions.  It  runs  a 
course  of  two  or  three  weeks,  but  is  subject  to  relapse.  It 
is  contagious,  and  is  due  to  a  streptococcus. 

It  bears  a  close  resemblance  to  the  fissures  of  the  lip  met 
with  in  syphilis,  but  is  marked  by  an  absence  of  all  other 
symptoms  of  syphilis. 


PIEDRA.  361 

The  treatment  consists  in  touching  the  diseased  parts  with 
the  sulphate  of  copper  or  alum,  or  an  antiseptic  solution, 
and  in  carefully  looking  after  the  nursing  bottles. 

Pernio.     See  Dermatitis  calorica. 

Pfundnase.     See  Rosacea. 

Phagmesis.  A  rare  condition  in  which  it  is  said  that 
feathers  instead  of  hair  adorn  the  body. 

Phtheiriasis.     See  Pediculosis. 

Pian.     See  Yaws. 

Piebald  Skin.     See  Leucoderma. 

Piedra  (Pe-ad'ra3).  Synonyms  :  Tinea  nodosa  ;  Tricho- 
mycosis nodosa. 

Symptoms.  This  disease,  or  deformity  of  the  hair,  is 
said  to  occur  only  in  Cauca,  one  of  the  United  States  of 
Colombia,  and  was  first  described  in  1874  by  Dr.  X.  Osorio, 
of  the  University  of  Bogota.  It  consists  in  the  occur- 
rence along  the  shaft  of  the  hair  of  from  one  to  ten  small, 
dark -colored  nodes  which  are  very  hard  and  gritty,  and 
rattle  like  stones  when  the  hair  is  combed  or  shaken.  The 
stony  hardness  of  the  nodes  gave  the  disease  its  name, 
"Piedra/'  which  is  the  Spanish  for  "stone."  These  nodes 
are  always  placed  at  irregular  intervals  along  the  hair-shaft, 
beginning  at  about  half  an  inch  from  the  point  of  exit  of 
the  hair,  the  root  being  unaffected.  The  disease  occurs 
most  commonly  in  women,  men  being  rarely  affected,  and  it 
is  the  head-hair  alone  which  exhibits  these  nodes.  The 
disease  is  non  contagious,  and  is  met  with  only  in  warm 
valleys. 

Etiology.  Dr.  Osorio  thought  that  the  nodes  were  pro- 
duced by  an  agglomeration  of  epithelium  in  certain  parts  of 
the  hair.  Dr.  Morris1  believes  it  is  due  to  the  use  of  a 
peculiar  mucilaginous  linseed-like  oil,  which  is  used  particu- 
larly by  the  native  women  to  keep  their  hair  smooth  and 
shiny.  Another  theory  is  that  it  is  due  to  the  use  of  the 
water  of  certain  stagnant  rivers  which  is  very  mucilaginous. 
Heat  seems  essential  for   its  production,  as  the  employment 

Lancet,  18  7 9,  x.  407. 
16 


362  DISEASES    OF    THE    SKIN. 

of  either  of  these  fluids  will  not  cause  the  disease  in  cold 
climates. 

Microscopical  examination  of  the  affected  hair  shows 
that  the  nodes  consist  of  a  honey-combed  mass  of  pigmented 
spore-like  bodies,  the  whole  mass  arising  from  one  cell  which 
sends  out  spore-like  columns  radially  in  all  directions.  As 
soon  as  the  cells  have  reached  a  certain  size,  they  seem  to 
alter  their  shape,  become  darker  in  color,  and  form  a  pseudo- 
epidermis.  It  is,  therefore,  a  fungous  growth.  The  nodes 
were  found  to  be  very  hard  to  cut,  and  when  considerable 
force  was  used  they  broke. 

Diagnosis.  Piedra  differs  from  trichorrhexis  nodosa  in 
the  stony  hardness  of  the  nodes,  in  its  occurring  principally 
upon  the  head-hair,  in  its  probable  etiology,  and  in  the 
microscopical  appearances  it  presents. 

By  the  use  of  hot  water  the  nodes  can  be  entirely 
removed. 

Pigmentary  Mole.     See  Nsevus  pigmentosus. 

Pigmental.     See  Naevus  pigmentosus. 

Pigmentgeschwulst.     See  Sarcoma. 

Pigmentkrebs.     See  Sarcoma. 

Pigmentsarcoma.     See  Sarcoma. 

Pimples.     See  Acne. 

Pinta  (PentV).  Synonyms:  Mai  de  los  pintos;  Tinna; 
Caraate  or  cute ;   Quirica  ;   Spotted  sickness. 

This  disease  occurs  only  in  southern  Mexico,  Panama, 
and  South  America. 

Symptoms.  According  to  Crocker,  from  whose  work 
this  account  is  drawn,  it  consists  of  scaly  spots  varying 
in  color,  shape,  number,  and  size.  They  show  them- 
selves first  on  the  uncovered  parts,  but  may  affect  any 
or  all  of  the  cutaneous  surface.  The  disease  spreads  by  the 
peripheral  extension  of  old  patches  and  the  formation  of 
new  ones.  The  patches  are  round  or  irregular  in  shape, 
sharply  or  ill  defined,  and  of  black,  gray,  blue,  red,  or  dull- 
white  color.  The  red  and  white  patches  are  deeper-seated 
than  the  others,  being  located  in  the  rete  and  corium.  The 
patches  may  be  of  uniform  color  or  of  different  tint,  but  do 


PITYKIASIS    ROSEA.  363 

not  change  their  color  after  they  have  once  formed.  They 
are  scaly  and  usually  feel  rough  and  dry.  The  hair  grows 
gray  and  falls.  There  is  some  itching,  and  a  bad  odor  ema- 
nates from  the  patient.  The  course  of  the  disease  is  chronic 
and  shows  no  tendency  to  recovery. 

Etiology.  The  disease  is  contagious  and  its  spread  is 
favored  by  dirt  and  neglect.  It  is  most  common  in  the  poor 
natives  of  Indian  stock.  It  is  of  fungous  origin,  and,  in 
fact,  seems  to  be  allied  to  chromophytosis. 

Treatment.  The  treatment  is  the  same  as  for  chromo- 
phytosis. 

Pityriasis  Capitis.     See  Seborrhcea  sicca. 

Pityriasis  Maculata  et  Circinata.     See  Pityriasis  rosea. 

Pityriasis  Pilaris.     See  Keratosis  pilaris. 

Pityriasis  Rosea  (Pi2t-i2-ri2-a'sis).  Synonyms  :  Pityriasis 
maculata  et  circinata  ;  Herpes  tonsurans  maculosus  (Hebra); 
Roseola  pityriaca  (Barduzzi) ;  Pityriasis  circine"  et  margine 
(Vidal) ;  Pityriasis  rosee  (Gibert) ;  Erytheme  papuleux 
desquamatif. 

An  acute  disease  of  the  skin  characterized  by  an  erup- 
tion of  rosy  red  macules  that  enlarge  into  dry,  scaly,  oval, 
or  annular  patches  with  rosy  red  peripheries  and  chamois- 
yellow,  wrinkled  centres  ;  it  runs  a  definite  course  and  ter- 
minates in  recovery. 

Symptoms.  Though  Gibert  described  pityriasis  rosea 
as  early  as  1868,  the  disease  is  but  little  known  in  this 
country,  not  because  it  does  not  occur,  but  because  it  is  not 
recognized.  Still  it  is  one  of  the  rarer  skin  diseases.  Most 
writers  tell  us  that  its  outbreak  is  preceded  by  slight  consti- 
tutional disturbances,  such  as  malaise,  loss  of  appetite,  and 
headache.  These  symptoms,  in  my  experience,  have  been 
as  conspicuous  by  their  absence  as  in  the  case  of  impetigo 
contagiosa.  The  eruption  itself  most  often  begins  upon  the 
upper  part  of  the  chest  a  little  above  the  breasts,  or,  accord- 
ing to  Brocq,1  at  the  level  of  the  waist-band,  anteriorly  and 
a  little  to   one  side,  where  he  locates   what   he  calls   the 

1  Annal.  Derm,  et  Syph  ,  1887,  viii.  615. 


364  DISEASES    OF    THE    SKIN. 

"  primitive  patch."  The  primary  lesions  are  miliary  or 
small  papules  of  pale-red  color,  surrounded  by  an  erythema- 
tous zone.  These  soon  enlarge  into  rosy  red,  slightly  raised 
macules,  and  slowly  increase  peripherally  into  oval  or 
rounded  patches  with  well-defined  borders  raised  somewhat 
higher  than  the  centres.  When  the  patches  have  attained  a 
diameter  of  half  an  inch  or  more  the  centres  begin  to  clear 
up  by  becoming  of  a  yellow,  old  parchment  color;  scaly  and 
shiny,  while  the  border  is  pale-red.  Later  the  centre  may 
disappear  and  rings  only  remain,  or  if  two  or  more  patches 
meet  at  their  borders  irregular  gyrate  figures  may  be  formed. 
All  the  lesions  do  not  attain  the  same  degree  of  development, 
and  in  a  well-developed  case  lesions  in  all  stages  will  be 
found.  The  lesions  are  slightly  scaly  from  the  commence- 
ment, and  the  furfuraceous  desquamation  continues  until 
the  faint  mark  left  by  the  lesion  disappears.  Itching, 
usually  slight  in  amount  and  only  when  the  person  is  warm, 
is  the  only  subjective  symptom.  Sometimes  it  is  severe. 
The  eruption  is  most  marked  upon  the  neck,  infra-  and  supra- 
clavicular regions,  sides  of  the  chest,  and  shoulders ;  it  may 
be  marked  also  on  the  abdomen  and  buttocks.  The  whole 
body  may  be  involved,  but  the  hands  and  feet  are  usually 
spared,  and  it  is  uncommon  on  the  face.  After  some  three 
to  six  weeks  the  disease  tends  to  spontaneous  recovery,  al- 
though it  may  last  for  two  months. 

Etiology.  We  know  nothing  about  the  causes  of  the 
disease.  It  affects  all  ages  and  both  sexes.  Crocker  thinks 
that  it  is  most  common  in  children,  but  most  all  the  cases 
I  have  seen  have  been  in  young  adults.  This  difference 
may  be  accounted  for  by  the  fact  that  he  has  a  large  chil- 
dren's dispensary  service.  The  disease  seems  to  occur 
epidemically  in  some  instances,  and  cases  are  apt  to  present 
themselves  in  groups.  Contagion  has  not  been  established. 
Bazin  regards  it  as  arthritic.  It  may  be  parasitic,  but  as 
yet  the  parasite  awaits  discovery.  Vidal1  describes  a  para- 
site that  he  names  the  microsporon  anomceon,  as  found 
in  pityriasis  circine*  et  margine,  a  disease  probably  the  same 
as  pityriasis  rosea. 

1  Annal.  Derm,  et  Syph.,  1882,  iii.  22. 


PITYRIASIS    RUBRA    PILARIS.  365 

Diagnosis.  Pityriasis  rosea  must  be  differentiated  from 
the  early  circinate,  scaling,  macular  syphiloderm  ;  annular 
psoriasis ;  seborrhcea  sicca  corporis  ;  and  disseminated  tri- 
chophytosis. The  one  most  distinguishing  feature  of  pity- 
riasis rosea  is  the  wrinkled  old-parchment  yellow  of  the 
centre  of  the  ring.  This  is  absent  from  the  lesions  of  all 
the  other  diseases  with  which  it  is  likely  to  be  confounded. 
The  syphilide  is  of  a  less  bright-red  color,  and  there  surely 
will  be  some  other  evidence  of  syphilis  to  guide  us.  Psori- 
asis is  far  more  scaly  ;  the  scales  are  of  a  white  color ;  the 
tips  of  the  elbows  and  the  anterior  face  of  the  knees  will  be 
specially  affected;  and  typical  psoriatic  patches  will  be  found 
somewhere.  Seborrhcea  corporis  occurs  upon  the  middle 
sternal  and  inter-scapular  regions  particularly  :  the  patches 
have  a  greasy  feel ;  the  scales  are  thicker  than  in  pityriasis 
rosea ;  and  the  lesions  show  little  tendency  to  spontaneous 
involution.  In  trichopliytosis  the  fungus  is  readily  found 
under  the  microscope,  which  is  a  decisive  test.  Apart  from 
that,  ringworm  does  not  spread  so  rapidly,  nor  involve  such 
wide  areas. 

Treatment.  Pityriasis  rosea  is  a  self-limited  disease, 
and  recovery  is  sure  to  take  place  in  a  short  space  of  time. 
My  experience  has  been  that  the  only  reason  for  treating 
the  disease  is  to  amuse  the  patient,  and  that  nothing  has 
any  marked  effect  on  it.  The  use  of  salicylic  acid  in  vase- 
line, ten  to  twenty  grains  to  the  ounce  is  as  good  as  any- 
thing. We  can  use  boric  acid  or  mild  sulphur  ointment, 
or  content  ourselves  by  allaying  the  itching  with  lotions  of 
carbolic  acid  (ten  grains  to  the  ounce),  calamine,  oxide  of 
zinc,  and  the  like. 

Pityriasis  Rubra.     See  Dermatitis  exfoliativa. 

Pityriasis  Rubra  Pilaris.  This  disease  has  recently  been 
described  bv  the  French  writers.  The  following  account  is 
abstracted  from  an  admirable  paper  by  Besnier.1 

It  has  been  confused  with  lichen  pilaris,  psoriasis,  lichen 
ruber  acuminatus  et  planus,  and  pityriasis  rubra.  Several 
cases  of  lichen  ruber  reported  in  this   country  have  been 

1  Annul.  Derm,  et  Syph.,  1889,  x.  253,  et  seq. 


366  DISEASES    OF    THE    SKIN. 

declared  by  the  French  to  be  cases  of  the  disease  under  con- 
sideration, as  well  as  the  lichen  psoriasis  of  Hutchinson. 

Symptoms.  A  typical  case  has  three  principal  elements  : 
1.  Asperities  of  the  follicular  orifices;  2.  Desquamation; 
3.  Roughness  of  the  skin  with  exaggeration  of  its  folds. 
The  disease  generally  begins  suddenly,  without  prodroma, 
but  there  may  be  some  malaise,  nervousness,  insomnia, 
hyperesthesia  of  the  finger-ends,  formication,  and  the  like. 
These  prodromata  are  of  short  duration,  and  rarely  cause 
the  patient  to  go  to  bed.  The  uncovered  parts  are  usually 
first  affected  with  the  eruption,  but  it  may  appear  primarily 
upon  the  trunk  or  extremities.  The  initial  lesion  may  be  a 
simple  exfoliation ;  an  erythema ;  a  scaling  erythema  ;  a 
fine  but  scanty  furfuraceous  desquamation ;  a  shiny  redness 
with  pityriasis;  desquamation  of  nail-bed,  or  fragility  of 
nail.  However  beginning,  the  more  pronounced  form 
appears  in  a  certain  number  of  days  or  weeks,  and  may 
develop  or  abort  at  any  point,  or  be  limited  to  any  region, 
or  involve  the  whole  body.  When  fully  developed  a  patch 
or  the  wThole  skin,  as  the  case  may  be,  presents  the  following 
characteristics  :  It  is  covered  with  elevations  that  are  gen- 
erally conical,  but  may  present  great  diversity  of  shape. 
These  may  be  discrete  or  coalesce.  They  may  be  so  small 
as  to  be  seen  only  by  the  aid  of  a  microscope,  or  elevated 
many  millimetres  above  the  surface,  with  corresponding 
diameter.  They  are  scaly,  and  vary  in  color  from  a 
silver-white  or  gray,  to  a  bright  or  opaque  red,  red-brown, 
or  rosy  yellow.  Their  summits  may  be  flat,  uneven,  cone- 
shape,  or  truncated,  giving  issue  to  a  hair  broken  off 
at  a  little  distance  above  the  surface  of  the  skin,  and  may 
be  sheathed  by  a  corneous  or  sebaceo-squamous  case.  In- 
stead of  a  hair  protruding,  it  may  form  only  a  small  comedo- 
like spot  at  the  centre  of  the  summit,  or  it  may  be  wanting, 
or  it  may  seem  to  exist  alone,  giving  to  the  region  the  appear- 
ance of  a  badly  shaven  beard.  Sometimes  the  cone  pre- 
sents a  crater,  at  the  bottom  of  which  is  a  black  point,  a 
punctured  scaly  plate,  or  a  psoriatic  point.  When  sev- 
eral elevations  coalesce  their  borders  disappear  and  form  a 
squamous  patch,  showing  the  central  points  and  the  asso- 


PITYRIASIS    RUBRA    PILARIS  367 

ciated  piliary  cones.  The  skin  is  scaly,  dry,  hard,  rough 
like  a  file,  and  presents  a  "  goose-skin"  appearance.  The 
scales  may  be  scraped  off  without  any  loss  of  blood.  The 
disease  is  generally  symmetrical,  but  the  lesions  may  be  dis- 
seminated without  order,  or  in  irregular  lines,  groups  or 
islands,  or  may  unite  in  tessellated  areas.  The  cone-like 
elevations  do  not  occur  on  the  scalp  and  are  rare  on  the 
soles  and  palms.  In  these  locations  the  disease  takes  the 
form  of  abundant  desquamation  upon  a  reddened  base.  All 
other  regions  may  be  affected,  the  cones  forming  about  the 
follicles  of  the  skin,  especially  about  the  hair  follicles. 
Some  variations  from  the  type  are  encountered  in  different 
regions,  but  characteristic  types  will  be  found  somewhere  on 
the  body.  The  hair  may  fall,  and  the  nails  may  be  de- 
formed, opaque,  and  raised  by  an  accumulation  of  scales 
under  them. 

The  general  condition  is  unaltered,  and  little,  if  any,  dis- 
comfort is  experienced.  The  duration  of  the  disease  is 
indefinite,  and  relapses  are  the  rule.  Second  and  subse- 
quent attacks  may  be  shorter  than  the  first. 

Etiology.  The  etiology  of  the  disease  is  obscure.  It 
occurs  at  all  ages,  and  in  both  sexes,  but  most  often  in 
infancy  or  youth,  and  in  males.  Many  causes  have  been 
assigned  to  it,  such  as  cold,  excesses,  rheumatism  ;  but  none 
of  these  can  be  definitely  said  to  be  the  cause. 

Diagnosis.  The  disease  is  to  be  diagnosed  from  ichthy- 
osis in  not  being  congenital;  in  attacking  by  preference 
the  joints,  scalp,  face,  and  neck ;  and  in  its  spontaneous 
recovery  for  a  time.  From  dermatitis  exfoliativa  by  its 
benign  course;  its  location  about  the  follicular  openings ; 
and  by  the  thick  scaling  of  the  palms  and  soles.  From 
lichen  ruber  acuminatum  the  diagnosis  is  difficult,  the  two 
being  considered  by  many  as  identical  Hebra  (Jr.)  has 
made  a  careful  study  of  the  two  diseases,1  and  we  give  here 
his  table  of  differential  diagnosis  between  them. 

1  Monatshefte  f.  prakt.  Permat.,  1889,  x.  101. 


368 


DISEASES    OF    THE    SKIN. 


Pityriasis  Eubra  Pilaris. 

1.  Develops  in  the  epidermis. 

2.  Efflorescences  bear  scales  from 

the  beginning,  and  often  con- 
sist of  accumulations  of  epi- 
dermic scales  alone  which 
can  readily  be  scratched  off. 

3.  Efflorescences  limited  to  folli- 

cle mouths,  especially  those 
of  hair  follicles. 

4.  Extensor  surfaces  of  the  ex 

tremities  especially  affected. 

5.  Microscopically       consist       of 

thickening  of  the  epidermis, 
with  lengtheningof  the  inter- 
papillary  projections  of  the 
rete  mucosum  in  certain 
places. 

6.  Color  of  efflorescences  scarcely 

differs  from  that  of  the  skin 
at  the  beginning.  After- 
ward becomes  rosy  or  brown- 
ish-red from  consecutive  hy- 
peremia. 

7.  Eoughness  of  the  extensor  sur- 

faces of  the  extremities,  and 
satin-like  smoothness  on  the 
trunk,  with  fine  scales. 

8.  No   accompanying    subjective 

symptoms. 


9.  No  implication  of  the  general 
health. 


10.  Spontaneous      recovery,      or 

chronicity  without  danger  to 
the  patient. 

11.  Cured  by  purely  local  means, 

though  often  obstinate. 


12.  Little  or  no  pigmentation  left. 


18.  Does  not    affect    the  mucous 
membranes. 


Licben  Ruber  Acuminatus. 

1.  Develops  in  the  cutis. 

2.  From  the  beginning  they  are 

smooth  and  glistening.  Scales 
form  only  late  in  the  disease. 


3.  Are  not  limited  to  the  follicle 

mouths. 

4.  Flexor  surfaces  more  affected 

than  extensor  surfaces. 

5.  Marked   collections    of  round 

cells  in  the  papillary  layers 
of  the  corium. 


From  beginning  a  bright  red, 
becoming  darker,  and  may 
change  to  deep  rusty-brown. 


7.  Everywhere    thickening    and 

roughness  of  the  skin,  in- 
creasing with  the  age  of  the 
disease. 

8.  Unbearable       itching,      great 

burning,  restlessness,  and 
jerking  movements  of  the 
limbs. 

9.  Fever,   oedema   (especially   of 

lower  extremities),  albumin- 
uria, sleeplessness,  general 
prostration,  and  loss  of 
weight. 

10.  Often  ends  in  death,  always 

attended  with  marasmus. 

11.  Cured,  if  at  all,  by  constitu- 

tional treatment,  as  with 
arsenic.  Unna's  ointment 
of  mercury  and  carbolic  acid 
good. 

12.  Deep-brown,    even     blackish- 

brown,      pigmentation      left 
which  may  last  for  months. 
13.  Affects    mucous   membranes, 
especially    of     mouth     and 
vagina. 


Psoriasis  at  times  bears  a  strong  resemblance  to  pityriasis 
rubra  pilaris,  but  it  seeks  the  elbows  and  knees  particularly  ; 


POLYTRICHIA.  369 

its  scale  is  larger ;  and  it  is  not  a  follicular  disease,  never 
presenting  comedo-like  plugs,  broken-off  hairs,  or  little 
elevations. 

Treatment.  No  satisfactory  treatment  has  been  found, 
but  the  remedies  applicable  to  psoriasis  or  to  ichthyosis  can 
be  used  with  advantage.  Like  in  that  disease,  an  attack  may 
be  overcome,  but  no  assurance  can  be  given  against  a  relapse. 
Thus  far  no  fatal  case  has  been  reported. 

Pityriasis  Versicolor.     See  Chromophytosis. 

Plaques  des  Fumeurs.     See  Leucoplakia. 

Plica  Polonica  (Pli'ka3  Pol-oV^-ka3).  Synonyms  :  Tri- 
chosis  plica ;  Trichoma ;  (Pol.)  Koltun  ;  (Grer.)  Weichsel- 
zopf;  (Fr.)  Plique  polonaise;  Polish  ringworm. 

Symptoms.  This  is  rather  a  condition  than  a  disease,  in 
which  the  hair  of  the  head  and  other  parts  becomes  matted 
together  into  various  shaped  masses,  on  which  rest  all  sorts 
of  extraneous  matters  deposited  from  the  air  ;  and  in  which 
are  harbored  vast  hordes  of  pediculi.  Sometimes  these 
matted  tresses  are  near  the  scalp,  and  sometimes  far  away, 
according  to  circumstances,  such  as  the  growth  of  the  hair 
and  disease  of  the  scalp.  Not  infrequently  an  oozing  eczema 
of  the  scalp  will  be  found.  The  masses  will  assume  all 
sorts  of  shapes  to  which  various  names  have  been  applied. 
An  offensive  odor  often  emanates  from  the  scalp.  Occur- 
ring among  ignorant  people,  as  is  usually  the  case,  these 
plicas  are  regarded  with  superstition.  The  patient  and 
friends  refuse  to  have  them  cut  off  lest  some  dire  disease 
befall  the  bearer. 

Etiology.  The  cause  of  the  condition  is  want  of  clean- 
liness combined  with  an  oozing  dermatitis  of  the  scalp  due 
to  pediculi  or  any  other  cause. 

Treatment.  The  treatment  consists  in  the  liberal  use 
of  soap  and  water,  and  curing  the  dermatitis.  If  allowed,  the 
speediest  way  of  beginning  treatment  is  to  cut  off  the  hair. 
The  patient  must  be  instructed  in  the  hygiene  of  the  scalp. 

Podelcoma.     See  Fungous  foot  of  India. 
Poils  Accidentels.     See  Hypertrichosis. 

Polytrichia.     See  Hypertrichosis. 

16* 


370  DISEASES    OF    THE    SKIN. 

Polypapilloma  Tropicum.     See  Yaws. 
Porpora  Emorrhagica.     See  Purpura. 
Poliotes.     See  Canities. 
Polyidrosis.     See  Hyperidrosis. 

Pompholyx  (Po2m/fo2l-i2x).  Synonyms ;  Dysidrosis  ; 
Cheiro-pompholyx. 

This  disease  was  first  described  by  Tilbury  Fox  and 
Jonathan  Hutchinson  from  the  same  case,  though  independ- 
ently of  each  other.  The  former  thought  that  it  was  due  to 
distention  of  the  sweat  glands,  and  named  it  dysidrosis, 
while  the  latter  named  it  cheiro-pompholyx  from  the  bullous 
character  of  the  eruption,  and  its  occurrence  upon  the 
hands.  As  it  occurs  upon  the  feet  as  well  as  the  hands, 
Hutchinson's  name  is  a  misnomer. 

Symptoms.  The  first  thing  that  the  patient  notices  is  a 
burning  and  itching  of  the  palms,  or  soles,  and  sides  of  the 
fingers  or  toes.  Jn  a  few  hours  small,  clear,  sago-grain- 
like vesicles,  sometimes  grouped,  and  with  an  erythematous 
zone  about  them,  appear  in  these  locations.  They  are  often 
very  numerous,  and  some  of  them  run  together  to  form 
small  and  large  bullae.  Their  contents  are  at  first  neutral ; 
later  they  become  turbid  and  have  an  alkaline  reaction. 
These  vesicles  do  not  tend  to  spontaneous  rupture.  In  a 
few  days  they  dry  up,  their  covers  fall,  and  large  and  small, 
dry,  red  surfaces  are  left  to  mark  their  location.  If  the 
lesions  have  been  verv  numerous  the  whole  of  the  old  skin 
may  be  shed.  In  slight  cases  the  palms  or  soles  will  be 
dotted  over  with  irregularly  shaped  red  spots  with  ragged 
edges.  As  a  rule  the  backs  of  the  hands  and  feet  are 
unaffected,  though  the  rule  has  rare  exceptions.  The  face 
may  be  the  site  of  a  similar  eruption,  and  be  covered  with 
firm  small  sago-grain-like  vesicles.  The  patients  are  seldom 
in  perfect  health,  but  are  usually  nervously  depressed. 
Hyperidrosis  of  the  affected  parts  commonly  accompanies 
or  precedes  the  outbreak,  and  sometimes  a  lichen  tropicus 
will  be  found  on  the  trunk.  The  duration  of  the  attack 
varies  from  a  few  days  to  three  or  four  weeks,  and  relapses 
in   the  same  or  following  years  are  common.     On  the  face 


POMPHOLYX.  371 

the  disease  has  no  definite  course,  but  lasts  for  months  or 
during  the  continued  action  of  the  cause.  Most  all  cases 
are  seen  in  the  summer.  It  is  usually  symmetrical,  though 
one  side  may  be  affected  before  the  other. 

Etiology.  Over  the  causes  of  the  disease  there  has  been 
and  still  is  active  discussion.  It  seems  to  be  in  some  way 
connected  with  the  sweat  glands,  but  whether  it  is  a  simple 
impediment  to  the  escape  of  the  sweat,  or  an  inflammatory 
disease  is  not  determined.  Some  able  pathologists  ally  the 
disease  to  herpes.  As  it  affects  the  face  it  is  certainly  a 
disease  of  the  sweat  apparatus,  since  it  occurs  in  most  cases 
in  washerwomen  who  are  exposed  constantly  to  heat  and 
moisture.  The  occurrence  of  the  disease  in  hot  weather 
also  points  to  the  sweat  apparatus  as  the  organ  at  fault. 
There  is  probably  a  vasomotor  neurosis  at  the  bottom  of 
the  trouble.  It  affects  all  ages  and  both  sexes,  though  most 
common  in  young  adult  women,  and  in  those  who  are  of 
nervous  temperament. 

Diagnosis.  Pompholyx  must  be  differentiated  from 
eczema,  scabies,  pemphigus,  and  erythema  bullosum.  It 
differs  from  eczema  in  its  vesicles  not  tending  to  break 
down  of  themselves ;  in  not  presenting  a  moist  surface  after 
the  vesicle-tops  fall ;  and  in  running  a  more  definite  course. 
The  sago-grain-like  appearance  of  the  vesicles  is  not  pecu- 
liar to  it,  as  it  is  frequently  seen  in  eczema  of  the  hands, 
and  is  due  to  the  thickness  of  the  epithelium  preventing  the 
ready  escape  of  the  fluid.  Scabies  may  bear  a  close  resem- 
blance to  pompholyx,  but  can  be  readily  differentiated  by 
finding  the  burrows,  and  by  the  presence  of  the  eruption  at 
the  same  time  upon  the  anterior  face  of  the  wrists,  the  breasts 
in  women,  the  genitals  in  males,  and  about  the  umbilicus  in 
both  sexes.  Pemphigus  of  the  hands  and  feet  is  exceed- 
ingly rare  in  adults,  and  pompholyx  has  never  been  reported 
in  infants.  Moreover,  pemphigus  lacks  the  vesicular  lesions 
of  the  sides  of  the  fingers.  Erythema  bullosum  is  always  on 
the  backs  of  the  hands,  and  is  not  itchy  though  it  may 
burn. 

Treatment.  A  simple  astringent  ointment,  as  of  oxide 
of  zinc,  or  diachylon  ;  or  one  of  the  oleate  of  zinc  or  lead  ; 


372  DISEASES    OF    THE    SKIN. 

or  an  alkaline  lotion,  will  allay  the  irritation  and  hasten  the 
disappearance  of  the  disease.  General  hygiene  should  be 
enforced;  and  tonics  of  iron,  arsenic,  or  whatever  seems 
indicated  by  the  condition  of  the  patient,  given. 

Porcellanfriessel.     See  Urticaria. 

Porcupine  Disease.     See  Ichthyosis. 

Porrigo  Contagiosa.     See  Impetigo  contagiosa. 

Porrigo  Decalvans.     See  Alopecia  areata. 

Porrigo  Favosa.     See  Favus. 

Porrigo  Furfurans.  See  Trichophytosis  capitis. 

Porrigo  Granule.     See  Pediculosis. 

Porrigo  Larvalis.     See  Impetigo 

Porrigo  Lupinosa.     See  Favus. 

Post-mortem  "Warts.     See  Tuberculosis  verrucosa  cutis. 

Prairie  Itch.  This  disease  has  been  found  to  be  in  most 
cases  a  combination  of  pruritus  hiemalis  and  scabies.  It 
is  not  a  disease  sui  generis. 

Prickly  Heat.     See  Miliaria. 

Prurigo  (Pru-ri'go).  Synonyms :  Strophulus  prurigi- 
neux ;  Scrofulide  boutonneuse  benigne ;  (Ger.)  Juckblat- 
tern. 

A  chronic  disease  of  the  skin  characterized  by  beginning 
in  infancy  as  an  urticaria,  and  changing  into  a  recurring 
eruption  of  pale,  hard,  exceedingly  itchy,  discrete  papules, 
especially  upon  the  extensor  surfaces  of  the  extremities.  It 
increases  in  severity  from  above  downward,  and  is  accom- 
panied by  enlargement  of  the  inguinal  glands. 

There  are  two  types  of  this  disease,  namely  :  prurigo 
mitis  and  prurigo  ferox.  These  two  blend  into  each  other. 
While  the  malady  is  more  commonly  reported  from  Vienna 
than  elsewhere,  it  occurs  in  many  countries.  Until  very 
recently  it  was  regarded  as  very  rare  in  this  country,  but  as 
Zeisler,1  of  Chicago,  has  met  with  twelve  cases  during  five 
years,  and  among  1370  skin  cases,  it  is  not  so  rare  a  disease 
in   that  section.      American  physicians   have  hesitated  in 

1  Journ  Cutan.  and  Gen.-urin.  Dis ,  1880,  vii.  408. 


PRURIGO.  373 

making  the  diagnosis  of  prurigo  because  they  had  in  mind 
rather  prurigo  ferox  than  prurigo  mitis,  as  a  type;  and  be- 
cause of  its  resemblance,  in  many  instances,  toother  diseases. 
The  name  is  used  by  most  French  writers  as  synonomous 
with  pruritus,  and  English  writers  quite  commonly  speak 
of  "  pruriginous  "  diseases  when  confusion  would  be  avoided 
by  using  the  adjective  "  pruritic." 

Symptoms.  The  disease  begins  in  infancy,  quite  com- 
monly toward  the  end  of  the  first  year,  as  an  outbreak  of 
urticarial  wheals  of  various  sizes  and  shapes.  The  urtica- 
rial eruption  persists,  but  after  a  time  a  preponderance  of 
small  wheals  will  be  remarked,  and  a  preference  for  the 
trunk  and  the  extensor  surfaces  of  the  limbs.  During  the 
second  or  third  year  the  urticarial  element  is  lost  and  the 
characteristic  papular  eruption  gradually  preponderates,  and 
at  last  takes  its  place.  The  papules  are  pinhead  to  hemp- 
seed  in  size,  flat,  firm,  of  the  color  of  the  skin,  or  of  a 
bright-red,  rosy,  or  yellowish-white  color,  and  in  many 
cases  so  little  raised  as  to  be  felt  rather  than  seen.  When 
the  skin  is  irritated  the  papules  may  assume  the  character 
of  small  wheals.  The  efflorescence  is  located  principally 
upon  the  extensor  surfaces  of  the  limbs,  and  more  sparsely 
on  the  trunk,  while  the  scalp,  the  flexures  of  the  large 
joints,  the  palms,  soles,  and  genitals  are  free.  The  papules 
are  not  grouped. 

Pruritus  is  intense,  so  that  excoriations  and  torn  papules 
are  present  over  all  the  affected  parts.  The  patients  have  a 
pale,  weary  expression  of  countenance,  and  evidently  are  in 
poor  condition.     The  skin  is  often  dry  and  may  be  scaly. 

When  the  lesions  are  but  few  in  number  and  scattered 
about  upon  the  extremities,  we  have  prurigo  mitis.  When 
a  great  number  of  papules  are  present,  and  the  disease  is 
widespread,  we  have  prurigo  ferox.  Now  we  have  the 
typical  form  of  the  disease  such  as  is  shown  in  the  Vienna 
skin  clinics.  We  note  that  the  skin  feels  rough  ;  that  it  is 
strewn  over  with  a  great  number  of  small  papules  which  are 
of  the  color  of  the  skin  or  pale-red  ;  defaced  with  scratch- 
marks  ;  eczematous  in  places  ;  darkly  pigmented,  it  may  be 
brown,  from  constant  irritation  of  the  scratching,  and  that 


374  DISEASES    OF    THE    SKIN. 

this  color  of  the  general  integument  is  in  strong  contrast 
with  the  pale  color  of  the  face  ;  that  the  skin  is  thickened 
in  some  places  while  the  flexures  of  the  joints  are  free  from 
change  and  as  soft  as  normal ;  that  these  changes  in  the 
skin  are  progressively  worse  from  above  downward,  so  that 
the  legs  from  the  knee  down  are  most  markedly  involved ; 
and  that  the  inguinal  glands  are  enlarged  so  as  to  form 
buboes.  Ecthymatous  lesions  may  arise.  The  intensity  of 
the  itching  may  be  so  great  as  to  prevent  sleep,  and  even 
in  some  cases  to  drive  the  patient  insane. 

The  duration  of  the  disease  is  indefinite  ;  it  may  last  a 
lifetime.  The  type  of  the  disease  remains  the  same  through- 
out— that  is,  prurigo  mitis  does  not  change  to  a  prurigo  ferox. 

Etiology.  Prurigo  affects  both  sexes,  though  more  prev- 
alent in  the  male  sex.  It  is  far  more  common  among  the 
poor  and  those  who  are  uncleanly.  It  is  not  uncommon  to 
find  several  members  of  the  same  family  with  the  disease. 
A  phthisical  family  history  has  been  affirmed  to  be  an  etio- 
logical factor  by  some  authorities.  Some  cases  are  better  in 
winter  and  some  in  summer.  It  is  a  disease  of  infancy  con- 
tinuing through  life.  A  neurosis  probably  is  the  underly- 
ing cause  of  the  phenomena,  and  it  seems  to  be  related  to 
urticaria.  Histological  studies  have  not  yet  put  the  disease 
upon  a  sure  anatomical  basis. 

Diagnosis.  The  diagnosis  is  made  by  the  occurrence  of 
pale  papules  upon  the  extensor  aspects  of  the  limbs  ;  by  the 
increasing  severity  of  the  symptoms  from  above  down- 
ward; by  the  enlargement  of  the  inguinal  glands,  and  by 
the  continuance  of  the  disease  from  early  infancy.  It  is  to 
be  differentiated  from  eczema  by  sparing  the  flexures  of  the 
joints ;  by  the  presence  of  its  characteristic  papules,  and  by 
its  greater  obstinacy.  From  papular  urticaria  it  can  be 
distinguished  only  by  its  general  course.  In  fact,  a  doubt- 
ful case  must  be  carefully  studied  over  a  considerable  length 
of  time  before  a  positive  diagnosis  can  be  made.  Scabies 
and  pediculosis  can  be  readily  separated  by  the  occurrence 
of  the  lesions  on  the  palms,  between  the  fingers,  and  on  the 
genitals  in  the  one  ;  and  the  parallel  scratch-marks  over  the 
shoulders  in  the  other.    Ichthyosis  spares  the  flexures  as  does 


PRURIGO.  375 

prurigo,  but  it  is  marked  by  polygonal  scales,  not  papules  ; 
and  is  free  from  the  great  number  of  excoriations  found  in 
prurigo  ;  it  is,  moreover,  a  disease  that  affects  the  whole 
body  surface  more  generally. 

Treatment.  The  disease  is  exceedingly  obstinate  to 
treatment.  The  patient  must  be  put  in  as  good  a  physical 
condition  as  possible  by  means  of  hygiene,  cod-liver  oil,  iron, 
and  good  diet.  Tincture  of  cannabis  indica  is  commended 
by  Crocker  for  relief  of  the  itching  in  doses  of  ten  minims 
increased  to  thirty  minims  to  a  ten-year-old  child,  given 
three  times  a  day  directly  after  meals,  and  intermitted  for 
two  weeks  after  every  six  weeks.  Simon1  and  others  rec- 
ommend pilocarpine  hypodermatic-ally,  fifteen  minims  of  a 
2  per  cent,  solution  once  a  day,  for  adults,  or  a  correspond- 
ing quantity  of  jaborandi  by  the  mouth.  After  the  dose  the 
patient  is  to  be  put  in  bed  and  covered  with  woollen  blankets, 
where  he  is  allowed  to  sweat  for  two  or  three  hours.  Carbolic 
acid,  fifteen  to  twenty  grains  a  day  in  pill,  and  the  bromide 
of  potassium,  have  their  advocates.  Antipyrine  and  phena- 
cetine  exert  a  controlling  influence  over  pruritus,  and  they 
are  amongst  the  most  valuable  internal  remedies  in  prurigo. 
The  latter,  though  not  so  active  as  the  former,  should  be 
tried  first  in  full  doses,  as  it  is  much  safer. 

External  treatment  is  very  important.  Naphthol  is 
most  highly  commended,  a  2  to  5  per  cent,  solution,  accord- 
ing to  age,  being  rubbed  in  every  night,  and  a  bath  of 
naphthol-sulphur  soap  being  taken  every  second  night.  In 
older  children  and  adults  the  soap  treatment  of  Hebra,  as 
described  in  the  section  on  Eczema,  is  useful.  Sulphur  oint- 
ment used  as  in  scabies  after  a  daily  bath ;  tar  used  as  in 
psoriasis ;  a  5  or  10  per  cent,  lotion  of  carbolic  or  salicylic 
acid,  or  the  same  combined  with  vaseline  ;  a  5  per  cent, 
boric  acid  ointment,  all  have  their  advocates,  and  all  may 
be  tried  in  obstinate  cases.  Baths  followed  by  inunctions 
of  cod-liver  oil,  simple  oil,  tar  oil,  or  lard,  are  often  useful  ; 
as  well  as  baths  of  alum,  soda,  and  corrosive  sublimate. 
Treatment  should  be  continued  for  weeks  or  months  after 
apparent  cure  of  the  disease. 

1  Berlin,  klin.  Wochenschr.,  1879,  xvi.  721. 


376  DISEASES    OF    THE    SKIN. 

The  prognosis  as  to  cure  is  bad,  excepting  in  recent  and 
not  severe  cases.  These  may  be  cured,  but,  as  a  rule,  all 
we  can  do  is  to  mitigate  the  patient's  discomfort.  Relapses 
are  the  rule. 

Pruritus  Cutaneus  (Pru-ri'-tu3s).  Itching  of  the  skin  is 
a  symptom  common  to  a  great  variety  of  dermatoses.  In- 
deed, it  has  been  said  that  skin  diseases  might  be  classified 
under  two  divisions:  those  that  itch  and  those  that  don't 
itch.  Eczema,  scabies,  urticaria,  prurigo,  pediculosis,  are 
all  eminently  pruritic,  but  do  not  concern  us  here. 

Symptoms.  By  pruritus  cutaneus  we  mean  a  functional 
neurosis  of  the  skin  whose  only  essential  symptom  is  itch- 
ing. This  induces  scratching,  and  scratch-marks  are  always 
to  be  found  as  a  secondary  symptom.  These  usually  are  in 
the  form  of  scratched  papules.  If  the  itching  is  great  and 
continuous,  we  will  have  other  secondary  effects,  such  as 
thickening  and  pigmentation  of  the  skin,  and  eczema  of 
various  degrees. 

The  itching  varies  greatly  in  degree  from  simply  an 
occasional  slight  attack  to  such  an  intense  degree  as  to 
render  the  patient's  life  unendurable  and  tempt  to  suicide. 
The  pruritus  is  commonly  paroxysmal,  but  in  some  cases 
the  pauses  between  the  paroxysms  are  so  short  that  the  itch- 
ing is  practically  continuous.  It  is  almost  always  worse  at 
night.  Changes  of  temperature  aggravate  the  itching,  as 
a  rule.  Very  commonly  warmth  makes  matters  worse,  and 
the  sufferer  will  begin  to  scratch  and  keep  on  scratching 
while  in  the  neighborhood  of  a  fire,  or  in  bed  warmly 
covered.  He  cannot  resist  the  impulse  to  scratch,  and  so 
in  bad  cases  he  shuns  society  and  becomes  morbid. 

Under  the  general  title  of  pruritus  are  often  placed 
various  paresthesia,  such  as  formication,  tingling,  and 
burning. 

The  pruritus  may  be  general  or  local.  Thus  we  have 
pruritus  universalis,  a  term  that  is  rarely  to  be  applied 
with  strict  accuracy,  as  it  is  seldom  universal,  and  only 
general.  In  these  cases  the  itching  is  now  one  place  and  now 
another.     Bulkley,1  by  a  series  of  observations  on  himself, 

1  Journ.  Cutan.  and  Gen.-urin.  Dis.,  1887,  v.  15'.'. 


PRURITUS    CUTANEUS.  377 

strove  to  establish  some  law  of  reflex  excitation,  in  which 
he  was  so  far  successful  as  to  find  that  if  he  scratched  one 
spot  that  itched,  he  relieved  the  sensation  there,  only  to  have 
it  break  out  elsewhere.  This  general  pruritus  is  most  often 
encountered  in  pruritus  senilis,  or  the  itching  of  the  skin 
of  old  people,  and  in  pruritus  hiemalis  and  pruritus  cesti- 
valis  which  are  induced  respectively  by  the  cold  of  winter 
or  the  heat  of  summer.  These  very  often  manifest  them- 
selves on  the  thighs  and  legs  only. 

Of  local  pruritus  we  have  many  instances.  Thus  we 
have  pruritus  ani  which  afflicts  both  sexes  and  in  which  the 
itching  extends  to  the  mucous  membrane  of  the  anus. 
This  same  extension  is  also  seen  in  pruritus  vulvae.  This 
localized  itching,  with  the  corresponding  pruritus  scroti  in 
men,  often  occurs  in  connection  with  pruritus  ani.  In  all 
these  three  the  parts  almost  always  become  thickened  and 
eczematous  from  the  constant  rubbing  and  scratching;  to 
which  they  are  subjected,  and  nymphomania  is  sometimes  a 
consequence  of  the  itching  vulva.  The  scalp,  face,  espe- 
cially about  the  nose  and  mouth ;  the  palms  and  soles,  and 
between  the  fingers  and  toes,  are  frequent  sites  of  itching. 
More  rarely  local  areas  anywhere  will  be  affected  with 
recurring  attacks  of  itching. 

Etiology.  That  the  pruritus  is  due  to  a  functional  dis- 
turbance of  the  sensory  nerves  there  is  no  doubt.  For  suc- 
cess in  treatment  and  accuracy  in  prognosis  it  is  necessary 
for  us  to  endeavor  to  determine  the  cause  of  such  disturb- 
ance. Hepatic  derangements  cause  a  certain  proportion  of 
cases.  The  intense  itching  of  the  skin  in  jaundice  is  evi- 
dence of  this.  Digestive  disorders  and  constipation  ;  excre- 
tory disorders,  as  of  the  kidneys  and  skin;  albuminuria; 
lithremia ;  and  diabetes,  all  have  influence  in  causing  pruri- 
tus. Depressed  mental  states,  and  the  disorders  of  the  ner- 
vous system  induced  by  the  abuse  of  tobacco,  tea,  alcohol, 
opium,  and  the  like,  produce  pruritus.  Reflex  influences 
from  the  sexual  sphere,  and  the  power  of  imagination,  are 
responsible  for  some  cases.  In  illustration  of  the  latter 
everyone  knows  how  many  people  will  begin  to  scratch 
when  the  subject  of  lice  is  mentioned;  and  how  that  long 


378  DISEASES    OF    THE    SKIN. 

after  the  acarus  is  killed  in  scabies  the  patient  will  continue 
to  complain  of  itching,  and  will  not  be  assured  that  he  is 
cured  of  his  disease. 

In  pruritus  senilis  the  skin  will  be  found  to  be  atrophied 
and  the  fatty  tissue  underlying  it  absorbed,  in  not  a  few 
cases.  Pruritus  ani  is  often  due  to  hemorrhoids  or  fissures 
of  the  mucous  membrane ;  or  to  ascarides ;  or  to  the  exces- 
sive use  of  tobacco.  Stricture  of  the  urethra  has  been  found 
to  be  the  cause  of  both  it  and  pruritus  scroti.  Pruritus 
vulvse  is  very  often  due  to  pregnancy  or  tumors  of  the 
uterus  or  ovaries.  In  this  form  diabetes  is  quite  com- 
monly the  cause.  Pruritus  hiemalis  begins  at  any  time 
from  October  to  January,  and  continues  until  the  spring  is 
well  advanced.  The  effect  of  cold  upon  the  skin  seems  to 
check  the  secretory  functions. 

Bulkley  has  found  pruritus  to  be  more  common  in  men 
than  women,  fifty  of  his  eighty  cases  being  men.  In  some 
families  an  itching  skin  seems  to  be  hereditary. 

Diagnosis.  If  we  bear  in  mind  that  pruritus  has  no 
lesion  of  its  own ;  and  if,  whenever  a  patient  complains  of 
itching  of  the  skin,  we  institute  a  search  for  the  pediculus, 
or  the  itch-mite,  or  their  lesions ;  or  the  wheal,  or  at  least  a 
history  of  it ;  and  find  none,  then  we  have  gone  far  towards 
establishing  a  diagnosis  of  pruritus.  Sometimes  it  is  diffi- 
cult to  determine  whether  an  eczema  is  secondary  to  the 
scratching  for  the  relief  of  itching,  or  the  itching  is  a  part 
of  the  eczema.  Only  an  attempt  at  curing  the  eczema  and 
long  observation  of  the  case  will  enable  us  to  make  a  true 
diagnosis.  Many  errors  of  diagnosis  will  be  changed  by 
close  study,  as  true  pruritus  is  not  so  common  as  other  itch- 
ing diseases.  Bulkley  found  but  eighty  cases  in  5000  pri- 
vate cases. 

Treatment.  To  find  and  remove  the  cause  is  the  first 
essential  in  treating  a  case.  How  difficult  this  task  may  be 
will  be  seen  by  a  study  of  its  etiology.  Nevertheless  the 
patient  must  be  considered,  and  every  organ  interrogated, 
and  any  deranged  function  regulated  as  far  as  possible. 
Tea,  coffee,  and  tobacco  should  be  interdicted;  a  dietary 
carefully  laid  down  ;  and  the  rules  of  hygiene,  such  as  those 


PRURITUS    CUTANEUS. 


379 


relating  to  exercise,  bathing,  and  clothing,  enforced.  To 
relieve  the  itching  as  such,  we  may  give  the  tincture  of 
cannabis  indica,  10  minims  three  times  a  day,  in  water  after 
meals,  and  gradually  increase  the  dose  up  to  20  or  30  minims ; 
or  the  tincture  of  gelsemium  in  10-minim  doses  every 
half-hour  till  one  drachm  is  taken  or  toxic  effects  produced ; 
hypodermatic  injections  of  pilocarpine,  ^  to  ^  of  a  grain  ; 
quinine,  10  to  15  grains  at  bedtime;  carbolic  acid,  1  to  2 
minims  three  times  a  day ;  wine  of  antimony,  5  to  7  drops 
after  meals  ;  salicylate  of  soda,  15  grains,  or  antipyrin  or 
phenacetine  in  full  doses.  Besnier  recommends  valerian, 
or  valerianate  of  ammonia.  But  the  relief  so  obtained  is 
transitory,  and  we  should  not  rest  content  until  we  have 
found  out,  and  where  possible  removed,  the  internal  under- 
lying cause.  Opium  should  never  be  given,  as  it  causes 
pruritus. 

The  external  treatment  is  of  great  service  in  alleviating 
the  itching,  even  if  it  does  not  cure  the  disease.  For  this 
purpose  general  baths  with  soda  (5viij-x  to  30  gallons),  or 
nitric  or  hydrochloric  acid  (§j  to  30  gallons),  may  be  used. 
After  the  bath,  the  body  is  to  be  dried  by  wrapping  in 
a  warmed  sheet  and  patting  the  skin  dry  ;  then  the  skin 
should  be  smeared  with  vaseline  and  powdered  with  corn 
starch  from  a  dredger.  For  local  pruritus  we  may  use 
lotions,  of  which  one  of  the  most  efficient  is  carbolic  acid : 
5j-ij  in  alcohol  dil.  Sj-  The  patient  should  be  cautioned 
to  tap  the  skin  gently  with  this,  and  not  rub  it  in.  So  used 
it  will  cause  no  damage  and  will  stop  the  itching  for  hours. 
It  may  be  used  as  a  spray  in  the  strength  of  half  an  ounce 
to  the  pint  of  water  with  one  ounce  of  glycerin.  To  this 
5  to  10  minims  of  oil  of  peppermint  may  be  added  (Hard- 
away).  Alkaline  lotions,  as  bicarbonate  of  soda,  5j  to  the 
basinful  of  water ;  or  acid  lotions,  such  as  vinegar  dabbed  on 
the  itching  spot,  will  often  relieve.  Liquor  carbonis  deter- 
gens,  5i  to  §iv  :  thymol,  5ij,  liquor  potassii,  5j»  glycerin, 
5iij,  aquae,  Sviij  (Crocker).  Liquor  picis  alkalinus,  3j  to 
oiv :  perchloride  of  mercury,  gr.  J-3  to  5J  of  water.  All  these 
are  well  attested  as  useful. 

For  pruritus   ani,   scroti,  et  vulvae,  sitting  over  a  basin 


380  DISEASES    OF    THE    SKIN. 

or  pail  of  very  hot  water  and  sopping  it  up  on  the  parts, 
followed  by  patting  the  skin  dry  and  using  a  starch  powder, 
will  often  give  the  patient  a  quiet  night.  If  an  eczema  is 
present,  that  must  first  be  cured.  Cocaine  lotions,  as  one  of 
20  per  cent  of  cocaine  and  5  per  cent,  of  glycerin  ;  or  men- 
thol 3  to  10  percent,  in  oil  of  sweet  almonds,  or  of  glycerin, 
and  water;  carbolic  acid  lotions,  are  also  useful,  as  well  as 
many  mercurial  ointments.  Bulkley's  antipruritic  powder,  of 
one  drachm  each  of  camphor  and  chloral,  rubbed  together 
till  liquefied,  and  added  to  one  ounce  of  starch  powder,  will 
sometimes  prove  very  effective.  Painting  the  parts  with 
nitrate  of  silver,  16  grains  in  spts.  setheris  nitrosi,  5j  j  is  another 
good  proceeding.  A  saturated  solution  of  boric  acid  is  also 
good.  When  the  parts  are  excoriated  neither  menthol,  pep- 
permint, nor  the  chloral-camphor  powder  can  be  used.  Sup- 
positories containing  belladonna,  cocaine,  or  creasote  may 
give  relief  in  these  cases. 

In  pruritus  hiemalis  it  is  sometimes  necessary  for  the 
patient  to  wear  linen  underclothing  next  to  the  skin ;  and 
over  these  the  woollens  usually  worn.  Other  patients  find 
more  relief  from  wearing  silk  underclothing.  The  treatment 
indicated  above  for  pruritus  is  applicable  here  also. 

In  some  obstinate  cases  of  general  pruritus  great  amelio- 
ration may  be  obtained  by  the  actual  or  Paquelin  cautery 
applied  lightly  along  the  spine.  The  same  means  has  some- 
times been  successful  in  localized  pruritus,  as  of  the  vulva 
or  scrotum,  but  now  the  parts  themselves  are  touched  with 
the  cautery. 

Prognosis.  The  prognosis  is  doubtful.  Some  cases  are 
very  obstinate,  and  some  are  incurable.  Happily,  thorough 
study  of  the  case  will  be  rewarded  in  most  cases  by  a  cure. 

Pruritus  Hiemalis.     See  Pruritus  cutaneus. 

Pseudo  Exantheme  Erythemato-desquamatif.  See  Pity- 
riasis rosea. 

Pseudo  Erysipelas.  By  this  term  is  meant  cellulitis  or 
diffused  phlegmon. 

Pseudo  Leucaemia  Cutis  is  a  very  rare  disease.     A  case  is 


PSORIASIS.  381 

reported  by  Joseph1  as  occurring  in  a  man  of  previous  good 
health.  It  commenced  as  a  number  of  small  glandular 
swellings  in  the  neck.  Shortly  after  their  appearance 
severe  general  pruritus  began  to  afflict  the  patient.  Then 
the  inguinal  and  axillary  glands  became  greatly  enlarged, 
and  a  general  eruption  of  hempseed-sized  papules  occurred. 
These  were  more  easily  felt  than  seen,  and  were  of  pale- 
red  color.  The  epidermis  over  them  was  unchanged. 
Wheals  also  appeared  that  changed  into  papules.  The  skin 
between  the  papules  was  dark-colored,  thickened,  and  dry. 
The  case  ran  a  chronic  course,  marked  by  relapses. 

Psora.     See  Psoriasis. 

Psoriasis  (So-ri2-a'-si2s).  Synonyms :  Lepra ;  Lepra 
alphos  ;  Alphos  ;  Psora  ;  (Ger.)  Schuppenflechte. 

A  disease  of  the  skin  characterized  by  an  eruption  of 
round  or  oval,  bright-red  patches  covered  with  more  or  less 
thick,  silvery  white,  adherent  scales  ;  by  occurring  especially 
upon  the  extensor  surfaces  of  the  elbows,  knees,  and  extremi- 
ties, and  upon  the  scalp ;  by  running  a  chronic  course 
marked  by  remissions  and  relapses  ;  and  by  being  more  or 
less  pruritic. 

This  is  one  of  the  more  common  skin  diseases,  forming  in 
this  country  about  3  per  cent,  of  all  cases. 

Symptoms.  Its  features  of  variously  sized,  sharply  de- 
fined red  patches  covered  with  more  or  less  abundant  sil- 
very white  scales  that  occur  specially  upon  the  extensor 
surfaces  of  the  elbows  and  knees,  are  so  pronounced  that  the 
disease  once  seen  is  readily  recognized  even  by  the  tyro. 

The  primary  lesion  of  psoriasis  is  always  a  rather  bright- 
red,  pinhead-sized  papule  covered  with  a  dry  silvery  white 
or  grayish  scale.  It  is  rare  to  meet  with  a  case  in  which 
these  small  lesions  are  seen  alone,  and  when  it  is,  it  is  called 
psoriasis  punctata.  Careful  search  of  any  but  an  inveterate 
case  will  be  rewarded  by  finding  these  lesions  somewhere  on 
the  body.  They  soon  begin  to  enlarge  by  peripheral  exten- 
sion into  larger  patches  which  have  received  various  names, 

1  Deutsche  med.  Wochenschrift,  1889,  p.  946. 


382  DISEASES    OF    THE    SKIN. 

although  all  the  same  disease.  When  they  attain  the 
diameter  of  about  one-quarter  of  an  inch  and  bear  a  rather 
thick  scale,  they  look  like  drops  of  mortar,  and  the  case  is 
then  spoken  of  as  psoriasis  guttata.  When  the  lesions  form 
coin-sized  patches  we  speak  of  psoriasis  nummularis.  A 
single  patch  may  grow  to  be  two  inches  in  diameter,  or 
even  larger,  and  preserve  its  circular  shape.  But  the  large 
patches  are  usually  formed  by  the  coalescence  of  several 
smaller  patches,  and  may  attain  to  a  size  sufficient  to  cover 
the  greater  part  of  a  limb,  or  even  the  trunk.  Its  circular 
outline  is  now  lost  and  the  patch  has  a  more  or  less  scal- 
loped, indented  border  bearing  so  strong  a  resemblance  to 
the  maps  drawn  by  children,  that  Piffard  suggested  the  term 
psoriasis  geograpliica  for  it.  But  the  more  usual  name  is 
psoriasis  diffusa.  After  a  patch  has  reached  a  certain  size 
it  may  clear  up  in  the  centre  and  form  a  ring,  and  in  this 
way  we  have  psoriasis  circinata.  Several  of  these  rings 
may  meet  at  their  circumference,  when  the  points  of  contact 
will  disappear  and  gyrate  figures  will  be  formed.  When 
the  eruption  is  so  general  as  to  involve  the  whole  or  the 
greater  part  of  the  body,  we  speak  of  it  as  psoriasis  univer- 
salis. Not  infrequently  these  cases  bear  a  striking  resem- 
blance to  dermatitis  exfoliativa. 

Every  case  of  psoriasis  does  not  exhibit  all  these  varieties, 
because  the  disease  may  stop  short  at  any  period  of  its 
evolution.  But  in  any  case  there  is  apt  to  be  a  number  of 
variously  sized  lesions.  Whatever  the  size  of  the  patch  may 
be,  it  will  always  be  observed  that  the  redness  extends  a 
little  beyond  the  scales.  The  amount  of  the  scaling  will 
vary.  Sometimes  the  scaling  will  be  but  slight ;  sometimes 
it  will  be  so  abundant  that  it  will  heap  up  into  such  crust- 
like masses  as  to  suggest  the  adjective  rupioide.  The  scales 
are  constantly  being  shed,  and  as  constantly  renewed.  They 
may  be  readily  scraped  off  with  the  nail,  and  if  this  is  care- 
fully done  a  delicate  glistening  membrane  will  be  exposed, 
under  which  will  appear  dot-like  red  points.  That  is,  we 
have  removed  the  epidermis  and  exposed  the  mucous  layer 
of  the  skin,  the  red  points  being  the  tops  of  the  slings  of 
bloodvessels  of  the  papillae.     This  is  thought  by  some  to  be  a 


psoriasis.  383 

characteristic  of  psoriasis,  but  with  care  it  may  be  produced 
in  other  diseases. 

The  color  of  the  scales  is  silvery  white  or  grayish. 
Darker  scales  are  due  either  to  the  deposition  of  dust,  or  the 
admixture  of  blood.  The  color  of  the  patch  will  vary  from 
a  pinkish  red  to  a  dark  red,  the  darker  color  being  seen 
upon  the  legs,  where  the  color  of  all  lesions  is  darker  on 
account  of  the  partial  stasis  in  the  flow  of  blood.  The 
disease  is  always  a  dry  one,  there  being  absolutely  no  dis- 
charge feature  in  its  course.  The  patches  are  sharply  de- 
fined, but  so  little  raised  that  they  can  be  nearly  all  scratched 
away. 

While  psoriasis  may  occur  anywhere  on  the  body,  and,  as 
we  have  seen,  may  become  universal,  its  most  frequent  loca- 
tions are  the  extensor  surfaces  of  the  limbs,  elbows,  and 
knees,  or  rather  the  face  of  the  tibiae  just  below  the  knee, 
and  the  scalp.  It  may  occur  upon  the  two  first  locations 
alone.  When  it  occurs  on  the  scalp  careful  examination 
will  show  some  lesion  elsewhere  on  the  body,  and  we  will 
usually  find  a  little  patch  in  front  of  the  ears,  and  very 
often  there  will  be  a  red  scaly  line  on  the  forehead  just  in 
front  of  the  hair  line,  a  feature  that  is  as  striking  and  as 
characteristic  of  psoriasis  as  the  corona  veneris  is  of  syphilis. 
The  hair  does  not  fall,  as  a  rule.  In  some  cases,  however, 
we  may  have  transient  or  permanent  alopecia.  The  whole 
scalp  may  be  covered  with  a  continuous  patch,  or  distinct 
scaly  patches  may  form  as  on  the  body.  In  any  event  the 
border  of  the  patch  will  be  sharply  defined. 

The  palms  and  soles  are  very  rarely  the  seat  of  the  dis- 
ease, and  then  only  as  part  of  general  psoriasis.  It  is  true 
that  a  few  cases  have  been  reported  in  which  it  has  been 
said  even  to  be  located  upon  one  hand  alone,  and  this  by 
competent  observers.  But  the  probabilities  are  all  in  favor 
of  such  cases  having  been  either  syphilis,  which  is  most 
likely,  or  squamous  eczema.  The  disease  is  bilateral  and 
sometimes  may  show  a  decided  tendency  to  symmetry. 

In  old  inveterate  cases  there  may  be  considerable  thicken- 
ing of  the  skin,  a  feature  that  is  usually  wanting,  and  fissures 
may  form  about  the  joints  that  may  be  painful  and  bleed. 


384  DISEASES    OF    THE    SKIN. 

This  may  also  occur  on  the  scrotum,  or  the  trunk  where  the 
skin  is  in  folds. 

The  nails  are  affected  in  some  cases,  becoming  opaque, 
lustreless,  furrowed  transversely,  discolored,  and  sometimes 
cracked  ;  while  they  are  raised  from  their  beds  by  the 
accumulation  of  scales  underneath  them.  All  the  nails  are 
rarely  diseased  at  the  same  time ;  usually  it  is  but  one  or 
two  nails  on  each  hand  or  foot.  Sometimes  the  disease  is 
limited  to  a  strip  along  the  side  of  one  nail 

There  is  no  constitutional  disturbance  in  this  disease,  the 
patients  usually  being  in  as  perfect  health  as  the  majority 
of  mankind.  Sometimes  they  will  have  pains  in  the  joints 
that  are  regarded  as  rheumatic  by  some,  and  as  neurotic  by 
others.  Itching  is  very  often  an  annoying  symptom. 
Sometimes  it  is  entirely  wanting. 

The  course  of  the  disease  is  variable.  Although  it  is 
always  chronic,  it  presents  at  times  acute  symptoms.  Re- 
lapses are  the  rule  to  which  there  are  few  exceptions.  In 
some  cases  the  skin  will  be  entirely  free  of  all  trace  of  the 
disease  for  months  or  years.  In  most  cases  this  freedom  is 
only  partial;  even  though  the  patient  thinks  he  is  clean, 
some  little  spot  will  be  discoverable.  The  duration  of  each 
patch  is  also  variable.  It  may  disappear  in  a  few  weeks  or 
remain  for  months.  Most  cases  are  better  in  summer,  to 
become  worse  in  winter.  When  the  patches  disappear  they 
do  so  completely,  though  a  slight  amount  of  scaling  may 
be  present  for  a  short  time.  In  a  few  very  rare  cases  a 
chronic  psoriatic  patch  has  become  papillomatous,  and  then 
epitheliomatous. 

Etiology.  Various  theories  have  been  advanced  in  the 
etiology  of  psoriasis,  and  some  facts  have  been  established  by 
our  study.  We  know  that  the  disease  is  hereditary  in  a 
number  of  cases.  Greenough1  found  the  proportion  as  high 
as  one-third.  It  may  occur  at  any  age.  Kaposi  has  re- 
ported a  case  at  eight  months  of  age.  It  usually  is  a  disease 
of  early  adult  life,  making  its  first  appearance  before  the 
thirtieth  year.     It  is  rare  after  the  fiftieth  year.      It  affects 

1  Boston  Med.  and  Surg  Journ.,  1885,  cxiii.  163. 


psoriasis.  385 

both  sexes,  and  all  conditions  of  life.  These  things  we 
know. 

While  the  majority  of  patients  seem  to  be  in  the  best  of 
health,  some  are  rheumatic,  or  gouty.  A  lowered  condition 
of  the  general  health  seems,  in  some  cases,  to  favor  an  out- 
break either  of  a  primary  attack  or  of  a  relapse.  Thus  it  is 
no  uncommon  thing  to  see  the  disease  in  women  grow  worse 
during  pregnancy  or  lactation.  Mal-assimilation  or  diges- 
tive disorders  also  seem  to  aggravate  or  provoke  the  disease, 
Hardaway  even  affirming  that  he  has  known  the  inordinate 
eating  of  oatmeal  to  cause  the  disease,  while  Gowers1  reports 
cases  produced  by  the  ingestion  of  borax  as  a  medicine. 
Polotebnoff2  has  written  an  elaborate  thesis  to  show  that 
the  disease  is  a  vasomotor  neurosis,  affirming  that  in  a 
majority  of  cases  there  will  be  found  evidences  of  either 
trophic  or  vasomotor  disturbances,  or  a  history  of  more  or 
less  profound  nervous  troubles  either  in  the  patient  or  his 
family.  A  number  of  cases  following  fright  or  nerve-shock 
have  been  reported.  In  the  VierteljaJirscTirift  f.  Dermat. 
u.  Syph.  for  1878,  Lang  brought  out  his  parasitic  theory, 
and  in  No.  208  of  Volkmann's  Sammlung  klinische  Vor- 
trdge  the  thesis  is  further  elaborated,  the  fungus  being 
represented  by  illustrations.  He  has  found  some  support 
from  other  observers,  but  the  theory  has  not  gained  credence 
from  the  best  authorities. 

It  is  a  well-known  fact  that  an  injury  to  the  skin  of  a 
psoriatic,  such  as  a  pin-scratch,  will  determine  the  location 
of  a  patch  of  psoriasis. 

Pathology.  Pathologists  by  no  means  agree  in  their 
teachings  as  to  the  histology  of  psoriasis.  By  some  it  is 
regarded  as  inflammatory,  while  others  believe  it  to  be  a 
keratolysis,  or  an  anomaly  of  cornification  in  which  an  im- 
perfect corneous  layer  is  formed.  Some  teach  that  the  pro- 
cess begins  in  the  rete,  and  the  changes  in  the  corium  are 
secondary ;  while  others  hold  the  reverse  view.  Lang 
names  his  parasite  epidermedopJiytony  and  describes  it  as 

1  Lancet,  October  24,  1884. 

2  Monatshefte  f.  prakt.  Dermat.,  1891,  Erganzungsheft  No   1. 

17 


386  DISEASES    OF    THE    SKIN. 

composed  of  mycelia  and  spores,  either  disseminated  or  in 
groups,  which  are  so  delicate  as  to  be  found  only  with  very 
high  powers. 

Diagnosis.  A  typical  case  of  psoriasis  presenting  round 
or  oval,  variously  sized  red  dry  patches  covered  with  thick 
silvery  white  scales,  scattered  more  or  less  generally  over  the 
body,  but  showing  a  marked  preference  for  the  extensor  sur- 
faces of  the  extremities  and  specially  of  the  elbows  and  knees, 
is  readily  recognized.  In  some  less  typical  cases  it  needs  to 
be  differentiated  from  syphilis,  eczema,  seborrhcea,  derma- 
titis exfoliativa,  lichen  ruber  acuminatus  and  planus,  Unna's 
seborrheal  eczema,  and  possibly  from  lupus  erythematosus. 
From  the  squamous  syphilide  as  a  secondary  stage  of  the 
disease  it  differs  by  showing  preference  for  the  extensor  sur- 
faces of  the  limbs  and  the  posterior  surface  of  the  trunk, 
though  there  are  many  exceptions  to  this  rule.  The 
syphilide  is  not  so  scaly ;  its  red  is  darker,  more  ham- 
colored  ;  the  lesions  are  more  infiltrated,  giving  a  more  shotty 
feeling  to  the  finger ;  they  do  not  itch ;  they  run  a  more 
acute  course,  and  are  of  more  uniform  size,  never  exhibiting 
the  patchy  character  of  psoriasis.  It  is  usually  easy  to 
establish  the  presence  of  other  manifestations  of  syphilis, 
such  as  sore-throat,  pains  in  the  bones,  fall  of  the  hair,  and 
perhaps  the  remains  of  the  initial  lesion.  The  late  scaly 
syphilide  is  never  general ;  is  unsymmetrical,  usually  con- 
sisting of  one  or  two  groups  of  lesions  that  show  no  tend- 
ency to  affect  the  elbows  and  knees.  The  lesions  are  more 
raised  and  prone  to  leave  scars.  There  will  also  be  the  his- 
tory of  past  syphilides  to  guide  us,  and  an  absence  of  those 
relapses  so  common  and  characteristic  of  psoriasis. 

Eczema  squamosum  is  far  more  pruritic  than  psoriasis 
usually  is  ;  the  patch  is  more  infiltrated  ;  the  scaling  is  less, 
the  scales  being  thinner ;  exudation  can  be  readily  induced  ; 
and  a  history  of  moisture  at  some  time  will  be  found.  The 
patch  of  eczema  is  generally  less  sharply  defined,  and  is 
more  apt  to  shade  off  into  the  surrounding  skin.  If  the 
scales  of  a  psoriatic  patch  are  removed,  a  delicate  mem- 
brane is  left  showing  red  dots — the  tops  of  the  bloodves- 


psokiasis.  387 

sel  slings  in  the  papillae ;  if  the  same  thing  is  done  in 
eczema  a  discharging  surface  will  be  left. 

Seborrhoea  may  simulate  a  psoriasis  when  it  occurs  in 
patches  on  the  chest,  or  as  thick  crusts  on  the  scalp.  The 
patches  on  the  chest  have  a  more  yellow  color  and  their 
scales  a  more  greasy  feel  than  is  the  case  in  psoriasis.  On 
the  scalp  the  crusting  of  seborrhoea  does  not  occur  in  such 
sharply  defined  patches,  and  its  crusts  are  very  greasy. 
In  either  case,  if  it  be  one  of  psoriasis  we  will  be  sure  to 
find  one  or  more  typical  lesions  somewhere  on  the  trunk. 

It  is  quite  impossible  to  differentiate  a  true  case  of  derma- 
titis exfoliativa  at  first  sight  from  one  of  general  psoriasis. 
If  it  does  arise  from  psoriasis  there  will  be  a  history  of  its 
gradual  spread  from  typical  lesions  quite  different  from  what 
obtains  in  true  dermatitis  exfoliativa,  which  is  more  rapid  in 
its  evolution.  Psoriasis  is  rarely  so  absolutely  universal  as 
is  dermatitis  exfoliativa.  Watching  the  case  for  a  time  will 
establish  the  diagnosis.  If  psoriasis  is  the  malady  it  will 
declare  itself  after  a  time  by  the  diffused  redness  clearing 
up  and  typical  psoriatic  patches  showing  themselves. 

Lichen  ruber  acuminatum  presents  small  pointed  papules 
upon  the  trunk  at  first,  and  not  the  large,  much-scaling 
papules  upon  the  extensor  surfaces  of  the  limbs  of  psoriasis. 
When  the  disease  becomes  general  we  will  have  the  history 
of  these  lesions,  and  a  much  greater  thickening  of  the  skin. 

Lichen  planus  occurs  by  preference  on  the  flexor  rather 
than  the  extensor  aspects  of  the  limbs,  and  in  the  form  of 
a  flat,  shining,  angular,  smooth  papule,  rather  than  a  round, 
freely  scaly  one.  The  color  of  its  patch  is  violaceous  and 
not  bright  red.  If  it  becomes  universal  it  does  so  evidently 
by  the  springing  up  of  new  small  lesions  between  the  old 
ones,  and  not  by  the  peripheral  growth  and  coalescence  of 
those  already  existing.  The  thickening  of  the  skin  is  also 
much  greater  than  in  psoriasis. 

In  the  diagnosis  from  seborrhoeal  eczema,  Unna  lays 
great  stress  upon  four  points :  1.  Seborrhoeal  eczema 
spreads  from  above  downward,  mostly  in  the  middle  line  of 
the  body,  and  its  lesions  are  quite  stationary  in  character ; 
while  psoriasis  begins  on  the  elbows  and  knees,  and  more 


388  DISEASES    OF    THE    SKIN. 

speedily  affects  the  whole  body.  2.  There  is  always  a  his- 
tory of  a  seborrheal  affection  of  the  scalp  in  seborrheal 
eczema.  3.  The  scales  of  seborrheal  eczema  are  fatty  and 
crumbling,  and  the  patches  are  yellowish ;  in  psoriasis  the 
scales  are  white  and  friable,  not  greasy,  and  the  patches  are 
bright  red.  4.  The  proneness  of  the  patches  of  seborrheal 
eczema  to  form  bow- shaped  figures,  or  rings  more  or  less 
broken.  Psoriasis  may  be  circinate,  but  the  margins  of  the 
figures  are  not  so  narrow  and  not  follicular  as  they  may  be 
in  seborrrheal  eczema. 

Treatment.  Though  external  treatment  alone  will 
remove  the  evidences  of  psoriasis  upon  the  skin,  producing 
a  cure  of  the  disease — if  that  may  be  said  of  a  disease  that  is 
almost  sure  to  relapse — we  sometimes  can  procure  more 
prompt  results  by  a  combination  of  internal  and  external 
remedies.  The  first  inquiry  in  all  cases  should  be  made  as 
to  the  general  condition  of  the  patient,  and  we  should 
endeavor  to  establish  in  him  as  perfect  a  state  of  health  as 
is  possible.  A  restricted  diet  certainly  does  have  a  good 
deal  of  influence  in  causing  an  amelioration  of  the  disease. 
No  hard  and  fast  lines  can  be  set  in  this  respect.  Under  my 
esteemed  teacher,  Prof.  Geo.  Henry  Fox,  who  is  a  strong 
advocate  of  dieting  in  skin  diseases,  I  have  seen  some 
patients  improve  under  a  strictly  vegetable  diet,  and  others 
do  equally  well  on  a  dietary  composed  largely  of  milk  and 
animal  food.  A  stout,  evidently  overfed,  plethoric  patient 
will  be  benefited  by  cutting  off  all,  or  nearly  all,  meat.  In 
this  class  of  patients  it  is  a  good  plan  to  insist  upon  a  milk 
diet  for  a  few  days.  An  anaemic,  underfed  patient  will,  on 
the  other  hand,  improve  under  a  more  liberal  dietary. 
Alcoholics,  and  especially  malt  liquors,  should  be  interdicted 
in  all  cases,  as  well  as  rich  gravies  and  highly  spiced  foods. 

Besides  these  general  measures  we  have  a  number  of 
drugs  that  have  gained  a  more  or  less  well-earned  reputa- 
tion as  remedies  for  psoriasis,  though  it  must  be  confessed 
that  they  are  more  or  less  empirical  remedies. 

Arsenic  would  be  named,  without  doubt,  by  most  general 
practitioners  as  the  remedy  for  psoriasis.  It  does  do  good 
in  this  disease,  but  at  the  same  time  it  is  not  to  be  con- 


psoriasis.  389 

sidered  as  a  true  specific.  In  acute  cases  it  aggravates  the 
disease  and  should  never  be  given.  In  chronic  cases  that 
have  proved  very  stubborn,  it  may  be  tried,  and  sometimes 
it  will  produce  a  speedy  cure.  The  vast  majority  of  cases 
will  do  quite  as  well  without  it.  It  may  be  given  in  the 
form  of  Fowler's  solution  with  or  without  the  wine  of  iron, 
and  administered  in  water  three  times  a  day  after  meals. 
The  initial  dose  for  an  adult  should  be  about  three  drops, 
and  the  amount  should  be  gradually  increased  until  the 
limit  of  toleration  is  reached.  Crocker  thinks  that  the  effi- 
ciency of  this  form  of  arsenic  is  enhanced  by  the  addition 
of  half  a  drachm  of  the  tincture  of  lupulus  to  each  dose. 
The  Asiatic  pill  is  the  favorite  mode  of  using  arsenic  in 
Vienna.     It  is  composed,  according  to  Kaposi,  of — 

R.  Pulv.  ac.  arseniosi,  75 

Pulv.  piperis  nigrse,  6 

Gummi  acaciae,  1  50 

Pulv.  althse.  rad.,  2 

Aquae,  q.  s.  M. 

Div.  in  pil.  no.  c. 

One  pill  is  given  after  meals,  and  the  dose  is  increased 
gradually  every  four  or  five  days  until  ten  or  twelve 
are  taken  a  day,  unless  some  constitutional  disturbance  is 
caused  before  then.  The  method  of  increase  is  by  first 
giving  one  pill  after  each  meal ;  then  two  pills  after  break- 
fast, and  one  after  the  other  two  meals  ;  and  then  two  after 
breakfast,  two  after  the  midday  meal,  and  one  in  the  even- 
ing, and  so  on.  Or  we  may  make  use  of  the  tablet  triturates 
of  arsenious  acid  with  piperina,  giving  those  containing  one- 
twentieth  of  a  grain  of  the  arsenic  in  the  same  manner  as 
the  Asiatic  pills.  Any  other  preparation  of  arsenic  may  be 
used.  Hypodermatic  injections  of  the  metal  have  been  em- 
ployed with  success,  but  it  would  be  hard  to  induce  an 
American  patient  to  endure  this  method.  The  administra- 
tion of  the  drug  must  be  persisted  in  for  a  long  time,  and 
it  may  prove  curative  by  itself. 

Alkalies  that  act  as  diuretics  are  often  very  helpful,  quite 
apart  from  any  indication  for  their  use  on  account  of  gout  or 
rheumatism.     A  beginning  psoriasis,  or  even  a  case  of  some 


390  DISEASES    OF    THE    SKIN. 

duration,  will  be  favorably  influenced  by  the  administration 
of  the  acetate  or  citrate  of  potassium  in  fifteen-grain  doses 
before  meals,  well  diluted,  and  followed  by  drinking  half  a 
glass  of  water.  The  undoubted  eflicacy  of  the  large  doses  of 
the  iodide  of  potassium  as  recommended  by  Haslund,1  may 
depend  in  part,  at  least,  upon  its  diuretic  action.  He  gives 
the  salt  in  increasing  doses  so  that  as  much  as  600  grains 
have  been  administered  to  one  patient  during  the  day. 
When  assistant  physician  to  the  New  York  Skin  and  Can- 
cer Hospital,  on  Dr.  G.  H.  Fox's  division,  I  tried  Haslund's 
plan  in  several  cases.  They  certainly  were  greatly  bene- 
fited. The  objections  to  this  method  are  the  expense  of  the 
drug  and  the  danger  of  the  sudden  production  of  poisoning, 
shown  by  palpitation  of  the  heart,  severe  headache,  and 
faintness,  and  necessitating  either  keeping  the  patient  in  a 
hospital  or  under  the  constant  attendance  of  a  physician. 

Turpentine  oil  is  highly  commended  by  Crocker  as 
follows :  It  may  be  given  in  capsule,  or,  preferably,  as  an 
emulsion  rubbed  up  with  mucilage  of  acacia.  The  initial 
dose  is  ten  minims  three  times  a  day  after  meals.  It  may 
be  increased  by  five  or  ten  minims  at  a  dose  until  the 
patient,  if  tolerant  of  it,  is  taking  thirty  minims  three  times 
a  day.  Barley-water  must  be  freely  drunk  during  the  day 
to  prevent  any  bad  effect  on  the  kidneys,  and  the  last  dose 
of  the  turpentine  should  not  be  taken  later  than  six  or 
seven  o'clock  in  the  evening.  Dyspepsia  and  irritability  of 
the  urinary  organs  contra-indicate  its  use. 

The  wine  of  antimony  in  five-  to  ten-minim  doses  is 
recommended  by  Mr.  Malcolm  Morris  as  efficacious  in  acute 
cases. 

Chrysarobin  by  the  mouth,  one-sixth  of  a  grain  in  sugar 
of  milk  three  times  a  day,  and  increased  to  one  or  two 
grains  at  a  dose,  acts  well  in  some  cases,  but  is  very  apt  to 
cause  so  much  nausea  and  vomiting  as  to  compel  its  discon- 
tinuance. 

Polotebnoff  advocates  the  use  of  bromide  of  potassium, 
believing  the  disease  to  be  a  neurosis ;  and  of  ergot. 

1  Vierteljahr.  f.  Derm.  u.  Syph  ,  1887,  xiv.  677. 


PSORIASIS. 


391 


External  treatment.  Before  making  any  application  to 
the  psoriatic  skin  the  scales  must  be  removed  by  bathing 
with  soap  and  water,  or  by  warm  alkaline  baths.  Some- 
times bathing  followed  by  inunctions  of  the  skin  with  sim- 
ple oil,  or  vaseline,  combined  with  attention  to  diet,  will  pro- 
duce a  cure.  Generally  we  must  resort  to  more  stimulating 
remedies.  The  most  useful  and  most  promptly  curative 
external  remedy  is  chrysarobin  (chrysophanic  acid).  The 
objections  to  it  are  its  tendency  to  produce  an  acute  derma- 
titis and  its  permanent  staining  of  everything  with  which 
it  comes  in  contact.  These  unpleasant  effects  may  be  in 
part  overcome  by  combining  the  drug  with  flexible  collodion 
or  traumaticin,  but  only  in  part.  The  dermatitis  is  always 
most  marked  upon  those  parts  in  which  there  is  laxity  of  the 
skin,  and  if  it  is  used  on  the  face  it  is  prone  to  produce 
great  swelling  about  the  eyes.  Care  must  be  taken  not  to 
get  it  in  the  eyes,  as  it  causes  violent  conjunctivitis.  These 
effects  forbid  its  .use  upon  the  face  or  scalp. 

The  most  active  form  in  which  to  use  the  drug  is  in  an 
ointment  as  of  lard,  lanolin,  or  vaseline.  Bassorin  and 
plasment  are  excipients  brought  out  in  1891.  Bassorin 
was  introduced  to  the  profession  by  Dr.  Geo.  T.  Elliot,1  of 
New  York,  and  shortly  afterward  by  Prof.  Pick,2  of  Prague. 
Plasment  originated  with  Messrs.  Dagget  and  Ramsdell,  of 
New  York.  These  excipients  have  the  merit  of  not  being 
greasy,  and  can  be  readily  and  entirely  removed  by  means  of 
water.  Flexible  collodion  or  traumaticin,  the  liquor  gutta- 
percha, are  good  excipients. 

The  strength  of  chrysarobin  should  not  exceed  one 
drachm  to  the  ounce,  as  a  rule,  though  in  exceptional  cases 
it  may  be  used  in  greater  strength.  Its  activity  is  increased 
by  the  addition  of  salicylic  acid  (3  per  cent.),  and  then  it  is 
best  to  use  it  in  a  lower  percentage,  even  5  per  cent,  being 
active  enough.  An  alkaline  bath  before  using  the  chrysa- 
robin increases  its  potency.  If  we  use  an  ointment,  it  should 
be  thoroughly  rubbed  in  once  a  day  after  the  scales  are 


1  Journ.  Cutan.  and  Gen.-urin.  Dis.,  1891,  ix.  48. 

2  Vierteljahr.  f.  Derm.  u.  Syph.,  1891,  xxiii.  633. 


892  DISEASES    OF    THE    SKIN. 

removed.  If  our  vehicle  is  bassorin,  plasment,  collodion,  or 
gutta-percha  solution  the  spots  should  be  painted  over  as  often 
as  the  film  that  the  application  leaves  falls.  The  patient 
should  always  be  warned  against  getting  the  drug  in  his  eyes. 
A  favorite  formula  of  Dr.  Geo.  H.  Fox  is  the  following  : 

R.  Chrysarobin.,  \  2rarts 

01.  cadi,  /  aa    ^Parts- 

Ac.  carbolici,  1  part. 

Ac.  oleic,  50  parts.     M. 

If  the  chrysarobin  produces  too  great  a  reaction,  it 
must  be  stopped  and  the  skin  treated  with  vaseline  and 
starch  powder,  or  an  alkaline  wash.  The  action  of  the 
drug  upon  the  skin  is  peculiar.  It  stains  the  skin  about  the 
patches  of  a  mahogany-red,  while  the  patches  become 
smooth  and  white.  It  discolors  the  nails  and  the  hair,  but 
after  a  time  the  staining  disappears.  Not  so  the  staining 
of  the  clothing,  which  is  permanent.  It  is  said  that  it  can 
be  somewhat  lessened  by  soaking  the  clothes  in  plain  water 
before  using  soap  in  washing. 

Before  chrysarobin  was  discovered  much  reliance  was 
placed  on  the  ointment  of  the  ammoniate  of  mercury. 
It  is  still  a  reliable  remedy,  but  it  cannot  be  used  over 
the  whole  body  in  a  general  psoriasis  on  account  of  the 
danger  of  absorption  of  the  mercury.  It  is  the  pleasantest 
and  promptest  application  to  the  scalp  and  face,  and  can 
be  used  there  while  chrysarobin  is  used  on  the  rest  of 
the  body.  Other  mercurial  ointments,  such  as  that  of  the 
yellow  oxide,  and  a  dilute  ointment  of  the  nitrate,  may  be 
used.  Lang  has  found  the  bichloride  of  mercury  in  collo- 
dion in  J  to  ^  per  cent,  strength  a  good  application.  It 
would  probably  be  an  unsafe  one  in  a  case  of  any  extent. 

Tar  is  another  old  and  reliable  remedy,  still  much  used 

in  France.     It  may  be  employed  in  an  ointment,  or  oil,  or 

dissolved  in  alcohol.     The  oil  of  cade,  oil  of  birch,  or  pure 

tar  may  be  used  in  the  strength  of  half  a  drachm  to  four 

drachms  to  the  ounce.     In  Paris  the  following  is  sometimes 

used  : 

& .  Glycerole  of  starch,  \  1QQ 

Oil  of  cade,  /  aa     1UU  parts' 

Green  soap,  5     "  M. 


psoriasis.  393 

This  is  to  be  rubbed  in  at  night,  the  patient  is  to  sleep  in 
a  flannel  gown,  and  wash  the  stuff  off  in  the  morning. 
Kaposi  recommends  the  following  : 

K .  01.  rusci,  50  parts. 

Etheris  sulphuris,  \  aa    75    " 

Alcoholis,  j 

Filter,  and  add 

01.  lavandulae,  2     "  M. 

Tar  in  any  form  is  a  dirty  application,  and  is  prone  to 
produce  inflammation  of  the  skin,  as  well  as  toxic  symptoms. 
Pyrogallol  (pyrogallic  acid)  is  efficacious,  but  can  only  be 
used  in  cases  in  which  the  eruption  is  not  extensive,  on 
account  of  its  poisonous  action  when  absorbed.  It  may  be 
used  in  the  strength  of  about  10  per  cent,  in  ointment.  It 
stains  the  skin,  but  causes  less  inflammatory  reaction  than 
chrysarobin  does. 

Thymol  was  introduced  by  Crocker.  It  may  be  used  as 
an  ointment  or  lotion  in  the  strength  of  15  grains  to  3 
drachms  to  the  ounce.  As  it  is  colorless  and  of  pleasant 
odor  it  is  suitable  for  use  on  the  face.  The  same  authority 
advocates  the  use  of  turpentine  locally.  He  uses  the  oleum 
pini  sylvestris  with  sufficient  oil  of  lavender  or  essence  of 
lemon  to  cover  its  odor.  If  used  undiluted  the  skin  must 
be  smeared  with  vaseline  to  prevent  its  cracking.  It  is 
better  to  use  it  diluted  with  olive  oil,  5j  oil  of  turpentine  to 
5vij  of  olive  oil,  the  proportion  of  the  oil  of  turpentine  being 
increased  as  the  skin  becomes  accustomed  to  it.  The  addi- 
tion of  oil  of  cade  or  oleum  rusci  to  the  mixture  increases 
its  efficacy. 

Salicylic  acid,  5  to  20  per  cent,  strength,  will  remove  the 
scales  and  in  some  cases  will  prove  curative.  The  soap 
treatment,  as  described  in  chronic  eczema,  is  of  great  value 
in  some  chronic  circumscribed  cases.  Sulphur  ointment, 
oleate  of  copper,  "  rufigallic"  acid,  10  per  cent,  in  ointment, 
resorcin,  have  all  done  well  in  some  cases.  Hydracetine, 
anthrarobin,  and  aristol  are  among  the  latest  remedies,  but 
have  not  proved  themselves  as  active  as  some  of  the  older 
ones. 

Some  patients  have  found  benefit  from  the  use  of  natural 

17*     * 


394  DISEASES    OF    THE    SKIN. 

mineral  waters  at  spas.  It  is  possible  that  much  of  the  bene- 
fit so  obtained  is  from  the  prolonged  and  regulated  bathing. 
Wearing  rubber  clothing  next  the  skin,  or  with  a  fine  piece 
of  muslin  between  the  rubber  and  the  skin  to  avoid  the  pro- 
duction of  eczema  by  the  rubber,  will  soften  and  remove  the 
scales,  and  hasten  the  disappearance  of  the  patches. 

Gallacetophenone  in  5  to  10  per  cent,  strength  as  oint- 
ment or  dissolved  in  collodion  may  be  tried,  but  is  not  as 
good  as  chrysarobin. 

Peognosis.  A  cure  of  psoriasis  may  be  promised  with  a 
fair  degree  of  certainty  as  far  as  the  removal  of  the  erup- 
tion then  out  is  concerned.  But  no  promise  can  be  made 
that  the  disease  will  not  relapse.  In  this  respect  psoriasis 
resembles  rheumatism  and  gout.  While  most  relapses  are 
readily  removed  in  the  course  of  a  few  weeks,  in  some  cases 
one  or  more  patches  will  be  remarkably  obstinate. 

Psorospermosis  Follicularis  Cutis  is  the  name  given  by 
French  writers,  notably  by  Darier,1  to  a  disease  of  the  skin 
cases  of  which  had  previously  been  reported  under  the  names 
of  lichen  spinulosum  (Hutchinson),  ichthyosis  sebacea  cornea 
(Wilson),  acne  sebacea  cornea  (Guibout),  ichthyosis  follic- 
ularis (Lesser),  keratosis  follicularis  (Morrow  and  White), 
acne  cornee  (Leloir  and  Vidal),  cacotrophia  folliculorum  (T. 
Fox),  and  sauroderma.  The  title  psorospermosis  was  given 
by  Darier  because  he  believed  that  he  had  found  certain  para- 
sites belonging  to  the  order  of  protozoa,  which  have  been 
named  psorosperms  in  causal  connection  with  the  disease. 
(For  description  of  the  disease  see  Keratosis  follicularis.) 

Pterygium  (Te2r-i2j/i2-u3m)  is  simply  an  overgrowth  of  the 
normal  nail-fold  at  the  proximal  end  of  the  nail  so  that  it 
covers,  to  a  greater  or  less  extent,  the  lunula.  It  may  be 
cut  off. 

Purpura  (Purpru2r-a3).  Synonyms  :  Hsemorrhoea  pete- 
chials ;  (Ger.)  Blutfleckenkrankheit. 

Symptoms.  By  this  term  is  meant  a  hemorrhage  into 
the  skin  which  is  not  caused  by  direct  traumatism.     It  is 

1   Ann.  de  Derm,  et  de  Syph.,  1889,  x.  597. 


PURPURA.  395 

always  readily  recognized  by  the  red,  purple,  or  blue-black 
color  that  it  causes,  which  cannot  be  made  to  disappear  by 
pressure.  The  hemorrhage  may  take  place  into  any  part  of 
the  skin  ;  into  the  subcutaneous  tissues ;  or  into  any  of  the 
glandular  apparatus  of  the  skin.  It  occurs  with  sudden- 
ness, and  produces  variously-sized  lesions  to  which  certain 
names  have  been  applied.  When  they  are  small,  from  pin- 
point-size to  perhaps  an  inch  in  diameter,  they  are  called 
petechia*.  When  occurring  in  the  form  of  more  or  less 
long  streaks  they  are  called  vibiees.  Large  bruise-like 
lesions  with  more  or  less  swelling  are  ecchymoses.  Blood 
tumors  of  all  sizes  are  ecchymomata  or  hcematomata.  The 
color  of  all  purpuric  lesions  depends  upon  their  age.  When 
first  formed  they  are  bright  red,  claret,  or  purple.  Before 
disappearing  they  pass  through  various  shades  of  color  such 
as  are  seen  after  an  ordinary  bruise,  becoming  blue-black, 
greenish-black,  or  brownish.  These  changes  are  due  to  the 
gradual  absorption  of  the  effused  blood  and  the  haematin 
deposited  from  the  blood  globules.  There  is  no  definite 
time  for  complete  absorption  to  take  place,  but  eventually 
no  trace  is  left  of  the  previous  hemorrhage. 

If  the  extravasation  of  blood  takes  place  into  the  hair  fol- 
licles we  will  have  papules  formed.  If  between  the  layers 
of  the  epidermis,  hemorrhagic  bullae  will  result.  Hemor- 
rhage into  sweat  glands  will  give  rise  to  hsematidrosis.  As 
complications  of  other  dermatoses  hemorrhage  may  occur,  as 
in  urticaria,  pemphigus,  and  eruptive  fevers,  but  these  should 
not  be  elevated  into  special  varieties  of  purpura. 

There  are  three  varieties  of  purpura,  namely,  purpura 
simplex,  purpura  hsemorrhagica,  and  purpura  rheumatica. 
It  is  convenient  for  us  to  preserve  these  varieties  for  a  time, 
though  the  results  of  the  latest  studies  seem  to  indicate  that 
the  second  variety  is  but  a  more  developed  form  of  the  first, 
cases  of  simple  purpura  having  been  seen  to  run  into  the 
hemorrhagic  form.  By  Crocker  and  others  the  third  variety 
is  regarded  as  a  form  of  erythema  exudativum.  It,  too, 
has  been  seen  to  run  into  the  hemorrhagic  form. 

Purpura  Simplex  is  the  most  common  variety,  and  usu- 
ally takes  the  form   of  petechise,  the  lesions  being  round  or 


396  DISEASES    OF    THE    SKIN. 

oval,  or  irregular  in  shape,  or  even  circinate.  Duhring  de- 
scribes a  case  of  this  rare  form,  as  does  Stelwagon.1  The 
lesions  appear  suddenly,  generally  without  antecedent  symp- 
toms, and  often  at  night.  Like  other  forms  of  purpura,  the 
lower  extremities  are  the  most  common  seat  of  the  eruption, 
especially  their  flexor  aspects,  but  any  part  of  the  skin  may 
be  attacked,  as  also  the  mucous  membranes.  Crocker 
affirms  that  in  children  the  lesions  appear  first  upon  the 
neck  and  upper  part  of  the  back.  The  lesions  appear  in 
crops,  and  most  often  are  symmetrical.  There  may  be  but 
a  single  outbreak,  and  the  whole  disease  may  be  at  an  end 
in  a  week  or  two.  But  it  may  be  prolonged  for  many  weeks 
by  a  succession  of  outbreaks.  There  is  usually  no  constitu- 
tional disturbance,  and  the  only  things  the  patient  complains 
of  are  the  spots,  and  perhaps  some  itching.  There  may  be 
lassitude,  malaise,  and  slight  elevation  of  temperature. 
Recovery  is  the  rule.  Exceptionally  purpura  simplex  passes 
over  into 

Purpura  Hcemorrhagica.  This  form  is  also  called  mor- 
bus macuhsus  Werlhoffii  and  land  scurvy.  It  usually 
begins  as  such,  and  is  heralded  by  pronounced  malaise, 
headache,  and  perhaps  convulsions.  It  begins  without  pro- 
dromata.  It  differs  from  the  previous  variety  by  the  more 
extensive  hemorrhages  that  take  place,  ecchymoses  forming 
rather  than  petechia,  and  by  free  bleeding  from  all  the 
mucous  membranes — nose,  mouth,  stomach,  urethra,  rectum, 
vagina.  These  are  so  copious  and  uncontrollable  at  times 
that  the  patient  will  literally  bleed  to  death  in  a  few  hours. 
Sudden  death  may  also  be  caused  by  hemorrhage  into  the 
meninges  and  brain.  An  excellent  study  of  this  fulminating 
form  of  purpura  has  been  made  by  Lock  wood.2  In  his  case 
there  was  a  rise  of  temperature  to  106.2°  F.  just  before 
death,  and  the  patient  died  in  about  sixty  hours  from  the 
onset  of  the  disease.  He  collected  thirty  cases,  in  thirteen 
of  which  the  patients  died  from  acute  anaemia,  internal 
hemorrhages,  or  septic  infection,  the  shortest  duration  of  any 

1  Journ.  Cutan.  and  Gen  -urin.  Dis.,  October,  1887. 

2  Medical  Kecord,  February  7,  1891. 


PURPURA. 


397 


one  case  being  seven  hours ;  in  eight  cases  death  was  due  to 
cerebral  hemorrhage ;  and  in  four  cases  the  patients  were 
pregnant.  Happily  all  cases  of  hemorrhagic  purpura  are 
not  fatal.  In  them  the  bleeding  is  moderate  in  amount,  and 
the  patient  is  gradually  restored  to  health.  Relapses  may 
occur. 

Purpura  Rheumatica.  This  is  also  called  peliosis  rheu- 
matica.  'It  resembles  purpura  simplex  in  every  way,  except- 
ing that  the  outbreak  of  the  eruption  is  preceded  or  followed 
by  pain  in  the  joints  accompanied  by  swelling,  the  malaise 
is  more  marked,  and  there  is  often  rise  of  temperature. 
The  eruption  is  often  most  abundant  about  the  joints.  The 
acute  symptoms  subside  in  two  or  three  days,  but  relapses 
are  frequent.  True  rheumatism  maybe  present  at  the  same 
time.  Valvular  heart  lesions  have  been  reported  to  occur 
after  this  variety  of  purpura,  even  without  true  rheumatism. 
Rarely  this  variety  may  pass  over  into  the  hemorrhagic 
form. 

Etiology.  Many  causes  have  been  assigned  to  account 
for  the  occurrence  of  purpura.  We  know  that  it  may 
occur  at  any  period  of  life,  in  both  sexes,  and  in  the  most 
varying  conditions  of  health.  There  is  no  doubt  that  pur- 
pura occurs  as  a  symptom  in  different  diseases  and  cachexia  ; 
after  the  ingestion  of  certain  drugs,  and  under  other  cir- 
cumstances too  numerous  to  catalogue  here.  Here  we  can 
readily  surmise  that  one  or  both  of  two  things  have 
occurred,  namely :  a  change  of  the  blood  itself  that  allows 
of  its  passing  through  the  walls  of  the  vessels ;  or  a 
change  in  the  vessel  walls  themselves  that  permits  the  blood 
to  pass  through  them.  Purpura  has  been  noted  after  the 
loosening  of  some  artificial  support  to  a  part  of  the  body, 
as  with  a  tight  bandage  continued  for  a  long  time.  It 
occurs  not  infrequently  in  old  age.  In  both  these  con- 
ditions it  is  due  to  a  weakening  of  the  tone  of  the  vessels. 
In  the  former  case  matters  right  themselves  in  a  few  days — 
a  happy  conclusion  that  cannot  be  anticipated  in  the  latter 
case.  Weakness  of  vesicular  walls  may  also  be  the  cause  of 
those  somewhat  rare  cases  of  purpura  without  cachexia  seen 
in  infants.     Other  cases  of  purpura  are  due  to  small  thrombi 


398  DISEASES    OF    THE    SKIN. 

lodging  in  the  smaller  vessels.  Some  cases  seem  to  be  due 
to  vasomotor  or  trophic  nerve  action  causing  either  sudden 
alterations  in  the  calibre  of  the  vessels  or  degenerations  in 
their  walls.  Recurring  purpura  has  been  noted  about  the 
point  of  greatest  pain  in  neuralgia. 

The  microbian  and  infectious  origin  of  purpura  is  stoutly 
defended  by  some  authorities.  Letzerich1  published  a 
brochure  on  this  subject  in  1889,  in  which  he  described  the 
"  bacillus  purpure  hemorrhagica  Letzerich  "  as  the  cause 
of  the  disease.  This  has  sharp  angles  and  edges,  is  readily 
cultivable,  and  pure  cultures  injected  into  rabbits  give  rise 
to  hemorrhages  either  spontaneously  or  on  slight  trauma. 

Diagnosis.  The  diagnosis  of  purpura  is  easily  made.  No 
other  disease  produces  brigbt-red,  slightly  elevated  lesions  the 
color  of  which  cannot  be  made  to  disappear  under  pressure. 
From  flea-bites  they  are  distinguishable  by  the  absence  of  a 
central  punctum.  Purpura  hemorrhagica  bears  a  close 
resemblance  to  scurvy,  but  in  the  latter  a  dietary  deficient  in 
vegetables  is  a  marked  etiological  factor ;  there  is  also 
greater  prostration,  swelling  of  the  gums,  loosening  of  the 
teeth,  and  brawny  swelling  of  the  limbs.  It  is  possible 
that  further  investigations  of  scurvy  may  show  that  it  is  but 
a  form  of  purpura  hemorrhagica  that  has  been  modified  by 
diet. 

Treatment.  In  simple  purpura  there  is  not  much  to  be 
done  except  to  put  the  patient  in  as  good  a  hygienic  condi- 
tion as  possible  and  relieve  symptoms.  In  peliosis  rheu- 
matica  and  purpura  hemorrhagica,  the  patient  should  be 
kept  absolutely  quiet  in  bed,  his  diet  made  of  the  most 
nutritious  and  easily  assimilable  kind,  and  ergot  and  iron 
administered.  Of  course,  if  there  is  hemorrhage  from  the 
nose,  vagina,  or  other  mucous  cavity  an  effort  must  be  made 
to  stop  the  flow  by  means  of  a  tampon,  ice,  hot  water,  or 
any  method  that  experience  has  proved  useful.  Ergo  tine 
may  be  employed  hypodermatically  ;  and  turpentine;  dilute 
sulphuric  acid  ;  nitrate  of  silver  in  pill  form  -|  to  J-  of  a 
grain  three  times  a  day ;  and  other  astringents,  have  been 

1  Monatshefte  f.  prakt,  Permat,,  1889,  p.  312. 


PUSTULA    MALIGNA. 


399 


found  useful.     Letzerich  recommends  for  bleeding  from  the 
gums — 


R .  Tinct.  ratanhise, 
Tinct.  iodini, 


10  parts. 
5     "         M. 


of  which  10  drops  are  to  be  put  in  a  wineglassful  of  water. 
For  this  purpose  other  astringents,  as  tannin,  alum,  and  the 
like  may  be  used. 

Prognosis.  From  the  beginning  of  a  case  it  is  not  pos- 
sible to  say  how  it  will  turn  out.  We  should  therefore  be 
very  guarded  in  our  prognosis.  Most  cases  met  with  do 
terminate  favorably.     Some  apparently  desperate  cases  do 


recover. 


Malignant 


Pustula    Maligna.       Synonyms :    Anthrax 
pustule ;  (Fr.)  Charbon. 

This  is  a  disease  of  cattle,  sheep,  and  horses,  in  which  it 
is  called  splenic  fever,  and  is  due  to  local  inoculation  with 
the  bacillus  anthrax  often  through  the  agency  of  flies.  If 
the  bacillus  gain  access  to  the  internal  organism  it  produces 
a  rapidly  fatal  general  disease  with  no  skin  lesion.  In  the 
human  the  exposed  parts — face,  hands,  and  neck — are  the 
most  frequent  sites  of  the  disease.  In  a  day  or  two  after 
inoculation,  the  patient  notices  a  burning  or  itching  of  the 
affected  part  and  the  formation  of  a  livid  red  papule  upon 
which  a  bulla  or  pustule  soon  forms.  This  ruptures,  the 
red  spot  changes  into  a  black  gangrenous  eschar,  the  parts 
around  it  become  indurated,  oedematous,  of  dusky  red  hue, 
and  studded  with  small  vesicles  or  pustules.  There  is 
marked  involvement  of  the  lymphatics,  and  enlargement  of 
the  neighboring  glands  that  may  suppurate.  In  favorable 
cases  the  slough  separates,  and  healing  by  granulation  takes 
place.  In  fatal  cases  the  gangrenous  process  extends 
rapidly,  symptoms  of  septic  infection  declare  themselves, 
and  the  patient  succumbs  to  the  disease  in  from  two  to  eight 
days.  In  all  cases  there  is  more  or  less  constitutional  dis- 
turbance. 

Diagnosis.  The  diagnosis  of  malignant  pustule  is  made 
mainly  by  the  rapidity  with  which  the  disease  develops  ;  the 
presence  of  the  gangrenous  patch  with  the  hard  indurated 


400  DISEASES   OF    THE    SKIN. 

tissues  about  it ;  and  the  severity  of  the  constitutional  symp- 
toms. The  finding  of  the  bacillus  will  verify  the  diagnosis. 
Treatment.  The  total  excision  of  the  diseased  patch  by 
means  of  a  free  incision  is  the  most  radical  and  effectual 
treatment  for  the  disease.  Injection  of  iodine  or  a  5  per 
cent,  solution  of  carbolic  acid  under  the  eschar  are  good 
methods  of  treatment.  The  hyposulphite  or  sulphite  of 
soda,  and  large  doses  of  quinia,  are  worthy  of  trial. 

Quinquaud's  Disease.     See  Folliculitis  decalvans. 
Radesyge.     See  Lepra. 

Red  Gum.  "An  obsolete  term  for  various  transitory  erup- 
tions in  teething  children."  (Foster.)  Commonly  this  is 
miliaria. 

Rheumatokelis.  A  term  applied  by  Fuchs  to  purpura 
occurring  with  rheumatism. 

Rhinophyma  (Ri2n-o-fi'ma3)  is  the  term  used  to  designate 
that  form  of  hypertrophic  rosacea  in  which  pendulous  tumors 
develop  on  the  nose.  These  may  attain  so  great  a  size  that 
they  will  hang  down  over  the  mouth. 

Rhinoscleroma  (Ri2n-o-skle2rVma3).  Synonyms:  (Fr.) 
Rhinosclerome ;  (Ital.)  Rinoscleroma ;    Perisarcoma. 

Symptoms.  This  is  an  exceedingly  rare  form  of  disease 
that  was  first  described  by  Hebra  and  Kaposi.  It  affects 
almost  exclusively  the  nose  and  its  mucous  membrane,  and 
assumes  the  form  of  flat  or  slightly  raised,  sharply  defined, 
isolated  or  confluent,  very  hard,  elastic  plates,  tumors,  or 
nodes  which  are  painful  on  pressure.  These  lesions  are 
located  in  the  skin  or  mucous  membrane  of  the  septum  of 
the  nose,  or  in  the  alse  and  the  neighboring  parts  of  the 
upper  lip.  They  can  be  raised  from  the  underlying  parts, 
but  the  skin  is  so  infiltrated  that  it  can  move  only  with  the 
growths.  The  color  of  the  skin  may  be  normal,  or  bright  or 
dark-brownish  red,  and  looking  like  a  keloid  or  hypertro- 
phied  scar.  The  contiguous  skin  shows  no  abnormalities 
whatsoever.  The  epidermis  over  the  growths  often  shows 
rhagades  from  which  exude  a  viscid  secretion  which  dries 
jnto  yellowish  adherent  scabs. 


RHINOSCLEROMA.  401 

The  disease  begins  as  a  thickening  and  hardening  of 
the  septum  or  one  or  both  alse  without  inflammatory  reaction 
or  pain.  Slowly  the  nose  becomes  deformed,  broad,  and  flat, 
and  at  last  by  progressive  thickening  of  both  septum  and 
alse  the  nostrils  become  occluded.  The  process  may  involve 
the  lips  so  that  the  opening  of  the  mouth  becomes  greatly 
lessened,  and  may  affect  the  gums.  More  frequently  it  pro- 
ceeds backward  along  the  nostrils  on  to  the  velum  palati. 
The  growth  shows  no  tendency  to  ulceration  or  retrograde 
metamorphosis.  At  the  most  superficial  parts  excoriations 
occur.  Late  in  the  disease  the  teeth  may  loosen  and  fall  out, 
and  the  gums  may  atrophy.  The  disease  may  begin  in 
some  cases  in  the  pharyngeal  vault.  The  epiglottis  and 
larynx  may  be  involved  in  the  process,  and  aphonia,  suffo- 
cative or  epileptic-like  attacks  may  occur.  There  is  no 
constitutional  disturbance,  and  the  only  subjective  symptoms 
are  those  of  discomfort  on  account  of  the  interference  with 
respiration.  The  disease  is  steadily  progressive  ;  shows  no 
tendency  to  recovery  ;  and  recurs  rapidly  when  the  diseased 
parts  are  cut  away. 

Etiology.  All  conditions  of  men  are  affected,  and  both 
sexes  with  about  equal  frequency.  It  usually  begins  be- 
tween the  fifteenth  and  fortieth  year.  It  is  most  frequent 
in  warm  climates.  A  bacillus  has  been  found  in  the  tissues 
that  is  regarded  by  some  as  the  cause  of  the  disease.  It  is 
described  as  short,  thick,  ovoid,  capsulated,  in  free  groups 
and  in  cells. 

Diagnosis.  The  location  upon  the  nose  and  upper  lip 
alone,  the  ivory-hardness  of  the  growths,  and  their  pro- 
gressive course  without  tendency  to  ulceration  or  softening, 
will  establish  the  diagnosis  as  against  syphilis,  epithelioma, 
and  sarcoma.  Keloid  rarely  occurs  upon  the  nose,  and 
never  runs  the  characteristic  course  of  rhinoscleroma. 

Treatment.  Treatment  is  very  unsatisfactory.  The 
growths  may  be  excised  er  curetted  away,  but  neither  pro- 
cess will  assure  against  a  relapse.  The  nostrils  may  be 
kept  open  by  means  of  sponge  tents  and  the  like.     Besnier1 

1  Annal.  Derm,  et  Syph.,  1891,  ii,  603. 


402  DISEASES    OF    THE    SKIN. 

recommends  boring  into  the  tissues  with  points  of  chloride 
of  zinc  for  the  purpose  of  giving  passage  to  air.  Pyrogallic 
acid,  10  per  cent,  in  vaseline,  has  been  recommended  as 
of  value. 

Prognosis.  The  prognosis  is  bad.  The  disease  is  pro- 
gressive, and  threatens  life  by  suffocation  on  account  of 
involving  the  larynx. 

Rhus  Poisoning.     See  Dermatitis  venenata. 

Ringskurv.  See  Trichophytosis  capitis  seu  corporis  seu 
barbae. 

Ringworm.  See  Trichophytosis  capitis  seu  corporis  seu 
barbae. 

Rissopola  Lombarda.     See  Pellagra. 

Ritter's  Disease.  See  Dermatitis  exfoliativa  neonato- 
rum. 

Rodent  TTlcer.     See  epithelioma.    . 

Rosacea  (Ros-a'ce-a3).  Synonyms :  Acne  rosacea ; 
Grutta  rosacea  seu  rosea ;  Acne  erythematosa  ;  (Fr.)  Acne 
rosee,  Couperose,  Rosacee,  Rosee ;  (Ger.)  Kupferrose, 
Kupferfinne,  Kupfrigegesicht. 

A  chronic  disease  of  the  skin,  limited  in  most  cases  to 
the  middle  third  of  the  face  from  above  downward,  and 
characterized  by  a  diffused  or  patchy  redness  made  up  of 
dilated  capillaries. 

This  disease  is  very  commonly  called  acne  rosacea,  but 
inasmuch  as  the  papules  that  often  occur  with  the  disease 
are  not  true  acne  pustules,  it  is  best  to  drop  the  "acne'' 
from  its  title. 

Symptoms.  Rosacea  is  one  of  the  more  common  of  skin 
diseases,  and  is  peculiar  in  affecting  only  the  middle  third 
of  the  long  diameter  of  the  face,  the  forehead,  nose,  and 
adjacent  portions  of  the  cheeks,  and  the  chin.  The  nose 
may  be  affected  alone,  and  in  many  cases  the  forehead 
escapes  entirely.  The  disease  has  three  forms  or  stages. 
The  first  consists  in  a  simple  redness  of  the  affected  skin 
with  more  or  less  well-marked  dilatation  of  the  capillaries. 
In  the  second  stage  there  is  an  added  element  of  superficial 


ROSACEA.  403 

papules  and  pustules,  and  perhaps  nodules.  In  the  third 
stage  there  is  marked  hypertrophy  of  the  skin.  The  pro- 
cess may  stop  at  any  stage.  An  oily  seborrhoea  may  com- 
plicate the  disease,  Unna  even  claiming  that  his  seborrhoeal 
eczema  is  the  first  stage  of  all  cases  of  rosacea. 

The  first  stage  varies  in  degree.  At  first  there  may  be 
faint  flushing  of  the  skin,  as  after  the  ingestion  of  hot  fluids, 
exposure  to  cold,  and  the  like.  This  being  repeated,  perma- 
nent dilatation  of  the  capillaries  takes  place.  The  dilated 
capillaries  are  not  evident  all  over  the  patch.  The  greater 
part  of  the  patch  may  present  an  even  redness.  The 
border  of  the  patch  is  ill-defined,  and  no  matter  how  fiery 
red  the  color  may  be  the  skin  feels  cool  to  the  touch.  This 
is  because  the  congestion  is  passive  on  account  of  a  sluggish 
circulation.  In  some  cases,  however,  there  may  be  but 
little  general  redness,  but  only  a  number  of  dilated  capilla- 
ries. These  telangiectases  are  best  seen  on  the  nose.  In 
some  cases  there  may  develop  a  congestive  seborrhoea  or 
even  an  erythematous  eczema,  which,  yielding  to  appro- 
priate remedies,  leaves  behind  an  undoubted  rosacea. 

The  second  stage  may  develop  from  the  first  after  the 
latter  has  lasted  a  considerable  length  of  time,  or  be  almost 
coincident  with  it.  The  number  of  papules  and  pustules 
may  be  considerable,  and  the  tubercles  large.  If  so,  the 
amount  of  redness  will  be  great.  The  peculiar  feature  of  the 
pustules  is  their  superficiality.  They  are  usually  quite 
small,  say  of  pinhead-size,  and  when  pricked  give  exit  to  but 
a  small  drop  of  thin  pus.  The  tubercles  are  enlarged  or 
clogged  sebaceous  glands,  but  all  these  lesions  are  but 
secondary  to  the  chronic  hyperemia,  and  not  primary,  as  in 
acne. 

While  the  majority  of  cases  never  go  beyond  the  second 
stage,  in  some  cases  the  continued  and  excessive  hyperemia 
leads  to  an  increase  of  connective  tissue,  and  the  nose,  tip 
and  sides  becomes  converted  into  a  lobulated  mass  of  tis- 
sue, sometimes  so  great  as  to  form  pendulous  tumors  hang- 
ing down  over  the  mouth.  This  last  condition  is  known 
as  rhinophyma.  The  whole  nose  is  of  deep-red  or  purple 
color,  and   studded  over  with   crater-like  openings,  leading 


404  DISEASES    OF    THE    SKIN. 

down  into  the  thickened  mass.  At  times  ulceration  occurs 
in  these  crypts  and  causes  additional  annoyance  and  de- 
formity from  destruction  of  tissue. 

While  in  the  vast  majority  of  cases  the  middle  third  of  the 
face  alone  is  affected,  in  some  cases  the  whole  face  becomes 
red,  and  the  redness  may  extend  down  upon  the  neck. 
Rosacea  is  seen  at  times  on  the  scalp  of  bald-headed  persons 
just  above  the  forehead. 

Etiology.  The  cause  of  the  disease  is  probably  a  vaso- 
motor reflex  neurosis.  Schwimmer  regards  it  as  a  tropho- 
neurosis ;  Unna  as  a  seborrhoeal  eczema.  It  occurs  in 
adult  years,  most  frequently  after  the  twenty-fifth  or  thir- 
tieth year,  though  it  may  occur  even  at  puberty.  There  is 
no  connection  between  it  and  acne.  While  many  patients  will 
tell  you  that  they  had  "  pimples  "  when  young,  as  many  will 
inform  you  that  they  have  always  had  a  good  complexion 
until  the  rosacea  began.  Women  are  more  frequently  af- 
fected than  men.  Digestive  disturbances  are  a  very  common 
cause  of  the  disease,  and  the  trouble  may  be  located  either 
in  the  stomach,  intestines,  or  accessory  digestive  organs. 
Drinking  of  spirits  will  undoubtedly  cause  it,  on  account  of 
producing  both  gastric  catarrh  and  reflex  dilatation  of  the 
facial  vessels.  The  inordinate  use  of  strong  tea  acts  in  the 
same  way,  and  probably  gives  rise  to  as  many  cases  as  does 
alcohol.  Exposure  to  the  weather  or  to  extremes  of  tem- 
perature will  cause  rosacea  without  digestive  disturbances, 
but  when  combined  with  the  latter  leads  on  to  the  most 
brilliant  examples  of  it.  Constipation,  menstrual  derange- 
ments, anaemia,  chlorosis,  the  menopause,  each  one  has  been 
noted  in  connection  with  rosacea.  The  use  of  cosmetics  has 
been  followed  by  it. 

Diagnosis.  When  we  meet  with  a  case  of  redness,  with 
or  without  papules,  pustules,  or  tubercles,  that  is  limited  to 
the  middle  third  of  the  vertical  diameter  of  the  face,  it  is 
probably  one  of  rosacea.  It  differs  from  acne  in  its  limited 
area,  the  superficial  character  of  the  pustules,  the  absence  of 
comedones,  and  the  capillary  dilatation.  Lupus  erythema- 
tosus may  occur  in  the  same  location,  but  in  it  we  do  not 
find  the  dilated  capillaries ;  but  we  do  find  thickening  of 


ROSACEA.  405 

the  skin,  adherent  scales  with  prolongations  from  their 
under  side,  a  sharply  defined,  slightly  raised  border  to  the 
patches,  and,  if  the  disease  has  lasted  any  time,  more  or  less 
delicate  cicatricial  tissue.  In  its  early  stage  the  diagnosis 
is  not  always  easy.  Lupus  vulgaris  should  not  confuse  us, 
as  in  rosacea  there  is  an  entire  absence  of  the  characteristic 
apple-jelly-like  tubercles  of  lupus.  The  tubercular  syphilide 
may  resemble  rosacea  in  its  second  or  third  stage,  but  soon 
it  undergoes  softening  and  ulceration — processes  that  do  not 
occur  in  rosacea.  Moreover,  it  is  not  symmetrical,  but 
occurs  in  the  form  of  groups  of  tubercles,  presents  no 
telangiectases,  and  evidences  of  other  syphilides  are  usually 
to  be  found. 

Treatment.  In  order  to  successfully  treat  rosacea,  we 
must  first  endeavor  to  remove  the  cause.  We  must  inquire 
as  to  the  condition  of  the  digestive  apparatus,  the  manner  in 
which  menstruation  is  performed,  exposure  to  heat  and  cold, 
and,  in  fact,  ascertain  the  patient's  general  condition.  Then 
we  must  address  ourselves  to  the  regulation  of  any  deranged 
function.  We  must  stop  the  use  of  alcoholics  in  any  form, 
and  the  ingestion  of  all  hot  fluids,  such  as  tea,  coffee,  and 
soup.  All  these  tend  to  produce  dilatation  of  the  blood- 
vessels of  the  face  and  to  keep  up  those  conditions  we  wish 
to  remove.  The  patient's  diet  should  be  carefully  regu- 
lated, and  such  things  as  pastry  and  sweets  cut  off,  so  as  to 
make  digestion  as  easy  as  possible.  Medicinally,  tincture  of 
nux  vomica,  the  mineral  acids,  or  alkalies  are  to  be  adminis- 
tered q.  r.  n.  Nux  vomica  has  often  seemed  to  render  good  ser- 
vice, even  without  there  being  marked  digestive  disturbance. 
Salol  is  a  good  remedy  in  many  cases  of  intestinal  fermen- 
tation. Ergot  or  ergotin  proves  useful  in  some  cases,  either 
with  or  without  uterine  disturbances.  Ichthyol  is  com- 
mended by  Unna.  The  ammonio-sulphate  is  the  prepara- 
tion to  use,  and  it  is  best  given  in  capsules  to  cover  the 
taste.     The  dose  is  three  drops  two  or  three  times  a  day. 

The  local  treatment  is  important  in  hastening  a  cure,  but 
is  not  of  itself  curative  in  well-marked  cases  of  reflex  rosacea. 
The  patient  must  be  instructed  to  protect  the  skin  from  the 
action  of  wind  and  weather,  by  either  applying  some  oint- 


406  DISEASES    OF    THE    SKIN. 

ment,  such  as  vaseline,  or  a  powder,  such  as  corn-starch,  before 
venturing  out  of  doors.  Then  the  face  should  be  bathed  in 
hot  water  every  night  before  going  to  bed,  the  water  being 
as  hot  as  the  skin  can  stand  without  burning,  and  it  should 
be  sopped  on  for  about  ten  minutes,  freshly  heated  water 
being  added  from  time  to  time,  so  as  to  maintain  a  uniform 
temperature.  This  is  beneficial  because  the  primary  dilata- 
tion of  the  vessels  is  followed  by  contraction.  After  the 
bathing  the  following  lotion  should  be  applied : 


R .  Zinc,  sulphat.,         \  . .         .  #  „ 

Potass,  sulphuret.,  J  '  a     3J  > 

Aquae  rosae,  ad     ^  iv ;      100 


M. 


It  is,  perhaps,  as  good  as  any  application  we  can  make. 
Van  Harlingen  gives  another  good  one,  as  follows  : 

R.  Sulphur,  precipitat.,  3j;  6 

Pulv.  camphorae,  gr.  v ;  |5 


Pulv.  tragacanth.,                           gr.  x ;  1 

Aquae  rosae,     ~|                                 2.  1AA 

t  •         i  •        r  aa     31  I  1^0 
JLiq.  calcis,      J                                 ^ ' 


M. 


Instead  of  lotions,  sulphur  ointment  (5J-5J),  or  the  white 
precipitate  ointment  may  be  used,  or  simply  powdered  sul- 
phur. In  obstinate  cases  Vleminckx's  solution  may  be 
used.     It  is  composed  as  follows  : 


R.  Calcis,  3^v5         ^ 

Sulphur,  sublimat.,  3J ;  10 

Aquae  destillat.,  ^  x ;        100 


M. 


Boil  together,  with  constant  stirring,  until  the  mixture 
measures  six  fluidounces,  then  filter. 

This  is  to  be  diluted  four  or  five  times  at  first,  and  used 
at  night  only,  followed  by  cold  cream  in  the  morning.  The 
dilution  is  to  be  lessened  by  degrees.  Any  of  these  reme- 
dies may  produce  a  dermatitis,  followed  by  desquamation, 
which  is  to  be  desired.  For  this  purpose  we  may  use  re- 
sorcin,  10  to  20  per  cent,  in  vaseline,  stopping  it  when  the 
skin  begins  to  peel.     Hillairet1  recommends  washing  the 

1  Prog.  Med.,  1880,  viii.  182. 


ROSACEA.  407 

face  in  the  morning  with  hot  water,  followed  by  a  solution 
of  oxide  of  zinc,  three  or  four  grains  to  the  ounce,  sopped 
on  for  half  an  hour.  Before  going  to  bed  the  following  is 
to  be  applied  to  the  face : 


Be .  Camphorated  alcohol,  8  ad  15 

Sublimated  sulphur,  30 

Distilled  water,  250 


M. 


After  six  days  this  is  to  be  discontinued  for  a  couple  of 
days,  and  then  begun  again.  Ichthyol  has  been  highly  ex- 
tolled by  Unna  and  others,  as  well  for  external  as  for  inter- 
nal use. 

If  the  case  is  highly  inflammatory  when  first  seen,  our 
first  attempts  should  be  in  the  direction  of  reducing  the 
inflammation  by  means  of  soothing  ointments.  After  a  few 
days  we  can  begin  the  treatment  of  the  rosacea. 

Surgical  procedures  are  necessary  to  hasten  the  removal 
of  pustules,  and  to  destroy  dilated  vessels  and  hypertrophic 
tissue.  Pustules  are  quickest  removed  by  the  curette,  as  in 
acne.  Dilated  vessels  are  best  destroyed  by  electrolysis 
with  the  electric  needle  attached  to  the  negative  pole,  intro- 
ducing it  perpendicularly  into  the  vessel  at  one  or  more 
points  of  its  course,  and  letting  it  remain  for  a  few  seconds 
until  the  vessel  appears  as  a  white  line.  The  method  of 
using  electrolysis  is  more  fully  described  under  hypertri- 
chosis. It  is  often  necessary  to  repeat  the  operation  several 
times  before  the  vessel  is  destroyed.  Multiple  scarification 
is  most  useful  in  reducing  red  patches.  It  may  be  done  by 
means  of  a  scalpel,  making  parallel  lines  near  together  and 
through  the  skin,  and  then  a  second  series  over  these ;  or  a 
multiple  scarifying  knife,  as  sold  in  the  shops,  may  be  used 
for  the  purpose.  After  scarifying,  bleeding  should  be  en- 
couraged for  a  few  moments  by  the  application  of  hot  water. 
Then  the  surface  should  be  swabbed  over  with  a  solution  of 
carbolic  acid,  two  drachms  to  the  ounce  of  glycerin  and 
water.  This  will  check  the  bleeding  and  constringe  the 
vessels,  No  after-treatment  is  needed,  as  a  rule.  If  reac- 
tion tends  to  go  too  far,  a  soothing  ointment  may  be  applied. 
The  operation  should  be  repeated  once  every  week  or  two. 


408  DISEASES    OF    THE    SKIN. 

It  is  astonishing  to  see  how  rapidly  the  redness  will  be 
reduced  in  many  cases,  and  this  without  deformity  being 
caused.  Multiple  scarifications  may  be  employed  for  the 
reduction  of  tuberculated  masses,  but  trimming  off  the  super- 
fluous tissues  is  a  more  speedy  method. 

Pkognosis.  In  cases  of  rosacea  arising  from  exposure  to 
weather  in  drivers  and  sailors,  and  those  following  similar 
pursuits,  we  cannot  expect  to  effect  a  cure,  as  the  patients 
cannot  do  the  one  thing  necessary — give  up  their  occupa- 
tions. In  most  all  other  cases  we  can  promise  great  amelio- 
ration of  the  annoying  redness,  and  in  many  we  can  effect  a 
cure ;  but  we  had  best  not  attempt  to  treat  a  case  that  will 
not  follow  our  directions  as  to  diet  and  hygiene. 

Rosee.     See  Rosacea. 

Rose  Rash.     See  Erythema. 

Roseola.     See  Erythema  roseola. 

Roseola  Pityriaca.     See  Pityriasis  rosea. 

Roseola  Syphilitica.     See  Macular  syphilide. 

Roseole  Squameuse.     See  Pityriasis  rosea. 

Rotheln  (Ru5t'e2ln),  or  German  measles,  is  a  mild  conta- 
gious disease  that  resembles  measles,  but  differs  from  it  in 
the  mildness  of  all  its  symptoms,  in  the  lighter  color  of  its 
lesions,  and  in  the  absence  of  the  crescentic  arrangements 
of  them.  Like  measles,  it  may  be  mistaken  for  either  an 
erythema  or  an  erythematous  syphilide,  and  its  diagnosis  is 
along  the  same  lines  as  is  that  of  measles,  which  see.  It  is 
not  so  blotchy  as  measles,  and  the  catarrhal  symptoms  are 
absent  or  but  slight.  Swelling  of  the  glands  of  the  neck  is 
a  symptom  that  may  or  may  not  be  present.  Febrile  move- 
ment is  slight.  The  lesions  may  take  the  form  of  small 
papules,  and  assume  rather  a  brownish  color  than  a  red. 
The  eruption  is  often  itchy,  and  the  lesions  may  occur  on 
the  mucous  membranes.  It  differs  from  scarlatina  in  the 
mildness  of  all  its  symptoms,  and  in  the  absence  of  the  dif- 
fuse scarlet  eruption  of  the  latter  disease. 

Rothlauf.     See  Erysipelas. 

Rupia.     See  Syphilis. 


SARCOMA.  409 

Salt-rheum.     See  Eczema. 

Salzfluss.     See  Eczema. 

Sarcocele  of  the  Egyptians.     See  Elephantiasis. 

Sarcoma  (Sa3rk-orma3).  We  are  here  interested  in  sar- 
coma of  the  skin  alone.  Sarcomas  may  be  primary  in  the 
skin,  but  most  often  they  are  secondary.  They  form 
variously  sized  tumors,  but  tend  to  run  a  malignant  course, 
multiplying  more  or  less  rapidly,  breaking  down,  affecting 
internal  organs  by  metastasis^  and  killing  the  patient  in  a 
few  months  or  years.  There  are  three  types  of  sarcoma — 
namely,  the  round-cell  sarcoma,  the  small-cell  sarcoma,  and 
the  melano  or  pigment  sarcoma.  Very  commonly  sarco- 
mata are  of  mixed  type  ;  or  sarcomata  may  be  divided  into 
two  varieties — the  pigmented  and  the  non-pigmented. 

According  to  Brocq,1  who,  following  Perrin,  has  made  an 
exhaustive  study  of  the  disease,  primary  melanotic  sarcoma 
originates  frequently  from  an  irritated  nsevus,  but  may  occur 
independently.  At  first  it  is  always  single  and  small.  It 
tends  to  enlarge  and  attain  the  size  of  a  nut.  In  shape  it  is 
oval  or  spherical.  It  is  nearly  always  sessile.  Its  color  is 
dark-blue  or  black.  It  is  very  hard  to  the  touch.  It  may 
remain  stationary  for  a  long  time,  but  in  course  of  time  new 
tumors  will  appear,  either  about  the  original  one  or  at  dis- 
tant points  by  means  of  the  lymphatics.  Some  of  the  origi- 
nal tumors  will  disappear,  while  new  ones  appear  ;  some  will 
break  down  and  form  irregular  ulcers  whose  floors  are  black 
and  uneven,  and  secreting  a  thick,  melanotic  liquid,  or  a 
little  pus,  or  almost  solid  black  matter.  The  viscera  become 
involved,  and  death  soon  occurs. 

A  rare  form  of  melanotic  sarcoma  is  described  by  Hutch- 
inson as  melanotic  ivhitlow,  which  at  first  is  a  chronic 
onychitis,  the  border  of  which  looks  like  a  lunar-caustic 
stain.  It  very  gradually  develops  into  a  fungating  tumor, 
slightly  pigmented.  The  nail  is  shed,  and  generalization 
occurs  (Crocker). 

Non-pigmented  primary  sarcoma  may  be  generalized  or 

1  These  de  Paris,  1885. 
18 


410  DISEASES    OF    THE    SKIN. 

localized.  The  generalized  form  begins  usually  upon  the 
extremities,  and  causes  upon  the  hands  and  feet  a  peculiar 
hard  oedema,  accompanied  by  tension  of  the  skin,  and  per- 
haps itching  or  pricking.  It  may  begin  as  brownish-red, 
livid,  purple,  or  blue  patches,  upon  which  little  pinhead-size 
nodules  appear,  which  gradually  enlarge.  In  some  cases 
little,  infiltrated,  isolated,  blue  or  reddish-brown  nodes  will 
form.  Sometimes  the  first  appearance  will  be  a  diffused 
cyanotic  patch,  which  later  will  become  a  bossy  elevated 
patch.  When  the  disease  is  fully  developed  the  hands  and 
feet  are  thick,  deformed,  infiltrated,  as  firm  as  cartilage, 
brown  or  blue  with  a  red  tint.  The  skin  is  glossy,  scaly, 
uneven.  The  nodes  maybe  raised,  pedunculated,  or  ulcerated. 
Similar  lesions  are  found  upon  the  rest  of  the  body,  though 
rarely  on  the  trunk.  They  may  remain  stationary,  disap- 
pear, fall  off,  multiply,  ulcerate,  or,  finally,  involve  the 
mucous  membranes,  and  cause  death. 

The  localized  form  develops  ordinarily  from  an  irritated 
nsevus,  and  is  most  often  encountered  on  the  extremities.  It 
forms  a  hard,  wrinkled  tumor,  which  may  ulcerate.  Its 
color  is  usually  that  of  the  normal  skin,  though  it  may  be 
red.  It  may  not  generalize  for  a  long  time,  or  it  may  do  so 
spontaneously,  or  after  an  attempt  at  removal. 

Sarcomas  are  very  vascular,  and  are  subject  to  profuse 
hemorrhage  when  injured  or  when  they  ulcerate. 

Etiology.  We  know  very  little  in  regard  to  the  etiology 
of  sarcoma.  It  occurs  at  all  ages,  some  of  the  most  malig- 
nant cases  being  seen  in  childhood.  Brocq  says  that  the 
localized  non-pigmented  sarcoma  is  most  frequent  in  women, 
and  that  the  generalized  form  is  most  frequent  in  robust 
men  of  forty  to  sixty  years.  Piffard  gives  the  ages  at 
which  they  are  most  prone  to  occur  as  before  the  fifteenth 
and  after  the  forty-fifth  year. 

Diagnosis.  The  diagnosis  of  sarcoma  is  generally  easy, 
but  at  times  it  is  difficult.  The  pigmented  forms  are 
usually  readily  recognizable  by  their  color.  The  non-pig- 
mented single  sarcoma  may  be  distinguished  from  epithe- 
lioma by  its  feel,  which,  though  firm,  lacks  that  stony  hard- 
ness that  is  characteristic  of  cancer.     Fibromata  are  not  so 


SCABIES.  411 

firm  as  are  sarcomata,  are  more  commonly  pedunculated, 
and  show  no  tendency  to  degenerative  changes. 

Treatment.  Excision  of  a  single  non-pigmented  sar- 
coma is  often  curative.  In  multiple  sarcomata,  and  in  the 
melanotic  variety,  operative  interference  is  usually  not  only 
not  curative,  but  has  often  seemed  to  hasten  generalization. 
Kobner  and  others  have  used  hypodermatic  injections  of 
arsenic  with  brilliant  results  in  some  cases.  Kobner  used 
Fowler's  solution  of  half  strength,  and  injected  two  and  a 
half  to  four  drops  of  it  once  a  day.  After  three  months  the 
dose  was  increased  to  seven  and  a  half,  and  then  to  nine 
drops.  Others  have  tried  arsenic  without  effecting  a  cure. 
Still  it  is  worthy  of  trial,  as  it  may  cure  the  disease  if  it  is 
well  borne  by  the  patient. 

Prognosis.  This  is  always  grave.  The  course  of  the  dis- 
ease is  nearly  always  from  bad  to  worse,  though  the  fatal 
result  may  not  be  reached  for  many  years.  Melanotic  sar- 
coma is  more  rapidly  fatal  than  is  the  ordinary  form. 

Satyriasis.     See  Lepra. 

Scabies  (Skab;i2-ez).  Synonyms:  The  Itch;  (^V.)Gale; 
(G-er.)  Kratze.  A  contagious  disease  of  the  skin,  due  to  its 
invasion  by  the  acarus  scabiei,  and  characterized  by  exces- 
sive itching,  worst  at  night,  and  by  excoriated  lesions,  pus- 
tules, and  cuniculi  upon  the  anterior  face  of  the  wrists,  be- 
tween the  fingers,  on  the  breasts  of  women,  the  penis  of 
males,  and  about  the  umbilicus  of  both  sexes. 

Symptoms.  The  popular  name  of  scabies,  which  is  the 
Itch,  gives  us  at  once  one  of  the  marked  features  of  the  dis- 
ease. Itching  is  always  present  in  it.  While  it  may  be 
somewhat  in  abeyance  during  the  day,  it  is  hardly  ever  ab- 
sent, and  at  night  in  bed  it  is  so  bad,  in  susceptible  indi- 
viduals, that  sleep  is  well  nigh  impossible.  The  itching 
gives  rise  to  scratching,  and  the  scratching  to  the  secondary 
symptoms  of  the  disease — scratched  papules  and  eczematous 
patches. 

The  first  thing  that  the  patient  notices  is  that  his  skin 
itches.  To  relieve  this  he  digs  into  his  skin,  and  sooner  or 
later,  according  to  the  resistance  of  his  skin,  he  produces 


412  DISEASES    OF    THE    SKIN. 

pinhead-size  excoriations.  Later,  the  irritation  continuing, 
eczematous  patches  result.  When  he  presents  himself  to 
the  physician,  the  latter  will  find  on  examination  the  evi- 
dences of  scratching,  and  he  will  notice  that  the  lesions  are 
located  principally  between  the  fingers,  on  the  anterior  sur- 
face of  the  wrists  and  somewhat  on  the  forearms,  about  the 
axillae,  upon  the  breasts  about  the  nipples  in  women,  upon 
the  male  genital  organs,  about  the  umbilicus  and  lower  part  of 
the  abdomen,  and  often  upon  the  buttocks  of  both  sexes,  and, 
in  children  especially,  upon  the  anterior  surface  of  the  ankles 
and  between  the  toes.  In  adults,  these  latter  situations  are 
not  so  frequently  affected.  Closer  examination  may  be  re- 
warded by  the  discovery  of  the  pathognomonic  sign  of 
scabies — namely,  the  cxmiculus,  or  burrow,  which  is  usually 
found  most  readily  on  the  inner  border  of  the  hand,  on  the 
inside  of  the  fingers,  and  on  the  penis.  It  forms  a  delicate, 
slightly  raised,  whitish  or  grayish,  wavy,  often  bowed,  line, 
about  one-eighth  to  one-half  an  inch  in  length,  and  having 
a  white  speck  at  one  end  which  marks  the  place  where  the 
itch  mite  is.  These  are  not  always  to  be  found ;  indeed,  in 
most  cases  they  are  difficult  to  find,  because  they  are  broken 
up  either  by  the  occupation  of  the  individual,  by  the  use  of 
soap  and  water,  or  by  scratching.  In  people  with  delicate 
skin  the  burrowing  of  the  itch  mite  will  set  up  an  inflam- 
matory process,  and  papules,  vesicles,  and  pustules  will  form, 
quite  independently  of  the  scratching. 

While  the  regions  mentioned  are  the  ones  always  affected 
in  well-marked  cases,  variations  in  the  extent  of  the  disease 
are  observable.  In  some  cases  the  hands  are  free,  and  but 
few  lesions  are  present  anywhere.  Here,  if  it  is  a  male,  the 
crucial  test  will  be  the  examination  of  the  privates,  where  a 
scratch-mark  or  a  burrow  will  be  found  almost  without  fail. 
In  other  cases,  hardly  any  part  of  the  body  will  be  free  from 
excoriations,  pustules,  or  eczematous  patches,  excepting  the 
face,  which  is  affected  only  exceptionally,  and  then  nearly 
always  in  children.  In  these  bad  cases  furuncles  and  large 
ecthymatous  pustules  join  themselves  to  the  already  multi- 
form eruption  of  scabies.  Urticaria  is  also  present  in  some 
cases,  its  wheals  being  interspersed  among  the  other  lesions. 


SCABIES.  413 

Should  some  intercurrent  fever  arise,  the  symptoms  of  scabies 
will  subside,  to  reappear  when  the  fever  is  past.  The  so- 
called  Norwegian  Itch  is  only  a  very  much  aggravated  form 
of  the  disease,  on  account  of  the  want  of  personal  cleanliness 
of  the  people.  The  face  in  this  form  may  be  affected,  the 
nails  split  and  shed,  and  the  palms  and  soles  covered  with 
thick  crusts. 

Etiology.  Scabies  is  due  to  the  irritation  set  up  by  the 
acarus  scabiei  and  by  the  scratching  employed  to  relieve  the 
same.  The  vesicles,  papules,  or  pustules  about  the  burrows 
are  due  directly  to  the  acarus  ;  it  may  be  on  account  of 
some  irritating  substance  secreted  by  it.  The  disease  is 
contagious,  but  requires  prolonged  contact,  as  by  holding  of 
hands,  or  sleeping  with  an  infected  person.  It  is  very  rare 
for  it  to  be  communicated  to  a  physician  in  examining  a 
patient. 

According  to  Greenough,1  it  is  most  prevalent  between 
the  ages  of  five  and  thirty,  and  comparatively  rare  after  the 
fiftieth  year.  This,  he  thinks,  is  due  to  the  fact  that  in  ad- 
vanced life  the  epidermis  becomes  harder  and  dryer,  and 
forms  a  less  suitable  habitat  for  the  acarus.  Ten  years  ago 
the  disease  was  not  common  in  this  country,  but  now  it  is  an 
every-day  occurrence  to  meet  with  new  cases  in  our  dispen- 
saries, and  not  so  very  infrequent  to  meet  with  it  in  private 
practice. 

Pathology.  The  acarus  scabiei  is  very  small,  being 
barely  visible  to  the  naked  eye,  the  female  being  but  one- 
sixtieth  to  one- eightieth  of  an  inch  loner,  and  the  male  still 
smaller.  Its  width  is  about  two-thirds  of  its  length.  It 
has  eight  legs — four  on  each  side  of  its  head,  to  which 
suckers  are  attached,  and  four  posteriorly,  to  all  of  which,  in 
the  female,  bristles  are  attached  ;  while  in  the  male  the 
inner  ones  are  wanting  in  bristles,  but  provided  with  suckers 
for  attaching  himself  to  the  female  in  copulation.  On  the 
back  are  a  number  of  short  bristles.  A  glance  at  the  accom- 
panying plates  will  describe  the  animal  better  than  words. 

The  acarus,  having  landed  on  the  skin,  soon  stirs  about, 

1  Boston  Med.  and  Surg.  Journ.,  Sept.  23,  1880. 


414 


DISEASES    OF    THE    SKIN. 


and  having  found  a  suitable  place,  it  rests  on  its  hind  feet, 
takes  an  oblique  position,  pierces  the  skin,  and  bores  a  hole, 
into  which  it  forces  itself.  It  lodges  in  the  deeper  layers  of 
the  epidermis,  above,  and  sometimes  in  the  mucous  layer.  The 
female  bores  a  burrow  equidistant  between  the  surface  of  the 
epidermis  and  the  level  of  the  papillae  of  the  corium.  Being 
prevented  by  the  bristles  on  her  back  from  moving  back- 

Fig.  39. 


ward,  she  moves  forward,  and  lays  her  eggs.  Her  duration 
of  life  is  from  six  weeks  to  two  months,  and  during  this  time 
she  lays  some  fifty  eggs.  These  hatch  out,  reach  the  sur- 
face of  the  skin,  meet  the  male,  become  impregnated,  bore 
in  their  turn  into  the  skin,  and  so  keep  up  the  process.  As 
the  thinnest  parts  of  the  skin  are  most  easily  punctured,  it 
is  just  in  these  parts  that  we  find  the  lesions  most  commonly. 
The  scratching  often   extends  far  beyond  the  sites  of  the 


SCABIES. 


415 


burrows.  Fournier  found  that  an  acarus  died  in  seven 
days  when  immersed  in  cold  water,  in  ten  days  when  in 
warm  water,  and  in  two  to  four  days  in  a  solution  of  green 
soap.  He  denies  the  commonly  accepted  view  that  the 
acarus  is  a  night-prowler,  though  he  allows  that  it  is  most 
active  at  night. 

Fig.  40. 


Diagnosis.  The  presence  of  pustules  and  scratch-marks 
between  the  fingers,  on  the  anterior  face  of  the  wrists,  about 
the  umbilicus,  on  the  breasts  in  women  or  the  genitals  in 
men,  is  enough  to  make  the  diagnosis  of  scabies.  If  a  cunic- 
ulus  can  be  found  it  will  be  corroborative  evidence.  Ec- 
zema is  more  patchy  and  does  not  occur  in  the  characteristic 
locations  of  scabies.  Pediculosis  vestimentorum  presents 
long,  parallel  scratch-marks  instead  of  the  small  excoriations 
of  scabies,  and  their  characteristic  locations  are  over  the 
shoulders,  about  the  girdle,  and  along    the   outside  of  the 


416 


DISEASES    OF    THE    SKIN. 


arms  and  the  inside  of  the  thighs  where  the  seams  of  the 
clothing  come.  The  itching  of  scabies  is  worst  at  night, 
while  that  of  pediculosis  is  not  so  marked.      Urticaria  is  a 


Burrow  of  scabies  with  acarus.     (After  Kaposi.) 

general  disease  characterized  by  wheals  and  shows  no  tend- 
ency to  localize  itself  in  certain  regions.  Should  urticaria 
complicate  scabies,  the  wheals  will  be  disseminated  while  the 
lesions  of  scabies  will  be  most  marked  in  their  characteristic 
locations. 


SCABIES.  417 

Treatment.  If  the  disease  is  recognized  there  is  no 
difficulty  in  curing  it,  though  there  are  various  methods  em- 
ployed. Perhaps  the  oldest  and  one  of  the  most  reliable, 
though  not  the  most  rapid  a  cure,"  is  to  have  the  patient 
take  a  warm  bath  with  soap  and  water,  scrubbing  himself 
thoroughly  so  as  to  remove  as  much  of  the  old  epidermis  as 
possible.  Then  he  should  dry  the  skin  with  vigorous  fric- 
tion, and  rub  into  every  diseased  spot  ordinary  sulphur  oint- 
ment. When  this  is  done  he  can  smear  the  rest  of  the 
skin  with  the  ointment,  put  on  the  same  clothes,  and  go 
about  his  business.  The  rubbings  Avith  the  ointment  are  to 
be  repeated  morning  and  night  for  three  days,  the  patient 
wearing  the  same  underclothing  by  day,  and  bed-  and  night- 
clothing  by  night.  At  the  end  of  three  days  another  bath 
is  to  be  taken,  the  clothing  changed,  and  the  patient  should 
then  present  him  self  for  examination.  If  fresh  lesions  are  found, 
a  second  course  should  be  taken,  which  most  always  will  be 
sufficient.  An  artificial  eczema  is  apt  to  be  set  up  by  the 
sulphur,  and  as  eczema  itself  itches  we  must  not  take  the 
continuance  of  pruritus  beyond  the  second  course  as  evi- 
dence of  the  scabies  not  being  cured.  It  is  better  to  stop  the 
sulphur  for  a  few  days,  and  put  the  patient  upon  a  mild, 
protective  dressing  to  his  skin,  such  as  vaseline  and  corn- 
starch. If  the  itching  grows  worse  instead  of  better,  a  third 
course  of  rubbing  must  be  crone  through  with.     Instead  of 

o  o  o 

plain  sulphur  ointment  we  can  add  balsam  of  Peru,  about 
half  a  drachm  to  the  ounce,  or  use  the  modified  Wilkinson's 
ointment,  as  follows  : 

R .  Sulph.  sublimat.j  I 
01.  cadini,  j 

Crete  preparat. 


Sapo  viridis,         \ 
Adipis,  j 


3iv; 

20 

•5ijss; 

10 

ij ; 

80 

M. 


This,  though  a  very  efficient  remedy,  forms  such  a  disgust- 
ing-looking mass,  and  is  so  irritating  that  it  is  fit  only  for 
public  practice,  ,5-napthol,  in  5  to  10  per  cent,  strength 
in  ointment  or  oil,  is  a  good  remedy,  free  from  the  sulphur 
smell,  and  not  so  irritating.     Kaposi   recommends  it  in  the 


following  form  : 

18* 


418  DISEASES    OF    THE    SKIN. 


/3-naphthol, 

15  parts 

Sapo  viridis, 

50      " 

Cretse  alb.  pulv., 

10      " 

Adipis, 

100      " 

M. 

and  Crocker  says:  "I  can  speak  of  it  in  the  highest 
praise."  It  is  well  fitted  for  private  practice.  McCall  An- 
derson extols  styrax  liquida  with  a  double  amount  of  lard. 
As  the  itch  is  very  prevalent  in  Scotland,  the  Doctor  should 
know  of  what  he  speaks. 

The  treatment  in  the  St.  Louis  Hopital  of  Paris  is  an 
heroic  one,  but  is  said  to  cure  in  one  hour  and  a  half.  Ac- 
cording to  Fournier  the  patient  is  scrubbed  violently  for 
half  an  hour  with  green  soap  ;  then  for  another  half-hour 
the  scrubbing  is  continued  while  he  is  in  a  bath  ;  then  he  is 
rubbed  with  this  ointment : 

Helmericli  s  Ointment. 


R.  Potass,  carbonat.,  ,^ss;       15 

Sulphur,  sublimat,  |[j  ;        30 

Adipis,  J  iv  ;     120 


M. 


Now  he  puts  on  his  clothes  without  removing  the  salve,  and 
is  discharged  cured.  In  private  practice  Fournier  recom- 
mends the  use  of  a  good  toilet  soap  for  the  preliminary  rub- 
bings, and  then  Bourguignon's  ointment  as  follows : 

R .  Glycerini,  200       parts 

Gum  tragacanth,  5 

Sulph.  sublimat.,  100  " 

Potass,  carb.,  35  " 

01.  lavandube, 

01.  menth  pip,  --         1  50    „  M 

Ol.  caryopnylli,     j 
01.  cinnamomi,     J 

This  is  to  be  followed  by  a  bath  and  powdering  with  corn- 
starch. It  cannot  be  used  for  children,  or  in  extensive 
cases  in  adults  where  there  is  much  excoriation. 

For  infants  and  young  children,  balsam  of  Peru  is  about 
the  pleasantest  application  we  can  make,  it  being  rubbed  in 
morning  and  night,  either  pure  or  diluted  with  sweet  oil : 
or  a  mitigated  form  of  sulphur  ointment  may  be  used. 


SCLEREMA     NEONATORUM.  419 

Sherwell1  commends  rubbing  in  dry  powdered  sulphur 
after  a  bath. 

In  all  cases  the  clothing  and  bedding  must  be  disinfected — 
washable  things  by  boiling,  and  cloth  clothing  by  ironing 
with  a  very  hot  iron.  All  affected  members  of  the  family 
must  be  treated  at  the  same  time.  An  irritable  condition  of 
the  cutaneous  nerves  may  last  at  times  long  after  the  scabies 
is  cured,  and  must  not  be  mistaken  for  a  still  active  itch. 

Prognosis.  The  prognosis  is  always  good,  provided  the 
applications  are  made  thoroughly  enough. 

Scall  or  Scalled  Head.     See  Favus. 

Scarlatina  (Ska3r-la3-tirna3).  Scarlet  fever  is  an  acute 
contagious  eruptive  disease,  characterized  by  a  quick  rise  of 
temperature  at  the  beginning,  redness  of  the  fauces,  a  straw- 
berry tongue,  and  the  appearance  of  a  fine  punctate  scarlet 
rash,  which,  first  appearing  on  the  neck,  chest,  and  flexures 
of  the  joints,  rapidly  spreads  over  the  whole  body.  The 
redness  may  be  even  over  all,  so  as  to  give  a  boiled-lobster 
appearance  to  the  skin  ;  or  the  red  points  may  be  distinct, 
although  close  together.  The  redness  usually  disappears  on 
pressure.  Vesicles  may  appear.  A  great  deal  of  constitu- 
tional disturbance  and  prostration  are  apt  to  attend  the 
eruption,  but  convalescence  is  well  established  in  the  second 
week  in  uncomplicated  cases.  Abundant  desquamation  fol- 
lows the  subsidence  of  the  eruption,  which  continues  for  days 
or  weeks. 

Diagnosis.  There  is  often  a  striking  resemblance  be- 
tween scarlatina  and  erythema  scarlatiniforme,  and  some 
other  erythemata.     (See  Erythema.) 

Scherende  Flechte.     See  Tricophytosis  capitis. 
Schmeerfluss.     See  Seborrhcea. 
Schuppenflechte.     See  Psoriasis. 
Scissura  Pilorum.     See  Atrophia  pilorum  propria. 
Sclerema.     See  Scleroderma. 

Sclerema  Neonatorum  (Skle2r-er-ma3).  Synonyms: 
Scleroderma  neonatorum  ;  Induratio  telie  cellulose  ;  (Fr.) 

1  N.  Y.  Med.  Journ.,  1889,  i.  482. 


420  DISEASES    OF    THE    SKIN. 

Algidite  progressive,  L'endurcissement  athrepsique;   (G-er.) 
Das  Sclerem  der  Neugeboren. 

This  happily  rare  disease  was  first  differentiated  from 
oedema  neonatorum,  according  to  Crocker,  by  Parrot,  in 
1877.  It  may  be  primary,  but  most  often  it  is  secondary, 
to  some  exhausting  disease,  such  as  pneumonia  or  intestinal 
catarrh.  It  may  be  present  at  birth,  and  rarely  occurs  after 
the  first  ten  days  of  life.  It  is  characterized  by  hardness 
of  the  skin,  which  generally  at  first  is  circumscribed  and 
affects  the  leg.  It  may  be  diffuse  from  the  first,  and  any  way 
it  soon  becomes  so,  and  extends  to  the  lumbar  region,  back, 
chest,  and  so  all  over  the  body,  becoming  universal  by  the 
fourth  day.  It  may  begin  on  the  face,  and  it  may  stop  be- 
fore becoming  universal.  It  may  be  but  slightly  developed 
on  the  chest.  At  first  the  skin  is  pale  and  waxy  ;  later,  it 
becomes  livid  and  cold,  and  the  child  looks  as  if  frozen. 
The  skin  becomes  attached  to  the  underlying  parts,  smooth, 
tense,  and  does  not  pit  on  pressure.  Movement  is  impos- 
sible for  the  child,  and  the  body  may  be  raised  without 
moving  a  joint.  When  the  face  is  affected,  it  is  impossible 
for  the  child  to  nurse.  Its  respirations  are  greatly  reduced 
in  number,  its  pulse  falls  to  sixty  a  minute,  its  breath  is 
cool,  and  it  dies  within  a  week.  The  primary  congenital 
cases  are  either  stillborn  or  die  in  one  or  two  days. 

Etiology.  The  cause  of  the  disease  is  obscure.  It  is 
seen  almost  exclusively  in  foundling  asylums  and  among 
the  very  poor.  It  is,  therefore,  a  disease  of  depressed 
vitality.  Langer1  regards  it  as  the  result  of  solidification  of 
the  fat,  which  in  infants  contains  31  per  cent,  of  palmatin 
and  stearin,  that  of  adults  containing  10  per  cent.  The  fat 
in  infants,  he  says,  is  nearly  all  concentrated  in  the  subcu- 
taneous tissues,  where  it  is  five  times  as  thick  relatively  as  it 
is  in  adults.  Naturally,  an  infant's  temperature  is  higher 
than  an  adult's,  and,  if  it  is  lowered  by  any  depressing  cause, 
the  fat  may  solidify.  Solidification  may  take  place  also 
under  the  action  of  cold,  or  by  oxidation,  as  in  fevers,  with- 
drawing some  of  the  constituents  of  the  fat.     Parrot  regards 

1  Wien.  med.  Presse,  1881,  xxii.  1375. 


SCLERODERMA.  421 

the  disease  as  one  of  desiccation  from  the  drain  of  a  diarrhoea, 
or  the  like. 

Diagnosis.  Sclerema  neonatorum  is  differentiated  from 
oedema  neonatorum  by  being  more  general  in  its  distribu- 
tion, by  the  skin  being  harder  and  more  tense,  and  not 
pitting  on  pressure,  and  by  the  rigidity  of  the  joints. 
Scleroderma  occurs  at  a  later  age  than  does  sclerema,  and 
the  skin  lacks  the  coldness  of  the  latter.  There  are  no 
other  diseases  with  which  sclerema  can  be  confounded. 

Treatment.  The  course  of  the  disease  is  almost  inevi- 
tably toward  a  fatal  termination,  and  little  more  can  be  done 
than  to  keep  the  little  body  as  warm  as  possible,  to  rub  in 
oil,  and  to  administer  concentrated  nourishment  and  stimu- 
lants. Money1  reported  a  case  in  1889  that  was  cured  in 
six  weeks  by  mercurial  inunctions.  There  was  no  history 
of  syphilis  in  the  case. 

Scleriasis.     See  Scleroderma. 

Sclerodactylie.     See  Scleroderma. 

Scleroderma  (SkleVo-du^nn'a3).  Synonyms:  Sclerema 
seu  Scleroma  adultorum  ;  Scleriasis  ;  Dermato-sclerosis  ; 
Chorionitis ;  Sclerostenosis ;  (Fr.)  Sclereme  des  adultes, 
Sclerodermic;  (Ger.)  Hautsclerem  ;  Hide-bound  disease. 

A  subacute  or  chronic  disease,  characterized  bv  the  skin 
being  hard  and  rigid. 

Symptoms.  The  name  of  this  disease  indicates  the  most 
peculiar  feature  of  it — that  is,  hardness  of  the  skin.  It  may 
come  on  without  apparent  cause,  the  patient  first  noticing 
the  stiffness  of  the  skin  ;  or  it  may  follow  exposure  to  damp- 
ness and  cold,  and  be  preceded  by  pains  of  rheumatic  nature. 
It  may  begin  in  any  part  of  the  skin,  but  has  a  preference 
for  the  upper  half  of  the  body.  It  is  usually  symmetrical, 
though  it  may  be  more  pronounced  on  one  side  than  on  the 
other.  Having  begun,  it  spreads,  it  may  be  very  slowly,  or 
it  may  be  so  rapidly  as  soon  to  involve  large  areas  of  the 
body.  It  often  runs  a  capricious  course,  growing  better  and 
worse,  and  leaving  sound  areas  in  the  midst  of  the  diseased 

1  Lancet,  1889,  i.  52(i. 


422  DISEASES    OF    THE    SKIN. 

parts.  There  may  be  one  patch,  or  a  number  of  them,  and 
the  patches  assume  many  shapes,  though  most  commonly 
they  are  elongated,  running  lengthwise  of  the  limb.  There 
are  two  varieties  of  the  disease  :  1.  The  infiltrating  form. 
In  this  there  is  a  good  deal  of  infiltration  of  the  skin,  which 
is  hard,  cannot  be  pinched  up,  does  not  pit  on  pressure,  and 
is  attached  to  the  deeper  structures.  The  appearance  given 
to  the  affected  part  is  cadaveric.  In  some  cases  there  may 
be  hard  oedema.  The  affected  part  is  usually  on  the  level 
of  the  surrounding  parts,  though  it  may  be  slightly  raised. 
The  infiltration  merges  gradually  into  the  neighboring  parts, 
its  border  being  ill-defined  and  more  readily  felt  than  seen. 
The  natural  folds  of  the  skin  are  obliterated,  ertyhema  may 
be  present  at  first,  and  telangiectases  are  frequently  ob- 
served upon  the  surface.  Not  infrequently  the  patch  has  a 
lilac  border.  The  color  of  the  skin  is  paler  than  that  of  the 
normal  integument,  and  in  some  places  it  may  be  that  of 
iovry.  Some  scaling  may  be  present,  or  pigmentation  of  a 
mottled  or  diffused  character  may  give  the  patch  a  fawn  to 
black  color.  Owing  to  the  stiffness  of  the  skin,  the  move- 
ment of  the  joints  is  interfered  with,  a  state  of  pseudo-anky- 
losis  being  established.  If  the  face  is  affected  it  loses  its 
expression,  and  the  features  become  immobile.  The  eyelids 
may  escape  for  some  time,  but  if  the  disease  passes  on  to  the 
atrophic  stage,  soon  to  be  mentioned,  the  eyes  become  wide 
open,  and  cannot  be  closed.  If  the  chest  is  much  affected, 
respiration  is  interfered  with.  The  temperature  of  the  skin 
is  usually  lowered  one  or  two  degrees.  It  may  be  normal, 
or  somewhat  elevated.  Sensibility  may  be  increased,  nor- 
mal, or  decreased.  Pruritus  is  at  times  annoying.  The 
secretions  of  the  skin  are  lessened  with  the  increase  of  the 
disease. 

The  disease  may  invade  all  the  mucous  membranes. 

To  this  form  the  second  or  atrophic  form  may  succeed 
after  months  or  years.  Crocker  thinks  that  it  is  probable 
that  atrophy  follows  the  (Edematous  infiltration  only.  When 
atrophy  begins  it  is  progressive,  and  the  skin  becomes  dry, 
wrinkled,  parchment-like.  It  is  most  often  the  upper  part 
of  the  body  that  is  affected — the  face  and  arms.     Continu- 


SCLERODERMA.  423 

ous  contraction  of  the  skin  produces  an  atrophy  of  the 
muscles  under  it,  so  that  finally  nothing  remains  of  the 
original  structures  but  the  skin  and  bones,  and  the  joints 
are  ankylosed.  The  face  being  affected,  we  will  find  a 
corpse-like  expression,  wide-open  eyes  with  ulcerated 
corneas,  shrunken  gums  with  loosened  and  falling  teeth. 
The  limbs  being  affected,  slight  injuries  will  produce  ulcera- 
tions over  bony  prominences,  and  the  limbs  will  be  semi- 
flexed. The  sclerodactylie  of  Ball  is  scleroderma  of  the 
atrophic  variety,  affecting  the  arm  and  causing  marked 
atrophy,  loosening  the  joints,  and  distorting  the  hands,  "  so 
that  the  third  and  fourth  fingers  are  curled  up  into  the  hand, 
the  first  and  second  are  bent  at  the  first  phalangeal  joint, 
while  the  thumb  phalanges  are  over-distended."     (Crocker  ) 

The  general  health  remains  unaffected,  often  for  years ; 
but  should  the  disease  be  very  pronounced,  at  last  a  maras- 
mic  condition  develops  and  death  occurs.  Apart  from  the 
pruritus  and  feeling  of  stiffness,  we  may  have  no  subjective 
sensation,  excepting  that  pain  on  pressure  is  exquisite.  At 
times  burning  is  complained  of.  The  disease,  when  of  the 
infiltrated  variety,  tends  to  a  slow  and  interrupted  course 
toward  recovery.  In  the  atrophic  variety  recovery  may 
take  place.  Of  course,  the  atrophied  skin  will  never  regain 
its  natural  texture,  but  the  disease  may  cease  to  spread  and 
increase.     At  best,  its  subject  is  but  a  sorry  specimen. 

Children  may  have  scleroderma,  the  youngest  reported 
case  being  thirteen  months.  In  them  the  disease  is  said  to 
run  a  more  rapid  course,  both  in  development  and  recovery, 
than  it  does  in  the  adult.  Vidal1  describes  a  form  of  sclero- 
derma following  a  lesion  of  the  skin,  such  as  an  eczema, 
which  gives  rise  to  a  lymphangitis,  and  is  usually  met  with 
on  the  leg. 

Etiology.  Women  are  far  more  often  the  victims  of 
scleroderma  than  are  men — three  to  one.  It  is  most  com- 
mon in  young  and  middle-aged  adults.  Apart  from  this, 
we  are  in  uncertainty  as  to  the  true  cause,  though  rheu- 
matism, gout,  exposure  to  cold  and  heat,  bad  hygiene  and 

1  Gaz.  des  H6p.;  1878,  li.  939. 


424  DISEASES    OF    THE    SKIN. 

poor  food,  and  neurotic  influences  have  each  been  found  in 
apparent  causative  relation  to  the  disease. 

Diagnosis.  There  is  no  other  disease  of  the  skin  with 
which  scleroderma  could  well  be  confounded,  excepting 
sclerema  or  oedema  neonatorum,  morphoea,  or  cancer  en 
cuirasse.  The  age  at  which  the  first  two  occur — namely, 
the  first  few  days  of  life — would  throw  them  out.  Morphoea 
is  a  localized  scleroderma,  and  the  diagnosis  is  therefore 
unimportant.  Cancer  en  cuirasse  is  more  rapidly  fatal  in 
its  course,  is  at  first  or  soon  marked  by  subcutaneous  nodules 
that  tend  to  break  down  and  ulcerate,  and  is  accompanied 
by  lancinating  pain. 

Treatment.  It  is  doubtful  if  treatment  is  ever  directly 
of  avail.  At  best,  it  is  unsatisfactory.  A  general  symp- 
tomatic treatment  with  tonics,  good  diet,  and  maintenance 
of  the  bodily  heat  is  indicated.  Galvanism,  inunctions  of 
the  skin  with  oil,  and  massage  may  be  tried.  West1  has  re- 
ported amelioration  in  one  case  by  the  external  use  of 
chaulmoogra  and  olive  oil  Graham2  advises  the  use  of 
anti-rheumatic  remedies. 

Prognosis.  While  recovery  may  take  place,  it  is  uncer- 
tain as  to  its  occurrence.  Death  may  result.  In  children 
the  prognosis  is  more  favorable. 

Scleroderma  Neonatorum.     See  Sclerema  neonatorum. 

Scleroma  Adultorum.     See  Scleroderma, 

Sclerostenosis.     See  Scleroderma. 

Scrofulide  Boutoneuse  Benigne.     See  Prurigo. 

Scrofulide  Crustacee  Ulcereuse.     See  Tuberculosis  cutis. 

Scrofulide  Erythemateuse.     See  Lupus  erythematosus. 

Scrofulide  Tuberculeuse.     See  Lupus  vulgaris. 

Scrofuloderma  (Sknrf-u^l-o-du^m'-a3).  Modern  pathol- 
ogy has  led,  or  is  leading,  us  to  use  the  term  tubercular  as 
synonymous  with  scrofula,  and  a  number  of  dermatoses  that 
were  for  many  years  regarded  by  authorities  as  scrofulo- 


1  Trans.  Path.  Soc.  Lond.,  1883,  xvi.  2o± 

2  Journ.  Cutan   and  Gen.-urin.  Dis  ,  1886,  iv.  332. 


SCROFULODERMA.  425 

dermata  have  been  proven  to  be  due  to  the  bacillus  tubercu- 
losis. The  most  brilliant  example  of  this  is  lupus  vulgaris. 
Many  of  the  scrofulides  of  the  French  have  been  shown  by 
more  careful  observation  to  belong  to  various  other  well- 
recognized  forms  of  skin  disease.  The  marks  of  a  scrofulous 
affection  are,  according  to  Bazin  :  1.  The  involvement  of 
the  deeper  layers  of  the  skin;  2.  The  sharply  circumscribed 
character  of  the  lesions  ;  3.  The  absence  of  pain ;  4.  Hyper- 
trophy followed  by  atrophy  of  the  affected  parts ;  5.  The 
reddish  violaceous  or  livid  color  of  the  lesions ;  and,  6.  In- 
delible cicatrices  left  by  the  same. 

In  the  present  condition  of  our  knowledge  of  the  subject, 
and  in  a  book  of  this  sort,  it  is  impossible  to  do  more  than 
to  place  here  a  few  affections  of  the  skin  that  do  not  fit  in 
under  other  well-established  diseases,  while  premising  our 
remarks  by  saying  that  they  are  either  really  instances  of 
cutaneous  tuberculosis,  or  will  eventually  be  taken  out  of 
their  present  position  as  scrofulodermata.  In  all  of  them 
we  have,  at  the  same  time,  that  general  make-up  of  the  indi- 
vidual that  long  has  been  recognized  as  scrofulous.  The 
patients  are  mostly  young  subjects,  flabby  of  flesh,  with 
pasty  or  doughy  complexions,  thick  upper  lips,  perhaps  with 
clubbed  fingers,  a  marked  tendency  to  chronic  catarrhal  in- 
flammations of  all  the  mucous  membranes,  chains  of  enlarged 
glands  in  the  neck,  and  perhaps  with  some  old  or  present 
bone  lesions.  They  are  usually  dull  and  apathetic,  and  are 
prone  to  die  with  tubercular  lung  diseases. 

The  most  common  scrofuloderm  is  that  resulting  from  a  sup- 
purating caseous  gland,  usually  of  the  neck — the  scrofulous 
ulcer.  The  gland,  before  it  breaks  down,  implicates  the  skin 
over  it,  and  it  becomes  of  violaceous  or  livid  color,  attached  to 
the  underlying  parts.  By  and  by,  the  skin  gives  way  at 
one  or  several  points  ;  the  sanious,  unhealthy  pus  escapes 
through  the  openings ;  these  enlarge,  coalesce  with  others, 
and  so  form  the  characteristic  ulcer.  This  has  undermined 
edges  ;  is  of  irregular  shape  ;  its  base  is  covered  with  flabby 
granulations  ;  it  discharges  a  thin,  sanious  pus  ;  shows  little 
tendency  to  crusting  ;  is  almost  painless,  and  heals  very 
slowly,   leaving   a  puckered,   disfiguring  scar.     This  same 


426  DISEASES    OF    THE    SKIN. 

form  of  ulcer  may  originate  from  what  is  called  a  scrofulous 
gumma,  a  subcutaneous  tubercle  independent  of  the  glands, 
that  slowly  enlarges  to  a  soft  tumor,  breaks  down,  and 
ulcerates.  These  tumors  frequently  occur  on  the  limbs,  and 
the  bones  may  be  involved  in  the  destructive  processes 
set  up. 

While  this  is  the  most  common  scrofuloderm,  we  occa- 
sionally meet  with  two  forms  described  by  Duhring — the 
large  and  the  small  pustular  scrofuloderm.  The  former  has 
"  large,  rounded,  ovalish,  or  irregularly  shaped,  yellowish, 
flat  pustules,  with  a  deep-red  or  violaceous  areola."  This 
begins  to  crust  in  the  centre,  and  the  crust  is  usually  flat 
and  scanty,  brownish  and  adherent.  Underneath  it  is  an 
ulcer  with  the  characters  and  course  of  those  just  described. 
There  may  be  one,  two,  or  more  lesions.  The  small  pus- 
tular scrofuloderm  "  consists  in  the  formation  of  pinhead 
and  small  split-pea-sized,  disseminated,  yellowish,  flat  pus- 
tules, with  usually  a  raised,  violaceous  areola."  These 
crust  over  with  depressed  yellowish  or  gray  adherent  crusts, 
which,  wrhen  removed,  or  when  they  fall  off,  leave  depressed, 
punched-out  scars  resembling  variola.  Their  course  is  very 
chronic  and  painless.  They  occur  upon  the  face  and  ex- 
tremities of  strumous  individuals. 

Etiology.  The  causes  of  these  scrofulodermata  are 
those  of  the  strumous  state,  and  need  not  be  gone  into  here. 
They  are  most  commonly  met  with  in  early  life. 

Diagnosis.  The  scrofulous  ulcer  differs  from  that  of 
lupus  vulgaris  by  an  entire  absence  of  the  characteristic 
lupus  tubercles,  and  by  its  history  of  beginning  in  a  caseous 
gland.  Moreover,  in  lupus  we  do  not  have,  as  a  rule,  the 
pronounced  strumous  condition  that  we  have  in  the  scrofulo- 
derm. The  pustular  scrofuloderms  sometimes  resemble 
syphilis,  but  there  is  an  absence  of  other  signs  of  syphilis, 
and  the  presence  of  the  strumous  state.  Moreover,  a  pus- 
tular syphilide  is  generally  far  more  disseminated  than  is 
the  scrofuloderm  ;  its  course  is  far  more  acute,  it  yields  more 
readily  to  treatment,  and  leaves  a  smoother,  less  disfiguring 
scar. 

Treatment.     The  treatment  of  the  ulcers,  as  well  as  the 


SEBACEOUS    CYST.  427 

softening  glands,  is  upon  surgical  principles.  The  regula- 
tion of  the  diet  and  hygiene  of  the  patient,  and  the  adminis- 
tration of  cod-liver  oil,  iron,  the  compound  syrup  of  the 
hypophosphites,  or  other  tonic,  is  the  most  essential  part  of 
the  medicinal  treatment.  Locally,  to  the  pustular  scrofulo- 
derms  we  may  apply  iodoform  ointment,  aristol,  or  other 
antiseptic  powder,  or  mercurial  ointments  or  lotions.  Crocker 
speaks  well  of  chaulmoogra  oil  emulsion  in  the  dose  of  ten 
to  thirty  minims,  combined  with  its  external  use  as  an  oint- 
ment in  the  strength  of  one  part  to  three. 

Scrofuloderma  Verrucosum.  See  Tuberculosis  verrucosa 
cutis. 

Scurvy.     See  Purpura. 

Sebaceous  Cyst.  Synonvms :  Atheroma ;  Steatoma  ; 
Wen. 

These  innocuous  little  tumors  may  occur  anywhere  on  the 
body,  but  are  most  common  on  the  scalp,  face,  neck,  and 
back.  They  vary  in  size  from  a  millet-seed  to  an  orange. 
They  may  be  rounded,  flattened,  or  hemispherical.  The 
skin  over  them  may  be  of  normal  color,  pale  on  account  of 
pressure,  or  red  if  the  cyst  becomes  inflamed.  They  may 
be  elastic  and  doughy  to  the  touch,  or  firm,  or  soft,  accord- 
ing to  the  condition  of  their  contents,  which  may  be  fluid 
and  honey-like,  or  more  cheesy.  They  tend  to  grow  slowly, 
and  give  no  trouble  except  by  the  deformity  they  cause.  In 
exceptional  cases  they  may  become  inflamed  and  ulcerate. 
The  hair  is  usually  absent  over  them  when  they  occur  on 
the  scalp.  Cysts  of  similar  nature  may  be  found  in  loca- 
tions where  there  are  no  sebaceous  glands,  and  even  under 
the  mucous  membranes.  These  are  called  dermoid  cysts, 
and  are  supposed  to  be  left  over  from  fcetal  life.  They  fre- 
quently contain  hair  and  teeth. 

Etiology.  Most  cysts  are  due  to  distention  of  a  seba- 
ceous gland.  The  origin  of  dermoid  cysts  is  undetermined. 
Indeed,  considerable  uncertainty  surrounds  the  pathology  of 
all  of  them. 

Diagnosis.  They  must  be  distinguished  from  fatty 
tumors  and  gummata.      Fatty  tumors  are  firmer  and  more 


428  DISEASES    OF    THE    SKIN. 

doughy  than  cysts,  are  more  often  lobulated,  occur  but 
seldom  on  the  scalp,  and  are  rarely  multiple.  Gummata 
are  more  rapid  in  their  growth,  attached  to  the  skin,  and 
tend  to  break  down  and  ulcerate. 

Treatment.  Complete  excision  of  the  tumor,  taking 
particular  care  to  remove  the  whole  sac,  is  the  only  treat- 
ment to  be  considered. 

Seborrhagia.     See  Seborrhoea. 

Seborrhcea  (Se2b-o2r-reV).  Synonyms :  Stearrhcea, 
Steatorrhea,  Seborrhagia,  Fluxus  sebaceus,  Acne  sebacea, 
Pityriasis,  Ichthyosis  sebacea,  Tinea  amiantacea  seu  asbes- 
tina,  Eczema  seborrhoicum,  Lichen  circinatus  ;  (Fr.)  Acne 
sebacee,  Acn6  fluente ;  (Ger.)  Schmeerfluss,  Gneis ;  (Ital.) 
Seborrea. 

A  functional  disorder  of  the  sebaceous  glands,  in  which 
there  is  a  hypersecretion  of  sebaceous  matter,  which  may  be 
of  too  fluid  or  too  thick  consistence,  and  forms  either  an 
oily  coating  or  greasy  crusts  on  the  skin. 

Symptoms.  Seborrhoea  is  a  functional  disease  of  the 
sebaceous  glands,  which  assumes  two  forms  depending  upon 
the  quality  of  the  products  of  the  glands.  Normally  these 
glands  secrete  only  sufficient  oil  to  keep  the  skin  soft  and 
supple.  This  normal  oil  is  not  visible  to  the  naked  eye. 
Under  certain  imperfectly  understood  conditions,  the  glands 
secrete  a  too  fluid  and  abundant  oil  that  is  readily  seen  as 
an  oleaginous  coating  of  the  skin.  This  form  of  seborrhoea 
is  called  seborrhoea  oleosa.  Under  certain  other  equally 
imperfectly  understood  conditions,  the  secretion  of  these 
glands  is  not  only  too  abundant,  but  also  too  consistent. 
Then  the  sebaceous  matter  cakes  upon  the  skin  in  the  form 
of  more  or  less  thick  plates  or  masses,  and  we  have  the  con- 
dition known  as  seborrhcea  sicca 

The  most  common  locations  of  seborrhoea  are,  naturally, 
those  regions  where  the  sebaceous  glands  are  the  largest  or 
most  numerous,  namely :  the  scalp,  the  chest,  the  inter- 
scapular region,  and  the  face. 

Seborrhcea  oleosa,  wdiile  it  may  occupy  any  or  all  of  these 
regions,  is  usually  subjected  to  us  for  treatment  only  when 


SEBORRHEA.  429 

it  occurs  upon  the  face.  Here  it  is  seen  most  often  on  the 
nose,  where  it  forms  a  greasy  coating.  At  times  this  is  so 
slight  as  to  be  felt  rather  than  seen,  imparting  a  slippery 
sensation  to  the  finger.  At  other  times  it  is  so  abundant 
that  it  can  be  seen  at  a  distance  as  drops  or  beads  of  oil, 
and  when  it  is  removed  with  a  cloth  or  blotting-paper  it 
leaves  an  oily  stain  upon  it.  When  it  is  wiped  off  it  at  once 
re-forms.  As  the  greasy  skin  catches  the  dust  the  face  is  apt 
to  look  dirty.  At  times  the  skin  of  the  nose  may  be  hyper- 
emia The  forehead  is,  likewise,  a  not  uncommon  site  for 
this  form  of  seborrhoea.  It  may  occur  on  the  scalp,  but 
attracts  notice  only  when  the  patient  is  bald.  Upon  the 
nose  it  may  occur  as  the  only  disease  of  the  skin.  Upon 
the  forehead  it  is  a  not  unusual  accompaniment  of  acne. 
Acne  and  comedones  may  complicate  the  disease  in  any 
location. 

Seborrhoea  sicca  occurs  with  much  greater  frequency  than 
does  the  oily  form  of  the  disease.  We  are  called  upon  to 
remove  it  from  all  the  regions  already  mentioned  as  the 
locations  for  the  manifestations  of  seborrhoea.  It  most 
usually  appears  in  the  form  of  yellowish  or  grayish  fatty 
plates  or  masses,  which  when  taken  and  rubbed  between  the 
fingers  impart  a  greasy  feel.  Upon  the  scalp  it  constitutes 
one  form  of  dandruff.  Here  it  may  be  general,  involving 
the  whole  scalp,  or  it  may  locate  itself  in  certain  places  in  a 
more  pronounced  way  than  in  others.  The  hair  is  dry,  and 
after  a  time,  the  seborrhoea  continuing,  it  begins  to  fall,  and 
at  last  baldness  is  established. 

In  this  form  of  seborrhoea  it  is  the  hairy  regions  that  are 
especially  affected,  and  we  find  it  in  the  eyebrows,  bearded 
portions  of  the  face,  and  the  hairy  portions  of  the  chest. 
The  axillae  and  pubes  are  rarely  affected.  In  all  these 
places  it  presents  similar  appearances,  yellowish  or  grayish 
fatty  plates.  Upon  the  chest  it  is  not  uncommon  to  see 
the  fatty  matter  in  little  heaps,  piled  up  as  it  were  about  the 
mouths  of  the  hair  follicles.  Close  observation  will  show 
that  the  follicle  mouths  are  wider  open  than  they  should  be. 
As  in  the  oily  form  the  skin  feels  greasy,  and  acne  and  come- 
dones are  present.      The  interscapular  region  is  frequently 


430  DISEASES    OF    THE    SKIN". 

affected,  and  both  here  and  on  the  chest  the  disease  often  takes 
the  form  of  round  or  irregularly  shaped  patches  which  look  as 
if  they  were  covered  with  a  brownish-yellow  varnish. 

Aside  from  the  appearance  of  the  fatty  crusts  and  a  slight 
amount  of  itching  when  the  patient  is  warm,  this  form  gives 
rise  to  no  symptoms.  When  the  crusts  are  removed  the 
underlying  skin  is  of  normal  appearance.  It  may  be 
slightly  paler  than  it  should  be,  but  it  is  never  moist. 
What  the  patient  complains  most  about  is  that  the  scales 
from  the  crusts,  becoming  loosened  fall  upon  the  clothing  and 
make  it  look  as  if  powdered.  If  the  patient  happens  to  be 
bald  he  does  not  find  the  yellowish  fatty  crusts  upon  his  bald 
head  at  all  ornamental.  But  the  most  serious  aspect  of  the 
case  is  that  if  the  disease  is  not  cured  it  is  very  sure  to  cause 
the  hair  to  fall,  especially  if  the  patient  is  at  all  predisposed 
to  baldness. 

There  is  a  second  variety  of  seborrhoea  sicca,  in  which  a 
varying  amount  of  dermatitis  is  added  to  the  seborrhoea. 
This  variety  is  the  lichen  circinatus  of  the  English,  and  the 
seborrhoea  corporis  of  Duhring.  Then  there  will  be  a  rim 
of  redness  about  the  fatty  crust,  und  when  the  crust  is 
removed  from  the  skin,  the  underlying  part  will  be  seen  to 
be  red.  In  this  variety  there  will  be  far  more  decided  itch- 
ing and  burning  than  in  the  preceding  variety.  It  is  to  be 
noted  that  although  the  skin  is  red,  it  is  always  dry  and 
never  infiltrated,  in  these  respects  differing  from  eczema. 
Upon  the  chest  and  back  the  eruption  will  assume  the  form 
of  circular  patches  covered  by  a  yellowish  or  brownish 
crust,  the  peripheries  being  of  a  more  or  less  bright  red. 
Or  the  surface  of  the  patch  will  be  smooth  and  appear  as  if 
it  had  been  varnished  over  with  a  brownish-yellow  varnish. 
Sometimes  two  or  more  patches  will  run  together,  and  then 
we  will  find  an  irregularly  shaped  patch  with  a  scalloped 
border.  These  patches  will  assume  large  dimensions  in  some 
cases.  There  may  be  one  or  several  patches  upon  the  chest 
or  back.  Instead  of  these  circular  patches,  ring-shaped 
patches  may  form.  These  tend  to  spread  at  the  circumfer- 
ence, and  to  clear  in  the  centre.  When  two  rings  meet  at 
their  peripheries  the  points  of  contact  give  way,  and  we  have 


SEBORRHCEA.  431 

irregularly  shaped  figures  with  a  scalloped  outline.  At 
times  the  rings  themselves  are  not  complete,  and  we  meet 
with  a  number  of  broken  rings  and  gyrate  lines  scattered 
over  the  chest  or  back.  Owir>g  to  the  constant  rubbing  by 
the  clothing  to  which  the  chest  and  back  are  exposed  in  all 
people,  and  to  the  influence  of  soap  and  water  in  those  who 
indulge  in  the  daily  bath,  the  crusts  are  frequently  missing 
from  the  circles  and  rings.  Then  the  eruption  consists  of 
red  rings  and  circular  patches,  which  on  close  inspection  are 
seen  to  be  made  up  of  a  number  of  red  points.  These  points 
are  the  open  mouths  of  the  sebaceous  glands  surrounded 
by  a  zone  of  inflammatory  redness.  This  variety  of  sebor- 
rhoea  sicca  is  met  with  also  on  the  scalp.  Indeed  it  is  never 
present  on  the  trunk  without  at  the  same  time  being  upon 
the  head.  Upon  the  scalp  it  is  seen  best  in  those  who  are 
bald.  We  find  at  times  the  same  rings  and  circles  that 
we  have  learned  to  recognize  upon  the  chest,  but  it  is  rather 
more  common  for  the  disease  to  assume  the  form  of  a  more 
diffused  patch  involving  a  large  part  of  the  scalp,  with  a 
zone  of  redness  about  the  edges.  When  the  disease  is  pres- 
ent in  this  pronounced  form  upon  the  scalp  it  is  very  prone  to 
pass  over  onto  the  adjacent  parts  of  the  forehead  and  thus  to 
form  as  it  were  a  corona  seborrhoicum.  This  corona  will 
take  the  form  of  a  yellowish  or  brownish  crust  with  a  red- 
bounding  line.  The  disease  may  in  like  manner  pass  over 
onto  the  adjacent  parts  of  the  skin  of  the  neck. 

Upon  the  nose  this  variety  of  seborrhoea  forms  a  yellow 
plate  with  a  red  line  about  it.  At  times  this  plate  may  be 
extensive  enough  to  cover  the  whole  nose.  More  frequently 
the  disease  is  limited  to  the  furrow  behind  the  alee  nasi,  and 
then  assumes  the  form  of  some  fatty  scales  upon  a  good  deal 
of  underlying  redness.  The  eyebrows  and  bearded  portions 
of  the  face  are  also  quite  commonly  affected,  but  rather  as  a 
diffused  redness  combined  with  a  branny  scaling,  than  as  a 
solid  plate  surrounded  by  a  red  line. 

Besides  the  regions  already  mentioned  as  the  usual  loca- 
tions of  seborrhoea,  we  also  meet  with  the  disease  upon  the  ears 
(in  the  tragus  and  behind  the  ears),  and  in  the  anal  fold. 
The  scalp  is,  however,  by  far  the  most  frequent  location  of 


432  DISEASES    OF    THE    SKIN". 

the  disease,  and  here  it  may  exist  alone  for  years.  When- 
ever it  exists  elsewhere,  it  is  sure  to  be  found  at  the  same 
time  upon  the  head. 

In  infants  the  disease  is  very  common,  taking  the  form  of 
thick  crusts  upon  the  scalp,  that  are  often  of  a  dirty-gray 
color.  These  give  the  careful  mother  a  good  deal  of  annoy- 
ance, she  being  in  great  dread  lest  someone  should  think 
that  she  is  not  careful  to  keep  the  precious  baby  clean.  This 
form  of  the  disease  is  usually  the  remains  of  the  vernix 
caseosa. 

Pityriasis  capitis  used  to  be  considered  a  form  of  sebor- 
rhea. It  should  be  considered  rather  as  a  scaling  off  of  the 
upper  part  of  the  corneous  layer  of  the  skin. 

Etiology.  The  usual  etiological  factors  of  seborrhea,  as 
given  in  the  text-books,  are  debility,  chlorosis,  constipation, 
and  a  number  of  other  things,  indicating  that  the  condition 
of  the  patient  is  below  par.  Of  course,  the  ability  of  these 
to  cause  dandruff  is  questioned.  But  that  they  are  quite 
capable  of  aggravating  the  disease,  I  have  no  doubt.  The 
disease  affects  all  classes  and  conditions  of  men,  all  ages, 
and  both  sexes. 

There  are  many  things  that  seem  to  indicate  a  contagious 
element  in  the  etiology  of  the  disease.  Cases  have  been 
reported,  in  which  a  husband  or  wife  has  contracted  dan- 
druff after  marriage,  he  or  she  having  been,  before,  free  of  the 
same.  Then,  those  experiments  of  Lassar  and  Bishop  point 
in  the  same  direction.  They  took  the  scales  from  the  head 
of  a  student  who  was  losing  his  hair,  and,  having  made  a 
pomade  of  them  with  vaseline,  rubbed  the  same  into  the 
back  of  a  guinea-pig,  and  the  pig  became  bald.  Up  to  two 
years  ago  we  accepted  without  question  the  theory  that 
seborrhea  was  a  functional  disease  of  the  sebaceous  glands. 
But  Unna  would  have  us  believe  that  there  is  no  such 
disease  as  seborrhea.  He  teaches  that  the  process  is  inflam- 
matory from  the  start,  and  that  the  oil  that  fills  the  epithe- 
lial scales  comes  not  from  the  sebaceous  glands  but  from  the 
sweat  glands.  What  we  have  called  seborrhea  sicca  he 
would  have  us  call,  for  the  present  at  least,  seborrheal  eczema. 
(See  Eczema  seborrhoicum.) 


SEBOREHGEA.  433 

In  support  of  his  thesis  he  presents  us  with  microscopical 
studies  and  certain  arguments.  His  work  has  been  re- 
viewed by  other  competent  pathologists,  and  I  believe  that 
many  of  his  observations  have  been  substantiated  by  their 
findings.  His  proposition  that  the  sebaceous  glands  are  not 
responsible  for  seborrhcea  has  not  been  accepted  generally. 
It  has  long  been  known  that,  to  a  seborrhcea,  a  dermatitis 
may  be  added,  and  that  this,  under  various  influences,  may 
become  an  eczema.  But  this  is  a  very  different  thing  to 
saying  that  seborrhoea  does  not  exist  and  that  all  those  cases 
that  we  have  been  accustomed  to  call  seborrhoea  are  but  a 
variety  of  eczema. 

What  we  call  seborrhoea  oleosa,  Unna  believes  to  be 
nothing  more  than  a  hyperidrosis,  to  which  he  gives  the 
name  of  hyperidrosis  oleosa.  This  view  he  must  take  of 
necessity,  on  account  of  his  theory  of  the  office  of  the  sweat 
glands. 

This  is  an  age  of  microorganisms,  and  all  diseases  are 
traced  to  a  parasitic  origin.  And  so  it  is  affirmed  that  the 
disease  under  discussion  is  contagious,  and  due  to  a  micro- 
organism. Up  to  the  present  time,  though  a  number  of 
parasites  have  been  found  on  the  scalp,  there  is  no  one  that 
can  hold  its  place  as  the  cause  of  the  disease.  Brooke,  of 
Manchester,  would  have  us  believe  that,  to  the  unknown 
parasite  of  seborrhoea  without  dermatitis,  another  equally 
unknown  parasite  adds  itself,  to  produce  the  dermatitis  and 
the  ring  formation. 

Diagnosis.  The  diagnosis  of  seborrhoea  is  usually  easy. 
It  is  to  be  recognized  by  the  presence  of  fatty  grayish  or 
yellowish  plates  or  crusts,  seated  either  upon  a  normal  or 
slightly  reddened  skin.  These  crusts  or  plates  differ  from 
those  met  with  in  eczema,  in  being  more  readily  removed, 
and  imparting  to  the  finger  a  greasy  feel.  Moreover,  the 
crusts  of  eczema  are  of  a  more  solid  consistence,  being  formed 
by  the  drying  of  an  almost  mucilaginous  discharge  upon 
the  skin.  When  eczema  occurs  upon  the  head  the  exuda- 
tion glues  the  hairs  together.  In  seborrhoea,  the  hairs  are 
not  glued  together,  but  are  dry  and  powdery.  In  eczema, 
there  is  more  or  less  itching  at  all  times,  while  in  seborrhoea, 

19 


434  DISEASES    OF    THE    SKIN". 

the  itching  comes  on  most  generally  when  the  head  is  hot, 
as  from  artificial  lights,  sweating  and  the  like.  In  eczema, 
there  is  moisture,  or  a  strong  tendency  thereto.  In  sebor- 
rhcea,  moisture  is  never  seen. 

Psoriasis  is  another  disease  with  which  seborrhoea  is  apt 
to  be  confounded,  as  it  too,  occurs  in  the  form  of  powdery 
scales  and  crusts  upon  the  scalp.  If  a  case  presents  itself 
with  these  conditions  upon  the  head  alone,  you  may  be  very 
sure  that  you  have  to  do  with  a  case  of  seborrhoea,  as  psoria- 
sis never  exists  upon  that  region  alone.  Seborrhoea  usually 
occurs  diffusely,  while  psoriasis  occurs  in  the  form  of  circum- 
scribed patches.  The  crusts  of  seborrhoea  are  yellowish  or 
grayish,  while  those  of  psoriasis  are  of  a  silvery  hue.  In 
some  cases,  however,  seborrhoea  will  occur  in  circumscribed 
patches,  and  the  crusts  of  psoriasis  may  be  of  a  grayish  hue. 

When  seborrhoea  occurs  upon  the  chest  and  back  in  the 
form  of  rings  with  scaly  centres,  we  have  before  us  a  more 
difficult  problem  in  diagnosis.  Now  we  must  decide  whether 
we  have  to  do  with  a  seborrhoea,  a  ringworm,  or  a  pityriasis 
rosea.  The  resemblance  to  ringworm  is  often  very  striking, 
but  ringworm  does  not,  as  a  rule,  occur  in  so  diffuse  a 
manner.  If,  at  the  same  time,  with  the  lesion  on  the  chest 
we  find  other  lesions  on  the  back  between  the  shoulder 
blades,  we  may  be  quite  sure  that  the  case  is  one  of  sebor- 
rhoea. Happily  in  any  doubtful  case  we  have  a  sure  resort 
in  the  microscope.  If  the  case  be  one  of  ringworm  we  will 
surely  find  the  tricophyton.  Upon  examining  the  scalp,  if 
the  disease  be  seborrhoea,  we  will  surely  find  plain  evidence 
of  it  there.  There  should  be  no  difficulty  in  recognizing 
the  presence  of  a  ringworm  on  the  scalp. 

In  the  differential  diagnosis  from  pityriasis  rosea,  we  are 
deprived  of  the  kindly  aid  of  the  microscope.  Here,  too, 
the  occurrence  of  seborrhoea  on  the  scalp  will  aid  us  in  our 
decision.  Moreover  pityriasis  rosea  is  generally  more  diffused 
over  the  trunk  than  is  seborrhoea,  and  occurs  also  on  the 
arms  and  abdomen.  By  close  inspection  we  may  trace  the 
development  of  the  disease  from  its  beginning  as  a  small  red 
spot  through  its  successive  growth  into  the  typical  oval  or 
annular   patch  with   its   withered   parchment  or   chamois 


SEBORRHEA.  435 

leather-like  looking  centre.  It  is  scaly,  never  crusted.  In 
some  cases,  however,  the  diagnosis  will  remain  somewhat 
doubtful. 

Treatment.  The  treatment  of  seborrhcea  is  simple.  It 
is  somewhat  in  favor  of  the  parasitic  theory  of  the  origin  of 
the  disease  that  the  drugs  that  are  most  efficacious  in  its 
cure  are  active  antiparisitics.  In  my  hands  by  far  the 
most  satisfactory  remedy  has  been  sulphur.  After  the 
removal  of  the  crusts  by  means  of  any  oil  or  grease  (this 
should  be  done  the  first  thing  whatever  remedy  is  chosen), 
the  sulphur  is  to  be  applied  in  the  strength  of  a  drachm  to 
the  ounce,  either  suspended  in  sweet  oil,  cotton-seed  oil,  or 
vaseline.  It  should  be  well  rubbed  into  the  scalp,  and  the 
application  repeated  every  night  for  one  week.  It  is  well 
to  advise  the  patient  to  wrap  his  head  up  in  a  towel,  or  to 
wear  a  night  cap.  After  one  week's  use  of  the  sulphur  the 
head  is  to  be  washed  with  soap  and  water,  and  the  oil,  or 
salve,  immediately  reapplied.  During  the  second  week  it 
will  be  sufficient  to  make  the  application  every  other  night. 
Thus  the  treatment  is  to  be  continued,  the  number  of  appli- 
cations being  reduced  until  they  are  made  but  once  a  week. 
By  this  time  the  disease  will  be  cured.  The  patient  is  to 
be  cautioned  that  relapses  are  likely  to  occur,  and  therefore 
it  will  be  best  for  him  to  keep  a  supply  of  his  oil,  or  salve, 
on  hand  so  as  to  attack  the  trouble  as  soon  as  it  shows 
itself. 

The  objections  to  sulphur  are  two  :  it  has  a  slight  odor, 
and  it  leaves  a  slight  yellow  powder  on  the  scalp.  The  first 
objection  is  of  not  much  importance  and  may  be  overcome 
by  adding  a  scent  to  the  oil.  The  second  is  lessened  by 
cautioning  the  patient  not  to  use  the  application  too  freely 
and  by  having  him  wash  the  head. 

If  your  patient  is  a  woman,  in  private  practice  you  will 
find  that  the  ointment  recommended  by  my  distinguished 
friend,  Dr.  Bronson,  will  be  a  very  elegant  as  wTell  as  effi- 
cient substitute  for  the  sulphur.     It  is 


R.  Hydrarg.  amnion.,  9j~*j  5-10 

Hydrarg.  chlor.  mitis,  By_iv       10-20 

Vaselini,  |j  100 


M. 


436  DISEASES    OF    THE    SKIN. 


This  is  to  be  used  in  the  same  manner  as  the  sulphur 
ointment. 

While  one  or  the  other  of  these  will  bring  the  case  to  a 
happy  issue,  it  is  well  to  have  a  variety  of  means  at  com- 
mand. You  will  find  benefit  by  using  salicylic  acid  in 
castor  oil,  three  per  cent,  strength :  resorcin  in  oil  or  vase- 
line in  about  five  per  cent,  strength  ;  or  a  solution  of 
hydrate  of  chloral,  a  drachm  to  the  ounce;  while  for  a 
soap  both  for  cleansing  and  stimulation  nothing  is  better 
than  the  tincture  of  green  soap.  If  the  scalp  is  peculiarly 
irritable  then  it  is  best  to  use  a  milder  soap,  such  as  Pears's 
glycerin  soap. 

The  treatment  of  seborrhoea  of  the  body  and  face  is 
upon  the  same  lines  as  that  for  the  head,  only  that  on  the 
body  we  can  use  an  ointment  instead  of  an  oil. 

For  the  seborrhoea  of  children,  usually  all  that  is  required 
is  to  keep  the  scalp  well  oiled  with  olive  oil.  If  this  does 
not  cure,  then  a  mild  sulphur  ointment  with  vaseline  may 
be  used. 

For  seborrhoea  oleosa,  dabbing  ether  on  the  part  will  most 
promptly  remove  the  greasy  look.  Washing  with  soap  and 
water  will  act  as  a  stimulant,  and  powdering  with  sulphur 
and  starch  will  prove  curative. 

In  all  forms  general  treatment  will  be  called  for  if  the 
patient  is  out  of  tone.  General  tonic  treatment  is  required 
in  nearly  all  cases  of  seborrhoea  oleosa. 

Under  Alopecia  furfuracea  will  be  found  further  directions 
as  to  the  treatment  of  seborrhoea  of  the  scalp  when  it  has 
led  on  to  baldness. 

Seborrhoea  Congestiva.     See  Lupus  erythematosus. 

Seborrhceal  Eczema.  See  Eczema  seborrhoicum  and 
Seborrhoea. 

Shingles.     See  Zoster. 

Siderosis  (Si2d-e2r-o'si2s).  A  defacement  of  the  skin  due 
to  the  entrance  into  it  of  small  particles  of  iron  or  steel,  pro- 
ducing blue-black  marks.     It  is  seen  in  iron-workers. 

Sommersprosse.     See  Lentigo. 

Sphaceloderma.     See  Dermatitis  gangraenosa. 


sYcosrs.  437 

Spargosis.     See  Elephantiasis. 

Spedalskhed.     See  Lepra. 

Spider  Cancer.     See  Telangiectasis. 

Spitze  Condylom.     See  Verruca  and  Syphilis. 

Stearrhoea.      See  Seborrhoea. 

Steatorrhoea.     See  Seborrhoea. 

Steatoma.     See  Sebaceous  cyst. 

Stigmasie.     See  Stigmata. 

Stigmata.     See  Haematidrosis. 

Stinkschweiss.     See  Bromidrosis. 

Stonepock.     See  Acne. 

Striae  et  Maculae  Atrophicae.  See  Atrophoderma  stria- 
tum et  maculatum. 

Strophulus.     See  Miliaria. 

Strophulus  Albidus.     See  Milium. 

Strophulus  Prurigineux  (Hardy).     See  Prurigo. 

Struma.     See  Scrofuloderma. 

Sudamina.     See  Miliaria. 

Sudatoria.     See  Hyperidrosis. 

Sudor  TJrinosus.     See  Uridrosis. 

Sueurs  Colorees.     See  Chromidrosis. 

Sweating,  Excessive.     See  Hyperidrosis. 

Sycosis  (Sik-o'si2s).  Synonyms  :  Sycosis  non  parasitica  ; 
Sycosis  menti ;  Sycosis  barbae  ;  Mentagra  ;  Acne  mentagra  ; 
Folliculitis  barbae ;  Folliculitis  pilorum ;  Herpes  pustulosus 
mentagra ;  Lichen  menti ;  Acne  sycosis  ;  (Fr.)  Sycosis  non 
parasitaire ;  Dartre  pustuleuse  mentagre ;  Adenotrichie ; 
(Ger.)  Bartfinne,  Bartflechte;  Fikosis  ;  (Eng.)  Barber's  itch. 

Definition.  A  chronic  follicular  and  perifollicular 
inflammation  of  the  long  hairs,  chiefly  affecting  the  bearded 
portions  of  the  face  ;  characterized  by  an  eruption  of  papules, 
pustules,  and  tubercles  perforated  by  hairs ;  by  the  forma- 
tions of  infiltrated  patches  ;  and  by  a  greater  or  less  amount 
of  crusting.  Sometimes  the  disease  is  so  intense  as  to  form 
abscesses. 


438  DISEASES    OF    THE    SKIN. 

Symptoms.  It  is  only  of  comparatively  recent  years  that 
this  disease  has  been  recognized  as  a  separate  entity,  and 
it  is  still  regarded  by  some  authorities  as  merely  a  form  of 
eczema.  The  disease  begins  by  the  formation  of  a  number 
of  red  inflammatory  papules  and  tubercles  which  are  more 
or  less  conical,  usually  raised  above  the  surface  of  the  skin, 
and  always  perforated  by  hairs.  Their  appearance  is  pre- 
ceded and  accompanied  by  disagreeable  local  sensations, 
such  as  pricking,  burning,  and  smarting,  and  at  times  by  a 
feeling  of  tension  in  the  part  on  account  of  swelling  of  the 
skin.  In  acute  cases  there  is  considerable  redness  of  the 
skin  between  the  papules,  and  the  inflammation  may  be  so 
intense  as  to  give  rise  to  enlargement  of  the  neighboring 
lymphatic  glands.  The  papules  and  tubercles  vary  in  size 
from  that  of  a  millet  seed  to  that  of  a  pea,  and  are  isolated 
or  grouped,  not  every  hair  follicle  in  a  diseased  part  being 
affected  by  the  peri-follicular  inflammation.  Only  in  very 
severe  outbreaks  or  in  acute  exacerbations  do  the  papules 
and  tubercles  tend  to  run  together  and  form  infiltrated 
patches. 

The  papules  and  tubercles  soon  change  into  pustules, 
which  preserve  the  same  characteristics  of  grouping  and  are 
likewise  always  pierced  by  hairs.  These  pustules,  conical 
in  shape,  and  perforated  by  hairs,  are  pathognomonic  of  the 
disease.  In  old  cases  they  are  met  with  in  the  infiltrated 
patches  arising  apparently  without  the  preceding  appear- 
ance of  papules  and  tubercles.  The  pustules  show  no  tend- 
ency to  rupture,  but  the  pus  accumulates  below,  swells  up 
alongside  of  the  hair,  appears  upon  the  surface  of  the  skin, 
and  dries  into  thin  crusts.  The  amount  of  crusting  is  never 
very  great,  far  less  than  in  eczema  of  the  beard,  and  is 
appreciable  mainly  when  the  beard  is  growing.  If  the  in- 
flammation is  very  intense  we  may  meet  with  small  cutaneous 
abscesses  here  and  there  instead  of  pustules.  According  to 
A.  R.  Robinson,  the  amount  of  pus  production  varies  with 
the  individual  attacked,  being  more  rapid  and  abundant  in 
the  robust  than  in  the  scrofulous ;  in  acute  than  in  chronic 
cases. 

The  hairs,  if  of  any  length,  are  early  affected  in  appearance, 


sycosis.  439 

becoming  lustreless.  They  are  first  firmly  seated  in  their 
follicles,  and  when  pulled  upon  give  rise  to  pain,  and  if 
extracted  their  root  sheaths  will  appear  as  clear  glassy 
cylinders.  Later,  as  pus  forms  more  abundantly  in  the  peri- 
follicular tissues,  and  the  follicles  themselves  are  involved 
in  the  process,  the  hair  becomes  loosened  and  easily 
extracted,  when  its  root  sheath  will  be  found  swollen  with 
pus.  If  the  pus  production  is  excessive  the  hairs  will  fall  of 
themselves  or  upon  the  slightest  traction.  When  this  occurs 
the  hair  papillae  may  be  so  damaged  that  no  new  hairs  will 
form.  In  chronic  cases  the  beard  is  markedly  thinned, 
though  permanent  loss  of  hair  is  the  exception. 

The  disease  may  attack  any  part  of  the  bearded  face,  and 
may  be  met  with  in  other  hairy  regions,  as  the  neck,  the 
eyebrows,  scalp,  axilla,  and  pubes.  But  the  beard  is  by  far 
most  often  the  site  of  the  disease,  the  other  situations  being 
affected  in  the  order  in  which  they  are  named.  Occurring 
in  the  beard  it  may  be  limited  to  a  single  region  and  show 
no  tendency  to  spread.  Thus  it  is  met  with  very  frequently 
upon  the  upper  lip  alone,  or  at  times  upon  the  chin  alone. 
It  may  attack  the  whole  bearded  face  in  an  acute  outbreak, 
or  it  may  involve  it  by  extension  from  a  limited  area  during 
a  number  of  successive  outbreaks.  In  chronic  cases  it  is 
usually  symmetrical.  The  course  of  the  disease  is  chronic 
and  made  up  of  a  number  of  acute  exacerbations.  If  left  to 
itself  it  may  produce  a  good  deal  of  deformity,  the  tubercles 
and  pustules  breaking  down,  ulcerating  and  leaving  cicatri- 
cial tissue  and  more  or  less  baldness,  though  this  is  excep- 
tional. 

A  typical  case  of  sycosis  presents  the  following  appear- 
ance :  upon  a  single  region,  two  or  more  regions,  or  upon 
the  whole  bearded  portion  of  the  face  there  will  appear 
a  number  of  isolated  or  grouped  papules,  tubercles  and  pus- 
tules pierced  by  hairs.  The  skin  about  the  lesions  is  red- 
dened and  swollen,  it  may  be  indurated,  and  there  is  a 
slight  amount  of  crusting.  There  is  no  tendency  for  the 
disease  to  spread  to  non-hairy  parts,  but  very  commonly  the 
eyebrows  will  be  similarly  affected,  and  a  blepharitis  will  be 
present.     When  the  case  is  watched  for  a  time,  marked 


440  DISEASES    OF    THE    SKIN. 

exacerbations  will  arise  often  without  apparent  cause,  last 
for  a  few  days,  and  then  the  disease  will  sink  into  a  subacute 
condition.  When  the  disease  affects  the  vibrissa  of  the 
nose,  by  extension  from  the  upper  lip,  the  Schneiderian  mem- 
brane becomes  swollen  and  exquisitely  sensitive.  The  dis- 
ease tends  to  run  a  chronic  course,  lasting  for  years. 

Etiology.  The  etiology  of  the  disease  is  not  settled. 
It  is  not  very  common,  perhaps  one  case  in  three  or  four 
hundred.  It  is  non-contagious.  It  is  seen  in  men  almost 
exclusively,  as  we  might  expect ;  and  attacks  them  most 
frequently  between  the  ages  of  twenty-five  and  fifty.  It 
affects  all  classes  and  conditions. 

Eczema  is  often  a  forerunner  of  sycosis,  the  one  process 
passing  over  into  the  other.  A  nasal  catarrh  is  the  cause  of 
the  majority  of  cases  occurring  on  the  upper  lip.  Shaving 
with  a  dull  razor  against  a  stiff  beard  is  sometimes  an  exciting 
cause,  though  those  who  do  not  shave  are  by  no  means  ex- 
empt from  the  disease.  An  irritant  applied  to  the  skin  may 
excite  it,  such  as  exposure  to  intense  heat,  the  dust  of  a 
workshop,  cosmetics,  and  the  like.  Exposure  to  inclement 
weather  is  regarded  by  Wilson  as  the  principal  cause.  One 
of  the  worst  cases  I  have  ever  met  with  was  directly  trace- 
able to  a  poultice  applied  to  the  face  for  the  relief  of  a 
neuralgia.  Given  a  hypersemic  or  irritable  condition  of  the 
skin  of  the  face,  arising  from  any  internal  or  external  cause, 
the  hairs,  especially  if  they  are  coarse,  may  excite  the  dis- 
ease, acting  as  irritants  when  touched  or  moved. 

Hebra  thinks  that  some  cases  may  be  due  to  an  abnor- 
mality in  the  growth  of  new  hairs.  Wertheim  ascribed 
the  inflammation  to  irritation  of  the  hair  follicle  by  hairs 
whose  diameter  was,  relatively,  too  large  for  their  follicles. 
By  many  the  staphylococcus  pyogenes  is  regarded  as  the 
sole  cause. 

Pathology.  The  disease  is  primarily  a  peri-folliculitis, 
the  hair  follicles  being  affected  secondarily,  and  after  them 
the  sebaceous  glands. 

Diagnosis.  The  distinguishing  characteristic  of  sycosis 
is  the  presence  of  pustules  pierced  by  hairs.     It  must  be 


SYCOSIS. 


441 


diagnosed  from  trichophytosis  barbae,  eczema  barbae,  the  small 
pustular  syphiloderm,  acne,  and  lupus.  The  differential 
diagnosis  of  sycosis  from  trichophytosis  barbae  is  as  follows : 


Trichophytosis  Barbae. 

Begins  as  a  small  scaly  spot,  a 
superficial  ringworm,  and  grad- 
ually involves  the  deeper  parts 
of  the  hair. 

Has  its  favorite  seat  upon  the 
chin  and  the  submaxillary  re- 
gion ;  rarely  attacks  the  upper 
lip.     Often  symmetrical. 

The  eruption  consists  of  tubercles 
and  nodules  which  tend  to 
group,  and  are  studded  with  a 
number  of  hairs.  The  inter- 
nodular  portions  of  the  skin 
often  remain  unaffected. 


Sycosis. 

Begins  suddenly  with  an  out- 
break of  papules  which  soon 
become  pustules,  each  of  which 
at  the  start  involves  a  hair. 

Its  favorite  seat  is  the  upper  lip, 
and  sometimes  it  alone  is  in- 
volved. Involves  the  hairy 
portions  of  the  face  more  gener- 
ally, and  often  symmetrical. 

The  eruption  consists  of  papules 
and  pustules,  each  of  which  is 
pierced  by  a  single  hair,  and 
they  show  no  disposition  to 
group.  The  intervening  skin 
is  generally  reddened,  and  may 
be  difiusedly  infiltrated;  and 
abscesses  may  form. 

Is  a  more  superficial  inflamma- 
tion. 

Hair  diseased  secondarily,  and 
comes  away  at  first  with  diffi- 
culty,  causing  much  pain. 
Later  is  easily  removed  and  its 
root  is  swollen  with  pus. 

Subjective  symptoms  of  pricking, 
burning,  and  tension  of  the 
part.  These  are  often  intense 
and  attended  with  swelling  of 
the  face. 

Limited  in  most  cases  to  hairy 
parts  of  face.  No  tendency  to 
extend  on  non-hairy  parts  of 
face  or  neck. 

No  fungus  present. 

The  course  of  the  disease  made 
up  of  a  number  of  acute  out- 
breaks.    Liable  to  relapse. 

The  differential  diagnosis  from  eczema  of  the  beard 
cannot  be  made  with  so  much  certitude,  and  often  we  must 
remain  for  a  while  in  doubt  as  to  the  true  nature  of  the  case. 
At  times  sycosis  is  left  by  a  preceding  eczema,  and  we  may 
meet  with  a  case  in  the  transition  stage  when  a  sure  diag- 
nosis would,  manifestly,  be  impossible.  A  typical  case  of 
pustular   eczema  is  attended  by  a  far  greater  amount  of 

19* 


Is  a  deep  inflammatory  process 
so  soon  as  the  hairs  become 
affected. 

Hair  is  diseased  primarily,  and  is 
twisted,  split  and  broken.  May 
readily  be  removed  by  slight 
traction  and  without  pain.  Its 
root  is  often  dry. 

Subjective  symptoms  slight,  may 
be  only  slight  pruritus. 


Patches  of  ringworm  often  pre- 
sent on  other  parts  of  the  body, 
and  sometimes  the  disease  ex- 
tends upon  the  neck  or  face. 

Hairs  and  scales  loaded  with  the 
trichophyton  fungus. 

Is  a  progressive  disease,  and  when 
cured  not  liable  to  relapse. 


442  DISEASES    OF    THE    SKIN. 

crusting  than  is  sycosis,  and  the  crust  is  of  a  more  greenish 
or  blackish  color.  Upon  removing  the  crust  in  eczema  a 
moist  and  oozing  surface  will  be  exposed,  while  in  sycosis 
we  will  do  no  more  than  remove  the  tops  from  a  number  of 
pustules.  In  eczema  the  pustules  break  down  more  readily 
than  in  sycosis,  and  they  are  not  so  accurately  located  about 
the  hairs.  In  eczema  the  whole  surface  of  the  skin  is  in- 
volved, and  the  process  tends  to  extend  upon  non-hairy 
parts  of  the  face.  While  exceptionally  eczema  is  confined 
to  the  hairy  portion  of  the  face,  this  is  always  so  in  sycosis. 
The  duration  of  the  disease  will  at  times  help  us  to  a  diag- 
nosis, sycosis  being  far  more  chronic  than  is  eczema.  In 
syphilis,  when  the  beard  is  involved,  we  will  find  pustules 
upon  other  portions  of  the  body,  and  the  history  will  help 
us  to  a  correct  conclusion.  Further  the  pustules  or  papules 
of  syphilis  are  grouped  in  circles  and  segments  of  circles,  are 
of  a  peculiar  color,  and  their  development  is  painless  and 
comparatively  slow.  Acne  is  scattered  about  the  whole  face, 
and  is  usually  met  with  in  young  persons.  Comedones  are 
present,  and  its  papules,  pustules,  or  tubercles  have  no  defi- 
nite relation  to  the  hair.  The  course  and  history  of  lupus 
are  so  different  from  that  of  sycosis  that  it  is  hardly  possible 
for  them  to  be  confused.  In  lupus  vulgaris  we  have  the 
characteristic  brown  tubercles  which  do  not  contain  pus,  are 
not  confined  to  the  hairy  portions  of  the  face,  generally  begin 
in  early  life,  and  tend  to  ulcerate  or  to  be  absorbed  and  leave 
behind  cicatrices. 

Treatment.  The  treatment  of  sycosis  is  both  general 
and  local.  While  many  cases  will  yield  to  local  treatment 
alone,  there  are  quite  as  many,  if  not  more,  which  require 
general  treatment.  The  surroundings  of  the  patient  must 
be  inquired  into,  and  his  mode  of  life,  and  we  should  en- 
deavor to  put  him  in  as  good  a  hygienic  condition  as  possi- 
ble. He  should  be  advised  against  exposing  himself  to  dust 
and  wind,  and  then  only  with  his  face  powdered  or  protected 
with  ointment,  and  even  against  smoking,  especially  in  the 
wind  where  the  smoke  blows  against  the  face.  The  proper 
regulation  of  the  diet  is  important.  Many  cases  will  improve 
if  we  stop  their  tea,  coffee,  hot  drinks  of  all  sorts,  ale,  beer, 


sycosis.  443 

and  spirits.  If  the  digestive  process  seem  at  all  embar- 
rassed it  is  well  to  put  the  patient  on  a  light  diet  for  morn- 
ing and  evening,  and  direct  him  to  take  his  principal  meal 
at  noon,  eating  meat  only  at  that  time.  Anything  that  is 
known  to  him  to  be  indigestible  must,  of  course,  be  pro- 
hibited. In  a  word,  the  diet  and  hygiene  of  the  patient 
should  be  regulated. 

What  medicines  we  should  administer  will  depend  upon 
the  stage  of  the  disease.  In  the  acute  stage,  when  there  is 
much  swelling  and  inflammation,  a  good  dose  of  blue  pill, 
calomel,  or  some  other  active  cathartic  is  to  be  ordered,  to 
be  followed  by  an  alkaline  diuretic.  When  pustulation  is 
active  the  sulphide  of  calcium  or  calx  sulphurata  will  do 
good.  Piffard  recommends  this  very  highly,  giving  one- 
tenth  of  a  grain  two  or  three  times  a  day. 

Small  doses  of  calomel,  as  one- tenth  of  a  grain,  three  times 
a  day,  for  two  or  three  days  at  a  time,  are  useful  in  relieving 
the  congestion  of  the  skin.  In  chronic  cases  iron,  cod-liver 
oil,  and  other  tonics  are  indicated  if  there  is  a  state  of 
debility.  Arsenic  is  advised  in  very  obstinate  cases.  If 
indigestion  is  present  we  must  address  our  remedies  to  its 
relief  before  we  give  calcium,  arsenic,  or  other  remedy  for 
the  disease  proper,  and  then  will  probably  have  no  need  of 
so-called  specifics. 

The  local  treatment  must  vary  with  the  condition  found, 
whether  it  be  acute  or  subacute.  When  the  disease  attacks 
the  upper  lip,  the  nose  must  be  examined  for  evidences  of 
catarrh,  and  that  condition  treated  if  found. 

In  the  management  of  an  acute  case  of  sycosis  soothing 
remedies  are  needed.  Hot  water  should  be  sopped  on  the 
part  for  some  five  or  ten  minutes  once  or  twice  a  day,  and 
this  should  be  followed,  if  the  beard  is  growing,  by  the  use 
of  a  simple  oil,  such  as  olive  oil  or  sweet  almond  oil ;  or  if 
the  face  is  shaved,  the  zinc  oxide  ointment  or  cold  cream 
may  be  used ;  or  better  still,  Lassar's  paste,  as  follows  : 


]&.  Amyli,  \  __         ...  q 

Zinci  oxidi,  J  '       3  J  > 

Vaselini,  ad      ^j ;        32 


M. 


444  DISEASES    OF    THE    SKIN. 

Powdering  the  part  with  corn-starch,  or  bismuth  and  talc 
after  smearing  on  a  little  vaseline,  will  at  times  give  ease 
and  comfort. 

If  the  process  is  attended  by  a  good  deal  of  oedema  and 
the  inflammatory  symptoms  are  severe,  warm  poultices  will 
relieve  the  disagreeable  sensations  of  the  patient  and  reduce 
the  inflammation.  In  some  cases  cold  starch  poultices  will 
be  better  borne.  Devergie  recommends  steaming  the  inflamed 
parts  every  second  day,  and  covering  the  affected  parts  con- 
stantly with  cold,  or  almost  cold,  thin  flaxseed  poultices. 
Even  in  the  early  stage,  if  the  inflammatory  symptoms  are 
not  very  intense,  a  mild  white  precipitate  ointment  will 
sometimes  check  the  disease.  Duhring  recommends  bath- 
ing the  face  with  "  black  wash,"  followed  by  zinc  oxide 
ointment  with  a  drachm  of  alcohol  or  half  a  drachm  of  cam- 
phor to  the  ounce,  spread  on  cloths  and  bound  on;  and 
speaks  well  of  the  oxide  of  zinc  ointment  with  fifteen  to 
thirty  grains  of  calomel  to  the  ounce. 

When  the  disease  has  reached  the  pustular  stage,  and 
there  is  more  or  less  crusting,  the  crusts  are  to  be  removed 
by  the  free  use  of  olive  oil,  or  oil  of  sweet  almonds,  letting 
it  soak  in  thoroughly  over  night  and  washing  the  part  with 
soap  and  warm  water  the  next  morning.  If  the  crusts  are 
thick,  it  is  a  good  plan  to  tie  up  the  bearded  face  in  a  towel 
after  anointing  it  with  oil.  After  the  crusts  are  gotten  rid 
of,  pull  the  hairs  out  of  the  pustules,  and  insist  upon  the 
patient  shaving  himself  every  second  day.  If  plenty  of  warm 
water  and  soap  are  used,  and  a  good  lather  formed,  the 
shaving  will  not  be  very  painful,  and  it  is  only  the  first 
shave  that  is  painful.  Epilation  of  the  hair  from  all  the 
pustules  and  papules  is  to  be  continued  until  they  cease  to 
form.  Shaving  is  to  be  continued  until  some  months  after 
the  skin  is  apparently  well.  It  is  possible  to  cure  a  case 
without  shaving,  but  the  cure  will  be  more  difficult  to  effect. 
The  patient  must  be  made  to  understand  that  epilation  is 
necessary  both  for  the  cure  of  the  affection  and  the  salva- 
tion of  the  hair.  After  epilating,  the  oxide  of  zinc  ointment, 
Lassar's  paste,  or  diachylon  ointment  is  to  be  used.  Sul- 
phur in  the  form  of  an  ointment,  half  a  drachm  to  a  drachm 


sycosis.  445 

to  the  ounce,  or  in  powder  will  sometimes  do  good,  but  often 
will  prove  too  irritating.  Tilbury  Fox  recommends  the  use 
of  the  following  ointment  after  shaving  : 

R.  Zinc  oxide,         1  aa     zi-  4I 

Zinc  carbonate,  J  dJ  ' 

Eose  ointment,  ad     ^j ;        32 1         M. 

Instead  of  an  ointment  we  may  use  oxide  of  zinc,  one 
drachm  to  the  ounce  of  linseed  or  other  oil.  Shoemaker 
advises  the  application  of  equal  parts  of  oleate  of  mercury 
and  olive  oil. 

In  subacute  and  chronic  cases  a  more  active  treatment  is 
necessary.  Here  our  aim  is  not  so  much  to  allay  inflamma- 
tion as  to  stimulate  the  skin.  To  this  end  we  may  use  the 
soap  and  salve  treatment  of  Hebra,  which  renders  such  good 
service  in  chronic  cases  of  eczema.  (See  page  170.)  In 
some  cases  better  results  will  be  attained  by  the  use  of  dia- 
chylon ointment,  or  Lassar's  paste  with  ten  or  fifteen  grains 
of  salicylic  acid  to  the  ounce.  In  very  obstinate  cases  where 
there  is  much  thickening  of  the  skin,  green  soap  may  be  kept 
applied  to  the  part  like  an  ointment  When  sufficient  inflam- 
matory reaction  is  produced,  emollient  measures,  as  in  the 
acute  stage,  should  be  used. 

Our  success  in  treating  these  cases  will  vary  with  the 
thoroughness  with  which  the  dressings  are  applied.  All 
ointments  must  be  spread  on  cloths,  not  on  the  skin,  and  the 
dressings  must  be  kept  continuously  in  close  contact  with  the 
affected  part.  Sometimes  a  sulphur  ointment,  one-half  a 
drachm  to  two  drachms  to  the  ounce ;  an  ointment  of  iodide 
of  sulphur ;  the  ointment  of  the  ammoniate  (gr.  xv-xxx  ad 
5j),  or  the  nitrate  (3j-ij  ad  5j),  or  the  red  oxide  (gr.  v-xv 
ad  5j)  of  mercury  will  prove  useful.  Robinson  recommends 
the  following  ointment : 

Be .  Ungt.  diachyli  (Hebra)  \ 
Ungt.  zincioxidi,  j 

Ungt.  hydrarg.  ammon., 
Bismuth,  subnitrat.,  5Jss;       51         M. 

He  has  found  cod-liver  oil  the  best  local  application  in 
strumous   subjects.      Veiel,  in    Ziemssen's  Encyclopaedia, 


ijss; 

50 

3HJ; 

3  Jss  ; 

5 

aa 

10 

o 

a  a 

20| 

446  DISEASES   OF    THE    SKIN. 

advises  painting  the  affected  parts  twice  a  day  with  a  two 
per  cent,  solution  of  pyrogallol  in  alcohol,  and  applying 
during  the  night. — 

]je .  Sulphur,  lact.  ^ 

Alcohol.,  >-  aa    30 

Aquse  rosse,      J 

Mucilag.  gum.  acacise,  TTlxx-xxx ;  M. 

Hans  v.  Hebra's  plan  of  treatment  is  to  epilate  and  shave, 
and  then  with  a  stiff  brush  to  rub  in  once  or  twice  a  day 
some  of  the  following  ointment : 

R.Ol.fagi,        I 
Flor.  sulph.,  J 
Pulv.  cretse  alb., 
Adipis,  \ 

Sapo.  viridis,  J  M 

Cover  with  flannel.  Devergie  recommends  painting  the 
part  every  four  or  five  days  with  a  solution  of  nitrate  of 
silver,  one  part  in  five  of  water,  by  weight. 

Behrend  has  obtained  good  results  by  scraping  the  affected 
parts  with  the  dermal  curette  and  dressing  with  a  simple 
ointment  or  oil.  All  abscesses  must  be  opened.  In  some 
cases  the  following  ointment  has  given  me  satisfaction  after 
other  combinations  have  failed 

& .  Hydrarg.  sulph.  rubri,  5 

Sulph  sublimat.  12 

Adipis,  ad     50 

01  bergamot.  q.  s  M. 

To  be  kept  on  constantly. 

Solutions  of  the  bichloride  of  mercury,  1  in  1000  ;  or  of 
resorcin  in  alcohol  5  per  cent,  strength,  after  shaving,  may 
be  used . 

Kaposi  recommends  the  following  : 

]&.  /?-naphthol.,  1 

Spt.  sapo.  viridis,  25 

Alcoholis,  50 
Bals.  peruv.,  2 

Sulph.  loti,  10         M. 

Boric  acid,  salicylic  acid,  and  numerous  other  reme- 
dies seem  to  do  good  in  some  cases.     To  assure  against  a 


SYPHILIS.  447 

relapse  it  is  necessary  to  continue  shaving  and  making 
applications  to  the  skin  for  four  or  five  months  after  ap- 
parent recovery. 

Prognosis.  This  is  one  of  the  most  obstinate  of  diseases. 
Left  to  itself,  when  once  under  headway  it  shows  no  tend- 
ency to  get  well,  and  has  been  known  to  last  twenty  or 
thirty  years.  Even  under  the  most  judicious  treatment  it  is 
an  obstinate  disease,  taking  weeks  or  months  before  a  cure 
is  effected.  Relapses  are  exceedingly  liable  to  occur,  and 
these  sometimes  show  a  disposition  to  recur  at  certain  sea- 
sons. Unless  the  hair  is  carefully  withdrawn  from  the 
inflamed  follicles  permanent  baldness  may  be  caused.  But 
the  disease  is  not  dangerous  to  life,  and  it  is  curable. 

Sycosis  Contagiosa.     See  Trichophytosis  barbae. 
Sycosis  Non  Parasitaria.     See  Sycosis. 
Sycosis  Parasitaire.     See  Trichophytosis  barbae. 
Sycosis  Parasitaria.     See  Trichophytosis  barbae. 
Sycosis  Parasitica.     See  Trichophytosis  barbae. 

Syphilis  *  (Si2f  i2l-i2s).  Synonyms  :  Malum  venereum  ; 
Lues ;  Morbus  Gallicus,  seu  Italicus,  seu  Hispanicus,  seu 
Neapolitanus,  seu  Indicus ;  (Fr.)  Verole,  or  Grosse  verole  ; 
(Ger.)  Lustseuche ;  (Eng.)  Bad  disorder,  Pox. 

Whole  books  have  been  written  upon  this  disease.  Here 
we  can  only  give  a  brief  outline  of  the  disease,  and  that  as  it 
affects  the  skin  alone.  For  a  further  account  of  the  disease 
the  reader  should  consult  the  larger  special  treatises. 

Symptoms.  Syphilis  may  be  acquired  or  hereditary. 
It  is  acquired  by  local  infection,  the  first  manifestation  of 
which  is  the  appearance  of  the  initial  lesion,  commonly 
called  the  chancre  or  hard  sore.  In  probably  ninety  per  cent, 
of  the  cases  this  initial  lesion  is  located  on  the  genitals,  and 

1  In  the  description  of  the  syphilides  I  have  followed  very  closely 
those  given  by  Prof.  G.  H.  Fox,  in  his  Photographic  Illustrations  of 
Skin  Diseases,  Treat,  N.  Y. ;  and  by  Prof.  E.  W.  Taylor  in  Bumstead 
and  Taylor's  Pathology  and  Treatment  of  Venereal  Diseases,  Lea, 
Philadelphia,  5th  ed.  1883.  To  both  of  these  gentlemen  I  would  ex- 
tend my  grateful  thanks  for  the  permission  to  use  their  books  that  was 
so  graciously  granted  to  me. 


448  DISEASES    OF    THE    SKIN. 

in  the  vast  majority  of  these  its  site  in  males  is  the  glans  and 
prepuce.  But  the  initial  lesion  may  be  found  on  any  part 
of  the  body,  and  within  the  mucous  cavities.  According 
to  a  table  of  one  hundred  and  ninety-eight  extra-genital 
lesions  compiled  by  Pospelow,1  the  female  breasts  were 
affected  in  sixty-nine  cases ;  the  lips  in  forty-nine  cases  ;  the 
throat  in  forty-six  cases  ;  and  then  in  very  much  less  fre- 
quency the  gums,  tongue,  chin,  eyelids,  nose,  trunk,  anus, 
arms,  and  legs.  Some  obscure  cases  of  syphilis  are  due  to 
the  initial  lesion  being  in  the  urethra  or  upon  the  cervix 
uteri  and  thus  having  escaped  detection. 

The  initial  lesion  appears  within  two  to  six  weeks  after 
inoculation  with  the  syphilitic  poison;  usually  the  interval  is 
less  than  four  weeks ;  exceptionally  it  may  be  ten  weeks. 
This  is  the  period  of  incubation.  Opinions  are  divided  as 
to  whether  the  initial  lesion  is  a  purely  localized  lesion,  or 
the  expression  of  a  general  constitutional  infection  that  first 
declares  itself  at  the  point  of  inoculation.  It  appears  to  me 
that  the  weight  of  the  argument  is  altogether  on  the  side  of 
the  last  opinion.  The  initial  lesion  may  assume  the  form  of 
a  scaly  patch,  a  dry  or  moist  papule,  a  superficial  erosion,  or 
a  circumscribed  ulcer  with  perpendicular  edge.  Induration 
of  the  base  is  a  characteristic  of  all  forms  of  initial  lesion  ; 
it  is  sharply  defined  and  imparts  to  the  fingers  a  distinct 
resistance  that  may  be  as  firm  as  cartilage.  Commonly  it 
is  parchment-like.  To  detect  it,  the  lesion  must  be  gently 
pinched  between  the  thumb  and  finger.  It  is  present  coin- 
cidently  with  the  appearance  of  the  initial  lesion  or  within  a 
few  days  afterward.  It  remains  for  a  long  time  after  the 
disappearance  of  the  lesion — for  two  or  three  months  or 
longer.  The  secretion  from  the  initial  lesion,  when  present, 
is  thin  and  chiefly  serous.  The  duration  of  the  lesion  is 
variable  ;  it  may  disappear  before  the  outbreak  of  cutaneous 
symptoms,  but  very  often  remains  for  some  time  after  this 
event.  Unless  there  has  been  ulceration,  no  cicatrix  will  be 
left.  It  may  leave  a  staining  of  the  skin  or  an  induration. 
It  is  usually  a  solitary  lesion,  though  it  may  be  multiple. 

1  Arch.  f.  Dermat.  u.  Syph.,  1889,  Hefte  1  u.  2. 


SYPHILIS.  449 

Enlargement  of  the  nearest  lymphatic  glands  accompanies 
the  initial  lesion.  If  on  the  external  genitals,  it  will  be  those 
of  one  or  both  groins.  They  become  hard,  and  are  painless 
and  freely  movable.  Suppuration  is  rare,  and  probably  the 
result  of  mixed  infection.  A  pleiad  of  glands,  three  arranged 
in  a  triangle,  is  quite  characteristic  of  syphilitic  infection. 

The  initial  lesion  may  at  first  assume  the  character  of  the 
soft  sore.  This  is  the  result  of  mixed  infection  with  both 
the  virus  of  syphilis  and  the  local  venereal  ulcer.  The  ulcer 
will  after  a  while  become  indurated  and  assume  its  proper 
characteristics.  It  is  in  these  cases  that  a  suppurating 
adenitis  may  develop.  Modifications  from  location  of  the 
initial  lesion  must  also  be  noted.  1.  Of  the  urethra.  These 
may  be  at  the  meatus,  in  the  fossa  navicularis,  or  deeper 
parts.  Those  at  the  meatus  attract  attention  by  causing  a 
slight  impediment  to  urination.  The  lips  are  found  glued 
together  by  a  scanty,  viscid  secretion.  The  normal  opening 
of  the  urethra  becomes  lessened  by  the  induration  which 
usually  involves  the  entire  circumference  of  the  meatus. 
Those  deeper  down  may  give  rise  not  only  to  interference  with 
urination,  but  also  to  some  pain,  and  later  to  a  muco-purulent 
or  purulent  discharge  like  that  of  gonorrhoea,  because  they 
cause  a  urethritis.  They  may  be  felt  as  a  hard,  tender, 
circumscribed  nodule,  and  be  seen,  with  the  endoscope,  as  a 
grayish-red  erosion  of  the  urethral  wall.  They  may  give 
rise  to  symptoms  of  stricture.  2.  Of  the  anus.  These 
may  be  without  the  anus,  at  its  margin,  or  within  the  anal 
ring,  and  usually  present  a  thickened,  fissured,  ulcerated 
surface.  They  are  of  a  pale  rose  tint,  and  decidedly  indu- 
rated. 3.  Of  the  fingers.1  They  may  be  seated  at  any  part 
of  the  phalanges,  but  most  often  are  at  the  sides  or  base  of 
the  nail,  or  at  its  free  margin.  They  begin  as  a  papule, 
pustule,  excoriation  or  fissure,  and  attract  attention  as  an 
obstinate  hang-nail  or  fissure,  and  we  find  an  irregular,  deep- 
red,  somewhat  elevated  mass  that  is  ulcerated  and  covered 
with  a  scanty,  serous  secretion.     The  finger  is  apt  to  be 

1  An  admirable  study  of  these  lesions  by  Dr.  R.  W.  Taylor  will  be 
found  in  the  Medical  Record,  1891,  xxxix.  69. 


450  DISEASES    OF    THE    SKIN. 

swollen  at  its  end.  The  epitrochlear  and  axillary  ganglia 
are  enlarged,  and  there  may  be  moderate  lymphangitis.  4. 
Of  the  lip.  They  are  usually  covered  with  a  greenish 
brown  crust  which,  when  removed,  leaves  either  an  erosion  of 
little,  if  any,  hardness,  or  an  ulceration  of  cartilaginous  con- 
sistence. The  lips  may  be  greatly  swollen.  They  may 
begin  as  a  fissure,  or  painful  excoriation.  The  lips  are 
nearly  equally  affected,  but  usually  only  one.  The  sub- 
maxillary glands  on  the  side  of  the  lesion  are  usually  first 
affected.  5.  Of  the  tongue.  Here  we  meet  with  hard  cir- 
cumscribed, flat,  slightly  elevated,  dull  red,  smooth,  pea-size 
nodules ;  or  a  round,  sharply  defined,  fleshy  red,  raised, 
hard  ulcer.  The  cervical  and  submaxillary  glands  are  en- 
larged. 6.  Of  the  throat.  The  patient  first  notices  diffi- 
culty or  pain  in  swallowing,  the  latter  in  the  region  of  the 
tonsils.  Then  the  submaxillary  and  cervical  glands  become 
swollen.  Examination  shows  an  intense,  limited  or  diffused, 
general  or  unilateral,  brown  or  dark  redness  of  the  pharynx. 
The  tonsils  are  enlarged,  hard,  and  red,  and  may  be  eroded 
and  perhaps  covered  with  an  ash-colored  deposit,  a  false 
membrane.  Or  we  may  find  an  irregular,  hard  ulcer  with 
gnawed- out  edges,  and,  may  be,  crater-shaped  floor  covered 
with  dirty-brown  or  grayish  deposit.  One  or  both  tonsils 
may  be  affected.  7.  Of  the  nipple.  These  are  usually  mul- 
tiple, and  may  take  the  form  of  an  erosion,  a  scaly  patch,  or 
an  indurated  fissure.  The  size  varies  from  that  of  a  lentil 
up  even  to  three  inches  in  diameter.  They  are  sometimes 
linear,  sometimes  sickle-shaped  along  one  side  of  the  nipple, 
and  sometimes  completely  encircling  the  nipple.  The  nipple 
isred,  or  dark  red,  enlarged,  hardened,  and  at  times  flattened. 
Mastitis  may  complicate  matters.  The  axillary  glands  are 
enlarged,  as  are  often  those  along  the  upper  edge  of  the 
pectoralis  major.  On  healing,  the  initial  lesion  leaves  a 
flattening  of  the  nipple,  and  perhaps  a  leaning  of  it  to  one 
side,  characteristics  that  should  put  us  on  our  guard  in  the 
examination  of  wet-nurses. 

About  six  weeks  after  the  appearance  of  the  initial  lesion 
(it  may  be  as  early  as  the  twenty-fifth  day,  or  as  late  as  the 
one  hundred  and  sixtieth),  we  have  the  stage  of  eruption  of 


SYPHILIS.  451 

the  so-called  secondary  syphilides.  Usually,  just  before  the 
outbreak  of  the  eruption,  examination  will  show  a  general 
enlargement  of  the  lymphatic  glands,  especially  the  epi- 
trochlear  and  post-cervical.  At  the  time  of  the  eruption, 
or  shortly  before,  the  patient  will  experience  certain  con- 
stitutional disturbances  such  as  severe  headache,  malaise, 
pains  in  the  joints,  and  a  rise  of  temperature  of  moderate 
extent.  In  very  many  cases  these  disturbances  either  do 
not  exist,  or  are  of  so  slight  severity  as  not  to  attract  the 
patient's  notice.  In  some  cases  a  more  or  less  profound 
anaemia  will  manifest  itself,  or  the  patient  will  fall  into  a 
markedly  cachectic  condition.  Either  of  these  may  last  far 
into  the  secondary  period  of  the  disease.  Weakly  individuals 
are  more  prone  to  these  severe  constitutional  derangements 
than  are  the  robust,  and  Fournier  teaches  that  they  are  most 
apt  to  appear  in  women. 

The  eruptions  of  syphilis  are,  for  convenience,  divided 
into  two  groups  named,  respectively,  secondary  syphilides 
and  tertiary  syphilides  ;  or  the  early  and  late  lesions.  No 
hard  and  fast  lines  can  be  drawn,  as  sometimes  those  lesions 
usually  seen  late  in  the  disease  manifest  themselves  early  in 
its  course.  The  secondary  syphilides  are  those  that  develop 
during  the  first  two  years  after  infection.  They  are  marked 
by  a  more  or  less  general  and  symmetrical  dissemination 
over  the  whole  cutaneous  surface ;  by  polymorphism  ;  by 
running  a  rather  definite  course ;  by  implicating  the  more 
superficial  parts  of  the  skin  and  mucous  membranes ;  and 
by  leaving  little,  if  any,  trace  of  themselves.  In  these  re- 
spects they  differ  from  the  lesions  of  late  syphilis,  which  are 
grouped  and  limited  to  certain  regions  ;  are  not  polymorphic ; 
show  less  tendency  to  run  a  definite  course,  involve  the 
deeper  structures,  and  are  prone  to  leave  permanent  scars. 

The  eruptions  of  secondary  syphilis  are  the  erythematous, 
the  papular,  and  the  pustular  syphilide.  The  first  eruption 
of  the  secondary  stage  is  an  erythematous  one,  the  macula?* 
syphilide,  or  the  syphilitic  roseola.  Unlike  other  syphilides 
which  are  all  largely  composed  of  new  cell  growth,  this  may 
be  a  hyperemia  without  cell  infiltration.  It  may  be  a  general 
eruption,  though   generally  most  marked  upon  the  trunk 


452  DISEASES   OF    THE    SKIN. 

and  flexor  aspects  of  the  limbs.  The  macules  are  about  the 
size  of  a  ten-cent  piece,  or  smaller,  of  a  faint  rose-red  color, 
circular  in  form,  and  little,  if  at  all  raised  above  the  skin. 
At  times  we  meet  with  annular  lesions  from  disappearance 
of  the  centre  of  the  macule.  The  lesions,  excepting  in  re- 
lapsing eruptions,  are  distinct  from  each  other.  They  be- 
come more  evident  on  exposure  to  cold,  it  being  no  uncom- 
mon thing  to  see  them  appear  upon  the  patient's  body  while 
he  is  before  us  stripped  for  examination.  After  being  out 
for  a  time  their  color  becomes  purplish-red,  changing  to  a 
tawny  or  yellowish-red,  and  later  to  a  brownish-yellow.  In 
their  early  stage  they  can  be  made  to  disappear  on  pressure. 
They  either  disappear,  and  leave  either  no  trace  or  some  pig- 
mentation, or  they  develop  into  papules.  They  often  coexist 
with  papules  and  pustules.  Their  evolution  usually  requires 
a  week  or  ten  days ;  sometimes  it  may  appear  very  rapidly. 
It  runs  a  course  of  one  or  three  months  if  not  removed  by 
treatment.  Relapses  occasionally  occur,  and  these  may  be 
met  with  as  late  as  the  end  of  the  first  year.  Then  it  is  usu- 
ally limited  to  certain  regions.  It  gives  rise  to  no  incon- 
venience, and  is  often  overlooked  by  the  patient  except  when 
it  appears  on  the  face  or  hands.  At  this  time  there  is  apt  to 
be  an  erythematous  condition  of  the  pharynx,  some  sore- 
throat,  a  rheumatoid  affection  of  the  joints,  falling  of  the  hair, 
and,  perhaps,  an  iritis,  and  mucous  patches  in  the  mouth, 
upon  the  vulva,  in  the  groin,  upon  the  scrotum  and  under 
surface  of  the  penis,  and  about  the  anus. 

While  the  diagnosis  is  easy,  if  we  have  seen  the  patient 
from  the  time  of  the  initial  lesion,  in  some  cases  we  must 
differentiate  between  it  and  mottling  of  the  skin  ;  an  ex- 
anthem  ;  a  medicinal  eruption ;  chromophytosis  ;  and,  if  we 
have  annular  macules,  trichophytosis  corporis.  From  mot- 
tling of  the  skin  it  is  diagnosed  by  the  fact  that  in  syphilis 
we  have  macules  of  a  reddish  tint,  interspersed  with  skin  of 
normal  hue,  while  in  mottling  we  have  light  macules  with  dull 
purplish-red  interspaces.  From  an  exanthematous  fever  it 
is  diagnosed  by  the  absence  of  catarrhal  or  gastric  symptoms, 
and  marked  pyrexia,  and  by  the  sluggish  character  of  its 
lesions.     From  a  medicinal  eruption  it  is  diagnosed  by  an 


SYPHILIS,  453 

absence  of  high  fever  and  gastric  disturbance,  and  by  its 
lesions  lacking  the  urticarial  or  oedematous  character.  From 
chromophytosis  it  differs  in  having  a  red  rather  than  a  cafe- 
au-lait  color,  by  not  being  scaly  nor  capable  of  removal  by 
scraping,  by  it.s  more  extensive  distribution,  and  by  the  ab- 
sence of  the  microsporon  furfur  from  the  scales  when  they 
are  examined  under  the  microscope.  From  trichophytosis 
it  differs  in  the  greater  extent  of  its  distribution,  and  the 
absence  of  the  trichophyton  fungus  from  scales  scraped 
from  the  skin.  From  pityriasis  rosea  the  differentiation  is 
sometimes  difficult  when  the  syphilitic  macules  have  assumed 
a  ring  form.  As  a  rule,  there  is  no  difficulty  as  a  pityriasis 
rosea  will  be  scaly,  and  will  present  not  only  rings  but 
macules  of  all  sizes,  while  the  syphilitic  macules  are  not 
scaly,  and  are  of  more  uniform  size. 

The  papular  syphilids,  while  usually  following  the  ery- 
thematous syphilide,  may  be  the  first  eruption  of  the  disease. 
Indeed,  a  great  many  cases  begin  as  a  maculo-papular  erup- 
tion. The  papules  may  develop  from  macules,  or  may  appear 
as  papules.  Very  commonly  both  macules  and  papules  will 
be  present  at  the  same  time.  If  it  follows  the  macular 
form  it  is  apt  to  appear  while  the  latter  is  fading.  The 
eruption  appears  as  a  greater  or  lesser  number  of  firm, 
rounded,  fleshy,  red  elevations  of  the  skin  varying  in  size 
from  a  pin's  head  to  one  inch  in  diameter.  After  continu- 
ing unchanged  for  a  certain  time  they  undergo  absorption  ; 
the  oldest  or  central  part  of  the  papule  disappears  first,  sinks 
in  a  little,  and  becomes  scaly.  It  is  then  that  slight  pruri- 
tus is  complained  of.  They  are  scattered  over  the  whole 
cutaneous  surface,  and  often  appear  in  well-marked  groups. 
They  are  prone  to  relapses,  and  sometimes  are  seen  as  a 
relapsing  eruption  in  the  tertiary  stage  of  the  disease,  when 
they  do  not  occur  as  a  general  eruption,  but  in  groups  upon 
one  or  more  regions  of  the  body.  According  to  their  size 
they  have  received  the  names  of  the  lenticular  and  miliary 
papular  syphilide,  the  former  being  the  larger  and  most 
common  eruption. 

The  lenticular  papular  syphilide  has  hemispherical  or 
flattened  lesions  forming  firm,  fleshy,  lentil  to  split-pea  sized 


454  DISEASES    OF    THE    SKIN. 

prominences  with  a  smooth  and  glossy  surface.  Not  infre- 
quently the  superficial  layer  of  epidermis  over  them  is  want- 
ing from  the  central  portion,  and  slightly  detached  around 
the  base,  forming  a  fringe  called  the  collarette  of  Biett. 
This  is  regarded  as  a  diagnostic  symptom.  The  color  of 
the  papules  is  at  first  light-red  ;  later  it  assumes  a  raw-ham 
color,  that  is  best  seen  on  the  legs.  From  the  knee  down 
they  may  have  a  purplish  or  hemorrhagic  appearance.  They 
are  usually  present  in  great  number  and  scattered  over  the 
whole  body.  On  the  face  they  are  apt  to  locate  along  the 
hair  line  on  the  forehead,  forming  the  corona  veneris.  On 
the  scalp  they  are  not  very  numerous,  and  are  apt  to  become 
papulo-pustules  and  crust ;  or  they  itch  slightly  and  are 
scratched.  The  palms  and  soles  are  usually  well  covered  in 
any  general  outbreak  of  them.  Here  they  appear  as  red- 
dish spots  under  the  thick  epidermis.  Desquamation  is  often 
seen  over  the  papules  in  the  palms  and  soles.  Sometimes 
the  eruption  is  very  slight  in  extent,  only  a  few  scattered 
papules  being  found.  This  syphilide  develops  slowly,  runs 
a  course  of  one  or  two  months,  and  disappears,  leaving  pig- 
mentation or  slightly  depressed  spots,  both  of  which  are  not 
permanent.  In  undergoing  resolution  they  may  become 
scaly  and  form  a  papulo-squamous  syphilide,  or  pustules 
may  form  on  them  during  their  course,  and  we  then  have 
the  papulo-pustular  syphilide. 

While  the  form  of  lenticular  syphilide  just  described  is 
the  typical  one,  we  see  at  times  larger  papules,  from  three- 
eighths  to  half  an  inch  in  diameter,  forming  the  large  flat 
papular  syphilide.  This  rarely,  if  ever,  forms  a  general 
eruption,  but  is  limited  to  certain  regions.  It  may  occur 
alone  or  with  the  lenticular  syphilide.  It  usually  follows 
the  latter  or  appears  when  it  is  fading.  It  frequently  comes 
as  a  relapsing  syphilide,  and  often  appears  late  in  the  second 
year.  It  has  a  flattened  surface  and  a  circular  outline. 
They  often  coalesce  and  form  patches  which  frequently 
become  scaly  and  resemble  psoriasis.  The  scaling  is 
never  very  great  ;  the  scales  are  thin  and  adherent,  and 
do  not  cover  the  whole  patch.  They  frequently  occur  upon 
the  flexor  aspect  of  the  extremities,  and  in  the  bends  of  the 


SYPHILIS. 


455 


joints.  Instead  of  forming  patches  by  coalescence  the  indi- 
vidual papule  may  enlarge  at  the  circumference  and  become 
depressed  at  the  centre  and  form  circinate  lesions,  whose 
surface  may  become  moist. 

The  moist  papule  or  mucous  patch  is  a  modified  form 
of  the  lenticular  papule,  and  is  simply  a  papule  subject 
to  heat  and  moisture.  They  are  found  where  two  folds  of 
skin  rub  together,  as  in  the  peno-scrotal  fold,  between  the 
scrotum  and  inside  of  the  thigh,  around  the  anus  and  vulva, 
and  upon  mucous  membranes.  They  are  of  circular  shape 
and  have  a  flattened  surface  which  is  sometimes  depressed 
in  the  centre.  Fresh  ones  have  a  bright-red  or  raw  appear- 
ance, but  they  soon  become  covered  with  a  dirty  whitish 
coating  made  up  of  thickened  and  softened  epidermis.  About 
the  anus  and  vulva  they  form  large  flattened  tubercles 
called  condylomata   lata.     (JFig.   42.)     They  give  forth  a 

Fig.  42. 


Condylomata  lata.     (After  Taylor.) 


most  sickening  odor  when  not  kept  clean.  When  in  the 
mouth  they  form  "  opaline  patches,"  looking  as  if  the  mu- 
cous membrane  had  been  pencilled  with  nitrate  of  silver. 
They  are  usually  not  elevated.  If  at  the  angle  of  the  mouth 
they  are  generally  fissured.  The  mucous  patch  is  one  of 
the  most  contagious   of  syphilitic  lesions,    the  evidence  of 


456  DISEASES    OF    THE    SKIN. 

infection  being  an  initial  lesion  of  syphilis,  and  not  a  mucous 
patch. 

The  miliary  papular  syphilide  is  much  rarer  than  the 
other  form  of  papular  syphilide  ;  in  fact,  is  one  of  the  least 
common  of  the  syphilides.  It  consists  of  numerous  pin- 
head  or  slightly  larger  sized  conical  papules  of  a  purplish- 
red  hue,  either  disseminated  over  the  whole  body  or  aggre- 
gated in  groups  forming  circles  or  segments  of  circles.  They 
are  developed  about  the  hair  follicles  and  have  depressed 
centres.  Many  of  them  may  be  surmounted  by  small  vesi- 
cles or  vesico-pustule.  This  constitutes  what  has  been 
named  the  vesicular  syphilide.  Sometimes  the  lesions  when 
closely  pressed  into  patches  may  be  scaly.  It  may  be  an 
early  lesion  or  a  relapsing  later  one.  In  the  latter  case  the 
eruption  is  not  abundant,  but  in  groups.  The  color  is 
brownish-red,  and  pigmentation  and  permanent  pitting  are 
left  by  them,  if  they  have  lasted  any  time.  They  rarely 
change  into  condylomata.  Their  evolution  is  rapid,  being 
fully  developed  within  two  weeks.  Pea-sized  conical  papules 
sometimes  are  seen  amongst  the  miliary  ones. 

The  diagnosis  of  the  papular  forms  of  syphilis  is  generally 
easy  because  other  symptoms  of  the  disease  will  be  sure  to 
be  present  and  to  establish  the  diagnosis.  It  is  possible 
that  error  may  arise  in  distinguishing  the  patches  of  scaling 
papules  from  psoriasis,  but  here  the  location  of  the  patches 
upon  the  flexor  surfaces  of  the  extremities,  and  over  the 
bends  of  the  elbows ;  the  scaling  not  being  commensurate 
with  the  patch,  but  having  a  red,  sharply  defined  border 
about  it ;  and  the  well-marked  infiltration  of  the  patches  are 
all  features  that  would  throw  out  the  diagnosis  of  psoriasis. 
The  miliary  papular  syphilide  may  be  confounded  with 
lichen  planus  or  keratosis  pilaris,  but  the  absence  of  itching 
is  always  in  favor  of  a  syphilide,  and  the  conical  or  rounded 
shape  of  its  papules  is  in  strong  contrast  with  the  flat, 
angular,  and  umbilicated  papule  of  lichen  planus.  The 
syphilide  is  also  a  much  more  widely  disseminated  eruption 
than  is  lichen  planus  or  keratosis  pilaris  likely  to  be. 

The  pustular  syphilide  is  the  last  eruption  belonging  to 
the  secondary  stage  that  remains  to  be   described.      It  is 


SYPHILIS.  457 

always  evidence  of  a  poor  condition  of  the  health  of  the  pa- 
tient who  bears  it.  It  may  be  the  first  eruption  of  syphilis, 
or  follow  the  erythematous  or  papular  form,  or  occur  later. 
It  may  develop  from  a  macular  or  papular  syphilide,  or  occur 
with  either  of  them.  It  may  assume  varying  forms  and 
sizes  to  which  in  the  faulty  nomenclature  of  the  older  writers, 
have  been  given  the  names  of  non-specific  lesions,  greatly  to 
the  confusion  of  the  student.  Prof.  Geo.  H.  Fox  has  done 
well  in  discarding  all  such  terms,  and  in  describing  two  forms 
as  the  lenticular  and  miliary  pustular  syphilide. 

The  lenticular  pustular  syphilide  (variola-form)  occurs  as 
a  disseminated  eruption  of  small,  hemispherical,  pea-sized 
pustules,  having  a  hard,  papular  base  and  more  or  less  of  an 
inflamed  areola.  It  may  develop  by  the  softening  up  of  a 
papule,  or  be  a  papulo-pustule  from  the  start.  In  the  latter 
case  its  outbreak  will  be  marked  by  fever,  which  is  apt  to 
recur  with  each  succeeding  outbreak.  The  eruption  may  be 
general,  or  upon  certain  regions.  The  lesions  are  discrete, 
and  do  not  form  marked  groups,  although  in  the  pustular 
eruptions,  as  in  others,  it  is  easy  for  one  who  looks  for  it  to 
find  groupings  in  circles  and  segments  of  circles.  A  few 
days  after  they  appear  they  begin  to  desiccate,  and  the  larger 
ones  may  umbilicate.  At  this  stage  they  become  crusted 
with  a  dirty-yellow,  brownish,  or  greenish-brown  crust. 
This  falls  soon  and  leaves  a  transient  pitting  and  pigmenta- 
tion.    Relapses  may  occur. 

The  miliary  pustular  syphilide  (acne  form).  This  erup- 
tion consists  of  millet- seed  to  pinhead-sized  acuminate  pus- 
tules developing  generally  from  papules  and  occurring  in 
small  groups  of  about  the  size  of  a  quarter  or  half  dollar. 
It  may  occur  as  a  general  eruption,  but  is  apt  to  be  more 
marked  and  lasting  on  the  extremities  than  on  the  trunk. 
The  lesions,  especially  when  occurring  upon  the  flexor  aspect 
of  the  joints,  are  liable  to  coalesce.  They  are  developed  in 
and  around  the  hair  follicles,  and  may  be  perforated  by 
hairs.  They  are  topped  with  small  crusts.  The  eruption 
lasts  two  or  three  months  by  the  outbreak  of  new  lesions, 
unless  controlled  by  treatment.  They  leave  pigmentation 
and  pitting  that  may  remain  for  several  months. 

20 


458 


DISEASES    OF    THE    SKIN. 


While  these  are  the  two  chief  varieties  of  the  early  pustu- 
lar syphilide,  there  is  another  variety  that  is  called  the  im- 
petigo-form syphilide,  and  occurs  most  commonly  in  the 
middle  or  latter  part  of  the  first  year  of  syphilis.  It  may 
occur  as  late  as  in  the  third  year.  In  it  the  pustules  are 
small  and  flat,  and  by  confluence  an  impetiginous  crust  is 
produced.  They  may  form  patches  with  crusting  only  at  the 
border.  This  form  is  met  with  usually  on  the  face,  arms, 
and  thighs.  A  few  superficial  ecthymatous  lesions  may 
develop,  but  ecthymatous  lesions  are  usually  late  manifes- 
tations. 

The  diagnosis  of  the  pustular  syphilis  is  usually  easy 
from  the  presence  of  other  symptoms  of  the  disease.  The 
lenticular  form  may  be  mistaken  for  variola  or  varioloid. 
It  differs  from  these  in  the  infiltrated  bases  of  the  pustules, 
in  being  composed  of  lesions  of  varying  size  and  age,  in  not 
occurring  in  the  mouth,  and  in  not  running  a  definite  rapid 
course.  The  miliary  form  might  be  mistaken  for  acne,  but 
it  is  never  confined  to  the  face,  chest,  and  back  as  is  acne, 
nor  does  it  present  comedones,  and  so  great  multiformity  of 
lesions. 

Tertiary  Syphilides.  The  erythematous,  papular,  and 
pustular  syphilides  are  those  eruptions  that  occur  in  the 
early  months  of  syphilis,  and  during  the  first  year.  As  we 
have  seen,  they  may  also  constitute  relapsing  eruptions  later 
in  the  disease.  Modifications  of  them  may  occur  late  m  the 
secondary  period  or  even  in  the  tertiary  period.  Besides 
these,  we  have  a  second  group  of  syphilides  that  occur  any 
time  after  the  first  year,  and  sometimes  as  late  as  twenty  or 
more  years  after  the  initial  lesion,  when  the  patient  may 
have  lost  all  remembrance  of  it.  To  these  eruptions  the 
name  of  tertiary  or  late  syphilides  is  given.  Their  peculiari- 
ties have  been  indicated  in  a  general  way  when  writing  of 
the  early  syphilides.  They  are  the  tubercular,  the  squa- 
mous, the  pustulo-crustaceous,  the  gummatous,  and  the 
ulcerative  syphilides. 

The  tubercular  syphilide  occurs  in  the  latter  part  of  the 
second  year  of  syphilis,  or  later.  Exceptionally  it  may  occur 
during  the  first  year  as  a  so-called  precocious  syphilide.    As 


SYPHILIS. 


459 


a  rule,  the  early  syphilides  cease  appearing  after  six  or  seven 
months,  and  then  after  a  varying  interval  of  rest  the  late 
lesions  appear.  These  may  .never  come  at  all,  usually  as 
the  result  of  judicious  treatment,  or  it  may  be  because  of  the 
vigorous   resistance  of  the  constitution  of  the  individual. 

Fig.  43. 


Annular  tubercular  syphilide.     (After  Taylor.) 


Tubercular  lesions  occur  in  the  form  of  clustered  nodules  in 
the  deeper  parts  of  the  corium.  At  first  they  are  of  faint 
red  color ;  gradually  they  become  a  dull  red,  and  later,  still 
darker.  In  size  they  vary  from  that  of  a  split-pea  to  that  of 
a  hazel-nut,  and  constitute  firm,  elastic,  fleshy  protuberances. 
They  are  round,  smooth,  and  somewhat  glossy,  or  flat,  rugous, 


460  DISEASES    OF    THE    SKIN. 

and  withered.  They  are  frequently  scaly.  Most  often  they 
are  arranged  in  circles  or  segments  of  circles  ;  or  they  may 
be  in  the  form  of  rings  from  the  first,  or  in  consequence  of 
the  disappearance  of  the  central  members  of  the  group. 
(Fig.  43.)  There  may  be  but  a  single  group ;  or  numerous 
groups  may  be  scattered  over  the  body  in  a  symmetrical 
manner.  A  very  frequent  location  for  them  is  the  posterior 
portion  of  the  neck,  or  the  face.  The  later  in  the  course  of  the 
disease  they  occur,  the  more  apt  they  are  to  form  but  a  single 
group.  If  uninfluenced  by  treatment,  tubercles  may  continue 
to  form  for  years,  the  old  ones  disappearing  and  new  ones 
coming.  They  disappear  either  by  absorption,  or  by  soften- 
ing and  breaking  down  and  forming  a  sharply  cut  ulcer  with 
perpendicular  edges  and  yellow  sloughing  base.  A  number 
of  the  lesions  breaking  down  at  once  and  coalescing,  a  large 
ulcer  with  scalloped  border,  indicating  its  composition  from 
single  lesions,  and  with  more  or  less  thick  greenish  crust, 
will  form.  In  either  case  they  leave  depressed,  smooth 
cicatrices,  at  first  pigmented,  but  later  white.  They  give 
rise  to  no  subjective  disturbances.  Rarely  do  they  form  a 
general  eruption. 

The  diagnosis  of  this  form  of  syphilide  is  usually  readily 
arrived  at  by  other  symptoms  of  syphilis.  Occasionally  it 
may  be  confounded  with  lupus  vulgaris  and  leprosy.  From 
lupus  it  is  differentiated  by  the  comparative  rapidity  of  its 
course,  lupus  being  a  disease  of  exceeding  slowness  of  de- 
velopment ;  by  its  occurrence  in  mature  years,  lupus  being 
a  disease  of  youth ;  by  its  sharp-cut  round  ulcers ;  by  its 
thick  greenish  crusts,  and  by  the  smoothness  of  its  cicatrices, 
those  of  lupus  being  puckered  and  deforming.  Syphilis  at 
times  bears  a  striking  resembrance  to  leprosy  when  its  tuber- 
cles are  located  in  the  eyebrows,  face,  and  ears,  but  the 
absence  of  anaesthesia  is  a  positive  diagnostic  sign  against 
leprosy.  Moreover,  other  symptoms  of  leprosy,  such  as 
swelling  of  the  ulnar  nerves  and  peculiar  brown  patches, 
will  be  absent. 

The  squamous  syphilide  is  not  usually  described,  as  it  is 
a  modified  form  of  either  the  papular  or  tubercular  lesion. 
In  using  the  term  here,  I  follow  my.  esteemed  master,  Prof. 


SYPHILIS.  461 

George  H.  Fox,  and  like  him  adopt  it  purely  on  clinical 
grounds.  He  applies  the  term  to  scaly  patches  of  circular 
or  irregular  form  that  occur  after  the  first  year  of  syphilis. 
These  patches  are  covered  with  thin  horny  scales  seated 
upon  an  infiltrated  base.  We  may  have  one  of  two  forms  : 
the  discoid,  or  the  circinate.  The  discoid  form  is  almost 
peculiar  to  the  palms  and  soles  and  neighboring  parts,  and 
constitutes  the  only  apparent  lesion.  The  round  patch  of 
varying  size,  but  with  a  sharply  defined  reddish  seam  be- 
yond the  scaling,  and  an  infiltrated  base,  tends  to  become 
serpiginous,  creeping  over  a  considerable  portion  of  the  skin. 
Sometimes  while  it  advances  at  one  border,  it  heals  at  the 
other ;  at  other  times  it  clears  up  in  the  centre,  leaving  an 
elevated,  scaling  marginal  ring.  The  ring  may  be  broken 
and  leave  a  curved  line,  and  if  two  or  more  of  these  lines 
meet  we  have  a  gyrate  figure.  Usually  but  one  palm  or 
sole  is  involved.  The  skin  is  apt  to  crack  in  the  natural 
creases,  and  then  the  patient  will  suffer  some  pain  and  dis- 
comfort. It  is  always  an  obstinate  lesion  to  cure,  persisting 
sometimes  for  months  or  years.  The  circinate  form  differs 
from  the  just- described  one  in  being  annular  from  the  first, 
and  in  occurring  not  only  on  the  palms  and  soles  but  else- 
where on  the  body. 

The  diagnosis  of  this  form  of  syphilide  from  a  squamous 
eczema  of  the  palm  is  often  one  of  great  difficulty.  The 
fact  that  only  one  palm  is  affected  is  always  suggestive  of 
syphilis.  Moreover,  in  syphilis  there  is  more  infiltration 
and  much  less  itching.  Indeed,  the  latter  may  be  entirely 
absent.  In  syphilis  the  lesion  is  often  crescentic,  with  sound 
skin  between  the  horns  of  the  crescent.  This  is  never  seen  in 
eczema.  Psoriasis  of  the  palm  is,  in  most  cases,  not  to  be 
thought  of  as  a  stumbling-block  in  diagnosis,  as  it  is  exceed- 
ingly rare  for  psoriasis  to  affect  the  palms,  and  then  only  as 
a  part  of  a  general  outbreak  of  the  disease.  Some  writers 
use  the  term  syphilitic  psoriasis  for  the  scaly  palmar  syphi- 
lide, but  it  is  a  most  faulty  method  of  nomenclature. 

The  pustulo-crustaceous  syphilide  is  characterized  by 
large  and  usually  deep-seated  pustules  or  ulcers,  covered 
by  prominent  and  peculiar  crusts.     It  is  the  ecthyma  form 


462  DISEASES    OF    THE    SKIN. 

of  Taylor  and  other  authorities.  It  occurs  as  a  late  form  of 
the  disease  and  as  a  localized  one ;  never  as  a  general  erup- 
tion. It  may  occur  as  a  precocious  syphilide.  It  is  seen  in 
debilitated  subjects,  and  is  of  gradual  development,  without 
febrile  symptoms,  as  in  the  pustular  syphilide.  It  has  pref- 
erence for  the  scalp,  face,  and  extremities.  It  assumes  three 
forms,  the  ecthymatous,  rupial,  and  pemphigoid. 

The  ecthymatous  form  begins  as  an  eruption  of  one  or 
more  round,  flat  pustules  of  a  diamater  of  one-quarter  to 
one-half  inch.  They  may  become  as  large  as  a  silver  half- 
dollar.  They  have  a  well-marked  inflammatory  areola  and 
a  swollen  and  indurated  base.  The  pus  soon  dries  and  forms 
a  flat,  greenish  or  brownish  black  crust,  whose  centre  is 
sometimes  depressed.  At  first  the  crust  fully  covers  the 
pustule,  but  later,  either  through  drying  or  on  account  of  an 
increase  in  the  size  of  the  pustule,  a  raw  rim  is  left  around  it. 
When  it  is  now  removed  it  exposes  a  typical  punched-out 
ulcer  with  its  base  covered  with  sanious  pus,  which  rapidly 
dries  into  a  new  crust.  Under  proper  treatment  the  pustule 
heals,  and  when  the  crust  falls  there  will  be  left  a  healed  or 
nearly  healed  ulcer.  A  permanent  cicatrix  is  left  when 
healing  is  completed,  which  is  smooth  and  white  eventually. 
This  syphilide  is  seen  most  often  on  the  legs  and  arms.  If 
the  course  of  the  disease  is  not  checked,  the  crust  is  cast  off 
by  increased  suppuration,  and  the  ulcerative  syphilide  is 
before  us. 

The  second  variety  of  the  pustulo-crustaceous  syphilide  is 
that  which  is  commonly  known  as  rupia.  It  differs  from  the 
preceding  variety  in  being  more  superficial  at  the  beginning 
and  in  forming  a  conical,  laminated  crust,  somewhat  resem- 
bling an  oyster- shell.  It  begins  either  as  a  superficial  pus- 
tule or  a  small  flattened  bulla  with  no  inflammatory  indu- 
ration. Upon  the  primary  lesion  a  greenish  crust  develops, 
under  which  ulceration,  with  suppuration,  occurs.  The  mar- 
gin of  the  ulceration  extends  a  little  beyond  the  original 
crust.  A  new  crust  forms  upon  it,  raising  up  the  original 
one,  and  this  process  being  repeated,  at  last  a  laminated  crust 
is  formed.  When  the  ulceration  extends  more  rapidly  in 
one  direction  than  another  it  will  follow  that  the  crust  will 


SYPHILIS.  463 

be  higher  at  one  end  than  at  the  other.  Crusts  may  form 
a  half-inch  or  more  in  height,  and  one  or  two  inches  in 
diameter.  If  the  lesions  are  numerous  they  are  usually 
small ;  if  few,  large.  When  these  thick  conical  crusts  are 
removed  the  ulcer  is  exposed  and  is  less  deep  than  in  the 
ecthymatous  form.  On  healing,  a  permanent,  smooth,  white 
cicatrix  is  left  at  last. 

The  third  variety  of  the  pustulo-crustaceous  syphilide  is 
the  pemphigoid  or  bullous  form.  It  is  a  very  rare  lesion  in 
acquired  syphilis,  though  quite  common  in  hereditary  dis- 
ease. It  consists  in  an  eruption  of  superficial,  purulent,  flat- 
tened bullae  from  one  to  five  centimetres  in  diameter,  which 
tend  to  dry  into  thick  crusts.  They  are  surrounded  by  a 
dull-red  areola,  and  are  soon  covered  by  dark  greenish-black 
adherent  crusts.  If  the  patient  be  in  fair  health  the  ulcera- 
tion under  the  crusts  will  not  be  deep.  If  the  patient  be  a 
broken-down  subject  the  ulceration  may  be  very  deep.  It 
will  leave  either  a  pigmented  atrophic  spot,  or  a  pronounced 
scar,  according  to  the  depth  of  the  ulceration. 

The  diagnosis  of  the  pustulo-crustaceous  syphilide  is  usu- 
ally easy  if  the  disease  is  known  to  the  observer,  as  no 
non-specific  disease  resembles  it  closely.  The  so-called 
ecthyma  eachectieum  is  more  inflammatory  than  is  the 
ecthymatous  syphilide,  and  more  superficial.  The  bullous 
syphilide  often  bears  a  striking  resemblance  to  pemphigus, 
and  can  be  diagnosed  only  by  a  study  of  all  the  features  of 
the  case. 

The  gummous  syphilide  is  perhaps  one  of  the  most 
characteristic  of  the  late  lesions  of  syphilis.  It  consists  in 
a  deposit  of  gummy  material  in  the  skin.  The  distinction 
between  some  tubercular  lesions  and  a  gumma  is  often  very 
indistinct,  and  made  principally  by  the  size.  The  gumma 
begins  in  the  subcutaneous  tissue  and  involves  the  skin  sec- 
ondarily. It  may  take  the  form  of  a  single  tumor,  a  group 
of  nodules,  or  a  diffused  infiltrated  patch.  It  is  nearly 
always  a  late  lesion,  and  while  it  may  undergo  absorption  it 
possesses  a  strong  tendency  to  break  down  and  ulcerate. 
(Fig.  44.) 

The  single  tumor  begins  as  a  small  pea-sized  nodule, 


464  DISEASES    OF    THE    SKIN. 

seated  in  the  subcutaneous  tissues  so  deeply  as  to  be  appre- 
ciated only  by  the  touch.  It  grows  slowly ;  in  the  course 
of  weeks  or  months  it  may  attain  the  size  of  a  nut  and  push 
up  the  skin  over  it  into  an  evident  tumor,  which  is  movable, 
firm,  elastic,  painless,  and  rolls  under  the  finger.  Increas- 
ing in  size,  it  involves  the  skin,  which  then  becomes  of  a 

Fig.  44. 


Gummata.     (After  Jullien.) 

dull  reddish  color.  When  the  skin  becomes  involved  the 
tumor  is  no  longer  movable,  and  soon  fluctuation  may  be 
felt  that  would  lead  the  inexperienced  to  open  it  as  an 
abscess.  If  he  did  so  it  would  be  a  mistake.  He  would 
find  only  a  little  pus,  a  gummy  substance,  and  some 
blood.  Left  to  itself,  the  tumor  may  be  absorbed,  or  it  may 
break  down  and  ulcerate,  leaving  a  characteristic  deep  and 
round  ulcer.  The  scalp  and  forehead  are  the  chosen  sites 
for  this  syphilide,  though  it  may  occur  elsewhere.  It  some- 
times attains  a  large  size — as  large  as  a  hen's  egg.  When 
this  lesion  occurs  as  a  precocious  syphilide,  it  is  usually  of 
small  size  and  multiple. 


SYPHILIS.  465 

When  gummata  occur  in  the  form  of  grouped  nodules  the 
skin  between  them  is  apt  to  become  infiltrated  with  a  gum- 
matous deposit,  and  the  patch  will  present  the  dull  brownish- 
red  color  of  the  late  syphilides.  The  individual  members  of 
the  group  run  a  course  similar  to  that  of  the  isolated  gumma, 
but  do  not  attain  its  size.  When  they  break  down  they 
form  a  large  irregular  ulcer.  This  variety  of  the  gumma  is 
frequently  met  with  upon  the  scalp,  the  nose,  the  outer 
aspects  of  the  extremities  about  the  joints,  and  around  the 
lower  portion  of  the  leg  and  ankle.  Diffuse  gummatous 
infiltration  of  the  skin  probably  precedes  all  serpiginous 
ulcerations.  Apart  from  this  it  is  rarely  seen,  and  almost 
always  ends  in  ulceration. 

Other  gummatous  deposits  are  known  as  syphilitic  dac- 
tylitis, admirably  described  by  R.  W.  Taylor,  and  syph- 
ilitic bursitis,  carefully  studied  by  E.  L.  Keyes.  One  being 
a  bony  and  the  other  a  synovial  disease,  they  do  not  here 
concern  us. 

The  diagnosis  of  the  gumma  must  be  made  with  care. 
It  may  simulate  other  forms  of  tumors.  It  is  not  as  hard 
as  the  sarcoma,  nor  as  compressible  as  the  lipoma,  and  it 
invades  the  skin.  An  abscess  is  usually  attended  by  pain 
and  signs  of  inflammation,  and  runs  a  more  acute  course 
than  does  the  gumma. 

The  ulcerative  syphilide,  according  to  Prof.  George  H.  Fox, 
merits  being  described  by  itself,  though  in  itself  only  a 
sequence  of  a  tubercular  pustulo-crustaceous,  or  gummatous 
syphilide ;  because  in  the  majority  of  cases  of  syphilitic  ulcers 
met  with  it  is  hard  or  impossible  for  us  to  say  what  the  pre- 
ceding lesion  has  been.  For  convenience,  he  describes  the 
superficial,  the  serpiginous,  and  the  deep  or  perforating 
forms  of  syphilitic  ulceration. 

The  superficial  syphilitic  ulcer  is  circular,  with  sharply 
cut  edges  and  dirty-yellowish  purulent  base.  It  most  often 
follows  a  pustular  or  pustulo-crustaceous  lesion,  and  may 
appear  comparatively  early  in  the  disease,  especially  in  de- 
bilitated subjects.  They  are  usually  of  the  size  of  a  quarter 
or  half-dollar,   and  frequently  coalesce  to  form  ulcerative 

20* 


466  DISEASES    OF    THE    SKIN. 

patches  with  scalloped  margins.     The  face  and  legs  are  their 
most  common  sites. 

The  serpiginous  ulcer  is  so  called  because  it  tends  to  creep 
over  the  surface,  healing  by  a  cicatrix  as  it  passes  along. 
It  may  develop  from  a  single  circular  ulcer  healing  in  the 
middle  and  at  one  side,  and  leaving  a  crescentic  or  "  horse- 
shoe "  ulcer  at  the  other  side,  with  a  sharp  convex  margin, 
beyond  which  is  a  narrow  zone  of  infiltration  upon  which 
the  ulceration  constantly  encroaches,  while  healing  at  its 
concave  border.  Or  a  group  of  crusted  pustules  or  softening 
tubercles  form  a  number  of  small  round  ulcers,  of  which  the 
outer  ones  usually  form  a  curving  line.  While  those  in  the 
centre  and  at  one  side  tend  to  heal,  new  lesions  develop  at 
the  periphery  of  the  opposite  side,  which  ulcerate  and  per- 
haps coalesce,  and  so  the  disease  creeps  on.  This  form  is 
often  observed  upon  the  back  and  on  the  extremities ;  it  is 
not  particularly  painful,  and  the  patient's  health  may  not  be 
impaired. 

The  deep  ulcerations  of  syphilis  result,  for  the  most  part, 
from  the  breaking  down  of  gummatous  deposits.  The  small 
ones  are  crater-like  in  shape.  Often  the  opening  of  the 
softened  tumor  is  smaller  than  the  softened  mass,  and  it  is 
not  infrequent  to  find  the  cavities  of  adjacent  tumors  run- 
ning together  subcutaneously. 

Ulcerative  syphilides  sometimes  are  covered  with  exu- 
berant granulations. 

The  diagnosis  of  syphilitic  ulcers  from  non-specific  ulcers 
is  most  important  from  a  therapeutical  standpoint.  A 
chronic  ulcer  located  anywhere  above  the  middle  half  of  the 
leg  is  in  most  cases  syphilitic.  If  it  is  not,  it  is  probably 
either  traumatic,  tubercular,  or  cancerous.  The  traumatic 
ulcer  is  acute  and  highly  inflammatory ;  of  irregular  shape ; 
has  a  history  of  traumatism  ;  and  heals  rapidly,  excepting 
in  very  broken-down  subjects,  under  simple  dressings.  The 
tubercular  ulcer,  if  from  broken-down  caseous  glands,  has 
a  history  of  the  previous  glandular  affection  ;  is  irregular  in 
shape ;  often  presents  a  number  of  sinuses  and  ridges  of  in- 
flamed tissues  ;  and  runs  a  sluggish  course.  If  it  is  a  lupous 
ulcer  there  will  be  found  somewhere  in  its  neighborhood  the 


SYPHILIS.  467 

characteristic  apple-jelly-like  tubercles ;  there  will  be  a  his- 
tory of  lasting  from  early  life ;  the  edges  of  the  ulcer  will 
be  shelving  or  undermined;  and  there  will  usually  be  more 
or  less  deforming  cicatrices  present.  A  cancerous  ulcer, 
usually  an  epithelioma,  will  have  a  history  of  beginning  in 
a  pimple,  wart,  mole,  or  such  like ;  will  be  irregular  in 
shape  with  an  uneven  floor ;  will  be  apt  to  be  attended  by 
lancinating  pain ;  will  usually  be  a  single  lesion,  located  on 
the  face  ;  and  will  have  a  raised,  waxy,  rolled-out  border 
over  which  delicate  bloodvessels  will  be  seen  to  course. 

The  diagnosis  of  ulcers  of  the  leg  lies  between  one  of 
syphilis  and  of  varicose  dermatitis.  If  the  ulcer  is  irregular  in 
shape  with  shelving  edges,  rather  superficial,  surrounded  by 
a  brawny,  infiltrated,  brownish  or  dark-red  tissue  with  more 
or  less  scaling,  and  there  are  varicose  veins  above  it,  we 
have  to  do  with  the  so-called  varicose  ulcer.  This  is  in 
sharp  contrast  with  the  round,  or  scalloped  bordered,  deep, 
punched-out  ulcer  with  perpendicular  edges  and  greenish 
base,  around  which  there  is  but  a  small  zone  of  redness. 
The  diagnosis  of  syphilis  is  strengthened  when  we  find  a 
number  of  ulcers,  or  the  cicatrices  of  old  ulcers.  As  a  rule 
the  syphilitic  ulcer  is  located  on  the  posterior  surface  of  the 
upper  half  of  the  leg,  while  the  varicose  ulcer  is  on  the  ante- 
rior surface  of  the  lower  third  of  the  leg.  The  diagnosis 
from  a  traumatic  ulcer  has  already  been  given. 

Over  the  pigmentary  syphilide  there  has  been  no  little 
discussion.  By  this  term  is  not  meant  pigmentation  follow- 
ing a  syphilide  which  is  sufficiently  common,  and  due  to  a 
staining  of  the  skin  with  hgematin.  It  is  a  true  pigmenta- 
tion without  antecedent  lesion,  and  is  most  always  seen  on 
the  sides  of  the  neck,  and  in  women.  It  is  composed  of 
irregularly  round  or  oval  spots,  one-eighth  of  an  inch  to 
one  inch  in  diameter,  with  ill-defined  margins,  and  cafe-au- 
lait  color,  which  does  not  fade  on  pressure.  The  color  may 
be  very  faint.  They  may  be  discrete  or  confluent.  When 
they  are  very  numerous  they  have  been  compared  by  Four- 
nier  to  a  "  network  of  lace  with  large  meshes."  It  is  one 
of  the  rarer  manifestations  of  syphilis. 


468  DISEASES    OF    THE    SKIN. 

General  Diagnosis  of  Syphilis.  Having  now  studied 
briefly  the  various  cutaneous  lesions  of  syphilis,  we  are  pre- 
pared to  state  those  general  features  of  the  sylphilides  that 
serve  to  distinguish  them  from  other  diseases  of  the  skin. 

One  marked  feature  of  them  is  that  they  do  not  itch. 
Itching  does  occasionally  occur  with  the  scaling  papular 
syphilide ;  and  in  some  cases  the  patient  will  complain  of 
an  itching  of  the  skin  that  is  quite  independent  of  syphilis, 
but  in  themselves  they  do  not  itch. 

The  early  eruptions  of  syphilis  exhibit  a  marked  poly- 
morphism, many  different  lesions  being  often  present  at  the 
same  time ;  as,  for  instance,  macules,  papules,  and  pus- 
tules. The  late  eruptions  exhibit  a  strong  tendency  to 
grouping  of  the  lesions  in  circles  and  segments  of  circles. 

The  color  of  the  lesions  is  peculiar,  and  perhaps  may  be 
best  described  as  that  of  raw  ham,  though  the  classic  term 
is  "  copper. '?  This  color  is  by  no  means  always  present. 
It  is  not  seen  in  the  early  bloom  of  the  early  lesions,  but  is 
pretty  sure  to  be  found  in  those  that  have  existed  for  some 
time,  and  in  the  late  lesions.  The  color  of  a  lesion  on  the  legs, 
it  must  be  remembered,  must  not  be  regarded  for  purposes 
of  diagnosis ;  it  is  upon  the  arms,  face,  trunk,  and  thighs 
that  we  must  look. 

Painlessness  is  often  a  suggestive  symptom  pointing 
toward  syphilis  when  we  have  to  decide  as  to  the  nature  of 
an  ulceration. 

It  is  well  not  to  lay  too  much  stress  upon  the  history  of 
the  case  in  making  up  our  mind  as  to  a  late  syphilide,  be- 
cause with  the  best  of  intentions  the  patient  may  forget  hav- 
ing had  an  insignificant  initial  lesion  some  twenty  or  per- 
haps thirty,  years  before. 

Space  will  not  permit  of  our  here  detailing  the  differential 
diagnosis  between  syphilis  and  the  many  diseases  which  it 
may  simulate  from  time  to  time.  For  this  the  reader 
must  be  referred  to  the  sections  upon  eczema,  psoriasis, 
lupus,  alopecia,  etc. 

Etiology.  That  acquired  syphilis  is  due  to  contagion 
we  know.  Further  than  this  we  know  little  of  certainty. 
Various   attempts  have  been  made  to  prove  its  bacillary 


SYPHILIS.  469 

origin,  by  Lustgarten  and  others,  but  at  present  the  best 
authorities  are  by  no  means  agreed  upon  the  correctness  of 
this  theory.1  We  can,  in  the  meantime,  speak  of  its  being 
due  to  a  specific  virus.  The  microbian  theory  is  also  ap- 
plied to  all  pustular  syphilides,  and  we  are  taught  that  they 
are  the  result  of  an  infection  of  the  specific  lesion  by  the 
pus  coccus. 

Hereditary  Syphilis.  Before  entering  upon  the  study 
of  the  treatment  of  syphilis,  we  must  stop  a  while  to 
consider  hereditary  syphilis.  This  differs  from  the  acquired 
form  in  having  no  initial  lesion,  the  disease  being  acquired 
in  utero  from  either  one  or  both  parents.  We  cannot  enter 
upon  a  discussion  of  the  many  conflicting  theories  as  to 
whether  or  not  the  child  is  diseased  on  account  of  springing 
from  a  diseased  ovum,  or  spermatozoa  ;  or  the  possibility  of 
the  disease,  acquired  by  the  mother  after  her  pregnancy, 
reaching  the  foetus  through  the  placental  circulation ;  or 
like  interesting  questions  over  which  the  battle  rages.  For 
us  now  it  suffices  to  make  the  bald  statement  that  the  dis- 
ease may  be  acquired  from  one  or  both  parents.  It  is  most 
sure  to  be  acquired  from  the  mother,  and  it  may  be  in- 
herited by  the  foetus  from  a  mother  infected  some  months 
after  conception.  It  is  possible  for  a  woman  to  show  no 
sign  herself  of  syphilis,  and  yet  to  give  birth  to  a 
syphilitic  child.  It  is  exceedingly  rare  for  the  apparently 
healthy  mother  of  a  child  hereditarily  syphilitic  to  be  in- 
fected by  it.  As  a  result  of  syphilitic  infection  in  utero,  the 
child  may  be  born  prematurely,  and  dead ;  it  may  be 
born  at  term,  dead,  and  showing  specific  lesions ;  or 
it  may  be  born  alive  with  some  syphilitic  eruption  ;  or,  as  is 
commonly  the  case,  the  eruption  may  not  appear  before  the 
second  or  third  week.  Miller,2  from  a  study  of  one  thou- 
sand cases  of  congenital  syphilis  in  a  foundling  hospital  in 
Moscow,  found  that  the  first  appearance  of  the  disease 
was  in  the  first  month  of  life  in  64  per  cent,  of  the  cases ; 

1  For  a  good  study  of  the  probable  origin  of  syphilis  consult  Finger, 
Archiv.  Derm.  und'Syph.,  1890,  p.  331. 

2  Jahrb.  der  Kinderheilk.,  1888,  xxvii.,  Heft  4. 


470  DISEASES    OF    THE    SKIN. 

and  in  the  second  month  in  22  per  cent.  In  congenital 
syphilis  there  is  a  marked  absence  of  that  sequence  of  events 
more  or  less  observed  in  acquired  syphilis,  but  the  diagnosis 
is  usually  quite  as  easy.  The  earliest  eruption  to  appear, 
as  to  point  of  time,  is,  according  to  Miller,  the  bullous 
syphilide,  which  he  met  with  in  25  per  cent,  of  the  cases. 
One  of  the  earliest  and  most  characteristic  symptoms  of 
hereditary  syphilis  is  "  snuffles,"  due  to  an  ozaena,  which 
gives  the  child  great  discomfort  by  interfering  with  breathing 
and  nursing. 

The  erythematous  syphilide  is,  according  to  Taylor,  the 
most  frequent  and  earliest  eruption ;  according  to  Miller, 
it  occurs  in  but  45  per  cent,  of  the  cases.  It  begins  on 
the  lower  part  of  the  abdomen  as  minute  round  or  oval 
spots,  that  disappear  under  pressure  at  first.  It  invades 
the  whole  body  within  a  week,  when  the  lesions  will  no 
longer  fade  under  pressure,  but  assume  the  characteristic 
syphilitic  color.  One  form  of  the  erythematous  syphilide  in 
children  is  seen  upon  the  inside  of  the  thighs,  about  the 
anus,  and  on  the  buttocks,  and  may  extend  down  to  the 
feet.  It  is  patchy  in  character,  the  patches  being  either  of 
small  size,  or  large  by  the  coalescence  of  several  smaller 
ones.  It  differs  from  intertrigo  by  its  patchy  character,  by 
its  darker  color,  and  by  its  wider  distribution. 

The  papular  syphilide  and  its  modified  forms  of  the  mu- 
cous patch  and  the  condylomata  lata,  are  the  most  common 
of  the  congenital  lesions.  The  lenticular  syphilide,  large 
and  small,  is  met  with  far  more  frequently  than  the  miliary 
papular  syphilide.  It  is  usually  a  symmetrical  and  gen- 
eral eruption.  They  may  be  smooth  or  scaly,  and  always 
have  the  raw-ham  color.  Mucous  patches  are  very  often  at 
the  junction  of  the  mucous  membrane  and  the  skin,  as  on 
the  lips  or  anal  orifice.  The  movements  of  the  parts  will 
give  rise  to  painful  fissures,  rhagades,  which  constitute  a  sign 
of  hereditary  syphilis  as  characteristic  as  the  "  snuffles." 
These  rhagades  Miller  met  with  in  70  per  cent,  of  his 
cases.  Mucous  patches  also  occur  in  the  cavity  of  the 
mouth.  Condylomata  lata  occur  where  two  skin  surfaces  rub 
together,  and  specially  when  there  is  more  or  less  moisture, 


SYPHILIS.  471 

as  about  the  anus  and  genitals,  in  the  groins  and  axillae, 
and  between  the  fingers  and  toes.  Their  color  is  usually  gray- 
ish-pink to  dark-brown ;  their  size  varies  greatly,  and  their 
surface  flat,  or  fissured  and  ulcerated,  and  exuding  an  offen- 
sive secretion.  They  are  characteristically  located  when  at 
the  angles  of  the  mouth,  in  combination  with  mucous  patches 
in  the  mouth  with  rhagades  between. 

The  pustular  syphilide  may  be  general,  but  is  usually 
most  pronounced  on  the  thighs,  buttocks,  and  face.  They 
show  a  tendency  to  group  about  the  mouth.  It  is  usually 
indicative  of  profound  syphilization.  The  pustules  may 
leave  scars.  Ecthymatous  pustules  may  develop,  but 
usually  not  till  late  in  the  disease. 

The  vesicular  syphilide  is  a  rare  form  of  early  congenital 
syphilis  of  severe  type.  It  is  never  general,  but  appears  as 
groups  of  closely  packed  together  vesicles  upon  the  chin, 
about  the  mouth,  or  on  the  nates,  forearms,  hypogastrium,  or 
thighs.  They  are  seated  upon  infiltrated,  brownish-red 
bases.  The  larger  vesicles  may  be  seated  upon  papules. 
This  eruption  is  apt  to  be  associated  with  a  pustular  or  bul- 
lous syphilide. 

The  bullous  syphilide,  unlike  what  obtains  in  adults,  is 
comparatively  common  in  congenital  infantile  syphilis.  Miller 
found  it  in  twenty-five  per  cent,  of  his  cases.  It  frequently 
exists  at  birth  or  as  the  earliest  syphilide,  and  is  indicative  of 
a  severe  form.  It  is  most  commonly  seen  on  the  palms  and 
soles,  which  are  often  covered  with  the  lesions,  while  few,  if 
any,  are  on  the  trunk.  The  face  is  a  favorite  location  for 
the  eruption.  They  are  either  tense  or  flaccid  ;  at  first  have 
sero-purulent  contents  that  soon  becomes  purulent.  They 
are  seated  upon  a  raw-ham-colored  infiltrated  base.  Hem- 
orrhage into  them  not  infrequently  occurs.  When  they 
rupture  or  dry  up  they  exhibit  an  unhealthy-looking  ulcer- 
ation that  soon  becomes  covered  with  a  greenish  crust.  Some 
of  them  may  dry  up  with  little,  if  any,  ulceration.  It  rarely 
relapses.  It  differs  from  pemphigus  in  occurring  upon  the 
palms  and  soles,  while  sparing  the  trunk,  and  in  the  profound 
cachexia  and  the  presence  of  other  signs  of  syphilis. 

The  tubercular  syphilide  is  not  common,  and  is  always  a 


472 


DISEASES    OF    THE    SKIN. 


late  lesion.  While  it  may  be  seen  as  early  as  the  sixth 
month,  it  is  more  apt  to  occur  much  later  as  a  relapsing 
syphilide.  In  appearance  and  course  it  resembles  the  same 
lesion  of  acquired  syphilis. 

The  gummatous  syphilide  is  also  a  late  manifestation  of 
disease,  and  is  sometimes  met  with  in  early  adult  life  as  a 
lesion  of  congenital  syphilis. 

Kaposi  regards  as  a  special  and  characteristic  symptom 
of  hereditary  syphilis  a  diffused  infiltration  of  the  palms 
and  soles,  the  skin  of  which  is  uniformly  brownish-red,  dry, 
shiny,  and  fissured. 

Besides  the  skin  lesions  the  infant  bears  certain  unmistak- 
able signs  of  syphilis.  It  has  a  marked  pallor,  and,  no  mat- 
ter how  blooming  it  may  appear  at  first,  it  soon  loses  flesh 

Fig.  45. 


Hutchinson's  teeth. 


and  assumes  "  an  old  man  "  countenance  It  has  a  character- 
istic, hoarse,  toneless  cry,  which  once  heard  will  be  remem- 
bered. Its  hair  is  scanty,  its  nose  is  apt  to  be  flattened,  and 
altogether  it  is  a  most  woebegone-looking  object.  The  skin 
eruptions  usually  occur  within  the  first  six  months  of  life, 
and  if  the  child  can  be  brought  through  that  period  it  may 
suffer  no  more.  Nevertheless,  congenital  syphilis,  like  the 
acquired  disease,  may  be  latent  for  years  to  crop  out  once 


SYPHILIS.  473 

more.  The  victims  of  congenital  syphilis  sometimes  show 
the  notched  or  peg-shaped  teeth  regarded  by  Hutchinson  as 
a  certain  sign  of  the  disease.  (Fig.  45.)  This  appearance 
is  presented  by  the  second  set  of  teeth  only,  and  is  not  abso- 
lutely diagnostic,  as  the  same  has  been  met  with  in  scrofula. 
The  two  middle  upper  incisors  are  those  which  are  depended 
on  for  diagnosis.  "  They  are  small,  often  converging,  some- 
times diverging.  The  cutting  edge  of  the  teeth  is  some- 
times narrowed,  rounded  off.  They  are  stunted  and  badly 
developed,  often  marked  with  seams  in  front,  and  of  a  dirty- 
brownish  color,  but  their  chief  peculiarity  is  found  in  their 
edges,  which,  being  thin  when  cut,  break  off  centrally,  leav- 
ing a  broad,  shallow,  vertical  notch  on  the  lower  border  of 
the  tooth."  (Keyes.)  It  is  subject  to  diseases  of  the  bones, 
one  of  the  most  characteristic  of  which  is  dactylitis.    Space 

Fig.  46. 


Dactylitis.    (After  Bergh.) 

will  not  permit  of  a  detailed  description  of  the  bone  and 
other  lesions  apart  from  those  of  the  skin. 

Treatment.  The  treatment  of  syphilis  is  by  the  use  of 
both  constitutional  and  local  remedies,  and  by  a  constant 
and  long-continued  watchfulness  on  the  part  of  the  physician 
over  the  patient's  hygiene  and  general  well-being.  One 
chief  obstacle  to  the  successful  treatment  of  a  case  is  the 
patient's  lack  of  faith  in  his  physician.  Most  patients,  just 
as  soon  as  the  eruption  for  which  they  sought  advice  fades 
away  will  cease  coming  to  the  physician,  and  will  pay  little 
heed  to  his  warning  that  unless  they  keep  themselves  under 
medical  supervision   for  three  or  four  years  they  will  be 


474  DISEASES    OF    THE    SKIN. 

liable  to  serious  troubles  later  on.  Nevertheless,  our  first 
duty  is  to  so  instruct  them.  Then  before  putting  the  patient 
upon  a  regular  course  of  treatment,  we  should  give  him  care- 
ful direction  as  to  his  exercise,  liberal  diet,  and  bathing,  and 
should  stop  his  alcohol,  insist  upon  his  taking  plenty  of 
sleep,  and  giving  up  the  use  of  tobacco.  This  last  is  not 
only  to  put  him  in  better  general  condition,  but  also  to  pre- 
vent mucous  patches  in  the  mouth.  The  patient  should  be 
cautioned  against  drinking  out  of  public  drinking-cups,  and 
apprised  of  the  danger  of  infection  of  others  by  means  of 
table  utensils,  pipes,  and  the  like.  Now  he  is  ready  for  his 
course  of  treatment. 

Constitutional  Treatment.  The  drugs  employed  and 
found  of  value  in  syphilis  are  chiefly  but  two,  namely  :  mer- 
cury, and  iodine  in  combination  with  sodium  or  potassium. 
These  drugs  are  given  in  varying  combination,  and  during 
varying  periods,  according  to  the  views  of  different  physi- 
cians. Mercury  is  the  remedy  relied  on  most  for  combating 
the  disease,  and  should  be  used  under  ordinary  circum- 
stances by  itself  alone  during  the  first  year  or  two  of  the 
disease.  The  iodides  exercise  a  marked  control  over  the 
ulcerative  syphilides,  and  in  the  late  or  precocious  manifesta- 
tions of  the  disease.  By  some  they  are  given  continuously  or 
as  the  sole  remedy  in  late  syphilis,  but  the  best  practice  is  in 
favor  of  their  administration  either  with  mercury  or  instead  of 
mercury  for  a  short  time.  Treatment  should  be  begun  as 
soon  as  we  are  sure  that  the  patient  has  syphilis.  As  an 
element  of  doubt  may  often  enter  into  our  diagnosis  of  the 
initial  lesion,  it  is  a  good  general  rule  not  to  administer  specific 
treatment  until  the  appearance  of  some  secondary  symptom. 
This  plan  has  the  additional  advantage  of  producing  a  moral 
effect  upon  the  patient,  who,  if  he  sees  an  eruption  upon 
himself,  will  be  more  apt  to  believe  that  he  has  syphilis,  and 
to  submit  himself  to  a  thorough  course  of  treatment. 

We  will  consider  first  the  treatment  of  early  syphilis  and 
the  use  of  Mercury.  This  drug,  regarded  by  the  majority  of 
physicians  as  the  sheet-anchor  in  the  treatment  of  syphilis, 
is  administered,  for  its  constitutional  effect,  by  the  mouth, 
by  inunction,  by  fumigation,  and  by  hypodermatic  injection. 


SYPHILIS.  475 

Of  these  different  methods  the  most  frequently  employed 
is  the  first — that  is,  by  the  mouth.  The  salt  of  mercury  that  I 
most  frequently  use  is  the  protiodide,  otherwise  called  the  green 
iodide.  This  may  be  exhibited  either  in  pill,  tablet  triturate, 
or  granule ;  and  as  the  tablet  triturate  is  easily  obtainable, 
very  reliable,  and  quite  inexpensive,  my  preference  is  for 
that  preparation.  Keyes  prefers  the  granules  of  French 
manufacture,  and  says  that  the  very  objection  raised  by 
many  authorities  to  the  use  of  the  protiodide,  namely,  its 
irritant  effect  on  the  intestinal  tract,  is  its  shining  virtue, 
because  instead  of  giving  warning  of  intoxication  by  causing 
salivation,  it  does  so  by  causing  diarrhoea.  The  dose  to 
begin  with  should  be  from  one-sixth  to  one-fifth  of  a  grain 
three  times  a  day  after  meals,  and  the  number  of  pills  in- 
creased every  third  or  fourth  day  until  there  is  a  little 
"  colicky  diarrhoea."  The  dosage  should  be  then  continued 
at  the  same  number  of  pills,  until  the  symptoms  are  con- 
trolled. Then  we  can  reduce  it  to  half  the  number.  It  may 
be  necessary  to  give  a  little  opium  at  the  same  time  with  the 
mercury  in  order  to  control  the  diarrhoea  if  it  is  deemed 
advisable  to  continue  at  the  point  of  full  tolerance,  and  this 
not  only  with  the  protiodide  but  with  other  salts.  Practi- 
cally the  dose  of  the  protiodide  may  be  put  at  four  or  five  of 
the  one-fifth-grain  tablets,  and  three  or  four  of  the  quarter- 
grain  ones. 

Many  prefer  to  use  metallic  mercury,  hydrarg.  cum  creta, 
or  calomel  in  the  dose  of  one  or  two  grains  two  or  three 
times  a  day  after  meals,  increased  every  three  or  four  days 
sufficiently  to  influence  the  eruption.  Salivation  is,  in  the 
general  run  of  cases,  to  be  avoided.  Some  authorities,  and 
among  them  Robt.  W.  Taylor,  prefer  to  combine  a  tonic 
with  the  mercury,  as  follows  : 


H  •  PiL  hydrargyri,  ^ij ;              2 

Ferri.  sulphat.  exsic,  ^j  5               1 

Ext.  opii,  gr.  v; 
Div.  in  pil.  no.  xl. 


66 
33 
30     M. 


Or, 

Div.  in  pil.  no.  xl 


R .  Hydrarg.  cum  cretse  ^ij ;  266 

Quinise  sulphat.,  §j  I  lj33     M. 


476  DISEASES    OF    THE    SKIN. 

In  severe  cases  where  it  is  necessary  to  get  the  patient 
rapidly  under  the  influence  of  mercury,  calomel  in  one- 
tenth-grain  doses  in  the  form  of  tablet  triturates  may  be 
given  every  hour  until  the  gums  become  tender.  Then  the 
calomel  should  be  stopped  and  the  treatment  continued  with 
a  small  dose  of  the  protiodide. 

Besides  these  preparations  of  mercury  we  may  use  the 
bichloride  in  doses  of  -^  to  y1-^  of  a  grain  in  solution.  It  is 
usually  given  in  compound  syrup  of  sarsaparilla  or  some 
bitter  infusion.  The  most  common  mode  of  administering 
it  is  in  combination  with  the  iodide  of  potassium,  the  so-called 
mixed  treatment,  the  formula  for  which  will  be  given  later 
when  speaking  of  the  treatment  of  late  syphilis.  The  best 
opinion  is  in  favor  of  reserving  the  use  of  iodine  until  the 
early  lesions  are  over.  The  tannate  of  mercury  is  well 
spoken  of.  Space  will  not  allow  of  mentioning  the  other 
salts  of  mercury  that  have  been  recommended. 

The  proper  quantity  for  administration  having  been 
learned  by  experiment,  the  drug  should  be  administered 
continuously. 

Where  practicable  the  use  of  mercury  by  inunction 
is  the  speediest  and  best  way  of  getting  the  patient  under 
the  influence  of  the  drug.  Its  great  advantages  are 
the  promptness  with  which  it  acts,  and  the  sparing  of  the 
stomach  and  intestinal  tract.  Its  great  disadvantages  are 
that  it  is  a  dirty  method,  impracticable  with  most  patients, 
as  it  attracts  notice  from  his  friends  and  attendants ;  and 
the  difficult  encountered  in  getting  the  patient  to  carry  out 
the  treatment  with  thoroughness.  It  is  admirable  for  hos- 
pital treatment.  The  patient  is  to  be  told  to  rub  into  his 
skin,  once  a  day,  a  piece  of  ungt.  hydrarg.  cinereum  of  the 
size  of  a  hazel-nut.  He  is  to  divide  the  mass  into  two  equal 
parts,  and  work  it  in  with  the  heel  of  his  hand  for  about 
fifteen  minutes,  while  he  sits  before  a  fire  or  in  a  warm  room. 
Before  beginning  the  inunctions  he  is  to  take  a  warm  bath, 
or  to  bathe  the  parts  about  to  be  rubbed,  so  as  to  open  the 
pores  of  the  skin.  The  first  day  he  is  to  rub  the  ointment 
into  the  bends  of  both  elbows  ;  the  second  day,  over  the 
sides  of  the  chest ;  the  third  day,  over  the  abdomen  ;  the 


SYPHILIS.  477 

fourth  day,  inside  of  the  thighs ;  and  the  fifth  day,  behind 
the  knees.  That  is,  he  is  to  choose  the  parts  least  covered 
with  hair ;  and  to  change  the  sites  of  the  inunctions  so  as  to 
avoid  setting  up  a  mercurial  eczema.  On  the  sixth  day  he 
is  to  take  another  bath,  and  begin  again  on  the  seventh  day. 
The  treatment  is  to  be  pursued  until  active  symptoms  of 
the  disease  are  overcome,  when  all  treatment  may  be  sus- 
pended. A  thorough  course  of,  say,  eighty  or  a  hundred 
inunctions  is  said  to  be  often  followed  by  a  permanent  cure. 
If  the  inunctions  are  to  be  made  by  an  attendant  he  should 
wear  a  stout  rubber  glove. 

Fumigation  is  a  method  which  is  not  used  as  much  now 
as  formerly.  It  requires  the  use  of  a  special  apparatus,  and 
a  great  amount  of  time  and  trouble.  Inasmuch  as  it  pos- 
sesses no  advantage  over  inunctions,  we  will  say  no  more 
about  it. 

The  hypodermatic  injection  method  of  administering  mer- 
cury, or  rather  the  deep  intra-muscular  method,  was  first 
advocated  by  Scarenzio  in  1854,  and  of  late  years  has  been 
much  experimented  with.  The  injections  are  usually  made 
deep  down  in  the  gluteal  region,  behind  and  above  the  great 
trochanter.  They  are  usually  painful ;  often  followed  by 
abscesses ;  require  daily  or  frequent  visits  to  the  physician's 
office  ;  and  do  not  seem  to  be  followed  by  sufficiently  lasting 
effects  to  warrant  their  frequent  employment.  They  are 
useful  where  we  wish  to  have  a  very  prompt  effect  from-  the 
mercury,  as  in  a  malignant  precocious  case  of  syphilis ;  or 
where  the  stomach  must  be  spared ;  or  where  the  disease  has 
not  yielded  to  the  ordinary  plans  of  treatment.  Patients  in 
this  country  seem  to  object  very  strongly  to  their  employ- 
ment. A  vast  number  of  salts  of  mercury  and  combinations 
have  been  introduced,  each  one  of  which  has  been  found  by 
its  introducer  the  best  and  most  reliable.  An  admirable 
study  of  them  will  be  found  in  Hare's  System  of  Therapeutics, 
vol.  ii.,  by  Prof.  R.  W.  Taylor.  Here  we  can  indicate,  and 
briefly,  but  a  few.  Taylor  gives  one  of  corrosive  sublimate, 
gr.  xl ;  glycerin,  5j  ;  distilled  water,  5iij  ;  of  which  twelve 
drops  are  used  at  each  injection.  The  albuminate  of  mer- 
cury, dose  15    minims;    the   formamide  (Liebreich),  dose 


478  DISEASES    OF    THE    SKIN. 

one-half  to  a  whole  Pravaz  syringeful  of  a  one  per  cent,  solu- 
tion ;  calomel,  1  part,  to  liquid  vaseline,  12  parts,  dose  a 
half  Pravaz  syringeful  once  a  week  ;  "  gray  oil,"  composed 
of  20  parts  of  pure  mercury,  40  of  liquid  vaseline,  and  5  of 
ethereal  tincture  of  benzoin,  dose  one-third  of  a  syringe- 
ful every  ninth  day  ;l  salicylate,  15  grains  to  the  ounce,  and 
many  others.  A  final  judgment  as  to  the  comparative  merits 
of  the  many  salts  cannot  yet  be  given. 

Duration  of  mercurial  treatment.  How  long  the  patient 
should  take  mercury  is  a  question,  the  answer  to  which  is 
very  variously  given  by  different  authorities.  Keyes  puts 
it  at  from  eighteen  months  to  four  years.  Taylor  says,  "  at 
least  two  years  to  two  years  and  a  half,  counting  from  the 
date  of  the  commencement,"  but  he  advocates  intermissions 
of  from  two  to  three  months,  iodide  of  potassium  being  given 
in  the  meantime.  Schwimmer2  advocates  giving  mercury 
for  two  or  three  months,  and  then  one  of  the  iodides  for  two 
months  ;  after  four  or  five  months  of  treatment,  making  a 
pause  of  two  or  three  months,  treating  any  local  lesion 
locally,  and  then  repeating  the  course.  Fournier3  usually 
administers  mercury  for  six  to  nine  weeks ;  then  pauses  six 
weeks ;  then  gives  another  six  weeks'  medication.  During 
the  first  year  he  puts  the  patient  through  four  courses ; 
during  the  second  year,  three  courses  ;  and  during  the  third 
year,  two  courses.  During  the  fourth  year  he  gives  the 
iodide  alone  for  six  weeks,  with  corresponding  intervals. 
Crocker  advices  stopping  mercury  about  every  six  weeks  to 
give  the  iodide  for  a  week  or  ten  days.  At  the  end  of  six 
months,  if  the  patient  has  been  free  from  symptoms  for  two 
or  three  months,  a  month's  pause  may  be  made,  to  be  fol- 
lowed by  a  six  weeks'  course  of  mercury.  And  so  through 
the  first  year.  During  the  second  year  he  alternates  a  six 
weeks'  mild  mercurial  course  with  a  one  or  two  weeks'  course 
of  the  iodide.  If  still  free  from  lesions,  treatment  may  be 
suspended  until  some  symptom  crops  out. 

1  Leloir  and  Tavernier :  Giorn.  ital.  d.  Mai.  Ven.  e  del  Pelle,  1889, 
xxiv.  247. 

2  Second  Supplement  to  the  Monatshefte  f.  prakt.  Dermat.,  1888. 

3  Gaz.  des  Hop.  1889,  No.  103 


SYPHILIS.  479 

Against  these  advocates  of  long-continued  mercurial  treat- 
ment there  are  others,  no  less  eminent,  who  advocate  the 
administration  of  mercury  only  during  the  duration  of  the 
symptoms,  and  for  a  few  months  afterward  ;  then  they  advise 
to  suspend  all  treatment  until  some  new  outbreak  of  the 
disease  calls  for  it.  In  combating  so  insidious  a  disease  as 
syphilis,  it  seems  to  me  wisest  to  err  rather  on  the  side  of  too 
long  continued  treatment  than  on  that  of  a  too  short  course. 

Late  Syphilis.  If  a  patient  comes  to  us  with  a  late 
syphilide  who  has  not  been  under  systematic  treatment,  the 
so-called  mixed  treatment  will  be  most  appropriate  to  his 
case.  As  usually  administered  it  is  made  up  according  to 
one  of  the  following  formulas  : 

R.  Hydrarg.  bichlor.,Yel   \  .  .. 

Hydrarg.  biniodidi,       j  o  -J    J- 

Potass,  iodidi,  3J~ij- 

Inf.  gentian   co.,  vel     \  l      ? ' 

Syr.  sarsaparillse  co.,     |  ^     "  M. 

Dose :  A  teaspoonful  three  times  a  day  after  meals. 

Or, 

H.  Hydrarg  biniodidi,  gr.  ss-ij. 

Ammon.  iodidi,  sjss. 

Potass,  iodidi,  3  ij-  25  j . 

Syr.  aurant.  cort.,  Eiss' 

Tr.  aurant.  cort.,  3j. 

Aquae,  q.  s.  ad     ^llj.            M. 
Dose  :    A  teaspoonful,  in  water,  three  times  a  day.     (Keyes.) 

If  a  patient  comes  to  us  with  a  gumma,  an  ulcerative 
syphilide,  a  group  of  serpiginous  turbercular  syphilides  of 
the  tertiary  period ;  or  if  any  of  these  or  other  deep  lesions 
threatening  destruction  of  tissue  appear  early  in  a  case  of 
prococious  or  malignant  syphilis ;  or  if  the  disease  attacks 
the  nervous  system,  the  larynx,  pharynx,  or  eye ;  in  fact,  at 
any  time  when  there  is  need  of  prompt  effects,  we  must  ad- 
minister the  iodides.  The  iodide  of  potassium  is  most  gen- 
erally used,  and  next  to  it  the  iodide  of  sodium.  There 
is  no  set  dose  for  the  iodide.  It  is  best  given  in  a  dose  of 
five  grains  in  solution,  in  water,  three  times  a  day,  before 
meals,  diluted  in  milk  or  in  Vichy  or  soda-water ;  or  some 


480  DISEASES    OF    THE    SKIN. 

three  hours  after  meals.  Delavan1  has  found  that  the  iodide 
can  be  given  most  satisfactorily  by  putting  five  drops  of  a 
saturated  solution  in  the  bottom  of  a  small  tumbler,  with 
fifteen  drops  of  essence  of  pepsin,  and  pouring  upon  it  two 
ounces  of  warm  milk.  This  is  to  be  set  away  in  a  cool 
place,  and  will  form  a  rennet  custard,  which  can  be  easily 
swallowed.  This  a  good  method  when  we  wish  to  give 
nourishment  with  the  medicine,  and  the  mixture  can  be 
given  a  pleasant  taste  by  adding  a  teaspoonful  of  sherry 
wine. 

The  dose  should  be  increased  by  one  or  two  drops  each 
day ;  that  is,  six  drops  t.  i.  d. ;  then  seven  drops  t.  i.  d., 
and  so  on,  until  the  nose  runs  and  the  eyes  water,  or 
some  symptom  of  iodism  develops.  The  most  convenient 
method  of  administration  is  to  have  a  solution  made  con- 
taining one  grain  of  the  iodide  to  each  drop  of  the  solution, 
so  that  every  drop  represents  a  grain.  Most  patients  bear 
iodine  well,  but  in  some  even  drop  doses  produce  iodism. 
Iodic  acne  is  very  often  induced,  but  should  not  cause  us  to 
stop  using  the  drug.  It  is  advisable  to  suspend  the  admin- 
istration of  the  iodides  from  time  to  time,  and  to  give  mer- 
cury, which,  after  all,  must  be  depended  on  for  curing 
syphilis. 

Now  and  again  we  will  meet  with  cases  that  do  not  im- 
prove either  under  mercury  or  iodine,  but  relapse  and  relapse. 
Such  cases  should  be  sent  out  of  town,  ordered  change  of 
air  for  a  time,  and  put  on  a  purely  tonic  course  of  treatment. 
Very  often  when  the  patient  returns  home  he  can  take  his 
medication  easily,  and  the  previously  obstinate  lesions  will 
yield  readily.  This  is  but  what  we  said  at  first :  the  pa- 
tient's general  condition  must  all  the  time  be  carelully 
watched  over. 

Salivation  is  an  unpleasant  accident  that  may  occur  either 
under  the  use  of  mercury  or  iodine.  At  one  time  it  was 
quite  common  ;  indeed,  mercury  was  purposely  pushed  so 
far  as  "  to  touch  the  gums,'?  and  of  course  often  was  over- 
done.    Its  symptoms  are  tenderness  of  the  teeth,  so  that 

1  Med.  Kecord,  1891,  xl.  651. 


SYPHILIS.  481 

pain  is  felt  when  they  are  snapped  together,  one  jaw  on  the 
other ;  the  gums  are  swollen  ;  there  is  a  metallic  taste  in 
the  mouth ;  a  fetid  odor  of  the  breath ;  increased  flow  of 
saliva  by  day  and  night ;  all  the  mucous  membranes  of  the 
mouth  are  swollen,  so  much  so  as  to  interfere  with  mastica- 
tion and  deglutition,  and  in  very  bad  cases  there  may  be 
ulceration,  loosening  and  fall  of  the  teeth,  and  caries  of  the 
bones. 

Prevention  is  always  better  than  cure,  and  to  this  end  we 
should  see  that  our  patient's  teeth  are  in  good  order  before 
beginning  treatment,  and  direct  him  to  wash  his  mouth  fre- 
quently with  chlorate  of  potash  solution,  ten  or  fifteen  grains 
to  the  ounce,  and  keep  his  teeth  clean.  The  patient  should 
be  seen  frequen  tly  at  first,  so  as  to  stop  the  mercury  before 
salivation  attains  any  serious  degree.  Salivation  having 
begun,  the  mercury  must  be  stopped,  and  the  potash  solution 
in  some  strength  may  be  continued,  and  one  or  two  drachms 
of  the  salt  swallowed  during  the  day.  Dilute  solutions  of 
Labaroque's  solution,  or  permanganate  of  potash,  or  other 
astringent,  may  be  used  for  a  gargle  and  mouth-wash.  A 
laxative  should  be  administered,  the  patient  kept  warm  in 
bed,  and  if  necessary  an  anodyne  given. 

Local  Treatment.  While  internal  treatment  by  mer- 
cury and  the  iodides  is  quite  competent  to  remove  the  syph- 
ilodermata,  their  disappearance  can  be  materially  hastened 
by  local  treatment  by  means  of  mercurial  applications. 
Ointments  of  metallic  mercury,  of  the  ammoniate,  the  red 
oxide,  and  the  oleate,  with  solutions  of  the  bichlorides  are  the 
preparations  most  generally  employed. 

Many  attempts  have  been  made  to  abort  syphilis  by  ex- 
cision of  the  initial  lesion,  or  its  destruction  by  means  of 
caustics.  These  have  been  failures  in  most  instances.  This 
is  not  to  be  wondered  at  in  the  light  of  R.  W.  Taylor's 
recent  studies,1  which  show  that  "  in  the  very  first  days  of 
syphilitic  infection  the  poison  is  deeply  rooted  beneath  the 
initial  lesion  and  extends  far  beyond  it,  infecting  all  the 
parts  beyond,  even  to  the  root  of  the  penis."      The  initial 

1Med.  Eec,  1891,  xl.  1. 
21 


482  DISEASES    OF    THE    SKIN. 

lesion  should  be  dressed  with  iodoform  or  calomel,  or  kept 
covered  with  dry  lint  powdered  with  either  of  these. 

It  may  be  said  that  in  all  the  early  and  generalized  syph- 
ilides  local  treatment  need  practically  to  be  applied  only  to 
lesions  on  exposed  parts  ;  that  is,  face,  neck,  hands,  and 
wrists.  The  erythematous  syphilide  is  usually  so  epheme- 
ral that  no  local  treatment  is  necessary.  Mercurial  baths 
may,  however,  be  used  for  general  outbreaks  of  syphilis. 
If  the  erythematous  lesions  persist  upon  the  exposed  parts, 
their  departure  can  be  hastened  by  the  use  of  the  ointment 
of  the  ammoniate  of  mercury  rubbed  in  morning  and  night. 
The  same  ointment  may  be  applied  to  the  papular  syphilide. 
A  still  more  prompt  effect  can  be  produced,  if  the  patient 
can  be  seen  often  enough,  by  the  physician  touching  each 
lesion  with  a  solution  of  the  bichloride  in  alcohol,  five  or 
ten  grains  to  the  ounce,  according  to  the  size  of  the  lesions 
and  the  profuseness  of  the  eruption.  Of  course,  if  the  erup- 
tion is  very  profuse  this  plan  cannot  be  followed.  It  is 
most  applicable  to  a  sparse  and  relapsing  eruption.  The 
mucous  patch  should  be  touched  with  the  nitrate  of  silver 
stick.  Condylomata  are  best  treated  with  dusting  powders, 
preferably  calomel  freely  applied,  and  covered  with  absorbent 
cotton. 

The  squamous  syphilide  of  the  palms  and  soles  is  often 
obstinate,  but. will  usually  yield  to  the  persistent  use  of 
mercurial  ointment.  Sometimes  it  will  be  necessary  to 
soften  the  part  by  having  the  patient  wear  sheet  rubber  next 
the  skin  for  several  days,  and  then  use  the  ointment.  If 
they  are  covered  with  a  very  much  thickened  epidermis  we 
may  have  to  remove  this  by  using  salicylic  acid  as  in  chronic 
squamous  eczema.  Mercurial  plaster  worn  continuously  is 
efficient. 

The  tubercular  syphilide  occurring  discretely  can  be 
touched  with  the  bichloride  solution  already  mentioned. 
When  in  groups  it  is  best  treated  by  means  of  mercurial 
plaster. 

The  gumma  may  be  covered  with  mercurial  plaster  or 
ointment.  It  should  not  be  incised  unless  it  shows  unmis- 
takable evidences  of  containing  pus. 


SYPHILIS.  483 

Ulcers  following  whatever  lesion  may  be  covered  with 
mercurial  plaster  or  ointment,  or  dressed  with  iodoform  or 
aristol.  If  they  become  sluggish,  they  may  require  stimula- 
tion just  as  a  simple  ulcer  does.  To  this  end  we  may  touch 
them  with  balsam  of  Peru,  or  add  the  same  to  our  mercurial 
ointment.  Some  ulcers  will  do  best  under  the  treatment 
applicable  to  a  simple  ulcer,  while  the  iodide  of  potassium  is 
pushed. 

Treatment  of  Congenital  Infantile  Syphilis.  The 
most  popular  method  is  to  spread  upon  pieces  of  flannel  a 
piece  of  mercurial  ointment  of  about  the  size  of  the  end  of 
the  finger,  and  tie  this  one  day  over  the  elbows  ;  another  day 
over  the  groins ;  another,  over  the  knees ;  and  another,  over 
the  abdomen,  allowing  the  movements  of  the  child  to  work 
the  ointment  into  the  skin.  Or  hydrarg.  cum  creta,  one 
grain  three  times  a  day  may  be  given  by  the  mouth.  Monti1 
recommends  the  following  : 

R.  Calomel  pur.,  1 

Ferri  lactatis,  2 

Sacch.  alb..  3  M. 

Ft.  in  pulv.  no.  x. 

Sig.  1-4  powders  daily. 

The  greatest  attention  must  be  given  to  the  hygiene  of 
the  child,  and  to  its  diet.  The  nose  must  be  kept  clear,  and 
if  this  is  not  practicable  it  must  be  fed  with  a  spoon.  After 
the  disappearance  of  symptoms,  put  on  tonics,  one  of  the  best 
being  the  syrup  of  the  iodide  of  iron.  In  all  other  respects 
the  treatment  of  infantile  syphilis  is  the  same  as  that  of  the 
acquired  form.  Kaposi  commends  the  tannate  of  mercury  for 
children ;   dose,  J  gr.  to  f  gr.,  t.  i.  d. 

Prognosis.  The  prognosis  of  syphilis  as  seen  at  the 
present  time  and  in  this  country  may  be  said  to  be  good. 
Many  cases  go  no  further  than  a  general  erythematous  or 
papular  eruption,  even  when  untreated.  In  one  of  robust 
health  the  disease  is  usually  readily  manageable.  In 
debilitated  subjects  it  sometimes  proves  intractable.  The 
worst  feature  of  the  disease  is  the  great  uncertainty  of  its 

1  Archiv  f.  Kinderheilk.,  1885,  vi.  1. 


484  DISEASES    OF    THE    SKIN. 

course,  no  one  being  able  to  promise  confidently,  no  matter 
with  what  treatment,  that  relapses  and  late  visceral  syphilis 
will  not  occur.  Therefore,  the  prognosis  should  be  guarded, 
while  it  is  remembered  that  rare  cases  of  secondary  infection 
attest  the  possibility  of  complete  recovery. 

The  prognosis  of  congenital  syphilis  is  not  as  good  as  is 
that  of  the  disease  as  it  affects  adults.  Many,  perhaps  most, 
of  the  cases  seen  in  public  institutions  die.  In  private  prac- 
tice more  can  be  done,  and  we  should  always  count  upon  the 
remarkable  reparative  powers  of  childhood  in  making  our 
prognosis.  A  great  deal  will  depend  upon  the  inborn  vigor 
of  the  child. 

Syringomyelia  (Si2r-i2n-go  mi-el'i2-as)  is  a  disease  of  the 
spinal  cord,  the  consideration  of  which  belongs  rather  to  the 
neurologist  than  the  dermatologist.  It  interests  us  because 
various  cutaneous  lesions  occur  during  its  course,  such  as 
glossy  skin,  hyperkeratosis,  hyperidrosis,  and  paronychia 
with  necrosis  of  the  phalanges  ;  and  because  in  some  phases 
it  resembles  certain  stages  of  leprosy. 

Syringocystadenoma.  This  is  the  name  given  by 
Unna  and  Torok1  to  a  peculiar  disease  of  the  skin  that 
probably  begins  in  embryonic  sweat  glands.  The  case  they 
described  was  of  seventeen  years'  standing  and  was  located 
upon  the  chest  and  abdomen.  It  began  in  the  neighborhood 
of  the  axillae  and  spread  forward  and  downward.  The  erup- 
tion consisted  of  a  number  of  small,  round,  hard,  raised 
papules  of  the  color  of  the  skin,  which  tended  to  grow  larger 
and  become  of  a  bluish-red  color.  There  were  no  subjective 
symptoms.  It  is  supposed  by  Besnier  to  be  identical  with 
the  multiple  tuberous  lymphangioma  of  Kaposi. 

Tache  Atrophique.     See  Atrophoderma. 

Tache  Bleue.     See  Pediculosis. 

Tache  Cafe-au-lait.     See  Nrevus. 

Tache  Congenitale.     See  Nsevus. 

Tache  de  Feu.     See  Naevus. 

1  Monatsheft.  f.  prakt.  Derm.  1889,  viii,  116. 


TELANGIECTASIS.  485 

Tache  Hemorrhagique.     See  Naevus. 
Tache  Pigment  aire.     See  Nsevus. 
Tache  Vasculaire.     See  Nsevus. 
Tache  Vineuse.     See  Naevus. 
Tache  Hepatique.     See  Chromophytosis. 
Tache  Ombrees.     See  Pediculosis. 
Tan.     See  Lentigo. 
Tanne.     See  Acne. 

Tattoo.  These  well-known  stainings  of  the  skin  by  means 
of  India-ink,  vermilion,  charcoal,  and  gunpowder,  although 
at  first  objects  of  pride  to  the  boy  or  girl,  later  are  apt  to 
become  objects  of  aversion.  They  are  very  difficult  to 
remove ;  indeed,  it  is  almost  impossible  to  remove  them  if  they 
are  at  all  extensive.  Patient  perseverance  in  going  over 
and  over  the  small  ones,  that  cannot  be  excised,  with  the 
electrolytic  needle  will  sometimes  greatly  lessen  them, 
though,  of  course,  we  thereby  substitute  a  white  cicatricial 
spot  for  a  colored  one.  The  needle  should  be  introduced 
perpendicularly  to  the  skin  and  deeply,  and  numerous  punc- 
tures arranged  in  rows  thus  made.  This,  of  course,  is  a 
very  slow  procedure.  Powder-grains  may  be  removed  by 
Keyes's  punch,  by  making  a  half  turn  over  them,  and  then 
snipping  off  the  small  piece  with  the  scissors.     (Fig.  47.) 

Fig.  47. 


O  "fa  OF  REAL  SIZE. 

Keyes's  punch. 

Teigne  Faveuse.     See  Favus. 

Teigne  Granulee.     See  Pediculosis. 

Teigne  Pelade.     See  Alopecia  areata. 

Teigne  Imbriquee.     See  Trichophytosis  corporis. 

Teigne  Tondante  seu  Tonsurante.     See  Trichophytosis 
capitis. 

Telangiectasis    (Te^-a^-jiWk'taVi's).     This  is  an  ac- 


486  DISEASES    OF    THE    SKIN. 

quired  dilatation  of  the  bloodvessels.  The  condition  is  well 
seen  in  rosacea.  But  it  seems  to  me  best  to  reserve  the 
term  for  those  cutaneous  lesions  in  which  acquired  dilata- 
tion of  the  bloodvessels  of  the  skin  is  the  only  condition 
present. 

Symptoms.  The  most  common  form  of  the  disease  is 
what  is  vulgarly  called  "  spider  cancer  "  or  ncevus  araneus. 
It  occurs  in  nearly  all  cases  upon  the  cheeks,  near  the  eye- 
lids or  bridge  of  the  nose,  or  indifferently,  but  may  occur 
anywhere.  It  is  usually  a  single  lesion,  and  consists  in  a 
small,  central,  bright-red,  slightly  raised  dot  from  which 
radiate  fine  red  lines.  They  sometimes  become  quite  large, 
though  usually  not  more  than  a  half-inch  in  diameter.  This 
form  is  seen  in  women  and  children.  It  occasionally  fol- 
lows some  slight  injury,  but  very  often  seems  to  come 
spontaneously. 

Telangiectases  in  the  form  of  simple  dilated  bloodvessels 
of  varying  size  and  shape  are  often  seen.  Under  the  same 
heading  Crocker  places  those  slightly  convex  or  flat,  hemp- 
seed-sized,  raised,  bright  crimson  or  purplish  spots  met  with 
in  old  people.  Their  favorite  site  is  the  upper  part  of  the 
trunk,  neck,  and  face. 

Teeatment.  The  treatment  of  telangiectasis  is  simple. 
It  is  only  necessary  to  introduce  the  electrolytic  needle  into 
the  red  central  spot,  and  turn  on  a  current  of  about  two  mil- 
liamperes.  The  mode  of  operating  is  similar  to  that  used  in 
destroying  superfluous  hair,  and  is  described  in  the  section 
on  Hypertrichosis. 

Tetter.     See  Eczema. 

Tinea  Amiantacea.     See  Seborrhcea. 

Tinea  Asbestina.     See  Seborrhoea. 

Tinea  Circinata.     See  Trichophytosis  corporis. 

Tinea  Cruris.     See  Trichophytosis  corporis. 

Tinea  Decalvans.     See  Alopecia  areata. 

Tinea  Favosa.     See  Favus. 

Tinea  Furfuracea.     See  Seborrhoea. 

Tinea  Imbricata.     Trichophytosis  corporis. 


TRICHOPHYTOSIS.  437 

Tinea  Kerion.     See  Trichophytosis  capitis. 

Tinea  Nodosa.  Under  this  name  and  that  of  Leptothrix, 
Paxton's  disease,  and  Trichomycosis  nodosa  have  been 
described  cases  of  parasitic  involvement  of  the  hair  which 
causes  the  hair  to  become  brittle  and  break  with  a  feathery 
fracture,  as  in  trichorrhexis  nodosa.  Besides  this  damage 
to  the  hair,  nodular  swellings  form  along  the  shaft. 
Leptothrix  involves  the  hair  of  the  axillae  and  scrotum, 
while  the  name  tinea  nodosa  has  been  applied  to  these  ap- 
pearances occurring  on  the  whiskers  and  beard.  They  are 
doubtless  allied  to  piedra.  A  somewhat  similar  disease  was 
described  by  Beigel  as  due  to  what  he  called  the  "  chignon 
fungus." 

Tinea  Sycosis.     See  Trichophytosis  barbae. 

Tinea  Tondens.     See  Trichophytosis  capitis. 

Tinea  Tonsurans.     See  Trichophytosis  capitis. 

Tinea  Trichophytina.     See  Trichophytosis. 

Tinea  Versicolor.     See  Chromophytosis. 

Trichauxis.     See  Hypertrichosis. 

Trichiasis  (Trrk-i2-a'si2s).  This  is  a  congenital  or  ac- 
quired displacement  of  the  ciliae  so  that  they  point  backward 
and  scratch  the  cornea.  Both  lids  of  both  eyes  are  usually 
affected.  The  best  treatment  is  the  destruction  of  the  hair 
by  means  of  the  electrolytic  needle,  as  described  in  the  sec- 
tion upon  Hypertrichosis. 

Trichomycose  Noueuse.     See  Piedra. 

Trichomycosis  Nodosa.     See  Piedra. 

Trichonosis  Cana  vel  Discolor.     See  Canities. 

Trichonosis  Furfuracea.     See  Trichophytosis  capitis. 

Trichophytie  Circinee.     See  Trichophytosis  corporis. 

Trichophytie  Sycosique.     See  Trichophytosis  barbae. 

Trichophytosis  (TrPk-o^frVo's^s).  A  contagious  dis- 
ease of  the  skin  and  hair,  occurring  most  often  in  children, 
due  to  the  invasion  of  the  epidermis  by  the  trichophyton 
fungus,  and  characterized  by  the  formation  of  circular  or 
annular  scaly  patches,  and  partial  loss  of  hair. 


488  DISEASES    OF    THE    SKIN. 

As  its  name  indicates,  this  is  a  disease  produced  by  the 
trichophyton  fungus.  It  may  find  lodgment  and  growth 
on  the  general  cutaneous  surface,  in  the  scalp,  beard,  or 
nails,  that  is  in  the  epidermic  structures.  In  these  different 
localities  it  develops  so  differently  as  to  produce  very  differ- 
ent clinical  pictures.  We  shall  describe  each  one  by  itself 
and  give  its  differential  diagnosis,  treating  all  matters  of 
etiology  and  treatment  collectively. 

Trichophytosis  Corporis.  Synonyms :  Tinea  circina- 
tus  ;  Herpes  circinatus ;  (Fr.)  Herpes  circine,  Trichophytie 
circinee  ;  (Ger.)  Scheerende  Flechte  ;  Ringworm  of  the  body. 

Symptoms.  This  is  the  simplest  and  most  readily  cured 
of  all  the  forms  of  ringworm.  It  begins  as  a  small,  pale- 
red,  slightly  raised  spot,  which,  growing,  spreads  out  into  a 
round,  sharply  defined,  scaly  patch ;  then  it  clears  up  in 
the  middle,  becomes  ring-shaped  and  advances  with  a  raised 
border  that  may  be  vesicular  ;  or  crusted  from  the  drying 
of  the  vesicular  contents ;  or  papular  and  scaly.  After  a 
time  it  either  ceases  to  spread,  or,  enlarging,  the  edge  of  the 
ring  becomes  broken  in  places.  At  last  it  undergoes  spon- 
taneous involution.  There  may  be  but  a  single  patch,  or 
there  may  be  a  number  of  patches.  If  two  circles  meet 
at  their  peripheries,  they  coalesce  and  form  gyrate  figures. 
Very  often  rings  do  not  form  and  wTe  have  only  a  round, 
sharply  defined,  scaly,  circular  patch.  The  exposed  parts — 
face,  hands,  and  neck — are  the  most  common  sites  for  the 
eruption.  In  rare  cases  ringworm  may  be  widely  dissemi- 
nated over  the  body.  A  slight  amount  of  itching  is  the 
only  subjective  symptom,  and  that  may  be  wanting. 

Another  form  of  ringworm  of  the  body  is  that  known  as 
eczema  marginatum,  which  is  ringworm  located  in  the  crotch 
or  axilla.  It  is  usually  of  a  more  highly  inflammatory  char- 
acter than  the  same  disease  on  other  parts  of  the  body,  and  re- 
sembles an  eczema  very  closely — in  fact,  it  is  often  compli- 
cated by  an  eczema.  The  edge  of  the  patch  is  sharply 
defined,  raised,  scalloped,  papular,  and  scaly,  while  the 
centre  may  be  smooth,  or  pigmented  and  crusted.  The 
patch  often  attains  large  dimensions,  running  down  the  in- 
side of  the  thigh,  up  over  the  abdomen,  and  backward  over 


TRICHOPHYTOSIS.  489 

the  perineum.  Usually  the  inside  of  both  thighs  is  affected. 
There  is  considerable  itching.  The  same  symptoms  are 
presented  when  the  axillae  are  affected. 

Tinea  imbricata  is  supposed  to  be  a  very  aggravated  form 
of  body  ringworm  occurring  in  tropical  countries.  But 
Manson1  says  that  it  differs  from  ordinary  ringworm  in 
affecting  a  very  large  part  of  the  body  at  the  same  time ; 
in  avoiding  hairy  parts,  and  sparing  the  hair;  in  an  ab- 
sence of  signs  of  inflammation ;    in  not  forming  a  single 

©  '  o  © 

ring,  but  ring  within  ring,  and  recurring  in  parts  gone 
over ;  in  having  large  abundant  scales ;  in  profuse  fungus 
growth ;  in  always  breeding  true  in  inoculation  experi- 
ments ;  and  in  occurring  only  in  certain  parts  of  the 
world. 

Diagnosis.  Trichophytosis  corporis  is  readily  diagnosed, 
as  its  appearance  is  distinctive.  Favus  of  the  body  may 
spread  out  into  a  circular  patch,  but  soon  it  will  show  the 
distinctive  sulphur-yellow  cupped  crusts.  Psoriasis  on  the 
body  will  have  a  brighter  red  color ;  its  scales  will  be  more 
abundant,  thicker,  and  brighter  :  it  will  be  found  on  the  tips 
of  the  elbows  and  over  the  knees,  and  will  be  more  profuse 
and  disseminated ;  and  examination  of  the  scales  will  show 
an  absence  of  fungus.  The  scaling  papular  syphilide  or  the 
squamous  syphilide  will  not  itch ;  there  will  be  no  fungus  in 
the  scales ;  the  color  will  be  raw-ham ;  the  base  will  be 
more  infiltrated  ;  it  will  run  a  more  chronic  course ;  and 
will  not  yield  so  readily  to  treatment.  Seborrhea  of  the 
chest  may  occur  in  rings,  but  its  location  will  suggest  its 

e.  ©      '  _  CO 

origin  ;  the  skin  will  be  greasy,  the  scales  will  rub  off  easily, 
and  there  is  no  fungus  in  them.  Eczema  of  the  crotch  or 
axilla  differs  from  ringworm  of  the  same  region  in  not  having 

©  ©  O 

a  so  sharply  defined  and  scalloped  or  festooned  border ;  in 
forming  a  more  evenly  diseased  patch  with  no  sound  skin  in 
it ;  and  in  having  no  fungus  in  the  scales  taken  from  it. 
Pityriasis  rosea  is  more  widely  distributed  than  is  ringworm, 
and  spreads  more  rapidly ;  it  is  not  so  scaly ;  has  a  more 
yellowish  center ;  is  usually  most  abundant  on  the  trunk ; 

1  Brit.  Journ.  of  Dermatol.,  1892,  iv.  5. 
21* 


490  DISEASES    OF    THE    SKIN. 

shows  no  fungus  under  the  microscope ;  and  the  eruption  is 
made  up  both  of  macules  and  rings. 

Trichophytosis  Capitis.  Synonyms:1  Herpes  tonsu- 
rans, seu  circinatus,  seu  squamosus ;  Tinea  tonsurans,  seu 
tondens ;  Porrigo  furfurans ;  Dermatomykosis  tonsurans 
(Kobner);  (Fr.)  Herpes  tonsurante,  Teigne  tondante  ou 
tonsurante,  L'herpes  circine  parasitaire  ;  (Grer.)  Scheerende 
Flechte  ;  (Slav)  Ringskurv  ;  Ringworm  of  the  scalp. 

Symptoms.  This  form  of  ringworm  is  seen  almost  exclu- 
sively in  infants  and  children.  As  puberty  or  early  adult 
life  is  reached  the  disease,  no  matter  how  long  continued,  and 
how  severe  it  may  be,  tends  to  get  well,  of  itself.  It  begins 
as  a  single  vesicle  or  a  small,  insignificant,  red,  scaly  spot 
that  would  pass  without  suspicion  of  its  nature  unless  other 
cases  of  ringworm  put  us  on  our  guard.  From  this  small 
beginning  the  disease  spreads  peripherally  to  form  a  circular 
patch,  which  is  red,  covered  with  grayish  scales,  sharply 
defined,  perhaps  slightly  elevated,  and  partially  bald.  In- 
spection of  the  patch  will  show  a  number  of  broken-off 
stumps  of  hair  with  split  ends.  These  stumps  are  char- 
ateristic  of  the  disease.  The  hair  growing  in  and  about  the 
patch  is  dry,  lustreless,  split,  and  brittle.  Attempts  at 
epilation  break  it  off,  and  if  it  is  indented  with  the  finger- 
nail it  will  take  a  sharp  angle  and  retain  it.  This  shows 
that  it  has  lost  its  resiliency.  Apparently  healthy  hairs  are 
sometimes  growing  from  the  patch.  The  size  of  the  patch 
varies  greatly.  It  may  be  no  larger  than  that  of  a  ten-cent 
piece,  or  it  may  be  so  large  as  to  denude  a  good  part  of  the 
scalp.  These  large  patches  are  usually  formed  by  the  co- 
alescence of  several  small  ones,  and  then  they  lose  their 
circular  outline  and  become  wavy.  There  may  be  but  a 
single  patch,  or  there  may  be  a  number  of  them.  After 
attaining  the  size  of  a  half-inch  to  one  inch  in  diameter,  the 
patches  may  remain  stationary  in  size,  or  increase  slowly. 
The  most  frequent  sites  are  the  vertex  and  parietal  regions. 
Pruritus  of  greater  or  less  degree  is  usually  complained  of, 

1  We  can  mention  here  only  the  more  common  ones,  as  their  number 
is  legion. 


TRICHOPHYTOSIS.  491 

and  it  may  be  the  first  symptom  that  draws  the  attention  to 
the  child's  scalp.  The  course  of  the  disease  is  exceedingly 
chronic.     It  does  not  produce  permanent  baldness. 

This  is  the  typical  "ringworm,"  as  seen  in  the  vast  ma- 
jority of  cases.  Sometimes,  instead  of  being  scarcely  or 
not  at  all  raised  above  the  surface  of  the  skin,  the  patch, 
usually  a  single  one,  begins  to  swell  up,  become  raised,  un- 
even, and  boggy,  and  we  have  the  condition  of  things  de- 
scribed as  kerion  (which  see).  Another  variety  is  what 
Liveing  terms  "bald  tinea  tonsurans.''  This  begins  as  an 
ordinary  ringworm,  but  after  a  time  the  hair  all  falls  out, 
the  scalp  is  smooth  and  without  scales,  as  in  alopecia  areata, 
and  at  its  border  there  may  be  found  short  broken  hairs, 
like  those  seen  in  the  latter  disease.  At  first  this  change 
takes  place  in  one  patch  alone,  and  we  will  be  guided  to  a 
right  diagnosis  of  the  disease  by  the  appearances  of  the 
other  patches.  Later,  these  too  become  altered,  and  then  it 
would  be  hard  to  make  the  diagnosis  without  the  history  of 
there  having  been  scaly  patches.  This  is  an  infrequent  form 
of  the  disease. 

Still  another  form  is  called  "  disseminated  ringworm." 
Here  the  patchy,  areated  character  of  the  disease  has  disap- 
peared, the  hair  has  apparently  grown  in  nicely,  and  there 
is  seemingly  only  a  scurvy  condition  of  the  scalp.  This  is 
a  dangerous  form,  because  the  child  is  often  regarded  as  well, 
and  yet  is  quite  capable  of  spreading  infection.  Careful 
examination  of  the  case,  by  causing  the  child  to  stand  with 
his  back  to  the  physician,  and  turning  the  hair  slowly  back- 
ward against  its  direction  of  growth,  will  show  here  and 
there  "  stumps,"  and  also  the  presence  of  hairs  that  stand  up 
from  the  head  for  a  few  moments.  Normal  hair  falls  quietly 
and  quickly  back  into  place,  which  is  not  the  case  with  hair 
affected  with  ringworm. 

A  pustular  form  is  sometimes  described.  It  is  simply  a 
ringworm  occurring  in  a  strumous  subject  in  whom  all  in- 
flammatory skin  diseases  are  prone  to  assume  a  pustular 
character. 

Diagnosis.  Trichophytosis  capitis  must  be  differentiated 
from  alopecia  areata,  favus,  eczema,  seborrhcea,  and  psori- 


492  DISEASES    OF    THE    SKIN. 

asis.  From  alopecia  areata  it  differs  in  being  scaly ;  in  not 
producing  perfectly  bald  patches ;  in  its  much  slower  prog- 
ress ;  in  the  presence  of  "  stumps;"  and  in  having  the 
trichophyton  fungus  in  the  hair,  as  seen  under  the  micro- 
scope. From  favus  it  differs  in  the  absence  of  the  sulphur- 
yellow  cupped  crusts  of  that  disease ;  in  not  having  such 
heaped  up  asbestos-like  crusts ;  in  forming  distinct  round 
patches ;  in  the  more  brittle  character  of  its  hair ;  in  not 
producing  red,  smooth,  permanently  bald  spots  that  later 
become  white  and  cicatricial,  and  in  showing  a  marked  ten- 
dency to  get  well  of  itself  as  puberty  is  reached.  The  diag- 
nosis between  them  by  the  microscope  is  not  easy  without  a 
knowledge  of  the  appearances  on  the  skin.  The  spores  of 
favus  are  more  polymorphous  and  somewhat  larger  than  those 
of  trichophytosis,  and  its  mycelia  are  more  abundant  than  its 
spores.  From  eczema  it  differs  in  the  more  circumscribed  and 
circular  character  of  its  patches ;  in  being  less  itchy,  and  in 
the  presence  of  broken-off  hairs  and  stumps.  The  presence 
of  these  broken-off  hairs  and  stumps,  and  of  the  fungus  in 
the  hair  and  scales  will  sufficiently  distinguish  ringworm 
from  both  seborrhoea  and  psoriasis. 

Trichophytosis  Barbae.  Synonyms :  Tinea  sycosis,  seu 
barbae ;  Sycosis  parasitaria,  seu  parasitica ;  Herpes  ton- 
surans barbae;  (Fr.)  Trichophytie  sycosique,  Sycosis  para- 
sitaire  ;  (Gr.)  Parasitische  Bartfinne  ;  (It.)  Sicosi  parasitaria ; 
(Eng.)  Barber's  itch,  Ringworm  of  the  beard. 

When  the  trichophyton  invades  the  beard,  at  first  it  forms 
simply  a  superficial  scaly  circular  patch  which  increases  in 
size,  just  as  on  the  scalp,  producing  broken-off  hairs  and  a 
partially  bald  area.  There  are  usually  several  of  these  areas 
upon  the  chin  and  cheeks.  If  not  checked  by  treatment  we 
have  the  more  characteristic  development  of  the  disease,  in 
which  there  will  be  either  some  pustules,  pierced  by  hairs,  or 
else  a  group  of  large  nodular  swellings,  varying  in  size  from 
a  split-pea  to  a  half- cherry,  arranged  in  the  form  of  a  circle. 
There  are  usually  several  groups  of  them.  The  nodules  are 
prominently  raised  and  usually  rounded.  (Fig.  48.)  They 
are  of  a  congested  red  or  purple  color.  They  may  be 
hard   and  scaly ;   or  give  exit  to  a  sticky  discharge ;   or, 


TRICHOPHYTOSIS. 


493 


rarely,  suppurate.  The  hair  over  them  is  broken,  or  more 
or  less  -wanting.  Usually  itching  and  burning  are  com- 
plained of. 


Fig.  48. 


Trichophytosis  barbae. 


Diagnosis.  The  disease  is  to  be  differentiated  from 
sycosis,  pustular  eczema,  and  the  tubercular  syphilide.  From 
sycosis  it  differs  in  affecting  the  lower  part  of  the  face  and 
sparing  the  upper  lip  ;  in  presenting  broken-off  hair  ;  in 
having  grouped  nodules  ;  and  in  the  presence  of  the  fungus 
in  the  hair.  Sycosis  is  more  acute  in  its  manifestations, 
and  is  characterized  by  its  many  discrete  pustules  pierced 
by  hair.  From  eczema  it  differs  in  the  same  points  as  it 
does  from  sycosis  and  also  in  being  less  crusted,  and  in  the 
ease  with  which  the  hair  can  be  plucked  or  will   break. 


494  DISEASES    OF    THE    SKIN. 

Eczema  is  also  a  disease  of  the  skin  and  not  of  the  hair.  The 
tubercular  syphilide  does  bear  a  resemblance  to  trichophy- 
tosis barbae  at  times.  It  differs  in  forming  but  a  single 
group,  in  being  of  a  darker  color,  and  in  undergoing  a 
steady  course  of  development  toward  final  recovery,  leaving, 
not  infrequently,  permanent  scars.  Other  symptoms  of 
syphilis  will  often  be  found,  and  its  whole  history  will  be 
different. 

Trichophytosis  unguium,  or  onycho-mycosis,  is  ringworm 
as  it  affects  the  nails.  It  begins  as  a  change  in  color  of  the 
nail-substance  and  with  a  loss  of  its  transparency.  The  nail 
becomes  uneven  and  thickened,  and  its  edge,  which  is  usu- 
ally the  part  first  attacked,  becomes  raised  from  its  bed  by 
an  accumulation  of  scaly  matter  under  it.  A  progressive 
atrophy  takes  place,  and  at  last  the  nail  breaks  and  falls 
either  in  part  or  as  a  whole.  There  may  be  but  one  nail 
affected,  or  all  the  nails  both  of  the  hands  and  feet  may  be 
attacked,  then  usually  consecutively. 

Diagnosis.  The  appearances  presented  by  the  nails  are 
so  similar  to  those  seen  in  psoriasis,  and  other  diseases  in 
which  the  nails  become  atrophied,  that  a  positive  diagnosis 
can  be  made  by  the  microscope  alone,  unless  there  should 
be  symptoms  of  the  one  or  the  other  disease  present  else- 
where on  the  body  as  a  guide. 

Having  now  described  the  different  varieties  of  ringworm 
with  their  differential  diagnosis,  we  pass  on  to  study  the  fac- 
tors common  to  all. 

Etiology.  The  cause  of  the  disease  is  contagion  with 
the  trichophyton  fungus.  This  contagion  may  be  direct, 
from  person  to  person,  or  indirect  by  means  of  brushes, 
towels,  clothing,  and  the  like.  It  is  possible  that  the  air 
may  become  so  full  of  the  fungus  in  epidemcs  in  crowded 
children's  asylums  that  contagion  may  be  by  means  of  the 
fungus  lighting  upon  the  head  or  body.  The  disease  is 
very  contagious,  much  more  so  than  is  favus. 

As  the  disease  is  quite  common  in  dogs,  cats,  and  horses, 
constituting  in  them  one  form  of  mange,  they  form  a  very 
frequent  source  of  contagion.     Ringworm  of  the  scalp  is 


TRICHOPHYTOSIS. 


495 


often  communicated  by  means  of  brushes  and  headgear. 
Ringworm  of  the  beard  is  conveyed  by  means  of  brushes, 
towels,  and  the  barber's  fingers.  Ringworm  of  the  nail 
comes  from  scratching.  Some  skins  seem  to  furnish  a 
better  soil  for  the  growth  of  the  fungus  than  do  others. 
Children  have  ringworm  of  the  scalp  ;  adults  almost  never. 
There  is  no  peculiarity  of  constitution  that  predisposes  to 
the  disease.  It  attacks  all  classes  and  conditions  of  society, 
though,  of  course,  it  is  most  common  among  the  crowded 
poor. 

Fig.  49. 

I » IB » a'|       q-  .         >  -.  ■     .-,  -  *  .    ~  '       -V    U    : 

^W^--ih-s  i1:'  i h "i ■  i " :=  f ■■         ■-' 


4'K 


Trychophyton   tonsurans  in  hair  shaft  and  follicle.     (After  Kaposi.) 


Pathology.  The  trychophyton  tonsurans,  the  fungus  of 
ringworm,  has  its  habitat  in  the  epidermic  structures  of 
the  skin.  On  the  general  cutaneous  surface  it  is  so  super- 
ficially located  as  to  be  readily  destroyed.  When  it 
attacks  the  hair  and  nails  it  penetrates  below  the  skin  in 
their  epidermic  structures,  and  is  much  more  difficult  of 
cure. 

The  exact  botanical  position  of  the  fungus  is  not  yet  deter- 


496  DISEASES    OF    THE    SKIN. 

mined,  but  there  is  no  doubt  but  that  it  is  a  special  form  of 
fungus.  (Fig.  49.)  It  consists  in  mycelia  and  conidia 
(spores),  the  proportion  of  which  to  each  other  varies  ;  in  the 
hair  of  the  scalp  and  beard  the  number  of  spores  far  exceeds 
that  of  the  mycelia.  Sometimes  they  are  so  numerous  as  to 
be  crowded  together  in  lines.  On  the  general  surface  the 
mycelia  are  far  more  numerous.  They  are  long,  slender, 
branched,  straight,  or  crooked  bodies.  The  spores  are 
round,  small,  and  refract  light.  Having  become  lodged  in 
the  skin  the  fungus  always  sets  up  a  certain  amount  of  irri- 
tation by  its  processes  of  growth.  If  it  lands  upon  hairy 
regions  it  attacks  the  hair  secondarily,  passing  down  the  walls 
of  the  hair  follicle  to  a  greater  or  less  depth  before  it  pene- 
trates the  cuticle  of  the  hair  and  gains  access  to  its  sub- 
stance. Having  gained  access,  it  vegetates  freely  and  may 
often  be  traced  throughout  the  whole  length  of  the  hair. 
Robinson  and  others  have  found  the  fungus  in  the  peri-follic- 
ular  tissue.  Its  presence  always  causes  more  or  less  peri- 
folliculitis, and  this  is  much  more  intense  in  the  beard  than 
in  the  scalp  hair,  which,  together  with  the  looseness  of  the 
subcutaneous  connective  tissue  in  the  beard,  will  explain 
the  reason  why  we  have  the  nodules  form.  If  the  peri- 
folliculitis is  very  great,  permanent  baldness  may  result.  In 
trichophytosis  unguium  the  fungus  grows  in  the  substance 
of  the  nails. 

Treatment. — There  is  no  disease  of  the  skin  much  more 
easy  of  cure  than  trichophytosis  of  the  general  surface  of 
the  skin,  and  none  much  more  difficult  of  cure  than  tricho- 
phytosis capitis. 

Trichophytosis  corporis  may  be  readily  cured  with  almost 
any  slightly  irritating  and  astringent  application,  and  by  all 
the  antiparasitics.  The  old  women  cure  it  by  means  of 
common  ink,  or  by  using  vinegar  in  which  a  copper  coin 
has  been  soaked.  We  can  direct  that  the  scales  be  removed 
with  soap  and  water,  and  an  ointment  of  sulphur,  or  am- 
moniate  of  mercury,  or  chrysarobin,  or  pyrogallol  be  applied, 
or  simply  paint  the  patch  with  tincture  of  iodine,  acetic  or 
sulphurous  acid,  or  a  solution  of  bichloride  of  mercury,  three 
to  five  grains  to  the  ounce.     The  last  is  a  good  method  for 


TRICHOPHYTOSIS.  497 

adults,  as  it  does  not  stain  the  skin,  and  one  application  will 
usually  cure  the  disease.  It  is  rather  too. strong  for  chil- 
dren. Other  applications  are  a  solution  of  hyposulphite  of 
soda,  two  drachms  to  the  ounce ;  oleate  of  copper,  half  a 
drachm  to  the  ounce  of  ointment ;  and  salicylic  acid,  5  or 
10  per  cent,  strength,  which  by  no  means  exhausts  the  list. 

Trichophytosis  cruris  et  axillae  is  not  so  easy  to  cure  as 
the  preceding  variety,  but  it  can  be  cured  by  any  of  the 
means  detailed  above.  In  using  chrysarobin,  here  as  else- 
where, we  should  bear  in  mind  its  irritant  qualities.  Tay- 
lor has  recommended  painting  the  part  with  two  to  four 
grains  of  bichloride  of  mercury  in  one  ounce  of  tincture  of 
benzoin.  Hardaway  speaks  well  of  modified  Wilkinson's 
ointment. 

Trichophytosis  capitis  is  the  most  obstinate  form  of 
ringworm  to  cure.  The  fungus  is  present  abundantly 
deep  down  in  the  skin,  and  each  hair  is  a  separate  focus 
of  disease.  The  difficulty  we  have  to  contend  against  is  to 
cause  our  remedies  to  enter  the  skin  deeply  enough  to  de- 
stroy the  fungus.  Nature  gives  us  a  hint  as  to  the  cure  of  the 
disease  when  a  kerion  forms  thai:  is  not  infrequently  followed 
by  disappearance  of  the  disease.  Most  of  the  so-called  reme- 
dies for  ringworm  are  irritants  to  the  skin,  and  do  good  quite 
as  much  by  the  irritation  they  cause  as  by  their  parasiticide 
properties. 

If  we  see  the  case  at  its  earliest  stage  we  may  sometimes 
succeed  in  aborting  the  disease  by  the  application  of  the 
bichloride  of  mercury,  five  or  ten  grains  to  the  ounce. 
Usually,  when  the  case  is  brought  to  us,  it  has  gone  too 
far  for  aborting  it.  Then  we  may  sometimes  cure  the  case 
promptly,  but  most  often  it  is  an  affair  of  months  and,  per- 
haps, years.  The  first  requisite  for  a  cure  is  faith  on  the 
part  of  the  patient,  so  that  the  second  element,  persistency, 
can  come  into  play ;  and  then  by  the  persevering  use  of 
parasiticides  a  cure  may  be  effected.  As  each  case  is  a 
source  of  contagion,  steps  must  be  taken  to  isolate  the  case 
if  it  occur  in  an  asylum  or  school.  If  it  occur  outside  of  an 
institution,  the  parents  must  be  cautioned  not  to  allow  the 
child's  hat  or  clothing  to  be  worn  by  any  other  child,  and 
the  child  must  be  taken  out  of  school.     To  still  further 


498  DISEASES    OF    THE    SKIN. 

assure  the  safety  of  others,  an  antiparasitic  must  be  applied 
to  the  child's  head,  such  as  a  1  or  2  per  cent,  solution  of 
salicylic  acid  in  alcohol  and  castor  oil.  The  child  should 
also  wear  a  linen  cap  over  the  whole  head.  These  regula- 
tions are  difficult  to  carry  out  in  private  practice. 

The  ringworm  patch  or  patches  should  be  scrubbed  with 
soap  and  water  so  as  to  remove  all  the  scales  before  we  make 
any  local  application.  Tar  soap  is  a  good  one  to  use  for  the 
purpose.  Then  the  hair  should  either  be  cut  short,  pulled 
from,  or  shaved  off  the  patches  and  for  about  a  quarter 
of  an  inch  about  them.  Now  the  case  is  ready  for  the 
chosen  parasiticide.  Whatever  is  used  in  the  form  of  an 
ointment  or  oil  should  not  be  smeared  over  the  surface, 
but  it  should  be  worked  in,  as  it  were.  The  remedies  we 
use  are  exhibited  in  the  form  of  ointments,  oils,  varnishes, 
pastes,  solutions,  and  plasters.  It  is,  unfortunately,  neces- 
sary to  give  a  lengthy  list  of  remedies  from  which  the 
reader  may  select.  One  of  the  oLlest  and  most  used  of 
them  is  the  officinal  sulphur  ointment,  full  strength  or 
diluted  according  to  reaction.  No  pustulation  should  be 
caused  by  our  applications.  Here,  as  elsewhere,  when 
an  ointment  is  mentioned,  it  is  to  be  understood  that  it 
may  be  made  with  lard,  vaseline,  lanolin  softened  with 
oil,  or  plasment  (mucilage  of  Irish  moss).  The  last  is  to  be 
preferred  because  it  is  not  greasy,  sinks  readily  into  the 
skin,  and  leaves  a  slight  film  over  the  patches  that  prevents, 
to  a  certain  extent,  the  escape  of  the  spores  into  the  air. 
The  persistent  daily  use  of  this  ointment,  combined  with 
epilation,  and  scrubbing  of  the  patch  with  soap  and  water 
about  once  a  week,  will  cure  the  disease.  Sulphur  may  also 
be  used  in  combination  with  other  drugs,  but  as  nothing  has 
yet  been  found  to  render  it  soluble  in  any  amount,  it  must 
always  be  exhibited  in  ointment  or  paste  form.  Mercury 
is  another  old  stand-by.  It  may  be  used  as  a  solution  of 
the  bichloride  in  alcohol  (grs.  j-iij  ad  §j),  whose  applica- 
tion should  not  be  entrusted  to  anyone  but  a  physician  or 
trained  nurse.  It  is  to  be  used  two  or  three  times  a  day, 
its  effect  carefully  watched,  and,  of  course,  it  should  not  be 
used  to  large  surfaces.    It  maybe  employed  as  recommended 


TRICHOPHYTOSIS.  499 

by  Kerley,1  who  reports  having  cured  a  number  of  cases  in 
from  two  to  twenty  weeks  by  using  a  solution  made  by  add- 
ing two  grains  of  the  bichloride  dissolved  in  sufficient  alcohol 
to  a  half-ounce  each  of  kerosene  and  olive  oil,  daily  rubbed 
into  patches  as  well  as  applied  all  over  the  scalp.  When 
inflammation  is  caused,  the  application  is  stopped,  and  a 
simple  ointment  is  used  until  the  irritation  subsides.  Then 
the  bichloride  is  again  applied.  The  scalp  is  to  be  washed 
often.  He  thinks  that  a  cure  will  be  hastened  by  using  a 
saturated  solution  of  iodine  on  alternate  days  with  the  bi- 
chloride solution.  Crocker  thinks  highly  of  the  bichloride, 
three  grains  dissolved  in  alcohol,  to  the  ounce  of  turpentine. 
Tincture  of  benzoin  is  a  good  excipient  for  the  bichloride, 
according  to  Leviseur,2  who  recommends  the  application  of 
it,  1  to  2  parts  of  Hg.  to  300  parts  benzoin,  once  a  week, 
with  the  daily  use  of  salicylic  acid  ointment  in  10  to  20  per 
cent,  strength.  All  the  mercurial  ointments  are  useful,  but 
not  so  prompt  in  their  action  as  other  remedies. 

The  remedies  recommended  in  the  treatment  of  ring- 
worm of  the  body  are  all  of  use  in  the  same  disease  of 
the  scalp,  and  need  not  be  repeated.  The  main  modifica- 
tion is  the  epilation  that  should  precede  their  application. 
Instead  of  using  tincture  of  iodine,  the  English  authors  com- 
mend Coster's  paint,  made  of  two  drachms  of  iodine  and 
six  drachms  of  the  light  oil  of  wood-tar,  which  is  to  be 
firmly  applied  with  a  stiff  brush.  A  black  crust  will  form 
after  two  or  three  days,  which  should  be  removed  with  the 
forceps.  The  part  should  then  be  washed  with  soap  and 
water,  and  the  paint  again  applied.  Two  or  three  applica- 
tions may  be  made  of  it  to  an  infant's  scalp,  or  it  may  be 
continued  longer  in  children  over  four  years  of  age. 

Chrysarobin  in  10  per  cent,  strength  in  traumaticin  or 
collodion  is  good,  its  tendency  to  produce  dermatitis  being 
ever  borne  in  mind.  Pyrogallol  in  5  to  15  per  cent,  in  the 
same  excipients,  with  or  without  the  addition  of  half  a 
drachm  of  salicylic  acid  to  the  ounce,  is  a  reliable  prepa- 

1  N.  Y.  Med.  Journ.,  1891,  liv.  396. 

2  Med.  Kec.,  June  1,  1889. 


500  DISEASES    OF    THE    SKIN. 

ration,  fi -naphthol  or  hydronaphthol  are  commendable. 
One  of  the  neatest  methods  for  treating  ringworm  is  that 
commended  by  Dockrell,1  and  it  has  proved  useful  in  my 
hands.  He  directs  that  after  shaving  and  washing  the  head 
with  a  5  per  cent,  hydronaphthol  soap  and  hot  water,  the 
part  is  to  be  dried  and  covered  with  strips  of  10  per  cent, 
hydronaphthol  plaster  so  that  they  overlap  at  the  edge.  Over 
all  is  to  be  poured  some  melted  10  per  cent,  hydronaphthol 
jelly.  At  the  end  of  four  days  the  plaster  is  to  be  re- 
moved, the  head  again  washed,  and  a  20  per  cent,  plaster 
applied  and  worn  for  one  week.  Finally,  a  10  per  cent, 
plaster  is  to  be  worn  for  ten  days.  If  not  well  then,  the 
process  may  be  repeated.  Naphthol  may  be  used  as  a  1  per 
cent,  solution  in  alcohol,  or  in  the  form  of  a  paste,  as  recom- 
mended by  Kaposi  :2 


R.  Naphthol., 

Spt.  sap.  viridis, 
Alcohol., 

1 

2 
50 

Bals.  peruv , 
Sulph.  loti, 

2 
10 

M. 

Either  may  be  applied  twice  a  day  for  two  or  three  days, 
and  then  followed  by  thorough  scrubbing  with  green  soap. 
Thymol  in  5  to  10  per  cent,  strength,  dissolved  in  chloroform 
and  olive  oil,  is  recommended  by  Malcolm  Morris. 

Harrison3  endeavored  to  effect  entrance  of  his  reme- 
dies to  the  deeper  parts  of  the  skin  by  first  applying  to  the 
scalp  solution  No.  1,  composed  of  half  a  drachm  of  potas- 
sium iodide  in  one  ounce  of  liquor  potassse.  After  a  few 
days  he  applies  solution  No.  2,  composed  of  three  grains  of 
corrosive  sublimate  to  one  ounce  of  sweet  spirits  of  nitre,  or 
of  water.  This  treatment  requires  careful  watching.  Foulis4 
recommends  rubbing  turpentine  into  the  scalp,  after  cutting 
the  hair,  until  it  smarts.  Then  it  is  to  be  scrubbed  with  10 
per  cent,  carbolic  soap,  dried,  and  painted  with  two  or  three 
coats  of  tincture  of  iodine.     When  dry  the  whole  head  is  to 

1  Lancet,  1889,  ii.,  1110. 

2  Wien.  med.  Woch.,  1881,  xxxi.  617. 

3  Brit.  Med  Journ.,  1885,  ii.  134. 

4  Ibid.,  1885,  i.  536. 


TRICHOPHYTOSIS.  501 

be  anointed  with  carbolized  oil,  1  in  20.  This  procedure 
is  to  be  carried  out  once  a  day.  Alder  Smith  has  found 
useful  a  saturated  solution  of  boric  acid,  as  follows : 


R .  Ac.  boric.,  £iv ;        15 

JEtheris,  £  v ;      150 

Alcoholis,  ad     Jjxx:     600 


M. 


It  is  to  be  freely  applied  after  washing  the  head  in  the 
morning,  and  two  to  five  times  during  the  day. 

In  very  chronic  cases  and  in  the  disseminated  form  it  may 
be  necessary  to  blister  the  patch  by  means  of  croton  oil  or 
acetic  acid.  Croton  oil  must  always  be  used  with  caution 
and  to  small  areas,  as  it  is  capable  of  producing  permanent 
baldness.  One  part  in  ten  of  olive  oil  is  usually  suffi- 
cient, but  the  strength  may  be  increased  till  we  have  it 
sufficiently  strong  to  cause  a  mild  degree  of  pustulation,  when 
the  hairs  may  be  easily  plucked.  In  disseminated  ring- 
worm a  drop  of  the  pure  oil  may  be  applied  to  each  diseased 
follicle,  and  as  soon  as  a  pustule  forms,  the  hair  should  be 
pulled  out.  In  very  obstinate  cases  electrolysis  may  be 
practised  to  individual  hairs,  which,  like  the  croton  oil,  will 
permanently  destroy  the  hair. 

Epilation  is  of  positive  value  in  treating  this  obstinate 
disease,  even  though  the  hair  does  break  off.  Some  hair 
with  its  fungus  will  come  out,  and  the  follicular  mouths  will 
be  rendered  more  open  for  the  entrance  of  our  applications, 
which  should  always  follow  epilation.  Besnier  epilates 
around  the  patches,  and  asserts  that  then  the  disease  rarely 
spreads  to  neighboring  parts. 

Treatment  should  be  continued  until  there  are  no  more 
stumps  or  broken  off-hairs  to  be  seen ;  till  the  microscope 
fails  to  reveal  any  fungus  in  the  hair  after  prolonged  search, 
and  until  the  scalp  is  no  more  scaly.  It  is  well  to  use  the 
following — 


H; .  Hydrarg,  ammon  ,  J) j  ;       3 

Hydrarg  chlor.  mitis,  $  ij  ;      7 

Vaselini,  %]  ;     30 


75 
50 
00       M. 


or  a  sulphur  ointment  for  several  months  after  apparent 
cure. 


502  DISEASES    OF    THE    SKIN. 

Trichophytosis  barbae,  is  treated  along  the  same  lines  as 
when  the  scalp  is  the  seat  of  the  disease.  The  beard  should 
not  be  shaved,  but  cut  short  with  scissors.  Here  epilation 
is  of  more  positive  value,  as  the  hairs  over  the  nodules  will 
come  out  easily.  It  is  possible  to  abort  the  disease  before  it 
has  implicated  the  hair  by  the  application  of  a  solution  of 
five  or  ten  grains  of  bichloride  of  mercury  in  alcohol.  A  10 
per  cent,  solution  of  resorcin  or  an  ointment  of  the  same 
strength  may  accomplish  the  same  end.  After  the  disease 
has  got  under  full  way,  systematic  epilation,  daily  shaving 
by  the  patient  himself,  and  the  thorough  application  of  one 
of  the  parasiticide  preparations  mentioned  in  the  preceding 
section  will  effect  a  cure. 

Trichophytosis  unguium  is  to  be  treated  by  producing  a 
paronychia.  This  may  be  done  by  Pelizzari's1  method  of 
keeping  green  soap  upon  the  nail  under  a  rubber  cot  for  a 
few  days,  until  the  nail  is  softened.  Then  equal  parts  of 
olive  oil  and  pyrogallic  acid  are  to  be  applied  till  the  nail 
loosens,  when  it  is  to  be  removed  and  the  finger  dressed  with 
iodoform.  Thin2  recommends  scraping  the  affected  nails 
very  thin,  applying  liquor  potassse  to  soften  them,  and  then 
dabbing  on  creasote,  or  acetic  acid,  or  a  solution  of  two  to 
five  grains  of  bichloride  of  mercury,  in  alcohol.  Crocker 
speaks  well  of  using  Harrison's  plan  for  treating  ringworm 
of  the  scalp,  which  see.  Solution  No.  1  should  be  applied 
after  scraping  and  kept  on  for  fifteen  minutes,  covered  with 
oiled  silk ;  then  No.  2  applied  in  the  same  way  and  kept  on 
for  twenty-four  hours.  These  should  be  repeated  till  the 
cure  is  effected.  If  the  skin  should  become  tender  or  begin 
to  peel,  the  solutions  should  be  stopped,  and  one  of  hypo- 
sulphite of  soda  used  until  the  skin  heals. 

Prognosis.  All  forms  of  ringworm,  excepting  that  of 
the  general  surface  of  the  body,  are  very  obstinate,  but 
persevering  and  intelligent  treatment  will  cure  them  all. 
The  most  obstinate  form  is  that  of  the  scalp,  and  a  speedy 
cure  should  never  be  promised. 

1  Giorn.  Ital.  d.  Mai.  Ven.  e  del  Pelle,  March,  1888. 

2  The  Practitioner,  May,  1887,  et  seq. 


TUBERCULOSIS    VERRUCOSA    CUTIS.  503 

Trichoptilose.     See  Atrophia  pilorum  propria. 
Trichoptilosis.     See  Atrophia  pilorum  propria. 
Trichorrhexis  Nodosa.     See  Atrophia  pilorum  propria. 
Trichoxerosis.     See  Atrophia  pilorum  propria. 
Tubercula  Miliaria.     See  Milium. 
Tubercula  Sebacea.     See  Milium. 

Tubercule  Anatomique.  See  Tuberculosis  verrucosa  cutis. 
Tuberculosis  Cutis. 

Symptoms.  This  form  is  a  rare  one,  having  been  met 
with  by  Chiari  but  five  times  in  between  3000  and  4000 
post-mortems,  of  those  who  had  died  of  tuberculosis.  It 
occurs  almost  exclusively  about  the  mucous  orifices — mouth, 
anus,  vulva,  and  glans  penis.  Crocker  describes  the  disease 
as  follows :  "  The  lesions  consist  of  one  or  more  discrete, 
shallow,  not  painful  ulcers,  which  form  apparently  sponta- 
neously, have  an  irregular,  eroded,  moderately  infiltrated 
edge,  and  when  the  crusts,  which  soon  cover  them,  are 
removed,  show  a  reddish-yellow,  granular  surface,  with  a 
thin,  scanty  secretion.  They  never  heal,  but  spread  slowly 
and  continuously,  and  may  coalesce  with  neighboring  ulcers, 
becoming  serpiginous ;  they  may  thus  extend  over  an  area 
of  one  or  more  square  inches  ;  but,  as  a  rule,  they  are  small. 
When  on  mucous  membranes,  yellow  miliary  papules  exist 
near  them."  They  are  due  to  local  infection  with  the  tubercle 
bacillus,  and  are  a  part  of  a  general  tuberculosis.  Their 
diagnosis  is  difficult,  though  their  nature  may  be  suspected 
on  account  of  the  other  and  evident  symptoms  of  the  primary 
disease. 

Treatment.  Treatment  is  unavailing,  though  iodol, 
iodoform,  or  aristol  may  be  applied. 

Tuberculosis  Verrucosa  Cutis.  Synonyms :  Verruca 
necrogenica ;  Lupus  verrucosus;  Scrofuloderma  verrucosum ; 
(Fr.)  Lupus  sclereux,  ou  1.  papillaire  verruqueux ;  Anatomical 
tubercle ;   Post-mortem  warts. 

These  names  have  been  given  by  different  writers  to  what 
may  be  regarded  as  simply  varying  aspects  of  the  disease 


504  DISEASES    OF    THE    SKIN. 

described  by  Riehl  and  Paltauf1  as  tuberculosis  verrucosa 
cutis.  It  is  one  of  the  rare  skin  diseases,  but  not  so  very 
infrequent  as  statistics  would  show.  It  was  met  with  four 
times  in  3726  cases  in  Prof.  Fox's  service  at  the  Yanderbilt 
clinic. 

Symptoms.2  The  disease  occurs  in  the  form  of  one, 
usually,  or  more  patches,  which  are  round  or  oval ;  or,  if  two 
patches  have  joined,  irregularly  shaped,  with  scalloped 
border,  and  perhaps  serpiginous.  In  size,  the  single  patches 
vary  from  that  of  a  lentil  up  to  that  of  a  silver  half-dollar. 
Around  the  patch  is  a  narrow  zone  of  erythema,  of  a  bright- 
red,  that  disappears  under  pressure.  Its  surface  is  smooth 
and  often  more  shiny  than  the  normal  skin.  Toward  the 
next  zone  it  is  slightly  elevated.  Its  follicular  openings  are 
preserved. 

Inside  of  this  zone  is  a  row  of  small,  discrete,  superficial 
pustules,  whose  covers  are  so  thin  that  they  break  easily, 
and  we  find  only  the  crusts  and  scales  left  by  them.  The 
color  of  this  zone  is  brown  or  livid  red,  and  it  cannot  be 
pressed  out  entirely,  showing  that  there  is  some  infiltration 
of  the  skin.  This  zone  is  slightly  raised,  but  the  one  to  its 
inner  side  is  markedly  so.  It  has  also  an  irregularly  knobby 
surface,  becoming  distinctly  warty  toward  the  centre  of  the 
growth,  the  warts  being  rounded  or  pointed.  The  nearer 
the  centre  the  warts  are,  the  larger  they  are,  some  of  them 
being  5  to  7  mm.  long.  The  whole  surface  of  this  zone  is 
more  or  less  scaly  or  crusted.  The  color  is  brownish-red. 
The  warty  growths  are  often  close  together  with  fissures  be- 
tween them,  and  little  erosions  and  pustules.  If  the  patch 
is  pinched  up  between  the  fingers  little  drops  of  pus  may  be 
made  to  well  up  from  between  the  papillae,  The  mouths  of 
the  follicles  are  destroyed.  In  some  cases  acute  inflamma- 
tion may  occur  and  then  the  patch  will  swell  up  and  become 
more  angry-looking. 

After  a  time  the  patch  begins  to  flatten  in  the  middle  by 
the  disappearance  of  the  warty  growths,  and  at  last  becomes 

1  Vierteljahr.  f.  Derm.  u.  Sypli.,  1886,  xiii.  19. 

2  The  description  here  given  is  taken,  for  the  most  part,  from  the 
above-mentioned  article  by  Kiehl  and  Paltauf. 


TUBERCULOSIS    CUTIS.  505 

changed  into  a  smooth  or  slightly  scaling  cicatrix,  which  is 
thin  and  soft,  with  a  delicate  sieve  or  net-like  appearance. 

The  patch  is  always  freely  movable  upon  the  underlying 
parts,  and  usually  gives  rise  to  no  subjective  symptoms. 
Sometimes  pain  is  complained  of  on  pressure.  The  growth 
is  by  the  addition  of  new  lesions  on  the  periphery  of  the  old 
patch,  and  is  usually  very  slow,  and  at  intervals,  with  pauses 
between.  It  is  a  chronic  affection  showing  no  tendency  to 
spontaneous  recovery. 

Such  is  the  typical  disease  and  its  course.  In  the  de- 
scriptions of  the  different  diseases  named  above  will  be  found 
some  deviations  from  the  type,  but  they  all  agree  in  the 
main,  and  are  probably  all  one  and  the  same  disease. 

Etiology.  The  cause  of  this  form  of  tuberculosis  is  the 
inoculation  of  the  skin  with  the  tubercle  bacillus,  which  has 
been  found  in  sections  taken  from  the  patches.  The  disease 
is  seen  most  frequently  in  men.  and  is  specially  prevalent  in 
butchers  and  those  who  have  to  do  with  animals.  Dead- 
house  attendants  are  also  its  victims,  not  infrequently.  It 
occurs  most  often  on  the  hands,  specially  on  their  backs, 
but  may  occur  anywhere.  Cases  have  been  directly  traced 
to  inoculation  with  tubercular  tissues. 

Diagnosis.  Though  allied  to  lupus  it  differs  from  it  by 
the  entire  absence  of  the  characteristic  lupus  tubercles,  and 
of  a  tendency  to  ulceration  ;  by  the  manner  of  healing  in 
the  centre ;  by  a  scar  in  which  no  relapse  takes  place  ;  by  its 
superficial  situation  in  the  skin  ;  by  the  purulent  matter  that 
can  be  squeezed  out  from  between  its  papillae :  and  by  the 
relatively  late  time  of  life  in  which  it  appears.  From  syphilis 
it  differs  in  its  more  chronic  course ;  in  the  absence  of  a  wall 
of  infiltration  about  it :  in  its  color  ;  and  in  showing  no  ten- 
dencv  to  break  down  and  ulcerate. 

Treatment.  The  growth  may  be  curetted  away,  and  the 
wound  afterward  treated  with  pyrogallol,  as  in  lupus.  Or 
it  may  be  destroyed  by  the  galvano-cautery.  or  by  electro- 
lysis. Or  it  mav  be  covered  with  a  twenty  per  cent,  salicylic 
acid  plaster,  which  Crocker  advises  to  be  followed  with  the 
fuming  nitrate  of  mercury  applied  with  a  piece  of  wood.    Or 


506  DISEASES    OF    THE    SKIN. 

it  may  be  destroyed  by  any  powerful  caustic,  but  it  must  be 
destroyed  entirely  or  it  will  crop  out  again. 

Pkognosis.  The  disease  is  more  readily  curable  than  is 
lupus,  and,  as  a  rule,  the  growths  are  readily  removed. 

Tumeurs  Folliculeuses.     See  Molluscum  sebaceum. 

Tumores  Sebiparis.     See  Molluscum  sebaceum. 

Tyloma.     See  Callositas. 

Tylosis.     See  Callositas. 

Tylosis  Linguae.     See  Leucoplakia. 

Ulcers.  Ulceration  is  a  symptom  common  to  many 
diseases  such  as  lupus,  syphilis,  scrofulodermata,  and  other 
destructive  processes.  For  these  the  reader  is  referred  to 
the  sections  treating  of  the  diseases  of  which  they  form  a 
part.  We  shall  here  deal  briefly  with  those  ulcers  of  the 
leg  that  form  so  large  a  part  of  every  dermatological  clinic, 
and  that  are  usually  called  varicose  ulcers.  They  are  lo- 
cated most  often  over  the  anterior  surface  of  the  leg  and  on 
its  lower  half.  They  may  be  superficial  or  deep.  They  are 
irregular  in  shape  with  sloping  or  undermined  edges,  and 
with  a  more  or  less  wide  zone  of  redness  and  infiltration  of 
the  skin  about  them.  Their  bases  may  be  covered  with 
flabby  granulations  ;  or  smooth  and  glazed  looking  with  thin, 
scanty  secretion ;  or  they  may  discharge  a  great  deal  of  sero- 
purulent  matter.  Some  of  them  bleed  readily,  some  do  not. 
There  may  be  but  one  ulcer,  or  there  may  be  several  of 
them.  One  or  both  legs  may  be  affected.  The  ulcer  may  be 
small,  or  so  large  as  to  encircle  the  leg  and  occupy  more 
than  half  its  length,  and  it  may  attain  this  size  either  by 
gradual  extension  of  itself,  or  by  the  junction  of  several 
ulcers.  They  begin  not  infrequently  as  a  number  of  small 
shelving  ulcers  on  a  red  and  densely  infiltrated  base.  These 
enlarge  rapidly  and  form  a  large  ulcer.  The  patient  com- 
plains of  more  or  less  spontaneous  pain,  and  the  ulcers  are 
often  very  tender.  The  feet  and  legs  are  sometimes  greatly 
swollen  and  feel  brawny.  It  will  be  noted  that  the  foot  and 
leg  are  marked  with  dilated  veins,  and  varicosities  can  be 
felt  sometimes  like  whip-cords  under  the  skin.     The  deep 


(JLCERS.  507 

veins  are  generally  swollen  at  the  same  time,  though  they 
cannot  be  felt  so  readily. 

Etiology.  These  ulcers  are  predisposed  to  by  standing 
for  hours  at  a  time,  and  it  is  standing  in  one  position  that  is 
particularly  obnoxious.  It  is  therefore  in  car-drivers,  black- 
smiths, cooks,  and  those  following  similar  occupations  that 
ulcerations  are  prone  to  occur.  A  loaded  condition  of  the 
portal  circulation  and  constipated  bowels  also  favors  vari- 
cosities and  the  occurrence  of  ulceration.  On  account  of  the 
chronic,  congested  condition  of  the  leg,  some  slight  trauma- 
tism that  in  the  normal  state  would  produce  a  hardly 
appreciable  damage  will  be  followed  by  a  breaking  down  of 
the  tissues  and  an  ulcer. 

Diagnosis.  It  is  most  important  to  diagnose  a  varicose 
ulcer  from  one  due  to  syphilis,  as  they  require  different  treat- 
ment, and  have  a  different  prognosis.  The  syphilitic  ulcer 
is  usually  located  upon  the  upper  half  of  the  leg,  and  toward 
its  posterior  surface,  or  about  the  knee.  It  has  an  infiltrated 
border,  but  by  no  means  as  broad  a  one  as  the  varicose 
ulcer.  It  lacks  the  marked  inflammatory  symptoms  of  the 
varicose  ulcer,  and  is  "  punched-out  looking  "  with  perpen- 
dicular edges.  It  is  round,  or,  if  formed  by  the  coalition  of 
several  softened  tubercles,  it  will  have  a  scalloped  edge  indi- 
cating its  origin  from  several  distinct  lesions.  As  a  rule,  it 
is  quite  painless,  and  there  are  several  ulcers  on  one  leg,  the 
other  being  free. 

Treatment.  If  we  can  confine  our  patient  absolutely  to 
bed,  and  keep  the  leg  snugly  and  evenly  bandaged,  the  ulcers 
will  heal  under  simple  dressings.  This  we  cannot  do  with 
most  of  our  cases.  Bandaging  the  leg  from  the  toes  to  the 
knee  is  an  essential  in  their  successful  management,  an  or- 
dinary roller  bandage  being  used  as  long  as  any  greasy 
applications  are  made.  In  ulcers  connected  with  varicose 
veins,  after  acute  symptoms  have  subsided,  bandaging  from 
the  toes  to  knee  with  a  rubber  bandage  is  excellent.  So  too 
in  all  ulcers  is  the  continuous  bath  with  warm  water,  or  by 
means  of  cloths  wrung  out  of  hot  water,  frequently  renewed, 
and  covered  with  oiled  silk. 

One  of  the  oldest  and  best  treatments  for  ulcers  is  to  touch 


508  DISEASES    OF    THE    SKIN. 

them  up  daily  with  balsam  of  Peru  and  cover  them  with 
oxide  of  zinc  ointment,  or,  better,  with  Lassar's  paste.  Dry 
dressings  for  the  ulcer  are  preferable  to  greasy  applications, 
and  for  this  we  may  use  iodoform,  iodol,  aristol,  subnitrate  or 
subiodide  of  bismuth,  or  dermatol,  one  of  the  latest  remedies. 
If  there  is  any  eczema  or  dermatitis  about  the  ulcer  it  is 
requisite  to  cover  the  powder  and  the  whole  patch  with  some 
mild  or  stimulating  ointment  according  to  the  state  of  the 
skin.  In  this  case  the  ulcer  must  be  dressed  once  or  twice 
a  day.  If  there  is  not  much  dermatitis  we  can  dispense  with 
the  ointment  and  do  the  leg  up  antiseptically  and  leave  it 
for  several  days.  Applications  of  nitrate  of  silver  may  be 
used  to  stimulate  an  atonic  ulcer  or  to  smooth  down  exuberant 
granulations.  Strapping  with  adhesive  plaster  is  another 
excellent  means  in  ulcers  upon  not  very  much  inflamed 
bases.  Skin-grafting  according  to  Thiersch's  method  is  the 
most  prompt  and  sometimes  the  only  way  to  cause  large 
ulcers  to  heal.  For  further  surgical  treatment  of  ulcers  text- 
books on  surgery  must  be  consulted. 

Ulcus  Rodens.     See  Epithelioma. 

Ulcus  Grave.     See  Fungous  foot  of  India. 

Ulerythema  (U2l-e2r-i2-the'ma3).  This  is  the  name  pro- 
posed by  Unna  for  those  diseases  in  which  there  is  a  more  or 
less  persistent  erythema  upon  which  follows  cicatrization  by 
a  process  of  absorption  of  inflammatory  infiltration,  and 
without  ulceration.  Under  this  heading  comes  lupus  ery- 
thematosus. Ulerythema  sycosiforme1  and  ulerythema 
ophryogenes2  are  two  other  varieties  of  this  form  of  disease . 
They  bear  a  resemblance  to  the  "  folliculitis  decalvans  " 
of  the  French.  They  both  affect  hairy  regions,  the  first 
having  a  predilection  for  the  beard,  and  the  second  for  the 
eyebrows.  In  their  course  they  present  symptoms  somewhat 
like  sycosis,  but  differ  from  that  disease  in  causing  perma- 
nent bald  patches,  and  the  destruction  of  the  skin  so  as  to 
form  cicatrices. 


1  Monatshefte  f.  prakt.  Dermat .,  1889,  ix  ,  No  3. 

2  Ibid.,  No  5. 


URTICABIA.  509 

Uridrosis  (U2r-i2d-ro'-si2s).  Synonym :  Sudor  urinosis. 
By  this  is  meant  the  excretion  by  the  sweat  pores  of  sweat 
loaded  with  the  constituents  of  the  urine,  specially  urea. 
The  sweat  then  often  has  a  urinary  odor,  and  deposits  crys- 
tals of  urates  upon  the  skin.  It  is  always  a  complication  of 
some  grave  general  disease. 

Urticaria  (U5r-ti2-ka'-ri2-a3).  Synonyms  :  Cnidosis  ;  (Fr.) 
Urticaire ;  (Ger.)  Nesselsuch,  Nesselauschlag,  Porcellan- 
friesel  ;  (Eng.)  Nettle-rash,  Hives. 

An  acute  or  chronic  disease  of  the  skin  characterized  by 
the  appearance  of  wheals.  This  usually  trivial  affection,  so 
common  as  to  be  a  matter  of  everyday  occurrence,  at  times 
may  assume  grave  symptoms,  or  entirely  nonplus  us  by  its 
persistency.     It  may  run  an  acute  or  chronic  course. 

Symptoms.  The  vast  majority  of  cases  run  an  acute 
course.  The  characteristic  feature  of  the  disease  is  the 
appearance  of  a  wheal — that  is,  a  firm,  flat,  circumscribed 
elevation  of  the  skin  which  is  at  first  pink,  and  then  white. 
They  may  remain  pink.  They  may  be  round,  oval,  annu- 
lar, or  elongated,  and  are  always  surrounded  by  a  red  areola. 
They  vary  in  size,  sometimes  being  no  larger  than  the  head 
of  a  pin,  and  sometimes  of  the  diameter  of  an  inch.  They 
show  no  tendency  to  group,  but  are  irregularly  disseminated 
over  the  whole  body.  Though  they  are  not  symmetrical  in 
distribution,  both-  sides  of  the  body  are  affected  at  the  same 
time,  and  they  show  some  preference  for  the  extensor  sur- 
faces of  the  arms  and  legs.  They  itch,  burn,  and  tingle, 
and  are  always  scratched.  They  are  ephemral,  each  lesion 
lasting  but  a  short  time — from  a  few  minutes  to  a  day.  Ex- 
ceptionally some  wheals  will  last  several  days.  New  lesions 
crop  out  as  old  lesions  fade,  and  thus  the  eruption  is  con- 
tinued. The  mucous  membranes  are  often  affected  at  the  same 
time  with  the  skin  ;  and  if  the  pharynx  should  be  attacked 
there  may  be  suffocative  symptoms.  The  duration  of  the 
disease  as  commonly  met  with  is  but  a  few  days,  and  not  infre- 
quently the  wheals  may  be  entirely  absent  during  the  day,  to 
break  out  again  at  night.  Very  often  when  the  patient  is  seen 
by  the  physician,  he  can  find  nothing  but  scratched  papules. 
But  the  patient  will  tell  him  that  when  he  is  undressing,  or 


510  DISEASES    OF    THE    SKIN. 

is  warm  in  bed,  the  itching  becomes  unbearable,  and  lumps 
looking  like  mosquito-bites  break  out  upon  him.  The  skin 
of  a  patient  with  urticaria  is  very  irritable,  so  that  a  sharp 
tap  upon  it  will  produce  a  wheal. 

The  outbreak  of  the  disease  may  be  sudden  without  con- 
stitutional disturbance,  or  there  may  be  some  burning  and 
tingling  of  the  skin  before  its  appearance.  Or  there  may 
be  some  febrile  movement,  and  some  evident  disturbance  of 
the  digestion  such  as  vomiting  or  dyspeptic  symptoms. 
When  the  disease  is  cured  the  lesions  disappear  without 
desquamation,  and  leave  no  trace  of  themselves.  Such  is  the 
acute  form. 

Chronic  urticaria  differs  from  the  acute  form  mainly  in 
its  duration.  Instead  of  recovery  taking  place  in  a  few  days 
or  weeks,  its  course  is  one  of  months  or  years.  Sometimes 
the  outbreaks  of  the  eruption  show  marked  periodicity, 
coming  out  at  stated  intervals  after  pauses  of  complete  im- 
munity. The  eruption  is  generally  not  so  extensive  in 
the  chronic  as  in  the  acute  form.  If  the  itching  has  been 
very  severe  and  the  scratching  proportionally  excessive, 
the  skin  may  become  pigmented,  as  in  other  chronic  prurigi- 
nous  diseases. 

The  wheals  assume  different  appearances  in  different  cases, 
and  different  adjectives  are  used  to  express  the  varying  pic- 
tures. It  is  not  necessary  to  burden  the  mind  with  these, 
though  they  are  convenient  for  descriptive  purposes.  Thus 
we  have  urticaria  tuberosa  seu  gigans,  where  the  lesions 
are  unusually  large ;  urticaria  bullosa,  where  the  wheals 
are  surmounted  by  bullae ;  urticaria  hemorrhagica,  where 
hemorrhage  into  the  wheals  occurs ;  urticaria  oedematosa, 
probably  the  same  as  acute  circumscribed  oedema,  or  acute 
angeio-neurotic  oedema,  where  the  wheal  occurs  in  locations 
in  which  the  subcutaneous  tissues  are  lax,  as  about  the  eye, 
nearly  closing  it,  or  on  the  tongue,  causing  it  to  swell  enor- 
mously and  threaten  suffocation  ;  urticaria  papulosa,  or 
lichen  urticatus,  where  the  wheals  are  small,  a  form  common 
about  the  buttocks  of  children. 

Urticaria  factitia  is  the  name  used  to  express  the  fact 
that,  on  account  of  the  irritability  of  the  skin,  a  wheal  may 


URTICARIA.  511 

readily  be  excited  by  local  irritation.  Urticaria  perstans 
simply  refers  to  the  persistent  character  of  the  single  lesion. 
Urticaria  maculosa  is  the  name  proposed  by  Fournier  to 
that  form  in  which  the  wheal  remains  red. 

Etiology.  The  causes  of  the  disease  are  more  numerous 
than  the  forms  it  may  assume.  Most  of  the  acute  and  many 
of  the  chronic  cases  are  dependent  upon  irritating  ingesta, 
such  as  shell-fish,  strawberries,  cheese,  pickles,  mushrooms, 
pork,  sausages,  even  mutton  in  some,  and  almost  anything 
in  other  people,  it  being  largely  a  matter  of  idiosyncrasy  ; 
medicinal  substances,  such  as  quinine,  cubebs,  copaiba,  sali- 
cylic acid,  opium,  and  other  drugs.  The  rupture  of  hydatid 
cysts  has  been  followed  by  urticaria.  Dyspepsia  in  its 
various  forms,  and  constipation,  are  common  factors,  especi- 
ally in  chronic  urticaria,  as  are  intestinal  worms  in  children. 
So  also  at  times  may  be  disorders  of  the  liver,  uterus,  and 
ovaries.  Gout,  rheumatism,  malaria,  and  functional  or 
organic  diseases  of  the  nervous  system  will  be  found  at  the 
bottom  of  many  cases  of  chronic  urticaria. 

Not  only  do  we  have  internal  causes  producing  the  disease, 
but  also  external  causes,  such  as  contact  with  the  jellyfish  ; 
crawling  of  caterpillars ;  the  action  of  cold,  or  sudden 
changes  of  temperature  ;  the  galvanic  current ;  and  bites  of 
insects.  Urticaria  is  a  common  accompaniment  of  scabies 
and  pediculosis. 

Pathology.  Urticaria  is  due  to  a  vasomotor  disturb- 
ance. At  first  there  occurs  a  spasmodic  contraction  of  the 
vessels  of  a  circumscribed  area  of  the  skin,  which  is  followed 
by  paralytic  dilatation  of  the  vessels  and  retardation  of  the 
circulation.  Serous  exudation  ensues,  forming  the  wheal, 
which  at  first  is  pink,  and  then  becomes  white,  on  account 
of  the  pressure  of  the  fluid  forcing  out  the  blood  from  the 
central  parts  of  the  wheal.  When  the  paresis  ceases,  the 
serous  exudation  is  absorbed  and  the  part  returns  to  its 
normal  condition. 

Diagnosis.  The  occurrence  of  wheals  is  pathognomonic 
of  urticaria,  as  they  occur  in  no  other  disease.  When  they 
are  present,  there  is  no  difficulty  in  diagnosis.  When  they 
are  not  present  and  we  find  only  scratch-marks  we  have  to 


512  DISEASES    OF    THE    SKIN. 

decide  whether  we  have  to  do  with  urticaria  or  eczema, 
scabies,  pediculosis,  or  dermatitis  herpetiformis.  Eczema  dif- 
fers from  urticaria  in  the  tendency  its  lesions  have  of  running 
together  and  forming  patches.  It  never  could  be  so  generally 
distributed  without  presenting  some  characteristic  patches. 
Scabies  shows  scratch-marks  on  the  hands  and  feet,  between 
the  fingers  and  toes,  in  the  axillae,  about  the  umbilicus,  and 
on  the  breasts  of  women  and  the  penis  of  the  male.  The 
cuniculi  may  be  found  in  most  cases.  Pediculosis  shows 
long  parallel  scratch-marks  over  the  back,  between  the 
shoulders,  along  the  outside  and  inside  of  the  limbs  where  the 
seams  of  the  clothing  come,  and  about  the  waist.  Dermatitis 
herpetiformis  presents  grouped  lesions,  which  usually  are 
vesicles,  but  may  be  papules.  Erythema  of  papular  or 
tubercular  variety  may  resemble  urticaria,  but  it  is  a  mark- 
edly symmetrical  disease,  and  burns  rather  than  itches. 

Tkeatment.  In  acute  urticaria  the  administration  of  a 
prompt  cathartic  or  saline  laxative  will  usually  cure  the  dis- 
ease if  due  to  some  irritating  ingesta.  Emetics  might  be 
useful,  if  we  see  the  case  before  stomachic  digestion  is  ended, 
but  in  most  cases  we  are  not  called  in  until  too  late  for  them 
to  be  of  service.  Saline  laxatives,  mineral  acids,  rhubarb 
and  soda,  salol,  resorcin,  or  other  intestinal  disinfectants  are 
of  service  in  the  more  chronic  cases.  Of  course  if  the  erup- 
tion is  due  to  the  ingestion  of  drugs  they  must  be  stopped. 

In  chronic  cases,  beside  medicinal  treatment  we  must  regu- 
late the  diet,  studying  each  case  for  itself.  It  is  often  well 
to  put  the  patient  on  a  strictly  milk  diet  for  a  few  days,  and 
then  add  other  articles  with  care.  Alcoholics  in  all  forms, 
and  especially  beer  or  other  malt  liquors,  should  be  pro- 
hibited. If  the  gouty  or  rheumatic  diathesis  is  at  the  foun- 
dation of  the  trouble,  it  must  be  combated.  If  the  out- 
break shows  marked  periodicity,  sulphate  of  quinine  may  do 
good.  Salicylate  of  soda  sometimes  does  good  service  even 
when  there  is  no  evident  rheumatic  tendency.  In  fact,  we 
must  endeavor  in  every  way  to  get  our  patient  into  a  normal 
state  of  health.  The  most  difficult  class  of  cases  are  those 
in  which  a  neurosis  alone  seems  to  be  the  cause.  Then  bella- 
donna, atropia,  arsenic,  the  bromides,  antipyrine,  phenace- 


URTICARIA    PIGMENTOSA.  513 

tine,  and  galvanism  may  be  tried.  Pilocarpine,  wine  of 
antimony,  colchicum,  ergot  are  also  commended  In  very 
obstinate  cases  the  patient  should  be  sent  away  from  home 
and  relieved  from  all  business  cares. 

Local  treatment  is  of  great  service  in  allaying  the  itching, 
but  it  will  not  cure  the  disease.  The  parts  may  be  sponged 
with  alkaline  lotions,  such  as  a  teaspoonful  of  baking  soda 
to  a  hand-basinful  of  water.  Sometimes  more  relief  is  ob- 
tained by  an  acid  solution,  such  as  vinegar,  pure  or  with 
water.  Carbolic  acid  in  vaseline,  or  alcohol  and  water,  is 
sometimes  very  efficacious.  In  vaseline,  10  per  cent,  strength 
is  sufficient ;  in  lotion  form  we  may  use,  to  the  adult  skin, 
one  to  two  drachms  to  the  ounce,  directing  the  patient  to 
dab  and  not  rub  it  on  the  skin.  Hardaway  prefers  using 
the  acid  in  a  spray,  two  to  four  drachms  to  the  pint,  with 
one  ounce  of  glycerin.  To  each  atomizerful  ten  drops  of  oil 
of  peppermint  may  be  added  to  increase  its  antipruritic  quali- 
ties. Menthol,  1  to  10  per  cent,  in  alcohol  or  almond  oil, 
is  said  to  be  efficacious.  Crocker  speaks  highly  of  liquor 
carb.  detergens,  5j  to  §iv ;  terebene,  5iv  to  §iv  ;  and  equal 
parts  of  sanitas  and  water.  Salicylic  acid,  twenty  grains  to 
the  ounce  of  castor  oil,  is  good,  but  disagreeable.  Camphor 
and  chloral  hydrate,  each  from  half  to  one  drachm,  rubbed 
together  and  added  to  one  ounce  of  starch  or  ungt.  simplex, 
is  another  good  antipruritic.  Chloroform  dabbed  on  renders 
prompt  relief.  Baths  are  sometimes  of  use.  Having  the 
patient  take  a  warm  bath  containing  either  two  to  six 
pounds  of  bran,  or  a  quarter  to  half  a  pound  of  bicarbonate 
of  soda,  or  an  ounce  of  nitro-muriatic  acid,  just  before  going 
to  bed;  then  drying  his  skin  by  wrapping  himself  in  a  warm 
sheet  and  patting  the  skin  dry ;  then  smearing  the  skin  with 
a  film  of  vaseline  and  dredging  over  this  corn-starch  powder, 
will  often  give  him  a  good  night's  rest. 

Prognosis. — The  vast  majority  of  cases  of  urticaria  re- 
cover in  a  few  hours  or  davs.  The  chronic  cases  often  are 
most  obstinate,  but  unless  some  severe  nerve  lesion  is  at  the 
bottom  of  the  case,  they  can  be  cured  by  patient  and  perse- 
vering effort. 

Urticaria  Pigmentosa.      Synonym  :  Xanthelasmoidea, 

22* 


514  DISEASES    OF    THE    SKIN. 

Symptoms. — This  is  not  an  ordinary  urticaria  that,  on  ac- 
count of  its  chronic  course  and  the  scratching  to  which  it  has 
been  subjected,  leaves  more  or  less  pigmentation  of  the  skin. 
Such  a  condition  of  things  is  not  infrequently  seen.  Urti- 
caria pigmentosa  begins  within  the  first  six  months  of  life 
by  an  eruption  of  wheals  or  tubercles,  which  at  first  are 
about  the  size  of  a  split-pea,  and  of  a  brownish  or  yellowish- 
red  color,  with  a  pink  areola.  Later,  they  may  increase  in 
size,  or  several  may  coalesce  to  form  a  large  one,  and  assume 
a  yellow  or  buff  color.  These  wheals  appear  in  crops,  and 
run  a  very  chronic  course,  each  one  persisting  for  weeks  or 
months.  They  then  shrink,  become  softened,  and  disappear, 
leaving  browish  pigmentation.  As  the  course  is  chronic,  we 
will  find  on  the  patient  wheals  or  tubercles  of  red  or  yellow 
color,  of  various  sizes,  some  hard  and  tense,  some  soft  and 
wrinkled,  and  brown  stains  of  the  skin.  Ordinary  urtica- 
rial evanescent  wheals  will  sometimes  be  found,  and  rubbing 
of  the  apparently  stationary  tubercles  will  cause  some  of 
them  to  enlarge.  The  wheals  are  most  often  located  on  the 
trunk  and  neck ;  then  on  the  limbs,  face,  and  head ;  but 
they  may  appear  on  any  part  of  the  body  surface  as  well 
as  on  the  mucous  membranes  of  the  mouth  and  pharynx. 
Itching  may  or  may  not  be  present.  After  a  number  of 
years  the  wheals  will  no  longer  come  out,  and  recovery  is 
generally  complete  at  about  the  age  of  puberty.  The  major- 
ity of  the  cases,  according  to  Crocker,  occur  in  boys.  We 
know  no  cause  for  the  disease,  and  thus  far  treatment  has 
been  in  vain. 

Vaccinal  Eruptions.  The  eruptions  that  accompany  or 
follow  vaccination  may  be  local,  starting  from  the  point  of 
inoculation ;  or  general,  and  due  to  the  absorption  of  the 
virus,  which  in  some  subjects  acts  as  do  medicinal  sub- 
stances in  other  people.  The  majority  of  them  are  due  not 
to  any  bad  quality  of  the  virus,  but  either  to  some  accidental 
infection,  or  to  idiosyncrasy.  Sometimes  an  ulcer  will  form 
at  the  site  of  the  vaccination ;  or  starting  from  this  point  we 
may  have  a  dermatitis,  cellulitis,  lymphangitis,  erysipelas, 
abscesses,  or  furuncles.  An  outbreak  of  impetigo  contagiosa 
may  originate  from  inoculation,  the  pus  of  the  sore  becoming 


VARIOLA.  515 

transferred  to  other  parts  by  the  finger-nails ;  or  an  eczema 
or  psoriasis  may  be  set  up  by  the  irritation  of  the  sore,  just 
as  they  may  follow  other  affections  of  the  skin. 

General  eruptions  usually  appear,  according  to  Hardaway, 
after  the  ninth  or  tenth  day  of  vaccinia,  and  assume  an 
erythematous,  papular,  or  papulo- vesicular  character.  The 
roseola  vaccina  of  Hebra  is  an  erythematous  eruption  of 
macular  character,  commencing  usually  upon  the  arms,  and 
sometimes  spreading  over  the  whole  body.  It  is  accom- 
panied in  some  cases  with  slight  rise  of  temperature  for  a 
few  hours.     It  disappears  and  leaves  no  trace. 

We  may  also  encounter  erythema  multiforme  and  urticaria 
complicating  vaccination.  It  is  possible  that  a  bullous  erup- 
tion may  occur,  but  this  is  very  rare.  Syphilis  also  may  be 
inoculated  in  arm  to- arm  vaccination.  Gangrene  may  occur 
in  the  sore  and  other  accidents.  All  of  these  eruptions  are 
rare. 

Varicella  (Va2r-i2-se2l/la3),  or  Chicken-pox,  is  an  eruptive 
fever  of  mild  grade,  which  is  characterized  by  an  outbreak 
of  a  greater  or  lesser  number  of  clear  vesicles,  of  pinhead 
to  pea-size,  and  varying  shape,  that  come  out  in  crops.  A 
long  vesicle  is  very  characteristic  of  this  eruption.  There 
is  usually  scarcely  any  constitutional  disturbance.  The 
mucous  membranes  may  be  involved. 

Variola  (Va2r-iro2l-a3),  or  Smallpox,  is  an  acute  contagious 
eruptive  fever,  characterized  by  very  severe  prodromal  symp- 
toms, such  as  headache  and  intense  pain  in  the  back  and 
legs,  and  the  appearance,  usually  on  the  third  day,  of  an 
eruption  of  minute  red  spots  that  soon  change  into  small, 
round,  hard,  shotty  papules.  The  eruption  is  first  seen  on 
the  face  about  the  mouth  and  on  the  neck  and  wrists.  In 
about  twenty-four  hours  after  its  first  appearance  vesicles 
form  upon  the  papules,  and  attain  their  full  development  by 
about  the  fifth  day.  They  then  are  umbilicated,  are  located 
upon  a  hard  base,  and  have  a  well-marked  areola.  Now 
they  change  into  pustules,  and  a  well-marked  secondary  fever 
attends  the  change.  After  about  four  or  five  days  the  pus- 
tules dry  up  into  crusts,  and  afterward  these  fall,  leaving 


516  DISEASES    OF    THE    SKIN. 

pitted  cicatrices  in  many  places.     The  mucous  membranes 
may  be  involved. 

Diagnosis.  Variola  bears  a  resemblance  to  the  pustular 
syphilide;  for  the  differential  diagnosis,  see  the  "pustular 
syphilide."  Acne  and  pustular  eczema  both  have  lesions 
resembling  those  of  variola,  but  are  limited  to  certain  regions, 
and  are  not  general  eruptions. 

Varus.     See  Acne. 

Vegetation  dermique.     See  Verruca. 

Vegetations.     See  Verruca. 

Venereal  Wart.     See  Verruca. 

Verbrennung.     See  Dermatitis  ambustionis. 

Verruca  (Ve2r-ru2/ka3).  Synonyms:  (Fr.)  Verrue;  (Ger.) 
Warze;  Warts. 

These  exceedingly  common  papillary  outgrowths  assume 
various  appearances,  to  which  descriptive  names  have  been 
given.  Thus  we  have  verruca  vulgaris,  or  the  wart  so  often 
seen  on  the  hands  of  children  and  young  people.  They  very 
in  size  from  that  of  a  hemp-seed  to  that  of  a  split-pea,  or 
larger  where  two  or  more  become  aggregated.  They  are 
sessile,  hard,  conical,  with  flattened  tops.  They  may  be 
smooth  or  uneven,  showing  their  papillary  formation.  They 
may  be  of  the  color  of  the  skin,  or  some  shade  of  yellow, 
brown,  black,  or  green.  There  may  be  a  number  of  them, 
and  they  may  be  isolated  or  aggregated.  They  may  occur 
elsewhere  than  on  the  hands.  Verruca  digitata  is  applied 
to  a  wart  in  which  the  papillae  are  separated  distinctly  from 
each  other.  They  occur  in  groups,  and  are  often  seen  on 
the  scalp.  Verruca  filiformis  is  a  wart  in  which  the  papillae 
are  not  only  distinct  but  fine,  almost  thread-like.  Each 
papillary  outgrowth  stands  by  itself.  They  are  soft  to  the 
touch,  and  occur  on  the  face,  eyelids,  and  neck.  Verruca 
plana  are  flat  warts,  but  slightly  elevated,  and  varying  in 
size  from  a  pin's  head  to  a  half-inch  in  diameter.  They 
sometimes  occur  in  large  numbers.  In  young  people  they 
occur  upon  the  face  and  backs  of  the  hands,  and  may  or  may 
not  be  pigmented.     In  old  people  they  occur  on  the  back 


VERRUCA.  517 

and  arms  and  are  pigmented.  In  them  they  are  called 
verruca  senilis,  or  seborrhceal  warts.  Verruca  acuminata, 
also  called  condyloma  acuminata,  vegetations  dermiques, 
spitzen  warzen,  and  venereal  or  moist  warts,  are  met  with 
in  the  anal  and  genital  regions  of  both  sexes,  as  also  in  the 
axillae,  under  the  hanging  breasts,  in  the  umbilicus,  and 
between  the  toes.  They  are  vascular,  sessile  or  pedunculated, 
and  composed  of  a  great  number  of  closely  aggregated  pro- 
jections of  various  shapes.  On  exposed  situations  they  are 
dry  and  of  the  color  of  the  skin ;  while  in  locations  that  are 
moist — that  is,  between  skin  folds — they  are  covered  with  a 
whitish  puriform  secretion,  and,  unless  kept  very  clean,  they 
emit  an  offensive  odor.  They  sometimes  attain  to  an  im- 
mense size. 

Etiology.  We  do  not  know  the  cause  of  warts.  They 
are  regarded  by  some  as  contagious,  and  parasites  have  been 
isolated  and  declared  to  be  the  morbific  agents.  They 
occur  more  frequently  in  the  young  than  in  the  old,  and 
may  be  congenital.  Verruca  acuminata  are  traceable  to 
irritating  discharges,  but  not  by  any  means  always  to  a 
gonorrhoea. 

Treatment.  The  treatment  of  most  all  warts  is  prompt 
and  efficient  by  means  of  the  currette,  scraping  them  off 
while  the  skin  is  slightly  stretched.  If  there  is  any  doubt 
about  their  returning,  their  bases  may  be  touched  with 
iodine  or  nitric  acid.  Generally  simple  scraping  is  suffi- 
cient. Electrolysis  may  be  used.  The  digitate  and  filiform 
warts  may  be  snipped  off  with  the  scissors,  but  this  presents 
no  advantage  over  the  curette.  If  operative  interference  is 
refused,  the  warts  may  be  removed  by  painting  with  tinc- 
ture of  iodine ;  or  a  saturated  solution  of  salicylic  acid ;  or  a 
20  per  cent,  solution  of  resorcin ;  tincture  of  thuya  ;  or 
nitric  or  glacial  acetic  acid.  In  the  country,  children's 
warts  are  removable  in  some  cases  by  the  application  of 
the  juice  of  the  common  milk-weed.  Acuminate  warts  may 
be  removed  by  keeping  them  clean  and  dry,  and  painting 
them  with  liq.  plumbi  subacetatis,  or  a  solution  of  the 
perchloride,  or  persulphate  of  iron ;  or  dusting  them  with 
salicylic  acid  and  starch,  or  boric  acid.     Chromic  acid  is  a 


518  DISEASES    OF    THE    SKIN. 

powerful  caustic.  Caustic  potash  is  not  a  safe  one  to  use, 
unless  care  is  had  to  limit  its  action  by  a  ring  of  wax  about 
the  wart.     The  galvano-cauterj  may  also  be  employed. 

It  is  said  that  warts  may  be  removed  by  internal  treatment. 
Sulphate  of  magnesia,  two  or  three  grains  to  a  child  and 
half  a  drachm  to  an  adult,  three  times  a  day,  is  one  remedy. 
Besnier  has  tried  this  method  in  a  number  of  cases  with  ab- 
solute unsuccess.  Tincture  of  thuya  occidentalis,  two  or 
three  times  a  day,  is  said  to  be  efficacious.  Crocker  thinks 
he  has  seen  cures  effected  with  full  doses  of  nitro-muriatic 
acid. 

Warts  very  often  disappear  of  themselves,  and  no  one  has 
ever  seen  them  fall. 

Verruca  Necrogenica.     See  Tuberculosis  verrucosa  cutis. 
Verrue.     See  Verruca. 
Verrugas,  Endemic.     See  Yaws. 
Vibices.     See  Purpura. 
Vitiligo.     See  Leucoderma. 
Vitiligo  Capitis.     See  Alopecia  Areata. 
Vitiligoidea.     See  Leucoderma. 
Wart.     See  Verruca. 
Warze.     See  Verruca. 
Warzenkrebs.     See  Carcinoma. 
•Warzenmal.     See  Nsevus  verrucosus. 

Washleather  skin  is  that  condition  of  the  skin  in  which 
certain  metals,  specially  silver,  mark  it  with  a  black  line.  It 
occurs,  as  a  rule,  in  patients  suffering  from  diseases  which 
directly  or  indirectly  affect  either  the  trophic  or  the  sensory 
nerves,  such  as  renal  disease,  phthisis,  erysipelas,  and 
hemiplegia.  It  sometimes  precedes  the  occurrence  of  bed- 
sores. 

Weichselzopf.     See  Plica. 
Wen.     See  Sebaceous  cyst. 
Whelk.     See  Acne. 
Xanthelasma.     See  Xanthoma. 


XANTHOMA.  519 

Xanthoma  (ZaVthc^ma3).  Synonyms :  Xanthelasma ; 
Vitiligoidea ;  Molluscum  chol6sterique ;  Fibroma  lipoma- 
todes. 

A  peculiar  disease  of  the  skin  characterized  by  the  ap- 
pearance of  discrete  patches,  or  tubercles  of  chamois  or 
lemon-yellow  color. 

Symptoms.  Xanthoma  may  assume  one  of  two  forms : 
Xanthoma  planum,  or  Xanthoma  tuberosum  or  tuberculatum. 
In  the  former  we  meet  with  flat,  chamois-leather,  or  lemon- 
yellow  plates  that  are  either  slightly  raised  above  the  level 
of  the  skin,  or  not  at  all  raised.  They  vary  in  size  from  an 
eighth  of  an  inch  to  an  inch  in  their  long  diameter,  feel  soft 
and  smooth  to  the  touch,  and  when  pinched  between  the 
fingers  no  infiltration  of  the  skin  is  perceptible.  They  are 
irregular  in  shape,  tending  to  form  elongated  figures.  When 
in  patches  they  feel  almost  velvety,  and  when  examined  with 
a  lens  thev  are  seen  to  consist  of  an  aggregation  of  small 
granules,  many  of  which  have  a  central  pinkish  punctum. 

Xanthoma  tuberosum  exhibits  lesions  of  the  same  color 
as  does  the  plain  variety,  or  they  may  be  of  reddish-yellow, 
but  they  are  raised  above  the  skin  and  may  attain  to  a  large 
size.  They  are  soft,  smooth,  round,  or  oval,  with  telan- 
giectases over  them  when  small.  When  large,  they  are  firmer 
and  more  irregular  in  shape,  being  made  up  by  aggregation 
of  a  number  of  smaller  tubercles.  Xanthoma  multiplex  is 
the  name  applied  to  cases  in  which  both  varieties  are  present. 
In  all  forms,  unless  there  is  jaundice,  the  skin  between  and 
about  the  lesions  is  normal  in  color,  Most  cases  give  rise 
to  no  subjective  symptoms,  but  there  may  be  some  itching 
or  burning.  If  the  disease  occur  upon  the  palms  or  knees  it 
may  cause  discomfort  or  even  pain  on  kneeling  or  handling 
objects. 

The  favorite  seat  of  xanthoma  planum  is  in  the  upper 
eyelid,  where  they  are  not  infrequently  seen.  They  there 
commence  at  the  inner  canthus,  most  often  of  the  left  eye, 
and  spread  in  a  semicircle  about  the  eye,  while  shortly  after- 
ward a  similar  growth  begins  on  the  right  upper  eyelid. 
Next  in  point  of  frequency  to  the  eyelids,  they  occur  upon 
the   flexures  and  mucous  membranes.     Xanthoma  tubero- 


520  DISEASES    OF    THE    SKIN. 

sum  is  most  frequently  seen  upon  the  knees,  elbows, 
knuckles  and  other  points  of  pressure,  the  trunk  being  not 
so  much  affected.  Symmetry  is  generally  observed.  Xan- 
thoma multiplex  is  often  very  widely  distributed.  Some- 
times the  lesions  run  in  streaks,  or,  as  in  Hardaway's  case,1 
are  arranged  like  a  zoster.  The  following  case  reported  by 
me2  is  one  of  the  most  extensive  on  record.3 

Michael  M.,  aged  five  years,  was  admitted  to  my  service 
at  the  Randall's  Island  Hospital  in  May,  1890.  From 
the  child's  sister  I  have  been  able  to  gather  the  following 
imperfect  history  :  The  eruption  appeared  when  the  child 
was  three  months  old,  without  any  antecedent  disease, 
and  came  out  all  over  the  body  at  the  same  time.  It  is 
thought  that  no  new  lesions  have  appeared  since  then ; 
that  there  has  been  no  change  in  the  size  of  the  lesions,  and 
that  some  of  them  have  disappeared.  The  boy  is  said  to 
have  always  been  well,  to  have  played  about  like  other  boys, 
and  never  to  have  been  jaundiced. 

Examination  of  the  boy  reveals  a  very  extraordinary  con- 
dition of  affairs :  The  whole  body  of  the  boy  is  occupied  by 
a  disseminated  efflorescence,  no  part  being  spared  except  the 
hands,  feet,  and  scalp.  The  lesions  are  about  the  size  of  a 
split-pea,  or  a  little  smaller,  are  soft  to  the  touch,  and  have 
a  central  depression.  Upon  the  face,  trunk,  shoulders,  and 
lower  part  of  the  legs  they  are  discrete,  and  scattered  about 
without  any  particular  arrangement.  Upon  the  extremities 
the  lesions  are  crowded  into  patches  of  various  sizes  and 
shapes,  with  normal  skin  between  them.  Even  in  the  patches 
the  lesions  are  distinct.  They  touch  each  other  but  do  not 
coalesce.  The  distribution  of  the  lesions  and  of  the  patches 
is  quite  symmetrical.  The  color  varies  from  a  lemon-yellow 
in  the  discrete  lesions  on  the  shoulders  to  an  orange-yellow 
in  the  patches.  About  the  joints  the  color  is  reddish-brown. 

In  the  right  eyelid  are  well  marked,  typical  xanthomatous 
patches  of  a  chamois-leather  color.  The  lower  lid  is  occupied 

1  St.  Louis  Courier  of  Med.,  October,  1884. 

2  Journ   Cutan  and  Gen.-urin.  Dis.,  1890,  viii.  241. 

3  See  frontispiece  for  illustration. 


XANTHOMA.  521 

by  one  continuous  patch,  running  from  the  inner  to  the  outer 
canthus.  On  the  upper  lid  there  is  a  small  tumor.  The 
left  lid  is  but  very  slightly  affected.  Upon  the  back  of  the 
neck  and  the  upper  part  of  the  back  are  a  number  of  light- 
brown  pigmentary  spots,  which  the  sister  says  are  the  re- 
mains of  some  lesions  that  have  disappeared.  Scattered 
about  the  trunk  are  a  number  of  depressed  scars,  apparently 
the  remains  of  a  recent  varicella. 

The  boy  is  very  thin,  of  blonde  type,  and  the  skin  is  pale. 
Apart  from  this  there  is  nothing  abnormal.  His  appetite  is 
good,  his  digestion  is  in  fine  condition,  and  his  urine  con- 
tains neither  albumin  nor  sugar.  Upon  the  left  buttock 
there  is  one  vascular  nsevus. 

The  skin  in  Xanthoma  is  not  alone  affected.  Xantho- 
matous bodies  are  found  in  the  liver,  mucous  membranes, 
and  tendons.  The  disease  is  progressive  for  a  time,  and 
then  may  remain  stationary  for  years,  or  may  undergo  spon- 
taneous resolution. 

Etiology.  Xanthoma  occurs  much  more  frequently  in 
adults  than  in  children,  and  that  form  that  occurs  in  the 
eyelids  is  much  more  common  in  women  than  in  men. 
Several  cases  may  be  seen  in  the  same  family,  and  the 
disease  is  sometimes  hereditary.  But  we  really  do  not  know 
as  yet  what  is  the  cause  of  the  disease,  though  various  theo- 
ries have  been  advanced.  Hepatic  diseases  ;  diabetes  ;  dia- 
thetic conditions  of  various  kinds ;  migraine ;  embryonic 
cells  left  in  the  skin  ;  each  have  been  found  in  connection 
with  one  or  many  cases.  Hardaway  may  not  be  wrong  in 
his  idea  that  it  is  a  diathetic  disease,  and  that  when  it  occurs 
with  jaundice  it  is  because  the  same  tubercles  have  been 
deposited  in  the  liver  as  in  the  skin,  and  the  jaundice  is 
secondary  to  them. 

Diagnosis.  The  diagnosis  of  this  unique  disease  is  made 
by  the  occurrence  of  chamois-leather-colored  soft  plates  or 
tubercles,  such  as  occur  in  no  other  disease.  3Iilium  may 
bear  some  slight  resemblance  to  xanthoma,  but  it  is  hard 
and  firm,  not  soft  and  velvety,  and  white,  not  yellow.     It 


522  DISEASES    OF    THE    SKIN. 

is  easily  squeezed  out  after  a  prick  through  the  skin  over 
them,  an  impossibility  in  xanthoma. 

Treatment.  In  the  way  of  treatment  we  have  no  sure 
resource  save  the  knife  and  electrolysis.  The  latter  is  the 
more  preferable  of  the  two.  In  so  general  a  case  as  mine, 
neither  plan  would  be  applicable.  Besnier1  reports  good  re- 
sults from  the  administration  of  phosphorus  in  cod-liver  oil, 
giving  one  milligramme  per  day,  and  increasing  the  dose 
each  day  by  a  quarter  of  a  milligramme  until  three  milli- 
grammes are  taken.  After  fifteen  days  this  is  stopped  and 
turpentine  is  given.  Stern2  tried  this  plan  without  success, 
but  succeeded  in  removing  patches  of  the  disease  from  the 
eyelids  by  the  use  of  a  ten  per  cent,  solution  of  corrosive 
sublimate  in  collodion. 

Xanthoma  Diabeticorum.  Besides  the  xanthoma  just  de- 
scribed there  is  another  form  which  is  regarded  by  many  as 
a  distinct  affection,  and  called  Xanthoma  diabeticorum. 

Symptoms.  It  is  an  exceedingly  rare  disease,  which  dif- 
fers from  ordinary  xanthoma  in  its  more  sudden  develop- 
ment ;  in  disappearing  sooner  or  later,  perhaps  to  recur  ;  by 
the  hardness  of  its  lesions,  which  are  never  macular  ;  by  the 
frequent  absence  of  a  yellow  color ;  by  the  presence  of  a  cer- 
tain amount  of  inflammation  ;  by  absence  of  jaundice,  and 
presence  of  diabetes  mellitus  ;  by  its  more  pruriginous  char- 
acter ;  by  avoiding  the  eyelids  ;  and  by  having  its  lesions 
about  the  mouths  of  the  hair  follicles.  In  fact,  it  resembles 
ordinary  xanthoma  mostly  in  its  location  upon  the  elbows, 
knees,  and  other  points  of  pressure,  and  in  the  general  con- 
figuration of  the  lesions.  The  treatment  should  be  directed 
to  the  diabetes  and  to  the  allaying  of  the  itching. 

Xeroderma.     See  Ichthyosis. 

Xeroderma  Pigmentosum.  See  Atrophoderma  pigmen- 
tosum. 

Yaws3  (Ya4z).  Synonyms  :  Framboesia  ;  Pian  ;  Parangi ; 
Verruga.     This   is  a  disease  that  occurs  only    in   tropical 

1  Journ.  de  Med  et  de  Chir.,  April,  1886. 

2  Berlin  klin.  Woch.,  1888  xxv.  393 

3  This  account  is  condensed  from  Crocker. 


ZOSTER.  523 

countries.  The  stage  of  incubation  lasts  two  to  eight  weeks 
and  without  special  symptoms.  The  stage  of  invasion,  with 
more  or  less  well-marked  fever,  which  abates  before  the 
eruption,  lasts  one  or  two  weeks.  The  eruption  is  preceded 
by  enlargement  and  tenderness  of  the  lymphatic  glands,  and 
consists  of  pinhead  to  lentil-sized,  slightly  elevated  papules 
on  a  broad  base.  The  papules  enlarge,  the  epidermis  splits 
and  curls  off  from  their  centres  and  exposes  a  yellowish 
point  which  develops  into  a  flat,  moist,  red,  or  pink 
tumor,  looking  not  unlike  a  raspberry.  These  tumors 
range  in  size  from  a  split-pea  to  a  nut,  are  round  or 
oval,  discrete,  or  coalesced  into  large,  irregular  masses. 
The  surface  of  the  tumor  is  covered  with  a  thin,  yellow- 
ish, foul-smelling  discharge,  that  dries  into  scabs,  which 
may  ultimately  form  rupia-like  crusts.  In  the  mouth 
and  in  moist  situations  no  crusts  form,  and  the  tumors  will 
resemble  mucous  patches.  They  reach  their  full  develop- 
ment in  from  two  to  four  weeks,  remain  stationary  for  months, 
and  then  dry  up  and  fall  off,  leaving  a  spot  on  the  skin 
that  eventually  disappears.  They  may  break  down  and 
ulcerate,  involving  both  the  adjacent  soft  parts  and  the  bones. 
The  tumors  are  not  tender.  The  disease  tends  to  recovery, 
but  is  subject  to  relapses.  Death  occurs  in  bad  cases.  It 
is  contagious,  and  one  attack  is  protective  to  a  certain 
extent. 

Treatment.  The  treatment  is  hygienic  and  by  tonics. 
Locally,  disinfectant  applications  should  be  used. 

Zaraath.     See  Lepra. 
Zona.     See  Zoster. 

Zoster  (Zo2st/u°r).  Synonyms  :  Zona  ;  Herpes  zoster  ; 
Ignis  sacer  ;  (Ger.)  Feuergiirtel,  Giirtelkrankheit ;  Shingles. 

An  acute  disease  of  the  skin  characterized  by  a  unilateral 
eruption  of  groups  of  vesicles  upon  reddened  bases  scattered 
along  the  course  of  certain  nerves. 

Symptoms.  Zoster,  like  psoriasis,  presents  such  marked 
lesions  that  once  seen  it  is  readily  recognized  when  seen 
again.  It  occurs  in  the  form  of  groups  of  vesicles  seated 
upon  red  bases,  and  arranged  along  the  course  of  nerves 


524 


DISEASES    OF    THE    SKIN. 


upon  which  there  are  ganglia.  (Fig.  50.)  The  vesicles  are 
at  first  filled  with  serum  that  afterward  may  become  cloudy. 
They  do  not  tend  to  break  down  of  themselves,  but  are  fre- 
quently ruptured  by  accident.  The  size  of  the  groups 
varies  greatly.  There  may  be  but  a  few  vesicles  or  a  large 
number  of  them  closely  crowded  together.      Sometimes  a 


Fig.  50. 


Zoster,  of  arm. 


group  is  no  larger  than  a  three-cent  piece,  and  sometimes  it 
is  several  inches  in  its  longest  diameter.  Sometimes  the 
vesicles  may  run  together  and  form  blebs.  The  shape  of 
the  groups  is  always  irregular.  There  may  be  but  two  or 
three  groups  or  a  score  of  them.  In  nearly  all  cases  the 
disease  is  unilateral,  though  it  is  not  uncommon  for  one  or 
two  groups  to  be  found  close  to  the  middle  line,  on  the  side 
opposite  to  the  site  of  the  disease.  All  the  groups  do  not 
come  out  at  once,  but,  as  it  were,  by  a  series  of  outbreaks,  the 
earliest  ones  to  appear  usually  being  those  nearest  the  point 
of  exit  of  the  nerve.  The  eruption  is  usually  at  its  height 
in  a  week,  the  vesicles  drying  up,  forming  a  crust  and  fall- 
ing off,  leaving  a  red  mark  that  soon  fades.  The  whole 
duration  of  the  disease  is  from  ten  days  to  three  or  four 
weeks. 

In  many,  if  not  most  cases,  the  patient  experiences  neu- 
ralgic pain  in  the  nerve  along  whose  course  the  eruption  is 
about  to  appear.     This  is  sometimes  wanting,  and  generally 


ZOSTER.  525 

lessens  or  disappears  when  the  eruption  appears.  Some- 
times the  pain  is  severe  during  the  duration  of  the  eruption, 
and  after  it  is  gone.  Tender  points  may  often  be  found  over 
the  points  of  exit  of  the  nerves,  just  as  are  found  in  neural- 
gia. In  some  patients  there  will  be  fever  before  the  out- 
break of  the  vesicles  or  the  successive  appearance  of  new 
groups.  The  vesicular  stage  is  preceded  by  an  erythemato- 
papular  stage.  Very  rarely  some  of  the  groups  may 
abort  at  this  stage.  Exceptionally,  zoster  may  occur  on 
both  sides  of  the  body.  In  nearly  all  cases  the  disease  does 
not  recur.  Exceptionally,  a  patient  may  have  several  at- 
tacks of  the  disease. 

Most  cases  of  zoster  occur  upon  the  trunk,  and,  it  is  said, 
specially  on  its  right  side.  It  also  occurs  upon  the  face,  on 
branches  of  the  fifth  nerve  when  it  may  involve  the  eye. 
The  neck  may  be  affected,  and  with  it  the  arm.  The  leg, 
too,  may  suffer.  Generally,  the  eruption  does  not  reach 
further  down  than  the  elbow7  and  knee,  though  it  may  occupy 
the  forearm  and  hand,  leg  and  foot.  In  rare  instances,  the 
tongue  and  pharynx  may  be  affected.  Various  names  are 
used  to  designate  the  location  of  the  eruption,  such  as  zoster 
frontalis,  ophthalmicus,  cervicalis,  intercostalo,  genito-crural, 
and  the  like. 

In  rare  cases  hemorrhage  may  occur  into  the  vesicles,  or 
they  may  be  purulent  from  the  start,  or  they  may  ulcerate 
or  become  gangrenous.  The  neuralgia  may  continue  in  old 
or  debilitated  subjects  in  so  severe  a  manner  as  to  threaten 
the  exhaustion  of  the  patient  from  pain  and  loss  of  sleep. 
Or  pruritus,  hyperesthesia,  or  anaesthesia  may  be  left  for 
some  time  after  the  disappearance  of  the  eruption.  Or 
paralysis  of  motion  may./ollow  the  attack,  as  well  as  atrophy 
of  muscles.  Scars  will  follow  the  disease  if  ulceration  has 
occurred. 

Etiology.  Zoster  occurs  more  often  in  children  than 
adults.  Sex  seems  to  have  little  influence.  It  follows  upon 
injuries  to  nerves  in  some  cases,  and  has  been  associated 
with  caries  of  the  ribs.  It  has  been  known  to  occur  while 
the  patient  was  taking  arsenic.  Jt  occurs  frequently  in  the 
damp  cold  weather  of  the  spring  and  autumn,  so  much  so  as 


526  DISEASES    OF    THE    SKIN. 

to  give  rise  to  epidemics.  Indeed,  some  regard  the  disease 
as  infectious  on  account  of  the  epidemic  character  it  some- 
times has.  Some  cases  seem  to  arise  from  peripheral  irri- 
tation of  cutaneous  nerves.  A  descending  peripheral  neuritis 
of  the  spinal  ganglion  is  regarded  by  Crocker  as  the  condi- 
tion most  frequently  associated  with  the  disease.  In  a  great 
number  of  cases,  disease  of  the  ganglia  upon  the  posterior 
roots  of  the  spinal  nerves  has  been  found  post-mortem. 
When  the  fifth  nerve  is  affected,  it  is  the  Gasserian  ganglion 
that  is  diseased. 

Diagnosis.  Zoster  in  most  cases  is  readily  recognizable. 
It  differs  from  eczema  in  having  larger  vesicles  that  do  not 
tend  to  rupture  ;  in  its  patchy  character,  the  patches  being 
located  along  certain  nerve  trunks  ;  in  the  neuralgia  that  ac- 
companies it ;  and  in  the  definite  course  that  it  runs.  Herpes 
facialis  or  preputialis  sometimes  resembles  zoster  quite 
closely,  but  in  them  there  will  often  be  a  history  of  previous 
attacks ;  they  will  not  occur  so  markedly  as  groups  of 
vesicles  upon  one  side  alone  ;  and  they  will  not  be  preceded 
by  the  same  amount  of  neuralgia.  By  some  authorities 
herpes  and  zoster  are  considered  to  be  the  same  disease. 

Treatment.  The  most  important  part  of  the  treatment 
of  zoster  is  to  prevent  the  breaking  of  the  vesicles,  and  the 
possible  ulceration  that  would  follow  and  leave  scars.  To 
this  end  we  should  avoid  ointments  and  use  dusting  powders, 
such  as  oxide  of  zinc,  or  bismuth,  or  starch,  or,  what  is 
better,  we  should  paint  the  vesicles  with  flexible  collodion 
with  or  without  morphia,  which  sometimes  seems  to  abort  the 
formation  of  vesicles.  It  is  also  advisable  to  cover  the  erup- 
tion with  a  soft  linen  bandage  to  prevent  rubbing.  If  the 
vesicles  have  become  broken  and  ulceration  has  ensued,  then 
we  have  to  treat  the  ulcers  on  surgical  principles. 

To  relieve  the  pain  of  zoster  the  galvanic  current  gives 
the  best  results,  one  sponge  electrode  being  placed  over  the 
spine,  and  the  other  passed  around  the  groups  for  ten  or 
fifteen  minutes  once  or  twice  a  day.  A  current  strength  of 
two  or  three  milliamperes  may  be  used,  and,  if  it  can  be  done, 
the  last  application  should  be  made  just  before  going  to  bed. 
Other  means  are  hypodermatics  of  morphia  ;  blistering  over 


ZOSTEK.  527 

the  root  of  the  nerve  ;  and  the  use  of  the  menthol  cone  or 
oil  of  peppermint.  Phosphide  of  zinc,  one-third  of  a  grain 
every  three  hours,  is  thought  by  some  to  relieve  the  pain 
and  limit  the  eruption.  For  the  persistent  neuralgia  that 
at  times  follows  these  cases,  arsenic,  or  strychnia,  iron, 
quinine,  cod-liver  oil,  and  a  good  nutritious  diet  are  neces- 
sary. Opium  may  have  to  be  given  to  allay  pain  and  pro- 
cure sleep. 

Prognosis.  Most  cases  of  zoster  run  a  favorable  course 
and  get  well  of  themselves.  It  is  only  in  old  or  debilitated 
people  that  we  need  fear  any  serious  results.  There  is 
always  the  possibility  of  the  occurrence  of  ulceration  and 
gangrene,  though  it  is  not  to  be  expected  in  the  vast  majority 
of  cases.  The  popular  opinion  that  if  zoster  occurs  on 
both  sides  at  once  and  forms  a  girdle,  the  patient  will  die,  is 
not  borne  out  by  the  facts. 


APPENDIX. 


The  following  formulae  are  given  as  guides  in  the  preparation 
of  prescriptions  for  the  treatment  of  skin  diseases.  Many,  if  not 
all  of  them,  have  been  well  tried  and  their  value  proved : 

A.    BATHS. 


Simple  Water  Baths: 

Cold     . 

.      40°  -  65°  F 

Cool     . 

.       65°-75°F 

Tepid  . 

.      85°-95°F 

Warm 

.       95°-100°  F 

Hot      . 

.     100°-110°  F 

Wet  Pack.  Wrap  patient  in  wet  sheet  and  roll  up  in  a  blanket. 
After  twenty  to  thirty  minutes  remove  the  pack,  rub  dry,  and  anoint 
with  oil  or  ointment.  Useful  to  remove  the  scales  in  psoriasis,  and 
to  diminish  hyperemia. 

Medicated  Baths.  To  an  ordinary  bath-tub-full,  say  thirty  gallons 
of  water,  add  for 

2  to  6  lbs.  bran. 


Bran  bath 
Potato-starch  bath 
Gelatin  bath 
Linseed     " 
Marshmallow  bath 
Size  bath 


1  lb.   starch. 

1  to  3  lbs.  gelatin. 

1  lb.   linseed. 

4  lbs.  marshmallow. 

2  to  4   "    size. 


These  baths  are  useful  in  erythematous,  itchy,  and  scaly  diseases. 

To  bath. 
Bicarbonate  of  soda  bath  .         .     2  to  10  ounces. 

Carbonate  of  potassium  bath    .         .     2  to    6       " 
Borax  bath        .....  3       " 

These  baths  are  useful  in  eczema,  psoriasis,  urticaria,  prurigo,  and 
pruritic  diseases. 

To  bath. 

Nitric  acid  bath         .....     1  ounce. 
Muriatic  acid  bath    .         .         .         .         .     1       " 
Or  may  use  of  each  .         .         .         .         .     J       " 

Of  use  in  chronic  pruritic  diseases. 

23 


530 


APPENDIX 


Iodine  Bath 


Iodine 

Iodide  of  potassium  vel 

Liquor  potass.       .... 

Glycerin       ..... 

Useful  in  scrofulous  and  squamous  diseases. 


To  bath. 
2-  to  1  drachm. 

j  ounce. 
1  to  2  ounces. 
2       " 


Bromine  Bath: 

Bromine   . 

Iodide  of  potassium 

Same  indications  as  iodine  bath. 


Potass,  sulphuret 
Used  in  scabies,  chronic  eczema,  lichen,  and  psoriasis. 


To  bath. 
20  drops. 
2  ounces. 


To  bath. 

2  to  4  ounces. 


Startin's  Compound  Sulphur  Bath  : 

To  bath. 
Precipitated  sulphur         ...         .2  ounces. 
Hyposulphite  of  soda       ...         .1  ounce. 
Dilute  sulphuric  acid        .        .         .         •     i       " 
Water 1  pint- 
Same  indications  as  the  sulphuret  of  potassium  bath. 


Mercurial  Bath: 

Bichloride  of  mercury 

Hydrochloric  acid      . 

Water 

Used  in  pityriasis  rubra  and  the  syphilides. 


To  bath. 

3  drachms. 
1  drachm. 
1  pint. 


.     B.    INTERNAL  USE. 

1.  Turpentine  Emulsion: 

J£ .  01.  terebinthinae,  1TLx-xxx ;         0.66-2 

01.  limonis,  TTLij ;                              1 

Mucilag.  acacise,  ^ss;                           16 

Aquae,  Ess]                          16          M. 
Sig.  A  teaspoonful   three   times   a  day  immediately  after  meals. 
One  quart  of  barley  water  to   be  drank  during  twenty-four   hours. 
(Crocker.) 

Used  in  psoriasis,  eczema,  and  hyperemias. 


APPENDIX. 


531 


2.  Mixed  Treatment: 

a.  R .  Hydrarg  bichlor.,  gr.  j-iij  ; 

Potass,  iodid.,  ^iv-viij;        16-32 

Tinct  cinchon.  co.,  Jf  iijss ;                 112 

Aquse,  %  ss ;                       16 


06-.2 


M. 


Sig.  One  drachm  in  water  t.  i.  d  one  hour  after  meals      (Taylor.) 

b.  R.  Hydrarg.  biniod ,  gr.  ss-ij ;  [03— .13 

Ammon.  iodid  , 
Potass,  iodid., 
Syr  aurant.  cort., 
Tinct.  aurant.  cort , 

Aquse,  ad     %  iij ;  100  M 

Sig.  One- half  ounce  t.  i.  d  after  meals.     (Keyes  ) 


gr.  ss-ij  ; 

3ss; 

2 

3y-3j; 

8-32 

Ijss: 

48 

sj; 

4 

ouj; 

100 

c.  R.  Hydrarg.  bichlor.  vel )  o>,  ...  # 
Hydrarg  biniod.,  j  *>  -  J  J  > 
Potass,  iodid.,  3J-ij  5 


Inf.  gent.  co.  vel  \ 

Syr.  sarsaparillse  co.,  J      £ 

Sig    One  drachm  t.  i.  d.  after  meals. 
These  three  are  used  in  syphilis. 


IV 


4-8 
128 


06-.  13 


M. 


3.           R .  Gurjun  oil,                         %  j ; 
Liquor  calcis,                     %  iij ; 

33(33 
100 1 

M. 

Sig.  One-half  ounce  twice  a  day. 

Used  in  leprosy. 

4.           R .  Tinct  guaiaci,                   TTLxl ; 
Tinct  aconiti,                    TlXij ; 
Aq.  camphorse,                 ,^ss; 

2 
16 

66 
13 

M. 

Used  in  chronic  skin  diseases,  specially  with 
Fox.) 

rheumatic 

taint      (T 

5.           R.  Tinct.  cannabis  indicse,     Tltx-xxx ; 
Pulv.  tragacanth.  co.        gr.  x  ; 
Aquse,                                  §  j ; 

0.66-2 
32 

m 

M. 

Used  in  pruritus  and  prurigo.     (Bulkley.) 

6.  Startin's  Mixture: 

R .  Magnesii  sulphat.,          3  vj_xij  j 
Ferri  sulphat.,                gj  ; 
Ac.  sulphur,  dil.,            %  ij  ; 
Syr.  pruni  virgin.,          %  j  ; 
Aquse,                    ad     %  iv ; 

20-30 

3 

6 

24 

100 

M. 

Sig.  One  drachm  t.  i.  d  after  meals,  through  a  tube. 


532 


APPENDIX. 


M. 


7.  Asiatic  Pills: 

J&.  Ac  arsenici,  gr.  lxvj. 

Pulv.  pip.  nigrse,  ^ix. 

Gum  Arabic.  1 

Aqu*,  }  aa     *8" 

Div.  in  pil.  no.  dccc. 

Sig.     One  to  three  pills  a  day  after  meals  and  increase  to  toler- 
ance. 

Used  in  psoriasis. 

8.  R.  Pil.  hydrarg.,  J}ij ;  2 

Ferri  sulphat.  exsic.,        £)j ;  1 

Ext  opii,  gr.  v ;  33     M. 

Div.  in  pil.  no.  xl. 

Sig.  One  t.  i  d.     (Taylor.) 

Used  in  syphilis.     Sulphate  of  quinine  may  be  substituted  for  the 
iron. 


9.  H.  Hydrarg.  ch lor.  mitis,       gr.  jss  ; 

Ferri  lactatis,  gr.  iij  ; 

Sacch.  alb.,  gr.  xv ; 

Ft.  in  pulv.  no.  x. 

Sig.  One  to  four  daily.     (Monti.) 

Used  in  infantile  syphilis 


M. 


C    EXTEKNAL  USE. 

a.  Caustics. 
1.   Cosme's  Paste  : 

j$ .  Ac.  arseniosi,  gr.  x ; 

Hydrarg.  sulphuret.  rub.,  3  ss ; 

Ungt.  rosse  vel  \  z 

Sacch.  alb.,        /  ^     ' 

To  destroy  epithelioma  or  other  new  growths. 


2 
16 


m 


M. 


2.  Marsden's  Paste  : 

R .  Pulv.  ac.  arseniosi, 
Pulv  gum  acacise, 


^    3j; 


M. 


Mix  with  water  to  form  a  paste  just  before  using,  and  apply  to  not 
more  than  one  square  inch  at  a  time. 
Same  indications  as  last. 


APPENDIX.  533 

3.  Bougard's  Paste  : 

R.  Wheat  flour,     \  --     fi0        , 

Starch,  /  aa     b°Parts' 

Arsenic,  1  part. 

Cinnabar,  )  >        . 

a  i  '     •  V  aa       5  parts. 

Sal.  ammoniac,      J  ^ 

Corrosive  sublimate,  ^  part. 

Sol.  chlor.  of  zinc  @  52°,  245  parts.      M. 

Grind  first  six  ingredients  to  a  fine  powder,  then  mix  them  in  a 
mortar      Add  solution  of  acid,  slowly  stirring.     Keep  in  earthen  jar. 

Sig.  Apply  accurately  to  part ;   keep  on  for  thirty  hours ;   follow 
with  poultice. 

4.  Depilatory  Paste  : 

R .  Barium  sulphid.,  5  ij  ;  8 

Zinci  oxidi, )  - ,  .   _ .  • .  -,  0 

Amyli,         }  aa     3nJ'  12  M> 

Make  into  a  paste  with  water  and  apply  a  thin  coating  for  ten  to 
fifteen  minutes,  then  clean  off  and  apply  a  bland  ointment. 

5.  Salicylic  Acid  (Crocker)  : 

R.  Glycerini,  £  j ;  321 

Ac.  salicyl.,  q.  s  ;  M. 

Make  in  consistency  of  thick  cream.     To  lessen  painfulness  of  appli- 
cation may  add 


R.  Ac  carbolici  vel  \  • ,  a 

Creasote,  J  ^ ' 

Used  to  destroy  warts,  lupus,  and  epidermic  thickenings 


M. 


6.    Vienna  Paste, 

R.  Calcis, 

Potassse. 


V  aa     p.  se.         M. 


Make  into  a  paste  with  alcohol  just  before  using 
Used  in  lupus  and  scrofulides. 

7.   Canquoi?i's  Paste  : 

R.  Zinci  chlor.,        1  aa      zi  •  4 

Ammon.  chlor.,  f  c        '^J  ' 
Pulv.  amyli,  3  jss ;  6 

Aquse,  q.  s. : 

Make  into  a  paste  at  time  of  using. 

Used  to  destroy  lupus,  epithelioma,  and  the  like. 


M. 


534 


APPENDIX. 


8.  Middlesex  Hospital  Paste. 

K  •  Zinci  chlor.,      \ 
Liq.  opii  sed  ,  J 
Amyli, 
Aquae, 

Same  indication  as  last. 

9.  R  •  Zinci  nitrat., 

Bread  mass, 

Mix  before  using. 


Sjss  ; 

3j; 


6 
32 


1  part. 

2  parts. 


M. 


M. 


b.  Lotions. 


1.  Belladonna  Lotion 


Be .  Tr.  belladon  ,  ) 
Glycerini,  j 
Aquae, 

Sig.  For  erysipelas.     (Piffard.) 


aa     1  part. 
8  parts. 


M. 


2.  Bismuth  Lotion : 

B  •  Bismuth,  subnitrat.,  gr.  vijss ; 

Zinci  oxidi,  3  ss ; 

Glycerini,  Tttxv ; 

Hydrarg.  bichlor.,  gr.  \ ; 

Aquae  rosae,  ^j ; 

For  rosacea  and  hyperaemic  conditions. 

3.  Calamine  Liniment  : 

B .  Pulv.  calamine,  9  ij  ; 

Zinci  oxidi,  3  ss ; 

Carron  oil,  %]  ; 

For  erythema,  eczema,  and  hyperaemic  conditions. 

4.  Calamine  Lotion : 

R.  Pulv.  calamine, 
Zinci  oxidi, 
Glycerini, 
Aq.  rosae, 

For  erythema  and  eczema. 

5.  Carbolic  Acid  Lotion  : 

Jjt.  Ac.  carbol., 


Alcohol.,  \ 


Aquae 
!Sig.  For  erysipelas.     (White.) 


3j; 

aa    Oss ; 


2 
1 

32 


2 

2 

32 


016 


M. 


66 


M. 


By; 

2 

£ss; 

2 

Wxv; 

1 

Zr, 

32 

66 


M. 


4 
250 


M. 


APPENDIX. 

6.    Carron  Oil  : 

R.  Aq.  calcis,        1 
01.  olivaa  vel     >- 
01.  lini,            J 
For  burns. 

Equal 

parts. 

7.   Coster's  Paint: 

R.  Iodine, 

01.  picis  liquidae, 

3  i-ij ; 
3J; 

4-81 
30 

8.   Fox's  C.  C.  C.  Mixture  : 

R .  Chrysarobim,  ^ 
01.  cadini,       J 
Ac.  carbolici, 
Ac.  oleici, 

aa     2 

1 
50 

parts. 

part, 
parts. 

Sig.  In  psoriasis. 

9.  Hardaway'  s  Lotion  for  Li 

chen 

planus  : 

R .  Sapo.  olivae  prep., 
01.  rusci,  \ 
Glycerini,  J 
01.  rosmarini, 
Alcoholis, 

aa 

ad 

7,  jss ; 
5  v"j ; 

100 

25 

4 

200 

10.  Kaposi's  Tar  Lotion : 

R.  01.  rusci, 

Etheris  sulphuris,  1 
Alcoholis,                / 
Filter  and  add 

01.  lavandulae, 

50 
aa     75 

2 

parts. 
u 

u 

Used  in  psoriasis. 

11.  Kummerf  eld' s  Lotion  : 

R.  Spts  campliorae,   \ 
Spts.  lavandulae,   J 
Sulph  praecip., 
Aq.  cologniensis, 
Aq.  destil., 

aa      ^  ss ;             2 
gr.  xv ;        1 

sj ;         ^ 
iij;        eo 

For  cosmetique. 

12.  Liquor  Picis  Alkalinus : 

R .  Picis  liquidae, 
Potass,  causticae, 
Aquae, 

3v; 

25 
12 
100 

5 

535 


M. 


M. 


M. 


M. 


M. 


M. 


M. 

(Dissolve  the  potassa  in  the  water  and  add  slowly  the  tar  in  a  mortar 
with  friction  ) 

In  chronic  eczema,  or,  diluted  ten  to  twenty  times,  in  acute  eczema. 


536 


APPENDIX. 


13.  Lotto  Alba  : 

Be .  Potass,  sulphurat., 
Zinci  sulphat, 
Aquae  rosse, 

In  acne  and  rosacea. 


3J 


IV 


4 

128 


M. 


14.  Lotio  Ac.  Boracis  : 

R.     Ac  boracis,  ^iv  vel  q  s  ;  16 

Etheris  sulph.  methyl ,  %  v  ;  160 

Spts.  vini  rect ,  ad    3  xx ;        640  M. 

In  ringworm,  after  washing  with  hot  water  and  soap  and  drying. 
Smith  ) 


:a. 


15.  Lotio  Plumbi  et  Opii: 

Bt  ■  Liq.  plumbi  subacetat  dil.,  )     - . 


Tinct  opii, 
Aquae, 

In  acute  inflammatory  conditions. 

16.  R.  /3-naphthol, 

Spts  sapo.  viridis, 
Alcoholis, 
Bals.  peruv., 
Sulph.  loti, 

In  sycosis.     (Kaposi.) 

17.  B-.  Glycerole  of  starch,  \ 

Oil  of  cade,  J 

Green  soap, 

Sig.  In  psoriasis.     External  use. 

18.  Piffard's  Substitute  for  Tar 

B     Ac.  salicyl , 
01.  lavandulae, 
01  citronellae, 
01  pini  sylvestris,  ; 

01  ricini,  ] 

In  eczema  capitis. 

19.  Be .  Sodii  hypophosphitis, 

Glycerini, 
Aquae, 

For  dermatitis  venenata.     (Morrow 


;j; 


32 


ad    Oj;      500 


gr.  xv  ; 

1 

3vJ; 

25 

Sjss; 

50 

gtt     XXX 

5 

2 

3  iJss ; 

10 

aa 

100 

parts 

5 

« 

gr.  x-xxx 

3yss; 

fss; 
ij; 

3Jss; 


0.66-2 

10 

2 

64 

48 


32 

16 
256 


M. 


M. 


M. 


M. 


M. 


APPENDIX. 

20. 

Sulphur  Lotion  : 

R  ■  Sulphuris  loti,  ] 
Alcohol., 

Etheris,              }■ 

a  a 

.^ij; 

8 

Glycerini, 

Potass,  carb ,    J 

Aq.  rosse, 

I^-iij; 

256 

Jsed 

in  acne. 

21. 

Thymol  Lotion  : 

R.  Thymol,          1 
Liq.  potassa?,  J 

a  a 

3J; 

4 

Glycerini, 

.?ss; 

16 

Aq.  sambuci, 

o  TiiJ ; 

256 

537 


M. 


For  seborrhcea  sicca  capitis, 
the  amount  of  thvmol. 


M. 

Also  for  pruritus  cutanea-,  with  double 


22.  Tinctura  Saponis  Viridis  : 

R.  Sapo.  viridis,  | 
Alcohol.,        J 

23.  Tinct.  Sapo?iis  Co.  of  Hebra 

R.  01   cadini, 

Saponis  viridis, 
Alcoholis, 
Filtra  et  adde 

Spts.  lavandula?, 

Stimulant  in  chronic  eczema. 

24.  Vleminckx's  Solution  : 

R  •  Calcis  viva?, 

Sulphur,  sublimat 
Aq.  destillat., 


a  a 


E<jual  parts 

sj; 

32 

3y; 

8 

3iv; 

fj; 
3*; 

16, 

32 
320 

M. 


M. 


M. 


Boil  together  with  constant  stirring  until  the  mixture  measures  -is 
fluidounces,  then  filter. 

Useful  in  scabies,  psoriasis,  and  acne. 


25.  R .  Zinci  oxidi, 
Ac.  carbol., 
Aqua?  calcis, 
For  dermatitis  venenata. 


1.   Bassorin  Paste 

R .  Basso rin, 
Dextrin, 

Glycerin, 
Water, 


IV 


3J; 

Oj; 


16 

4 
500 


ML 


i  White.) 
c.  Ointments. 


4S  parts. 
25      " 
10      " 
ad     100      " 


M. 


23* 


538 


APPENDIX 


2.   Bismuth  Ointment: 

R .  Bismuthi  subnit.,  \ 
Kaolini,  J 

Vaselini, 

For  chloasma.     (Unna. ) 


aa   3jss; 

gvj  ad^jss;     30 


3.  R  .  Ac.  borici, 

gr.  x ; 

Ac.  salicylici, 

gr  xv ; 

l 

Ungt.  aquae  rosfe, 

Ij; 

30 

For  chromidrosis.     (Van  Harlingen.) 

4.   Chrysarobln  Ointment : 

R .  Chrysarobin,  gr.  1 ; 

Ac.  salicylici,  gr  x  ; 

Plasment  vel  \  ^  • . 

Adipis,  J  ^J  > 

Used  in  psoriasis  and  ringworm. 


0 


3 

30 


M. 


M. 


M. 


5.  R.  Chrysarobin,  \ 
Ichthyol,         j 

aa     gr.  lxxv ; 

5 

Ac.  salicyl., 

gr   xxx ; 

2 

Ungt.  simpl , 

liij; 

100 

Used  in  leprosy.     (Unna  ) 

6.  Diachylon  Ointment  (Hebra) : 

R  .  Olive  oil,  ^  xv  ; 

Litharge,  giij,  gvj 

Boil  together  to  a  good  consistence  and  add 


Oil  of  lavender, 

7.  R.  Hydrarg   amnion., 
Bismuthi  subnit , 
Ungt.  aq.  rosa?, 

Used  in  lentigo.     (Hardaway.) 


8.  R.  Hydrarg.  amnion., 

Hydrarg.  chlor.  mitis, 
Vaselini, 


3 J J ; 
3j; 


480 
120 


4 

30 


@j-ij ;        5-10 

^ij-iv;      10-20 
5  J ;  100 


M. 


M. 


M 


Used  in  seborrhea  sicca  capitis  and  pityriasis  capitis.     (Bronson  ) 


9.  R .  Hydrarg.  bichlor.,  gr.  j-v ;  1-5 

Ac.  carbol.,  gr.  xx ;  20 

Ungt  zinci  oxid.,  ^j ;  500 

Used  in  lichen  ruber.     (Unna.) 


M. 


APPENDIX. 


539 


10.  R .  Ac.  salicylici,  gr.  x ; 

Ungt  hydrarg.  ox.  rub.,      3  j  ; 
Ungt.  aquse  rosse,  3  yj ; 

For  blepharitis.     (Webster  ) 

11.  R.  Hydrarg.  protiodid  , 

Hydrarg.  amnion., 
Ungt.  simplicis,  ^j 

Used  in  acne.     (Duhring.) 


66 


4' 
24 


gr   v-xv;      0.33-1 
gr   x-xxx ;  0.66-21 


12.  R.  Hydrarg.  sulph.  rubri,     gr.  xv 


Sulph.  sublimat 
Adipis, 
01.  bergamot, 
Used  in  sycosis.     (Behrend." 


ad 


q.  s. 


13.  R.  Ungt.  diachyli  (Hebra),  \    .- 
Ungt.  zinci  oxidi,  J 

Ungt.  hydrarg.  ammon., 
Bismuth,  subnitrat., 


z  Jss ; 


32 


1 
24 

75| 


50 

10 
5 


M. 


M. 


M. 


M. 


aa 


In  sycosis.     (Robinson  ) 

14.  Lassa?''s  Paste : 

R .  Zinci  oxidi, 
Amyli,  _ 
Vaselini, 

As  a  protective  application  and  as  excipient  for  other  drugs. 

15.  Naphthol  Ointment  : 


32 


M. 


R.  /3-napthol, 

Cretan  preparat., 
Sapo.  viridis, 
Adipis, 

Used  in  scabies.     (Kaposi.) 

3iij>  Bij  ;     15 

^rjss;            10 

,^jss;             50 

ad      |  iij  ;            100 

16.  Naphthol  Ointment: 

R.  /3-napthol, 

Sulph    precip., 
Vaselini,         Y 
Sapo.  viridis,  J 

10  parts. 
50      " 

aa     25       " 

Used  in  acne.     (Lassar.) 

17.  R  .    Ac.  salicylici, 

Sulphur,  precip., 

Lanolini, 

Vaselini, 

2^3  parts. 
10-15      " 
70      " 
18      " 

M. 


M. 


M. 


For  chromophytosis.     (Brocq/ 


540 


APPENDIX. 


18.  R.  Sulphur., 

Potass,  carb  , 
Adip.  benzoat., 
01.  chamomilis, 

Used  in  scabies.     (Wilson.) 

19.  Helmerich's  Ointment  : 

R.  Sulphur., 
Potass,  carb., 
Adipis, 

Used  in  scabies. 


3j; 

3ss; 


3viiJ 


20.    Wilkinson's  Ointment  (Hebra) : 

I 


R .  Sulphuris,  \ 
lini,  j 


01.  cadini 
Sapo    viridis, 
Adipis, 
Cretse  preparat., 

Used  in  scabies. 


aa 


21.  R.  01.  fagi,         \ 
Flor.  sulph.,  J 
Pulv.  cretfe  alb., 
Adipis,  \ 

Sapo.  viridis,  J 

In  sycosis.     (H.  Hebra.) 


aa 


aa 


3ss; 


3v; 


22.  R .  01.  cadini,    \  M  . 

Zinci  oxidi,  /  o      J 

Ungt.  aquae  rosse,  ^j  ; 

In  chronic  eczema. 


23.  R.  Glycerini, 

Gum.  tragacanth., 
Sulph.  sublimat , 
Potass,  carbonat, 
01.  lavandulse, 
01.  menth.  pip , 
01.  caryophylli, 
01.  cinnamomi, 

Used  in  scabies.     (Bourguignon  ) 

24.  R .  Zinc  oxide,         ) 

Zinc  carbonate,  / 
Rose  ointment, 

In  sycosis  after  shaving.     (T.  Fox.) 


aa 
ad 


a  a 


3.1 


32 

8 
160 

2 


30 
15 

120 


20 

80 
10 


10 

5 

20 


2-4 
30 


200  parts. 

5      " 

100      " 

35      " 

1.5   " 


4 
32 


M. 


M. 


M. 


M. 


M. 


M. 


M. 


APPENDIX. 


541 


d.  Miscellaneous 
1 


Anti-pruritic  Powder , 

R .  Camphori, 
Zinci  oxidi, 
Amyli, 


Corn  Remedy : 

R .  Ac.  salicylici, 

Ext.  cannabis  indicae, 
Alcoholis, 
JEtheris, 
Collodion  flex., 


3ss; 

3 

3y; 

15 

3iv; 

30 

M. 


(Bulkley.; 


gr.  xv ; 
gr.  viij  ; 

m>i; 

Vf[lxxv 


Apply  with  brush  three  times  a  day  for  one  week, 
pick  out  corn.     (Vigier. ) 


66 

M. 

Soak  feet  and 


3.  Epilating  Stick : 

R.  Cerae  flavae,  ^iij  ; 

Laccae  in  tabulis,  3  iv ; 

Picis  burgundicae  %  x ; 

Gummidamar.,  ^jss5 


12 
16 
40 

48 


M. 


Make  in  stick  one-half  to  one  inch  in  diameter  and  two  inches  long. 
(Bulkley) 


4.   Glycerin  Jelly 


R  .  Gelatini,                            gr.  xxv ; 
Glycerini,                         gr.  ccxxv ; 
Aqua?,                                  3  iv ; 

1 
15 
16 

Glycerole  of  Subacetate  of  Lead: 

R  .  Plumbi  acetat.,                 gr.  cxx ; 
Plumbi  oxidi,                  gr.  lxxxiv ; 
Glycerini,                          3J ; 

8 
6 
32 

66 


M. 


M. 

Digest  the  lead  in  the  glycerin  heated  to  300°  F.  in  an  oil  bath  for 
half  an  hour,  constantly  stirring.    Filter  in  a  chamber  heated  to  300°  F. 

Dilute  from  three  to  seven  times  with  water  and  glycerin,  and  use  as 
astringent  and  sedative  in  chronic  eczema      (Squire  ) 


INDEX 


4  BSCESS,  53 

A     Absces  tuberiforinis.  54 
Acantholysis,  54 
Acanthosis,  54 
Acid,  oleic,  46 

oxynaphthoie.  4V 
Acne,  54 

adenoid,  315 

albida,  319 

artificialis,  67 

atrophica,  68 

cachecticorum.  r>v 

cornea,  68,  394 

cornee,  394 

erythematosa,  402 

fluente,  68,  428 

frontalis,  68 

hypertrophica,  69 

indurata.  56 

keloid.  69,  148 

ir.entagra,  69,  437 

miliare  scrofuleuse.  68 

miliaris,  69 

necrotica,  68 

pilaris,  68 

rodens.  68,  69 

rosacea,  402 

rosee,  402 

scrofulosoriun,  69 

sebacea,  42S 
cornea,  394 

sebacee,  42  S 
cornee,  27"> 

-irnplex.  55 

sycosis,  437 

syphilitica,  69 

tuberculoide,  69 

varioliformis,  68,  321 

vulgaris,  55 


Achorion  Schoenleinii,  22^ 

Achroma,  290 

Acrochordon,  69 

Acrodynia.  70 

Addison's  keloid,  70 

Adenoma,  70 

Adenotrichie,  437 

Agnine,  46 

Ainhum,  70 

Albinism,  71 

Aleppo  boil,  bontou.  or  evil,  71 

AJoidite  progressive.  71.  420 

Algor  progressivus,  71 

Alopecia,  71 

adnata,  71 

areata,  79 

circumscripta.  79 

follicularis,  7 

furfuracea.  76 

pityrodes,  76 

prematura  idiopathica, 
symptomatica,  75 

senilis.  72 

syphilitica,  7v 
Alopecie  innominee.  S 
Alphos,  381 
Anaesthesia,  85 
Anatomical  tubercle,  503 
Angioma,  So,  331 

cavernosum,  382 

pigmentosum   et    atrophicum. 
88 
Angio-keratoma. 
Angioses,  86 
Anhidrosis,  SQ 
Anonychia.  87 
Anthrarobin.  46 
Anthrax,  102,  399 
Area  celsi,  79 


544 


INDEX. 


Area  occidentalis  diffluens,  79 
Argyria,  87 
Aristol,  46 

Arrectores  pilorum,  34 
Arthritidepseudo-exanthematique, 

87 
Arzneiexantheme,  96 
Asteatosis,  87 
Atheroma,  87 
Atrophia  pilorum  propria,  92 

unguium,  96 
Atrophoderma,  87 

albidum,  90 

idiopathica  diffusa,  90 

pigmentosum,  89 

senilis,  90 

striatum  et  maculatum,  91 
Aussatz,  284 
Autographism,  96 

t)AD  disorder,  447 
)     Baker's  itch,  96,  180 
Baldness,  71 
Barbadoes  leg,  96,  189 
Barber's  itch,  96,  437,  492. 
Bartfinne,  96,  437 

parasitische,  492 
Bartflechte,  96,  437 
Bassorin,  46 
Birth-mark,  332 
Biskra  bouton  or  beule,  96 
Blackheads,  117 
Blasenausschlag,  96,  352 
Blutfleckenkrankheit,  96,  394 
Blutgeschwur,  96 
Blutschwar,  96 
Blutschweiss,  96 
Boil,  96,  237 
Bouton,  97 

Bouton  d'  Amboine,  97 
Brandrose,  97 
Brandschwar,  102 
Bricklayer's  itch,  97,  180 
Bromidrosis,  97 
Bucnemia  tropica,  98,  189 
Bulla,  the,  38 

nACOTKOPHIA      folliculorum, 
\j     278,  394 

Calculi,  cutaneous,  98,  320 


Callositas,  98 

Callus,  98 

Calotte,  the,  229 

Calvezza,  71 

Calvities,  71 

Cancer  en  cuirasse,  106 

tubereux,  272 
Cancroide,  99,  195 
Canities,  100 
Caraate,  362 
Carbuncle,  102 
Carcinoma,  105 

lenticulare,  106 

melanodes,  106 

tuberosum,  10(5 
Chair  du  poule,  107,  1 22 
Chalastodermia,  149 
Chaleur  du  foie,  107 
Chancre,  107,  448 
Chap,  107 
Charbon,  107,  399 
Cheiro-pompholvx,  107,  370 
Chelis  or  cheloide,  107,  272 
Chicken-pox,  515 
Chignon  fungus,  487 
Chilblain,  107,  126 
Chloasma,  107,  111 
Chorioblastosis,  110 
Chorionitis,  110,  421 
Chromidrosis,  110 
Chromophytosis,  111 
Cicatrix,  the,  40 
Cingulum,  115 
Claret  stain,  332 
Classification,  49 
Clastothrix,  93,  115 
Clavus,  115 
Cnidosis,  116,  509 
Collodion,  45 

Colloid   degeneration  of  the  skin, 
116 

milium,  116 
Comedo,  117 
Condyloma,  121 
Congelatio,  121,  126 
Connective  tissue,  subcutaneous,  28 
Corium,  28 
Corn,  115 
Cornu  cutaneum,  121 

humanum,  121 
Couperose,  402 


INDEX. 


545 


Grasses  parasitaires,  111,  122 

Creolin,  47 

Crusta  lactea,  122,  174 

Crust,  the,  39 

Cute,  362 

Cutis  anserina,  122 

pendula,  149 

tensa  chronica,  122,  421 

unctuosa,  122,  428 
Cyanopathie  cutanee,  110 
Cyanosis,  122 
Cyst,  sebaceous,  427 
Cysticercus  cellulosa?  cutis,  122 
Cysto-adenoma,  122 


DACTYLITIS,  473 
Dandruff,  123 
Dartre  pustuleuse  mentagre,  437 

rongeante,  309 

vive,  153 
Dartrous  diathesis,  123 
Dasyma,  254 

Decrepitude  infantile,  123 
Defluvium  capillorum,  79 
Defcedatio  unguium,  123 
Delhi  boil,  123 
Demodex  folliculorum,  118 
Dermalgia,  123 
Dermatalgia,  123 
Dermatitis,  124 

ambustionis,  124 

calorica,  124 

congelationis,  126 

contusiforme,  217 

epidemica,  131 

exfoliativa,  134 

neonatorum,  136 

fungoid,  327 

gangrenosa,  136 
infantum,  138 

glandularis  erythematosa,  303 

herpetiformis,  139 

malignant  papillary,  339 

medicamentosa,  144 

papillaris  capillitii,  148 

papillomatosa  capillitii,  148 

traumatica,  127 

venenata,  127 
Dermatol,  47 
Dermatolysis,  149 


Derm  ato mycosis  favosa,  223 

Dermatomykosis  tonsurans,  490 

Dermato-sclerosis,  421 

Dermatosis  Kaposi,  88 

Diabetide,  150 

Diagnosis,  34 

Distichiasis,  151 

Don'ts,  49 

Dracontiasis,  243 

Durillon,  98 

Dysidrosis,  151,  370 


ECDERMOPTOSIS,  321 
Ecthyma,  151 

infantile  gangreneux,  138 
terebrant  de  l'enfance,  138 
Eczema,  153 

ani,  172 

aurium,  173 

barbae,  174 

capitis,  174 

crurum,  176 

exfoliativum,  132 

foliaceum,  132 

genitalium,  177 

hypertrophicum,  327 

infantile,  184 

intertrigo,  178 

labiorum,  178 

mammarum,  178 

mammellarum,  178 

manuum,  180 

marginatum,  187,  488 

narium,  181 

palpebrarum,  181 

pedum,  182 

seborrhoicum,  187 

tuberosum,  327 

unguium,  182 

universal,  183 
Elephantiasis,  190 

Graecorum,  283 
Emphysema,  194 
Endurcissement  athrepsique,  420 

du  tissu  cellulaire,  194,  420 
Engelures,  194 
Ephelides,  281 
Ephidrosis,  251 

cruenta,  19,  243 

tincta,  110 


546 


INDEX. 


Epidermis,  25 
Epidermolysis,  194 
Epithelialkrebs,  195 
Epitheliom  kystique  benin,  195 
Epithelioma,  195 

contagiosum,  201,  321 
Epitheliomatose  eczematoide  de  la 
mamelle,  339 

pigment  aire,  88 
Equinia,  201 
Erbgrind,  202,  223 
Erysipelas,  202 
Erysipeloid,  206 
Erythanthema,  207 
Erythema,  207 

exudativum,  213 

fugax,  210 

gangrenosum,  220 

hypersemicum,  207 

intertrigo,  208 

iris,  216  . 

lseve,  210 

mamelonne,  220 

multiforme,  214 

neonatorum,  211 

nodosum,  217 

paratrimma,  210 

pernio,  208 

roseola,  210 

scarlatiniforme,  212 

simplex,  208 

urticans,  210 
Erytheme  centrifuge,  303 

papuleux  desquamatif,  363 
Erythrasma,  220 
Erythrodermies  exfoliantes,  132 
Erythromelalgia,  222 
Esthiomene,  222,  309 
Europhene,  47 
Exanthemata,  222 
Excoriation,  the,  40 


i;AECY,  201,  223 

l1     Favus,  223 

Feuergiirtel,  232,  523 

Feuermal,  232,  331 

Fibroma,  232 

fungoides,  234,  327 
lipomatoses,  234,  51 9 
molluscum,  232 


Fibromyoma,  234,  329 

Figwart,  234 

Fikosis,  437 

Filaria  sanguinis  hominis,  192,  234 

medinensis,  234,  243 
Finnen,  54,  234 

Fischschuppenausschlag,  234,  261 
Fish-skin  disease,  235,  261 
Fissure,  the,  40 

Flachenkatarrh  der  haut,  153,  235 
Flachenkrebs,  235 
Fleckenmal,  235,  330 
Flechte,  fressende,  309 

kleien,  111 

nassende,  153 
Fleshworms,  117 
Fluxus  sebaceus,  235,  428 
Folliculitis  barbre,  235,  437 

decalvans,  235 

pilorum,  437 

rubra,  236 
Fragilitas  crinium,  92 
Framboesia,  148,  236,  522 
Freckles,  236,  281 
Frieselausschlag,  236,  318 
Fuchsine,  47 

Fungous  foot  of  India,  236 
Furunculus,  237 

orientalis,  242 
Furunculi  atonici,  151 


GALE,  411 
Gallacetophenone,  47 
Gangrene,  symmetrical,  137,  242 
Gangrenes  multiples  cachectiques, 

138 
Gansehaut,  122,  242 
Gefassmaler,  242,  331 
Gelatin  preparations,  46 
Geromorphisme  cutane,  242 
Gesichts'  atrophie,  91,  242 
Glanders,  201,  242 
Glanzhaut,  91,  242 
Glossy  skin,  91,  242 
Gneis,  242,  428 

Gommes  scrofuleuses,  242,  426 
Goose-flesh,  122 
Granuloma  fungoides,  243,  327 
Grayness,  100 
Greisenhaftigheit  der  kinder,  243 


INDEX 


547 


Grocer's  itch,  180,  243 
Grubs,  117 
Grutum,  319 

Guinea-worm  disease,  243 
Gumma,  243,  463 
Gune,  243 

Gurtelkrankheit,  243,  523 
Gutta  rosacea  seu  rosea,  402 


HAARMENSCHEN,  243,  254 
Hsematidrosis,  243 
Hsemorrhcea  petechialis,  244,  394 
Hair,  anatomy  of,  30 

ringed,  101 

superfluous,  254 
Hand  and  foot  disease,  358 
Harlequin  foetus,  263 
Hautfmne,  244 
Hautgries,  244 
Hauthorn,  121,  244 
Hautkrebs,  244 
Hautsclerem,  421 
Heat  eruption,  153 
Hemorrhagic  cutanee,  244 
Herpes  circine  parasitaire,  490 

circinatus,  249,  488,  490 
bullosus,  249 

cretace,  249 

esthiomenos,  309 

facialis,  244 

gestationis,  249 

imbrique,  249 

iris,  249 

parasitaires,  249 

phlyctsenoides,  249 

progenitalis,  247 

pustulosus  mentagra,  437 

squamosus,  490 

tonsurans,  249,  490 
barbae,  492 
maculosus,  363 

tonsurante,  490 

zoster,  249,  523 
Herpetide,  249 

exfoliatives,  132 

maligne  exfoliative,  249 
Hide-bound  disease,  421 
Hirsuties,  254 
Hives,  509 
Homines  pilosi,  250,  254 


Homines  sylvestris,  250,  254 
Horn,  cutaneous,  121 
Hiihnerauge,  115,  250 
Hutchinson's  teeth,  472 
Hyalom  der  haut,  116 
Hydradenomes  eruptifs,  250 
Hydroa,  250 

bulleux,  250 
Hydro-adenitis,  250 
Hydroxylamine,  47 
Hygroma  cysticum   colli  congeni- 

tum,  250 
Hyperesthesia,  250 
Hyperidrosis,  symptoms,  251 
Hyperkeratosis  follicularis,  278 
Hypertrichosis,  254 
Hypohidrosis,  261 
Hystricismus,  261 


1 CHTH YOL,  48      . 

1     Ichthyosis,  261 

Ichthyosis  follicularis,  275,  278,  394 

palmaris  et  plantaris,  99 

sebacea  cornea,  394,  428 
Idrosis,  251 
Ignis  sacer,  265,  523 
Impetigo  contagiosa,  266 

granulata,  271 

herpetiformis,  271 

parasitica,  266 

simplex,  266 
Induratio  telese  cellulosse,  419 
Inflammatory    fungoid    neoplasm, 

272 
Initial  lesion  of  syphilis,  448 
Intertrigo,  208,  272 
Ionthus,  54 
Itch,  411 


J 


UCKBLATTERN,  372 


KAHLHEIT,  71,  272 
Kelis,  272 
Keloid,  273 

of  Addison,  325 
of  Alibert,  275 
Keratodermie   symetrique  des  ex- 
tremites,  99 


548 


INDEX. 


Keratoma  follicularis,  263 

palmare  et  plantare,  98 
Keratosis  circumscripta,  275 

diffusa,  263,  278 

follicularis,  276 

pigmentosa,  278 

pilaris,  278 

senilis,  279 
Kerion,  279 
Knollenkrebs,  272,  281 
Kohlenbeule,  281 
Koltun,  369 
Kopskurv,  281 
Kratze,  411 
Kraurosis  vulvae,  281 
Kreisfleckige  Kahlheit,  80 
Kupferfinne,  281,  402 
Kupferrose,  281,  402 
Kupfriges  gesicht,  281,  402 


T  ANOLIN,  46 
\j    Lausesucht,  281 
Leichdorn,  115,  361 
Leiomyoma  cutis,  281 
Lentigo,  281 

maligna,  88 
Leontiasis,  283,  284 
Lepothrix,  283,  487 
Lepra,  284,  381 

alphos,  381 

arabum,  284 

vulgaire,  290 
Leprosy,  284 

Lombardian,  350 
Leucasmus,  290 
Leucoderma,  290 
Leucopathia,  290 

unguium,  293 
Leucoplakia,  293 
Leuksethiopes,  293 
Lichen  circinatus,  294,  428,  430 

hypertrophicus,  300 

menti,  437 

obtusus,  300 

pilaris,  278 

planus,  298 

polymorphe  chronique,  301 

ruber  acuminatus,  295 
moniliformis,  300 

scrofulosorum,  302 


Lichen  simplex,  155,  303 

spinulosum,  394 

syphiliticus,  303 

tropicus,  318 

urticatus,  303 

verrucosus,  300 
Lineae  albicantes,  303 
Linsenmal,  330 
Liodermia  essentialis  cum  melanosi, 

etc ,  88 
Lipoma,  303 
Liquor  guttae  perchse,  45 
Liver  spot,  107 
Lousiness,  344 
Lues,  303,  447 
Lupoid  acne,  315 
Lupus  erythematodes,  303 

erythematosus,  304 

exedens,  309 

exfoliativa,  309 

exulcerans,  309 

hypertrophicus,  310 

lymphaticus,  316 

miliaris,  315 

papillaire  verruqueux,  503 

papillomatosus,  310 

sclereux,  309,  503 

sebaceus,  303,  309 

superficialis,  303,  309 

tuberculosus,  309 

verrucosus,  309,  310,  503 

vorax,  309 

vulgaris,  309 
Lustseuche,  447 
Lymphadenie  cutanee,  327 
Lymphadenoma,  315 
Lymphangiectasis,  315 
Lymphangioma,  316 

tuberosum  multiplex,  317 
Lymphodermia  perniciosa,  317,  327 
Lymphorrhagia  pachydermia,  316 
Lymphosarcoma,  317 


MACULE,  the,  36 
Maculae  caeruleae,  346 
et  striae  atrophica^,  317 
Madesis,  317 
Madura  foot,  236 
Mai  de  los  pintos,  362 
la  rosa,  350 


INDEX, 


549 


Mai  roxo,  350 

Maladie  des  vagabonds,  317 

Malum  venereum,  447 

Mamillaris  maligna,  339 

Masque,  107 

Mask,  107 

Measles,  324 

Meissner's  corpuscles,  29 

Melanoderma,  317 

Melasma,  317 

Melanosarcoma,  318 

Melanosis  lenticularis  progressiva, 

88 
Melastearrhee,  110 
Melitagra,  318 
Mentagra,  318,  437 
Microsporon  anomaeon,  364 

furfur,  113 
Miliaria,  318 
Miliary  fever,  319 
Milium,  319 
Mitesser,  320 
Mole,  pigmentary,  330 
Molluscum  cholesterique,  321,  519 

contagiosum,  321 

epitheliale,  321 

fibrosum,  232 

pendulum,  232 

sebaceum.  321 

sessile,  321 

simplex,  232 

verrucosum,  321 
Monilethrix,  324 
Morbilli,  324 
Morbus  elephas,  189,  324 

gallicus,  447 

hispanicus,  417 

indicus,  447 

italicus,  447 

maculosus  Werlhoffii,  396 

neapolitanus,  447 

pediculare,  344 
Morphoea,  325 
Morpion,  327 
Morvan's  disease,  327 
Moth  patch,  107 
Mother's  mark,  330 
Mucous  patch,  455 
Myasis  externa  dermatosa,  327 
Mycetoma,  236,  327 
Mycosis  frambcesiodes,  148 


Mycosis,  fungoides,  327 

microsporina,  111,  329 
Myoma,  329 
Myxcedema,  329 


V  .EVUS  araneus,  335,  486 
l\      flammeus,  332 

lipomatodes,  330 

pigmentosus,  330 

pilosus,  330 

sanguineous,  331 

simplex,  333 

spilus,  330 

tuberosus,  332 

vascularis,  332 

venous,  332 

verrucosus,  330 
Narbengeschwulst,  335 
Kails,  anatomy  of,  32 
Narben  keloid,  335 
Neoplasm,   inflammatory   fungoid, 

327 
Nerven  neevus,  335 
Nesselausschlag,  335,  509 
Nesselsuch,  509 
Nettle  rash,  335,  509 
Neuralgia  of  the  skin,  123 
Neuroma  cutis,  335 
Nodules,  ephemeral  cutaneous,  335 

subcutaneous       rheumatismal, 
335 
Nodosites   non-erythemateuses  des 

arthritiques,  335 
Noli  me  tangere,  309 
Nodulus  laqueatus,  336 


fPDEMA  cutis,  336 

VJ_j     (Edema  neonatorum,  336 

Oil  de  Perdrix,  337 

Oleum  chcenoceti,  46 

physeteris,  46 
Oligamie,  337 
Oligosteatoses,  337 
Oligotrichia,  337 
Onychatrophia,  337 
Onychauxis,  337 
Onychia,  338 
Onychogryphosis,  337 
Onychomycosis,  339 


550 


INDEX. 


Ophiasis,  80 
Osmidrosis,  97 


PACHYDERMATOCELE,    149, 
339 
Pachydermia,  339 
Pacinian  corpuscles,  30 
Paget' s  disease  of  the  nipple,  339 
Panaritium,  342 
Panne  hepatique,  107 
Panniculus  adiposus,  28 
Panaris  nerveux,  341 
Papillar  beerschwamahnliche  mul- 
tiple Geschwulste  der  Haul,  327 
Papilloma,  342 

neuropathic,  335 
Papule,  the,  36 
Parangi,  522 
Parasitic  diseases,  342 
Paronychia,  343 
Pastes,  45 

Patients,  examination  of,  44 
Paxton's  disease,  344,  487 
Pedicularia,  344 
Pediculosis,  344 

capitis,  344 

pubis,  346 

vestimentorum,  345 
Pelade,  80 

Peliosis  rheumatica,  397 
Pelioma  typhosum,  350 
Pellagra,  350 
Pemfigo,  352 
Pemphigus,  352 

foliaceus,  354 

gangrsenosus,  138 

neonatorum,  354 

pruriginosus,  354 

vegetans,  354 

vulgaris,  352 
Perforating  ulcer  of  foot,  358 
Periadenitis  sudoripara,  359 
Perifolliculitis  suppurees  et   con- 

glomerees  en  placards,  359 
Perionyxis,  360 
Perisarcoma,  400 
Perleche,  360 
Pernio,  126,  361 
Pfundnase,  361 
Phagmesis,  361 


Phlyzacia  agria,  151 
Phthiriasis,  354,  341 
Phyto-alopecia,  80 
Pian,  522 

ruboide,  148 
Piebald-skin,  290 
Piedra,  361 
Pigmentmal,  330 
Pigmentgeschwulst,  362 
Pigmentkrebs,  362 

sarcoma,  362 
Pimple,  54,  362 
Pinta,  362 
Pityriasis.  428 

capitis,  363 

circine  et  margine,  363 

maculata  et  circinata,  363 

nigricans,  110 

parasitaire,  111 

pilaris,  278 

rosea,  363 

rubra,  132 

pilaris,  366 

versicolor,  111 
Plaques  des  Fumeurs,  369 
Plasment,  46 
Plica  Polonica,  369 
Plique  polonaise,  369 
Podelcoma,  369 
Poils  accidentels,  254 
Poliothrix,  100 
Poliotes,  370 
Polyidrosis,  251 
Polypapilloma  Tropicum,  370 
Polytrichia,  254 
Pompholyx,  352,  370 
Porcellanfriesel,  372,  509 
Porcupine  disease,  372 
Porrigo,  223 

contagiosa,  266 

decalvans,  80 

favosa,  223,  372 

purpurans,  372,  490 

granule,  372 

lavalis,  223 

lupinosa,  223 
Porrigophyta  scutulata,  223 
Portwine  mark,  332 
Pox,  447 
Prairie  itch,  372 
Prickly  heat,  318,  372 


INDEX. 


551 


Pronunciation,  scheme  of,  53 

Prurigo,  373 

Pruritus,  cutaneous,  372 

hienialis,  377,  380 
Pseudo     exantheme     erytheniato- 
desquamatif,  380 

erysipelas,  380 

leucaemia  cutis,  380 
Psora,  381 
Psoriasis,  381 
Psorospermose    folliculaire    vege- 

tante,  275 
Psorospermosis    follicularis   cutis, 

275,  394 
Pterygium,  394 
Purpura,  394 
Pustula  maligna,  399 
Pustule,  the,  38 


Q 


CIXQUAUD'S  disease,  235,  400 
Quirica,  362 


RADESYGE,  400 
Raymond's  disease,  137 
Eed  gum,  400 
Eesorcin,  48 
Eete  Malpighii,  27 
Eheumatokelis,  400 
Ehinophyma,  400,  403 
Ehinoscleroma,  400 
Ehus  poisoning,  402 
Eingkurv,  402,  490 
Eingworm,  402,  492 

honeycomb,  250 

of  the  body,  488 

of  the  scalp,  490 

Polish,  369 
Eisipola  lombarda,  350 
Eitter's  disease,  136,  402 
Eodent  ulcer,  197,  402 
Eosacea,  403 
Eosee,  402,  408 
Eose  rash,  408 
Eoseola,  210,  408 

syphilitica,  408 

pityriaca,  363 

squameuse,  408 
Eotheln,  408 
Eothlauf,  408 


Eubeola,  324 
Eupia,  408,  462 

escharotica,  138 


C  ALOL,  48 

O     Salt  rheum,  153 

Sarcocele,  Egyptian,  409 

Sarcoma,  409 

Sarcomatosis  generalis,  327 

Satyriasis,  284,  411 

Salzfluss,  153 

Sauriasis,  261 

Sauroderma,  394 

Scabies,  411 

Scale,  the,  39 

Scall  or  scald,  153 

Scalp,  hygiene  of,  74 

Scarlatina  symptoms,  417 

Scheerende  flechte,  419,  488,  490 

Schmeerfluss,  419 

Schuppenflechte,  381,  419 

Scissura  pilorum,  92,  419 

Sclerem  der  neugeboren,  420 

Sclerema  neonatorum,  421 

Scleriasis,  421 

Sclerodactylia  421,  423 

Scleroderma,  421 

circumscribed,  325 
Sclerostenosis,  424 
Scrofulide     boutonneuse    benigne, 
372,  424 

crustacee  ulcereuse,  424 

erythemateuse,  303,  424 

tuberculeuse,  309,  424 
Scrofuloderma,  424 

ulceratiye,  327 

yerrucosum,  427,  503 
Scurvy,  land,  396 
Sebaceous  glands,  anatomy  of,  33 
Seborrhagia,  428 
Seborrhea,  428 

.  congestiva,  303,  436 

nigricans,  110 
Seborrheal  eczema,  436 
Shingles,  436,  523 
Sicosi  parasitaria,  492 
Siderosis,  436 

Skin,  anatomv  and  phvsiologv  of, 
25 

lesions  of,  34 


552 


INDEX. 


Smallpox,  515 
Soaps,  medicated,  46 
Sommersprosse,  281,  436 
Spargosis,  437 
Spedalskhed,  284,  437 
Spaceloderma,  136,  436 
Spider  cancer,  437,  486 
Spitze  condylom,  437 
Spotted  sickness,  362 
Stearrhoea,  428,  437 

nigricans,  110 
Steartorrhoea,  428,  437 
Steatoma,  437 
Stigmasie,  437 
Stigmata,  437 
Stinkschweiss,  437 
Stonepock,  54,  437 
Stratum  corneum,  27 

mucosum,  27 
Striae  et  maculae  atrophica?,  437 
Strophulus,  437 

albidus,  319,  437 

prurigneux,  372,  437 
Struma,  437 
Sndamina,  318,  437 
Sudatoria,  251,  437 
Sudor  urinosus.  437 
Sueurs.coloraes,  437 
Sweat  glands,  anatomy  of,  33 

blue,  110 

green,  111 

red,  111 

yellow,  110,  111 
Sweating,  excessive,  437 
Sycosis,  437 

capillitii,  148 

contagiosa,  447 

franibcesia,  148 

non-parasitica,  336,  437,  447 

parasitaria,  447,  492 

parasitica,  343,  447,  492 
Syphilis,  447 

hereditary,  469 
Syringo  cystadenoma,  484 

myelia,  484 


TACHE  atrophique,  484 

1      bleue,  484 

cafe  au  lait,  484 
congenitale,  484 


Tache  de  feu,  332,  484 

hemorrhagique,  485 

hepatique,  107,  485 

ombrees,  485 

pigmentaire,  485 

yasculaire,  332,  485 

vineuse,  485 
Tactile  corpuscles,  29 
Tan,  485 
Tanne,  117,  485 
Tattoo,  485 
Teigne  du  pauvre,  223 

faveuse,  223,  485 

granulee,  485 

imbriquee,  485 

pelade,  80,  485 

tondante,  485,  490 

tonsurante,  485,  490 
Telangiectasis,  485 
Tetter,  153,  486 
Therapeutical  notes,  45 
Tniol,  48 
Thilanin,  48 
Tinea  amiantacea,  428,  486 

asbestina,  428,  486 

barbae,  492 

circinata,  486,  488 

cruris,  486 

decalvans,  80,  486 

favosa,  223,  486 

hcosa,  223 

furfuracea,  486 

imbricata,  486 

kerion,  279,  487 

lupinosa,  223 

maligna,  223 

nodosa,  361,  487 

sycosis,  489,  492 

tondens,  489,  490 

tonsurans,  487,  490 

trichophytina,  487 

vera,  223 

versicolor,  111,  487 
Tinna,  362 
Trichauxis,  254,  487 
Trichiasis,  487 
Trichoclasia,  93 
Trichoma,  369 
Trichomycose  noueuse,  487 
Trichomycosis  nodosa,  361,  487 
Trichomykosis  capillitii,  279 


INDEX. 


553 


Trichomykosis  favosa,  223 
Trichonosis  cana,  100,  487 

discolor,  100,  487 

furfur acea,  487 

poliosis,  100 
Trichophytosis,  487 

barbae,  492 

capitis,  490 

corporis,  488 

unguium,  494 
Trichophytie  sycosique,  492 
Trichophyton  tonsurans,  495 
Trichoptylose,  93 
Trichoptilosis,  503 
Trichorrhexis  nodosa,  93,  503 
Trichosis  hirsuties,  254 

plica,  369 
Trichoxerosis,  503 
Tubercle,  the,  37 
Tubercula  miliaria,  503 

sebacea,  503 

anatoniique,  503 
Tuberculum  sebaceum,  319 
Tuberculosis  cutis,  503 

verrucosa  cutis,  503 
Tumenol,  48 

Tumeurs  folliculeuses,  506 
Tumor,  the,  39 

multiple    fungoid    papilloma- 
tous, 327 
Tumores  sebiparis,  506 
Tvloma,  98,  506 
Tylosis,  98,  506 
Tylosis  linguae,  506 

1TLCER,  40,  506 
U     grave,  236,  508 

perforating,  of  the  foot,  35S 

rodens,  508 
Ulerythema,  303,  508 
Uridrosis,  509 
Urticaire,  509 
Urticaria,  509 

pigmentosa,  513 


V 


ACCLXAL  eruptions,  514 
Varicella,  515 

gangrenosa,  138 


Variola,  515 
Varus,  54,  516 
Vegetation  dermique,  516 
Venereal  wart,  516 
Verbrennuug,  516 
Verole,  447 
Verruca,  516 

necrogenica,  503,  518 
Verrue,  516,  518 
Verrugas,  endemic,  518,  522 
Vesicle,  the,  37 
Vibices,  518 
Vitiligo,  290,  518 

capitis,  80,  518 
Vitiligo  idea,  518,  519 


WART,  516,  518 
Warts,   post-mortem,    372, 
503 
Warze,  516,  518 
Warzenkrebs,  518 
Warzenmal,  518 
Washleather  skin,  518 
Weichselzopf,  369,  518 
Wen,  518 
Wheal,  the,  39 
Whelk,  54,  518 
Whitlow,  melanotic,  409 


XANTHELASMA,  518,  519 
Xanthelasmoidea,  513 
Xanthoma,  519 

diabeticorum,  522 
Xeroderma,  261,  522 

pigmentosum,  88,  512 
Xerodermic  pilaire,  278 


VAWS,  522 


yARAATH,  523 
Li     Zona,  523 
Zoster,  523 


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the  Ear.  New  (4th)  and  enlarged  edition.  In  one  imperial  octavo 
volume  of  about  750  pages,  with  235  engravings  and  120  illustrations 
in  color.     Preparing. 

KOCH'S  REMEDY  IN  RELATION  ESPECIALLY  TO  THROAT 

CONSUMPTION.    In  one  octavo  volume  of  121  pages,  with  45  illus- 
trations, 4  of  which  are  colored,  and  17  charts,  Cloth,  $L  50. 

BRUCE  (J.  MITCHELL).  MATERIA  MEDICA  AND  THERA- 
PEUTICS. New  (fifth)  edition.  In  one  12mo.  volume  of  about  600 
pages.     Cloth,  $1  50.     See  Students1  Series  of  Manuals,  p.  14. 

BRUNTON  (T.  LAUDER).  A  MANUAL  OF  PHARMACOLOGY, 
THERAPEUTICS  AND  MATERIA  MEDICA;  including  the 
Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of 
Drugs.  Third  and  revised  edition,  in  one  octavo  volume  of  1305 
pages,  with  230  illustrations.     Cloth,  $5  50 ;  leather,  $6  50. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth 
American  from  the  fourth  English  edition.  In  one  imperial  octavo 
volume  of  1040  pages,  with  727  illustrations.  Cloth,  $6  50; 
leather,  $7  50. 

BUMSTEAD  (F.J.)  and  TAYLOR  (R.  W.)  THE  PATHOLOGY  AND 
TREATMENT  OF  VENEREAL  DISEASES.  New  edition.  See 
Taylor  on  Venereal  Diseases. 

BURNETT  (CHARLES  H.)  THE  EAR:  ITS  ANATOMY,  PHYSI- 
OLOGY AND  DISEASES.  A  Practical  Treatise  for  the  Use  of 
Students  and  Practitioners.  Second  edition.  In  one  8vo.  vol  of 
580  pp.,  with  107  illus.     Cloth,  $4  ;  leather,  $5. 


4  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

■DUTLIN,  (HENRY  T.)      DISEASES   OF   THE   TONGUE.      In  one 

pocket-size  12mo.  vol.  of  456  pp.,  with  8  col.  plates  and  3  woodcuts. 

Limp  cloth,  $3  50.     See  Series  of  Clinical  Manuals,  p.  13. 
pARPENTER  (WM.  B  )     PRIZE  ESSAY  ON  THE  USE  OF  ALCO- 
^     HOLIC  LIQUORS  IN  HEALTH  AND  DISEASE.     New  Edition, 

with  a  Preface  by  D.  F.  Condie,  M.D.     One  12mo.  volume  of  178 

pages.    Cloth,  60  cents. 
PRINCIPLES  OF  HUMAN  PHYSIOLOGY.     A  new  American, 


from  the  eighth  English  edition.     In  one  large  8vo.  volume. 

QARTEa  (R.  BRUDENELL)  AND  FROST  (W.  ADAMS)     OPHTHAL- 
MIC SURGERY.     In  one  pocket-size  12mo.  volume  of  559  pages, 
with  91   engravings  and  one  plate.     Cloth,    $2  25.     See  Series   of 
Clinical  Manuals,  p.  13. 

pHAMBERS  (T.  K.)  A  MANUAL  OF  DIET  IN  HEALTH  AND 
DISEASE.    In  one  handsome  8vo.  vol.  of  302  poges.    Cloth,  $2  75. 

pHAPMAN  (HENRY  C  ).  A  TREATISE  ON  HUMAN  PHYSIOLOGY. 
In  one  octavo  volume  of  925  pages,  with  605  illustrations.  Cloth, 
$5  50  ;  leather,  $6  50. 

CHARLES    (T.    CRANSTOUN).      THE    ELEMENTS    OF    PHYSIO^ 
LOGICAL  AND  PATHOLOGICAL  CHEMISTRY.     In  one  hand- 
some octavo  volume  of  451  pages,  with  38  woodcuts  and  one  colored 
plate.    Cloth,  3  50. 
pHURCHILL    (FLEETWOOD).     ESSAYS   ON    THE   PUERPERAL 
^     FEVER.    In  oneoctavo  volume  of  464  pages.    Cloth,  $2  50. 
pLARKE  (W.  B.)  AND  LOCKWOOD   (C.  B.)      THE  DISSECTOR'S 
MANUAL.    In  one  12mo.  volume  of  396  pages,  with  49  illustrations. 
Cloth,  $1  50.     See  Students''  Series  of  Manuals,  p.  14. 
pLASSEN'S  QUANTITATIVE  ANALYSIS.    Translated  by  Edgar  F. 
^     Smith,  Ph.D.  Inone  12mo.  vol.  of  324pp.,  with  36  illus.  Cloth,  $2  00. 
pLELAND  (JOHN).    A  DIRECTORY  FOR  THE  DISSECTION  OF 
^     THE  HUMAN  BODY.    In  one  12mo.  vol.  of  178  pp.    Cloth,  $125. 
pLOUSTON  (THOMAS  S.)      CLINICAL   LECTURES   OS   MENTAL 
^     DISEASES.    With  an  Abstract  of  Laws  of  U.  S.  on  Custody  of  the 
Insane,  by  C.  F.  Folsom,  M.D.    In  one  handsome  octavo  vol.  of  541 
pages,  illustrated  with  woodcuts  and  8  lithographic  plates.      Cloth, 
$4  00.     Dr.  Folsom's  Abstract  is  also  furnished  separately  in  one 
octavo  volume  of  108  pages.     Cloth,  $1  50. 
pLOWES  (FRANK).    AN  ELEMENTARY  TREATISE  ON  PRACTI- 
^     CAL  CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALY- 
SIS.    New  American  from  the  fourth  English  edition.    In  one  hand- 
some 12mo.  volume  of  387  pages,  with  55  illustrations.    Cloth,  $2  50. 
pOATS  (JOSEPH).    A  TREATISE  ON  PATHOLOGY.     In  one  vol.  of 
^     829  pp.,  with  339  engravings.     Cloth,  $5  50  ;  leather,  $6  50 
pOHEN  (J.  SOLIS).     DISEASES  OF  THE  THROAT  AND  NASAL 
PASSAGES.     Third  edition,  thoroughly  revised.     In  one  handsome 
octavo  volume.     Preparing. 

COHEN  (3.  SOLIS).    A  HANDBOOK  OF  APPLIED  THERAPEUTICS, 
one  large  12mo.  volume,  with  illustrations.     Preparing 

pOLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY  AND 
PATHOLOGY.  With  Notes  and  Additions  to  adapt  it  to  American 
Practice.  By  Thos.  C.  Stellwagen,  M.  A.,  M.D.,  D.D.S.  In  one  hand- 
gome  8vo.  vol.  of  412  pp.,  with  331  illus.    Cloth,  $3  25. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS.  5 

pONDIE  (D.FRANCIS).    A  PRACTICAL  TREATISE  ON  THE  DIS- 
^     EASES  OF  CHILDREN.    Sixth  edition,  revised  and  enlarged.    In 

one  large  8vo.  vol.  of  719  pages.     Cloth,  $5  25  ;  leather,  $6  25. 
pORNIL  (V.)    SYPHILIS:  ITS    MORBID  ANATOMY,  DIAGNOSIS 
^     AND  TREATMENT.    Translated,  with  notes  and  additions,  hy  J. 

Henry  C,   Simes,  M.D  ,  and  J.  William  White,  M.D.    In  one  8vo. 

volume  of  461  pages,  with  84  illustrations.     Cloth,  $3  75. 

pULVER  (E.  M.)  AND  HAYDEN  (J.  R.)    MANUAL  OF  VENEREAL 
^     DISEASES.     In  one  12mo.  vol.  of  289  pages,  with  33  illustrations- 
Cloth,  $1  75. 

TjALTON  (JOHN  C.)  A  TREATISE  ON  HUMAN  PHYSIOLOGY. 
Seventh  edition  thoroughly  revised,  and  greatly  improved.  In  one 
very  handsome  8vo.  vol.  of  722  pages,  with  252  illustrations. 
Cloth,  $5  ;   leather,  $6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.    In 

one  handsome  12mo.  vol.  of  293  pp.     Cloth,  $2. 

rjANA  (JAMES  D.)    THE  STRUCTURE  AND  CLASSIFICATION  OF 

^     ZOOPHYTES.   Withillust.onwood.  In  one  imp.  4to.  vol.    CI. ,$4. 

TiAVENPORT  (F.  H.)  DISEASES  OF  WOMEN.  A  Manual  of  Non- 
Surgical  Gynaecology.  For  the  use  of  Students  and  General  Prac- 
titioners. New  (second)  edition..  In  one  handsome  12ino.  volume 
of  314  pages  with  107  illustrations.     Cloth,  $1  75.     Just  ready. 

TjAVIS  (F.H.)  LECTURES  ON  CLINICAL  MEDICINE.  Second 
edition     In  one  12mo.  volume  of  287  pages.     Cloth,  $175. 

TYE  LABECHE'S  GEOLOGICAL  OBSERVER.  Inone  large8vo.  vol. 

■^    of  700  pages,  with  300  illustrations.    Cloth,  $4. 

TJIEHL  (C.  LEWIS).  THE  SCIENCE  AND  ART  OF  PHARMACY, 
In  one  octavo  volume  of  about  500  pages,  fully  illustrated.  Pre- 
faring. 

TlRAPER  (JOHN  C.)  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents  and  Practitioners  of  Medicine.  In  one  handsome  octavo  vol- 
ume of  734  pages,  with  376  illustrations.     Cloth,  $4. 

TYRUITT    (ROBERT).     THE   PRINCIPLES    AND  PRACTICE    OF 

■^  MODERN  SURGERY.  A  new  American  from  the  12th  London 
edition,  edited  by  Stanley  Boyd,  F.R  C.S-  In  one  large  octave 
volume  of  965  pages,  with  373  illustrations.    Cloth,  $4  ;  leather,  $5. 

DUNCAN  (J.  MATTHEWS).  CLINICAL  LECTURES  ON  THE  DIS- 
EASES OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital. 
In  one  octavo  volume  of  175  pages.    Cloth,  $1  50. 

DUNGLISON  (ROBLEY).  MEDICAL  LEXICON;  A  Dictionary  of 
Medical  Science.  Containing  a  concise  explanation  of  the  various 
subjects  and  terms  of  Anatomy,  Physiology,  Pathology,  Hygiene, 
Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics.  Medi- 
cal Jurisprudence  and  Dentistry  ;  notices  of  Climate  and  of  Mineral 
Waters  ;  Formulae  forOfficinal;  Empirical  and  Dietetic  Preparations; 
with  the  accentuation  and  Etymology  of  the  Terms,  and  the  French 
and  other  Synonymes.  Edited  by  R.  J.  Dungli.-on,  M.D  In  one 
very  large  royal  8vo.  vol.  of  1139  p.iges.  Cloth,  $6  50  ;  leather, 
$7  50  ;   half  Russia,  $8. 

EDES  (ROBERT  T)  TEXT-BOOK  OF  THERAPEUTICS  AND  MA- 
TERIA MEDIC  A.  In  one  8vo.  volume  of  544  pages.  Cloth.  $3  50  ; 
leather,  $4  50. 


6  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

pDIS  (ARTHUR  W.)  DISEASES  OF  WOMEN.  A  Manual  for  Stu- 
dents and  Practitioners.  In  one  handsome  8vo.  vol.  of  576  pp., 
with  148  illustrations.     Cloth,  $3  ;  leather,  $4. 

■nLLIS  ( GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY. 
Being  a  Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection. 
From  the  eighth  and  revised  English  edition.  In  one  octavo  vol. 
of  716  pages,  with  249  illustrations.     Cloth,  $4  25  ;  leather,  $5  25. 

T»MMET  (THOMAS  ADDIS).     THE  PRINCIPLES  AND  PRACTICE 

""  OF  GYNECOLOGY,  for  the  use  of  Students  and  Practitioners. 
Third  edition,  enlarged  and  revised.  In  one  large  8vo.  volume  of 
880  pages,  with  150  original  illustrations.    Cloth,  $5;  leather,  $6. 

pRICHSEN  (JOHN  E.)  THE  SCIENCE  AND  ART  OF  SURGERY. 
A  new  American,  from  the  eighth  enlarged  and  revised  London 
edition.  In  two  large  octavo  volumes  containing  2316  pages,  with 
984illus.     Cloth,  S9;  leather,  $11. 

"PARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS. 
Fourth  American  from  Fourth  English  edition,  revised  by  Frank 
Woodbury,  M.D.    In  one  12mo.  volume  of  581  pages.   Cloth,  $2  50. 

piNLAYSON  (JAMES).  CLINICAL  DIAGNOSIS.  A  Handbook  for 
Students  and  Practitioners  of  Medicine.  Second  edition.  In  one 
12mo.  volume  of  682  pages,  with  158  illustrations.     Cloth,  $2  50. 

pLINT    (AUSTIN).    A    TREATISE  ON  THE  PRINCIPLES    AND 

■^  PRACTICE  OF  MEDICINE.  Sixth  edition,  thoroughly  revised 
and  largely  rewritten  by  the  Author,  assisted  by  William  H.  Welch, 
M.D.,  and  Austin  Flint,  Jr.,  M.D.  In  one  large  8vo.  volume  of 
1160  pages,  with  illustrations.     Cloth,  $5  50  ;  leather,  $6  50. 

A  MANUAL   OF  AUSCULTATION  AND  PERCUSSION;    of 

the  Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of 
Thoracic  Aneurism.  Fifth  edition,  revised  by  James  C.  Wilson, 
M.D.  In  one  handsome  12mo.  volume  of  274  pages,  with  12  illus- 
trations.    Cloth,  $1  75. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  HEART.  Second  edition,  enlarged 
In  one  octavo  volume  of  550  pages.     Cloth,  $4  00. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES 
AFFECTING  THE  RESPIRATORY  ORGANS.  Second  and  revised 
edition.     In  one  octavo  volume  of  591  pages.     Cloth,  $4  50. 

MEDICAL  ESSAYS     In  one  12mo.  vol.,  pp.  210.    Cloth,  $138. 

ON   PHTHISIS:    ITS    MORBID    ANATOMY,    ETIOLOGY, 


etc.     A  series  of  Clinical  Lectures.     In  one  8vo.  volume  of  442 

pages.     Cloth,  $3  50. 
pOLSOM  (C.  F.)     An  Abstract  of  Statutes  of  U.  S.  on  Custody  of  the 

Insane.     In  one  8vo.  vol.  of  108  pp.     Cloth,  $1  50.      Also  bound 

with  Clouston  un  Insanity. 
POSTER  (MICHAEL).     A  TEXT-BOOK  OF  PHYSIOLOGY.     Fourth 

and  revised  American  from  the  fifth  English  edition.     In  one  large 

octavo  volume  of  1054  pages,  with  282  illustrations.     Cloth,  $4  50; 

leather,  $5  50. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 


"POTHERGILL  (J.  MILNER).  THE  PRACTITIONER'S  HANDBOOK 
OF  TREATMENT.  Third  edition.  In  one  handsome  octavo  vol- 
ume of  664  pages.     Cloth,  $3  75  ;  leather,  $4  75. 

pDWNES  (GEORGE) .  A  MANUAL  OF  ELEMENTARY  CHEMISTRY 
(INORGANIC  AND  ORGANIC).  New  edition.  Embodying  Watts' 
Physical  and  Inorganic  Chemistry.  In  one  royal  12mo.  vol.  of 
1061  pages,  with  168  illus.,  and  one  colored  plate.  Cloth,  $2  75; 
leather,  $3  25. 

pOX  (TILBURY)  and  T.  COLCOTT.  EPITOME  OF  SKIN  DIS- 
EASES, with  Formulae.  For  Students  and  Practitioners.  Third 
Am.  edition,  revised  by  T.  C.  Fox.  In  one  small  12mo.  volume 
of  238  pages.     Cloth,  $1  25. 

■pRANKLAND  (E  )  and  JAPP  (F.  R.)  INORGANIC  CHEMISTRY. 
In  one  handsome  octavo  vol.  of  677  pages,  with  51  engravings  and 
2  plates.     Cloth,  $3  75;  leather,  $4  75. 

"PULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR 
PASSAGES.  Their  Pathology,  Physical  Diagnosis,  Symptoms  and 
Treatment.  From2dEng.ed     In  1  «vo.  vol.,  pp.  475.   Cloth,  $3  50. 

pANT  (FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  A 
Multum  in  Parvo.  In  one  square  octavo  volume  of  845  pages,  with 
159  engravings.     Cloth,  $3  75. 

piBBES  (HENEAGE).  PRACTICAL  PATHOLOGY.  In  one  very 
handsome  octavo  volume  of  314  pages,  with  60  illustrations,  mostly 
photographic.     Cloth,  $2  75. 

piBNEY  (V.  P.)  ORTHOPAEDIC  SURGERY.  For  the  use  of  Prac- 
titioners  and  Students.     In  one  8vo.  vol.  profusely  illus.     Prepg. 

pOULD  (A.  PEA.RCE).  SURGICAL  DIAGNOSIS.  In  one  12mo. 
vol.  of  589  pages.    Cloth,  $2.    See  Students'1  Series  of  Manuals,  p.  14. 

pRAY  (HENRY).    ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 

^  Edited  by  T.  Pickering  Pick,  F.R.CS.  A  new  American,  from  the 
eleventh  English  edition,  thoroughly  revised,  with  additions,  by 
W.  W.  Keen,  M.D.  To  which  is  added  Holden's  "Landmarks, 
Medical  and  Surgical."  In  one  imperial  octavo  volume  of  1098 
pages,  with  685  large  and  elaborate  engravings  on  wood.  Cloth,  $6  ; 
leather,  $7  ;  very  handsome  half  Russia,  raised  bands,  $7  50.  The 
same  edition  is  also  issued  with  veins,  arteries,  and  nerves  distin- 
guished in  colors.  Price,  cloth,  $7  25  ;  leather,  $8  25  ;  half  Rus- 
sia, $8  75. 
GRAY  (IANDON  CARTE"R).  A  PRACTICAL  TREATISE  ON  THE 
DISEASES  OF  THE  NERVOUS  SYSTEM.  In  one  handsome 
octavo  volume  of  about  650  pages,  richly  illustrated.      Shortly. 

GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND 
MORBID  ANATOMY.  Sixth  American,  from  the  seventh  London 
edition.  In  one  handsome  octavo  volume  of  540  pages,  with  167 
illustrations.     Cloth,  $2  75. 

GREENE  (WILLIAM  H)  A  MANUAL  OF  MEDICAL  CHEMISTRY. 
For  the  Use  of  Students.  Based  upon  Bowman's  Medical  Chem- 
istry. In  one  12mo.  vol.  of  310  pages,  with  74  illus.  Cloth,  $1  75. 
GRIFFITH  (ROBERT  E.)  A  UNIVERSAL  FORMULARY,  CON- 
TAINING THE  METHODS  OF  PRE  PA  RING  AND  ADMINISTER- 
ING OFFICINAL  ANDOTHER  MEDICINES.  Thirdandenlarged 
edition.  Edited  by  John  M.  Maisch,  Phar.D.  In  one  large  8vo. 
vol.  of  775  pages,  double  columns.     Cloth,  $4  50;  leather,  $5  50. 


G 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

ROSS  (SAMUEL D)  A  SYSTEM  OF  SURGERY,  PATHOLOGICAL, 
DIAGNOSTIC,  THERAPEUTIC  AND  OPERATIVE.  Sixth  edi- 
tion, thoroughly  revised  In  two  imperial  octavo  volumes  contain- 
ing 2382  pages,  with  1623  illustrations.  Strongly  bound  in  leather, 
raised  bands,  $15. 

—  A  PRACTICAL  TREATISE  ON  THE  DISEASES,  INJU- 
ries  and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland 
and  the  Urethra.  Third  edition,  thoroughly  revised  and  much 
condensed,  by  Samuel  W.  Gross,  M.D.  In  one  octavo  volume  of 
574  pages,  with  170  illus.     Cloth.  $4  50. 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE 


AIR  PASSAGES.    Inone  8vo.  vol.  of  468  pages.    Cloth,  $2  75. 

GROSS  (SAMUJL  W.)  A  PRACTICAL  TREATISE  ON  IMPO- 
TENCE,  STERILITY.  AND  ALLIED  DISORDERS  OF  THE 
MALE  SEXUAL  ORGANS.  Fourth  edition.  Edited  by  F.  R. 
Sturgis,  M.D.  In  one  handsome  octavo  volume  of  165  pages,  with 
18  illustrations.     Cloth,  $1.50. 

HABERSHON  (S.  0.)  ON  THE  DISEASES  OF  THE  ABDOMEN, 
AND  OTHER  PART*  OF  THE  ALIMENTARY  CANAL.  Second 
American,  from  the  third  English  edition.  In  one  handsome  8vo. 
volume  of  554  pages,  with  illus.     Cloth,  $3  50. 

HAMILTON  (ALLAN  McLANE)      NERVOUS   DISEASES,   THEIR 
DESCRIPTION  AND  TREATMENT.    Second  andrevisededition 
In  one  octavo  volume  of  598  pages,  with  72  illustrations.   Cloth,  $4. 

HAMILTON  (FRANK  H.)  A  PRACTICAL  TREATISE  ON  FRAC- 
TURES AND  DISLOCATIONS.  New  Eighth  edition,  revised  and 
edited  by  Stephen  Smith,  A.M.,  M.D.  In  one  handsome  8vo.  vol. 
ot  832  pages,  with  507  illustrations.   Cloth,  $5  50;  leather,  $6  50. 

HABDAWAY  (W  A )  MANUAL  OF  SKIN  DISEASES.  In  one 
12mo.vol.of  440  pages.  Cloth,  $3 
HA*E  (HOBART  aMOR^)  A  TEXTBOOK  OF  PRACTICAL 
THERAPEUTICS,  with  Special  Reference  to  the  Application  of 
Remedial  Measures  to  Disease  and  their  Employment  upon  a 
Rational  Basis.  With  articles  on  various  subjects  by  well-known 
specialists.  New  (2d)  and  revised  edition.  In  one  handsome  octavo 
volume  of  650  pages.  Cloth,  $3  75;  leather,  $4.75. 
TTARE'S  (HOBAR  AMOPY)  Eoitor.  A  SYSTEM  OF  PBACTICAL 
THERAPEUTICS.  By  American  and  Foreign  Authors.  In  a 
series  of  contributions  by  78  eminent  Physicians.  Three  large 
octavo  volumes  comprising  3544  pages,  with  434  illustrations.  Com- 
plete work  jv st  ready.  Price  per  volume:  Cloth,  $5;  leather,  $6; 
half  Russia,  $7  00.  For  sale  by  subscription  only.  Address  the 
Publishers. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo. 
volume,  669  pages,  with  144  illustrations.  Cloth,  $2  75;  half 
bound,   $3. 

A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.     In  one 

12mo.  volume  ot  310  pages,  with  220  illustrations.     Cloth,  $]  75. 
A    CONSPECTUS   OF    THE    MEDICAL   SCIENCES.      Com- 


prising Manuals  of  Anatomy,  Physiology,  Chemistry,  Materia 
Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics.  Second 
edition.  In  one  royal  12mo.  volume  of  1028  pages,  with  477  illus- 
trations. Cloth,  $4  25  ;  leather,  $5  00. 
HEUWAN  (G.  ERMST).  FIRST  LINES  IN  MIDWIFERY.  In 
one  12mo.vol.  of  198  pages,  with  80  illustrations.  Cloth,  $1  25. 
Just  ready.     See  Students'1  Series  of  Manuals,  p.  14. 

HERMANN  (L)  FXPEhlMENTAL  PH  A  KM  APOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Translated  by  RoVert  Meade  J^mith  M.D.  In  one  12mo.  vol. 
of  199  pages,  with  32  illustrations.     Cloth,  $1  50. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS.  9 

HILL  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS  DIS- 
ORDERS. In  one  8vo.  volume  of  479  pages.  Cloth.  $3  25- 
HILL1ER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES.  2d  ed. 
In  one  royal  12mo.  vol.  of  353  pp..  with  two  plates.  Cloth,  $2  25. 
HIRST  (BARTON  C.)  AND  PIERSOL  (GEORGE  A  )  HUMAN  MON- 
STROSITIES. Magnificent  folio,  containing  about  150  pages  of 
text  and  illustrated  with  engravings  and  39  large  photographic  plates 
from  nature.  In  four  parts,  price  each,  $5.  Parts  I.  and  IE.,  just 
ready.  Part  III.,  In  a  ftio  days  Limited  edition,  for  sale  hy  sub 
scription  only. 

HOBLYN  (RICHARD  D.)  A  DICTIONARY  OF  THE  TERMS  USED 
IN  MEDICINE  AND  THE  COLLATERAL  SCIENCES.  In  one 
12mo.  vol.  of  520  double-columned  pp.    Cloth,  $150;  leather,  $2. 

HODGE  (HUGH  L.)  ON  DISEASES  PECULIAR  TO  WOMEN,  IN- 
CLUDING DISPLACEMENTS  OF  THE  UTERUS.  Second  and 
revised  edition.     In  one  8vo.  volume  of  519  pages.     Cloth,  $4  50. 

HOFFMANN  (FREDERICK)  AND  POWER  (FREDERICK  B.)  A 
MANUAL  OF  CHEMICAL  ANALYSIS,  as  Applied  to  the  Examina- 
tion of  Medicinal  Chemicals  and  their  Preparations.  Third  edition, 
entirely  rewritten  and  much  enlarged.  In  one  handsome  octavo 
volume  of  621  pages,  with  179  illustrations.     Cloth.  $4  25. 

H OLDEN  (LUTHEr  )  LANDMARKS.  MEDICAL  AND  SURGICAL. 
From  the  third  English  edition.  With  additions,  by  W.  W.  Keen, 
M.D.     In  one  royal  12mo.  vol.  of  148  pp.     Cloth,  $1. 

HOLLAND  (SIR HENRY).  MEDICAL  NOTES  AND  REFLECTIONS. 
From  3d  English  ed.  In  one  8vo.  vol.  of  493  pp.  Cloth.  S3  50. 
HOLMES  (TIMuTHY).  A  TREATISE  ON  SURGERY.  Its  Principles 
and  Practice.  A  new  American  from  the  fifth  English  edition.  Edited 
by  T.  Pickering  Pick  F.  R  C  S  In  one  handsome  octavo  volume  of 
1008  pages,  with  428  engravings.     Cloth,  $6  ;  leather,  $7. 

A  SYSTEM  OF  STJRGER*.   With  notes  and  additions  by  various 

American  authors.  Edited  by  John  H.  Packard,  M.D.  In  three  very 
handsome  8vo.  vols,  containing  3137  double  columned  pages,  with 
979  woodcuts  and  13  lithographic  plates  Per  volume,  cloth,  $6 ; 
leather,  $7;  half  Russia,  $7  50.  For  sale  by  subscription  only. 
TTORNER  (WILLIAM  E.)  SPECIAL  ANATOMY  AND  HISTOLOGY. 
*-L  Eighth  edition,  revised  and  modified.  In  twolarge8vo.  vols,  of  1007 
pages,  containing  320  woodcuts.     Cloth,  $6. 

HUDSON   (A.)      LECTURES   ON    THE    STUDY    OF   FEVER.      In 
one  octavo  volume  of  308  pages.     Cloth,  $2  50. 
TTUTCHINSON  (JONATHAN).  '  SYPHILIS.    In  one  pocket  size  12mo. 
■"-    volume  of  542  pages,   with   8  chromo-lithographic   plates.     Cloth, 
$2  25.      See  Series  of  Clinical  Mamcols,  p.  13 

HYDE  (JAMES  NEVINS) .  A  PRACTICAL  TREATISE  ON  DISEASES 
OF  THE  SKIN.     Second  edition.    In  one  handsome  octavo  volume 

of  676  pages,  with  85  engravings  and  2  colored  plates.   Cloth,  $4  50$ 

leather,  $5  50. 
JACKSON  (GEORGE  T).    THE  READY-REFERENCE    HANDBOOK 
U      OF  DISEASES  OF  THE  SKIN.     In  one  12mo.  vol.  of  450  pp.,  with 

50  illustrations.    $2.75.     Just  ready. 
TAMIEiON(W.  ALLaK).    DISEASES  OF  THE  SKIN.    Third  edition. 
**      In  one  octavo  volume  of  656  pages,  with  wood-cut  and  9  double-page 

chromo-lithographic  plates.     Cloth,  $6.     Just  ready. 
TONES  (C.  HANDFiELB).    CLINICAL  OBSERVATIONS  ON  FUNC 
J       TIONAL  NERVOUS  DISORDERS.    Second  American  edition.    In 

one  octavo  volume  of  340  pages.     Cloth.  $3  25. 
TULER  (HENRY)        A  HANDBOOK  OF   OPHTHALMIC    SCIENCE 
"      AND   PRACTICE.      In   one  8vo.   volume   of  442  pages,   with   124 

wood-cuts,  27  chromo-lithographic  plates,  test  types  of  Jaeger  and 

Snellen    and    Holmgren's    Color  blindness   test.      English   edition. 

Cloth,  $5  50;  leather,  $6  50. 

KING  (A.F.  A)  A  MANUAL  OF  OBSTETRICS.  New  (5th)  ed.  In 
one  12mo.  vol.  of  450  pp.,  with  150  illus.  Cloth,  $2.50.  Just  ready. 


10      LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

TZLEIN  (E.)  ELEMENTS  OF  HISTOLOGY.  Fourth  edition.  In 
one  pocket-size  12mo.  volume  of  376  pages,  with  194  engravings. 
Cloth,  $1  75.     See  Students*  Series  of  Manuals,  p.  14. 

T  ANDIS  (HENRY  G  )  THE  MANAGEMENT  OF  LABOR.  In  one 
handsome  12mo.  volume  of  329  pages,  with  28  illus.     Cloth,  $1   75. 

T  A  ROCHE  (R.)    YELLOW  FEVER.    In  two  8vo.  vols,  of  1468  pages. 

U     Cloth,  $7. 

PNEUMONIA.    In  one  8vo.  vol.  of  490  pages.    Cloth,  $3. 

T  AURENCE  (J.  Z.)  AND  MOON  (ROBERT  C.)     A  HANDY-BOOK 
JJ     OF  OPHTHALMIC  SURGERY.     Second  edition,  revised  by  Mr. 
Laurence.     In  one  8vo.  vol.  pp.  227,  with  66  illus.     Cloth,  $2  75. 
T  AWSON  (GEORGE) .  INJURIES  OF  THE  EYE,  ORBIT  AND  EYE- 
LIDS.    From  the  last  English  edition.     In  one  handsome  octavo 
volume  of  404  pages,  with  92   illustrations.  .  Cloth,  $3  50. 
T  EA    (HENRY   C).     CHAPTERS   FROM   THE    RELIGIOUS   HIS- 
U     TORY  OF  SPAIN;   CENSORSHIP  OF  THE  PRESS;    MYSTICS 
AND  ILLUMINATI;  THE  ENDEMONIADAS  ;  EL  SANTO  NINO 
DE  LA  GUARDIA;    BRIANDA  DE  BARDAXI.     In  one  12mo. 
volume  of  522  pages.     Cloth,  $2.50. 

SUPERSTITION  AND  FORCE;  ESSAYS  ON  THE  WAGER 

OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND 
TORTURE.  New  (4th)  edition,  thoroughly  revised.  In  one  hand- 
some roval  12mo.  volume  of  about  550  pages.     In  press. 

STUDIES  IN  CHURCH  HISTORY.     The  Riseoi  the  Temporal 

Power — Benefit  of  Clergy — Excommunication.  New  edition.  In 
one  handsome  12mo.  vol.  of  605  pp.     Cloth,  $2  50. 

AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 


IN  THE  CHRISTIAN  CHURCH.     Second  edition.     Inonehand- 
some  octavo  volume  of  685  pages.     Cloth,  $4  50. 

LEDGER.  THE  MEDICAL  NEWS  PHYSICIAN'S  LEDGER.  Con- 
tains 300  pages  ledger  paper  ruled  in  approved  style.  Strongly 
bound  with  patent  flexible  back.     Price,  $4. 

LEE   fHENRY)  ON  SYPHILIS.     In  one8vo   volume  of  246  pages. 
Cloth,  $2  25. 
LEHMANN  (C.  G.)     A  MANUAL  OF   CHEMICAL  PHYSIOLOGY. 
In  one  8vo.  vol.  of  327  pages,  with  41  woodcuts.    Cloth,  $2  25. 
T  EISHMAN  (WILLIAM).     A  SYSTEM  OF  MIDWIFERY.     Includ- 
•*-*     ing  the  Diseases  of  Pregnancy  and  the  Puerperal  State.     Fourth 
edition.     In  one  octavo  volume  of  about  800    pages,  with  about 
225  illustrations. 

LUCAS  (CLEMENT).  DISEASES  OF  THE  URETHRA.  Preparing. 
See  Series  of  Clinical  Manuals,  p.  13. 
LUDLOW  (J.  L.)  A  MANUAL  OF  EXAMINATIONS  UPON  ANAT- 
OMY,  PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDICINE, 
OBSTETRICS,  MATERIA  MEDICA,  CHEMISTRY,  PHARMACY 
AND  THERAPEUTICS.  To  which  is  added  a  Medical  Formulary. 
Third  edition.  In  one  royal  12mo.  volume  of  816  pages,  with  370 
woodcuts.     Cloth,  $3  25;   leather,  $3  75. 

LUFF'S  MANUAL  OF  CHEMISTRY,  for  the  Use  of  Students  of 
Medicine.  In  one  12mo.  volume  of  522  pages,  with  36  illustrations. 
Cloth,  $2.     Just  ready.     See  Students'  Series  of  Manuals,  p.  14. 

LYMAN  (HENRY  M.).  THE  PRACTICE  OF  MEDIC 'NE.  In  one 
very  handsome  octavo  volume  of  925  pages,  with  170  illustrations. 
Cloth,  $4  75  ;  leather,  $5  75.     Just  ready. 

LYONS  (ROBERT  D.)  A  TREATISE  ON  FEVER.  In  one  octavo 
volume  of  362  pages.     Cloth,  $2  25. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS.  11 


M 
M 

M 


M 
M 

M 

M 

M 
M 
N 


AISCH  (JOHN  M)    A  MANUAL  OF  ORGANIC  MATERIA  MED- 

ICA.       New  (5th)  edition.      In  one  very  handsome  12mo.  volume  of 

544  pages,  with  270  engravings.   'Cloth,  $3.    Just  ready. 
ARSH  (HOWARD).     DISEASES  OF  THE  JOINTS.     In  one  12mo. 

volume    of  468  pages,    with  64  illustrations  and   a  colored  plate. 

Cloth,  $2.     See  Series  of  Clinical  Manuals,  p.  13. 
AY  (C.  H.)    MANUAL  OF  THE  DISEASES  OF  WOMEN.    For  the 

use  of  Students  and  Practitioners.     Second  edition,  revised  by  L. 

S.  Rau,  M.D.     In  one  12mo.  volume  of  360  pages,  with  31  illus- 
trations.    Cloth,  $1   75. 
EIGS  (CHAS.  D.)    ON  THE  NATURE,  SIGNS  AND  TREATMENT 

OF  CHILDBED  FEVER.    In  one  8vo.  vol.  of  346  pages.    Cloth,  $2. 
1LLER  (JAMES) .  PRINCIPLES  OF  SURGERY.  Fourth  American, 

from  the  third  Edinburgh  edition.    In  one  large  octavo  voluma  of 

688  pages,  with  240  illustrations.     Cloth,  $3  75. 
ILLER    (JAMES).     THE    PRACTICE    OF    SURGERY.      Fourth 

American,  from  the  last  Edinburgh  edition.     In  one  large  octavo 

volume  of  682  pages,  with  364  illustrations.     Cloth,  S3  75. 
ORRIS  (HENRY).     SURGICAL  DISEASES  OF  THE  KIDNEY. 

12mo.,  554  pages,  40  woodcuts,  and  6  colored  plates.     Cloth,  $2  25. 

See  Series  of  Clinical  Manuals,  p.  13. 
ULLER  (J.)     PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY. 

In  one  large  8vo.  vol.  of  623  pages,  with  538  cuts.     Cloth,  $4  50. 
USSER  (JOHN  H.).     MEDICAL  DIAGNOSIS.     In  one  volume  of 

about  600  pages.     Preparing. 
ATIONAL  DISPENSATORY.     See  Stille  $  Maisch,  p.  14. 


MATIONAL  MEDICAL  DICTIONARY.     See  Billings,  p.  3. 

"M"ETTLERHIP  (E.)      DISEASES  OF  THE  EYE.    Fourth  American, 
•"     from  fifth  En^h        edition.     In  one   royal    12mo.    volume  of  500 

pages,   with  164  illustrations,   test-types  and   formulae   and  color 

blindness  test.     Cloth,  $2. 
"M"OBRL«  (  vm.  F),  AND   OLIVER  (CHAS.   A.).     TEXT-BOOK   OF 
±*    OPHTHALMOLOGY.     In   one  8vo.  volume  of  about   500    pages, 

with  illustrations.     In  press. 
Q WEN  (EDMUND).   SURGICAL  DISEASES  OF  CHILDREN.    12mo., 
^  .  525  pages,  85  woodcuts,  and  4  colored  plates.     Cloth,  $2.    See  Series 

of  Clinical  Manuals,  p.  13. 
pARRISH  (EDWARD).    A  TREATISE  ON  PHARMACY.    With  many 

Formulae  and  Prescriptions.  Fifth  edition,  enlarged  and  thoroughly 

revised  by  Thomas  S.  Wiegand,  Ph.G.      In  one  octavo  volume  of 

1093  pages,  with  257  illustrations.     Cloth,  $5  ;  leather,  $6. 

PARRY  (JOHN  S)  EXTRA-UTERINE  PREGNANCY.  ITS  CLIN- 
ICAL HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREAT- 
MENT. In  one  octavo  volume  of  272  pages.  Cloth,  $2  50. 
PARVIN  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OBSTET- 
RICS. Second  edition.  In  one  handsome  8vo.  volume  of  701 
pages,  with  239  engravings  and  a  colored  plate.  Cloth,  |4  25; 
leather,  $5  25. 

PAVY  (F.  W.)  A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION, 
ITS  DISORDERS  AND  THEIR  TREATMENT.  From  the  second 
London  edition.     In  one  octavo  volume  of  238  papes.     Cloth,  $2. 

PAYNE  (TOSEPH  FRANK).  A  MANUAL  OF  GENERAL  PATHOL- 
ogy.  Designed  as  an  Introduction  to  the  Practice  of  Medicine. 
Handsome  octavo  volume  of  524  pages  with  153  engravings  and  1 
colored  plate.     Cloth,  $3  50. 


12  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 


pEPPER'S  SYSTEM  OF  MEDICINE.     See  p.  2. 

PEPPER  (A.  JO     FORENSIC  MEDICINE.     In  press.     See  Students' 
■"•      series  of  Manuals,  p.  14. 

SURGICAL  PATHOLOGY.    In  one  12mo.  volume  of  511  pages, 

with  81  illus.    Cloth,  $2.     See  Stv dents'  Series  of  Manuals,  p.  14. 

piCK  (T.  PICKERING)  FRACTURES  AND  DISLOCATIONS. 
In  one  12mo.  volume  of  530  pages,  with  93  illustrations,  Cloth,  $2. 
See  Series  of  Clinical  Manuals,  p.  13. 

piRRIE  (WILLI  OI).  THE  PRINCIPLES  AND  PRACTICE  OF  SUR- 
GERY. In  oire  handsome  octavo  volume  of  780  pages,  with  316 
illustrations.    Cloth,  $3  75. 

PH^Tni1?^  wViL/  TREATISE  ON  THE  SCIENCE  AND  PRAC- 
TICE  OF  MIDWIFERY.  Fifth  American  from  the  seventh  Eng- 
lish edition.      Edited,  with  additions,  by  R.  P.  Harris,  M.D.     In 

™\?ct21°  voIume  of  664  Pages,  with  207  woodcuts  and  five  plates. 
Cloth,  $4;  leather,  $5. 

—  THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRA- 
TION AND  HYSTERIA.    In  one  1<W  vol.  of  97  pages.   Cloth,  $1. 

pOWER  (HENRY).  HUMAN  PHYSIOLOGY.  Second  edition.  In 
one  12mo.  volume  of  396  pages,  with  47  illustrations.  Cloth,  $1  50. 
See  Students'  Series  of  Manuals,  page  14. 

pYF-SMITH  (PHILIP   H.).     DISEASES   OF  THE   SKIN.      In  one 

*-      octavo  volume  of  450  pages,  with  illustrations.     Preparing. 

P^m1?!  (CHAS.  W.).  BRIGHTS  DISEASE  AND  ALLIED  AFFEC 
TIONS  OF  THE  KIDNEY.  Octavo,  288  pp.,  with  18  handsome  illus- 
trations.    Cloth,  $2. 

"DALFE  (CHARLES  H.)     CLINICAL  CHEMISTRY.      In  one  12mo. 

volume   of  314  pages,  with  16  illustrations.       Cloth,  $1  50.     See 

Students'  Series  of  Manuals,  page  14. 
"DAMSBOTHAM   (FRANCIS   H.)     THE  PRINCIPLES  AND  PRAC- 
M>    TICE  OF  OBSTETRIC  MEDICINE  AND  SURGERY.    Inoneim- 

perial  octavo  volume  of  640  pages,  with  64  plates,  besides  numerous 

woodcuts  in  the  text.     Strongly  bound  in  leather,  $7. 
pEMSEN(IIA).   THE  PRINCIPLES  OF  THEORETICAL  CHEMIS- 
XVi     TRY.    New  (fourth)  edition,  thoroughly  revised,  and  much  enlarged. 

In  one  12tno.  volume  of  325  pages.     Cloth,  $2.     Just  leady. 

REYNOLDS  (J  RUSSELL).  A  SYSTEM  OF  MEDICINE.  Edited, 
with  Notes  and  Additions,  by  Henry  Hartshorne,  M  D.  In  three 
large  8vo.  vols.,  containing  3056  closely  printed  double-columned 
pages,  with  317  illustrations.  Per  volume,  cloth,  $5  ;  leather,  $6; 
very  handsome  half  Russia,  $6  50.     For  sale  by  subscription,  only. 

RICHARDSON  (BENJAMIN  W.)  PREVENTIVE  MEDICINE.  In 
one  octavo  vol.,  of  729  pp.     Clo.,  $4;   leather,  $5. 

ROBERTS  (JOHN  B).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  In  one  oc  avo  volume  of  780  pages,  with 
501  illustrations.     Cloth,  $4  50  ;  leather,  $5  50. 

ROBERTS  (JOHN  B.)  THE  COMPEND  OF  ANATOMY.  For  use  in 
the  Dissecting  Room  and  in  preparing  for  Examinations.  In  one 
16mo.  volume  of  196  pages.     Limp  cloth,  75  cents. 

ROBERTS  (SIR  WILLIAM).  A  PRACTICAL  TREATISE  ON  URI- 
NARY AND  RENAL  DISEASES,  INCLUDING  URINARY  DE- 
POSITS. Fourth  American,  from  the  fourth  London  edition.  In 
one  verv  handsome  8vo.  volume  of  609  pages,  with  81  illustrations. 
Cloth   $3  50. 

COLLECTED  CONTRIBUTIONS  ON  DIET  AND  DIGESTION. 

In  one  12mo.  volume  of  270  pages.     Cloth,  $1  50. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS.  13 


R 


"DOBERTSON  (J.  McGREGOR).  PHYSIOLOGICAL  PHYSICS.  In 
■">  one  12mo.  volume  of  537  pages,  with  219  illustrations.  Cloth,  $2  00. 
See  Stzidents'  Series  of  Manuals,  p.  14. 

OSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE 
NERVOUS  SYSTEM.  In  one  handsome  octavo  volume  of  726  pages, 
with  184  illustrations.     Cloth,  $4  50;  leather,  $5  50. 

SAVAGE  (GEORGE  H)  INSANITY  AND  ALLIED  NEUROSES, 
PRACTICAL  AND  CLINICAL.  In  one  12mo.  volume  of  551  pages, 
with  18  typical  illustrations.  Cloth,  $2  00.  See  Series  uf  Chnical 
Manuals,  p    13. 

S CHAFER  (EDWARD  A.)  THE  ESSENTIALS  OF  HISTOLOGY, 
DESCRIPTIVE  AND  PRACTICAL.  For  the  use  of  Students. 
New  and  enlarged  edition.  In  one  handsome  octavo  volume  of 
311  pages,  with  325  illustrations.     Cloth,  $3  00.     Just  ready. 

SCHMITZ    AND    ZUMPT'S   CLASSICAL  SERIES.    In  royal  18mo. 
ADVANCED  LATIN  EXERCISES.    Cloth,  60  cents  ;  half  bound, 
70  cents. 

SALLUST.     Cloth,  60cents;  half  bound,  70  cents. 
NEPOS.     Cloth,  60  cents;  half  bound,  70  cts. 
VIRGIL.     Cloth,  85  cents;  half  bound,  $1. 
CURT1US.     Cloth,  80  cents;  half  bound,  90  cents. 

SCHREIBER  (JOSEPH).  A  MANUAL  OF  TREATMENT  BY  MAS- 
SAGE AND  METHODICAL  MUSCLE  EXERCISE.  Translated 
by  Walter  Mendelson,  M.D.,  of  New  York.  In  one  handsome  octavo 
volume  of  274  pages,  with  117  fine  engravings. 

SEILER  (CARL)  A  HANDBOOK  OF  DIAGNOSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  THROAT  AND  NASAL  CAV- 
ITIES. New  (4th)  edition.  In  one  very  handsome  12mo.  volume 
of  about  400  pages,  with  about  100  illustrations,  and  2  beautifully 
colored  plates.     Preparing . 

SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  New  (second) 
edition.  In  one  handsome  octavo  volume  of  268  pages,  with  13 
plates,   10  of  which  are  colored,  and  9  engravings.     Cloth,  $2  00. 

SERIES  OF  CLINICAL  MANUALS.  A  series  of  authoritative  mono- 
graphs on  important  clinical  subjects,  in  12mo.  volumes  of  about  550 
pages,  well  illustrated.  The  following  volumes  are  now  ready : 
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SIMON  (W.)       MANUAL  OF  CHEMISTRY.     A  Guide  to  L.ectures 
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SLADE(D.D.)   DIPHTHERIA;  ITS  NATURE  AND  TREATMENT. 
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SMITH   (EDWARD).    CONSUMPTION;   ITS  EARLY  AND  REME- 
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SMITH  (J.LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  IN- 
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larged In  one  large  8vo.  volume  of  881  pages,  with  51  illustra- 
tions. Cloth,  $4  50  ;  leather,  $5  50. 
SMITH  (STEPHEN).  OPERATIVE  SURGERY.  Second  and  thor- 
oughly revised  edition.  In  one  very  handsome  8vo.  volume,  of  892 
pages,  with  1005  illustrations.     Cloth,  $4  ;  leather,  $5. 


14  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

STIHE  (ALFRED).  CHOLERA,  ITS  ORIGIN,  HISTORY,  CAUSA- 
TION, SYMPTOMS,  LESIONS,  PREVENTION  AND  TREAT- 
MENT. In  one  handsome  12mo.  volume  of  163  pages,  with  a  chart 
showing  routes  of  previous  epidemics.     Cloth,  $1  25. 

STILLE  (ALFRED).  THERAPEUTICS  AND  MATERIA  MEDIC  A. 
Fourth  revised  edition.  In  two  handsome  octavo  volumes  of  1936 
pages.     Cloth,  $10;  leather,  $12, 

STILLE  (ALFRED)  AND  MAISCH  (JOHN  M.)  THE  NATIONAL 
DISPENSATORY:  Containing  the  Natural  History,  Chemistry, 
Pharmacy.  A^ti  >ns  and  Uses  of  Medicines.  Including  those  rec- 
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STIMSON  (LEWIS  A.)  A  TREATISE  ON  FRACTURES  AND 
DISLOCATIONS.  In  two  handsome  octavo  volumes.  Vol.  I.,  Frac- 
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A  MANUAL  OF  OPERATIVE  SURGERY.    New  edition.    In 

one    royal   12mo.    volume   of  503   pages,    with    342    illustrations. 
Cloth,  $2  50. 

STUDENTS'  QUJZ  SERIES.  Manuals  in  question  and  answer  for 
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STURGES  (OCTAVIUS).  AN  INTRODUCTION  TO  THE  STUDY 
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SUTTON  (JOHN  BLAND).  SURGICAL  DISEASES  OF  THE  OVA- 
RIES AND  FALLOPIAN  TUBES.  Including  Abdominal  Preg- 
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LEA  BROTHERS  &  CO  'S  PUBLICATIONS.  IS 

TANNER  (THOMAS  HAWKES) .  A  MANUAL  OF  CLINICAL  MEDI- 
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ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    From 

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TAYLOR  (ALFRED  S.)  MEDICAL  JURISPRUDENCE.  Ninth 
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ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDICAL 

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TAYLOR  (HOBERT  W.).  A  CLINICAL  ATLAS  OF  VENEREAL 
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THOMAS  (T.  GAILLARD)  AND  MUNDE  (PAUL  F.)  A  PRACTICAL 
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Cloth,  $5;  leather,  $6. 

THOMPSON  (SIR  HENRY).  CLINICAL  LECTURES  ON  DISEASES 
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THOMPSON  (SIR  HENRY).  THE  PATHOLOGY  AND  TREAT- 
MENT OF  STRICTURE  OF  THE  URETHRA  AND  URINARY 
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TODD  (ROBERT  UENTLEY) .  CLINICAL  LECTURES  ON  CERTAIN 
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TREVES  (FREDERICK).  OPERATIVE  SURGERY.  In  two  octavo 
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VAUiiHAN  (VICTOR  C),  and  NOVY  (FRED'K  G.)  PTOMAINES 
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CHEMICAL  FACTORS  IN  THE  CAUSATION  OF  DISEASE. 
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Cloth,  $2  25. 


16  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

VISITING  LIST.  THE  MEDICAL  NEWS  VISITING  LIST  for  1893. 
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WALSHE  (W.  H.)  PRACTICAL  TREATISE  ON  THE  DISEASES 
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WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND 
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two  large  8vo.  vols,  of  1840  pp.,  with  190  cuts.    Clo.,  $9;  lea.,  $11. 

WELLS  (J.  SOELBERG).  A  TREATISE  ON  THE  DISEASES  OF 
THE  EYE.    In  one  large  and  handsome  octavo  volume. 

WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR 
TO  WOMEN.  Third  American  from  the  third  English  edition.  In 
one  octavo  volume  of  543  pages.     Cloth,  $3  75  ;  leather,  $4  75. 

ON   SOME  DISORDERS   OF    THE    NERVOUS  SYSTEM   IN 

CHILDHOOD.     In  one  small  12mo.  vol.  of  127  pages.     Cloth,  $1. 

WHARTON  (HENRY  R).  MINOR  SURGERY  AND  BANDAGING. 
In  one  very  handome  l2mo.  volume  of  498  pages,  with  403  illustra- 
tions, many  of  which  are  photographic.  Cloth,  $3. 
WHITLA  (VILLIAM).  DICTIONARY  OF  TREATMENT,  OR  THE- 
RAPEUTIC INDEX.  Including  Medical  and  Surgical  Therapeutics. 
In  one  square  octavo  volume  of  917  pages.     Cloth,  $4. 

WILLlAMb  (CHARLES  J.  B.  ano  C.  T.)  PULMONARY  CONSUMP- 
TION :  ITS  NATURE,  VARIETIES  AND  TREATMENT.  In 
one  octavo  volume  of  303  pages.     Cloth,  $2  50. 

WILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY.  A 
new  and  revised  American  from  the  last  English  edition.  Illustrated 
with  397  engravings  on  wood.  In  one  handsome  octavo  volume 
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THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE.    In 

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WINCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 
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A.M. ,  M.D.     In  one  handsome  8vo.  vol.  of  484  pages.    Cloth,  $4. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
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volume  of  550  pages.    Cloth,  $3  00. 

WOODHEAD  (G.  SIMS).  PRACTICAL  PATHOLOGY.  A  Manual 
for  Students  and  Practitioners.  In  one  beautiful  octavo  vol.  of  497 
pages,  with  136  exquisitely  colored  ill  us. 

YEAR-BOOK  OF  TREATMENT  FOR  1892.  A  Critical  Review  for 
Practitioners  of  Medicine  and  Surgery.  In  contributions  by  20 
well-known  medical  writers.  12mo...  of  494  pages.  Cloth,  $1  50. 
Ready  shortly.  In  combination  with  The  Medical  News  and  The 
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YEAR-BOOK  OF  TREATMENT  FOR  1891,  similar  to  above.  Cloth, 
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YEO  (I  BURNEY)  ON  FOOD  IN  HEALTH  AND  DISEASE.  In 
one  12mo.  volume  of  590  pages.  Cloth,  $2..  See  Series  of  Clinical 
Manuals,  p.  13. 

YOUisG  (JAMES  K.).  ORTHOPAEDIC  SURGERY.  In  one  12mo. 
volume  of  400  pages,  with  illustrations.     Preparing.