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>w 
Plate  I.
                Nnevns LiporrLatodes.
(From a Photograph of one  of the  author's patients
                    (Frontispiece .) 
         A PRACTICAL TREATISE

                   ON


DISEASES OF THE SKIN,
FOR THE USE OF STUDENTS AND PRACTITIONERS.
       SECOND EDITION,

THOROUGHLY REVISED AND ENLARGED.
                BY

     JAMES NEVINS HYDE, A.M., M.D,
                •u
PROFESSOR OF SKIN AND VENF.REAL DISEASES, KISII MEDICAL COLLEGE, CHICAGO; DERMATOLOGIST
   TO THE MICHAEL REESE HOSPITAL, CHICAGO ; AND ONE OF THE PHYSICIANS FOR
     DISEASES OF THE SKIN TO THE PRESBYTERIAN HOSPITAL, CHICAGO.
     PHILADELPHIA:

LEA BROTHERS & CO.
         1888.
 
NMR
~H394-p
   Ift86
      Entered according to the Act of Congress, in the year 1888, by
               LEA BROTHERS & CO.,
in the Office of the Librarian of Congress, at Washington.  All rights reserved.
DORNAN, PRINTER,

   PHILADELPHIA. 
MORIZ  KAPOSI
PROFESSOR OF DERMATOLOGY IN THE UNIVERSITY OF VIENNA, AUSTRIA,
THESE PAGES ARE, WITH HIS GENEROUS CONSENT,
ttespecifjnllg Inscribed
BY
THE AUTHOR. 
 
           PREFACE  TO THE SECOND EDITION.


  The work  of revision,  required by exhaustion  of the first  and
the demand for a second edition of this treatise, has been carefully
conducted  with results  that are declared upon every page here  pre-
sented to the reader.  There have been added new chapters devoted
to the description of several cutaneous maladies whose names were
a few years ago unknown;  others have  been wholly rewritten;  none
has  been  left untouched.   The  need of conforming  to  the classi-
fication and  nomenclature of  diseases  of the skin adopted by the
American  Dermatological  Association,  has  involved a labor which
it is believed  has largely added to the practical  worth of the  book.
Personal observation of more than ten thousand cases of cutaneous
diseases in  both public and private practice, has  furnished an experi-
ence which has been made to serve  here as far as was  practicable
in the illumination of the teaching embodied in almost every para-
graph.  Nearly one hundred  pages have thus been added, together
with a number of new wood cuts and  two  portraits of rare diseases
of the skin in colored  plates.
  The author  is anxious to express  his sense  of  gratitude to the
profession  for the favorable reception accorded to the first edition
of the treatise; and desires to acknowledge his great obligation in
the preparation of its successor,  to the later  authors  especially, in
cutaueous medicine, whose works are named in the brief but selected
bibliography appended at the close of the volume.
  He  has  also to extend his thanks to Dr. Frederick AY. Mercer,
and to Dr.  Albert J. Ochsner of the  Pathological Laboratory of the
College, for aid in  the  preparation of specimens and  drawings; as
also  to his assistant, Dr. Frank  H. Montgomery,  for services ren-
dered while the work has been passing through the  press.
Chicago, March. lsSS. 
 
PREFACE  TO  THE  FIRST  EDITION.
   The increasing recognition of the gravity of many cutaneous dis-
 orders, and of the importance of their accurate study,  is shown by
 the rapidly augmenting number of observers  in this department of
 medicine,  and by  the numerous valuable  contributions constantly
 made to it, both in this country and abroad.  For the convenience of
 the general  practitioner  it therefore  becomes  necessary  at  shortly
 recurring  intervals that some  one should attempt  the  task  of  pre-
 senting in a comprehensive form the results of  the latest observation
 and experience.
   The author is aware of the degree to which  he must  claim indul-
 gence in the present effort to perform  this duty.  The extent of the
 subject and the limitations of  a single volume, require the omis-
 sion of much detail  of secondary importance.  AYith regard to that
 which it. has  seemed proper to include, he has endeavored to write
 concisely, to set forth only what can be held as the truth, to be frank
 in the admission of the weakness with which the most skilful physi-
 cian stands in the presence of many grave and  not a few benign  dis-
 orders, and to cultivate a wholesome doubt of that which has  not
 been  shown to be  worthy of trust.  How far he may have fallen
 short of attaining this end these pages will declare.
   He has to express his indebtedness to  the standard  works  on
 dermatology  of foreign authorship, especially the  exhaustive and
 invaluable work of Hebra, and  the  Lectures on the Diseases of the
 Skin  lately given to the profession  by  Professor Kaposi, which con-
 tain  the mature conclusions of his vast  experience.   AYith these
 should be  named the writings of Sir Erasmus  AAilson,  Dr. Tilbury
 Fox,  Dr.   Neumann,  Dr. McCall Anderson, Dr. Behrend, and  the
 syphilographers, to whose works special  reference  is made  in  the
chapter  devoted to their  theme.  Among the  books of American
authorship, he is under special obligation to the  sterling work  of Dr.
Duhring,  of Philadelphia, and  to the excellent treatises of Drs.
Piffard, Fox, and Bulkley, of New York.
  All these are named by title in the brief and selected bibliography 
viii          PREFACE TO THE  FIRST  EDITION.

appended at the close of the volume.   No less valuable aid  has been
obtained by consulting the papers of American  and foreign authors
contained in  the journals specially devoted to diseases of the skin,
among  which, as the  representatives of the  English  tongue,  the
Archives of  Dermatology,  lately edited by Dr.  Bulkley,  and  the
current Journal of Cutaneous and Venereal Diseases, edited by Drs.
Piffard and Morrow, deserve special mention.
  The author is also very greatly indebted to Dr. Charles Heitzmann,
of New York, not  merely for the  information  gathered  from  the
study of his original researches in pathology, but particularly for his
kindness in furnishing advanced sheets of the chapter on the skin, in
his  work on  Microscopic Morphology, which has just issued from
the press.    From  this work,  with Dr. Heitzmann's  permission,
several  illustrations have been borrowed, which appear in the chapter
on anatomy, the details of which subject are also very largely drawn
from  the same rich  store.  The first of the drawings representing
sections of  the skin, is from the faithful pencil of Dr. H. D.  Schmidt,
of New Orleans, who, in order to produce it, interrupted, without
hesitation,  his  arduous labors  in  connection  with  the  subject  of
pathology.    To  his  colleague, also,  Dr. Frederick  AY. Mercer,  of
Chicago, the  author is glad  to express his indebtedness for  the skill
with which a  number of pathological specimens have  been  prepared
and mounted for special study, and original drawings produced for
the first and  several subsequent  chapters of  the  book.   To Dr.
Duhring, of Philadelphia, he is further indebted for valuable sugges-
tions made during the course of preparation of the manuscript.
  Medicinal measures are, in these pages, expressed in terms of both
the apothecaries' scale and the metric system.   It is to be noted, how-
ever, that the latter are not in all cases literal translations of the terms
of the former, many of the formulae, especially those for preparations
designed to be topically employed, being  metrically composed, the
relative proportions of the ingredients remaining unchanged.
  The changes which it has been advisable to make, in the  matter of
nomenclature, classification, and other equally important subjects, are
concisely explained in the chapters devoted to each.
  Chicago, No. 240 Wabash Avenue,
         February, 1883. 
?j?rr3
CONTEXTS
	PAOE
Anatomy and physiology of the skin......	17
(lencral symptomatology.........	. 48
General etiology..........	. CO
General diagnosis ..........	<J(J
General prognosis .........	. 71
General therapeutics ........	73
Classification...........	. 90
DISEASES  OF THE SKIN
                            CLASS I.
                   DISORDERS OF THE GLANDS.
1. Of the Sweat Glands
    Hyperidrosis
    Sudamen  .
       Miliary fever
    Anidrosis  .
    Bromidrosis
    Chromidrosis
    Uridrosis  .
       Dysidrosis .
       Hsematidrosis
2. Of the Sebaceous Glands
    Seborrhoea.
    Comedo
    Cyst  ....
       (A.) Milium
       (B.) Steatoma
    Asteatosis .
 95

 99
100
101
102
103
105
105
106
107
107
118
124
124
12(3
128
   CLASS II.

INFLAMMATIONS.
Exanthemata  ....
    Morbilli (measles)
    Rotheln (German measles).
    Scarlatina (scarlet fever)  .
129
130
133
134 
X
CONTENTS.
       Variola (smallpox)
             Varioloid
       Varicella (chicken-pox)
       Vaccinia (cow-pox)
     Erythema simplex
         Erythema intertrigo  .
     Erythema multiforme
     Urticaria  ....
         Urticaria pigmentosa .
     Dermatitis ....
         (A.) Traumatica .
         (B.) Venenata
         (C.) Calorica    .
                 Congelatio
         (D.) Medicamentosa  .
         (E.) Gangrsenosa
Erysipelas    ....
Furunculus   ....
Anthrax  .....
     Pustules from cadaveric infection
     Pustules and other lesions resulting  from
      tiles and insects
     Delhi boil, Aleppo evil, Biskra bouton
Phlegmona diffusa  .
Pustula maligna
Herpes    ......
     Herpes iris
     Herpes gestationis
Herpes zoster ....
Dermatitis herpetiformis
Psoriasis.....
Pityriasis maculata et  circinata
Dermatitis exfoliativa
     Dermatitis exfoliativa infantum
Pityriasis rubra
Lichen planus ....
Lichen ruber  ....
Eczema  .....
    The local varieties of  eczema
        Eczema of the scalp .
        Eczema of the face
        Eczema of the lips
        Eczema of the nostrils
        Eczema of the ears
        Eczema of the lids
        Eczema of the beard
        Eczema of the genital organs
        Eezema of the anus and anal region
mds
nflicted by
rep- 
CONTENTS.
		PAGE
LYznna of the nipple and breast of women		. 307
Eczema of the umbilicus ......		. 3(i8
Eczema of the superior and inferior extremities		. 308
Eczema of the hands and feet.....		. 310
Eczema as it affects the nails		. 313
Eczema of the tropics (prickly heat)		. 314
Prurigo ........		. 316
Acne ........		. 319
Acne Rosacea .......		. 329
Sycosis ........		. 334
Dermatitis papillaris capillitii .		. 338
Impetigo ........		, . 340
Impetigo contagiosa .....		. 342
Impetigo herpetiformis .....		. 344
Ecthyma ........		. 345
Pemphigus .......		. 348
CLASS III.		
                           HEMORRHAGES.
Cutaneous haemorrhages  ......
Purpura  .........
    (A.) Simplex    .......
            Purpura urticans.    ....
            Purpura rheumatica (peliosis rheumatica)
    (B.) Hsemorrhagica (morbus maciilosus Werlhofii)
            Purpura scorbutica (scurvy)
            Purpura pulicosa     ....
            Haemophilia     .....
6-)4
354
354
355
355
356
357
357
357
                             CLASS IV.
                          HYPERTROPHIES.
1. Of Pigment......
    Lentigo   .......
    Chloasma.......
        Melanoderma, chloasma eachecticorum
        Addison's disease    ....
        Argyria     ......
2. Of Epidermal and Papillary Layers
    Keratosis  .......
       (A.) Pilaris.....
       (B.) Senilis.....
    Molluscum epitheliale   ....
    Callositas.......
        Callositas of hands with unusual complication
        Perforating ulcer of the foot (mal perforant du pied)
    Clavus    ..........
360
360
361
362
362
363
366
366
366
368
369
374
375
375
378 
•
CONTENTS.
    Cornu cutaneum
    Verruca   ....
        Multiple cutaneous tumor,
        Papilloma .
    Verruca necrogenica
    Nsevus pigmentosus  .
    Xerosis   ....
    Ichthyosis
        Simplex
        Hystrix
        Ichthyosis congenita  .
    Onychauxis
    Hypertrichosis .
3.  Of Connective Tissue
    Sclerema neonatorum
    Scleroderma
    Morphcea .
    Elephantiasis
        Lymph scrotum
Rosacea
    (A.) Erythematosa
    (B.) Hypertrophica
Framboesia
    Parangi
    Donda ndug-u
accompanied by intense pruritus
CLASS V.
                             ATROPHIES.
1. Of Pigment
    Leucoderma
    Albinismus
    Vitiligo   ....
    Canities   .    .    .     .
2. Of Hair   ....
    Alopecia  ....
        Congenital  .
        Senile ....
        Premature  .
    Alopecia furfuracea .
    Alopecia areata .
        Neurotica  .
    Atrophia pilorum propria .
    Trichorexis nodosa
        Nodose swellings of shaft of hair
        Piedra ....
3. Of Nail    ....
    Atrophia unguis 
CONTENTS.
xm
4.  Ok Cutis......
    Atrophia cutis   ....
    Atrophia senilis
    Atrophia maculosa et striata
        Blanching atrophy of the skin
        Glossy fingers
                             CLASS VI.

                           NEW GROWTHS
1.  Of Connective Tissue
    Keloid
    Cicatrix
    Fibroma
    Neuroma  .
    Xanthoma .
    Adenoma  .
2.  Of Muscular Tissue
    Myoma
3.  Of Vessels .
    Angioma  .
        Noevus vasculosus
        Telangiectasis
    Angioma pigmentosum et atropl
    Angioma eavernosum
    Lymphangioma .
4.
    Rhinoscleroma .
    Lupus erythematosus
    Lupus vulgaris .
    Scrofuloderma  .
        The papular scrofuloderm (lichen scrofulosorum
        The small pustular scrofuloderm
        The large pustular scrofuloderm
        Tuberculosis of the skin
        Ainhum
        Podelcoma .
        Synovial lesions of the skin
        The Sartian disease
    Syphiloderma
        Chancre
    Syphiloderma maculosum
        Papillosum .
        Vesieulosum
        Pustulosum
        Bullosum
        Tuberculosum
        Tuberculosum serpiginosum
    Gumniatosum  .... 
xiv                         CONTENTS.

                                                                   PAGE
        Erythanthema syphiliticum......    •    •   °-l
        Syphiloderma infantile, acquisitum et haereditarium.    .    •   521
        Chancroid...........544
Lepra.............549
    (A.) Lepra tuberosa..........549
    (B.) Lepra maculosa..........°52
    (C.) Lepra aneesthetica.........553
    Pellagra............560
    Actinomycosis  ........-••   °bl
Carcinoma    ........••••   561
    Epithelioma...........562
        Superficial...........562
        Deep, or tubercular  .........  563
        Papillary...........563
        Cancer of the head  .              ......564
        Cancer of the lower lip........565
        Cancer of the genital organs.......565
        Cancer of the extremities  ........  566
        Paget's disease of the nipple.......566
        Cancer of the connective tissue .......  573
        Tuberose carcinoma  ........    .  573
        Melanotic, or pigmented carcinoma......574
Sarcoma.............  575
    Melanotic sarcoma (melano-sarcoma)......577
    Mycosis fungoides..........578

                             CLASS VII.

                              NEUROSES.

Hyperaesthesia............581
    (A.) Pruritus...........581
             Pruritus narium .........  583
             Pruritus genitalium   ........  583
             Pruritus ani    .........  583
             Pruritus hiemalis (prurigo hyemalis, etc.) ....  588
             Prairie itch, etc..........589
     (B.) Dermatalgia..........590
 Anaesthesia............591
    Vasomotor and trophic neuroses   .......  592
    Myxcedema...........  595

                             CLASS VIII.

                         PARASITIC AFFECTIONS.

 1. Vegetable............597
     Tinea favosa...........597
     Tinea trichophytina..........603 
CONTENTS.
XV
     (A.) Tinea circinata
          Onychomycosis
              Tinea imbricata (Tokelau ringworm, etc'
     (B.) Tinea tonsurans .
              Tinea kerion
     (C.) Tinea sycosis
              Precautions to be observed in managing  tinea favosa
                and tinea trichophytina
     Tinea versicolor
          Myringomycosis
          Erythrasma .
          La Perleche
Animal
  Scabies
     Demodex folliculorum
     Pulex penetrans (sand flea)
     Filaria medinensis (guinea worm)
     Cysticercus cellulosae .
     Echinococcus   ....
     Distoma hepaticum
     Leptus (harvest bug) .
     Kriptoptes monunguiculosis
     Dipterous larvte in the human skin
     Ixodes  (wood-tick)
  Pediculosis.
     Pediculosis capillitii
     Pediculosis corporis
     Pediculosis pubis
          Pediculi  and acari transferred  to  man  from the lower
            animals
          Cimex lectularius
          Pulex iritans  (flea)
          Culex pipiens (mosquito) 
 
LIST  OF  ILLUSTRATIONS.
                              Plate  I.
Case of naevus lipomatodes, from a colored photograph of one of the author's
    patients (frontispiece).

                              Plate II.
Xanthoma of elbows and knees, from a photograph of one of the author's
    patients (page 458).
 1. Vertical section of the skin of the thumb ....
 2. Subcutaneous fat-tissue, after extraction of fat by turpentine
 3. Columnae adiposae........
 4. Vertical section of the  skin, after  injection from beneath  with
      Berlin blue   .....
 5. Vascular and nervous papillae  .
 6. Horizontal section of the scalp of a negro
 7. Prickle-cells of the mucous layer
 8. (a) Pacinian  body after  staining with  silver, showing  superim-
      posed endothelial layers;  (b) Section of the same from a duck's
      bill .
 9. Section of hair-follicle during the formation of a new hair
10. Hair-follicle in longitudinal section  ....
11. Lower portion of hair-pouch from the lip of a kitten
12. Transverse section of hair and follicle
13. Sebaceous glands of the second class from the alas of the
14. Coil-gland.........
15. Sweat pore, traversing  the epithelial layers of the skin
16. Vertical section of one-half of nail and matrix
17. Implantation of the nail at its border
18. Irido-platinum needle
19. Milium needle  .
20. Scarifying spud .
21. Epilating forceps
22. Grappling forceps
23. Skin-grafting scissors
24. Cutisector  .
25. Dermal curettes .
26. Glass pleximeter
27. Comedo-extractor 
XVI11
LIST  OF ILLUSTRATIONS.
FIG.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.

38.
39.

40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.

59.

60.
61.
62.

63.
64.
65.
66.
67.
68.
69.
Cutaneous punch..........
Section of a comedo..........
Cysts of the scalp, one of them laid open to exhibit the contents
Microphotograph of the bacillus scarlatinas.....
Vertical section of pustule at the beginning of pustulation in variola
Vertical section of one-half of an undeveloped pustule
Vertical section of anthrax
Section of anthrax
Bacilli of malignant pustule
Longitudinal section of the third spinal ganglion of the right lumbar
  region, from a case of zoster .
Vertical section of skin in psoriasis
Vertical  section of the skin of the forearm, from a
  eczema.......
Molluscum epitheliale     ....
Molluscous corpuscles     ....
The author's case of molluscum verrucosum
  Varieties of cutaneous horns .
of one of the
Vertical section of a pointed wart
Verruca necrogenica .
Ichthyosis hystrix, vertical section
The Russian " dog-faced man "
Elephantiasis of foot and leg
Elephantiasis of the scrotum
Vitiligo in a negro boy
Trichorexis nodosa
Keloid
Multiple fibromata
Large single fibroma
Neuroma of the skin
Microscopic structure of neuroma of skin
Lupus erythematosus of the face, from a photograph
  author's patients......
Lupus vulgaris  of the face,  from  a photograph
  author's patients......
Section of a lupus nodule.....
Section of lupus of the face    ....
Facial  cicatrices  of tubercular  syphilodermata, from a photograph
  of one of the author's patients
Syphiloderma papulosum  .
Vegetating condylomata of the  vulva
Palmar syphiloderm ....
Ulcerative tubercular syphiloderm   .
Syphilitic gummata of head and face
Lee's lamp for fumigation .
Lepra tuberculosa   ....
case of chronic
of one  of the
PAGE
 90
120
127
138
144
145
200
200
207

216
226

265
370
371
373
380

383
386
393
399
412
413
425
441
448
452
452
457
457

474

480
482
483

503
508
511
512
518
520
538
550 
LIST  OF  ILLUSTRATIONS.
XIX
FIG.		PAGE
70.	Tubercular leprosy, from a photograph of a leper in the Sandwich	
	Islands............	551
71.	Anaesthetic leprosy, with mutilating results, from a photograph of	
	a leper in the Sandwich Islands .......	553
72.	Larynx of a leper, with lepra tuberculosa......	554
73. 74.	[■ Larynges of lepers, with tubercular leprosy .....	555
75.	Bacilli of leprosy, from one of the author's patients	556
76.		567
77.	Sarcoma, microscopical appearances in section of nodule removed	
	from one of the author's patients.......	576
78.	Mycosis fungoides, drawn from an oil painting of one of the author's	
		578
79.	Achorion Schoenleinii.........	600
80.	Epidermis invaded by the trichophyton......	607
si.		614
82.	Filaments and spores of the trichophyton from the beard	621
83.	Microsporon furfur ..........	627
84.	Microsporon minutissimum ........	630
85.	Female acarus, fecundated ........	634
86.	Acarian furrow . ..........	635
87.	Demodex folliculorum.........	642
ss.	Leptus............	646
S9.	Leptus autumnalis..........	646
90.		646
91.		647
92.	Larvae removed from body of child.......	647
93.	Pediculus capillitii (male).........	649
!»4.	Ova of head-louse, attached to hair.......	650
95.	Pediculus corporis (female)........	652
96.		656
 
 
I.
AN ATOMY AND PHYSIOLOGY OF THE SKIX.


  The skin of the human body is its living envelope, intimately
associated with underlying structures, and  by its  situation  brought
into intimate relation also with the external world.   It is a complex,
elastic, and sensitive organ, varying greatly in different conditions of
climate, age, sex, health, and race; and differing also in the charac-
teristics exhibited in different localities upon the  same  individual.
Thus, in color there is a  wide range between the fair skin of the
blonde and the black of the  negro, betweeen the  rosy pink of the
infant's palm and  the  dark brown hue of the genital region of the
aged.   The skin varies also in pliability and thickness, being delicate
and lax over  the lids, the lips, and the prepuce; and  much thicker
and more firmly attached over the palms and the soles.
  It is important to note  that  the  appearance of  the  skin, even in
conditions of health, also changes within appreciable limits.   It is the
exposed parts, such  as the face, which the eye of the physician  most
frequently searches, and which  betray evidence of  mental emotions,
physiological fluxes, sedentary or active habits of life, and fatigue or
unusual conditions  of vigor.
  Viewed externally, the  skin  is seen to be traversed by superficial
and deeper furrows, dotted by numerous depressions representing the
mouths of its follicles, and provided very generally with  coarse or
fine downy hairs which  are in  some parts represented by a growth
sufficient to conceal the skin from view.  This pilary growth serves
not merely as an ornament of  the  body, but also  as a protection to
some  of its regions most sensitive to thermal changes.
  By its extraordinary sensitiveness to different degrees of temperature
and to the physical properties of the bodies with which it is brought
into contact, the skin  becomes, even when  unaided  by the eye, a
valuable means of preserving  the human frame from external injury.
This  protective function is, in part, related to the horny character of
its  outer layer, as a consequenccof which the loss  of  essential fluids
and the ingress of noxious  substances are equally restricted.
  One of the most  important functions of the skin is the part which
it plays in the regulation of the bodily temperature.   The temperature
variations  at  its  surface, modified  naturally  by the  character  and
quantity of the clothing, when  such is worn, produce corresponding
variations in the  smooth muscles  and contractile bloodvessels of the
skin.   By enlargement or diminution of the lumen of these vessels,
whether resulting directlv  from the action of  heat  or  cold at the 
18      ANATOMY  AND  PHYSIOLOGY OF  THE  SKIN.
surface, or  indirectly through  an  effect upon the  vasomotor centres,
large quantities of blood are brought to or removed from  the  super-
ficies of the body.  In the one  case, the blood is  cooled by evaporation
Fig. 1.
  Vertical section of the skin of the thumb, partly diagrammatic,  a, stratum corneum, traversed by
ducts of two glands ; 6, rete mucosum with prolongations extending between papillae beneath ; between
a and 6 is seen the stratum lucidum ; c, papillary layer of corium.  Near the centre of the figure is
seen a nervous papilla; d, reticular layer of corium with vascular plexus, nucleated connective tissue
and interspaces ; e, four coil-glands ; /, fat-globules in the meshes of the connective tissue.

at the  surface;  in the other, the loss of  heat by such  evaporation is
greatly restricted.   This process is materially influenced bv accelera-
tion or retardation of the heart's' action,  whether  produced bv moral 
SUBCUTANEOUS  TISSUE.
19
or physical causes.  It is also modified by the occurrence of sweating,
as a result of which heat in varying amounts is rendered latent; and
either watery vapor escapes  from the surface or sweat is exuded in
drops, the aggregate  of which  may be several pounds in weight in
the course of twenty-four hours.
   In a limited  degree, the skin is capable of acting as a respiratory
agent, eliminating carbonic acid gas with  watery vapor, and possibly
also absorbing oxygen in small amount.  Its  power of absorbing
aliments,  medicaments, and toxic  substances, in either  gaseous or
liquid  state, is  greatly  restricted  so  long  as  its horny  external
covering  is intact.   Such  absorption, when it  occurs,  is  probably
effected through the  portal of the ducts of the cutaneous  glands.
Gaseous  and volatile  substances, as well as several of the  oils and
fats, may at times penetrate the skin through these avenues.
   The skin is provided with a natural  unguent, by which,  in a state
of health, it is constantly anointed.   The tatty and oily secretions of
the skin  are concerned, not  merely in  the anointing  of the general
surface and of the hairs,  but also in the  regulation of the bodily
temperature, by  preventing the maceration of the  tissues by the
sweat.
   The complex organ which is called the skin  is essential to the life
of the individual.   The  sexual, and possibly other  organs of the
human body, may have their functions arrested, or be eveu obliterated
bv destructive processes, and life still continue;  but if the functions
of the skin were all  suspended for  a  sufficient period of time, the
result would be fatal.  In its important relations alone to the compli-
cated processes by which  the  heat of the body is  maintained  at a
relatively  fixed  standard,  the  skin  exhibits  its importance to the
general economy.  It is thus seen  to  be, not an isolated membrane
stretched  mechanically over an artificial machine, but  one  of several
living and potential systems of the body, each  of which  is in inti-
mate union with  all others.
   The  integument  of the body, when  studied by   the aid of the
microscope, is found to be  composed of several organic parts.  These
are : the subcutaneous connective tissue resting on the deeper struc-
tures of the body; then, more externally, the corium, or true  skin;
lastlv, an outermost coat, the epidermis, or cuticle.   Beside these, the
skin contains coil-glands, sebaceous  glands, hairs, nails, blood- and
lymph-vessels,  muscles, pigment, and nerves.   It will be instructive
to study  the deeper parts before those more  superficially disposed, as
their mutual relations are thus made clearer.

                     Subcutaneous  Tissue.

   The subcutaneous tissue is differentiated from the corium  between
the third  and fourth  months of foetal life.   It is a structure serving
a mechanical purpose as a receptacle for fat, and for the support of
vessels and nerves passing from the  tissues beneath to  the corium,
which lies next above it." It contains, also, coil-glands, some of the 
20    ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN.

hair-follicles  more  deeply seated  than their fellows,  and  Pacinian
corpuscles.   There is  no distinct  boundarv line  between its  upper
limits and the overlying corium, to which  it projects columnar masses
of fat, extending obliquely to  the  coil-glands and  the hair-follicles
above, often  with  lateral, horizontally  disposed prolongations of
similar shape.  It is built  up of loose connective-tissue bundles, pro-
longed  from  the  aponeuroses, fa seise, and  the  membranes  lying
beneath.
   It is firmly attached to the skin  over the extensor surfaces of the
articulations, the palms,  the soles, and the groins by short and coarse
bundles, between which are single or  multilocular spaces  lined  with
endothelia, secreting a mucoid fluid.   These are the bursa? mucosas.
Elsewhere, as in the eyelids, the penis, the scrotum, and  the auricle
of the ear, the attachment  to the skin is by loose, delicate connective
tissue, containing   no  fat-globules.    All  other  fibrous  tracts are
arranged obliquely, admit, by  their extension, of  various degrees of
pliability, and inclose rhomboidal spaces  containing more or  less
numerous fat-globules.   These are tabulated, bounded by a delicate,
fibrous connective tissue, and  abundantly  supplied with bloodvessels.
This  is termed the panniculus adiposus.
 Subcutaneous fat tissue, the fat having been extracted by turpentine.  B, bundles of fibrous connec-
tive tissue, carrying injected bloodvessels ;  C, capsules of fat-globules, with oblong nuclei.  Magnified
500 diameters.  (After Heitzmann.)

  The deposit of  fat in the body is greatly reduced in all diseases
productive  of emaciation, but  never wholly disappears in  life.   In
cases of obesity,  fat is deposited in excess of normal limits, and  may
then be concerned in the production or aggravation of disease.  It is 
THE  CORIUM.
21
Fig. 3.
  Columnie adipo-<a3. a, epidermis ; 6, erector pili muscle ; p, horizontal prolongations of the column ;
 c, coil-gland suspended in the latter ; /, fibrous bundles of corium ; g, panniculus adiposus; k, band of
 fibrous tissue extending to the latter.  (After Warren.)

 largely due to the greater or less  volume of the  panniculus  adiposus,
 that the natural outlines of the body are made graceful and attractive
 to the eye, or the reverse.

                           The Corium.

   The Corium,  Derma, Cutis Vera, or True Skin, is composed
 of bundles of fibres of connective tissue, whose decussations produce
 a dense felt-work, coarsest toward the subcutaneous tissue, upon which
 it rests  inferior!v,  and finest superiorly in  the outermost portion,
 which is in contact with the epidermis above.  Its general character-
 istics are well described by Heitzmann as follows :  " The bundles are
 bounded in  many instances by a very  dense basis-substance, repre-
 senting the elastic fibres, and  separated from each other by narrow
 layers of a cement-substance (Thomsa), which, in its chemical features.
 is kindred  to the glue-diving basis-substance of the fibrous connective
                 ©    ©    ©
 tissue in general.   In this cement-substance there are  imbedded deli-
 cate  formations of  protoplasm,  greatly varying in amount  in  the
 derma of persons  of different age.  They represent formations analo-
gous  to  nuclei, formerly  called  'connective-tissue  cells,'  at present
considered  as compact masses, or delicate reticular layers of living
 matter, which, with a power of five hundred diameters of  the micro-
scope, look finely  granular.  The whole glue-giving  basis-substance
of the bundles is traversed by a delicate reticulum of living matter,
in direct union with all protoplasmic formations between the bundles,
with all blood- and  lymph-vessels, with all nerves,  and  with  the 
22      ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN.

columnar epithelia, nearest to the capillary  layer.  Only the meshes
of the network of the  living matter contain  the glue-giving basis-
substance,  which, as the history of development of the connective
tissue demonstrates, is produced by a chemical alteration of the life-
Vertical section of skin after injection, from beneath, of areolar tissue with Berlin blue.
       a, epidermis ; /, corium ; y, panniculus adiposus.  (After Warren.)
lessHprotoplasmic fluid  itself.  The bundles of the connective tissue
of the derma accompany all elongations  of an epithelial character.
They produce  the  follicles around the root-sheaths of the hair, the
capsules around the coil-glands, and the layers which surround their
ducts.   The bundles of connective tissue are traversed in an oblique
direction by bundles of smooth muscular fibres, by relatively scanty
bloodvessels in the derma, by numerous  capillaries in the papillary
layer, by a  system of lymphatics, and by numerous medullated and
non-medullated nerves."

   Pars Reticularis.—The reticular layer of the corium is made
up, as  has been seen, of interlacing connective-tissue bundles, with
interspaces increasingly larger from without inward.   The fineness of-
the bundles increases,  on the contrary, from within outward, being
finest where the minute papillae of the corium project  into the rete,
and coarsest near the subcutaneous tissue.

   Pars Papillaris.—The  papillary layer  of the  corium  lies in
contact with the rete above, and  is  connected below with the deeper
reticular portion of the true  skin.   Between the rete and the papillse
of the derma a hyaline substance is interposed which Unna believes
may be identical  with the  so-called  cement-substance  described as
separating  the fibrillse of the corium.   The basal membrane once 
THE  CORIUM
23
thought to be stretched between the rete mucosum  of the epidermis
and  the papillary layer of the corium, cannot be demonstrated to
exist.
                               Fig. 5.
  Vascular and nervous papillae,  a, vessel; 6, nervous papilla; c, vessel; d, nerve-libre ; e, cor-
pusculum tactus; /, transversely divided nervous filaments ; g, epithelia of rete.  (After Biesiadecki.)

   The name of  this portion of the derma is intended to describe its
chief characteristic, the  existence of  numerous digital prolongations
of the corium, made up of delicate fibres of connective tissue, which
do not interlace, and are abundantly provided with  nuclei.   The
papillae spring each from a single, or several from a common,  ovoid
base;  their bulbous, conical, or blunt apices reaching into the rete,
which also dips down between them.   They differ in size in different
parts of the body, and also in their  disposition and shape, being in
places arranged  in linear  series, and  in  others  in concentric whorls,
with definite centres, producing thus  crossing  furrows, visible to the
naked eye as markings upon  the outer surface of the epidermis.
   In horizontal  sections of the skin, the papilla?, being transversely
divided, appear as circular or  ovoid areas, in which can be recognized
centrally a transversely or obliquely divided capillary loop.   Between
these areas the inter-papillary reticulum of the mucous layer is seen.
   According to Unna, who bases  his statements upon the wide varia-
tion  between the largest sized papillae and their entire absence in some
regions, the papillary layer of the corium represents merely "an ex-
tremely variable border-phenomenon.'"   Certain it is that the growth
of the  rete downward and of  the  corium  upward results in mutual
effects  of pressure and  counter-pressure whose equilibrium is  con-
stantly adjusted  by the mechanical and vital necessities of such union. 
24      ANATOMY AND PHYSIOLOGY  OF  THE  SKIN.

  When the papillae are completely exposed, after the  removal of the
overlying so-called cement-substance and  of the  epidermis above,
their exterior surface  is seen  to be uniformly marked with series after
series of alternating furrows and ridges of exceeding  delicacy, more
or less concentrically  disposed.   These are supposed by Unna to be
grooves with ridges on either  side, into  which  are admitted  corre-
sponding dentations to be recognized on the under surface of the layer
of epithelial cells next to the corium.

                               Fig. 6.
  Scalp of a colored man—horizontal section.  R, rete mucosum ; Pi, row of columnar epithelia, cut
obliquely, supplied with dark-brown pigment-granules; Pa, papilla, cut transversely ;  D, derma.
Magnified 500 diameters. (After Heitzmann.)

   Two varieties of papillae  are  distinguished—the vascular and  the
nervous ;  the former containing the terminal loops of a minute artery
and  vein;  and the  latter, the ultimate filamentous  termination of a
non-medullated nerve-fibre.
   The greater  number of papillae  are of the vascular variety, being
traversed  by a vertically disposed loop of vessels, consisting of an
arterial and venous capillary.   Their office is evidently not merely
to supply nutriment for the epidermis above, but also to provide for
the cooling of the blood when brought in large quantities to the sur-
face of the body.  Occasionally, two or more of  such  loops can be
recognized in a single papilla.
   The nervous papillae contain the tactile corpuscles, which subserve
an important purpose in providing for the insensibility of the integu-
ment.   These  are  described in connection with  the nerves  of the
skin.   It is  to be noted that ultimate  terminations of nerves can be
recognized in the vascular papillae, and that at times minute vascular
loops can be seen in the papillae largely occupied with the corpuscles
of touch.
                         The Epidermis.

   The Epidermis, Scarf-skin,  or Cuticle, is the most external
of the several  membranes of the body, being in close contact on  one
side  with the corium, or true skin, and exposed on  the other to  the 
THE  EPIDERMIS.                    25
atmosphere by which it is surrounded.   The  latter surface is there-
fore relatively drier, while the  former is  constantly moistened  by
fluids from the vessels which ramify beneath it.
   Xo genetic  relation  can be established between the epidermis and
the corium, intimate as is their union and mutual relationship.  The
former is developed from the ectoderm, the latter from  a superficial
laver of  the mesoblast.  Their behavior  both  in health  and disease
is marked by  the widest difference.
   The epidermis differs greatly in  thickness in different portious of
the  body, that, for example,  of the  palms and soles exceeding, in
vertical section, that which covers  the dorsum of these same  organs,
and that protecting such sensitive parts as the lids, lips, temples, and
prepuce.
   The epidermis is composed of the following layers, named in order
from within outward : the stratum mucosum, the stratum granulosum,
the stratum lucidum, and the stratum corneum.  All of these several
strata, or layers, are histogenetically  derived from the one which is
deepest in situation.

   The  Stratum  Mucosum,  Mucous Layer,  Prickle-layer,
Rete  Mucosum, Rete Malpighii or  Malpighianum,  is  the
deepest of the epidermal layers, and rests upon the corium below.  The
 latter is intimately united with it by a series of interdigitationswhich
 are commonly described as prolongations of the derma  into the sub-
 stance  of the rete, but  it is equally true  that  the rete  sends down
 prolongations into the derma.  The two, for reasons which doubtless
 originate in  the need of an  intimate union to resist friction and to
 insure vascular supply, are thus closely locked together.
    The stratum mucosum is built up of nucleated epithelia, epithelial
 cells, or corpuscles,  polyhedral  in  outline  and  diffusely  colored.
 These  are  masses of  granular  protoplasm.
 living  matter,  which by  their  relations  to
 each Other form a protoplasmic  network en-
 veloping the entire surface of the body and
 lining  all channels and cavities which are in
 direct or indirect connection  with the surface.
 These elements are flattened by reason of their
 apposition, and separated from each other by
 an  intercellular substance, which has  been de-
 scribed  as  a "cement-substance."  There is,
 without  question,  a  system  of channels  be-
 tween  the  epithelia,  by which the  fluids of
 nutrition are conveyed from  cell to cell.   All
 are, however, uninterruptedly united to each
 other bv means of delicate spokes, known as
 prickles, spines, or thorns.   The living mat-
 ter, which  produces  a delicate  reticulum  within each  protoplasmic
 bodv,  its points of intersection  being termed  nuclei,  nucleoli,  and
 oranules furnishes the  filaments  already described, which thus  pro-
Fig.
Prickle-cells of the mucous
        layer. 
 26     ANATOMY AND PHYSIOLOGY  OF  THE  SKIN.

 duce continuity through all the living layers of the epithelial elements,
 as well as through the underhung layers of the connective tissue.
 The epithelia are  unprovided  with either blood- or lymph-vessels;
 but, when living, are supplied with a large number of nerves, which,
 in the shape of very minute  beaded fibres, traverse the intercellular
 substauce, and are in direct communication  with the reticulum of
 living matter within the protoplasmic bodies themselves.
   The living masses of protoplasm,  just described, play the most
 important part  in  all the pathological and  physiological processes
 observed in the skin.  It is probable that, in  the  embryo, all  the
 appendages of the skin are formed directlv by their  assimilative and
 reproductive processes ; and it  is certain that, in health and disease,
 they furnish the organic matter of all secretions.
   The epithelia next the  corium are columnar in form, of a diffuse
 brownish  hue,  and arranged with  their long axes  nearly at  right
 angles to  the plane of  that portion of the corium upon which they
 are  superimposed.   More  externally they have pronounced poly-
 hedral outlines, and the cell nucleus of each is large and distinct.
   Above this columnar-shaped pavement, irregularly  rounded and
 cubical  epithelia, with large, single or multiple, spherical nuclei, are
 packed  between the papillae of the corium, rising from below; and
 horizontally flattened bodies of the same general appearance lie in
 strata above the level of the conical apices of the papillae.  Here the
 threads of protoplasm  between the  cells are voluminous,  forming
 thick and broad strands  connecting  the elements.  Between these,
 outwandered  leucocytes may at times be recognized.   In the more
 externally disposed rows of epithelia the prickles become shorter and
 the cells flatter, till finally they lie in  a uniformly horizontal  plane.

   The Stratum Granulosum, or Granular Layer of  the epi-
 dermis, is built  up of one or two, rarely more, rows of horizontally
 disposed granular bodies, united to each other  by short and broad
 threads.  Between  these, the intercellular spaces are  so  contracted
 that nutritive fluids cannot  filter easily outward; and the nuclei of
 the cells are  usually shrunken in size.  These  have been carefully
 studied by Ranvier, Kolliker, Waldeyer, and  others.   According to
 these observers,  the roundish granules which  give this layer of epi-
 thelium its peculiar name  and appearance,  consist of  eleidin, or
 kerato-hyalin, a substance essential  to the process of cornification in
the elements making  up the  horny  layer of the skin, nails, etc.
These granules begin to appear in the neighborhood of the nuclei of
some of the large prickle-cells in the rete, but  are best studied in the
granular layer, whose  cells are often  completely  filled with them.
According to Unna, the color of the skin in the"white races  depends
 upon this layer alone.

   The Stratum Lucidum,  or Septum Lucidum, of Oehl, lies  im-
 mediately above  the stratum  granulosum, and appears  under  the
microscope  as a  delicate, brightly colored line, consisting  of two or 
bloodvessels.
27
three rows of transversely disposed, glistening epithelia, differing in
translucency from those situated  on either side.   It thus marks with
tolerable distinctness the  boundary liues of the rows of cells above
and below it.  Its epithelial bodies have suddenly lost the refractive,
shining granules of  kerato-hyalin, conspicuous in the stratum granu-
losum below.  These granules are generally supposed to have disap-
peared in consequence of their solution in the protoplasm of the cell-
body, which has thus acquired an added brilliancy  and clearness.

   The Stratum Corxeum, or  Horny Layer of the epidermis, is
its outermost and widest layer, extending from the stratum lucidum
below to the external environments of the body.  In  its lower por-
tion, the polygonal  plates of which it  is composed  indicate very
clearly their relationship to the cells in the prickle-layer.  The nuclei
appear in  places, only, as shrivelled and inconspicuous relics of the
protoplasmic threads.  Occasionally, on the edges,  rudiments of the
prickle-threads  may still  be recognized.   Still  more externally, the
dried, lifeless, and horn-like  plates of which this layer is composed,
become mere cornified shells, generally  lying  in  horizontal  strata,
more curled and wrinkled  as the surface of the skin is reached, often
imbricated, but preserving the polygonal outlines of epithelia relieved
of the forces of pressure and counter-pressure exerted  in the deeper
parts of the epidermis.   These  elements are rarely pigmented, save
in  the ease of the  negro, where the intense  staining of the deepest
parts of the mucous layer is to a degree spread to the external strata.
Such staining in the colored races is produced by granules of pigment
arranged about an unaffected nucleus in the prickle-cells.
   According to Unna, after digestion with pepsin  and trypsin, it  is
seen  that the horny cells are connected by  more  or less  persistent
threads,  visible after more prolonged  digestion as a large-meshed
reticulum, with strands formed  from a double row of  cornified fila-
ments united by short horny bridges.

                         Bloodvessels.

   The Arteries and Veins supplying the skin spring from sub-
cutaneous branches  which  penetrate the fasciae beneath, and proceed
by subdivision to be distributed to  all portions of the integument
below the epidermis, the distribution being especially abundant about
the glands  and follicles of the skin, and the inferior and superior
parts of the corium.   They are always more abundant upon  the flexor
than the extensor faces  of the extremities.  Just beneath the papil-
lary layer of the corium there is  a minutely ramifying plexus of fine
capillaries, whose loops extend into the papillae above, as already de-
scribed.  This and  the coarser plexus  in the deeper portion of the
derma are so well defined  that they might well be designated as supe-
rior and  inferior partes vasculares of the corium.   Still a third vas-
cular district is found  in  the subcutaneous connective tissue where
the vessels are numerous. 
28      ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN.

  The  arterioles which  supply the  sweat-glands  surround the coils
of the latter in a delicate basket-like plexus, and  terminate  in  two
or three veinlets, one of which  always  accompanies the duct of the
gland upward as far as the papillary layer, where it anastomoses with
the vessels of that part of the skin.  The ascending arterioles supply
also the sebaceous glands  and  hair-follicles; and, finally, breaking
up into smaller and yet smaller branches, furnish  a single or double
capillary loop to each papilla.  The capillaries of the papillary layer
anastomose freely with  those  transversely  arranged  in  the upper
portion of the hair-follicle, loops  from which  also pass to the seba-
ceous glands.   The hair-papilla has a vascular supply similar to that
of the other papillae of the corium.
  Unna divides the vessels distributed to the skin into the papillary
system, and the system of the coil-glands and fat tissue.  The former
includes the ascending loops which traverse the vascular  papillae,  and
the branches supplying  lower portions of the  corium.   The latter
embraces the vessels running upward to  the coil-glands and down-
ward to the fat tissue.   Iu the papillary vascular system, the  arteries
are narrow and the veins wide.  The vessels consist merely of an endo-
thelial tube augmented, as the subcutaneous tissue is reached, by both
media and adventitia.  According to Hoyer, there is a singular duplex
arrangement of  vessels in  the  distal phalanges of both fingers  and
toes, in  consequence of which there is a direct communication between
the arteries and veins.
  Vasomotor nerves  are twined  around these  vessels  in  all their
ramifications.  The whole  vascular system, as thus arranged,  plays a
most important part in all the healthy and morbid processes which
occur in the skin, as well as in the sudden physiological  changes  dis-
tinguishable to the eye in the phenomena of blanching and blushing.

                      Lymphatic Vessels.

  The skin in all its  parts is  provided with a  system of  lymphatic
channels, designed to subserve  the necessities of the important pro-
cesses of  absorption,  and  traversed by lymph whose  currents are
continuously directed to  the large vessels  of the structures  beneath
the skin.   Unna divides these channels into : first, juice-spaces, pro-
vided or not with independent walls, usually the latter, and not freely
communicating with the  endothelium-lined vessels;  second, lymphatic
vessels proper, which communicate directly with the bloodvessels.
  The juice- or lymph-spaces separate the epithelial bodies  that make
up the stratum mucosum of the epidermis, and also extend  between
the protoplasmic threads or prickles that unite them.   Such conduits
may be  regarded either as delicate excavations in the so-called cement-
substance  between the epithelia, or as irregular channels  in a  softish,
viscid, albuminoid, and readily coagulable substance existing between
the protoplasmic threads.  In the  latter event, these spaces would be
comparable to the impressions made by thrusting at random a pencil
into  a mass  of  soft putty.  At times, this intercellular  substance 
NERVES.
29
seems capable of obstructing the conduits by which it is tunnelled.
These  same  juice-spaces exist  in  the papillae  of the  corium, and
encircle the different glands, hair-follicles, and nail-beds  of the skin.
They also  sheathe  the connective-tissue  fibrillae of the  corium and
surround the fat-cells.
   The  lymphatic vessels are relatively few, but form a continuous
mesh work  with  transversely and  vertically disposed branches  sup-
plying all  parts of the skin below the epidermis.   The juice-spaces
communicate with these vessels in the papillary portion of the corium
through minute orifices in the vascular walls, the  ves.sels themselves
being here represented by blind terminal  loops.  As they pass to the
deeper portions of the corium and  below it, these vessels  increase in
size.
   The current of the  lymph  is from the papillary apices in every
direction to all parts  of the rete, like the currents in the delta  of a
river, a  reflux occurring at the lower  limit  of  the  interpapillary
depressions of the rete downward, possibly through the sweat-pores
which traverse the epidermis at these points.   Thence  the  current
Hows freely downward to the lymphatic  vessels in the corium,  but
the stream from the juice-spaces about the coil-glands and fat tissue
is retarded by  reason of a more restricted communication with  the
lymphatic  vessels below.  In consequence of the retardation due to
this anatomical peculiarity, the formation of fat by  filtration is
facilitated.

                             Nerves.

   Non-medullated and medullated nerve-fibres, each in  places being
substituted for the other, are supplied to  the skin  from horizontally
disposed bundles of nervous twigs in the  subcutaneous tissue.   These
traverse the corium in connection with the bloodvessels, and  become
finer as they  ascend, till they form a subepithelial  plexus just below
the epidermis.
   Exceedingly delicate Non-medullated Fibres penetrate to the
epidermis between the epithelia in great abundance.  Here, traversing
the intercellular substance by the side of  the juice-spaces, they either
terminate between the prickle cells as ultimate  bulbous  terminations
of finely beaded fibrillae, or they penetrate the epithelia  themselves
in pairs.   Each prickle-cell is supplied with a pair of these beaded
filaments, which may be either applied to the nucleus  of the  cell, or
be seen to  encircle the nucleus more or less completely.   Above  the
stratum granulosum these nervous threads cannot be recognized.
   Similar nervous filaments are supplied  to the sheaths of the  hairs
and the ducts of the coil-glands.  It  is by means of these numerous
and  delicate  fibres that the perception of sensation in the  skin is
accomplished.
   Motor filaments, discovered by Thomsa, are  also distributed to the
sheaths of the bloodvessels, in which they are finally  lost.   Other
motor filaments supply the muscles, and trophic nerves are distributed 
30      ANATOMY  AND  PHYSIOLOGY OF  THE  SKIN.

to all the secreting organs of the  skin, and  to all its protoplasmic
formations.

  The Medullated Nerve-fibres of the skin  have  been care-
fully studied by Dr. A. R. Robinson,1 of New York.   According to
the latter, one or several loops of such fibres  pass upward into  the
papillae, and then turn backward to the subpapillary region.   Some
of these, after such reversion, again  ascend to  an adjacent papilla.
Yet others are supplied to the Pacinian and tactile corpuscles.

  The Pacinian  Corpuscles, named from the anatomist  Pacini,
also called Corpuscles of Vater, exist subcutaneously only upon
nerves intended for cutaneous supply, and are small, oval bodies, two
or more millimetres in diameter.   Each consists of a  series of con-
centric, nucleated, and vascular capsules, arranged after the manner
of the  capsules of the onion, more  closely united at the periphery

                               Fig. 8.
 Pacinian body, after silver staining,      Section of Pacinian body, from a duck's bill. g.L,
showing superimposed endothelial lay-    lamellar envelope ;  g.h, hyaline zone of the lamel-
ers.  (After Renaut.)                lar envelope ;  bt, terminal bulb of the nerve ; y.p,
                              n.g.p, layer investing the cavity of the body. (After
                              Renaut.)

than at the centre, and surrounding a protoplasmic core.  The medul-
lated nerve to which the body is attached gradually loses its myeline
envelope, and terminates in the centre  of this core, after  traversing
the greater part of its axis, in one or several, minutely club-shaped,
nervous filaments.   The myeline sheath is lost  in the tissue  of the
concentric capsules.  According  to Ranvier,  the  nerve may, after
A Manual of Dermatology, by A. R. Robinson, M B., etc. New York 1884. 
nerves.
31
supplying  one capsule, subsequently  penetrate a second, or even a
third.   In such cases the nerve regains its sheath as it issues from
the corpuscle at its opposite pole.   Robinson  believes that the nerve
forms a plexus or  loop within the corpuscle, and again  leaves it  at
one of its poles.
   The precise function of the  Pacinian  corpuscle is unknown.  Its
connection with the tactile sense is  suggested  by its location, since
these bodies are most numerous in  the subcutaneous  tissue  of the
nipple, the penis, the digits, and parts similarly sensitive.   It bears
an evident analogy to  the organ of vision, each body having  a cap-
sular character; each  being provided with a special nerve-filament,
which  enters  the  corpuscle at one pole; each  also receiving its im-
pressions  at the extremity of the capsule opposite that where  it
receives its nervous supply.
   According  to Krause, the  Pacinian  corpuscles are  concerned  in
the appreciation of impressions  produced  by pressure  and  traction.
Whether  specially concerned in  the distinguishing  of sensations
originating in  heat, cold, moisture, pressure, traction, or weight, it is
evident that they contribute  but little, if at all, to the reception  of
ordinary impressions  upon the skin,  and, at this date, they are not
known to play any part in cutaneous diseases.

   The  Tactile  Corpuscles (Corpuscles of Meissner,  or Wagner)
(see Fig. 5) are other oval-shaped bodies found in about  one of four
of the papillae in the pars papillaris  of the corium.  They  are com-
posed of  from  one to three  capsules, each receiving  a medullated
nerve-fibre and made up of closely compressed,  flat, connective-tissue
fibres with minute  nuclei, which are so packed  together as to form a
spindle-shaped mass, occupying  the  greater part of the papilla  in
which each is found.   A  somewhat denser connective-tissue capsule
encloses each.  The myeline sheath of the nerve-fibre  is lost in the
fibrous tissue of the corpuscle.  Externally viewed, they seem to  be
tra n s v e rse 1 y st ri ated.
   The axis-cylinder of the nerve-filament distributed to each divides
into numerous delicate  nervous threads which in  part encircle the
corpuscle  and  also penetrate within.  According to Dr. Robinson,
each corpuscle is  provided with  an  afferent  and efferent nerve, the
former approaching the corpuscle from  the subpapillary region and
entering at  or near its base.   Occasionally the afferent fibre  is fur-
nished  by an adjacent papilla.   As the filament  that enters the
corpuscle  frequently divides,  two or  more efferent fibres may then
escape from it.
   The discovery of nervous filaments  in and  among the epithelia  of
the epidermis in such abundance as to provide fully for tactile sensa-
tion  in  the skin,  leaves  the   exact function of these  corpuscles   in
partial obscurity.   There  can be little  doubt,  however, as  to their
association with the perception of certain qualities of foreign  bodies
with which the skin may  be brought into contact. 
32     ANATOMY  AND  PHYSIOLOGY OF  THE SKIN.


                           Pigment.

  The hue of the living integument is due in part to the degree of
vascularity and  distention  of the vessels in the corium, and  in  part
also to pigmentation of the epidermis.   This pigmentation depends
upon a distinct and uniform coloration of the epithelia, chiefly those
found  in the lower  strata of the  epidermis, and also  to  minute
granules of pigment entangled in  the reticulum of living matter in
the same part.   Extreme variation in the distribution of pigment is
noticeable both  iu health and disease, and in individuals and races,
being, at times certainly, proportioned  to climatic  and similar influ-
ences.   This is well  illustrated by the wide range between the flaxen-
haired and pink-eyed albino, and the blackest specimens of the negro,
each with small exception of African descent.
  It has been  already noted that in the colored  races the pigment
may stain the epithelial cells and their nuclei, as  high as the granular
layer; and that to this  layer only the  peculiar color of the skin of
the white races is due.   Pigment is not found normally either in the
horny layer of the skin or in the subepithelial tissues.   Waldeyer
alone claims to have recognized it  in normal  connective tissue.
  The relation existing  between the two sources of skin coloration,
viz., the blood and the pigment, is interesting and suggestive.  The
eye unaided,  looking at the outer surface of the  body, makes no dis-
tinction  between these two color sources.  It is  indeed probable that
the pigment originates from the coloring matters of the blood.   It is
certain that solar heat  exerts a manifest influence upon both, and
that in extravasations of blood into the substance of the  skin, every
shade of color which can be detected iu the spectrum can be  at times
distinguished.

                            Muscles.

   Striated Muscular Fibres extend from the subcutaneous tissue
into the derma, and in  the case of  man are found  chiefly upon the
face and neck, where they are the analogues of  more powerful  skin-
 moving muscles possessed by several  of the lower animals.  Some,
as those in the region of the face, serve to give expression to mental
emotion by the production of movements in  the features.

   Non-striated Muscular Fibres exist either as minute oblique
 fasciculi in connection  with glands  and follicles  of the  skin •  or as
annular bands, such  as those which  surround  the nipple;  or as
 radiating and more or less parallel rods, such as antagonize the orbicu-
 laris in the lids.

   The  Arrectores, or Erectores, Pilorum are muscles usually
 found  in connection with the  hair-follicles.   They originate  by
 several minute  fasciculi  from the papillary portion of the corium ">nd
 are inserted at several points  into the outer layer of several  adjacent 
hairs.
33
hair-follicles, just  above the plaue of the  apex of the hair-papilla.
Their general direction is oblique, and their muscle-bundles are both
embraced and traversed by elastic fibres which form a dense network
about them.   Elastic threads also connect them intimately with  the
connective-tissue bundles  of the corium,  and serve as tendons at
either extremity of each muscular fasciculus.
   The oblique direction and mode of attachment of these muscles
result in their inclusion of the sebaceous glands connected with  the
hair-follicles in the angle subtended by their muscular fibres.   It
follows,  therefore, that by  their  contraction they  can aid in  the
expulsion of the sebaceous secretion formed in the gland.   But their
intimate union with the elastic tissue, which is evenly and  generally
distributed throughout the framework of the corium, results in their
discharge of a still more  important  function in connection with  the
regulation of the bodily temperature.  Their anatomical connections
are such that contraction of the arrectores pilorum  serves to approxi-
mate  several of the papillae  of the corium, the hair-papilla  being in
this view regarded as one of such cones.   Thus, by their contraction
the sebaceous secretion  may be extruded, or, as  more particularly
exhibited in the  lower animals, such hairs may be erected  as  the
bristles of the boar.   But by virtue of  direct compression exerted
upon the skin, the blood may be driven from the surface in a centri-
petal direction and its cooling to a great degree prevented, as in  the
well-known  phenomena  resulting in  the  production  of  the cutis
aascrlna  or  " goose flesh."   The  reverse  of this  naturally follows
when the muscles expand under the influence of external heat.

                              Hairs.

   Hairs are cylindrical, elongated, and pointed epithelial filaments,
derived from the epidermis, and obliquely implanted in depressions
in the rete and corium, known as hair-sacs, or hair-follicles.  They
are found in  all portions  of the body except the palms and soles,
the dorsum  of the distal phalanges of the hands  and feet, and  the
skin of the  penis.  Hairs occur  in  three  tolerably distinct classes.
There are the fine downy hairs, or lanugo, covering the face, trunk,
and limbs; the long and  soft hairs,  such as are implanted  upon  the
scalp,  pubes, and axillae; and  the short-  hairs, including  the  soft
varieties seen upon the brow, and the stiff hairs of the lids.
   The hairs are first developed  in  the  third month of foetal life,
when a  short epithelial  cone is formed,  whose  base  is gradually
surrounded  by  connective-tissue  cells,  and  finally  indented  from
below  by a  rudimentary  hair-papilla.   Gradually  the tip  of  the
rudimentary hair  perforates  the primitive  hair-cone, and becomes a
mature filament.
   At  about the  period  of birth, sometimes earlier,  occasionally
later, the  bed-hairs, as they are called by Unna, are  replaced  by
papillary  hairs.   The term  bed-hair is  applied  to  primary  hairs
unprovided  with  papillae, and implanted  in shallow follicles from
                                  3 
34      ANATOMY  AND  PHYSIOLOGY OF THE  SKIN.
the  sides  of which  productive  epithelial  offshoots  have  been  sent
out.   Usuallv  at the end  of  foetal life these  bed-hairs  have been
Fig. 9.
Fig. 10.
  Section of hair-follicle during the formation
of a new hair,  a, external and middle root-
sheaths ; b, vitreous membrane ; c, papilla, with
vascular loop; d, external root-sheath ;  e, in-
ternal  root-sheath;/, cuticle  of hair-follicle;
g, cuticle of  hair; h, i, young hair; 1, bulb  of
old hair; It,  debris of external root-sheath  of
hair recently expelled.  (After Ebneb.)
HP
/"_
  Hair-follicle in longitudinal section,  a, mouth
of follicle; 6, neck; c, bulb; d, e, dermic coat;
/, outer root-sheath ;  g, inner root-sheath; h,
hair; lc, its  medulla; I, hair-knob; m, adipose
tissue; n,  hair-muscle;  o, papilla of skin; p,
papilla of hair;  s, rete mucosum, continuous
with outer root-sheath ; ep, horny layer ;  I, seba-
ceous gland.
for  two  months  growing  out  of the  hair-bed, or  that  part of the
epithelium found in the central part of the hair-sac.
   In  studying  the  mature hairs, the  parts to  be considered are the
hair-follicle,  and the bulb, shaft, and point of the hair. 
HAIRS.
35
  Hair-follicle.—The hair-follicle is a sac-like depression in the
corium, in which the  hair-filament is implanted by  its bulb,  and
there firmly secured.  The direction or set of this  follicle is always
at an oblique angle with the plane of the  cutaneous  surface where
it opens;  and  thus is determined the set of  the hairs, which  is
always  fixed, and at  a similar angle.   Viewed  as  a whole, the
integument of the body over  its entire  area  exhibits  determinate
whorls  of both short  and long hairs with  definite centres, such  as
those which may be recognized  at the vertex of the  scalp, the centres
of the lips, the umbilicus, etc.   By this disposition the symmetrical
appearance of the hairy parts is  preserved,  and, as a consequence of
the  same provision, physiological loss  of the hair of  the head is
not  productive  of deformity, but rather  adds dignity to the aspect
of the elderly man.
   The hair-follicle embraces the lower two-thirds of that portion  of
the hair which is embedded in the skin, together  with  the  envelopes
of the latter, termed its sheaths.   Above; the sebaceous glands the
limits of the hair-follicle are lost in the papillary  layer.   It is  con-
stituted  of the  connective tissue  of the corium in three layers :  an
external, longitudinal, fibrous layer; a middle, transverse layer; and
an  internal,  homogeneous,  or  vitreous layer.  At the  base of the
sac a fibrous pedicle mav often  be traced as low as the subcutaneous
tissue.
   If the hair-pouch were made artificially by thrusting into the skin
from without inward a  blunt-pointed pin, before  which the tissue
was gradually  pushed, it  is evident  that  the external layer,  the
stratum corneum, of the epidermis would be the  first depressed, and
finally cover  the inner surface of  the pouch.  This  represents the
inner  root-sheath  of  the hair.   Next to this the pin would carry
before it the mucous layer of the epidermis, which  then would  form
the  outer root-sheath of the hair.   Outside of both  would lie  the
connective tissue of the corium ;  this is the hair-follicle.

   The  Outer  Root-sheath, or,  as  Unna prefers  to call it,  the
prickle-iaver of the hair-follicle, accompanies the involutions of the
stratum corneum, and the stratum granulosum  from without, into the
funnel-shaped neck of the hair-pouch as  far as the openings of the
ducts of the  sebaceous  glands.   There, abandoned by the two other
layers of the epidermis, it is thinned in  proportion as the papilla,
which rises from below and which  it closely surrounds, increases in
size.  It thus forms a hollow cylinder traversed by the hair and its
envelopes, with  a relatively wide, external, funnel-shaped  opening,
onlv partially filled by the shaft of the hair, and a  narrower opening
within, which embraces the neck of the hair-papilla.

   The  Inner Root-sheath, or,  as Unna prefers to call it,  the
matrix of the  root-sheath, is externally in  relation with the outer
root-sheath or prickle-layer of  the hair-follicle.  The  protoplasm of
the  cells of which it is constituted contains kerato-hyalin in varying 
36      ANATOMY  AND PHYSIOLOGY  OF  THE SKIN.

quantities,  the amount being  naturally  greater in  the cells lying
nearest the hair-filament,   The part of the sheath forme rly termed
Henle's layer is the more externally situated,  cellular  envelope  of
this internal root-sheath, most conspicuous iu that part of  the hair-

                                Fig. 11.
  Lower portion of hair-pouch from the lip of a kitten.  F, follicle ; T, transverse sections of con-
nective-tissue bundles of derma; M, arrector pili muscle ; IS, inner root-sheath ;  OS, outer root-
sheath ; P, papilla; C, cuticle ; R,  root of hair ; H, hyaline,  or so-called structureless membrane.
Magnified 500 diameters. (After Heitzmann.)

sac which is above  the level of the papilla.   That part of the sheath
formerly called Huxley's layer, is  the more  internally  situated  part
of the same sheath, somewhat higher in the follicle.  Both of these
terms  are now falling into desuetude as not  actually descriptive  of
distinctly different  structures, but  only  of one structure in different
situations.   That structure, whether  it  is  termed  the internal root-
sheath, or matrix  of  the root-sheath, springs from the neck of the
papilla, and  rises  as  high  as the  neck of the follicle.   It contains 
HAIRS.
37
kerato-hyalin, which is actively concerned in the cornification of the
hair tissue.
   Between this structure and the cells constituting the cortex of the
hair, there is found, according to Unna, the  common matrix of the
cuticulae, forming respectively the cuticle of the root-sheath, and the
cuticle of the hair.  The former is composed of cells with their long
axes parallel to  the circumference of the hair, while  those forming
the cuticle of the hair are arranged perpendicularly to the surface.
These cuticulae are  securely  locked  together by projection of their
cell edges, while  united iu the hair-follicle.

   The Bulb, or Root, of the hair is that portion which is embedded
in the skin, toward  which the shaft of the hair gradually increases in
thickness as it descends.   It is embraced by the hair-follicle, though
its root-sheaths  are-interposed, and  implanted below at  the base of
the sac  upon a nipple-shaped prolongation of the corium,  which may
be regarded as  analogous to the vascular papillae  of the papillary
layer of the corium.
   The  bulb of the hair embraces the papilla, and is constituted of
pigmented cells  externally,  forming what  is  called  the cortex or
cortical portion.   This is the larger of the two  structures of  which
the  hair is  composed, and its  cells  become vertically elongated and
narrow as they are pushed outward in the process of growth.
   The  innermost structure of the hair is called its  medulla, a tissue
composed of non-pigmented, horizontally broadened cells containing
kerato-hvalin.   It rests directlv upon the
apex of  the papilla below, and passes           Fig. 12.
thence  through the centre of the shaft of
the  hair like a  delicate  cylindrical  core.
Air-spaces  occur between  its epithelial
cells as it rises toward the funnel-shaped
opening of  the hair-sac,  but  air does not
enter the bodv of the individual cells.
  The Shaft of the  Hair  is  that
portion which extends from its exit at the
surface of the skin  to its extremity.  The
latter,  when  uncut,  always  tapers  to  a
perfectly acuminate point, as is illustrated
in the  uncut hairs  of the lids, and of the
lower animals. The shaft is either straight,
curled,  wavy, or  alternately varied  in
diameter, producing the peculiar character
of the growth seen  upon the scalp of the negro, these variations being
due to  tlic different degrees  of flattening of the shaft in a transverse
direction.
  The  color  of the hair is  dependent upon  the pigment it contains,
the  proper color of the hair-cells, and the quantity of air  contained
Transverse section of hair and
       follicle. 
38     ANATOMY  AND  PHYSIOLOGY OF THE SKIN.

in the  medulla.   Variation iu these three factors produces the wide
range between a snowy whiteness and an ebony black.
  The membrane which invests  the shaft of the hair is the cuticle,
already described, composed of numerous flattened plates, regularly
overlaid so as to resemble fish-scales when viewed under  the  micro-
scope on the flat side, and the  overlapping shingles of the roof of a
house when seen on  the edge.

  The Cortical, or main, Substance of the  Shaft of the hair
is here also enwrapped by the  cuticle, and composed of flat, nucleated,
fusiform, epidermal  cells.  The strength, elasticity, and extensibility
of the hair are chiefly due to the cortical substance, and in  particular
to the firmness with which these  epidermal cells are attached to
each other.

   The Medullary Substance  of  the  Shaft of the hair is
found best developed in the short and strong hairs of the beard  and
eyelashes, being  wanting iu the lanugo hairs.   It consists of a loosely
packed mass  of  epidermal elements, differing in shape, developed in
the centre of the axis of the  shaft.   This part of the hair contains
also the pigment and fatty matters which are here arranged as in the
rete of the epidermis.   Seen under  the  microscope,  the medulla
appears as a  continuous  or  interrupted longitudinal band, extending
from the bulb, or the part implanted in the follicle,* to the  extremity
or point.  The purpose of this  difference  in the constitution of the
cortex aud medulla of the hair is doubtless to insure, on well-known
mechanical principles, a  maximum of  strength, extensibility,  and
elasticity, with a minimum of volume.
   The coloring matter of the hair is stored in both its horny  and
medullary  portions,  and  is distinct both  within and between  the
epithelial elements of which it is composed.  This pigmentation  cor-
responds, as Heitzmann  has shown, in great part to the  amount of
pigment distributed to other parts of the integument,  and sustains a
close relation to the general nutrition of the body.   Its subjection to
the influence  of  the  trophic nerves is well demonstrated bv the phe-
nomena of rapid blanching of the hairs.   Excessive sweating, whether
physiological or induced by  the action of pilocarpine,  has  also a
distinct influence upon the shade of color of the hair.
   On transverse section  hairs present an ovoid or ellipsoidal outline,
occasionally suggesting an irregularly compressed circle.  The degree
of this flattening differs in different races, and, as has been shown,
is the cause of variability  with  respect to straightness or  curliness.
As hairs  are to  a marked degree  hygroscopic, and not only absorb
but  can  be  deprived  of a portion of  their water, these "states of
waviness are subject to variation  according to the aqueous condition
of the media  by which an individual is surrounded.
   Hairs  differ  from  nails not only in their anatomical features, but
particularly as to their physiological reproduction.  The  former are
periodically cast off  and  replaced by new filaments; the latter are so 
sebaceous  glands.
39
shed and reformed only in disease, and  in health enjoy a continuous
growth during the life of the body.
   When  a hair is about to be shed it separates from its papilla in the
hair-follicle and rises in the latter till it  reaches above the level of the
papillary apex.   It is  thus  for  a time  held in place with sufficient
firmness  by  the prickle-layer only, and thus forms  the bed-hair de-
scribed above.   Later an epithelial bud is  projected either into the
vacant follicle below or into the corium  on either side, from which a
new hair is formed, somewhat as the hair is formed  in the primitive
cone of foetal life.   Later the growth outward of the new papillary
hair pushes  the bed-hair from its connection  with the prickle-layer,
and the latter is shed.

                       Sebaceous Glands.

   The sebaceous glands are  pyriform  bodies,  usually  racemose in
development, situated in the corium, never in the subcutaneous tissue,
which furnish a more or less  consistent and fatty secretion destined
to anoint the skin and hairs.   They can be  usefully distinguished as
in three  separate classes, though only  two  of these  classes  include
glands which arc in the embryo associated with hairs.
   The first class, as proposed by Sappey,  includes the sebaceous glands,
which art", strictly speaking, appendages of  the hairs and hair-folli-
cles.   They  are developed  early  in  foetal life  from  minute, lateral,
bud-like prolongations from the outer root-sheath of the hair.  From
two to six of these spring from the prickle-layer of the hair-follicle;
and the prickle-cells in the axis of each bud speedily undergo fatty
metamorphosis.  In the mature  gland  each acinus  is  formed of a
mcmbrana propria, on which are ranged layers  of nucleated cuboidal
epithelia undergoing fatty metamorphosis.    Gradually the fatty cells
are pushed outward toward the duct of the gland, where, sooner or
later, their rupture releases numerous drops of fat just where the hair
emerges  from the closely applied  follicle below to the funnel-shaped
mouth of the hair-pouch above.   Externally, each gland is provided
with a layer  of connective tissue.   On account of the clearly defined
relations of these bodies, Unna would call them the "glands of  the
hair-follicles."   They are found in connection with the long and soft
hairs,  as  of the  scalp and axillae, several grouped  around  a single
hair-sac.
   The second  class includes the large and complex glandular struc-
tures  to which the lanugo, or rudimentary hairs, seem accessory, the
orifice of their  ducts opening directly  upon the cutaneous surface.
These  are chiefly found upon the  so-called non-hairy portions of  the
skin, as the face in both sexes, and portions of the trunk and extrem-
ities.
   The third class  includes much  the smaller  number.   These  are
sebaceous glands opening directly upon  the  surface and unconnected
with hairs or hair-follicles.   Such are the glandulae odoriferse of  the
male and  female genitalia (glands of Tyson), the Meibomian  glands, 
40     anatomy and physiology  of  the skin.

and those existing about the lips and in the areola of the nipple.
These might be designated as the  "glands of the mucous orifices."
Sebaceous glands of the second class from the alse of the nose.  (After Sappey.)
  The sebaceous secretion is found to contain, chemically, water, pal-
mitic and oleic acids, palmitin and olein, soaps, and the saline constit-
uents of the other organic animal compounds, chlorides and  phos-
phates of the alkalies and earths.  It has been already shown that
the extrusion of the secreted sebum from  the ducts of these glands
is greatly favored by the action of the arrectores pilorum muscles, by
whose contractions the gland is to a degree compressed.   This is the
reverse of what occurs in the coil-glands, whose secretion is impeded
by the action of these same muscles.

                         Coil-glands.

  The Coil-glands,  also  termed  Sweat,  or   Sudoriparous
glands, are globular coils situated in the subcutaneous tissues and in
the deeper portions of the corium.  They appear first in the fifth 
COIL-GLANDS.                         41
month of fetal life as  buds projected  downward  from the prickle-
layer of the epidermis.  Unna has demonstrated that these projections
always form between the papillae of the corium, and spring from the
prolongations of the rete  between these papillae.   Long, thin cones
of epithelium thus gradually traverse the corium, and become slightly
bulbous  at  the  lower extremity to form later the coil.  The lumen,
when formed,  extends  rapidly  to the  epidermis,  and after this  is
reached,  an opening is  made  from within  outward, which  becomes
the sweat-pore.
   These glands after birth are found in all parts of the body, but in
certain regions, such as the axillae, the  groins,  the palms, the soles,
and about the anus, they are either numerous, of unusual size, or
peculiarly arranged.   They  are specially numerous in the palms and
soles, where, according to Krause, there are between  two and three
thousand to the square inch.

                              Fig. 14.
  Coil of the sweat-gland.  S, tubule lined by cuboidal epithelia ; T, central calibre of the tubule;
D beginning of the duct; C, connective tissue with injected bloodvessels.  Magnified 500 diameters.
(After Heitzmann.)

   The coil  is a convoluted tube terminating in a ccecal pouch, lined
with cubical epithelia of granular appearance which are the secretory
cells of  the gland.  Outside of these are muscular  fibres  running
parallel with, or in  a spiral  direction  about the coil.   Surrounding
both muscle-bundles and epithelium is a connective-tissue membrane.
The o-lomerulus, or coil,  is globular in outline  and reddish-yellow in
color!  In  the larger glands irregular dilatations and constriclions of
the tube  are conspicuous.
   The excretory duct of the coil-gland passes from the glomerulus
below to the epidermis above, in a straight or spiral course.   It is 
42      ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN.

lined with a delicate hyaline cuticle discovered by Heynold, beneath
which is a double layer of cuboidal epithelium.  Externally is a mem-
brana propria, uuprovided  with muscular  fibres.    Its  outermost
sheath is the  usual  connective-tissue layer.  When the duct reaches
the borderline of the epidermis, its inner cuticle and external connec-
tive-tissue sheath are both lost.   Here it becomes the sweat-pore.
  The sweat-pore traversing the epithelial layers of the skin.  BP, papilla with injected blood-
 vessels ;  V, valley between two papillse:  I), duct in the rete mucosum ; E, E, epidermal layer •  PL
 coarsely  granular epithelia, deeply stained with carmine ; P, duct with corkscrew windings in the
 epidermal layer. Magnified 200 diameters. (After Heitzmann.)

   The Sweat-pore  is a continuation of the excretory duct of the
 coil-gland after the loss of its cuticle and conuective-tissue sheath.  It
 is the  loss of these sheaths and the  consequent intimate relation of the
 canal to the epithelia of the  epidermis that  furnish the  special basis
 for this distinction.  The sweat-pore is merely a wall-less  canal or
 channel, spirally directed or running a straight course from the duct
 of the  coil-gland below to  the outermost stratum of the epidermis
 above.   It has no other wall than that formed  by the cells of the
 prickle-layer below and of the other  layers of the 'epidermis, which
 successively surround  this  canal,  narrow below and funnel-shaped
 above.  Hence the lumen of the sweat-pore, if such a  term be per-
 missible, is in free communication with the juice-spaces of the epi-
 dermis.
   The secretion of  the coil-glands consists largely  of globules of  fat
 and  granules of pigment,   Their  function, therefore, is plainly the
 lubrication of the skin  with unguent, a task performed only in small
 part by the sebaceous glands, and by them chiefly for  the pilary
covering of the body.   The  palms of the hands and  the soles of the
 feet, where no sebaceous glands exist, are thus lubricated with fat by
 the coil-glands. 
COIL-GLANDS.
43
   The total number of the coil-glands in the body is estimated to be
 between two and three millions, and the total length of the uncoiled
 glands about eight miles.  These figures serve to give an approximate
 idea of their very great physiological importance, and of the extent
 to which violation of the rules of hygiene possesses interest from the
 pathological point of  view.
   The function of the sweat-pores, which communicate directly with
 the excretory duct of the coil-glands, is distinct from that of the coil-
 glands, since it provides for the transmission outward of the watery
 fluids of the skin.  The channel described as the sweat-pore is in
 ample and free communication with the intercellular  spaces of the
 epidermis; and this anatomical peculiarity provides fully for all the
 needs of evaporation at the surface of the body.
   The sweat excreted  by the body differs under varying conditions of
 temperature, humidity of the  air, and the amount and character of
 the  articles ingested  by the individual,  either  as  food,  drink,  or
 medicament.   Nearly ninety-eight per cent, of the  secretion is pure
 water, the remaining proportions  representing the saline constituents
 of the other fluids furnished by the  animal in life.  In all chemical
 analyses of the sweat,  a source of error lies in the difficulty of securing
 the  fluid secretion  unmingled  with  that  produced by the sebaceous
 glands; and the same,  it may be said in passing, is true of the chemical
 analysis of the sebum.   According to Duhring, the iodide of potas-
 sium, benzoin, succinic and tartaric acids may be excreted with  the
 perspiration.
   Unna, following in  the line first indicated by Meissner, asserts that
 the  coil-glands actually produce  the subcutaneous fat-cushion ; and
 the  anatomical basis  of  such a statement is clear.   The  coil-glands
 and  the fat-cushion appear at the same period of foetal life and develop
 iu the same proportions.   At birth the clusters of fat are  most con-
 spicuous where the coil-glands are  most numerous.   In the adult,
 the greater number of coil-glands are subcutaneous  in  situation and
 are  closely surrounded by fat  tissue; while those glands which do
 not  descend below the  corium, though  not  thus surrounded,  are
 regularly met by columns of fat advancing toward them from below.
  The credit of discovering and naming these fat columns belongs to
 Dr.  J. Collins Warren,  of Boston, whose  studies were  principally
directed  to the anatomy  of the  thick cutis vera.1   The  back and
shoulders  of  a vigorous  adult  furnish au  integument much thicker
than  the  hide of  many pachydermatous  animals.  The papillae  are
imperfectly formed, and represented by  an untlulating  line.  The
follicles  of the lanugo hairs penetrate only the superficial layers of
the cutis.  From the bases of the hair-follicles, nearly vertical clefts,
or slender, columnar-shaped spaces, extend obliquely to the panniculus
adiposus, which were fitly termed by Warren,  "fat-columns  or fat-
canals," as thev are entirely occupied  by  adipose tissue.   (See Figs.
3 and 4.)
  These columns are about  four mm. in  length, and are  slightly

            1 Satt.Tthwaite's Manual of Histology, p. 420.  Now York, 1881. 
 44     ANATOMY  AND  PHYSIOLOGY OF THE SKIN.

 wider than the hair-follicles  above.   Their long axes form a slight
 angle with that of the follicle, but they are nearly parallel to that of
 the erector pili muscle.   Two horizontal prolongations are given off
 on either side of the middle of this axis, partly fat-filled.  Near this
 point Dr. Warren called attention to  "the coil of a sweat-glancl, held
 in place by a few delicate fibres."  The duct  of  the gland runs  to
 the top of this space, whence it may be traced to the side of the hair-
 follicle.   The connective-tissue fibres seem to terminate abruptly at
 the edges of these  columns.   The cleft slightly widens below, and on
 the side toward which  its axis leans the  fibres of connective tissue
 form  a  bundle penetrating below to the subcutaneous  fat.  The
 erector pili muscle is inserted partly  into the base of the follicle and
 partly into the apex of  the  fat-canal.
   These columns  correspond in number  to the hairs.  The blood-
 vessels which  they contain,  springing from the subcutaneous  plexus,
 bifurcate at the lateral clefts.
   The  later  studies  of Unna demonstrate very clearly  that the fat-
 columns, first recognized by Warren, invariably advance toward the
 coil-glands, the  latter either singly or in  groups; and that the con-
 nection of the fat-columns with the hair-follicles is a mere incident  of
 that advance.
   The  alternation of muscular fibres with the secretory cells of the
 duct of the coil-gland is a provision for  the extrusion of the gland-
 secretion  onward.   The same anatomical  arrangement  permits  free
 communication  between the epithelia and the lymph-spaces which
 reach into the connective-tissue sheath of the gland.   As a result, the
 lymph flows freely among the secreting elements of the gland and its
 duct.   This lymph,  loaded with fat, streams away from the coils, and
 before it reaches the lymphatic trunks  its fat-globules are filtered away
 in the subcutaneous tissue.   Such  is the  interpretation  of this rela-
 tionship by an author whose studies of the  mutual interdependence  of
 the several component parts of the integument have furnished  the
 most  interesting and fruitful results.

         The Odorous Emanations from the  Skin.

   The  skin of the  human  body in health is  the constant source of
 odorous emanations, which, in pathological  conditions, may  be  greatly
 increased or otherwise changed.   The nature  and exact sources of
 these  emanations are as yet imperfectly understood.   Were these ex-
 clusively of a volatile, gaseous, or vaporous composition, even though
 such fluids were capable of condensation upon external bodies this
could scarcely explain tJie well-known fact that  some of  the lower
animals are capable of tracing the track of  the human being for miles
over a wind-swept path, till  the soil pressed by the foot is  covered
with water.  There is strong reason to believe  that these emanations
are the sole sources by which some  contagious  and infective  diseases
are communicated  from one individual  to  another, a fact which
suggests that  these  emanations may  at  times  contain living matter 
THE  NAILS.
45
derived from the protoplasmic masses of which the body is built up.
These  emanations are  properly regarded  as having their origin  in
the secreting system  of the skin, but in what proportion the several
secreting glands participate in  the product is difficult to establish.
The sweat at times,  even to human nostrils,  exhales a distinct odor,
though, as before indicated, to what extent this is due to its admixture
with the sebaceous material it is difficult  to  determine.   Peculiarly
fetid and disgusting odors occasionally originate in chemically altered
sebum, where the influence of the sweat secretion  must be, Irom the
locality under examination, partly  eliminated.

                           The Nails.

   Nails are dense, elastic, and translucent concavo-convex plates,  or
shells  of horny tissue, placed  upon the  dorsum of the terminal
extremities of the distal phalanges  of the fingers and toes.   Each has
a free  border at the distal portion of the pulp of the digit, with sides
and proximal  borders  let into  distinct furrows  of the  skin.   The
convex surface  of  the uail  is  exposed, the  concave regarding the
phalanx, and being implanted upon the nail-bed beneath.
   In the embryo the first change looking  to the future formation  of
a  nail consists  in  a  peculiar  smoothness and  brilliancy  of the
epidermis  covering the dorsum of the  distal  phalanges.   Later, an
epithelial ridge  or line with a groove in front  of it traverses the tip
of the  finger.   Thus, three regions are defined : that behind the ridge,
the nail-wall; that iu the groove, the nail-bed; and that in front of the
groove, the pulp of the last phalanx of the digit.  A collection of large
prickle-cells at the orifice of the nail-fold soon furnishes the first trace
of the  rudimentary  nail.  Mature  nail-cells finally  push forward
between the prickle and horny layers of the nail-bed, which, by fan-
shaped bundles  of follicles, is firmly united to the periosteum of the
phalanx.   Lastly, a thin  plate of horny material with a free edge, is
visible externally in the fingers  and toes of the newborn child.
   In the adult, what is termed the matrix of the nail, is the tissue
from which the horny plate  springs.   It is  separated, as shown by
Hans  Hcbra, into, first,  a  posterior  part, filled with from three  to
six rows of papillae.   Next, in advance of this, is a  lenticular  space
with curved borders,  the  anterior  limit of which  corresponds  to the
anterior  border of the  lunula.  The area  included in these two divi-
sions is provided with papillae grouped in symmetrically converging
ridges, decreasing  in size as they pass forward.  This  forms the
matrix of  the nail.    Further forward, the nail-bed proper—in other
words, the tissue that supports, rather than produces the horny  plate
—is composed of higher ridges of papillae whose grooves and summits
are covered with prickle-cells, and whose  height is uniformly main-
tained  as they stretch forward toward the pulp of the finger.
   Attention has been already called to the fact  that the digital arteries
communicate directly with venous  spaces  and veins  in the nail-bed,
an anatomical peculiarity  demonstrated by  Hover.  This arrangement 
46
ANATOMY  AND
PHYSIOLOOY OF THE SKIN.
evidently provides for the safety of these slender and exposed organs
in conditions arresting temporarily either  the venous or  the  arterial
current.
 Vertical section of one-half of nail and matrix,  a, nail substance ; b, horny layer ; c, mucous layer;
d, papilla? of corium ; e, nail furrow destitute of papillse ; /, horny layer of the ungual furrow rising
above the nail; g, papillse of skin of dorsal surface of the finger.

  The Nail,  or, as it  is termed by Unna, the true nail or nail-plate,
originates only from the floor of the nail-fold as far forward as  the
anterior edge of the lunula.   As to its  formation, it may, therefore,
be imagined as springing from  its matrix vertically in  the form of
an involuted, shield-shaped plate, its convexity regarding  the proximal
phalanx.   It may then be viewed as pressed downward over its nail-
bed in  front, with partially unfolded edges enwrapped  by the epi-
dermis  of the sides, the narrowed point  of the shield, elongated when
untrimmed, projecting at some distance  beyond the tip of the finger.
  With this conception, it is easy to understand that the nail is  con-
stituted of horny  filaments, or  coherent  strata of cornified  cells,
passing from the matrix or floor of the nail-fold.   The upper surface
of  the nail  grows, therefore, from the bottom of the nail-fold ; the
under surface from the lunula; and  the intermediate layers  propor-
tionately from the  parts between.  It is firmly attached to the  nail-
bed by ridges upon  its  under surface, which interlock with corre-
sponding grooves on the  upper face of the bed.
  The Nail-fold, creseentic in shape,  clasps the nail posteriorly and
at the sides.   It is formed  of  connective tissue, whose  bundles are
interpenetrated by  numerous coil-glands and fat-columns.  The  epi-
dermis  beneath the nail exhibits prickle, granular, and horny layers.
As the  nail is gradually liberated from  its bed, both  at the sides  and
point, the cornification of the horny  layer becomes more complete, so
that finally, as the nail-plate is pushed forward, it  no longer  rides
over the cells of the rete, but over a completely cornified tissue.
   If the pulp of any nail-bearing phalanx  be pressed with moderate
force against any  firm object,  the naked eye can  detect upon the
surface of the nail, just behind  its free border, a whitish and yellowish
band, convex anteriorly and somewhat  increasing in width laterally. 
THE  NAILS.
47
This line, described  by Unna,  is also  visible when  no  pressure is
exerted  upon  the digit,  its  width  varying  under  the  conditions
described.  This border represents the space in which the three layers
of the epidermis from the skin  of the  point  of the finger, viz., the
horny, the granular,  and the prickle-layer, successively come in con-
tact  with the under surface of the nail.

                                Fig. 17.
  Implantation of the nail at its border.  P, papillse decreasing iu size toward the middle line; R, rete
mucosum, which broadens toward the border of the nail, and forms irregular prolongations; R', E,
epidermal layer ; N, plate of the nail. Magnified 500 diameters. (After Heitzmann.)
   The lunula is the relatively light-colored space extending from the
middle part  of the nail-fold posteriorly to its  well-defined  convex
border in front.  After artificial removal  of the nail-fold, it  is  seen
to extend to the posterior and enclosed border of the  nail-plate.   It,
therefore, represents that part of the matrix of the nail which is  not
concealed by  the nail-fold.   Its color is not due to absence of vascu-
larity,  but  solely  to  opacity  of  the keratoginous cells (Ranvier)
which are concerned in the production of the horny threads that form
the nail. 
48
GENERAL  SYMPTOMATOLOGY.
                               II.

         GENERAL  SYMPTOMATOLOGY.

  In cutaneous, as in other diseases, the clinical  signs or symptoms
of the morbid process are those .by which it is recognized alike by the
patient and the physician.   It is usual to divide these into subjective
and objective : the former,  those appreciated by the  patient alone in
consequence of his sensations; the latter, by the eye and the touch of
another who  undertakes  the investigation of  the disease.   It should
be remembered, however—and this is a matter of some importance in
this connection—that many objective signs are made manifest to the
eye and touch of the patient himself, and liable to be interpreted or
misinterpreted  by  him, with consequences  which  should  not be
ignored.

  Subjective Symptoms.—The  purely subjective  symptoms of a
disease of the skin are those manifested  to the patient by sensations
other than those connected  with vision and his own sense of touch.
They include sensations of itching, smarting,  tingling, pricking, and
burning; sensations as of increased  or  diminished susceptibility to
the contact of foreign  bodies;  of  increased or diminished  tempera-
ture ; pain in various grades of severity; and disordered sensations,
as of the crawling of insects over the part, currents of hot or cold
vapors or liquids, and compression of portions of  the  skin  by either
cords, bands, or closely fitting plates. The character of the subjective
sensations experienced by a patient  often proves  an aid to the phy-
sician in recognizing the nature, not merely of a present disease, but
of one also which has preceded.   Thus the sensation produced by an
attack of erysipelas  is rarely an itching, while the latter  is highly
characteristic of eczema and scabies ; the pain of zoster and the ting-
ling of urticaria being distinctly different, not only from each other,
but from the subjective symptoms named above.

  Objective Symptoms.—The study of the objective symptoms of
a cutaneous disease is of paramount importance.  In no  respect does
the skilled physician so distinguish himself from one who is inexpert
as in the recognition of the typical or  atypical objective characters
presented in diseases  of  the skin.   The study is  one which can be
neglected safely by no diagnostician, and its rewards  are precious in
every department  of medical  science.  These symptoms are spread
before the eye, and their legibility increases with every hour of care-
ful  attention.
  These signs of skin disease—or, more literally, skin injury—are
called lesions, and it is usual to classify them  as primary and second- 
elementary lesions.
49
ary.  Such a division  is,  however, open to criticism, since, viewed
from the standpoint of time merely, some of the so-called primary
lesions of the skin become in turn secondary and even, tertiary.  Thus
a  papule which might at  one moment be called primary, may  be
transformed wholly or in part into  a  vesicle, which thus becomes a
secondary lesiou ; and such  vesicle  again, in  the evolution of  a dis-
ease, may become a tertiary pustule.  The  latter finally may  result
in  a quaternary crust.   In the following pages these symptoms of
skin disease will be distinguished as elementary and consecutive.

                     Elementary Lesions.

   Iu describiug the average size of cutaneous lesions, it is less con-
venient to state their  measurement iu fractions of a line or millimetre
than to  convey an approximate idea by a comparison  with familiar
objects of relatively  fixed dimensions.  The objects  usually selected
for this purpose are, beginning with the smallest, the seeds of poppy,
mustard, and  rape; the coffee-bean; the  pea; the bean;  the cherry;
the  finger-nail; the chestnut;  the horse-chestnut; the egg of the hen
and of the goose ; and the orange.   To these may also be added the
point and the head of a pin.  The student  will  find it useful  to
familiarize himself with the size of the small seeds  mentioned, that
their names may at once suggest to him the relative size of the lesions
to which they are compared.

   Macul.e, Spots,  or Stains, are  generally circumscribed
alterations in the color of the  integument, differing as
to the  size, shape, hue, and duration of the dyschromia,
and unaccompanied by elevation or depression of the
SURFACE.
   Examples of maculae are to be found in the exanthematous rashes
(measles);  in  localized  hyperaemiae  of the  capillary  plexus of the
corium,  disappearing in various degrees  according  to the pressure
exerted   on  the part  (rosacea);  in visible acquired  development  of
bloodvessels in the skin (telangiectasis);  in congenital vascularization
of the surface  (uaftvi); in variously colored blood extravasations and
stases (purpura); in  stains  produced by  contact with dyes (hand-
workers  in aniline); and in pigmentary changes such as those pro-
duced by solar heat (freckles),  or by  leprosy.
   Extensive non-circumscribed changes in the skin color are seen  in
the course of several general disturbances of the economy, as in yellow
fever, cancer,  chlorosis, albinism, Addison's  disease,  argyria, and
icterus.
   Spots of various color and device are also produced by the  inten-
tional or accidental introduction of pigmented particles beneath the epi-
dermis, as by the process of tattooing, the explosion of gunpowder, etc.
   Maculae exhibit  a  wide variation  in color from a rosy pink to a
chocolate-brown or even a black.  This difference has suggested the
employment of such descriptive terms as roseola, erythema, and pur-
                                4 
50
general  symptomatology.
pura, which have, unfortunately, served to distinguish both features
of diseases and diseases themselves.
  A macula which encircles another lesion, as, for example, the halo
around the vaccine vesicle, is called  an  areola.   Linear hemorrhagic
streaks are called vibices; punctate and larger extravasations of blood
are termed petechias aud ecchymoses.

  Papula, or Papules, are  solid or compressible,  ephem-
eral  or  persistent,  circumscribed projections  from  the
surface  of the  skin,  varying in size  from a  poppy-seed
to a coffee-bean.
  These  exceedingly common skin  symptoms vary greatly in their
shape, color, location, career, and significance.   Thus they may be
flattened  at the apex,  acuminate or pointed,  conical,  rounded,  or
depressed at' the summit to form an  umbilication.  They may  be
pale, rosy, dark or lurid-red, purplish, or even blackish.   They may
develop in transitory or persistent  processes;  they  may  be trans-
formed into lesions containing fluids ; may desiccate and furnish scales
either at apex or base; may degenerate  into  ulcers: or enlarge into
tubercles or tumors.  They may be scratched, torn, or rubbed  so
as to  lose their typical appearance ; they may come and go;  be
sensitive  to sudden  changes in the blood-current, and yet be them-
selves persistent.
  The mixed forms described above are generally named vesico-papular
or papulo-vesicular, papulo-squamous, papulo-pustular, lesions, etc.
  Lesions which  simulate the  papule  and which, though  described
under  that title,  really  belong to another category,  are the small,
semi-solid elevations of the surface which form at the orifices of the
ducts of the cutaneous glands and follicles.  Thus  they  may consist
of little  heaps of epidermis about  the hair-follicles  (lichen pilaris,
keratosis pilaris), or of inspissated sebum collected in one or all of the
acini of the sebaceous glands (milium, comedo).
  The concomitants of an eruption of papular type also vary.  Thus
there may be a febrile  process, or extensive infiltration of the skin
about and beneath the papules (prurigo); or itching of the  most in-
tolerable  character  (eczema papillosum); or production  of trifling
sensations of annoyance, as a slight burning without other subjective
symptoms (acne, lichen planus).
  Papules which are transformed into  moist  lesions become covered
with a crust.  Papules which are scratched  or torn by the finger-
nails usually betray the fact in the minute and flat blood-scale dried
upon their surface.  Papules which ulcerate may be  followed  by
scars.  Papules which have undergone the process of involution may
be followed by macular sequelae.

  Pomphi, Urtioe, or Wheals, are more or less transitory
rosy-red and whitish, irregularly shaped and sized eleva-
tions OF THE SURFACE OF THE SKIN, PRODUCED BY BLOOD-STASrS
IN SPASM  OF THE VESSELS, ACCOMPANIED  BY A  TINGLING  OR 
ELEMENTARY  LESIONS.
51
PRICKING SENSATION AND CHARACTERIZED  BY RAPIDITY  OF EVO-
LUTION AND FREQUENCY  OF RECURRENCE.
  The  typical wheal is seen  in  the disease  known as  nettle-rash
(urticaria), where closely packed, shining, roundish and whitish, pea-
to finger-nail-sized elevations of the skin are visible,  surrounded by a
slightly rosy border.   They are  firm to the  touch,  and arranged in
patches, circles, bands, gyrations or striations, often disappearing in a
brief time and recurring  with or  without a renewal  of the cause.
They are occasioned  by a  rapid  exudation of serum into the rete or
pars papillaris of the corium.  This is  supposed to  be due  to clonic
vascular spasm,  producing  irregularities  in  the lumen of the skin
capillaries, under the influence of the vaso-motor nerves which supply
a small area of the superior pars vascularis of the derma.   The sen-
sations produced  by the  wheal are particularly stinging,  burning,
pricking, and itching.  They are often surrounded by an areola.
  "Giant" wheals are such as enlarge to the  dimensions of an egg
or a tomato,  or cover extensive areas of integument, as, for  example,
the entire surface of the buttock or shoulder.
  Relics of  disappeared wheals are usually  transitory erythematous
maculae, but in rare cases  a  more or less  deep  pigmentation is left,
which slowly disappears (urticaria pigmentosa).
   it should  be borne in mind that at  times the wheal-like condition
is assumed by papulae, as also by  lesions resulting from such trauma-
tism  as the bites of insects, reptiles, horses, dogs, etc.

   TlJBERCULA, OR  TUBERCLES, ARE  CIRCUMSCRIBED, SOLID, GEN-
ERALLY INCOMPRESSIBLE,  AND PERSISTENT,  NODOSITIES  OF  THE
SKIN, VARYING IN SIZE FROM A  COFFEE-BEAN TO A CHERRY.
   They may  be largely projected from the free surface of the integu-
ment, or be deeply seated in the skin, and but a small portion become
evident  to the view  externally.   Their varieties as to shape, color,
size,  and other features, correspond iu  great part to those  described
in connection with papules.   They may be attached  by a  broad base
to the skin, or be pedunculated,  or even pendulous.   Their seat is
usually in the deeper portions  of the corium or the subcutaneous
connective tissue.  Degenerating and ulcerating tubercles are followed,
as  might  be supposed in  view of their volume,  by  considerable
destruction of tissue, and in  cases of repair by correspondingly exten-
sive  cicatrices.   Tubercles are seen in such diseases as fibroma, mol-
luscum epitheliale, syphilis, leprosy, sarcoma, and cancer.
   Tubercles are often described as merely enlarged papules; but the
distinction  between  these two forms of lesion will be better recog-
nized when attention is paid to the particular  portiou of the skin in
which each takes its  origin.   Papules spring oftenest from the super-
ficial  layers  of the  derma; tubercles, on  the  other hand, from the
deeper.  This being remembered,  it will be  clear that at times a
tubercle mav project from the surface to a less extent than  a papule,
though its larger volume  is  evident as  soon as the skin within which
it has developed is handled. 
52
GENERAL SYMPTOMATOLOGY.
  Phymata,  Tumores,  or  Tumors,  are  masses  of  solid
tissue, or  of solid  tissue more  or less  commingled with
FLUIDS OF VARIABLE  CONSISTENCY, DIFFERING IN  SIZE, SHAPE,
COLOR, AND IN THE BENIGNITY OR MALIGNITY OF THEIR CAREER,
EITHER LOCATED WITHIN OR  BENEATH THE SKIN, OR,  BEING AT-
TACHED  TO THE LATTER, PROJECTING  FROM IT TO A  VARIABLE
EXTENT.
  The mere fact that a lesion of the skin  approaches in dimensions
the size of a tumor is in itself an element of gravity.  Tumors may
originate in mere  hyperplasia of the  living matter; may consist of
new formations of greater or less danger to the vicinage, or the gen-
eral economy;  may be formed of blood or lymphatic vessels, or both
in the same lesion; may embody large fluid-containing cysts; may
be built up of nervous tissue, fat, bundles of connective-tissue fibres,
glandular elements, and indeed of any of the elements which exist
physiologically in the human integument.
  Examples of tumors are seen in fibroma, sarcoma, carcinoma, and
rhinoscleroma.

  Vesiculje, or Vesicles, are elevations of the horny layer
of the epidermis with limpid, lactescent, or sanguinolent
fluid contents, varying  in  size from a  poppy-seed to a
coffee-bean.
  Typical vesicles are  seen  in the  minute  and transitory lesions
occurring in the vesicular form of eczema.  They are usually filled
with a clear serum.  Variations from this type are, however, com-
mon.   Thus, they may be flattened, acuminate, roundish, umbilicated,
or conical;  may be fully distended or partially collapsed  upon their
contents; may have  a  short  or long duration;  may be distended
with milky, chylous, or a blood-stained fluid ;  may be  opalescent,
yellowish, reddish, or blackish in color ;  several may coalesce to form
a many-chambered  lesion; and a single  one or several such may
undergo transformation into pustules or bullae.  Vesicles may termi-
nate by accidental or spontaneous rupture, their contents freely flow-
ing forth upon the surface of the peripheral integument; or they
may desiccate to a crust; or may even terminate by one of the ulcera-
tive processes.   They may or may not be accompanied by pruritus.
Minute vesicles, which  are merely the external apices of large-cham-
bered accumulations  of fluid  beneath, occasionally form upon the
surface of the skin.
  Such are seen in the course of lymphangiectasia.

  Pustul.e, or  Pustules,  are  circumscribed cutaneous ab-
cesses, covered with an epidermal roof-wall, and varying
in size from a millet-seed to a filbert.
  The typical pustule  contains pus, and  is  colored yellowish, yel-
lowish-green, or  brownish-green, according to the admixture of its
contents  with  blood.  The pus being an inflammatory product  it
necessarily indicates the occurrence, at the base of the pustule of an 
CONSECUTIVE LESIONS.
53
inflammatory  process.  Pustules,  like  vesicles,  may  be roundish,
acuminate, globoid, conical, umbilicated, surrounded by an inflamed
or normal integument; maybe superficially or deeply seated; may
terminate by rupture or desiccation ;  may  or may not be followed by
an ulcer and ultimate cicatrix.   They may be seated either upon the
free surface of the  skin, or at an  orifice  of a follicle,  in which ease
they represent an inflammation with  purulent product  in the duct or
gland beneath.
  Pustules  may originate as such ;  or as a consequence of transfor-
mation of vesicles; or  after  a change iu  a papule, which may thus
come to have a  purulent apex.  According to  Auspitz, they invari-
ably originate from vesicles.   Pustules often result  in  the formation
of crusts, the latter varying  in color according as the  pustules from
which they originated contained a  clear serum or blood.
  Transitional forms between vesicles and pustules are termed vesico-
pustules.   Pustules of a large size  and resting  upon  an indurated,
engorged, and elevated base are often called ecthymatous.
  Pustules  are  seen in syphilis, variola, eczema, scabies, acne, and
many other cutaneous diseases, including several forms of dermatitis
medicamentosa.

  Bullae, or Blebs, ape-superficial  or deep-seated eleva-
tions  OF  THE  SKIN  HAVING FLUID  CONTENTS, DIFFERING  IN
COLOR,  SHAPE,  AND  CAREER, AND  VARYING IN SIZE FROM  A
COFFEE-BEAN TO A GOOSE'S EGG.
  Blebs have been  described  as large vesicles ;  but this fails to define
exactly their pathological character.  Like vesicles  they may contain
serum, lymph, blood, or pus ; and be variously colored in the degrees
according to which their contents become visible  through a  semi-
transparent roof-wall.   They may be globoid,  hemispherical,  oval,
crescentic,  seini-crescentic,  conical, and even exhibit angles.   They
may be seated  upon  an apparently  unaltered  or evidently  morbid
integument; and may or may not  present a peripheral  areola.
  Bullae may persist  or rupture ;  may desiccate or degenerate into
ulcers; may collapse after the escape of their contents, and the roof-
wall become glued to the base from which it was originally raised.
  Bullae  usuallv occur in extremely debilitated  states of the system,
and  are,  as a  rule, of graver portent than  other fluid-containing
lesions of the skin.  They occur in scalds and  burns, in pemphigus,
leprosy, erysipelas,  syphilis, and moist  gangrene.

                     Consecutive Lesions.

  Soiiam.e, or  Scales, are attached or exfoliated epithe-
lial LAMELLAE,  WHICH  HAVE  BECOME APPRECIABLE AT THE
SURFACE  AS THE RESULT OF SOME MORBID PROCESS IN THE SKIN.
  A physiological  desquamation is  constantly in progress  over the
superficies of the body, whose evidences are not pronounced in skins
properly cleansed by ablution.  Iu  disease processes,  however, des- 
54             GENERAL  SYMPTOMATOLOGY.
 quamation may occur as a distinct symptom in various forms.   Thus
 the  scales  may be minute, fine,  branny,  dirty-white,  or yellowish  ;
 they may be larger, pearly-white, shining;  dry or fatty; aggregated
 so as to  resemble flaky pie-crust; exfoliating  in extensive sheets, as
 from the entire sole of the foot or palm  of the hand;  or in glove-
 finger-like sheaths,  as  from  the surface  of a digit.  They may be
 scanty, scarcely perceptible, and  so attached as  to require  force for
 their removal; they may fall spontaneously in a pulverulent shower,
 being  so abundant  as  to fill  the garments or  bed-clothing  of the
 patient.
   Furfuraceous desquamation  is that form in which  fine bran-like
 scales are shed from the surface.
   Scales occur in eczema, psoriasis,  pityriasis,  ichthyosis,  syphilis,
 and in several of the parasitic diseases of the skin.
   It should not  be forgotten that scales are frequently intermingled
 with other lesions, ofteu they succeed  the latter.   Thus a papule may
 scale at its apex, or  surround its base with a collarette of loosened
 epidermal plates, beneath or between which a macular stain is visible.
 Again, they may develop from the macule, the tubercle, or the tumor.
 Though  generally conceded to be evidences of a dry and  non-dis-
 charging disease of the skin, they are at times accompanied or suc-
 ceeded by moisture of the part affected.
   The term "scales" is sometimes applied to  the flattened plates  of
 dried sebum which form on the scalp and portions of the trunk  in
 seborrhcea sicca.

   Crust.e, or Crusts, upon  the  skin, are relics  of  the
 desiccation of its pathological products.
   Crusts never occur as primary symptoms of disease.   When formed
 by  the desiccation of serum  only they  are of a yellowish,  straw-
 yellowish, or  reddish-yellow hue; when composed largely  of dried
 pus  they are  colored greenish, or greenish-yellow; and, when  there
 has been an admixture of blood, they are usuallv brownish or blackish.
 At times they suggest in appearance gum, honey, or Venice turpen-
 tine ; in  shape they may have the form of the concavo-convex lid of
 a watch-case;  in color and shape they may resemble the  half-shell of
 the oyster, or  the  carapace of a small turtle.  They may be delicate
 and thin ; bulky and thick ;  friable or mealy ; may be firmly attached
 to the subjaceut tissues, or  readily separable; may cover a sound,
 though tender and reddened epidermis; may conceal a superficial,  or
 deep, foul-based ulcer, by whose secretions from beneath they are
 raised above the plane o£the skin and increased in thickness.   They
 may be circumscribed and no larger than a small finger-nail; may
envelop an entire limb or organ, as the leg or  the peuis ; or, finally,
 may be so irregularly disposed among other lesions, papules, pustules,
excoriations, and open ulcers, that it is difficult  to define their out-
 line, and even to recognize their  identity.  Crusts formed  of dried
sebum  are greasy to the touch, dirty-yellowish in shade,  and usuallv
seated  upon a non-infiltrated base.  : Crusts are common in eczema 
CONSECUTIVE  LESIONS.
55
 syphilis, leprosy, seborrhea, and a large number of other diseases of
 the integument.

   Excoriations are  superficial  solutions of continuity,
 USUALLY  INVOLVING PORTIONS  OF THE  SKIN  AFFECTED  WITH
 PRURITUS, AND RESULTING FROM  MECHANICAL VIOLENCE.
   Excoriations, in appearance among the most trivial of skin lesions,
 possess a value from the diagnostic standpoint which  can  scarcely
 be overestimated.   They occur  as  striated, linear, punctate, circular,
 or irregularly shaped, furrowed wounds, at times involving  areas of
 flat surface, oozing with serum or blood, covered with dried blood or
 crusts,  yellowish  or reddish  in hue, and for  the  most part  both
 induced and accompanied by severe pruritus.  They mav coexist with
 hyjieraemia and infiltration of  the skin  beneath, brought on by the
 irritative character of the continuous, or, more frequently, interrupted
 cause by which they were begotten.
   Excoriations become significant according as they indicate  scratch-
 ing, tearing, or other species of wounding by  the finger-nails, and
 rubbing portions  of the integument with foreign bodies.   In the
 former case they are significantly recognized in those portions of the
 body most accessible to the hands,  though in the case of eczematous
 children and infants they may originate by the  rubbing  together of
 the knees; or the leg of  one  side by the feet and toes of the other.
 The loss of tissue may extend deeper than the rete—at times invading
 the papilhe of the corium, which bleed in consequence.
   Excoriations may occur without  the appearance of other lesions, as
 in the disease called pruritus ;  but where itching is severe and induced
 by a cutaneous exanthem, the lesions constituting the latter  may be
 intermingled with, obscured, or even obliterated by excoriations and
 the pathological processes to which they give origin.  Thus macules,
 vesicles, pustules, and papules may undergo change;  and the recog-
 nition of the type of the existing disease be correspondingly difficult.
 Excoriations  are common in skins wounded by lice, bed-bugs, and
 gnats ;  in the subjects of eczema, scabies, intertrigo, and prurigo ; and
 iu  individuals with special sensitiveness of the integument to the
 action of a medicament employed either internally or externally.

   Rhagades,  or  Fissures,  are  linear  solutions of  con-
 tinuity,  USUALLY  OCCURRING  IN  PREVIOUSLY  INFILTRATED
 PORTIONS OF THE SKIN.
   They may  extend to  the derma, and  even invade  yet  deeper
 structures; may be  painful, or the  reverse; dry, secretory, or in-
 crusted ; are  often hemorrhagic, and usuallv formed with sharply cut
 walls.   They are of frequent occurrence in the vicinity of the articu-
 lations, in which situations they are induced or aggravated  by the
joint-movement stretching or  tearing tissues whose extensibility has
 been diminished by any morbid  process.   Fissures may terminate in
 ulceration.   They vary as to length, curve, and tenderness.  They
 are often exquisitely painful, and greatly complicate the skin disease 
56
GENERAL  SYMPTOMATOLOGY.
in which they occur.   They may follow the  curve traced  by the
boundaries of bodily organs near which they occur—as, for example,
the line of the posterior junction of the ear with the head, or of the
breast of a woman with  the thoracic wall where  it  rests.  Fissures
occur in eczema, syphilis, dermatitis, and lichen ruber.

   Ulcer a, or  Ulcers, are losses of  substance  resulting
from  a  previous pathological  process   involving  the
corium, and, in cases, the subcutaneous tissue.
   Cutaneous ulcers  differ  greatly in  size, shape, color, edges, base,
career, and, indeed, in  all their characteristics.  Every ulcer has an
outline, base, floor, edges, and secretion.  The outline may  be cir-
cular, crescentic, reniform, ovoid,  serpiginous, or with horseshoe-like
contour.   The base,  or underlying tissue, may  be  soft, supple, indu-
rated, or in a state of active inflammation,  with consequent infiltration.
The floor  may -be glazed,  shallow, deep, excavated, cup- or  funnel-
shaped, " worm-eaten," crateriform, sloughy, covered  with a tenacious
or  readily removed  secretion, granular,  puriform, or hemorrhagic.
The edges may be clean-cut,  having a punched  appearance, under-
mined, everted, ragged, regular, or contracting, with a whitish inner
border of advancing cicatrization.  The secretion  may be  scanty,
limpid, puriform, profuse, ichorous, and  odorless  or exhaling an
offensive stench.  They may be so crust-covered as to be invisible, or
so exposed and erosive in action  as to  render the  affected surface in
the highest degree unsightly.   They may be acute or chronic, insen-
sitive or productive of intense pain ; may  heal by cicatrization, remain
open for a lifetime, or prove fatal by  either destruction of  parts
essential to life, or by exhaustion  of the vital forces.

   Cicatrices, or Scars, are new formed substitutes for lost
conn ective tissue.
   Scars  never succeed  excoriations, fissures,   or other solutions of
continuity in the skin, which have not penetrated as far as the derma,
and resulted in destruction of a portion of the elements of which the
latter is built up.   They possess the highest importance  for the
diagnostician, since they point invariably to a pathological  process
whose career is terminated, the characteristic features of which they
frequently embody   They may be regarded as the  special and per-
sistent imprints upon the integument,  of the serious disorders from
which it has suffered.
   To a  certain extent, as  already shown, scars retain  traces of the
special peculiarities  of the lesions, and even of the diseases, which
they succeed.  The identification, however, of  the individual prede-
cessor in each instance is, in the present  state of our knowledge, not
always  possible from  a study of cicatrices alone.   The  extent of
knowledge  in this direction is, however, rapidly increasing; and in
many cases the certainty thus acquired is of incalculable value to the
diagnostician.
   Scars are remarkable for their tendency to contraction and gradual 
GENERAL SYMPTOMATOLOGY.
57
decoloration.   They may be  minute,  punctate,  extensive  in  area,
attached to underlying tissues, depressed, raised above the plane of
the peripheral skin, seamed with  furrows, pliable and soft, indurated,
traversed  by ridges, knotted, and  as irregular in contour as the ulcers
already described.  They may extend in digital, linear,  or annular
prolongations toward contiguous  portions of the skin, and by subse-
quent contraction induce considerable distortion and deformity. Thus
they may drag down an eyelid, and ectropion ensue; may glue the
lobe of the ear to the cheek ; may evert lip or nostril.   When recent,
they are usually reddish in tint;  when  older, be pigmented in centre
or circumference; or, as is common, exhibit a gradual decoloration,
centrifugal in its progress.  They may be the seat  of  pain from an
entrapped nerve-filament; may  reopen  to ulceration;  or be  accom-
panied by no subjective sensation.  Not rarely they become the origin
of the disease  known as cicatricial  keloid.   Scars are  unprovided
with hairs, papillae, or the  orifices of sweat-pores and sebaceous gland
ducts.   As implied in the definition given above, scars may result
from any disease  or injury of the skin which involves loss of connec-
tive-tissue elements in the corium.
   To these lesions Bazin adds, as elementary forms, the  mucous patch
of syphilis; the  cuniculus, or furrow, produced in the skin by the
acarus scabiei; and the sulphur-colored crusts  of favus.   These,
however,  are not general, but  special features of individual disorders,
and are best studied in connection with the latter.

   The elementary lesions of the skin  are termed by Auspitz, "anthe-
mata;" groups of such lesions, "synanthemata ;" and, as in accord-
ance with common  usage, generalized  eruptions  affecting  the entire
surface of the  body, " exanthemata."   The word "erythanthema" is
used by  this writer to describe  groups composed of several of the
elementary lesions of the  skin, as, for  example, of  papules, vesicles,
and pustules rising from a common, reddened, and hyperaemic base.
   In addition to  the names of the lesions of the  skin just enumerated,
certain peculiarities of cutaneous symptoms are described in qualifying
terms, which here require definition.  They relate chiefly to the color,
shape, distribution, and method or period  of evolution of lesions as
they are observed in  individual cases.   The more important of  these
terms, as  used  by modern writers, are arranged below, alphabetically,
with a brief explanation  appended to  each.  A much larger list of
obsolete adjectives, employed  by  older authors,  is purposely omitted.

Aboominalis.  Located on the abdominal surface.
Acquisitus.  Acquired.
Acumixatus.  Having a pointed apex.
Acctus.   Of acute course.
Adultorum.  Occurring in adult years.
ikVnvAi.is.  Occurring in the season of summer.
Aggregates.  Collected in patches.
AGruts.   Acute, or angry in appearance.
Ai.Binus.  Of whitish color.
Axgiectaticus. Vascularized. 
58
GENERAL  SYMPTOMATOLOGY.
Annularis.  In the form of a ring.
Annulatus.   In the form of a ring.
Apyreticus.  Unaccompanied by fever.
Areatus.  Occurring in areas.
Artificialis.  Producible artificially.
Asymmetricalis.   Of different distribution on the two lateral halves of the
  body.
Autumnalis.  Occurring in the fall of the year.
Brachialis.   Occurring on the surface of the arm.
Cachecticorum.  Occurring in debilitated subjects.
Capitis.  Occurring on the head, usually the scalp.
Cavernosus.  Large chambered.
Chronicus.  Chronic in course.
Circinatus.   Of circular outline.
Circumscriptum.  Having a definite contour.
Confertus.  Arranged in close proximity, with coalescence of lesions.
Confluens.  Arranged in close proximity, with coalescence of lesions.
Contagiosus.  Capable of communication by contagion.
Corporis.   Occurring on  the  surface of the body;  employed  usually to
  designate an  eruption upon  the trunk,  as distinguished from that on the
  head or extremities.
Crustosus.   Crusted.
Crystallinus.  Of crystalline appearance.
Diffusus.  Irregularly disposed.
Discretus.   Having isolated lesions.
Disseminatus.  Disseminate, without regularity of distribution.
Eruption.  Is used of the totality of all patches and lesions upon the person
  of one individual.
Erythematosus.  Having a reddish blush.
Essentialis.  Idiopathic.
Exfoliativus.  Having a tendency to exfoliation  or shedding from the
  surface of the body.
Exulcerans.  Is  employed  by French   writers to  designate  superficial
  ulcerations, or lesions with a tendency to such a process.  By English  and
  American authors it is sometimes  used to designate unusually deep ulcera-
  tions.
Facialis.  Located on the face, usually as distinguished from the scalp.
Favosa.  Displaying crusts of  favus.
Febrilis.  Accompanied by a febrile process.
Femoralis.  Occurring on the surface of the thigh.
Fibrosus.  Composed of fibrous tissue.
Figuratus.  Having a figured appearance.
Flavescens.  Of yellowish hue.
Foliaceus.  Resembling a leaf or leaves.
Follicularis.  Concerning the cutaneous follicles.
Fungoides.  Resembling a fungus.
Furfuraceus.  Exhibiting numerous, fine, bran-like scales.
Guttatijs.  Of the size of a drop of water.
Gyratus.  Having a serpiginous  or gyrate outline.  This  is usually the
  result of a coalescence of imperfect circles or semicircles.
Herpetiformis.   Vesicular or herpetic in type.
Hiemalis.  Occurring in the winter season.
Humidus.  Accompanied by moisture.
Hypertrophicus.  Characterized by hypertrophy.
Hystrix.  Having lesions projected or erected  like quills.
Imbricatus.   With crusts or scales overlaid like tiles.
Impetiginodes.  Pustular.
Infantilis.  Occurring in infancy.
Intertixctus.  Distinguished by color.
Iris.   Occurring in more or less distinctly defined concentric rings.
Labialis.  Occurring upon the surface of the lip. 
GENERAL  SYMPTOMATOLOGY.
59
Lenticularis.  Of the size of a small bean.
Livinus.  Deeply colored.
Maculosus.   Discolored.
Madidans.  Characterized by moisture.
Marginatus.   Having a defined margin.
Medicamentosus.  Produced by external or  (more commonly)  internal
  medication.
Mela nodes.  Of blackish color.
Miliaris.   Of the size of a millet seed.
Mitis.  Of mild, benignant type—the reverse of agrius.
Multiformis.  Exhibiting simultaneously  several types  of  elementary
  lesions.
Neonatorum.  Occurring in the newborn.
Neuriticus.  Having nervous association.
Nigricans.   Of black or blackish color.
Nodosus.  With development of nodes or tuberosities of the surface.
Nummularis.  Of the size of small coins.
Oleosus.  Accompanied by an oily secretion.
Palmaris.  Occurring on the palms.
Parasitarius.  Produced by an animal or vegetable parasite.
Parasiticus.   Produced by an animal or  vegetable parasite.
Patch.  The  aggregation of several isolated or confluent lesions.
Phlegmonosus.  Accompanied by deep-seated  inflammation.
Phlyct^xoides.  Characterized by groups of small vesicles.
Pigmentosus.  Accompanied by pigmentation.
Pilaris.  Related to the hair.
Plantaris.   Situated on the soles of the  feet.
Planus.  Flat.
Polymorphous.  This is  the Greek equivalent of the Latin multiform.
Pr^eputialis.  Situated upon the prepuce.
Pkogexitalis.  Situated on the exposed mucous surfaces of the genitalia.
Pruriginosus.  Accompanied by itching.
Pubis.  Located upon the  skin or hairs of the pubes.
Punctatus.   Occurring in dots or points.
Rhagadiformis.  Fissured, or tending to produce fissures.
Rosaceus.  Having a rosy or pinkish hue.
Ruber.  Red, usually dark red in color.
Soutiformis.   Having the shape of a shield.
Sebaceus.  Concerning the sebaceous glands  or their secretion.
Senilis.  Occuring in advanced years.
Sercigixosus.  Literally, creeping—advancing iu irregular gyrations.
Siccus.  Dry,  unaccompanied by moisture.
Solitarius.   Having an isolated lesion, or with isolated lesions.
Sy.mmetricalis. Similarly distributed on the two lateral halves of the body.
Toxicus.  Poisonous.
Unifokmis.   Exhibiting lesions all of one type.
Universalis.  Affecting the entire  surface of the body.
Urticatus.   Accompanied by wheals.
Utekinus.  With association of uterine disorder.
Yariegatus.   Exhibiting several distinct colors.
Vasculosus.  Accompanied by vascular development.
Vernalis.  Occurring chiefly in the spring of the year.
Versicolor.  Exhibiting  several shades of the same color.
Vulgaris.  Of the usual  or commonly observed type. 
60
GENERAL  ETIOLOGY.
                               III.

                GENERAL ETIOLOGY.

  The study of the causes of diseases of the skin gives us a glimpse
of the etiology of diseases in general.   In the lowest representatives
of life, the  greatest dangers to existence originate in exposure to
assault from other and  stronger representatives  in search  of their
prey,  in other terms an external danger.   In man, the highest  repre-
sentative of the animal  scale, the perils of existence are complicated
by his social necessities and his artificial methods.   He can never,
however,  at  any period of his existence, divest himself from the
necessity  of exposure  to external  peril.  The plan  of his organs
and the play of his  normal activities are perfect, even to the recovery
from  all  but  mortal  injury and  repair of  moderate  loss   The
struggle  for  existence  of the ideal man  is intended  to be with that
which is  without; his body meanwhile furnishing him with a com-
fortable tenement and a fair  fortress.   In  the purview of nature
there  should be no internal revolt.  'When such occurs, it is usually
the result of his ignorance, his  folly, or his vice.
  Viewed in this light, the causes of the  diseases of his skin will be
seen to differ but little from those which induce disease in his other
organs.  Exposed to cold,  he  suffers from a pneumonia; to injury,
a fracture or a dislocation ; to  the  contact of poisons, he vomits or
purges; to contagion from his fellow-man, he  has  the cholera or
plague ; all these are capable of producing diseases of his skin.   But
meantime his  organs have a tender care for themselves and each
other, compared with which the solicitude of a mother for her child
becomes  insignificant.   The stomach  refuses  to digest  itself;  the
lung,  unwounded, admits no air to the pleura; the bladder, so long
as it  is  unruptured by  violence, permits no drop of urine to pass
into the  peritoneal sac.   In the  same  proportion,  and under the
same  general  law, do the viscera refuse to generate a poison  which
will injure  the integument; and the  fluids of the  body, a vicious
" humor " which will damage the bones.
  Reasoning thus from analogy alone, it  will be seen that the  preva-
lent doctrines  respecting blood-poisons of internal origin  must be
greatly restricted.  Eczema alone,  in  its  manifold  forms, furnishes
more  than one-half of all  the  diseases  of the  skin ;  and yet every
one of these several  forms can be produced at will and artificially
upon  the integument of  man.
  Again,  it  is not to be forgotten that the body is really  invested
with a continuous  skin  which not  only is extended  over  its outer
surface, but is  also  reflected so as to line all  passages by which it is
traversed within.   This  inner  investment, called the mucous  mem- 
GENERAL  ETIOLOGY.
61
brane, is as truly a part of the skin as the epidermis and corium of
the face or hand.  This  is clear:  first, as  shown from the facts of
evolution,  because representative  animals of the  lower scale are
found capable of complete inversion,  by  which  the outer  skin
becomes the inner  or digestive, and the inner, in turn, the outer or
protective  organ; second, as shown  by  histology,  the  anatomical
characters of the skin  and mucous membrane being similar; third,
as shown by pathology, the extroverted mucous membrane rapidly
undergoing the transformation which causes it to resemble the skin;
while the  inverted skin,  as when the thighs  are by disease kept in
continuous contact and moistened, assumes the characteristic features
of mucous  membranes.   In the study  of cutaneous  etiology,  it is
manifestly proper to regard  as of external origin all causes which
operate from  without upon either the outer or the inner skin of the
body.
   This much  premised, it can be said that the large proportion of all
diseases of the integument originate  either from the action  of  solar
heat  and  light;  temperature changes at the surface  of the body;
contact with various fluid and solid  substances with the  production
of either frictional, traumatic, or  toxic effects;  or  the development
upon and within the skin, of vegetable  parasites.  It remains merely
to consider these causes  somewhat in detail, remembering that at
times several  influences  cooperate in the production  of a  given
effect.
   The action of solar light  upon the skin  is usually coincident with
the operation of another mode of motion called heat.   To the former
are to  be  attributed the production of  freckles, "tan," and other
pigmentations  of the  surface; to  the  latter, the erythema, eczema,
and various grades of dermatitis which may follow exposure to the
direct rays of the sun.   Other temperature effects, including those
produced by extremes of both heat and cold, are to be classed in the
same  category.   According  to  Hebra,  exposure of the skin  to a
temperature over  100°  Fahrenheit,  produces merely a  transient
erythema,  which under a further elevation of 65° F. will not subside
for several days.  At a  temperature of 212° F., all  grades of acute
dermatitis areawakened with the production of bullae, up to the point
where complete destruction of the integument occurs.
   The influence  of the seasons is of the same general character.
S<»me cutaneous  diseases are worse  in summer; others  in winter.
Prickly heat (lichen tropicus) is peculiar to certain warm seasons;
frost-bite and  its  subsequent hyperemia,  exudation,  or  gangrene,
occur in winter; pruritus is common in cold weather; erythema  mul-
tiforme is most frequent in the autumn and the spring.
   The questions originating when  considering  the  influence  of
climate, are so complex  that they are  differentiated with difficulty.
Thev involve  the study of soil",  potable water,  diet, atmospheric
humidity  and temperature,  and  the  sociological  conditions  of a
given locality.    Pellagra  is  said to  originate in  certain  coun-
tries  from the diet of the people.  The severe forms of ringworm 
62
GENERAL  ETIOLOGY.
observed in India result probably from exuberance of vegetation in
the parasite under the influence of heat and moisture.  The aggra-
vated species of scabies seen in Norway is doubtless the product of
filth and  cold, with  the itch-mite  as an exciting cause.   It  must,
however, be admitted  that the more extensive the study of diseases
claimed to be peculiar to given degrees of latitude and longitude, the
less  they  are  found to depart from the  types recognized in  other
countries.
  Frictional effects are perceptible in the action upon  the skin, of
the clothing.  Coarse flannel is known  to excite pruritus, especialty
when aided by profuse sweat  and the  muscular movements of the
laborer.   Trusses, corsets, napkins,  " pads,"  supporters,  crutches,
orthopaedic  apparatus, hat-bands,  stockings, garters, and a long list
of similar articles, are responsible for many disorders, especially when
soiled with physiological or pathological secretions.  So in  the occu-
pation of men, bakers, masons, confectioners,  blacksmiths, tailors,
and  an equally long list of laborers  and tradesmen suffer  from the
results of  friction, to which is often  added the influence of trauma-
tism or the action of chemical irritants.
  Traumatism plays  a most  important  part in cutaneous etiology.
It includes  the action in scratching  of the  nails, the knees,  heels,
elbows, etc., well  illustrated  in the  case of infants whose  hands are
confined, as well as the influence of several articles used for the same
purpose—pieces of cloth of various kinds, etc.   In this way excoria-
tions, and even  infiltrations  of the  skin, are induced.  Under the
head of traumatism should be considered  also injuries of the surface
produced by animals, occasionally with the added effect of a toxicant.
Here are  included the wounds produced by  lice,  fleas, bugs, and
acari; the bites of serpents, horses, dogs, and cats; and the accidents
producing  traumatism of every  kind, not omitting the intentional
wounds inflicted by the surgeon and  their results.
  Toxicants operate upon the surface with  and without the produc-
tion of traumatism.  Thus the worker  in dyes and  the  wearer of
the dyed garment manufactured, may suffer alike; while vaccination,
when it produces  a generalized exanthem,  operates first in the wound
made by the lancet of the vaccinator.  Medicaments  used upon the
outer skin, such as mercury, croton oil, iodine, antimony, and nitrate
of silver, are capable of engendering disease ; and those which, being
swallowed, operate  as  irritants  to the inner skin or  mucous  mem-
brane, may have a similar effect.  Others being  swallowed and sub-
sequently  absorbed from the gastro-intestinal tract, produce a toxic
effect upon the skin  in  the effort  to  eliminate them.   Thus the
bromide and  iodide  of potassium, quinine,  arsenic, copaiba, and
many other articles of the materia medica, occasion  erythematous,
vesicular,  pustular, and bullous  rashes of variable persistence and
different external characteristics.
  To the class of toxicants must  be added the articles  of food and
drink, which  under  ordinary  circumstances,  and perhaps  to the
majority of individuals, serve to  nourish the body, but yet operate 
GENERAL  ETIOLOGY.
63
as poisons to the few.  Thus alcoholic drinks, shell-fish, preserved
meats, certain fruits, cheese, pickles, and many other dietary articles,
are known to originate or  aggravate pruritus, urticaria, eczema, and
acne.   Cracked wheat, Graham bread, oatmeal, and buckwheat have
been  found, in certain  susceptible individuals,  to induce pruritus,
urticaria, and occasionally decided roughness of the skin.  It should
be remembered in this connection that any  undigested or indigesti-
ble article of food may excite  similar effects at one time and not  at
another, in the same individual, the resulting difference being due to
the varying condition  of the alimentary canal.
   An important list of toxicants is furnished by the poisons either
of animal  origin or  requiring for the mature development of their
germs, culture in animal fluids or tissues.   All of  these are external
sources of disease.   None  is  known to be generated  de  novo in  the
human body.   To  this class  belong the  exanthematous  fevers,
glanders,  farcy, malignant pustule, and syphilis.  Some require trau-
matism for  their introduction  into the system ; some do not, and
some arc capable of introduction both with and without traumatism.
   This class  includes the  cutaneous disorders due to the presence of
bacteria.  In the present state of pathological science, it is impossible
to define accurately the etiological importance of the microbes which
have  been demonstrated to exist in a number of diseases of the skin.
In some,  for example, lepra, these bacteria maybe  recognized as effi-
cient  factors of the disease; in others, as, for example,  lupus vulgaris
and syphilis, the etiological  value of the bacilli  which have  been
recognized  in  tissues  affected  with these  diseases  cannot to-day  be
irrefutably demonstrated.
   Some cutaneous diseases are produced by the growth of the vege-
table parasites upon and within the skin  and hairs, and in the folli-
cles.   To this class belong  ringworm of the  scalp, beard, and skin;
tinea versicolor, and favus.
   Of the causes of diseases named, it may be said that no one of
them is necessarily productive of such effects.  The majority of men
and women  expose themselves daily to the action of light and heat,
are subjected to friction, suffer from wounds of the integument, and
come in contact with toxic agents, without exhibiting a disease of the
skin.  Often there is a marked degree of sensitiveness of the integu-
ment peculiar to the individuals who suffer, which  may exhibit itself
in several members of one family,  or exist  in one person  for but a
brief period of time.  Again, an  individual idiosyncrasy may  be
exhibited, in consequence of which  an  article, harmless to all others,
becomes to one person only a source of serious discomfort.
   The various physiological  changes of the  human body  are never
the causes of diseases of the skin, but at times furnish special oppor-
tunities for the operation of such causes.  Thus in the  rapid tissue
evolution of early life, eczema and lupus are relatively common—
carcinoma and  tinea versicolor rare.   At puberty the  hairs of the
beard of the male are liable  to the incursions of  the' trichophyton;
and  the nipple and breast of the woman  become the seat of eczema 
64
GENERAL  ETIOLOGY.
from  epiphora of milk.   The old man and the old woman may be-
come  the victims of cancer, aggravated forms  of pruritus, and horny
growths.  Dentition,  menstruation,  pregnancy, and  the menopause
disturb the physiological equilibrium, aud at times render the access
of other disturbing forces exceptionally facile.  The sexual appetite
leads  to excesses which bear fruit in  attacks of herpes, pruritus, and
syphilis.  And the unceasing excretion from the  skin  surface,  with
constant deposit there of effete material, may, when there  is prolonged
disregard of the  laws of cleanliness, induce a liability to disease of the
skin,  which is especially marked in the case of infants and children.
  The power to transmit skin disease by heredity is of less  impor-
tance  than  is generally supposed.   It is most conspicuous in  the in-
stances of hereditary syphilis;  but even here the transmission of the
disease is not without singular exceptions, and is limited to certain
periods of the disease in the progenitors.   The transmitted disease is
also most common  in the  foetus, which is in direct  communication
with  the  mother,  and rapidly  diminishes in frequency with every
month of separate  existence, till late and very late instances of hered-
itary  syphilis have come to be received with suspicion.   Many of the
examples cited of  hereditary transmission of cutaneous  diseases are,
without  doubt, cases of coincidence, which, considering  the number
of patients affected annually with eczema and psoriasis  for example,
should not be regarded as of very rare occurrence.
  The list of causes recognized as directly productive of diseases  of
the skin are, without question, under special circumstances, capable
of  operating as indirect  etiological factors.   Temperature changes,
contacts with the external world in all harmful degrees, and toxicants
are prime agents in the production of diseases of internal organs; and
these, in turn, may induce changes in the skin, of the nature of disease.
The uterus, the  stomach, the liver, the kidney, the heart, the nervous
centres, and the  intestinal tract may become disordered, and the result
be declared not  only in disturbance  of the function of  these  organs,
but in an attack of urticaria, pruritus, jaundice, or erythema.
   Without attempting  to decide whether the preponderance of evi-
dence is in favor of internal or external causes as productive of the
greater number of cutaneous maladies, it is certain that disorders of
the digestive tract sustain to many of them a most important relation.
Thus the several conditions included under the  somewhat indefinite
term  " dyspepsia," habitual constipation due to torpor of the intestinal
tract, a portal circulation  impeded  by functioual disturbance of  the
liver, and many other affections of the alimentary canal may  each be
productive of cutaneous  accidents or complicate the results of  the
latter.  In  the  same proportion, diseases of the kidncvs,  suprarenal
capsules, spleen, and  generative organs of both sexes may induce  or
be  complicated by diseases of the skin.
   The influence of the nervous system, when considered in this con-
nection, may be  either directly or indirectly exerted.  There is  scarcely
any efflorescence upon the surface of the integument, the arrangement
of whose lesion is not in part determined by the nervous fibres wdiether 
GENERAL ETIOLOGY.
65
with or without the intervention of an effect upon the bloodvessels.
Both  vaso-motor and trophic nerve-fibres are capable of inducing
skin changes  either after direct lesion or stimulation of the nervous
centres, or through the medium of the latter after peripheral acci-
dents of the  same kind.  Passive congestions of the surface, leading
to oedema and violaceous blush of the skin, often  result from circu-
latory changes;  and, in  fine, any constitutional disease, by impairing
general nutrition, arresting repair,  hastening waste, or in other direc-
tions impoverishing the protoplasm of the body, is capable of inducing
disorder in the skin as  in other organs.   Thus in cancer, chlorosis,
amemia, and  cholera there are significant alterations  in  the hue of
the integument which not merely  possess a diagnostic value for the
clinician, but attest the sympathetic unity of each  organ of the body
with all others.
   There are  authors who affirm, with eminent French dermatologists,
that certain states  or diatheses explain the origin of many cutaneous
maladies.  These diatheses, whether termed "arthritic," "dartrous,"
"lithsemic,"  or "herpetic," cannot  be demonstrated as efficient causes
for the production  of the diseases attributed to them.  The chief ex-
ponents of these opinions are not agreed among themselves as to the
names of such supposed systemic conditions, nor as to the symptoms
by which they are  betrayed, nor as to  the  exact method of combating
their effects.   The claim that these states  are of a nature analogous
to the tuberculous  or syphilitic diathesis, is to-day well nigh deprived
of foundation, since the bacterial origin of tuberculosis and syphilis
is at least on the road to demonstration.  The complexus of symptoms
characterized by evolution without demonstrable cause, by frequency
of recurrence, by obstinacy under treatment, and  by  alternation of
cutaneous with other maladies, is no proof of a diathesis, but rather
of the  failure of science to appreciate  perfectly all the several condi-
tions which produce the result.   As to the group of phenomena well
described by Dr. Da Costa1 as characteristic of litlnemia, even  with
the fullest recognition of such conditions the cutaneous symptoms
displayed by  those who are the subjects of that state are neither con-
stant, 'uniform, nor peculiar.   While  no wise physician would  hesi-
tate to treat patients for the relief of such  states when there was coin-
cidence of skin disease,  he would not be, therefore,  justified,  even
after  coincident relief  of the entire group of symptoms of disease,
in attributing one part of this group to  a constant association with
the others in  the case of all patients.
   Without attempting fully to discuss or  to settle these questions, it
is necessary to establish the fact that the eruptive phenomena  in any
skin are produced  by a  multitude of ever-shifting and varying com-
binations of  causes.  Even the syphilodermata are influenced from
hour to hour by drugs swallowed,  by  external irritants, and  by con-
ditions of the general health, such as a transitory diarrhoea, or  a fit
of coughing.  In the light of our present knowledge, it  is  the part

   i The Nervous Svinptoms of Lithremia.  American Journal of the Medical Sciences, p. 313, 1881.
                                5 
66
GENERAL  DIAGNOSIS.
of the physician, on the one hand, to neglect consideration of no effi-
cient factor in the origin or evolution of a cutaneous disorder; and,
on the other hand, to refuse to assign to a diathetic state only a group
of symptoms which may occur  iu  persons  where no  such systemic
condition can account for the evidences of disease.
                              IV.

                GENERAL DIAGNOSIS.

  The establishment of an accurate diagnosis in cutaneous diseases is
essential to their successful management.  This statement is rendered
necessary in this connection by the  prevalence of a belief among the
uneducated that the disorders of the skin, exhibited for the most part
in visible  symptoms, can be  safely  treated  on general principles,
without a recognition of the nature of the malady.   By many prac-
titioners the demand  for an  accurate diagnosis is ignored  in  conse-
quence of a too general impression that the desired end  is  to be
pursued through great and perplexing obscurity.   Yet with patience,
method, a habit of careful  observation (without which no physician
is successful), and  a  reasonable degree of skill, both  the practitioner
and  student  can,  in  the large proportion  of all cases, attain their
purpose.
  It is a popular error that the sole requisite for establishing a diag-
nosis is the exhibition of the  affected  portion of the integument  to
the eye of him who is consulted with a view to its relief.  The phy-
sician is supposed to inspect this surface attentively for a few moments,
and  then  to  pronounce definitely upon the  nature of the disease
present, and the therapeutic measures to be adopted.  But far more
than this is  requisite, and, indeed, fully as essential here  as  in  the
investigation of disease involving any other organ of the body.
   It is first necessary to secure a history of the physical and mental
condition of the patient in the past ;  then should  follow the  special
history of the disorders of the skin  ; lastly, an examination  of the
affected integument.   For the  purpose of methodically arriving at
these facts, and of preserving them for future reference, thev  should
be  systematically  recorded.  The  following are some of the  points
 upou  which it will generally be found useful to secure information :
   The name, residence, age, sex, occupation, and married or unmarried
 state of the patient should  be known, as also, whenever practicable,
 the  health-history of parents and children.   In the case of women it
 is not only necessary to learn the history of the menstrual function in 
GENERAL  DIAGNOSIS.
67
the past, but of the  highest  importance to be  informed as to  the
previous occurrence of abortions and miscarriages, and, if such have
occurred, the order obserxed by  these with relation to the birth of
viable infants.   The significance and value of several  of these facts
have been described in the chapter on etiology.   With respect to the
history of the products of conception, it should never  be forgotten that
these  have a most important bearing upon  the question of syphilitic
infection; and  the  absolute exclusion of syphilis in any obscure case
is a long step in the direction of an accurate diagnosis.  In the case
of male  patients, questions will  usually elicit  either admission  or
denial of the fact of a precedent or present venereal disease, and the
answers should be  regarded as valueless or trustworthy according as
they are or are not substantiated  by corroborative clinical facts.
   Then should follow some record of the habits of the patient, as to
active or  sedentary employment,  bathing, food, and  drink, including
under the latter term the use of beer, wine, and  spirits.  The history
of any previous disorders, whether of the skin or other organs, should
be satisfactorily  clear ; and, with respect to  the latter, the dates of
occurrence, recurrence, and  convalescence be at least  approximately
discovered.  The patient should also  make  known whether he  has
had  refreshing sleep; whether he  has undergone   mental  anxieties
(domestic, financial, etc.) ; whether he has suffered  in his digestive,
respiratory, circulatory, genito-urinary, or nervous system.
   This much ascertained, the patient should be encouraged to narrate
as succinctly as possible, and as far as may be in his own  terms, the
history of the  present cutaneous disorder.  He  should give the sub-
jective sensations  it  has produced, as  also  the  objective  features
presented to his own vision and  touch.  In the case of infants  this
information  will, of  course, have to be obtained from  the mother or
nurse.  The treatment to which the disease has  been subjected should
then be detailed.   This frequently furnishes a  key alike to the diag-
nosis and therapy of the disorder.  In an incredibly large proportion
of all cases, ignorautly directed and vicious internal or  external medi-
cation has either  begotten  or aggravated the disease  of the skin.
This much ascertained, the physician is ready to examine the affected
surface for himself.
   During, however, the  verbal interrogations which are required for
this part of  the exploration of the case, the watchful  and observant
practitioner  will   probably have secured  for  himself some useful
information  of which  the patient is  totally  unconscious.   Much of
this is difficult to describe, as it is the rich  fruit of a wide experience
and  careful  scrutiny.  With a  gentle, courteous, and sympathizing
manner, the  diagnostician must combine the art  of a  detective and the
skill  of a  swordsman.  Glancing occasionally at  the face of his
patient while making record of the answers given, he  will, of course,
have observed  any eruption upon that portion of the body.   He  will
have made a mental  note of the  temperament of the sufferer, or  any
movement made by the latter indicating a  tendency  to scratch or rub
anv  portion  of the skin.   He will have noticed the  posture, clothing, 
68
GENERAL  DIAGNOSIS.
and head apparel;  the  existence of hair on  the scalp or  extensive
baldness ; the condition  of the exposed hands, as indicating  manual
labor or the reverse ;  and, in the absence of facial  lesions, will have
observed  the general tint of  the skin of the face,  as indicating
anaemia, chlorosis,  or a  general  condition  of cachexia.  The  facial
expression, as indicative of anxiety or placidity, habits  of debauch,
sexual excesses,  etc., will not have escaped his  attention.   All this
and much more will have possibly enabled the questioner to direct his
interrogatories into the  channel where  they would elicit  the most
useful responses.  The posture, cries, facial expression, and  general
condition of nutrition of the infant will have been no  less carefully
noted.
  Proceeding to the examination of the affected integument, the phy-
sician must assure himself of a good  light,  as colors are best distin-
guished by  daylight, and  artificial illumination should  be reserved
for exploration of the  cavities of the  body.  The air  of the apart-
ment should be sufficiently warm to permit  of exposure of the person
without discomfort.  Adult males and children of both sexes should
have the clothing completely removed, so that all portions of the skin
may be inspected.   One  portion of the body may, however, be exam-
ined,  and then recovered, if desired, while the examiner proceeds  to
direct his attention  to another.  In the  case  of women  the  investi-
gation should be conducted with all the  tact and delicacy  to which
the sex is entitled.
  The  examination, whenever practicable,  should  extend over the
entire surface of the integument.  The importance of this point can
scarcely be exaggerated.   It  must be  remembered that  the  physician
should  be very much wiser than his patient, and  the  assurances  of
the latter are always to be  accepted with  reserve.   Thus, one who
exposes his leg merely, stating that this is the  only part of his body
affected,  may have  concealed beneath his  clothing  extensive  vari-
cosities of the veins of the thigh, a typical syphilitic exanthem over
the belly, a  significant scar on his elbow, an extensive patch of tinea
versicolor on the surface of the chest, or a blennorrhagic  discharge
from  the urethra, the medication of which has induced  the rash  for
which he seeks relief.  These are not the rare, but the  common cases
of a daily experience.
  Observation should be had at this time of the general and special
features of the eruption.   As to the former, the following consider-
ations should be borne in mind :
  A  symmetrical eruption,  one  equally distributed over  the two
lateral halves of the body, is rarely the result of an etiological factor
operating upon the outer skin.  It more often points to an  efficient
cause of so-called internal origin, one influencing  the  inner  skin  or
the internal organs.  An eruption affecting the  covered  integument,
never creeping out  upon the  exposed  surfaces, suggests the operation
of the clothing; as the latter may chance to prove the nidus  or pro-
tector of a parasite, the  fabric which has been  colored  by a noxious
dye, the recipient of a chemically altered secretion, which has proved 
GENERAL DIAGNOSIS.
69
irritating to the surface, the instrument  of friction, or the source  of
increased temperature at the surface  by  its non-conductivity of heat
and unseasonable thickness.  An eruption, accompanied by excoria-
tions and scratch-lines,  is that usually most severe in the parts most
accessible to the hands,  and least developed where the latter have the
least play, as over some parts of the  back.  An eruption  limited  to
the hands is likely to be one induced by an agent to which the hands
alone have  been  exposed, as those originating  in  the trades and
domestic occupations;  while in  the latter, an eruption more distinct
on the right hand, and  especially about  the right  thumb  and  index
finger, tells its  own story when the hand-worker is not ambidextrous
or left-handed.  Artificially and intentionally produced eruptions, as
in malingering, hysteria, mental depravity and insanity, usually occur
also iu parts to which the  right hand finds easy access.
   Eruptions occurring on  the  face, hands, and genitalia  of  men,  or
face, hands,  and mammae of women,  point to external contact  or
contagion (poison-ivy, scabies, croton-oil, etc.); since, next  to the face,
the hands are more commonly brought in contact with the parts named
in the sexes respectively, as the wearing apparel of each suggests.
   An eruption, limited to  the forehead,  suggests au inspection of the
hat-band, the veil, or the overlying false hair; to the ears of women,
a  glimpse at  possibly cheap  ear-rings;  to the  centre of the root  of
the neck, before or behind, a  scrutiny of the collar-buttons and
collars; to  the anus of the baby, an inquiry as  to  the changing of
its napkins; to the wrists of the adult, a question  as to the cuffs
worn;  to  the feet, information respecting  gaiters,  varicose  veins,
recently cut corns, and  ill-fitting shoes.  Eruptions  springing from
each of these causes have  been  long and vainly treated as "diseases
of the blood."
   Eruptions markedly  asymmetrical are indicative of asymmetrically
operating causes—that  is,  the accidents of environment, or else influ-
ences exerted  within the  body unequally on its two lateral halves.
Thus an  orthopaedic apparatus, worn to correct talipes, excites  an
eczema in the leg only  of the affected side; and zoster of the trunk is
evident on that side supplied by the intercostal  nerve  which has been
inflamed.   The greater stress may be  laid on this peculiarity, as the
law of symmetry, in eruptions not occasioned by causes operating  on
the outer skin, is faithfully observed in nature.  The earlier syphil-
ids, the quinine exanthem, rubeola,  and  even  lupus erythematosus,
are remarkable illustrations of this fact.
   Proceeding  next  to  the special visible characteristics of the erup-
tion, the physician will not fail  to note  an acuteness  or chronicity of
lesions; their color, size, distribution, tendency  to become aggregated
in patches,  or  the reverse; and  the evidence presented as  to  change
in type, the sequence or  coexistence of several lesions at the same
time"—that is, the multiformity (polymorphism) or uniformity of the
eruption.   He will  observe whether  the limit of the  affected  skin is
well defiued against that which is normal, or scarcely to be outlined 
70
GENERAL  DIAGNOSIS.
with a pen  or  pencil.  He will rupture a bleb, pustule, or vesicle,
should such be found, to discover the nature of its contents.  He will
remove one  or several crusts in sight, to expose the surface on which
they rest.  He will  remove a few scales with the dermal curette  for
a similar reason.  He will as carefully inspect  the  skin where  the
disease has  existed,  as that where it does exist.   He will  pinch up
between  his thumb  and finger a portion of each, in order to deter-
mine its infiltrated  condition; its  atrophy; or its attachment to  the
tissues beneath.  He will pass his hands over the surface to recognize
the firmness or softness of the lesions, their dryness or moisture, and
the existence of sebaceous or perspiratory secretion.   He  will look at
the mouths of the follicles, where such secretion  is retained or abun-
dantly exuded.  He will discover any lice or ova on the hair; any
ascarides at play about  the anus; any unnatural formation  of  the
nail, or deformity of its matrix.  He will examine for inguinal, post-
cervical, axillary, and epitrochlear adenopathy, and will thus be often
greatly aided in his task.   This done, he will question in turn  for
himself, and by the methods recognized iu medical science, the organs
of the body other than  the skin.   He will inspect the tongue care-
fully, and then, if he is through with the mouth, he will be guilty of
great error.   The gums rarely deceive the questioning eye;  the inside
of the lips, fauces, and tonsils  are all to be searched.  A mucous patch
here will  often echo the story of a palmar or plantar syphiloderm.
The laryngoscope may be called  for  in  syphilis, cancer, lupus, and
leprosy.   The degree of distention  of the belly and the  region of
hepatic dulness should not be  overlooked.   The genitalia of men,
and of children and infants, can usually be explored.   For women
unaffected with syphilis or disease limited to these parts, an exception
in this particular should usually be made.
   With the necessary reserve  of all very obscure cases, it may be said
that the physician who has conscientiously conducted an examination
after the manner described above, is in  possession of the diagnosis
for which he seeks.   If the facts thus acquired have been properly
recorded, and yet do not spell out such a diagnosis to  his  eyes, they
are probably legible to others with a wider experience or riper judg-
ment, to whom such a record is shown.   It is not claimed that this
exhaustive method of examination is requisite in every case, as, for
example, in order to recognize  an acne or to differentiate  erysipelas
from erythema.  But it is certain that few obscure cases of skin  dis-
ease will remain such under severe scrutiny, and  the establishment of
a  thorough and  exhaustive method of examination  is important in
the earliest experience with disease.   Let the student or practitioner
conduct  such an examination in the first few cases of eruption upon
the surface  of the body  for which his  advice  is sought, and he will
establish a habit of  observation in comparison with which his pecu-
niary or professional success  in the  management of  the  same cases
will be indeed of trivial worth.
   Upon one special point should the inexperienced physician be
guarded.   It relates to  the acceptance of a diagnosis which is  not 
GENERAL  PROGNOSIS.
71
based upon such an examination as that given in outline above.   A
diagnosis by a patient is usually faulty, and the verdict of even skilled
practitioners may be founded  upon an error.   The careful diagnos-
tician should  commence his  task in a spirit of scepticism, and pro-
nounce definitely only upon ascertained facts.  The man who says he
has an " eczema " may be louse-bitten; the woman who has been " over-
heated" may  prove  syphilitic.  The patient recognized as suffering
from  ringworm of the beard may  not have been infected under the
hands of the barber.   Finally, the eruptions upon patients unmistak-
ably syphilitic,  are often of  other  than  syphilitic origin.  They are
men,  women,  and children exposed daily to the accidents from which
the non-infected suffer.   They exhibit acne,  physiological alopecia,
and dermatitis  medicamentosa equally with  those  who have  not
sinned sexually.
   The microscope is an instrument whose  aid in establishing a diag-
nosis of cutaneous disease can rarely be dispensed with.  The con-
tributions it  has made to the knowledge had on  the subject of path-
ology are of  inestimable value; and  as  a  means of diagnosis it can
be used with  advantage both at the time  of the first examination of
a patient, and afterward for the more leisurely examination of hairs,
scales, crusts,  or portions of tissue.   Those unable to secure the cost-
lier and elaborate instruments sold by the  makers, should take pains
to provide themselves with a fairly good student's stand, and a fifth
and half inch objective for use in the diagnosis of skin diseases.
   The diagnosis of  special diseases  of the skin  is described in the
chapter devoted to each.
                               Y.

                GENERAL  PROGNOSIS.

  The prognosis of most diseases of the human body is formulated
with a view to the decision of the serious question of life or death.
Occasionally this  question arises  in  connection with skin  diseases.
Many of the latter are trivial; some are grave; a few, inevitably fatal
in their termination.   Thus general  exfoliative dermatitis, leprosy,
sarcoma, carcinoma, at times lichen ruber, and variola in the unpro-
tected, are of grave portent;  while the ordinary congestions and exu-
dations, the great majority of all cases of acquired syphilis in adults,
and the entirely curable diseases  induced by parasites do not excite
alarm iu the breast of the average patient with respect to his longevity.
  The questions, however, as to his future, which are urgently pressed
by the victim of cutaneous disease, are both numerous and important, 
72
GENERAL  PROGNOSIS.
He is anxious as to the time during which he must suffer; as to the
possibility of conveying his disease to his progeny or other members of
his family;  as to the disfigurement of his person which might result;
as to the scars which he may have  to carry for  the remainder of his
life; as to the possible recurrences of his malady iu the future.   The
responses to these questions will be largely influenced by the prog-
nosis of the physician.
   Some diseases of  the skin are acute, rapidly pursue their  course,
and are then prompt to disappear.  Others are  chronic, rebellious to
treatment of the most energetic and skilful character.  Others, again,
though not shortening life, are never relieved while life is continued.
Some disappear, only to reappear at more or  less  regular intervals.
There  are cutaueous diseases which affect one individual  but once in
his lifetime; others which reappear at the instant the patient is again
exposed to their exciting cause.   There are cutaneous diseases so dis-
torting and  destructive in their  effects,  that their victims have com-
mitted suicide under the influence of the morbid emotions which they
have as a consequence experienced.
   The mental distress  occasioned by even an  insignificant cutaneous
disorder is often out of all proportion to its exciting  cause; and this
should always be regarded  in establishing a prognosis.   The  sexual
hypochondriac  has  been made insane by an acne; and the man or
woman affected with syphilis has been made wretched for years by a
recurrent erythema.
   Again, a  disease of the skin may coexist with grave lesions  of in-
ternal  organs, and the  prognosis of the  disease of the one be great lv
influenced by that demanded by the other.  Thus there is occasional
coexistence of syphilis and phthisis.  Pruritus may be associated with
Bright's disease of the  kidneys;  and the eczema  of an infant starving
for want of breast-milk may hasten its marasmus to a fatal termination.
   Upon the answers given to his patient inquiring as to the prog-
nosis of the disease of the latter, will largely depend  the  professional
success of the physician.   Scrupulous honesty should be here welded
with all the skill that science can command.  That a disease does not
endanger  life, is not an argument in favor of its amenability to treat-
ment.   The practitioner should never suffer himself to be pushed bv
his patient to the position that an obstinate disease is readily manage-
able.   It is the height of  folly  to estimate lightly that zoster of the
forehead,  the scars of which the  patient will exhibit to all who after-
ward look upon his  face both in life and death.   He who engages to
relieve an alopecia areata in the  month, may have a year  in which to
repent his precipitancy.  There  is no way in which the conscientious
physician can so readily secure the confidence of his patient, and with
it that willingness to submit to  appropriate treatment, which  is be-
gotten  of  such confidence, as by demonstrating his ability to forecast
the future of a disease; in  other  words, to  describe accurately its
prognosis. 
GENERAL THERAPEUTICS.
7a
                               VI.

             GENERAL THERAPEUTICS.

   A consideration of the subject of the methods of treating skin
diseases in general, suggests at  once the intimate relation which sub-
sists between the integument and other organs of the body.  The
etiology of one, largely explains the causes of the disorders in all.
The pathological  processes  in  each are  subordinated  to the  same
general laws.  The principles  of treatment are very similar, in all
the disorders of the body.
   The object to be attained by treating a cutaneous disease is, first,
its complete relief; second, where  the latter is  impossible, such a
management of the morbid  process as will mitigate its severity and
render the victim of the disease more comfortable.   A higher and
more scientific achievement than either is the prophylaxis by which
man is enabled to escape the disease altogether.  He can by his wis-
dom largely  diminish the danger to which his integument is exposed.
He can, to a certain extent, shelter himself from extremes of tem-
perature,  traumatism, toxic agents, and the contagious  diseases.  He
can, by observing the simple rules of hygiene, fortify his skin against
the lesser evils which may befall it.   If it be true that "the people
perish for the want of knowledge,"  it is certain that once in posses-
sion of it, they can  greatly enhance their comfort and prolong exist-
ence.   Here, however, the subject under consideration involves dis-
ease which is actually present and in progress.
   Like all other diseases of the body, those of the skin may be divided
into three classes with relatively fixed limits.
   The first  embraces all the diseases which have a natural tendency
to pursue their  course to a favorable termination.  It embraces  all
those affections which,  either mild  or severe, require  absolutely no
treatment of an active character.  It is the duty of the skilful phy-
sician to watch the evolution of these  maladies, and to discharge a
most  important part  by refraining from  all  therapeutic measures
which in  such cases  might prove hurtful.  By his judicious counsel
also, he hinders patients and their  friends from pursuing a course
which might prove prejudicial to the disease.
   The second class embraces all those affections of the skin which
are either inevitably fatal or hopelessly remediless while life is pro-
longed.  Fortunately, this includes but a small proportion of the large
list.   Here the duty of the physician  is  plain.   He should assuage
pain, attempt to  relieve deformity,  administer to the comfort of the
afflicted in other ways, and, by his patient courage, inspire confidence
and hope.  It must not be forgotten  that the skill of man has not 
74
general  therapeutics.
yet reached the acme  of human  need.   In the presence of many
diseases of the body, he stands absolutely helpless; and the spee<best
way to success in such cases is to begin by an honest admission of the
plain  fact.
  The third class of affections naturally embraces all not included in
the other two.  Here disease may be prolonged or shortened iu its
course, rendered acute  or chronic, made more or less endurable, per-
mitted to become inveterate, or be absolutely relieved, by prompt and
energetic measures, according as it is, or is not, judiciously and skil-
fully  managed.  Here  are gained  the most brilliant successes of the
dermatologist;  here also occur his  most humiliating failures.
  In  the  presence of a cutaneous  disease which requires  treatment,
a question naturally arises as to whether this treatment shall  be in-
ternal, that is, by medicaments ingested;  or external, that  is, by local
therapeusis; or by combination of the two methods at the  same time.
  With regard to the first question (concerning the Internal treat-
ment  of skin affections), which is  one of pressing importance, it can
be safely said that there are  no remedies  to  be given by  the  mouth
which can  be described as certainly and  specifically curative of the
diseases of the skin.  The number  of medicinal agents employed
with this  end in view  is incredibly large, by  far  the greater  part
being obtained from the vegetable kingdom.   With few  exceptions,
for the most part enumerated  below, the most esteemed of  these exert
only  an indirect  therapeutical  effect  upon  the integument.   The
larger number of medicaments  thus used are, it must be admitted,
without  value of  any  kind,  but  will  probably  continue  to  be
vaunted as possessing specific virtues so long as credulity  on  the one
hand, and avarice on the other, move the mass of mankind.
  Arsenic has long stood at  the head of the list of remedies  as
valuable, when ingested, for the relief of cutaneous disorders.  It is
known  to  exert its  effects almost exclusively upon  the epithelia  of
the skin, and upon these, so  far as therapeutic effects are concerned,
only when they are  in indolent conditions of subacute and  chronic
exudation.   It is known to exert  an unfavorable influence upon the
epidermis when the  latter  is in  a  condition of active  inflammation.
Operating  in this limited  class of cases  favorably, it also  operates
slowly, requiring months for the  production of its curative effects.
Its administration is at all times  attended with the hazard  of pro-
ducing toxic  effects, which, however, when the result of the  exhibi-
tion of the drug in  medicinal  doses, are  usually limited  to  a mild
exanthem upon the  skin, moderate  coryza, and some redness from
congestion of the vessels iu the eyes and eyelids.
  It is  used  chiefly in psoriasis, acne, squamous eczema, pemphigus,
and lichen ruber; its dosage in cases of children being relatively large.
It should be invariably administered only after eating, and  a mini-
mum  dose be first employed  in order to test the susceptibility of the
patient to its action.  It should be remembered that the  toxic effect
of this, as also of several of the other drugs mentioned below, is
often  speedily noticed  after the first  exhibition of a relatively small 
GENERAL THERAPEUTICS.                75
dose.  Toleration once  established, the  dosage may be  cautiously
increased.
   The  forms  in  which  it is usually administered are the prepara-
tions of arsenious acid, such as the liquor potassii arsenitis (Fowler's
solution);  the liquor arsenici et hydragyri  iodidi (Donovan's solu-
tion); the liquor arsenici chloridi;  and the Asiatic pill.   Duhring's
modification of this pill is obtained by making two  grains (0.13) of
arsenious acid, and  thirty-two grains (2.2) each of black pepper and
liquorice powder,  into  thirty-two  pills by  the aid  of a  sufficient
quantity of mucilage.  Arsenic is also at times advantageously com-
bined with other indicated medicinal substances, such as iron and the
iodide of potassium.
   in the first edition of this treatise, it was stated that an unpreju-
diced view of its  action, even in  cases  properly selected  for its in-
ternal administration, would  justify the conclusion that arsenic  is in
diseases of the skin a  remedy  of uncertain effect,  and, in  that
proportion, disappointing.   Subsequent  investigation, made particu-
larly by American observers, has more than  established this position.
Dr. G. H. Fox, of New York,1 after collation  of the  experience of
a  number  of experts in this country  concluded  that the common
practice of giving arsenic  in  many cutaneous diseases   was both
harmful and  irrational,  not  merely because of its effect in inducing
cutaneous  congestion and pruritus,  but because.1 of the reliance  placed
upon it  to the exclusion  of other  and better methods of treatment;
and that the  beneficial effects  supposed to follow its administration
were often due to other causes.   He  also  called attention  to the
striking fact that no series of carefully recorded eases had ever been
published  in which notable  therapeutical results had been shown to
result solely from its administration.
   These  conclusions elicited a number of statements from  well-
known physicians having experience in the management of cutaneous
diseases, who, for  the most  part, assented to Dr. Fox's conclusions.
Even in pemphigus, psoriasis, chronic  eczema, and lichen  ruber,
where the  remedy has been thought to possess  special efficacy, it has
in cases conspicuously failed.
   It is safest to conclude, first, that arsenic, instead of  being one of the
earliest, should be one of the last remedies selected in the management
of cutaneous  diseases by  the general practitioner; second, that, when
thus  selected, its value will  probably prove  greatest if the eruptive
lesion be  superficially seated,  generalized,  diffused, or  in evident
association with neurotic symptoms; third, that in any case its failure
should not be regarded as definite, if only Fowler's solution has been
administered.

   The value of Mercury in the syphilodermata is incontestable, and
its injudicious employment in many cases springs  from that precise
fact.   The vulgar  prejudice  that many  disorders of  the skin, really
not syphilitic, are obscure manifestations of lues iu a preceding  gen-
i Journal of Cutaneous and Venereal Diseases.  June, 1886, p. 179. 
76
GENERAL  THERAPEUTICS.
eration, and amenable  to  mercurial treatment, is a striking illustra-
tion  of the necessity  of  accurate  diagnosis  in  cutaneous  diseases.
Few non-syphilitic affections are  benefited by continuous  courses  of
mercury,  though  the  value of the  metal as an  alterative in  this
small proportion  of cases must  be admitted.  The  corrosive sub-
limate is  often  superseded,  in consequence  of its irritative effects,
by the  compounds  of the  metal with iodine.  The gray powder is
useful  chiefly in  case of infants and children, though its not. infre-
quent development of the corrosive chloride has  largely limited its
favor with Americans.  Calomel and the mercurial  pill  should be
employed only for transient effect, as, when administered  for long
periods, they are much more apt to produce  ptyalism  than the other
preparations mentioned.

  Iodine and its compounds are also chiefly used by  the dermatolo-
gist  in  syphilitic disorders  of the  skin,  but they possess a wider
range  of value  than  the  mercurials in  the treatment  of other
cutaneous affections.  Here, too, the abuse  of the drug furnishes a
long  list  of cutaneous disorders either  originated or aggravated by
its  employment.  As  in the  use  of arsenic, toleration  should be
established before large doses are exhibited.  ' The compounds chiefly
used  are the iodides of potassium, sodium, lithium, and ammonium,
and iodoform.   It has been administered for the relief of the scrofulo-
dermata, lupus,  keloid, and syphilitic  affections of the skin.  As  to
the latter it may be added  that in the  earlier symptoms of lues it
is often a source of  positive injury.

   Cod-liver Oil is a remedy of special value in diseases of the skin,
and  was  for  that reason  held in  high favor by the distinguished
Hebra, though its action  is almost exclusively that of a  nutrient of
the general system.   It  is  employed  chiefly for  its roborant effects,
and  these  are  similar to  those  of  the  digestible   aliments.   Its
special value  in  the treatment  of  infants and children affected with
cutaneous  diseases cannot be  questioned.   It is,  however, of great
use also in maturer years, and is advantageously exhibited in eczema,
lupus, scrofula, syphiiis, scleroderma, and in  all  the disorders of the
integument accompanied by wasting.

   Quinine, administered both as a tonic and antiperiodic, is largely
employed in cutaneous medicine for its generally recognized systemic
effects.   It  produces,  in  certain susceptible  individuals,  a peculiar
smoothness and  softness  of the skin, which usually disappear  when
the drug  is suspended.   Like arsenic  and iodine, it  is occasionally
the cause  of  a  generalized exanthem, and  is capable of producing
other toxic  effects, such as failure of the heart's action, dizziness, and
tinnitus aurium, symptoms recognized under the designation of cin-
chonism.   It will, of  course, exhibit its happiest  effects  in malarial
affections with  coincidence  of cutaneous symptoms in the forms of
disease of the skin associated with  a neurosis. 
GENERAL  THERAPEUTICS.
77
   Ergot, whether by exerting an effect upon the muscle-bundles or
vessels of the derma, or upon the uterus, or yet by its influence upon
the general  economy, is thought to possess some value in the treat-
ment of several cutaneous diseases occurring in both  sexes.  Such are
acne, purpura, and a few other disorders.

   Calx Sulphurata may be regarded as the most efficient of the
sulphur compounds for internal use in cutaueous diseases.   Its recog-
nized value iu furunculosis  has  led  to  its employment  also  in
eczema, acne, and  impetigo.   It is given in doses of from one-tenth
(0.004) to one-fourth (0.016) of a  grain, three  or  four times daily.
Chrvsarobin has  been  administered   internally  by Stocquart1 and
others in doses of one-sixth  (0.01) of a grain  for a  number  of
cutaneous disorders.  Ichthyol, mentioned  later as of  some value
when  externally  employed, has also  been given  by  the mouth.
Jaborandi and Pilocarpine, probably as the result of the free dia-
phoresis which  they excite, have  unquestionably exerted immediate
therapeutical effects in a number of cutaueous disorders.

   Tar, Carbolic Acid, and Phosphorus are remedies  which have
been employed internally with appreciable effect  in certain cutaneous
maladies, but the action of each is uncertain, and at times highly preju-
dicial.  They have  been  used with  advantage  in  cases of lupus,
eczema, psoriasis,  and pruritus ; but their internal administration has
been to  a  great degree a bar to their general  employment.   The
" perles" of phosphorus, and the elegant  elixirs of the same drug now
in the market, seem to have obviated this difficulty in the instance of
at least one of these articles.

   Unpromising as  is confessedly this brief review of the remedial
influence which  internal medicaments are capable of  directly exerting
upon the skin, it  must  not be forgotten that, while the treatment of
the patient and  the treatment of the  patient's skin are practically one,
there is some distinction to  be drawn between them.  No one would
claim that castor oil, for example, possessed any efficacy  in the frac-
ture of a femur, yet such a  cathartic is  frequently ordered  by the
surgeon, with the  happiest effect upon the condition of his patient in
a splint.  Such precisely is the inestimable value of a properly con-
ducted internal medication in cases of cutaneous disease.
   The consideration of this point introduces us at once and properly
to the broad field of general medicine.  He is  totally unfit to treat
cutaneous diseases who  is not qualified by education and experience
for the general practice of medicine.   The internal  treatment of the
patient suffering from a disease of the skin, is that  which is in each
case indicated by  his general condition.   Thus the aperients, cathar-
tics, diuretics, and  occasionally even  the  anodynes, are demanded,
and, when judiciously employed, accomplish beneficial results.   Few
i Ann. de Derm, et de Syph. 1884. 
78
general  therapeutics.
practitioners can afford to dispense with the use of the  preparations
of iron, for example, in cases of amemia.  Even the patient affected
with a parasitic disease may need  one of the bitter  tonics, and the
youth with vegetations upon the glans may require first to be rid of
his blennorrhagia.
  Among the medicinal substances indicated by the general condition
of the patient affected with a disease  of the skin yet  not directly
acting  upon  that organ, none  are more useful  than the  diuretics,
cathartics, and remedies  acting as stimulants to the secretions of the
chylopoetic viscera.  At this day  no educated physician believes in
employing medicines with a view to either the so-called  "driving
out" or "driving in" of a disease of the skin, much less to a use of
evacuants with a view to carrying  off a supposititious maten'cs morbi.
The remedies suggested above are undoubtedly, for the most  part,
useful  in diminishing the congestion of the cutaueous capillaries, an
important point not only with  respect to the comfort of the  patient
but to the relief of his ailment.
  He who accomplishes  the largest success will not, finally, neglect
consideration  of the diet, hygiene, and social surroundings of the
patient.  The chief value of many of the mineral springs and health
resorts of this country lies in the change  of the  manner of living
which  they  invite  and  necessitate.  Sunshine,  pure air,  recreation
after the care and  toil  of business, chauge of climate,  of foods and
drinks,  and  even of cooks, often  decide  the  question of  speedy
recovery.   Unfortunately, both in this country and abroad, many of
the health resorts  are peopled by unscrupulous charlatans, with a
myopic tendency to attribute all the benefits to be derived from  these
sources  to  the medicinal virtues  of this or that particular  spring,
aided always  by treatment according to their own peculiar methods.
Many patients affected  with disease  of the skin are thus made worse
by a temporary residence at noted  health resorts, and, therefore, it is
often the case that a  visit to the  seashore, the mountains, or any
healthful  place  in the country proves conducive to far  greater prac-
tical results.
  This uuderstood, it is admitted that many of the springs of our own
country possess  a therapeutical value in cutaneous diseases actually
dependent  upon  the constituents  of their waters.   A  new study of
this interesting  and important subject  is  demanded by the annual
discovery of  new sources within the borders of the United States,
which give a large promise for the future.  Many of those ignorantly
recommended as valuable for  the  entire list  of cutaneous disorders
are either entitled to no  such encomium or may be usefully employed
only in a limited number of  skin affections.   Large  successes are
undoubtedly  to be credited to the  scores of ferruginous,  sulphuretted,
chlorinated, alkaline, arsenical, purgative, and other springs  whose
names appear in the lists given by European writers on this subject.
Most of these are represented  in this country by waters of equal, if
not greater value, furnished by the numerous spas of Michigan, Vir-
ginia, New York, Colorado, New Mexico, Utah, and  other States and 
GENERAL  therapeutics.
79
Territories of the Union.   As these are  brought within reach of a
larger  portion  of the population of the country by greater railway
facilities, their medicinal value will be better  appreciated, and they
will be much more systematically employed than at present.  They
offer a most promising future for the internal treatment of diseases of
the skin in this country.
  In the External treatment of diseases of the skin, the indications
are, to hasten repair when  this  is possible;  to alleviate distress, if
palliatives  only are admissible; to  destroy absolutely or excise the
diseased  tissue, when this is justifiable.  The following are the prin-
cipal substances employed as external applications :
  Wati-:r, either pure or medicated by holding other substances in
solution  or mechanical  suspension,  is applied either in  baths or
lotions.  Baths, local or general, may be employed for  days contin-
uously, or  but for  a few moments at  a time.   They are given with
water  of varying temperature,  cold, warm, or  hot.  Cold baths of
short duration are generally followed by a  sharp reaction, the skin
becoming congested after the normal temperature of the surface is
regained.  Thus it is that cold sponging  of the inflamed  skin  is
usually grateful so long as it  is continued; and  is succeeded after-
ward by an aggravation of the  symptoms which it was intended to
relieve.  Continued  applications of cold water are not open to this
objection.
   Hot baths are followed by a  more  or  less enduring relaxation of
the  integument, while those  given  with  tepid  water  are chiefly
macerative of the surface.   It should be remembered that the appli-
cation of watery lotions to the broken surface of the skin, is liable to
be followed by endosmosis, unless the specific  gravity of the serum
of the blood and that of the fluid of the bath or lotion are nearly the
same.  This imbibition of  fluids by the  broken skin is accompanied
by slight  swelling of the tissues  and  productive  of  disagreeable
sensations.
   The most perfect of all  methods by which water is applied to the
surface of  the body,  is that which  most resembles the water-bath in
which the  tender skin of the foetus is safely immersed for consecutive
months.   Here the bath is continuous; the temperature, that of the
viscera of the living animal; and  the delicate skin of the unborn
child, anointed with  a fatty substance which actually interferes with
the  macerative action of the surrounding fluid so long as  vitality is
preserved  at  the average  standard.  The comfort and therapeutic
value of a bath prepared and administered iu approximation to this
ideal, can scarcely  be overestimated.  Were it not for the difficulties
with  which it is attended, so  far  as relates to many portions of the
surface of the body, it would be possible  with this single therapeutic
measure to rob the exudative affections of the skin of a  great part of
their formidable features.
   in acute inflammations of the skin, the application of pure water, 
80
general  therapeutics.
even when of proper temperature, is often prejudicial to the integu-
ment; and soap and water washings may prove quite harmful.   The
greatest cautfon must be exercised in giving instruction to patients as
to the washing of the inflamed skin.
   Water for external application, as in the bath, is medicated by the
addition of a large number of substances, such as marine  salt,  sodic
and potassic salts, alum, tannin, the mineral acids, mucilages, gelatin,
bran, and, especially in the  Southern  States of this country,  the
orange leaf.
   The alkaline bath, made by adding the bicarbonate or the biborate
of sodium to water of the proper temperature in the proportion of
twelve ounces of either salt to thirty gallons, is usually grateful to
the inflamed skin.  Sulphur baths  are best prepared by adding an
ounce of Yleminckx's solution1 to the same quantity  of water.
   When employed as a lotion, water is made to produce a sedative
effect by the  addition of opium,  belladonna, glycerine, carbolic acid,
hydrocyanic  acid, zinc,  bismuth, mercury, lead,  and the  alkaline
bicarbonates  with the sodic biborate.   It is rendered stimulating by
the admixture of alcohol,  most of the acids and alkalies in stronger
solution than in  the soothing or sedative lotions;  and  by a  large
number of substances which operate upon the surface either mechani-
cally or chemically.   It is also rendered astringent when tannin, lead,
and  similar  medicaments  are dissolved in it; and  by its  union  in
various degrees with soaps and alkalies a solvent effect is produced,
either upon the cuticle itself or upon pathological or foreign products
upon its surface.
   Water is employed also, both in the form of the douche and vapor
bath.   When evaporation is  prevented, by covering the wet surface
of the  body with  an impermeable  tissue, such as  gutta-percha or
rubber  cloth, still further macerative effect is produced.  The sweat
alone is in the same way converted into a macerating agent.
   Lotions other than those  containing water are often serviceable.
The fluid in  such case may be alcoholic, ethereal, or oleaginous, and
medicated to any desired effect.
   Soaps are of great value wheu applied to the skin.  The hard, or
soda, soaps are employed chiefly for the purposes of ablution.   The
soft, or potash, soap has a  wider  therapeutic range.   In consequence
of the  small excess of caustic potash which it contains, it not only
serves to cleanse the skin of any accumulations  upon  its surface,
native or foreign, but also  to exert a mild, destructive effect upon the
horny layer of the epidermis.   Digested with rectified spirits of wine
in the  proportion of two  parts of the  soap to one of the alcohol, it
forms the well-known " spiritus saponis kalinus" of Hebra, a prepa-
ration  which the modern  dermatologist employs   constantly  with
admirable  results.

  i The formula is:
            fy. Calcis,                Sss;            16
               Sulphur sublim.          gj;            32
               Aq. dest.               Sx;           3'20|   M.
             Coque ad gvj [200] deinde flltra.
             Sig. "Vleminckx's Solution." 
general  therapeutics.
81
  Medk a i ed Si >aps, containing carbolic acid, glycerine, tar, sulphur,
and various oils, are sold in the shops, but contain so small a portion
of the individual  medicament from which each is named, that they
are practically worthless except for purposes of ablution.  The author
has had such prepared under cold pressure, so as to contain medicinal
substances  in therapeutic proportions ;  but, after experimentation, has
concluded that other forms of administration are preferable.
  Fatty  and Oily Substances are applied to  the skin  either
directlv by pouring, or by friction, or by the mediation of compresses,
bandages, etc., which are saturated or spread with the material to be
applied.    The oils may be used for either nutritive, soothiug, or
stiniulating'effects.   To the first and second classes  belong cod-liver,
lard, olive, almond, linseed,  neat's-foot, castor,  and similar  oils ; to
the third class, the oil of tar, of cade, of white birch, of the  cashew
nut, and of juniper.
  Fatty substances are  also applied  in the form  of ointments or
pomades.   They are compounded with various medicinal substances,
according to the requirements of each case, such as  the salts  of mer-
cury, zinc,  copper, lead, and sulphur; pyrogallol, chrysarobin, carbolic
and hyposulphurous acids; tar, camphor,  iodoform, balsam of Peru,
hydrate of chloral, the extracts of opium, belladonna, etc.
  The products of petroleum  refinement, known as Vaseline and
C< >smoline, though not true fats, are increasingly employed for similar
purposes, and  continue to enjoy high favor in this country and abroad.
They are particularly useful as bases for ointments for application to
the hairy portions  of the body, such  as the  scalp,  when more con-
sistent salvo paste the hairs to the surface in an unsightly mass.
  Glycerine—even the best—is, when applied  in its purity to the
skin,  usually  irritating.    It is, however,  exceedingly useful when
diluted or  made a  component part of lotions and  ointments.   When
combined with starch it  makes, in different proportions, a series of
combinations known as glyceroles, or glycerolates.  These are pasty,
semi-solid  substances which  are capable  of varied  medication, as in
the glycerole of the subacetate of lead proposed by Dr. B.  Squire, of
London.   They are useful chiefly  as protectives  of  the  surface.
Glycerine,  when used in  a fluid soap, is an  exceedingly valuable agent
when a milder effect is desired than  that  produced  by the spirit of
soap described above.   The Vienna  preparation known  as  Sarg's
fluid soap is an admirable substitute of this sort when a soft shampoo
is required for the  scalp.
  The Pastes employed for local application in diseases of the skin
have been  greatly  perfected by Lassar and Unna.1
  These pastes are valuable especially in the exudative  affections,
where  salves  are  often  either not well tolerated or  actually prove
irritating to the skin.   The pastes, when applied  to such surfaces,
form a protective and adhesive dressing, which may be medicated as
desired.
1 Monatsh. f. prakt. Perm., February and March, 1884.
                 6 
82
general  therapeutics.
  They are prepared with kaolin [terra alba, or Armenian bole of
red color, when it  is desirable to have the application resemble the
color of the skin], gum, lead, dextrine, glycerine, and other substances.
Formula? for each are here appended :
  Kaolin in a pure state, with equal  parts of vaseline or glycerine, or
with almoud, olive, or linseed oil, in the proportion of two to one, is
readily applied in a thin layer over  the skin.  When it is desired to
add the oxide of zinc, or the plumbic acetate, the kaolin  and oil or
glycerine are first carefully mixed, in order to prevent the formation
of aii  insoluble  compound—e. g.,  R.  Kaolini  pur., ol. lini [vel
glycerini], aa 30 parts; zinci oxidi,  liq. plumb, subacetat,,  aa 20. M.
  For making lead pastes, litharge is boiled with twice the quantity
of vinegar till the latter has evaporated and a damp but drying paste
is left, which may be, on occasion, remoistened with a small quantity
of vinegar—e. g., Ty,.  Lithargyr.  subt. pulv. 50;  aceti, 80.   Coque
usque ad consistent, pastas : deinde  adde ol. lini [v. glycerini, v. ol.
olivae],  10.  M.
  In  the two  forms of  pastes above described,  the  adhesive and
desiccative  qualities are obtained  from the main ingredients, but in
those  resulting from  combinations of  gum,  starch, and dextrine,
these  results are for the most part obtained by the addition of other
ingredients, such as sulphur, zinc,  etc.    A good basis, semi-solid,
rapidly drying, and fixing its ingredients well upon the surface, is the
following:   Py,.  Amyli  oryzse,  3;  glycerini,  2;  aq. dest. 15. M.
Coque ad remanent. 15.  For convenience, the solid substances are
mixed at once with the glycerine,  starch, and water, and then heated
together.   I^j.  Zinci  oxid.  50;  acid,  salicylic  2; amyli oryzse,
glycerini, aa 15;  aq. dest. 75.  Coque ad 140.  For a sulphur paste  :
Ty,.  Sulphur,  prsecipit, 40;  calc.  carb.  2;  zinc.  oxid. 20;  amyl.
oryzse, 15; glycerini, 20; aq. dest. 75.  Coque ad 120.
  Here  is  a formula  giving a  combination of  starch and  lead re-
sembling cream :  Tfy. Amyli oryzse, 10;  glycerin. 30; lithargyr. 30;
acet. 60.  Evapora  ad  80.  By adding 10 parts more of litharge, and
20 more of vinegar, and evaporating  to 90, a thicker and cement-like
paste is formed.
  To make use of dextrine, the officinal pulverized article is  selected,
and a simple paste of this forms a good drying base.  An added half-
weight of glycerine is required if powders are also combined  with the
paste—e. g., Ty,. Zinc. oxid. 40; dextrin., aq. dest., aa 20 ; glycerin. 40 ;
sulphur, sublim.  [vel. sod. sulpho-ichthyol.] 2.   Coq.  A mixture of
dextrine and  lead  is thus prepared :   1^. Lithargyr. 30; acet. 50.
Coque ad remanent. 50; adde dextrin., aq., glycerin., aa 15.   Coque.
If too consistent, these pastes are  made to spread easily by the addi-
tion  of a few  drops of hot  water.  Such water is  not required in
making  the paste if another fluid be one of the constituents, as, 1^.
Dextrin., glycerin.,  liq. plumb, subacet,, aa 10.  M.   Coq.  ft, pasta.
  For the gum  pastes, gum arabic  is used in the proportion of one
part of mucilage and glycerine to  two of the powder selected, mixed
without  heat—e.g., Ty,.  Zinc.  oxid.  40;  hydrarg.  oxid.  rub.  2: 
general  therapeutics.
83
mucilag. acac, glycerin.,  aa 20.  M.    B.  Cret. prseparat,, sulphur.
sublim., aa 2;  picis liquid.  8;  amyli, 20; mucilag. acac, glycerin.,
aa 15. M.   It.  Acid, salicylic, 20 ; glycerin. 20; mucilag. acac. 30;
ol. ricini,  10.  M.
  The author gives  the  following details respecting the availability
of these pastes for different ingredients  :  Lead is best used as an
acetate, either in a simple paste or  with dextrine;  the carbonate,
oleate, and iodide combining well with both.   Zinc oxide combines
well with kaolin, lead, starch, dextrine, and gum.  Sulphur combines
well with the three  last named, poorly  with  kaolin, and not at all
with lead.  Ichthyol suits well with all save the gum pastes.  Naphthol,
calomel, corrosive sublimate, red and white precipitate, carbolic acid,
chloral hydrate, camphor, and salicylic acid can be incorporated with
all, the last named in smaller proportion  with gum paste.   Tar is
better united  with starch, dextrine, and  gum, than with the others.
Iodine and iodoform naturally do not suit well with the starch and
dextrine pastes.   Chrysarobin and pyrogallol are united with kaolin
and gum  pastes,  but  acids in general destroy the adhesiveness of the
gum pastes and should  not be added to them.   Fatty and soapy
substances, if commingled in large amounts with these pastes, injure
their special properties.
   Powders are  mechanically  dusted over the surface of the skin for
the purpose of protecting it, and occasionally in order, also, to  pro-
duce an astringent or anti-pruritic effect.   In order to be serviceable,
they should generally be rendered impalpable by sifting them care-
fully through a fine silk  bolting-cloth.   They are composed of starch,
magnesia, lycopodium, bismuth, boric acid, camphor, tannin, oxide of
zinc, iodoform, salicylic  acid, and similar substances.  The articles
sold by grocers as "Oswego Gloss Starch" and "Corn Starch Farina"
are usually much more finely bolted than the dusting-powders extem-
poraneously prepared by chemists. As  absorbent powders, the starchy
substances are open to the objection of forming little pasty rolls or
"cakes," when  wet with  serum or sweat.  Lycopodium, which is
seen under the microscope  to consist  of irregularly globular pollen
sporules,  never behaves in this way, and is, for that reason, deservedly
popular.
   Dr. Faithful,  of Australia,  has recently suggested  the preparation
of medicated powders by first dissolving them in alcohol, ether, or
chloroform.   The solution is then  mixed with starch  or  French
chalk.  Evaporation of the menstruum is conducted without artificial
heat, and a fine,  medicated starch or chalk powder results.
   Plasters are employed when it  is desired to exert a more or less
continuous effect upon the  skin, and are thus necessarily consistent
and desirable.  The  resin  plasters are less useful in  skin diseases,
because more irritating than the lead plasters.   Unna's plaster-mulls
arc described below.   The mercurial plasters are useful, especially in
syphilitic lesions of the skin.
  " A valuable addition to the  list of  methods for applying medicated
ointments to the  skin has been  devised by Unna.  His Salve-muslins 
84
general  therapeutics.
 or salve-mulls are strips or bandages of muslin  thoroughly impreg-
 nated and thickly spread with ointments medicated  by almost every
 desirable substance, from the oxide of zinc to  tar, thymol, salicylic
 acid, and mercury.   They  are elegantly made, and, when  imported
 to this country, surrounded by impermeable tissue, so as to be quite
 fresh and sweet when used.   They are efficacious, and, as a rule, well
 liked by patients.  The chief objection to their  general  employment
 in this country  is the expense of importation.   The author has used
 them with great advantage  in skin diseases of the exudative class
 affecting the extremities.
   Unna's "Plaster-mulls" seem to be less  useful.    They are
 plasters  thinly spread on gutta-percha cloth, and  manufactured with
 a wide  range  of medicinal constituents.  They serve a good purpose
 in the protection of parts of the skin exposed to friction.
   Lanolin, or wool-fat, was first  introduced as a salve-base by Dr.
 Oscar Liebreich, of Berlin.   It is a peculiar substance obtained from
 keratinic tissues,  and contains cholesterin  fat instead of glycerine,
 with but thirty per cent, of water.   It has a bright yellowish color,
 a distinct odor of the sheep, and is neutral,  never, when pure, acid in
 reaction.  The  Berlin  specimens  that  first  came  to this market
 required the addition of from ten to twenty per cent, of an ordinary
 fat in order  to overcome  the  consistency of the lanoline.  But, in
 1886, Prof. Liebreich called attention  to  a lanolinum  purissimum
 which he had  substituted for the former, and which, being free from
 cholesterin compounds,  required no such fatty addition.
   This substance seems now to  have  outlived  the  period both  of
 extravagant praise and denunciation.   It  is readily absorbed from
 the  surface  of  the  skin, and, either pure or  medicated, may  be
 regarded  simply as a useful  addition to the bases of ointments  for
 employment upon the skin.
   The Oleates of zinc, mercury, copper, lead, and other metals have
 been employed with advantage  in the topical treatment  of disorders
 of the skin.   Of these, the oleates of mercury and lead are decidedly
 the  most valuable.   The  latter  is represented  by Hebra's white
 diachylon ointment.   The oleate of mercury is serviceable  in syph-
 ilitic, parasitic, and other disorders.
   Collodion and Traumaticine are employed for the purpose of
 applying a remedy to the skin, and at the  same time protecting  or
 contracting the surface to which the application is made.   Traumati-
 cine is the name given to a solution of gutta-percha  in  chloroform,
 in the proportion of ten per cent.    In this  way bismuth, cantharides,
 sulphur, chrysarobin, oxide  of zinc, white precipitate,  iodine, and
 other substances may be with advantage  applied  to  the  surface, and
 the action of each definitely limited to the margins of a single patch
of disease.
   The several varieties  of Tar, crude and distilled, together with its
derivatives, occupy an important place among efficient topical agents.
In general, they seem to exert upon the epidermis a local  influence
which extends more deeply  as the remedy is continuously applied. 
GENERAL THERAPEUTICS.
85
At times, both irritative and inflammatory effects are thus induced ;
and when absorption from the skin occurs, even systemic intoxication.
Pix liquida, or the oleum picis, is  the favorite article of this group
with most  American physicians;  but  the oleum cadini or  oil  of
juniper, and the oleum rusci or oil of birch, are rather more generally
employed by experts.   The last-named, found in purity and abun-
dance, and to be had at a low price in our  own  markets,  is recom-
mended above the others.   In Vienna  the distilled oil  is preferred ;
but there is good reason to believe that the  crude  oil is decidedly
more efficacious.
   The  skill of a physician  entrusted with the management of a dis-
ease of the skin might almost  be measured  by his success in the use
of tar.   He who has not had experience in its employment is urgently
advised to select one member of the tar family and learn thoroughly
how to apply that, singly and in  combination, either  in  lotion  or
salve.  Properly  employed, it  will  favor involution  of lesions, less-
ening  hypenemia,  infiltration, scaling,  and  discharge.  It  serves
admirably as an antipruritic.   As indicated  above, it may, however,
produce severe inflammation of the skin.
   To produce the benign or emollient effects of tar, it is best mixed
with some soothing or astringent powder, and  with this end in view
nothing is  better than chalk.   Spender's  hints1 for making such an
ointment are admirable.   Finely  levigated chalk  is strewed  into
melted  lard in a  stone jar, the whole being  stirred till it  is cold.
Then at first the smallest quantity of tar sufficient to make a brownish
smear of color is  added to  the quantity of salve  employed  for  use.
This color can be successively deepened at will.  Auspitz advises the
use of  the tars in a pure state, applied in very small  quantities with
a  strong bristle-brush and well rubbed in.   In combination with one
of the  most valuable of all substances for topical use  in cutaneous
therapeutics,  viz., sulphur, tar enjoys a  special reputation:   The
Wilkinson  salve modified (q. v.) represents such a combination.
   Ichthyol, fish-oil, sulpho-ichthyolate  of sodium  or ammonium,
introduced  to the profession by Dr. Unna, is the distillate of a bitu-
minous and sulphurous deposit of  petrified fishes and marine fossils
found  in Tyrol.   Its chemical formula is C,fiH36S3Na206.   It  has a
tarry appearance,  odor,  and   consistency.   It is soluble  in  water,
partly so in ether and alcohol, and can be incorporated in any desired
proportion  with fat, vaseline, and  lanolin.  It has  been used both
pure and  diluted;  and several proprietary articles  (plasters, soaps,
salves,  and medicated  cotton) are sold in  the  market,  It has been
used both  at  home and  abroad in  cases of leprosy, pruritus, acne,
sycosis, eczema, psoriasis, and a number of other cutaneous disorders.2
It is used  in solutions and  salves  of from  ten  to twenty per cent.
strength.  As before stated, it is also administered internally, more

  i r-ractitioner, June, 1883, p. 402.
  - Sc> Baumann and Schutten : Monatsh. f. Prakt. Derm., 1883.  I mm : same journal, 1882; Deut.
med. Zeit  , 188:!. Sam ml. klin. Vort., l£8o ; Lorenz ; Deut.  med. AVoch., 1885 ; Stehvagon and Pif-
fard : Jour'n of Cut. and Yen. Dis., 188<5 ; Zeisler:  Chicago Med. Journ. and Exam , 188G. 
86
GENERAL  THERAPEUTICS.
particularly in the management of rheumatism, in doses  of from
fifteen to twenty drops.  It does not seem to have a disturbing effect
upon the stomach.
  This substance has not yet been employed to an extent sufficient
to establish its position firmly as a remedial agent in diseases of the
skin.  Personal employment  of it in a series of different cases, the
greater number being of eczema and lupus, led to the impression that
it was not superior to tar in a therapeutic  sense.  It will probably
secure a place among the useful articles in this list.
  Unpleasant results have been reported as following its application
in a single instance (Sinclair).  A four-months old infant sank into
a state of stupor  two hours after its head  and limbs were  smeared
with a salve composed of one part of ichthyol to five of vaseline.
  A group of substances which occupy a therapeutical position inferior
to the tars, but which  serve an important end in the management of
cutaneous diseases by the production  of similar effects, are, carbolic
acid, creasote,  salicylic acid, benzol,  naphthol,  iodol,  chrysarobin,
pyrogallol, resorcin, and jequirity.
  Eesorcin in ointments of the strength of  five to twenty per cent,
serves as an antipruritic and  alterative.  Dr.  Stehvagon  reports an
anodyne effect following  its use.   This  same  experimenter  has
modified Ihle's formula by adding  a  drachm (4.) of resorcin  to one
to two  drachms  (4.-8.)  of castor-oil,  five  minims (0.33) of Peru-
vian balsam and four ounces (128.) of alcohol, for use in  alopecia
and seborrhcea of the  scalp.   It is a valuable parasiticide in lotions
of the strength of from five to ten per cent.
  Naphthol, or (S naphthol, as  it is termed chemically,  first intro-
duced by Kaposi, has fairly retained its place in the list  of efficient
topical remedies.   It is chiefly valuable in scabies, but  has also been
used in  the management  of eczema,  psoriasis, and other exudative
affections.   Van Harlingen1 has found it answer  well  in  seborrhcea
of the scalp.   Neisser  has described renal disorders as resulting from
its use in children, but MM. Josias and Nocard2 report that in ordi-
nary medicinal  doses  it is harmless.   The fact  that  the naphthol
preparations are odorless and  do not stain the skin is to be set down
in their favor.
  Jequirity (abrus precatorius), employed by ophthalmologists for
the purpose of inducing artificial inflammation of the conjunctiva, has
been  used by Dr. Shoemaker3 in the management of lupoid and other
ulcers.   One part of the cleansed, decorticated, and bruised grains,
macerated  for twenty-four hours, and reduced by rubbing in a mortar
to a smooth paste, was added  to sufficient water to make  four parts.
This emulsion  was  used for local application.
  Sulphur, employed popularly chiefly as a laxative or for the local
treatment  of  scabies,  has also  a deserved reputation   in cutaneous
therapeutics, as an external agent in a wide range of non-parasitic

    1 Amer. Journ. of the Med. Sci., Oct. 1883.      2 Ann. de Derm, et de Syph., May, 1885.
    3 Lancet, Aug. 1884, p. 185. 
GENERAL  THERAPEUTICS.
87
 disorder.-.  Hebra once  regarded it as valueless in eczema, but his
 opinions on this  point are not now generally accepted.  The precipi-
 tated sulphur is to be preferred to the other compounds of the phar-
 macopeia.   It may be mechanically incorporated with salve-bases or
 chemically combined  with vaseline and other petroleum  products, a
 process  by which experiments  have led the author to  believe  its
 therapeutic value is not increased.  It is also applied after mechani-
 cal  union with various  substances as a  lotion.  It  is irritating to
 the acutely inflamed skin, but much better tolerated in conditions of
 subacute or chronic exudatiou than the tars.
   Mercury and its compounds are of value in the  local treatment of
 many disorders of the skin, syphilitic and not syphilitic.  Corrosive
 sublimate as a parasiticide is of great importance in the treatment of
 several  cutaneous disorders due  to the presence of bacteria, as, for
 example, lupus vulgaris.   Calomel,  the oxides,  iodides,  and  the
 ammonio-chloride, are chiefly  used in the  form of  ointments,  but
 the black wash, prepared with the mild  chloride,  is  of great value
 in eczema.   Piffard1 has  called attention to the fact that the officinal
 ointment of white precipitate is made with  pure lard instead  of as
 formerly with lard and wax ; and to this change, tending to hasten
 the  absorption of the  mercurial, he attributes some  late failures with
 this admirable salve.   Disagreeable dermatitis  followed  by scaling
 has been reported to follow its  use in the strength of forty grains
 (2.66) to the ounce (32.) by Mr. W. E. Green, of London.2
   Chloral-camphor and  Piiknol-camphor have value chiefly as
 antipruritics.   The former is obtained by rubbing together the hydrate
 of chloral and gum-camphor (Bulkley) till  they form a clear liquid
 of  pungent odor.    Phenol-camphor is made by  gradually adding
 camphor to melted crystals of carbolic acid, a colorless liquid resulting
 having the fragrant odor of camphor without that of the acid.  It is
 a useful  local  anicsthetic agent, being  insoluble in  water, but freely
 soluble in chloroform, ether, and alcohol.
   Many Agents are employed upon the surface of the integument to
 produce  in various degrees a Caustic or Destructive effect.  Among
 these may be named the thermo-cautery (Paquelin knife), galvano-
 caustic apparatus,  the mineral acids and alkalies, ethylate of  sodium,
 arsenic, chloride of zinc, several mercurial compounds, acid nitrate of
 mercury, bichloride of mercury,  chloride of antimony, sulphate of
 copper, and nitrate of silver.  Several of these substances in weak
 solution are employed as milder agents for the production of irritative,
or even various inflammatory, effects.   To the latter class  should be
added  iodine  iu tincture, chloroform, tartar emetic, croton  oil, and
cantharides.
  These  destructive effects are of advantage in the treatment of dis-
orders of the integument due to parasites, either animal or  vegetable.
Of  those employed for this purpose, and not  mentioned above, may
be named petroleum and staphysagria, for the destruction of lice;
' Journ. of Cut. and Ven. Dis , Oct. 1866.            2 Brit. Med. Journ., 1885. 
88
GENERAL  THERAPEUTICS.
sulphur, styrax, and balsam  of Peru, for  the  destruction of acari;
sulphur and  its compounds, and a number of derivatives from tar,
for the destruction of vegetable parasites.

   A variety of Surgical and other Appliances are found useful as
adjuvants in the treatment of skin diseases.   They may be employed
to support, protect, or  compress the surface, or merely to aid in the
retention of dressings  or  external medicaments.   Thus the ordinary
roller bandage is applicable to many portions of the body; the sus-
pender, or suspensory bag,  over the scrotum;  elastic or inelastic
stockings to the feet and legs;  kid. rubber, and thread gloves to the
feet and fingers; and various skull-caps, face-masks, and mittens are
employed in  the  case of infants and children  to  protect  affected
surfaces from the dangers of scratching.
   It is an axiom in dermatology that a salve is worth far more to
the patient when it is spread on muslin,  and thus  retained in contact
with the  skin, than when it is merely smeared  or  rubbed over the
surface.   It is this important feature which has doubtless contributed
so largely to the reputation of Unna's salben-mulle, or salve-muslins.
In order to secure the  retention of such salve-spread muslins in con-
tact with the surface, the common muslin roller, which  exercises  more
or less compression, is  inferior to the light  and more pervious cheese-
cloth bandage.   This is especially true when the dressing is made by
the patient, who is, in  general, far less expert than either the trained
nurse or the physician.
   Apart from the surgical apparatus  required for ablation of tumors
or other severe operations, a number of instruments  are required for
the daily use of the dermatologist.  Among these  may be named :
   A set of variously sized dermal curettes.  These sharp-edged spoons
are for erasion of the  surface, and should consequently have in each
a fenestrum large enough to permit  the escape of all collected sub-
stances  from the floor of the spoon.
   Epilating forceps with  easy springs and smooth blades meeting in
perfect apposition.
   A set of Piffard's comedone extractors, provided at each extremity
with  a differently sized, minute, spoon-shaped, and  perforated bowl,
the  convex surface of which is pressed over the comedo with the
orifice immediately over the black head of the plug.    This is a  great
improvement  over the old-fashioned comedo extractor shaped like a
watch-key, and the discomfort to the patient is by  its use greatly
reduced.
   A set of half-inch  and four-inch lenses  for examining the surface
of the skin.
   Needle-holders with light handles for firmly grasping needles for
use in  opening pustules, etc  The latter  should be, some of  them
flat with a double-cutting edge, others rounded neatly on an emery-
wheel, and all of them very carefully disinfected  if  used more  than
once.   Too  many precautions  cannot  be taken in  the  practice of 
GENERAL  THERAPEUTICS.
89
dermatology, with respect to the disinfection of all  instruments made
to penetrate  the skin.
                                    Fig. 18.
Irido-platinum needle.

     Fig. 19.




   Milium needle.

     Fig. 20.
Scarifying spud.

   Fig. 21.
    Epilating forceps.


       Fig. 22.






Piffard's grappling forceps.

       Fig. 23.
Skin grafting scissors.


     Fig. 24.
Piffard's cutisector. 
90                     CLASSIFICATION.

                              Fig. 25.
Dermal curettes.

  Fig. 26.
ItEMAH.V-CO-NY
Hess's glass pleximeter. For observing the skin under pressure.

                 Fig. 27.
Piffard's modification of Unna's comedo extractor.
Fig. 28.
Keyes' cutaneous punch.
   Probes,  exploring needles, fine dressing-forceps, delicate straight
and curved scissors, and other instruments from the ordinary pocket-
case of the surgeon, are indispensable.  The instruments required for
use in connection with  the  galvanic battery are enumerated in  the
chapter on hirsuties.
   For detection of different degrees of temperature  at the surface, the
author has employed for several years the thermo-electric differential
calorimeter.   The  thermopiles  of this apparatus act upon a galva-
nometer needle suspended by a single filament of the cocoon of the
silk-worm, and it  is thus as sensitive  as  is required  for  the  most
delicate observations.




                              VII.

                    CLASSIFICATION.

   The numerous attempts which have been made to classify diseases
of the skin  according to their nature and relations,  have  been a
response to the generally recognized demand for a systematic arrange-
ment of all scientific facts.   As regards dermatology, not only have 
CLASSIFICATION.
91
 these attempts been numerous and based upon different principles, but
 the results which they have  accomplished  have been in the highest
 degree divergent.  No single classification yet devised has hitherto
 secured general acceptance.  While it is certain that no one of them
 has been perfect and that each has exhibited defects, it is equally true
 that of the larger number each has possessed some merit of its own.
 No perfectly satisfactory classification  of cutaneous  diseases can  be
 generally accepted till the knowledge of diseases of the skin has been
 greatly enlarged.
   One  of the  most satisfactory of the systems  thus far proposed is
 that of  Hebra.   By  it  cutaneous   disorders are  arranged in  the
 following nine classes :

                  Class     I.  Disorders of Secretion.
                  Class    II.  Hypersemias.
                  Class   III. Exudations.
                  Class   IV. Hemorrhages.
                  Class    V.  Hypertrophies.
                  Class   VI.  Atrophies.
                  Class  VII.  New  Growths.
                  Class VIII.  Neuroses.
                  Class   IX.  Parasites.

   Since this classification was devised by Hebra, none has been pro-
 posed  which compares in ingenuity with the arrangement by Auspitz
 of the diseases of the skin into natural groups.  The principle of this
 classification is to place together those diseases and groups of diseases
 which  present a clinical unity ; the general pathological process  being
 the  predominant characteristic  for selection,  and individual patho-
 logical characteristics,  such  as  symptoms,  localization, anatomical
 peculiarities, etc., are only brought thus predominantly forward  when
 coinciding with the  real  nature  of the class, group, or disease  in
 question.1
   Auspitz's nine  classes are: 1. Simple Inflammatory Dermatoses ;
 2.  Angioneurotic  Dermatoses; 3. Neuritic  Dermatoses ;  4. Stasis
 Dermatoses;  5. Hemorrhagic Dermatoses;  6. Idioneuroses;  7. Epi-
 dermidoses; 8. Chorio-Blastoses;  9.  Dermatomycoses.
   Under these  classes,  by the aid of divisions and  subdivisions,  an
 elaborate scheme is presented, which  embraces fully not only  all
 cutaneous diseases, but  all pathological processes recognized in the
 skin.   This system, accepted with  modifications by Hans Hebra,2 has
 unquestionably been followed by a greater advance in the nosology of
 cutaneous medicine than any of those  which have been proposed since
 Hebra  first offered his.3

  > System d. Hautkrankheiten.  Wien, 1881.
  2 Die Krankh. Veranderung. derHuut.  Braunschweig, 1884.
  3 An exceedingly ingenious and comprehensive scheme of classi,fication of diseases of the skin,
embracing most of the principles upon which the best of previous classifications were based, was pre-
sented by Dr. E. B. Bronson, of New York, at the meetingof the American Dermatological Association,
in August, 1887. 
92
CLASSIFICATION.
  Auspitz's classification is, however, open  to  various  objections on
the part  of the student of dermatology.   It is  elaborated to the
extent of  setting the names of some diseases in  more than one family;
and is, hence, confusing to the beginner.  It is better adapted to the
needs of the expert  than of the young student, for it  introduces to
the study  rather of morbid processes in the  skin than  of the  com-
plexus of  those processes which are recognized  in disease.
  Whether the principle  of classification be anatomical, etiological,
or pathological; whether it be  based on the processes actually occur-
ring in the skin, or on those deeper factors and  forces operating cen-
trifugally  upon the skin, and on which that organ depends for all its
functions  and even its existence;  whether  it  proceed etiologically
from the causes which are immediate, or those which are remote, it is
easy to see that,  as  knowledge  in  each of these directions  enlarges,
the exact position of any one disease in any given classification  must
be rendered insecure.  Never was this  observation  more suggestive
than at this day, when the pathogeny of numerous skin disorders is
revealed in the light thrown on the subject  by the discovery of new
and hitherto unknown inferior  organisms.
  Indeed, to this last cause, awaking grave doubts as to the precision
of much that was once esteemed fact, may be attributed the declining
interest in the general  subject of classification of diseases of the  skin.
The  earnest discussion of this theme has been practically deferred by
common consent to a date when the questions thus suggested can be
more satisfactorily answered.   Several  recent  writers have  actually
contented  themselves with an alphabetical arrangement of the names
of skin diseases,1 as an order useful simply for reference.
  The classification observed  in  this edition  of this  work is that
adopted by the American  Dermatological Association, August 29,
1878, and revised  by the same body, August 28, 1884.  It is that
of Hebra   modified.   Its claims on  American  students cannot be
ignored.   It has been  presented and adopted by the recognized expo-
nents of Dermatology in America.   It has  been made  for nearly ten
years  the  basis of dermatological  study in  some  of the leading
medical schools of this country.   It is not claimed  for  it that it is a
perfect system, but one in which the names of many disorders  have
merely a provisional position.   It will, without  question, be revised
from time to time, by the body which first gave it to the world, and
which  by its aid  has fostered  the  study of cutaneous medicine in
America as it was  never fostered before.  It is employed here as a
valuable, convenient, and accepted nosological scheme, in which, it is
distinctly  admitted, a rearrangement of many  terms is demanded
from year to year by the advances of science.
Van Harlingen : Handbook of the Diagnosis and Treatment of Skin Diseases. Phila., 1884. 
CLASSIFICATION.
93
CLASSIFICATION  OF DISEASE;
       THE  AMERICAN  DERMA

Class I. Disorders of the Glands.
    1. Of the Sweat Glands.
         Hyperidrosis.
         Sudamen.
         Anidrosis.
         Bromidrosis.
         Chromidrosis.
         Uridrosis.
    2. Or the Sebaceous Glands.
         Seborrhcea:
           a. oleosa.
           b. sicca.
         Comedo.
         Cyst:
           a. Milium.
           b. Steatoma.
         Asteatosis.

Olass II.  Inflammations.
         Exanthemata.
         Erythema simplex.
         Erythema multiforme:
           a. papulosum.
           b. bullosum.
           c. nodosum.
         Urticaria.
           pigmentosa.
         Dermatitis i1
           a. traumatica.
           b. venenata.
           c. calorica.
           d. medicamentosa.
           e. gangrenosa.
         Erysipelas.
         Furunculus.
         Anthrax.
         Phlegmona diffusa.
         Pustula maligna.
         Herpes simplex.
         Herpes zoster.
         Dermatitis herpetiformis.
         Psoriasis.
         Pityriasis maculata et  cir-
           cinata.
         Dermatitis exfoliativa.
         Pityriasis rubra.
         Lichen:
           a. planus.
           b. ruber.
         Eczema:
           a. erythematosus.
           b. papulosum.
           c. vesiculosum.
           d. madidans.

  i Indicating affections of this class not properly
included under other titles.
 OF  THE  SKIN  ADOPTED  BY
OLOGICAL ASSOCIATION.

           e. pustulosum.
           /. rubrum.
           g. squamosum.
         Prurigo.
         Acne.
         Acne rosacea.
         Sycosis.
         Impetigo.
         Impetigo contagiosa.
         Impetigo herpetiformis.
         Ecthyma.
         Pemphigus.

Olass III. Hemorrhages.
         Purpura:
           a. simplex.
           b. hemorrhagica.

Class IV. Hypertrophies.
    1. Of Pigment.
         Lentigo.
         Chloasma.
    2. Of Epidermal  and Papil-
             lary  Layers.
         Keratosis:
           a. pilaris.
           b. senilis.
         Molluscum epitheliale.
         Callositas.
         Clavus.
         Cornu cutaneum.
         Verruca.
         Verruca necrogenica.
         Nevus pigmentosus.'
         Xerosis.
         Ichthyosis.
         Onychauxis.
         Hypertrichosis.
    3. Of Connective Tissue.
         Sclerema neonatorum.
         Scleroderma.
         Morphcea.
         Elephantiasis.
         Rosacea:
           a. erythematosa.
           b. hypertrophica.
         Framboesia.

Olass V. Atrophies.
    1. Of Pigment.
         Leucoderma.
         Albinismus.
         Vitiligo.
         Canities.
    2. Of Hair.
         Alopecia. 
94
CLASSIFICATION.
         Alopecia furfuracea.
         Alopecia areata.
         Atrophia pilorum propria.
         Trichorexis nodosa.
    3.  Of Nail.
         Atrophia unguis.
    4.  Of Cutis.
         Atrophia senilis.
         Atrophia maculosa et striata.

Olass  VI.  New Growths.
    1.  Of Connective Tissue.
         Keloid.
         Cicatrix.
         Fibroma.
         Neuroma.
         Xanthoma.
    2.  Of Muscular Tissue.
         Myoma.
    3.  Of Vessels.
         Angioma.
         Angioma  pigmentosum  et
           atrophicum.
         Angioma cavernosum.
         Lymphangioma.
4.
Rhino-scleroma.
Lupus erythematosus.
Lupus vulgaris.
Scrofuloderma.
Syphiloderma:
           a. erythematosum.
           b. papulosum.
           c. pustulosum.
           d. tuberculosum.
           e. gummatosum.
         Lepra:
           a. tuberosa.
           b. maculosa.
           c. anesthetica.
         Carcinoma.
         Sarcoma.

Olass VII. Neuroses.
         Hyperesthesia:
           a. pruritus.
           b. dermatalgia.
         Anesthesia.

Olass VIII. Parasitic Affections.
    1.  Vegetable.
         Tinea  favosa.
         Tinea trichophytina:
           a. circinata.
           b. tonsurans.
           c. sycosis.
         Tinea versicolor.
    2.  Animal.
         Scabies.
         Pediculosis capillitii.
         Pediculosis corporis.
         Pediculosis pubis. 
DISEASES  OF  THE  SKIN.
                         CLASS  I.

                 DISORDERS OF THE GLANDS.

   In this class of disorders are grouped all  the functional disorders
of the sweat or coil-glands, the sweat pores, and the sebaceous glauds.
These disorders  may be  betrayed in  quantitative  or qualitative
changes in the secretion,  or in retention of  the latter in the whole or
in a part of the  secretory apparatus.   When a disease  of the skin
ceases to be  purely  functional  in type, and is accompanied by an
exudative  process,  glandular or periglandular  in  situation, such
disease is properly classed with another and in this particular related
group of affections.


               1.  Of  the Sweat Glands.

                         Hyperidrosis.

                   (Jr. inrep, in excess ;  vdup, water.

Hyperidrosis is an exaggerated quantitative effusion of sweat, the secretion
       accumulating in visible drops upon the surface of the skin.

   Symptoms.—This   condition,   also  termed  Idrosis,  Hydrosis,
Ephidrosis,  Sudatoria,  Polyidrosis,   and  Hyperhidrosis,   may  be
physiological as the result of active exertion in  a medium of high
temperature ;  or it may be  pathological in character, and in the latter
case be either general  or  partial.
   General sweating to a pathological extent  occurs chiefly in the obese,
but also in those who are the subjects of constitutional disease (phthisis,
the various febrile  disorders,  etc.).   It is the fertile  source  of the
various forms of intertrigo, sudamina, and miliaria.   Local hyperi-
drosis is the exaggerated quantitative effusion of sweat limited to certain
definite portions of  the skin, as the palms,  soles, dorsa of the  hands
and feet,  the interdigital  spaces, the genitals, the axillae, and temples.
In such cases the secretion occurs moderately or  greatly in excess,
varying in  this respect somewhat  in different  degrees of temperature, 
96
DISEASES  OF  THE  SKIN.
and of rapidity of the circulation ; is occasionally, but not commonly,
accompanied by fetor; and always  occurs  to  a marked extent.   It
may involve one or both sides of the body, being generally symmet-
rical at the extremities, and asymmetrical upon portions of the face.
   Its topical expression may be studied iu the hands, which are con-
tinually moistened, clammy, or  dripping with fluid  within a brief
time after the most  careful drying  of the  parts.  In the  case of a
woman, the instincts of whose  sex prompt her to take such precautions,
the dress  is  constantly protected from contact  with the  macerated
palms by a handkerchief or similar article which is always in readi-
ness.   The disadvantages thus arising in individuals of both  sexes
who are engaged as tradespeople,  artists,  hand workers,  etc.,  can
be readily estimated.  In women of social position,  no small com-
plaint is made of the disagreeable result produced after wearing  kid
gloves for even a short time, the material of which is  soon  soiled by
its complete saturation with the secretion  from the skin.
   With and without this local excess, occurs the hyperidrosis  of  the
feet, aggravated by the mechanical force  of gravity and  the need of
constant covering.  The stockings and the leather of the boots, shoes,
or gaiters are saturated with the secretion, and  become rapidly subject
to chemical  alteration.  There is usually an  offensive odor  of  the
region,  originating partly in the primary  fetor  of the secretions them-
selves, and partly in  the  subsequent chemical decomposition  of  the
latter, rapidly progressing under the influence  of the soiled  and often
stinking investments of the feet.
   The  integument, constantly macerated, may become both painful
and tender; very rarely there is vesiculation or exfoliation of patches
of sodden epidermis.   When  the genitals are involved, especially in
the male, erythema and intertrigo are the frequent results.
   Etiology.—The disease may be in  rare cases  congenital.   In others
it  is associated in one person with disorders not apparently  related to
it.   The author has  at present in hospital a woman,  twenty-four
years of age, affected with severe tylosis of the feet, from which  are
exfoliated extensive lamellated casts of the soles.  She also has typical
hyperidrosis of the hands.
   In  no portion  of the  nervous system  has  a  localized centre  for
excito-sudoral or inhibitory effects  been  recognized.  Traumatisms,
gliomata, gummata, scleroses, and other lesions affecting the cerebrum,
medulla,  cord,  ganglia,  and trunks of the  sympathetic  nervous
system have been followed by local and general hyperidrosis, but they
have all repeatedly failed  to induce  such  morbid" sudoral symptoms,
while a fit  of anger  or  sudden  fright  has been as conspicuously
effective as any.   In short, the predominant influence of the nervous
system in an etiological  sense must  be admitted  here as in physio-
logical sweating: and the sympathetic branches of that  system must
be assigned the greater influence for the most cases.   A paralysis or
paresis of the sympathetic is held to explain the occasional coincidence
of pulmonary and cardiac disorders,  with either general or partial 
HYPERIDROSIS.
97
excessive sweating.  Compression of the sympathetic by adenomata,
aneurisms, carcinomata, etc., has been followed by marked symptoms
of this disorder.   The disease is encountered in individuals of both
sexes, and  in all ages and degrees of general health, as also in those
who are and  those  who  are not  careful as to cleanliness.   There is
reason to believe that the facial asymmetrical hyperidroscs associated
with  migraine, neuralgias,  hemicrania, etc.,  are  etiologically  and
pathologically distinct from the similar symmetrical  affections of the
hands  and feet.  The latter certainly occur with conspicuous frequency
in young  women who are the subjects of hysteria, chloro'-auaemia,
some  form of dysmenorrhcea, or  cardiac  trouble.  In one  young
ivoman under the author's observation,  there was  an habitual pulse
of fifty-five to the  minute without  dicrotism,  the patient being in
other respects well.
   Pathology.—Robinson, who  has  examined a number  of sections
from the  palm of the hand, failed  to  detect  any abnormal  feature
either  in the glands or the epithelium. The disorder is to be regarded
as purely functional; and any anatomical changes  in the coil-glands
or  sweat-pores  arc  probably  accidents  of such  derangement  of
function.
   Treatment.—When  universal, hyperidrosis is to be treated inter-
nally bv the aid of such remedies as are iudicated by the general
condition  of the patient.  The various  ferruginous touics, mineral
acids, arsenic, strychnia, quinine (the latter particularly when, as is
often the case, a malarial affection is  responsible for the disorder), and
ergot,  with both belladonna  and atropine, arc  all  of unquestionable
value.  Even  though  but  temporarily serviceable, belladonna  and
atropine are well used  at the outset  of most cases.   Aconite, jabor-
andi and  pilocarpine,  white agaric (agaricine  is  recommended  in
doses of one-sixth of a grain (0.011), repeated  as  required), carbolic
and salicylic acids may be named  as  in the second rank.
   External treatment  is often promptly efficacious, and  can rarely be
neglected   iu any case.   The  simplest method is  by  wiping,  not
washing,  the surface until it  is  dry,  and applying  the  dusting-
powders, such as lycopodium, talc, salicylic acid, boric acid, bismuth,
magnesia,  hydrate of chloral one  part to five  or six of starch, and
starch  itself, the chief objection to  the  latter  being its tendencyto
form cakes or rolls after its union with the sweat.   Alternately with
these, or in lieu of them, baths or lotions may be employed, aqueous
or alcoholic, and  medicated with corrosive sublimate, tannic acid, zinc
sulphate, alum, permanganate of potassium, or  the sea salt now  sold
in packages  for  domestic use.   Dr.  G. H.  Fox1  advises  a lotion
containing one  part of quinine to  oue hundred  of alcohol.   Van
Harlingcn recommends the use of juniper tar or carbolic  acid soap
with the bath, as alone sufficient to relieve some cases.
  For hyperidrosis of the  feet,  the treatment by the method  of

                 1 Journ. of Cutan. and Veil. Dis., 1885, p. 24 
98
DISEASES  OF  THE  SKIN
Hebra has, deservedly, high repute.   It consists in neatly and com-
pletely enveloping the entire foot and toes separately, after thorough
washing  and drying, in  strips of cotton cloth over which  is  spread
to the thickness of the blade of a common knife, the  unguentum
diachyli  albi  elsewhere  described.   This  latter is made by boiling
one part  of the best  litharge with about four parts of pure  olive oil,
to which a little water is added  while the  materials  are  stirred
together  over a  slow fire.  The parts are well bandaged,  and  the
patient either remains subsequently at rest or pursues his  vocation,
wearing  over the feet,  shoes and  stockings which  have  not  been
previously used.   In twenty-four hours, the feet  are redressed with-
out washing, after dry rubbing with  charpie and a dusting powder.
This is repeated daily for  ten to  twenty days, after which  a dusting
powder may be  substituted for  the  local dressing.   A  parchment-
like  desquamation  of  the  epidermis  in  thick,  yellowish-brown
lamella?  occurs, beneath  which an  epidermis is  formed,  new  and at
first  tender, but  apparently normal.   When the  latter  has lost its
tenderness, the feet  are  for the  first  time washed with  water.   In
case  of failure, the  routine of treatment  is,  as often as necessary,
again carried out. It is scarcely necessary to add that no  ill effects
are known to have  resulted from the therapeutic measures adopted
for checking a local  hyperidrosis.
   For the  diachylon salve  may  be substituted tar, ichthyol,  or
naphthol ointments.  Fredericq  employs  finely  pulverized  tartaric
acid, applied at first  with some caution, and always in small quanti-
ties.   Stewart first bathes the  feet in  hot water and then soaks them
for a few moments, and once only, in a solution of the permanganate
of potassium, four  to six grains to  the ouuee, (0.266-0.4 to  32.),
after which, the  plaster  selected  for  use may be applied as directed
above.   Legoux  orders pediluvia of tar water twice daily, for three
days, followed by a  painting of the feet with a  solution  of the  per-
chloride  of  iron.  Morrow1 recommends foot-baths in  the extract of
pinus canadensis, followed by  the  application of boric acid, or  sali-
cylic acid, mixed with lycopodium.   Lastly, Brandon, experimenting
on the permeability  of the  skin  to ethers and gases, claims to have
solved the problem  of local treatment  with  a " liquor  anti-hidror-
rhoicus," prepared from  the chloric ethers.
   Prognosis.—The  future of any case  of  hyperidrosis is uncertain.
The disease, whether local or general, may spontaneously disappear,
recur, be promptly amenable  to  treatment, or prove obstinate to all
therapy.   Dr. Myrtle 2 reports the case of a male patient, seventy-
seven years old, who sweat to death after repeated recurrences of
severe hyperidrosis,  and  after  temporary relief from  the  use  of
Fowler's solution.
1 See his resume of this subject in the Journ. of Cutan. and Ven. Dis., vol. v. p. 68.
2 Medical Press, Feb. 25, 1886. 
SUDAMEN.
99
                            Sudamen.

                          Lat. sudor, sweat.

 Sudamina are discrete, superficially seated, millet-seed sized  and larger,
               translucent vesicles, resembling seed-pearls.

   Symptoms.—-In this disorder, also termed Miliaria Crystallina, the
 lesions are thickly agglomerated, but discrete, transitory, and translu-
 cent, pin-point sized  vesicles,  resembling  dew-drops  or  seed-pearls,
 upon  the  surface of the skin, often  requiring  the touch to define
 their real character.  They are usually limited to certain regions of
 the body, as the trunk, and here more generally upon the face and
 sides of the belly, and the iliac regions, though they may occur upon
 any part.   Their course is  rapid, both in  evolution and involution,
 and their sequelae are  exceedingly delicate desquamative flakes, the
 thin  roof-wall which originally covered the sweat-drops having been
 lifted  from the superficial stratum of the horny layer of the epidermis.
 They  contain each a droplet of sweat, which is removed by evapora-
 tion.   They are  usually preceded by an attack of pruritus, and  may
 follow the  hyperidrosis of systemic debility,  enteric  and continued
 fevers, phthisis,  inflammatory  rheumatism, pneumonia,  and other
 asthenic conditions.  They may also result from  violent exercise, the
 elevated temperature of the summer season,  flannel  underclothing,
 vapor baths, and the application of  wet and hot  cloths to the surface
 of the skin.
   The lesions are the  result  of the accumulation of sweat between
 the most superficial layers of the stratum corneum, in high tempera-
 tures of the body, or of the medium by which it is surrounded, and
 usually in states of adynamia.  They may hence occur  at all  ages,
 and in both sexes.
   Robinson states that  they form rapidly on the face of laundresses,
 and  in women from the thirty-fifth  to the fiftieth year of life, where
 also they are isolated and disappear  slowly.
   Three  forms  of sudamina  have been  described:  (a), sudamina
 alba;  (b),  sudamina  rubra; and,  (c),  sudamina  crystallina.  The
 last-named  is the only form to which the term sudamen is properly
 applied, since it  alone  of the  three designates a purely  functional
 derangement of the sweat-secreting apparatus.
   The first term, sudamina  alba (miliaria  alba),  is applied to lesions
 where there is maceration of the vesicular wall and the contents be-
 come   opalescent.  This is rare.   The second term, sudamina rubra
 (miliaria  rubra, lichen  tropicus, "prickly heat"), is applied to in-
 flammatory lesions which may  accompany profuse sweatiug.  These
 are numerous pin-point to pin-head sized vesicles surrounded by a
 reddish halo, or  papules of  the same dimensions, or the two lesions
commingled, almost invariably accompanied  by hyperidrosis, though
the latter  may  be absent  in high  temperatures.  The  marked
tingling, pricking, and burning sensations by which they are  accom- 
100               DISEASES OF THE  SKIN.
panied, are  often in the highest degree  distressing, and may  solicit
rubbing of the affected part, though the scratching elicited by  severe
pruritus is  not common.  Minute crusts  may  form after  vesicular
rupture.  The attack may be mild or quite severe, and last for a few
days, or for  as many weeks or months,  as the  result of continuous
aggravation,  or of the production  of new crops of lesions after each
recurrence of the cause.   It is not i*arely complicated in obese  indi-
viduals, by all  varieties of intertrigo and eczema.
   The  sudamina crystallina are,  however,  the sole  lesions which
may be properly considered  in this  class of affections.  They are
always  free from  all inflammatory  symptoms, presenting a limpid,
dew-drop-like aspect that is characteristic.
   Etiology.—The disease is induced by excessive sweating; often in
consequence of an elevated temperature; also, however, as a  result
of a systemic asthenia, as indicated above.
   Pathology.—Dr. Robinson has studied  the anatomy of the sudamen
with special care.  Its contents are pure sweat without admixture of
lymphoid corpuscles.  The  fluid  collects between the laminse of the
deeper part of the corneous layer.  The author supposes a rupture of
the wall of the sweat-duct, but with  our present  knowledge  of the
anatomy of this part of the skin, we can  see  in his illustrations the
obliterations  merely of the sweat-pore by a sudden effusion of watery
fluids toward  the epidermis, which pass with moderate  pressure
through the wall-less sides of the  pore into  the spaces between the
epithelial  cells, where a chamber is readily formed.
   This  is made clearer  by the author's exact description of actual
dilatation of the duct of the coil-gland, where there is "not an escape
of sweat into the  neighboring tissue," which  he recognized  in the
corium.   The  sudamina exhibiting  this peculiarity appear on the
face, chiefly of women.
   Diagnosis.—No difficulty can arise in making a diagnosis,  if the
peculiar characters of the sudamen be kept  in view.   All pustular
lesions  have different contents;  all  bullous  lesions are  larger;  or
seated on an engorged  base;  or  lack the limpid  clearness  of the
sudamen,  because, however transparent the contents, they are mostly
covered by a thicker and less transparent roof.  The halo about the
lesions of miliaria rubra, or their  rosy-pinkish  shade will determine
their character.  In varicella the lesions  are chambered.
   Treatment.—Only the simplest treatment is required.  The lesions
may be dusted with  one or several of the  dusting powders, such as
starch, lycopodium, or boric acid,  named in the chapter on General
Treatment of Cutaneous Diseases.   The  general  treatment  is that
indicated  by  the condition of the patient.

   Miliary  Fever, or the  suette miliaire of the French,  is  an
epidemic  disorder, accompanied by sweating and  a cutaneous exan-
them.   Pineau1 gives a  description of the disease as it occurred in
epidemic form in the island of Oleron, wmere, of one thousand patients
1 Archiv. Gener. de Med., Jan 1882, p. 25,; 
ANIDROSIS.
101
affected, between one hundred and fifty and two hundred perished.
The eruption appeared in the form of hypersemic maculae, disappearing
under pressure, after which there rapidly formed myriads of reddish
or whitish, grouped, unequally sized, and acuminate papules, rising
from  a whitish and macerated  surface.   Among these were inter-
spersed lesions of sudamina.  The region of the face was not spared,
and  the  conjunctivae were occasionally affected.  In the course  of
from two to four days, pin-head to bean-sized, varioliform but non-
umbilicatcd pustules formed  in the site of some of the papules, the
contents  of which  disappeared  by resorption,  the final lesions pre-
sented being large,  flat, reddish papules, the skin, of the face particu-
larly, becoming generally reddened and swollen.   In the course  of
from  ten to twelve days, general desquamation ensued  with  large
palmar and plantar losses.   Relapses occurred in some  cases with
general redness of  the  surface, or with crops  of reddish  plaques,  or
yet again with the occurrence of furuncles.   The sensations were those
of myriads of needles thrust into the  skin.  The exanthem was accom-
panied in some cases by fever, and in others not.  In fatal cases death
resulted from exhaustion.
   Geber, however,  and other writers  believe that the lesions described
are not peculiar to  any special disease; and deny the possibility of  an
independent miliary fever.


                           Anidrosis.
                     Gr. a, privitive;  vdop, water.
This name is properly applied to those morbid conditions where no sweat is
  secreted from  the  surface of the body.  The word Hypohidrosis is more
  exactly used to designate a relative, general or partial decrease in the quan-
  tity of the sudoral fluid. The former term is, however, often used to include
  the latter.

   Complete anidrosis occurs naturally only when the sudoral appa-
ratus has been  involved in destructive or other changes in the skin
(scars, atrophy, etc.).
   Diminution in the quantity of sweat excreted, or its complete sup-
pression, whether general or local, is a symptom of several disorders,
but as a  separate cutaneous affection has  no existence.   It  is suffi-
ciently common in  many cutaneous diseases, as, for example, ichthy-
osis, psoriasis, and  some  forms of eczema.   But in these, the symp-
tomatic character of the anomaly is illustrated  by the well-known
fact that when the skin  is relieved  of these cutaneous troubles, the
function  of sweat secretion is restored.  Similarly, in neuralgias and
certain forms of paralysis, a circumscribed and temporary anidrosis
may be the local expression of the  nervous disturbance, precisely as
in the case of the asymmetrical  hyperidroses.   Lastly, there are indi-
viduals exhibiting  the  idiosyncrasy of sweating either not at all  or
quite imperceptibly in  elevated temperatures, phenomena which 
102
DISEASES  OF  THE  SKIN.
should be ascribed rather to peculiarities in the equilibrium of the heat-
exchanging forces, than  to congenital  deficiency of the sweat-glands.
   According  to  Geber,  Strauss and Bloch  regard  the occurrence of
hypohidrosis and anidrosis as differential diagnostic  symptoms of dif-
fuse myelitis and poliomyelitis as against cerebral paralysis.
   Treatment.—The measures capable of stimulating the  sweat secre-
tion are:  the ingestion of water in quantity by the mouth, the ex-
ternal application of heat in a dry or moist atmosphere, and the use
of jaborandi or pilocarpine by the mouth or hypodermatic injection.
In  the  anidrosis accompanying cutaneous  disease,  the indication is
always primarily for the relief of the latter.


                          Bromidrosis.
                  Gr. /Jpw/ior, a stench;  vdop, water.
This disorder is also termed Bromhidrosis, Osmidrosis, and fetid or stinking
                              sweat.

   Symptoms.—Here the perspiration is effused  in such a state that it
can be immediately perceived to possess an unusual odor, or, as Hebra
taught was the case with the majority of patients, to be rapidly changed
to that condition.   It is often associated with  hyperidrosis, or may
occur quite independently of the latter,  and like the latter also be either
general or partial.  The odor may be either agreeable or disagreeable,
having been iu various cases compared to that of several flowers and
fruits, as well as to that  of various stench-emitting animals.  In this
respect the sweat presents a striking analogy to  the urine, with which
it sustains a close and well-recognized  physiological  relation.
   General bromidrosis may be physiological, as in  the case of indi-
viduals of the African race,  or in those of dark skins who are pro-
fusely sweating during  labor or in exalted temperatures.  General
pathological  bromidrosis is  rare.   The odors  emanating  from  the
person in  ulcerating syphilodermata, smallpox, and other  general dis-
orders, may, in certain cases, be associated with the  sweat secretion,
but in others doubtless are connected with the decomposition of patho-
logical products of the inflammatory process.
   The local varieties of bromidrosis affect the regions in  which the
sweat is oftenest secreted in excess, and its immediate  evaporation
prevented, as  in the axillae, groins, feet, ano-genital, inter- and  infra-
mammary regions.  In a qualitative seuse, every degree  of odorous-
ness is  noted, from that which is merely slightly agreeable or offen-
sive, to the most intolerable stench.  When complicated by a seborrhcea
in situations where the parts are not only warm, moist,  and covered
by clothing, but also subjected to friction  and long uucleansed, the
most intolerable and nauseous fetor is  perceived.
  Sweat may be effused  in a normal condition, upon and within the
articles  of clothing worn,  and subsequently generate a stench by
chemical changes  both in the clothing and the fluid  by which that 
CHROMIDROSIS.
103
clothing is  saturated.  This  should never be forgotten in the prac-
tical management of any case.
   Treatment.—The  treatment of bromidrosis is,  in  general, that of
hyperidrosis already described.    Thin1 has successfully  employed
stockings and cork soles dried thoroughly, after saturation for hours
in a jar containing  a solution of boric acid.  The efficacy  of this,
he ascribes to the fact that the odor is the result of the development
in the secretions  of the bacterium fcetidum.   An ointment is also em-
ployed by him for similar purposes,  produced by making a  solution
of the acid in glycerine, and incorporating  it with a fatty basis of
white wax and almond oil, making thus a "glycerated cream of boric
acid."  Armingaud, of the French Academy, has reported excellent
results following the subcutaneous injection of three grains (0.20) of
the nitrate of pilocarpine, eight of which operations were successful
in reducing the abnormal sweating fetor.   Clement Hawkins2 finely
triturates fifteen  grains (1.) of the red oxide of  lead, and to this adds
gradually oue  ounce (32.) of Goulard's extract.   This is  used as a
lotion following a nightly foot-bath containing an ounce (32.) of alum.
   Fox (1. c.) advises a one per cent, solution of chloral, or potassium
permanganate as a topical application.
   Internally the sodium salicylate has been employed with success in
five grain (0.33) doses.

                         Chromidrosis.

                     Gr. xpuf*a, color; vdup, water.
By this term is indicated the condition in  which effused sweat exhibits an
  abnormal color,  yellowish, reddish, greenish, or blackish.  The term Cyan-
  hidrosis has been employed to indicate blue sweating.

   In these cases there  has been usually a copious secretion of fluid.
Authors  have variously attributed the color  to the presence  of  com-
pounds  of  phosphorus,  iron,  cyanogen, indican,  Prussian   blue,
luematin, chromogen,  and even  to parasitic vegetations upon the
surface.   Women, much more often than men, exhibit the free deposit
of pigment upon the  skin,  and,  in view of the  admitted rarity of
chromidrosis, the suspicion arises that in some of the cases reported,
there was free pigmentation of the surface by which the fluid exuded
Mas immediately stained or colored.  Duhriug  reports a single case
of red sweating  in a vigorous male  patient.   Usually, however, the
phenomena occur in persons who betray some evidence of impairment
of other  organs  than  the skin,  or  who  are debilitated in general
health, thus furnishing an indication for their treatment.
   Babesia," of Pesth, reports some interesting cases  of this disorder,
which appear to  have been produce! by the presence of bacteria.  ^ In
four patients, three  of them women, there was considerable pruritus
with  pale red  to blood-red sweat;  in oue, the skin and hairs were

       i Practitioner, December, 1881, p. 2101.
       2 Brit. Med. Journ., May 7, 1881.                     s Lancet, 18b2. 
104               DISEASES OF THE SKIN.
 reddened.   The axillae were the source of this colored perspiration.
 In all the cases microscopical  examination revealed  similar changes.
   The hairs of the axilla? were thin, pale-red, brittle; and surrounded
 with a colloid-looking, rusty, or bright-red sheath, in  places of con-
 siderable thickness and having a rough surface.    It consisted of red
 masses, presenting a radiating striation, more or less confluent, appa-
 rently proceeding from fibres of the cortex of the hair, or from some
 broken part of its surface.  The-radiating striation was found to  be
 due to the aggregation of round or ovoid bacteria, scarcely a micro-
 millimetre in  diameter, which Mere united in zooglcea masses  by a
 reddish, intermediate substance.  Xodular swellings  on the hair were
 produced by the infiltration of the organism  between the separated
 fibrils.  The roots of the hair were free from bacteria.   The red tint
 of the sweat Mas found to depend upon  numerous roundish  masses
 of zooglcea.
   T. C.  Fox1  also has reported two cases in which a deep bluish-
 black  pigment was exuded upon the  skin of the circum-orbital
 region.  The  amorphous granules were found insoluble in almost all
 hot or cold reagents, but displayed a deep blue color  M'hen moistened
 with glycerine, and a  purplish  hue when dissolved in  hot sulphuric
 acid.
   The hypothesis, that certain cases  described  as chromidrosis are
 really instances of mechanical  washing of pigment to  the surface in
 the profuse sweating  of the debilitated, is strengthened by the phe-
 nomena of simultaneous hair coloration.  Thus,  Prentiss2 reports the
 case of a young woman affected with  acute cystitis and  passing puru-
 lent urine, whose hair, under  the  influence of profuse SM^eating  in-
 duced  by the action  of pilocarpine,  changed  speedily from a light
 blond  to a nearly jet-black  hue.  At  the  meeting of  the American
 Dermatological Association, in 1881, the author  exhibited hairs of a
 middle-aged man which had changed  in a night from a grayish-white
to a .greenish  and yellowish-brown hue; and in commenting upon
 these,  Dr.  White, of  Boston,  stated that he  had observed several
 similar cases of hair coloration as the result of profuse sweats.
  In the year 1884, this same observer reported to  the Association
 the case of a M'orkman in a sugar refinery M'hose sweat from the left
 side of the  body was of a bright yellow color for  several months, and
where, though sought  for, no bacteria were discovered.
  In a case observed by Bergmann, a mycelium  was recognized
Mdiich was  subsequently cultivated  on paste.   Eberth has recognized
bacteria in  both normal and yellow sweat.
  Le  Roy de  Mericourt, first to name  this disorder,3 has  also4 de-
scribed a case of rosy sweating in an infant.
  Fereol believes that in these cases there is actually an absence of
 sweat and  prefers to call the disorder chromocrinia.
  In all  cases, before accepting statements of patients as to the exist-

    i Med. Press and Circular, Jan. 1, 1881.           2 Phila. Med. Times, July 2, 1881.
    3 Arch. gen. de Med., Nov. 1857.               4 La France Medic., 1884. 
URIDROSIS.
105
encc  of symptoms of this character, it  is needful to eliminate the
possibilities of deceit and  accident.  Coloring matters received upon
the hands may be, either in wilfulness or ignorance, transferred to the
surface of the body.
   The treatment is that of the general condition  of the patient ex-
Inciting these symptoms.

                            Uridrosis.

                     Gr. ovpov, urine;  vdup, water.

   While a small amount of urea is to be recognized in normal sweat,
it may, under peculiar  conditions, be increased,  and, together  with
urinary salts, deposited upon the skin surface after evaporation of the
exuded fluid.  Such symptoms have usuallv occurred  either as the
result of grave constitutional affections, such  as cholera, or of organic
renal  disease, accompanied by anaemia ;  or of the ingestion of jabo-
randi.   In a few cases, the symptoms  have  been  presented in  indi-
viduals who were apparently in good health.  The salts of the urine
appeared upon  the skins of  these patients  in  the form of minute
lamelhe, or a fine powder of whitish  color and crystalline aspect.   In
some cases reported the symptoms have  been noted to precede  by a
few days a fatal  issue.
   The constantly adjusted equilibrium between the sweat and the
urinary excretion Mould explain, for cases of a mild type, temporary
augmentation in  the urea formed  in  the sweat of unusually free dia-
phoresis.   Geber supposes that decomposition products, such as the
carbonate of ammonium,  possibly aided by the volatile fatty acids,
may in part  account for these conditions.

   Dysidrosis.—Under  the  names Dysidrosis  and  Cheiro-pom-
pholyx, Tilbury Fox  and Hutchinson, of  London,  respectively,
described cases in which deeply imbedded, pin-head sized, acuminate,
primarily translucent vesicles occur upon the palmar and  inter-digital
surfaces.  Both  in consequence of coalescence and  increase  in  size,
bullae may subsequently form an inch or more in  height, filled with an
alkaline or slightly acid fluid supposed to be sweat.   Partial  absorp-
tion  occurs if the lesions be undisturbed, after  which desquamation
ensues from a reddened non-discharging  surface.  The  cuticle about
the lesions may be sodden, and macerated, or reddened;  it is usually
painful and  swollen.  There is often produced a sensation of prick-
ing, burning, or itching.   The eruption is most commonly discovered
upon  the hands, and less frequently upon the  feet; though other por-
tions of the body may be involved.
   Xo little controversy has arisen respecting  the exact nature of this
disease, Fox and Crocker, on the  one  hand,1  claiming a  sudoral
origin for the malady;  while Robinson2 concludes, from a careful

  i The Histology of Dysidrosis, London, 1878, from Trans, of the Path. Soc. of London, vol. xxix.,
1878
  2 Pompholyx, Arch, of Derm., 1877, vol. iii. No. 4, p 289. 
106
DISEASES  OF  THE  SKIN.
study of a single case, that "everything points against its being an
affection of the sweat-glands."   In his treatise this author names the
disorder pompholyx, classes it M'here it  properly  belongs among the
exudative affections of the skin, and describes it as a neurosis.  The
evidence on  this point is striking.  Fox says:  "  I  never knew any
patient  Mrho  had  this disease   ....  well."  He describes a
condition of  well-marked  cachexia  in  all   his  cases.   Robinson's
patient  was sickly for years, had tM'ice suffered  from fracture of the
femur, had lost three of six children, and Mas " depressed."  The
severest lesions exhibited  by patients  observed by the author, Mere
those in a woman who had  chronic enlargement of the spleen; and
in a man who was profoundly cachectic, suffered from night sweats,
had a sallow  hue of the skin, and subsequently died paraplegic.
   Geber, however, in studying two cases of this kind in middle-aged
men coming under his observation, believed that the lesions were not
pemphigoid.

   HiEMATiDROSis, or bloody sweat, reported  as observed by several
authors (Foot, Ebers, Parrot), is a name applied to conditions  in
which blood  has been seen to exude from an unbroken skin.  The
phenomena described  under  this title  belong  properly to the en-
semble  of symptoms  called haemophilia, and may in  some cases  be
due  to  direct  transudation  of  red and  white blood-corpuscles and
fibrine  into the inter-epithelial  spaces traversed by the sweat-pores.
Geber points  to the neuralgic, hyperaesthetic, pruritic, or  emotional
symptoms  that are usual precursors to the flow of pale or bright red
blood.  The  fact that the patients thus affected are mostly  women,
hysterical,  dysmenorrhceic,  or  near the  puberal epoch, also  throws
light  upon these cases.  In many of them  petechiae, or  signs  of
hemorrhage into other tissues of the body, were observed.

   Iu  the effort to eliminate certain substances, accidentally or other-
wise introduced  into the  system, the  sweat may  possibly become
charged  Mrith  iodine, turpentine, tar,  arsenic,  phosphorus,  and other
articles.  After the ingestion of the last-named  substance, the secre-
tion  is  said   to  have  occasionally become  luminous.   Doubtless
several  of the  eruptions  described  iu  the  chapter  ou  dermatitis
medicamentosa are due  to  a  similar  eliminative effort, especially
those  accompanied by excessive sMreating and  the  production of
vesiculation.
   With equal reason it may be  inferred that the sweat is at times
charged with  excrementitious and other products of the body;  as,
for example, the principles of the bile.   During the late civil war the
author observed several patients affected with yello\v fever Mdiose skins
exhibited the characteristic hue of that disease, aud whose sweat M'as
similarly  colored.   The  so-called " Galactidrosis,"  from  supposed
metastasis of milk, does  not occur.  Cases thus described have been
instances of pathological sweat in the puerperal  state. 
SEBORRHCEA.
107
              2. Of the Sebaceous Glands.

 • The disorders named in this group all  depend upon functional
derangements of the sebaceous glands, whose office, it Mill be remem-
 bered, is the supply in part of  the  physiological unguent  of the
 skin and hairs.   What  proportional part of this process is borne by
 the coil-glands, and what part by the sebaceous  glands, it is difficult
 to determine.  It should be  remembered  that the varieties of acne,
 which is a disorder of the sebaceous glands and their  periglandular
 environment, are described  in Class II., among the inflammations of
 the skin.

                           Seborrhcea.
                  Lat. sebum, tallow;  Gr. peu, to flow.

 Seborrhcea is a functional  disorder of the sebaceous glands, exhibited in an
  abnormal condition of the secretion as it collects upon the surface of the skin.
  This disorder is also termed  Steatorrhea, Acne Sebacea, and Dandruff.

   Symptoms.—Seborrhcea occurs in two forms, according to the con-
 dition of the excreted  product.   These are  known  as seborrhcea
 sicca and seborrhea oleosa.    The tMro forms are recognized clinically
 as of separate occurrence;  and also as existing  occasionally  at  the
 same time in one person.  Either form of the  disease may be limited
 to certain sites of preference,  or be generalized so as to extend  over
all portions of the body provided with  sebaceous glands.  The most
common  seats of the disease are: the scalp, the  face,  the genital
 region, the  dorsum of the body between the scapulae, and  the anterior
 surface of the chest.  It appears  at all periods of life, and in  both
sexes.   As  the  sebaceous glands are mainly appendages of the hair-
 follicles, the lesions of the disease differ somewhat, according as they
occur in  the regions covered M'ith long or lanugo hairs.   In the same
proportion, a difference exists in the career  of the disease.  At times
it is a  trivial  and short-lived  affection ; at  others it is persistent and
intractable,  lasting for years,  and possibly for a  lifetime.  The indi-
viduals  thus  affected  exhibit a  difference   also  with  respect  to  the
general condition of their  health.  Some  are  anaemic, chlorotic, or
asthenic  ; some  are of the  sanguine temperament, fleshy, red-faced,
and thick-skinned; others  again  are  absolutely  healthy, so  far as
cau be discovered, except for  the local sebaceous disorder.  This last
fact is  one of  some significance.  One may see exaggerated  types of
seborrhea in vigorous men  who have worn  for one month merely, a
skullcap, to which  Mas fastened an apparatus for relief of fracture
of the lower jaw.
  The skin affected M'ith a  seborrhcea is usually anaemic, and  either
dry or humid.  In  such cases the  subjective  sensations  are  either
slight  and  limited to a moderate  degree  of itching,  of which  the
patient docs not complain until  he is questioued  upon the subject, 
108
DISEASES  OF  THE  SKIN.
or altogether wanting.  At other times the glands, or periglandular
tissues, are affected M'ith a mild form of inflammation, and  then the
involved surface may be reddened and become the seat of a  consider-
able pruritus.

                  Seborrhcea Sicca (or Squamosa)

is the most common of all forms of the disease, and occurs upon
both  the  hairy  and non-hairy portions of the integument.   In the
former situation,  M'here it  is  vulgarly known as " dandruff,"  it is
called—

   Seborrhgea  Capillitii, iu  consequence of its  limitation to the
hairy  scalp.   In  its  ordinary manifestations, the affection  is recog-
nized  in  the  adult,  by  the  formation  in  this region,  of greasy,
whitish or yellowish pellicles of dried  sebaceous matter, which  may
be freely  shed from the surface and cover the shoulders of  the indi-
vidual whose  scalp is  involved.   At other times these fatty plates are
more or less  adherent  to the  scalp surface, or piled up in laminae,
one  upon another.  These  may closely mat  the hairs together, per-
ceptibly near the exit of the latter from their follicles;  or be abun-
dantly  disseminated through the mass of the hairs,  some of which
penetrate  a flattened greasy  scale, as a tM'ig might be passed through
the centre of a leaf.  In consequence of their deprivation of unguent,
the hairs to which the affected glands are accessory, become dry and
lustreless,  and  fall from  their  follicles.   If the  process  be  not
arrested, atrophy of the hair-follicle ensues, and the resulting alopecia
is permanent.
   Fortunately,  the seborrhcea is usually symmetrical,  and,  corre-
spondingly, the baldness  M'hich it  occasions.  The  disfigurement
then resulting is of the character of symmetrical senile alopecia, and
is chiefly annoying as the loss of hair is  premature.  When the loss is
asymmetrical, which is  decidedly the exception, the disfigurement is
greater.
   The affection  may be circumscribed, and in conspicuously selected
patches where thin, mealy, grayish, or whitish scales cover the p'atch :
or thick yellowish masses may paste the hairs firmly to the surface
of the scalp.  The disease  may  also extend over  the entire surface
of the scalp uniformly; or, as  is frequently  noticed, fringe the brow
at the line  of the hairs,  and theu extend chiefly over the vertex,
being conspicuous at the line where the hairs are parted from vertex
to brow.
   Beneath the scales or  crusts of dried  sebum the  scalp is usually
lustreless  and of  a slate-gray  color.   As the disease  does  certainly
occur at times  in types intermediate between functional and inflam-
matory forms, the adjacent  tissues  may present a hyperaemic or
even  exudative  feature, M'ith true epithelial desquamation  and con-
siderable  itching.   One group  of  cases, assignable to  this  class,
deserves attention.  In them there is a tolerably well-diffused sebor-
rhcea sicca of the  scalp, and, here and there, irregularly distributed 
SEBORRHCEA.
109
 over the surface,  are  filbert-sized, generally circular,  dark reddish
 patches, covered with a moist secretion or a friable, granular, reddish
 and yellowish crust.  These are scalp excoriations produced by the
 finger-nail.   They are most common in "nervous" patients, Mho
 cannot resist forcibly digging  the scalp on slight provocation.
   Occurring in infancy, the disease is well  known as " milk crust,"
 or as crusta lactea.   This may be  merely persistence of the dried
 yernix caseosa about the vertex in the newlv born, or it may occur
 in scalps which have been perfectly cleansed 'after birth.  The crust
 differs  somewhat  in color with the  tint of the child's complexion ;
 and may vary from a light yellow  to a dark  brown.  It may be
 thick,  greasy, and  mat the hairs together; or  be  thin, dry, 'and
 friable.   It is a frequent complication of the eczematous disorders
 of this region, and, as  a consequence, more  often in the adult, every
 variety of hyperaemia and inflammation may affect the tissue beneath
 the crust.   Ln infants and children, however, the  resulting alopecia
 is never permanent,  as  the rapidly growing follicles hasten to repro-
 duce the hair.  The disease is also  neither contagious  nor  followed
 by cicatrices, points  upon  which mothers are usually solicitous.
   The regions of the  brow,  the surface covered by the beard of
 the male, and the  pubic hairs may be involved in  the disease.
   Seborrhcea of the non-hairy portions of the body mav exist upon
 the face (forehead,  cheeks, chin,  and nose), trunk, and genitals.

   Seborrhcea Faciei is characterized chiefly by the accumulation
 of thick, dirty-yellowish,  and  even yellowish-black,  accumulations
 of sebaceous  matter, often  adherent  to the surface  and  disfiguring
 the  features by the  artificial mask  produced.  This is exceedingly
 conspicuous about the  nose, M'here the disease is at time symmetri-
 cally disposed.  There  Mas lately exhibited to the medical class at the
 author's clinic, a young woman with a complete cast, covering the nose
 uniformly from root to alae, composed of only yellowish-grav sebum.
 Such masses once removed, the skin beneath is generally found to be
 pallid  or slightly  reddened, with the orifices of the sebaceous ducts
 patulous;  while the  under surface of the separated crust is  seen to
 project  doM'nward in  corresponding delicate prolongations,  which
 Kaposi compares  to stalactites.  The crusts are rapidly reformed
 when the disease is not arrested.  They are found in  the  furroM's on
 either side of the nostrils,  on the brows, the cheeks, and the pavilion
 of the pinna of the  ear.   They are most  common  at the puberal
 epoch in both sexs, M'hcn  the sebaceous glands of the skin undoubt-
 edly sympathize with the changes occurring in the beginning  of  the
 sexual life.

  Skborrhcea Trunci is chiefly seen about the clavicles, scapulae,
sternum, and umbilicus.  Its features  are less pronounced than those
of some other localities, probably because the friction by the clothing
even in persons who neglect the  care of their skins, serves to stimu- 
110
DISEASES.OF  THE SKIN.
late to a moderate degree the sebaceous glands of these regions.  The
disease occurs here in circumscribed or, more frequently, illy defined
patches M'hich by confluence  may describe  irregularly reticulated
figures of reddish tint, when, as is  usually the case, the few loosened
fatty plates have been removed  by friction.  According to Duhring,
mIio has carefully studied these features, the chest patches are circular,
pale reddish in color, defined in outline, separate or associated in large
groups, and covered with  withered, greasy, grayish-yellow pellicles,
the eruption here  much resembliug ringworm of  the body.   About
the umbilicus, the fatty matters are remarkable for their tendency to
speedy decomposition, with the production of an exceedingly  fetid
odor, which may prove to be the source of a mild grade of inflamma-
tion.   In the latter event, a reddish  halo surrounds the  umbilical
depression, M'hich may be the source of a thin, sero-purulent discharge.

   Seborrhcea Genitalium is usually located in men in the'sulcus
behind the corona  glandis, though in individuals with a  tight  or
redundant prepuce  it  may be more extended.   In women,  the
accumulation  occurs about the  clitoris and  vestibulum, though the
external  labia may  be covered M'ith the  secretion  in  various degrees
of fluidity.  The  smegma  preputii supplied by the glands of Tyson
may be thus the source of trouble  either  by its retention, or secretion
in abnormal quantity or quality.   In either event the tendency, as in
umbilical seborrhcea, is to decomposition, fetid odor, and subsequent
irritation, M'hich may provoke inflammation of severe grade.   The
retention  of  this  smegma  beneath a  tight  prepuce in  the male
may provoke  a long list of reflex  symptoms, such as incoordination
of movements in the lowTer extremities, nocturnal enuresis and pollu-
tions, hernia, and  irritability of the testis.  In  some cases the secre-
tion forms a ring as hard as the rind of cheese encircling the glans.
It should be remembered that the young of both sexes as  well  as
adults  are liable to be thus affected; and that in young female chil-
dren these symptoms may have a medico-legal interest in connection
with suspicion of criminal  attempts.

  SEnoRRHCEA Generalis, affecting the entire surface of the body,
is an exceedingly rare disorder.  It has been described by authors as
Ichthyosis Sebacea, Cutis Testacea, and Pityriasis Tabcscentium.  In
the infant, the skin is universally spread with a greasy layer, rapidly
renewed after removal, beneath which the skin seems  to be varnished
in reddish-broM'n  shades.   The consequent stiffening of the  integu-
ment produces painful  fissures, inability  to take the nipple, and con-
sequent marasmus.   In adults, there is noticed the same marasmus ;
M-ith greenish to blackish crusts  covering the trunk and  extremities,
and desquamation of lamellae of the sebaceous  accumulation, corre-
sponding, for the most part, to regions of the skin  mapped out by its
normal furrows and  folds. 
seborrhcea.
Ill
                         Seborrhoea Oleosa

 is in its pronounced features rarer than seborrhcea sicca;  but to a less
 distinct degree is a condition sufficiently common in many forms of the
 disease.  Here the sebaceous secretion is poured out as an oily fluid
 upon the surface both of the hairy and so-called non-hairy parts  of
 the skin.  In the former situation, both in adults and infant's, the free
 oily substance is seen to cover as a coating both skin and  hairs, and,
 especially in bald adults, to produce a glistening and shining appear-
 ance of the seal]).  It often concretes into masses which are described
 above as the crusts of seborrhoea  sicca.   The same greasy layer cau
 be seen in the non-hairy  portions of the skin, especially about the
 nose, forehead, and checks.  Free drops of oil can be  occasionally
 wiped  from  such  surfaces M'ith a  handkerchief.  The ducts of the
 sebaceous follicles are  here  either patulous or plugged M'ith  come-
 dones ;  the surface may be reddened or pallid, but is usually cold to
 the touch.  The oily substance serves to entrap particles of dust, soot,
 etc., floating  in  the  air, and  often thus  a  peculiarly dirty or even
 blackish hue of the face is produced.  Some of the forms of seborrhcea
 described  above in connection M'ith the umbilicus and genitalia, are
 of this  variety.  In the negro, M'here the sebaceous glands are usually
 well developed and active,  the oily forms of seborrhea are common ;
 and the flux, at times, almost physiological.  Even  in the absence of
 their frequent anointing with palm-oil, one can sec the naked blacks
 in  Africa M'ith exposed skins shining from exuded grease.

   Etiology.—Seborrhoea may be due to local or general causes.   This
 is a point which  should be  clearly understood, as  Hebra, with his
 superb  powers of observation, noticed  that the  majority of his cases
 occurred in young male and female subjects affected  M'ith chlorosis or
 conditions analogous to that state.  It  is a clinical fact of ready veri-
 fication ; but it is clear that many cases are essentially of local origin ;
 and, as before indicated, a  seborrhcea  can be artificially produced in
 a  healthy individual in the  course of a  few Mccks  by very simple
 local measures  without interference  M'ith  the general   economy.
 Women with  long hair are  usually disposed to take special care of
 the scalp, upon which it grows.   Men  with short hair are more apt
 to attend chiefly to its disposition  upon the head, and to neglect the
 care of the scalp.   For the  seborrhcea sicca of the hairy parts, neglect
 of the scalp is a frequent cause; for the same disease of the non-hairy
 portions of the skin, in by  far the greater number of all  cases, chlo-
 rosis, struma, malnutrition, obstinate constipation, disorders of  diges-
 tion and  menstruation, and sedentary  habits of life, are  unquestion-
 ably  responsible.   The  exanthematous and other  fevers  are  often
 followed by asthenic states in M'hich  the same condition prevails.
 Hebra  has  pointed out the fact that the  sebum of  individuals M'ho
 have  fattv livers from  chronic  alcoholism,  is  peculiarly  fluid and
oily;  and it will be observed  that few  of all  the  disorders of the 
112
DISEASES  of  the  skin.
sebaceous glands characterized by inspissation of the secretion occur
in such persous.
   Pathology.—It will be remembered  that the sebaceous secretion is
produced iu consequence  of a fatty transformation  of the epithelia
lining  the acini  of the sebaceous glands; it is, therefore, directly de-
rived from the living matter of the protoplasmic elements of the rete.
A seborrhcea  is, therefore, strictly speaking,  a catarrh  of the  epi-
dermis;  and the name is in this connection properly  used, since most
of the so-called catarrhs of the skin are in reality not such, the effused
fluids being furnished by the bloodvessels.   Typical forms of sebor-
rhoea are  strictly anomalies of secretion  only, unaccompauied by in-
flammatory processes in either  the glands  or periglandular  tissues.
While other exceptional forms are without question thus complicated,
the variations  in the  sebaceous  product  as to  quantity, inspissation,
fluidity,  tendency to  rapid  decomposition  and exhalation of fetid
odors, may be  due to variability in the transformation of the epithelia
into fat under the influence of the trophic nerves, but this is a matter
of conjecture.   It is certain  that these conditions  are largely under
the influence of external agents, such as  friction, temperature, and air
currents.  In  many cases the product of  the disorder  is composed, for
the greater part, of epithelial masses mingled M'ith a relatively small
quantity of sebum, thus justifying further the view explained  above
regarding its catarrhal nature.
   The unguents naturally found in excess upon the body or parts of
it, such as the vernix caseosa, are, of course, physiological in character.
   Diagnosis.—Seborrhcea is to be distinguished from :

   Eczema.—The objective points of difference between eczema and
seborrhcea depend upon the inflammatory character of the first named
disease, easily recognized,  M'hether upon the  face or scalp,  by the
reddened, infiltrated, or discharging skin, and the considerable degree
of itching which it occasions.   In squamous eczema, the scales are
rarely  so abundant as to be shed freely from the surface,  and are not
greasy.  It should be  remembered, however, that the two diseases
may and do coexist.   Eczema of the scalp in infants  is especially apt
to be accompanied by a seborrhoea, a  fact M'hich  clearly shows that
the technical distinctions between  many  diseases, useful  though they
be for  analytical study, are not always capable of clinical demonstra-
tion.

   Ichthyosis.—This is a congenital  disease, usually involving the
entire  surface  of the body, while seborrhoea  is generally acquired,
and  rarely  universal.   The distinction  between ichthyosis and the
rare generalized  forms of  seborrhcea, described above, might involve
a difficulty.  But  in  the  latter, the greasy  charactei of the crusts,
their color, and the marasmic condition of the subject of the disease,
would  sufficiently distinguish the two disorders.

   Impetigo and Impetigo Contagiosa.—Here the only possibility
of error would originate in the discovery of either of the two diseases 
SEBORRHCEA.
113
 named, in the stage of crusting, especially upon the scalp.  But both
 are  acute  disorders, M'ith crusts much  bulkier than the sebaceous
 matters formed in seborrhcea, and beneath such crusts the integument
 is reddened and evidently the seat of an exudation.

   Keratosis Pilaris.—In this disease,  also,  there is  a  chronic
 accumulation of matters, partly sebaceous, on the hairy and non-hairy
 portions  of the skin.  But, unlike  seborrhcea,  the  sebo-epithelial
 heaps are  here aggregated in pin-head  sized masses  about the hair-
 follicles  only, and never  accumulate in such quantities as to paste
 the  hairs  to the surface.  The disease is also most common  on the
 extensor surfaces of the extremities.

   Lupus  Erythematosus.—Hebra, in 1845, described a Seborrhcea
 Cougestiva, M'hich it  would  be  indeed  difficult to distinguish from
 lupus erythematosus,  as the  two are practically  identical.  Typical
 cases of the two diseases are widely different and readily distinguished;
 the atypical forms might lead to confusion.   But lupus erythematosus,
 though occurring on the face, is rare on the scalp; it is accompanied
 by infiltration and the production of a new growth; and is followed
 by a characteristic scar.   Its lesions are darker red than the conges-
 tive patches beneath certain seborrheas of the non-hairy parts.  The
 scales of  lupus are  tenacious  and  dry, and  require scraping for
 their removal;  those  of seborrhcea are readily detached, greasy, and
 often cover the shoulders of the patient.  The contour of the sebor-
 rheic patch is ill defined,  M'hile that of lupus is very  distinct, excep-
 tion being made of the mask-like crusts  seen in certain of the facial
 seborrheas, when the greasy character  of the layer is very evident.
 Lastly, seborrhcea is a  disease of puberty chiefly, while  lupus erythem-
 atosus is  likely to  be first  seen in  the  earlier years of childhood,
 M'hen facial seborrhcea is rare.

   Psoriasis.—Psoriasis of the scalp may resemble seborrhoea sicca.
 But the latter is rarely developed in such a universal  exanthem as is
 frequent in the  former.   Few doubtful cases will come under obser-
 vation, in which a psoriasic patch on the elbow, knee, leg, or sacrum,
 will not  point to the  nature of the disease.   The  scales of psoriasis
 are  lustrous,  larger, and  not greasy, unless fatty applications have
 been  made to soften them; and the}' cover, moreover, a reddened and
 exuding patch of integument.  Psoriasis of the scalp and face prefers
 the areas of the  forehead adjacent to the hairs of the scalp, and rarely
 departs boldly to the nose and the furrows beside the nostrils, favorite
 sites of a seborrhea.

   Syphilis.—Some forms of the pustular syphilodermata  located
 upon the  scalp and face, if  observed  only in  the stage of crusting,
 might be confounded with seborrhea.  Here the history of the case,
the discovery  of other  signs of syphilis (adenopathy, mucous patches,
etc.),  and the  puriform character of the secretion beneath the crust,
                                8 
114
DISEASES  OF THE  SKIN.
should point to the identity of the disease.   In syphilitic crusts about
the angles of the nostrils, there is often a peculiar reddish-brown tint
of the skin at  the edge of  the patch, the so-called " copper " color,
M'hich is significant.   Crusts of the hairy scalp iu syphilis  are very
often  accompanied by post-cervical  adenopathy, and especially by in-
durated enlargement of* the occipital glands.

  Tinea Circinata and Tinea Tonsurans.—In ringM-orm  of
the hairy parts, as also of the body, the  microscopical discovery of
the parasite Mill ahvays point to the nature of the disease.  Upon the
scalp, the affected  patches are seldom as diffuse as in seborrhea;  are
usually circular; are often accompanied by fragility of the hairs; and,
in the latter case, the  discovery of stumps  of hairs is  significant.
There is also a history of contagion and absence of the greasy condi-
tions  of the scales characteristic of seborrhea.

   Treatment.—The  internal treatment of seborrhea  is often of the
highest importance.  The preparations most often indicated are: Iron
in anaemic  young women; cathartics in sluggishness of the boMels;
and cod-liver  oil when there  is  impairment of nutrition.   Duhring
recommends the sulphide of calcium in doses  of  from one-tenth
(0.0066) to one-fifth (0.0133) of  a  grain.  Arsenic, employed in  the
manner suggested by Sir Erasmus  AVilson, is praised by Hebra:

      R.  Vin. ferri                     f^jss;       50
          Syrup, simpl.        j            f ..         g|
          Liq. potass, arsenit.   j              •"
          Aq. destill.                      ffij;       601     M.
      S.  A  teaspoonful to be taken three times daily with the meal.

   In  many cases, the acid iron mixture of Startin, or some modifi-
cation of it, admirably meets  the indications present:
      R.  Magnes. sulph.                  ^ij;      64!
          Ferri sulphat.                Bss-'^j ;   0.66-1133
          Acid, sulph. dilut.           f^ij-fSiv;     8-161
          Infus. quassise                adf^iv;     128     M.
      S.  A teaspoonful in water, through a tube, after eating.

   The preparations of malt  and mal tine, now  largely employed in
the treatment of wasting diseases, will be found available in cases
where the  cod-liver oil cannot be  M'ell  taken.   Lastly, the bitter
tonics may be needed.  Throughout the treatment, the  physician
should insure a careful observance  of the laws of hygiene.   Sunlight,
nutritious  food, and open air  exercise are not to be disregarded.   In
the large  cities of  this country,  many  young  women  of indolent
habits are  greatly benefited by sending them to the riding-schools for
an hour's equitation daily.
   The  indications to be met by local  treatment in  seborrhea are:
first,  the removal of the crusts and the fatty matters accumulated
upon the  surface: second,  the  restoration of the deranged function
of the glands. 
SEBORRHCEA.
115
  Upon the scalp, it is always M'ell to warn patients, especially if the
disorder is aggravated, and occurs in young women with apparently
luxuriant  tresses, that a considerable loss of hair will result.  Many of
the filaments are so impoverished by the chronic course of the disease,
and so loosened in  their  follicles, that a complete cleansing of the
scalp surface will bring them  aM'ay in quantities sufficient to threaten
a speedy baldness ;  and it is not rarely the case that patients attribute
this to the treatment rather than to the disease.   The fatty accumula-
tions  are  first to be  soaked   in  some oily fluid to facilitate their
removal;  and for this purpose olive  oil, cod-liver oil, vaseline, cold
cream, almond  oil, glycerine, or lard is usually employed.   The
article selected should be used in excess, and in quantity sufficient to
permeate  all crusts.   It  may  be poured over or rubbed into the scalp
several times in the twenty-four hours; and at night  a flannel  or
other  cap be worn to insure still  further success.   In the case of
children  and infants, considerable gentleness  is required  in  thus
treating the scalp, especially  in the  subsequent M'ashings,  lest the
surface be irritated.   In young women it  is rarely necessary to cut
the hairs.   As soon as the soaking with oil is  insured, the crusts are
to  be  removed  by M'ashing with soap and  water, though when the
accumulations are bulky, masses may be gently removed with fingers
or comb.   When the  scalp is quite tender, ordinary toilet, or Sarg's
glycerine  soap, may be applied with warm water; but it is usual, in
the case of adults,  to employ the spirit us saponis kalinus of Hebra,
two ounces (64.) of green soap digested in one (32.) of alcohol, filtered
and flavored with  lavender   or bergamot.   The surface  should be
thoroughly sponged M'ith the spirit, and  then warm Mater added till
the foam  of the lather is  abundantly produced over the scalp, M'hen
an  excess of Mater is finally used to  cleanse the  part of both crusts,
oil, aud soap.   The scalp  and hairs  are  then  thoroughly dried,  and
anointed  with some bland, fatty substance, if  the surface exposed  is
tender and irritable;  if not,  with some stimulating pomade.
   The last-named precaution is an important one.  However exten-
sive the seborrheic crusts, it is possible  to remove  these completely
by the measures described above, in every case; and M'ith  the  first
experiment  patients are often delighted.  Their disappointment  is
correspondingly great M'hen they discover that the seborrhea is not
yet at end, and  that, in  the course of a few days, the fatty plates are
as  freely  as ever deposited  on the scalp, disseminated through the
hairs,  and  showered  upon the shoulders.  Some will  even declare
that the soapy applications aggravate the disorder by increasing the
seborrheica.   It should, therefore, never be forgotten that, having got
rid of the extraneous matters accumulated upon  the surface, there is
still to be remedied a functional disorder of the  sebaceous  glands  of
the part.
   In everv case, then, after the use of the soap and M'ater, which may
be  repeated as often as need be, daily, at intervals of several days,  or
once in the M'eek, the scalp is  to be  thoroughly anointed.   For this
purpose olive oil, cod-liver oil properly scented, almond oil, vaseline, 
116
DISEASES  OF  THE  SKIN.
 or glycerine and water, may be used.  In  the course of a few days,
 in most  instances, a  more  stimulating  plan of  treatment may be
 adopted ; and, in that event, alcohol may be combined, for example,
 with the oil of sweet almonds, half an ounce (16.) of the latter to five
 ounces (160.) of the  former, to which  half a drachm (2.) of carbolic
 acid may be added, the whole  flavored with the oil of bergamot.
   Van Harlingen recommends the oleum  moringae  nucis, or oil of
 benne, as a substitute for others, since it  does not dry and clog, as do
 the latter.  An ounce (32.) of this rubbed  up M'ith five grains (0.33)
 of powdered benzoin, and digested for three hours over a water-bath,
 with the addition of three  drops of absolute alcohol, and filtered,
 furnishes an excellent basis for oily mixtures to be used on the scalp.
   Dr. Morison,1 of Baltimore, has devised  an ingenious instrument
 for the application of oily fluids to the scalp.   The latter are retained
 in a small  reservoir, to which  is connected  a comb M'ith  perforated
 teeth.   Through the latter the article  selected for medication  of the
 scalp readily passes down to the surface between the hairs.
   In  the place of oils after these ablutions the ointments are often
 used with more advantage.   For this purpose the beuzoated oxide
 of zinc  ointment, cold cream, or salves  containing ten per cent, of
 tannin may be applied.
   In cases where milder effects are required, the scalp may be washed
 iu water containing such alkaline substances as borax, ammonia, and
 the  carbonate  of potassium.   The popular  prejudice against  these
 articles is based  upon  the abuse of strong alkaline  lotions  in the
 hands of inexperienced persons.   Such lotions may be readily  tested
 by the  tongue  for  the degree of softness required for the  scalp.
 They should, in the management  of all cases, be followed by an oiling
 or greasing of the surface.   Women solicitous about  their personal
 appearance are apt to object to such  inunctions, preferring greatly
 the drier conditions of the scalp and hair,  a  prejudice often respon-
 sible for the disease in question.
   Veiel recommends the following formula :
      R.  Extr.  cinch, frig. par.          £)j ;             U5
          Bals. peruv.              gtts. xv;             1
          Cantharid. tinct.    gtts. xxiv-3ss;         1.5—2]
          Succ. citri                  fflxv;             1 j
          Ungt. pomat.                Jjss;            501        M.
      S. To be rubbed into the scalp once or  twice daily.

   The  tars  are  useful in  many obstinate  cases.   Tar soap may  be
employed in the washing ;  or the  oleum  rusci added in the strength
of one to ten parts to the other salves recommended above.   Ichthyol
in ointments of  the strength of five to  ten  per cent., and resorcin  in
spirit lotions of ten grains (0.66) to the ounce (32.) have also proved
efficacious.
   Repeated applications and patient care  of the scalp are necessary to
secure complete relief  in the case of a disease as  essentially chronic
as seborrhea.   At times the local  treatment may be changed with
1 Maryland Med. Journ., January, 1885 
SEBORRHCEA.
117
advantage.  Sulphur enjoys a high reputation in the treatment of all
sebaceous gland disorders; and in the form of an ointment, one to two
drachms (4.-8.) to the ounce (32.) of cold cream, it is often of service.
The author has used M'ith success the hypochloride of sulphur, which
has lately come into our markets from the  English laboratories.  But
it  is open to  objection on account of its odor, which can scarcely be
disguised.   Beside  these, the  tinctures of  cantharides, capsicum, and
nux vomica are frequently incorporated m ith advantage into lotions
and pomades for use upon the scalp.   Most of the latter can be made
sufficiently fluent for use in this situation,  by adding a drachm (4.) or
two (8.) of glycerine to the ounce (32.) of  lard  or cold cream.  The
alterative effect of the mercurials is also as evident here as  in  many
other cutaueous disorders.   At the head of the  list, for  this special
purpose, stands the red oxide  of mercury in the strength of from two
to four  grains (0.133-0.266) to the ounce (32.) of ointment; but the
white precipitate, the ammoniated mercury, and calomel,  in the pro-
portion  of five to ten grains (0.333-0.666)  to the ounce (32.) may be
often substituted for the former with advantage.   Solutions of cor-
rosive sublimate, in  the strength of two to  four grains (0.133-0.266)
to the ounce (32.) of fluid, may prove of use in obstinate cases.   Hil-
lairet recommends a lotion containing from tMO  to four fluidrachms
(8.—16.) of sulphuric ether and two to four  drachms (8.-16.) of borax
dissolved in eight fluidounces  (256.) of distilled Mater.
   Viguier advises  the following  lotion for use in  seborrhoea of the
scalp, in those cases more particularly w here loss of hair is threatened  :
R. Santal. ess.		)		
Rosar. ess.		y aa n\,v;		30
Chimaphil. umbell.	ess	»J		
Pilocarpin. muriat.		gr. vijss;		50
Spts. vin. rectif.		3»j;	100	
Camphor, spts. 1				
Glycerin. >		aa 3j gr. xv;	5	
Cantharid. tinct. )				
Dissolve the pilocarpine	in	the alcohol, and then add the other ingre-		
dients.				
  The  treatment  described  in outline above,  may  be used  M'ith
success  also for the relief of seborrhea of the non-hairy portions of
the body, especially the face.  Here, it will be  observed, the  crusts
have a singular tendency to re-form, and  the most persistent care is
necessary  to  secure permanent relief.   Occasionally, after  cleansing
the surface by soap and  spirit  lotions, according to the indications of
each case, it is of advantage to apply the ointment selected for subse-
quent application, not only by gently smearing it on the part with the
tips of  the fingers (always  the most effective method),  but also by
spreading it on a compress, M'hich, for the night at least, may be fixed
in contact m ith the part.
  Unna's lead-plaster mulls, used for this purpose in Germany, may
be fairly  mcU  imitated  by  draM'ing strips  of  cheese-cloth  through
heated diachylon  ointment and  then  smoothly  smearing them M'ith
the same material. 
118               DISEASES OF THE  SKIN.
   When  this tendency to reformation of the crust is abated, one or
more  of  the dusting powders  may  be  at  times employed  M'ith
advantage for the purpose of protecting the skin or exercising upon
it an astringent effect.
   The local treatment of  seborrhea of  the genitals is somewhat
different.   Ointments  rarely answer well in disorders of  the mucous
surfaces ;  and the green soap is too irritating for similar employment.
Here washing with a good  toilet  soap and Marm water  is sufficient
for the purposes of cleanliness, and diluted lotions containing alcohol,
in the  form of whiskey, brandy, or aromatic  wine, suffice to procure
relief.   These can be made  astringent M'ith tannin, alum, or the zinc
sulphate, and, when there is pain or tenderness,  opium can be added.
In this form of the disease,  as also  in seborrhea of the umbilicus,
carbolic acid or the chlorinated soda may be  necessary to  correct
fetor.   In the generalized varieties of the disease the surface is  to be
thoroughly anointed with oil.   The body, especially that of infants,
is to be swathed in flannel or other good non-conductor of heat; and
a roborant treatment directed  to the general adynamia.
   In the  grave forms  of seborrhea of infants described  as keratosis
sebacea, ichthyosis sebacea, etc., the body must be kept anointed with
oils or fats.   Artificial feeding is demanded by the condition of the
mouth.
   Prognosis.—In forming a prognosis in cases of seborrhea, it  must
be remembered that  the disease is frequently an obstinate one; and
the resulting loss of hair, if symmetrical, may be remediless.  Much
may be done in the way of saving that which is left.  Facial sebor-
rhea is much more amenable to treatment; and  seborrhea of the
genitals and umbilicus is  an entirely manageable  disease.   When
the affection is generalized, the prognosis  is in the highest degree
unfavorable.

                            Comedo.
                      Lat. comedo, a spendthrift.
Comedo is a disease in which an inspissated secretion, lodged in the excretory
  ducts of the sebaceous glands, becomes visible upon the surface in yellowish-
  white or  brownish-black points.

   Symptoms.—Comedones  occur  exclusively in the ducts  of the
sebaceous  glands, and consist  of a whitish fatty  plug  formed by the
inspissation of the secretiou of these glands, one extremity of which
is visible at the surface when  the plug is in situ.   Occasionally they
project to  an appreciable  distance above  the general level of the
integument; but often the extremity of the plug is slightly depressed
below  that level.   There  may be but two or three  upou the face,
which  is their most common seat; or  the nose, forehead, cheeks, chin,
the front and back of  the  neck, and the back of the  trunk, and the
penis may be thickly studded with them.   The  visible extremity of
the comedo varies in size  from a needle-point to a pin-head.  They
arc readily expressed from the follicles in M'hich they are  lodged, and 
COMEDO.
119
 M'hen  thus examined are seen to be whitish moulds  of inspissated
 sebum, one to two lines in length, the exposed extremities of which
 have become blackened by the dust and dirt entrapped at that point.
 In consequence of this suggestive appearance of the mass, the disease
 has beeu vulgarly known as " black heads" and " skin worms."  The
 deformity produced in the face when these lesion* exist there in large
 numbers, is strikingly conspicuous; and  it is for  the relief of this
 chiefly, that the practitioner is consulted.   The subjective symptoms
 awakened are of trifling moment.  The disorder is essentially chronic
 in its course.   Isolated comedones may be observed for years in one
 situation without apparent change  or  modification of any  sort, and
 M'ithout producing the slightest local or constitutional derangement.
 Others appear, only  to disappear under the influence of the  usual
 hygienic regimen of the skin of the face.   Others, again,  serve  to
 irritate the skin in  which they are implanted, precisely as though
 they were foreign bodies; and the sebaceous glands and peri-glandular
 tissues, with and without the operation of such cause, exhibit grades
 of  hyperemia and inflammation.  Comedones may occur as the sole
 lesious of the skin, even to the extent of very great multiplicity;  or
 they may coexist with other diseases of the glands, chiefly acne.  They
 may occur at any period of life, but, like seborrhea, are most fre-
 quently observed at the puberal epoch in both sexes.  According to
 Kaposi, the disease tends to disappear in women earlier than in men,
 in  M'hose case it  may be  prolonged to the  twentieth  or  thirtieth
 year.
   Crocker1 has called attention to  the occurrence of comedones  in
 children, with a special tendency to grouping  in places subjected  to
 heat aud moisture,  and also to occurrence upon the hairy scalp.
   Occasionally a  so-called "double"  comedo is  formed, a plug  of
 inspissated sebum being expressed from the skin, each extremity  of
 which  is discolored.  Whether this  be due to a duplicity of efferent
 ducts in a single  gland, or to an artificial or pathological connection
 between two adjacent glands, is not clear.2
   Etiology.—Much  has been written with  reference to the improper
 care of the skin as a cause of comedo, the neglect of soap in washing
 the face, and the influence of the trades, as in the case of those who
 work in metals, dust, and tar.  But observation  shows that these are
 exceptional causes.   Very obstinate  and generalized lesions  occur  in
 the skin of  intelligent young men  and women of the upper social
 classes, who  regularly wash their faces M'ith toilet soap, are rarely
 exposed to dust, and  whose habits  and recreations are of the most
 healthful character.   On  the  other hand, observing the  grimy faces
 of coal heavers, machinists, masons, and  ink manufacturers, one  is
 impressed M'ith the  singular rarity of  the  disease in such laborers.
 The cause of  the  constipation of the gland is unquestionably to  be
sought  for elsewhere,  in the most of cases.  It is true that chlorotic
1 Lancet, April 19, 1884.
2 A. II Ohmann-Dumesnil: Journ. of Cutan. and Ven. Dis., February, 188G. 
120                DISEASES OF  THE  SKIN.
young women, affected also with  dyspepsia and torpor of the bowels,
may exhibit the disease;  and equally certain  that  many cases occur
in peculiarly thick-skinned brunettes, or  men with  a characteristic
reddish-broMn  and greasy-looking  complexion.    But  for  all  this,
many  such  never suffer  from  comedones, while  often a perfectly
healthy, fair-skinned girl  will be greatly, mortified by the  disfigure-
ment of her face.
                              Fig. 29.
 Section of a comedo,  a, excretory duct of a sebaceous gland filled with a comedo ;  it contains also
two small hairs with brush-like inferior extremities;  into it opens a small hair-follicle, c, whose
contained hair, d, after touching the opposite wall of the duct, curves downward at/.  (After Kaposi.)

  In yet other patients there is unmistakable connection between this
disorder and chlorosis, scrofulosis, dyspepsia, habitual constipation of
the bowels, menstrual derangements, and cachexia.   This connection
is  demonstrated by the remarkable improvement manifested in the
untreated skin when improvement of the general  health is  assured.
  Pathology.—The mass  termed the  comedo is  a collection of con-
centrically packed epithelial plates mingled with masses of cholesterine,
fragments of epithelia undergone fatty transformation, minute lanugo
hairs, and, occasionally, upon  the  exterior, the  acarus folliculorum.
This little mite, first detected  by Henle, in  the  ceruminous glands,
was by Simon and others once thought to be the cause of the comedo, 
COMEDO.
121
a view which is now abaudoned by all dermatologists.   The parasite,
in persons  upon M'hose skin it exists, can be detected in masses of
commingled sebum and epithelial plates scraped from the free surface
of the integument,  as  also upon the surface of  those M'ho  do not
exhibit any disorder of the sebaceous glands.  The comedo plug is
located either  in  the excretory duct of the sebaceous gland or in the
pouch-shaped  canal common  to  the sebaceous  gland and  the  hair-
follicle.  It will be remembered that in the class of sebaceous glands
chiefly involved in the comedo, the hair-follicle is rather an appendage
to the former, the relation between  the  tMro, evident upon the scalp
for example,  being here  reversed.   According to Biesiadecki, the
hair-follicle often forms  here an obtuse or even a right angle M'ith
the duct of the gland, and the point of the hair being thus projected
against the wall  of the duct, is  occasionally curved doMmvard upon
itself, exciting thus an irritation at the point of impact and subsequent
multiplication of the protoplasmic  elements lining the canal.  Thus
he explains the epithelial  character of the outer  envelope of the plug;
the special occurrence of the disease at the puberal epoch, when, as is
well known, there  is an  especially active  growth of the hairs; and,
lastly, the  frequent discovery of lanugo filaments in the expressed
contents of the common excretory duct.
   Diagnosis.—The recognition of the disorder is attended M'ith no
difficulty, patients  themselves being  usually sufficiently observant to
identify the affection, though frequently misled  as to the character of
the "skin  worm."   It is, as might be expected, a frequent coincident
of acne; its lesions, when commingled with those of the disease last
named, being  either in preponderance or so infrequent as scarcely to
attract the  attention of the patient.  A condition someM'hat resembling
the comedo may be produced upon the face M'hen tar, or ointments of
mercury and sulphur are  applied to it at the same time, the resulting
black  sulphuret appearing conspicuously at various points upon the
skin, often at  the orifices  of the sebaceous glands.
   Curiously  atypical  cases, however, are occasionally  observed, and
these might confuse  one  unfamiliar with the singular variations dis-
played in almost all sebaceous gland disorders.  Thus Cauty1 reports
a remarkable case in a boy ten years of age, who Mas somewhat im-
becile but well nourished.   The upper part of the back, both shoulders,
and the  outside of both  arms were covered with short bristles, of a
clear,  darkish brown-yellow color,  and acuminated apices.   These
bristles M-ere,  at  the edges of the  group, gradually shortened  from
their full length of three  thirty-seconds  of an inch, until they joined
the skin, M'hich  Mas at the junction raised into polygonal, flat disks,
finally graduating to the  sound integument  of  the hands, chest, and
back.   The feeling communicated to the hand on passing it over the
shoulders Mas exactly similar to that of touching  a coarse brush, and
the bristles gave May under the  touch, resuming  an upright position
i Medical and Surgical Journal, March 4, 1882, p. 237. 
122               DISEASES OF THE  SKIN.
afterward.   There were a few pink macula? over the body, and con-
siderable scaly thickening on  and around the patellas.   The bristles
were expelled comedones, containing very  few immature  hairs and
very little  sebum, drying up into a horny  substance.  They were
firmly  attached, requiring more force to remove them than to extract
a well-rooted  hair;  and  M'hen  removed  they left a  small, central
depression, surrounded by a circle of torn  epithelium, which retained
them in position.   They averaged one hundred to the  square inch,
and had existed over three months.
  A somewhat similar case was exhibited  by Dr. Warren,  before the
New York Dermatological Society, January 26, 1886, and described
as keratosis follicularis.
  Treatment.—The internal  treatment  of the patient affected M'ith
comedo is  largely that described  in  connection with  the  subject of
seborrhea.   Cod-liver oil, iron,  the  bitter  tonics,  and  preparations
indicated by any special condition of the  patient's  health,  are not to
be omitted.  Open-air  exercise,  bathing, and the  avoidance of all
medicinal and dietary articles M'hich  might  tend  to  aggravate  the
disorder, are also imperative.
  Even aggravated cases of comedo are completely relieved by natural
processes in the course of time.  These  processes are, however, slow,
and  may require years for their  completion.  The rarity of come-
dones  in  middle  life and  advanced  years  sufficiently attests this
fact.   Presumably this natural cure is due  to  the  more vigorous
groM'th of lanugo hairs M'ith the increment of age,  which thus push
forward slowly to  the surface the excrementitious mass,  until  it is
gradually removed by  ordinary  friction and ablution.  Absence of
comedones  from the scalp, where the hair is  vigorous, is certainly a
significant fact.
  Comedones are removed artificially by the  aid of an extractor.  The
instrument formerly  employed  for this purpose was  shaped like a
watch-key, the cylinder of  which  had a smooth bore and bevelled
extremity.   This clumsy tool is  far surpassed by the  exceedingly
convenient comedo-extractor  designed  by Unna and  modified by
Piffard (see Fig. 27).   Each end has a couvex bowl-like surface, with
apertures cut to gauge and the orifices slightly counter-sunk.  It is pro-
ductive of far less pain to the patient than other instruments, and can
be wielded, on account of its  long shank, M'ith greater precision and
ease by the physician.   The surface to be operated upon is best previ-
ously moistened by spraying it with a thymol and glycerine, or euca-
lyptol  and  glycerine solution.  Often a sharp-edged or well-rounded
needle, firmly held in a needle-holder, may be advantageously em-
ployed, alternately M'ith the extractor, in opening certain follicles or
somewhat loosening the plug of others.   All of these instruments
should  be  scrupulously disinfected  before  use.  With the present
knowledge had on the subject of transmission of disease, the  danger
of such manipulations as these with  uncleansed  instruments  should
never  be  overlooked.   Wigglesworth  suggests the performance of 
COMEDO.
123
the operation at  night;  and there are good reasons for selecting the
hour before retiring as the time for all vigorous topical applications
to the face.   Ointments  then applied can be left in contact M'ith  the
skin during the hours of sleep; and the patient be  at liberty to
resume  his usual vocation in  the daytime M'ith his  face free from
conspicuous evidence of local treatment.
   An ordinary watch-key, the thumb-nail, or a spatula  may also, on
occasion, be  used in the extraction of comedones, which  may be, if
few, removed at one sitting, or, if numerous,  on separate occasions.
Repetition of the process is usually required by the reformation of the
plugs.
   Once they are  removed, the skin should be sponged and bathed
with hot Mater, then thoroughly dried, and anointed M'ith an ointment
which may be medicated to suit the indications of each case.  Sulphur,
as iu all the functional disorders of the sebaceous glands, enjoys here
also the highest  reputation.  In the strength of one-half to  one
drachm (2.-4.)  to the ounce (32.) of cold cream or vaseline, it  may
be applied as an ointment;  or as a lotion, iu combination M'ith spirits
of Mine, glycerine, etc. The author has frequently used with advantage
the mild application suggested by Piffard in acne, equal  parts of sub-
limed sulphur, alcohol, compound tincture of lavender, glycerine, and
camphor water.
   Mercurials are also of some advantage locally, and, as before indi-
cated, should not be employed at the same time M'ith  preparations of
sulphur.   The use at night, especially in obstinate cases, of the white
precipitate ointment, or one compounded of two grains (0.133) of the
red oxide to the ounce (32.) of cold cream xvill often prove of benefit.
One to two grains (0.066  to  0.133) of corrosive sublimate  to the
ounce (32.) of glycerine and rose-water  may be  substituted  for the
latter in coarser skins.
   When the extraction of the plug is not  attempted  nor permitted,
something may yet be done to remove the inspissated mass.  Repeated
sponging  every third night M'ith one ounce (32.) of the green soap,
digested in an equal quantity of Cologne water, M'ill, at first certainly,
seem to render the comedo more conspicuous, but M'ill slowly operate
to dissolve the sebaceous secretion.
   Unna has lately observed that the blackish discoloration  of the
comedo extends to a certain  degree below the  external  extremity of
the plug, a circumstance, in  his opinion, militating against  the dust
and dirt theory,  by M'hich the hue of the comedo point  has  been ex-
plained.  He concludes  that this is the result of pigmentation,  such
as that producing the coloration of the hair, nails, and skin in several
other anomalous conditions.    Having this in  view, he  prescribes an
ointment containing four parts of kaolin, three of glycerine, and two
of acetic acid, with or without  the  addition of a small quantity of
ethereal oil.   This is applied at night, the eyes being carefully closed,
for a few nights  in succession, when  the black  points of the lesions
are removed, and the comedones then readily extracted.  Citric or
dilute hydrochloric acid is employed, M'ith the same  end in  view. 
121               DISEASES OF  THE SKIN.
The author has employed this formula  in  about fifteen  cases, M'ith
varying results.  It cannot be considered as efficient in every form of
comedo.
  Actors, actresses, and women of fashion will occasionally persist in
using variously colored toilet powders M'hile under treatment, the
injurious ingredients of which are often the cause of the disease.  The
practitioner may then either refuse to be responsible for  the care of
the  case; substitute a  harmless  for a  noxious  powder; or gently
anoint the face after his treatment of it with a blaud ointment, upon
the surface of M'hich the theatrical effects are subsequently produced.
In such cases the use of soap  and water M'ith each  dressing is even
more than usually imperative.
  Comedones of "the penis need  not be treated.   This injunction is
suggested by the occasional demand made upon the physician by the
sexual hypochondriac, who regards  these lesions M'ith a degree of
alarm M'hich he can best appreciate  who  has been  confronted with
these cases.
  Prognosis.—As the disease tends naturally to a spontaneous, though
occasionally  long-deferred resolution,  the  prognosis is  favorable.
Treatment in  many cases will accomplish much in hastening the re-
sult.  The most obstinate forms are  those in which the face, back of
the ears, inside of the  auricle, neck, and  shoulders are studded with
relatively small, indolent comedo points, about which the orifice of
the duct  rises in a whitish rim.  This,  M'hen  felt M'ith  the finger,
produces the impression of hyperplasia of the wall of the duet.  Such
cases, however, are nearly allied  to the forms of acne described else-
where.  With exceeding rarity, the comedo is merely the first step of
a more serious local affection.   In early life a single prominent lesion
is formed, and though the plug be frequently removed and finally be
no longer reproduced, the orifice of the duct remains  patulous in
middle life.   Slowly thereafter its Malls undergo a  metamorphosis
and a Marty epithelioma results.

                              Cyst.
                        Gr. kvgtiq, a bladder.
Sebaceous cysts are millet-seed  to egg sized and larger,  milky-whitish, or
  yellowish-white, encysted tumors  of the  sebaceous  glands,  occasionally
  having  the  color  externally of the normal integument,  either imbedded
  within the skin or projecting above it.
  The term sebaceous cyst is applied by some authors to one merely
of the two disorders  of the  skin to  which it properly belongs, viz.,
the wen.  In  these pages it includes  both milium and steatoma.

                          [Ad  Milium.
                      Lat. milium, a millet-seed.

  Symptoms.—Milia, also  called Grata, occur upon and about the
eyelids,  the  cheeks, the temples; the penis, scrotum, and  corona 
CYST.
125
glandis of men; and the internal  face of the labia minora of woman.
They are millet-seed  to  pin-head sized,  globoid masses,  rarely at-
taining the dimensions of a coffee-bean, showing within the epidermis
as though kernels  of  rice Mere  lying there immediately  beneath  a
translucent  layer  of  tissue.   • They  occasionally project  from  the
surface to such an extent  as  to  resemble small-sized vesicles filled
M'ith  milky  contents.  In color  they are  yellowish  and M'hitish.
They are often congenital;  and can be recognized about the lids and
temples  of the  newly born infant; they  are also  seen, hoM'ever, in
middle life, M'hen  they develop  very  slowly, and sometimes  persist
for years.  They  are  often observed in  the neighborhood  of cica-
trices, M'hich latter in  such cases  have usually been  effective in their
production.  They occasion no subjective sensation, and are usually
so insignificant as  to  induce  no deformity.   They  never degenerate
by ulcerative processes, but M'hen not artificially removed are, in the
course of years, exfoliated  in the natural  processes of physiological
desquamation.
   Etiology.—Milia are at times produced  mechanically, the stroke of
a knife-blade, accidentally or by the processes of surgery,  separating
one  or more of the acini of a sebaceous  gland from the main body.
The contracting bands of a cicatrix,  after the destruction of tissue
from any cause,  may operate in a  similar May  with a  precisely
similar result.   Having this  in view, it  may be said generally that
milium is always the result of a cause which prevents the transform-
ation of the epithelium lining the gland into fat,  and the subsequent
excretion of this upon the free surface of the skin.   These causes are
thus, for the most  part, obscure, but all are probably of purely local
significance.
   Pathology.—When  a milium is incised  externally, a spherical body
of nearly corresponding size may be expressed, though it may require
tearing  from  a  minute pedicle  beloM', M'hich represents the  attach-
ment  to  the  hair-follicle.  The  small  mass thus  extracted  is then
seen to be composed of several thin envelopes suggesting the capsules
of the onion, and representing cornified epithelia  not undergone fatty
metamorphosis, in  the centre of M'hich is a fatty nucleus.   This mass
represents the contents of one or more acini of a superficially situated
sebaceous gland, cut off from the main  body of the follicle in the
manner described above, and ahvays covered M'hen in situ, as Kaposi
has shoM'n, by a delicate layer of the superimposed corium containing
papille.  Usually  the orifice of the excretory duct cannot be appreci-
ated  in  milia, though occasionally these  lesions  are developed M'hen
the orifice is patulous.
   These  singular  bodies  do  not  ahvays  represent conditions  of
mechanically pent-up  sebum, as the  epithelia  from  M'hich their con-
tents are produced  seem at times indisposed  to fatty transformation
and  particularly apt to develop into horny or other formations. Thus
Foster  of Boston, describes one where the process of calcification had
been apparentl)' complete;  Wagner has observed  colloid contents in
certain opalescent  lesions which  appeared  in the  cheeks and temples 
126
DISEASES  OF  THE  SKIN.
of a woman; Barensprung and Hebra report numbers of acutely pro-
duced milia folhnving  pemphigus and erysipelas; and  Virchow and
Rindfleisch describe milia of the hair-sac and similar lesions accom-
panied by cyst of the hair-follicle adjacent,   It Mould seem rational
to conclude that, in cases, the cause of milia is to be sought in obscure
changes by which the epithelia of the gland  are primarily affected.
  Robinson believes that milia originate  from miscarried embryonic
epithelia from a hair-follicle or from the mucous layer of the  epi-
dermis.
  Diagnosis.—Milia might be mistaken for  minute vesicles contain-
ing a milky fluid, but  puncture of the lesion, with  expulsion of its
contents, would  at  once  disclose the  character of each.   Comedones
M'ith blackish  external points, surrounded by the patulous  orifice of
the excretory duct and prolonged more deeply into  the substance of
the skin, could scarcely be confounded M'ith milia.
  The  most minute of  the lesions of xanthoma have a yellowish
color and cannot be as readily scraped away from the subjacent tissue
as can milia.
  Treatment.—Milia rarely  require  treatment, as they are usually
relatively few in  number,  and produce neither subjective  sensation
nor deformity.   If desired, they may be opened with a fine milium
needle, and their contents turned out.  To insure their non-recurrence,
the little  sac left after the operation may  be entered  with a needle
dipped in a fifty per cent,  solution  of chromic acid.   This  operation
may have to be repeated  in the rare cases where the  lesions exhibit a
special tendency to recur.
  The simplest and most elegant  method of removing these and many
similar-sized lesions of the skin is by the galvanic battery.  With
from four to six cells  iu  the current, the negative pole is connected
with a fine needle M'hich is introduced within and beneath the lesion,
while the moistened sponge of the positive pole is in  contact with the
skin of the patient,  The  operation is bloodless and  effectual; insig-
nificant or no scars resulting.
   The prognosis is always favorable.

                          IB. |  Steatoma.
                           Gr. criap, fat.

   This form of sebaceous cyst is also called Wen, and  Atheroma.
   Symptoms.—The  history of the  development  and career of Mens
does not greatly differ from that of  milia, already described.   They
are  usually  slow  of  growth;  unattended  by subjective sensation;
occur as single or multiple tumors on the  head, trunk, or  genitals;
and,  being larger  than  milia, may  attain  the  size of a hen's egg.
They are situated  beneath, within,  or upon  the skin; are usually un-
attached to the deeper contiguous tissues ;  and develop into irregularly
globular, occasionally  large button-shaped, masses, covered^by an
integument usually unprovided with hairs.   This envelope may be
quite  normal  in  hue;  or  unnaturally  whitish  from pressure* or 
CYST,
127
through the long- hairs
Fig.  30.
Cysts of the scalp, one of them being laid open
     to show its contents. (Gkoss.)
especially upon the bald scalp of certain fleshy men of middle years,
reddened, shining, and greasy in appearance.  At times they are  to
be distinguished only by passing the fingci
of the scalp beneath M'hich they  are
hidden ; at others, they are so con-
spicuous in consequence of physio-
logical alopecia as to occasion consid-
erable  disfigurement.   Thev  varv
greatly in  consistency, but  usually
produce to the touch a certain feeling
of elasticity, especially if the cyst be
tensely distended.   They  are  rarely
attacked by inflammation, resulting
in suppuration and ulceration.
   Tumors  of this kind  are  rarely
exceedingly numerous.   MacLaren's
patient,' a lad nineteen years old, ex-
hibited tumors over the entire  sur-
face of the  body, M'hich proved on
examination to  be sebaceous cysts,
but M'hich presented all the appear-
ances of multiple fibromata,
   Pathology.—AVens  represent  an
advanced grade of distention of  the
sebaceous glands by their contents, and a response to the  constant
pressure in  hypertrophy of the glandular envelope.   Their contents
are semi-solid, curdy, cheesy, and granular; or fluid and milky ;  or
fluid and purulent,   These are the inspissated or chemically altered
products of the gland secretion, recognizable  as such by the materials
of M'hich they are  composed, masses of fat  and  debris of epithelia,
with an occasional lanugo or undeveloped hair.                HEW
   Diagnosis.—Steatomata are to be distinguished from fatty tumors,
M'hich, however, are more commonly observed  about the scapulas,
loins, buttocks,  and  extremities; M'hile  wens  are very  rare except
about  the  scalp and neck.   They lack also the peculiar "pilloM'y"
feel of fatty tumors.  Suppurating M'ens in these  regions may readily
be mistaken for circumscribed abscesses, if regard be not had for the
history of the tumor  usuallv long preceding.   Syphilitic  nodes  of
the same part  are usuallv both tender and  painful;  osteomata are
also firmly attached.
   Treatment.—The  removal of a wen is  accomplished by excision,
after previous puncture of the sac, and the removal of its contents.
Several fatal cases,  however, are  on record as  the  result of  this
operation ; due not so much to the nature of the excised  tumor as  to
its situation, surgical wounds  of the  scalp being  particularly liable
to erysipelatous  and other complications.   As the incision required
for the removal of the wen must necessarily extend for some distance
l Brit. Med. Journ., Out. 1886. 
128
DISEASES  OF  THE  SKIN.
on  either side of the  tumor, a linear scar results which on the bald
scalp is often very conspicuous as a relic of the lesion.   In conse-
queuce of the possibility of danger, many surgeons prefer destruction
of a prominent section of the  mass M'ith acid or alkali, leaving the
sac,  after expulsion of  its contents, to wither gradually,  though it
may then be often M'ithdraM'n by forceps.
  Complete obliteration  is sometimes effected by puncture, expression
of contsnts, and the subsequent induction of artificial inflammation in
the M'alls of the cyst by injection of tincture of iodine, pure sulphuric
ether, and other irritating fluids, as in the operation for the relief of
hydrocele.  With  the antiseptic precautions observed in surgical
practice to-day, the removal of these  lesions from any part of the
body may be  regarded as unattended with great risk.
   Prognosis.—The  removal of the wall of the cyst  is not followed
by a return of the lesion.  In debilitated and cachectic patients there
may  be  spontaneous  ulceration and  sloughing,  M'ith  or without
surgical interference.   Mr. Thomas Bryant1  reports a  carcinomatous
tumor following the removal of a steatoma  from  the  buttock  of a
woman sixty-three  years of age.


                           Asteatosis.

                        Gr. a, privitive; creap, fat.
Asteatosis is that condition of the skin in which there is absolute or relative
                 deficiency of the sebaceous secretion.

   Symptoms.—Insufficient  lubrication of the  skin by its  natural
unguent may be either general or partial, and occur either as an  idio-
pathic or symptomatic disorder.  It is produced artificially by any
agents which  continually M'ithdraw the fatty substance from the skin
surface, as  in those trades necessitating the constant immersion of
any parts of the body in strong alkaline  solutions, or waters highly
impregnated with the salts  of lime  and potash.   As an  idiopathic
affection,  it is of very rare  occurrence, but  it  is not  an infrequent
accompaniment of other  local  or  constitutional  diseases, such  as
psoriasis, lepra, angioma pigmentosum et atrophicum, ichthyosis, and
lichen ruber.  In these cases the skin becomes dry, often thickened
and indurated, and, as a consequence, friable, prone to desquamation,
fissures, and chaps.  When handled, the absence of sebaceous secretion
is noticeable in the objective sensation produced.   It is a M'ell-marked
feature of the marasmus of old  age.   Some authors have  described,
under this title, the dry thickening and induration of the palm of the
hand, accompanied by curving of the fingers toward the plane of their
flexor tendons, which is  occasionally to be observed  among laun-
dresses.   But considering  the  absence of sebaceous glands from the
palm, where in the author's experience this affection is most pronounced,
it should be properly  excluded from the list of sebaceous disorders.
i Brit. Med. Journ., May 31, 1884. 
EXANTHEMATA.
129
   Treatment.—No internal medicaments are known to have the power
of stimulating especially the sebaceous secretion.  None, indeed, could
be capable of having such  action when, as is  often  the  case in the
disorders described above as characterized  by  asteatosis, there has
resulted an atrophy of  the sebaceous glands.   The most  that can  be
accomplished  is the external application of an artificial unguent; and
for this purpose cod-liver oil, almond oil, palm oil, vaseline, lard, or
butter may be employed.   Vaseline is in  many cases to be preferred,
as the other articles named are liable to become rancid after oxidation,
and thus  act as irritants to the skin.   With such  partial  or general
lubrications, however, a Marin bath M'ith soap and  water should  be
ordered  every second  or third  day, immediately after M'hich the
inunction may be repeated.
   Prognosis.—In  all those cases M'here the  asteatosis is induced  by
agents operating externally upon  the surface, a reasonable  hope of
recovery may be entertained after the withdrawal of the  cause.  Per-
sistence of the latter is liable to be  succeeded by the occurrence of
eczema or dermatitis medicamentosa.   A  complete cure can  scarcely
be expected M'hen  this condition is really a symptom of one of the
disorders already named.
                         CLASS   II.

                        INFLAMMATIONS.

                         Exanthemata.

                   Gr. el-avdt/fia, blossoming, flowering.

The Exanthemata are specific fevers, frequently occurring in epidemic form,
  communicable by contagion, preceded by a period of incubation, and char-
  acterized by systemic disturbance, with an efflorescence upon the skin, of
  different type in each, as also by involvement of other organs of the body, a
  single attack often conferring immunity upon an affected individual during
  his or her lifetime, against subsequent attacks of the same disease.

   F.u- a detailed  consideration of the phenomena of the exanthema-
tons fevers, the  reader is  referred  to the standard  treatises on  the
subject,  in  the field  of general  medicine.   Brief space  is allotted
here, merely to a description of the  cutaneous lesions by which they
are severally characterized.   These are unlike in each disease; and yet
all exhibit certain common characteristics.   In all, the  eruptions are
symmetrical; and in typical cases, general.   In each, the efflorescence
is  succeeded by  a desquamative or exfoliating condition of the skin.
In each there is,  M'ithin relatively fixed limits, a distinct stadium of
the pathological  process, within M'hich it  is  completed, and beyond
                                 9 
130
DISEASES  OF  THE  SKIN.
which, however persistent may be  its remote  sequelae, there is no
chronic manifestation of the disorder.   Each  also is  produced solely
by its  own specific contagium, derived exclusively from an animal
body affected with the same disease, being never, so  far as known,
generated from any other source,  nor merging  by  imperceptible
degrees the one into another.  Two of these  may rarely concur, but
under  such  circumstances the  one  is ahvays  pronounced in  its
features, M'hich either  closely  precede or follow  those  of another.
No specific medication  is known to be capable of  arresting any one
of them, each  pursuing its course uninterruptedly to a favorable or
fatal termination, according to the intensity of  the poison present in
each case, and  the more or less favorable or  unfavorable conditions
of the sufferer.  Finally, it seems probable that, at  no distant date,
specific bacteria or micrococci M'ill be demonstrated  to be etiological
factors in the production of each.


                            Morbilli.
                       (Measles, Rubeola.)
Measles is a specific, contagious, febrile disorder accompanied by a cutaneous
  exanthem and an acute catarrh of the mucous surface of the  respiratory
  tract.
  This disease is preceded by a period  of incubation lasting  from
eight to twenty-one (usually from  ten to twelve) days, a  period in
which there may be no evidence of ill health, or merely a moderate
degree of lassitude and inappetence.  To this  succeeds a proclromic
fever,  the temperature rising to  103°-104°F., occasionally alter-
nating with chills, or a sensation of chilliness, dryness of the skin,
pains in the head, thirst, occasionally sweating, rarely convulsions in
children,  and,  almost invariably,  a serous  catarrh  of the mucous
surfaces.  By  the  second  or third day  the  temperature  begins to
decline,  while  the catarrhal symptoms increase.  These  are mani-
fested  in sneezing, a copious secretion from  the eyes and  nose, and
engorgement of the exposed mucous surfaces, especially of the  con-
junctiva,  nares, and throat.  Occasionally,  the tongue  and  fauces
exhibit a few  isolated, minute, reddish puncta.  In consequence of
the implication of the larynx, trachea,  and ultimately  the larger
bronchi, there  is a hoarse,  frequently an incessant and  teasing cough,
of a  convulsive character, accompanied by  expectoration  of mucus
in moderate  quantity.  This prodromic period lasts  from three to
five days, but is, in exceptional cases, prolonged to twice that length
of  time.  Upon  its conclusion, the exanthem appears, usually on
the fourth day, with aggravation of the fever, the  temperature rising
to 104°-106°  F., and  remaining at that  point  till the eruption has
reached  its  apogee, when  it commonly declines pari passu M'ith the
severity of the skin symptoms.
   The eruption of measles  usually appears  first upon the face (the
forehead and temple), and thence extends iu about thirty hours over 
MORBILLI.
131
the  neck, upper portion of the trunk,  and  superior  extremities.
Between  the fourth and  sixth  days of the disease, it  has  usually
attained its deepest shades of color, and its maximum of development
over  the entire surface of  the body,  including  the palms and soles.
This maximum  attained,  the  eruption  gradually fades;  the tumid
condition of the  skin, most noticeable on the face, also subsides; the
catarrhal symptoms and cough become less annoying; and the patient
enters upon the period of desquamation.
   The eruption is characterized by the occurrence of reddish, yellowish-
red,  mulberry-red,  deep raspberry-red, or,  in  extreme cases, viola-
ceoiis-tiuted, small finger-nail sized  maculae, either  not elevated or
very slightly raised above  the general  level of the  integument;
or by the occurrence of large pin-head sized, discrete papules, much
more  rarely pin-point sized vesicles, corresponding in color to the
shades described  above, and highly suggestive of the first efflorescence
in  variola.  These  lesions become pale under pressure, exhibiting
theu  a yellowish tint, and are often set together very closely,  particu-
larly over the upper segment  of  the body, in patches suggesting a
crescentic outline.   The term " suggesting" is here used purposely;
as  it is difficult,  by selecting a single patch, to determine by the eye
alone the existence of such a configuration; while  yet an examination
of  the eruption  as  a  whole  may  often very clearly  convey this
impression to the sight.   In other Mords, the crescentic outline is far
less distinct than, for example, in  certain of the papulo-crustaceous
syphilodermata.   Usuallv, patches of sound skin can be recognized,
even  M'hen the eruption appears to be confluent, complete confluence
never occurring  so  as to form a sheet or mask over an entire area
of  the skin.   Individual lesions  may  so merge as to be well-nigh
indistinguishable separately ; yet, on the whole, the eruption deserves
fhlly the plural character of its Euglish name.  It is made up in all
 cases of innumerable elements, M'hose identity is never M'holly lost.
The subjective sensation aMakened is occasionally  a  severe itching or
burning; frequently this is a matter of insignificance in comparison
with  other disagreeable symptoms—c. g., the cough, coryza, and fever.
   Desquamation is  accomplished usually with cessation of fever and
the  production  of  yellowish-brown pigmentations of the  surface
where the elements of the eruption  have existed, involution being
first manifested in  the  site of the  lesions which were earliest to
develop.  Gradually and simultaneously, the catarrhal  symptoms of
the respiratory passages diminish  in severity.   This  final stage of
the disease is  usuallv  terminated  in a fortnight from the  date of
invasion.
  The  complications and anomalies of measles  depend: upon the
intensity of the poison, displayed in  the most formidable  symptoms
M'here human beings are crowded together, as in camps and prisons;
upon  the  degree of physical  vigor;  and  also  upon  the  various
hygienic  surroundings of the  victims  of  the disease.   Thus, the
period of efflorescence may be unusually prolonged; the eruption may
disappear suddenly, and as rapidly reappear; the cutaneous  symp-
toms  may alone  be Manting; the  latter  may  be  commingled  with 
132
DISEASES  OF  THE  SKIN.
petechiae due  to  cutaneous  extravasation  of blood, M'hich may be
also accompanied by severe epistaxis;  and the catarrhal condition of
the mucous surfaces affected may terminate in croupal  or diphthe-
ritic disease, may  be followed  oy  capillary bronchitis,  catarrhal
pneumonia, and even  by pulmonary tuberculosis.  Typhoid condi-
tions may also supervene, and chronic inflammatory affections of the
eyes and of the Schneiderian membrane result.
  The pathology of the cutaueous lesions in measles is that merely
of acute hyperemia occasionally passing  into exudation, limited for
the most part to the vascular papillse of  the corium  and  the  peri-
follicular plexuses of bloodvessels.  Post-mortem, the eruption fades,
as the result of the gravity of the  blood, from the anterior aspect of
the body as it reclines  upon the dorsum.
  While it is possible that the cause of this disease M'ill be one day
demonstrated  to  depend upon some  of  the inferior organisms,  no
observer can  yet claim to  have conclusively  established the fact.
Bacteria, of small size and great mobility, have  been  found in the
blood by Coze and  Feltz ; micrococci  in the trachea  by Klebs;
spherical bodies in the breath of children, and, post-mortem, in the
lungs and liver by Braidwood and Vacher; and  similar organisms
in the vesicles  and pustules  of malignant  measles by Keating and
Formad.1
  The disease is one of infancy chiefly, probably  because at that age
there  is  always the largest  number of  individuals unprotected  by
previous attacks.   In every case, the malady results from contagion,
mediate or immediate,  from an infected human subject.   It spares no
age or sex, though much  rarer in  advanced  years  than at other
periods  of life, probably because of the  large number who, at  such
periods, enjoy immunity.
  The diagnosis of importance  is between scarlatina  and variola.
Typical  cases with a well-developed eruption can  be scarcely mis-
taken for either, if the symptoms  displayed are  assigned  their full
weight.  It would be useless, however, to deny the fact that atypical
forms occur, which have again and again confused the most expert
diagnosticians ; and in all cases  of doubt  the prudent practitioner
will refuse to decide as to the nature of the disease till the symptoms
have, in  the lapse of time,  been fully declared.   The resemblance
between  illy-developed measles and certain of the  eruptions seen in
varioloid, is in the highest degree striking; and the greatest skill, at
a given moment of time, will in cases utterly fail  to make a decision-
between  the two.  A distinctly crescentic character of the eruption,
the presence of catarrhal symptoms, the continuance of the fever after
the efflorescence is completed, the color of the eruption, and the dis-
covery of the nature  of  the disease from M'hich. the  contagion was
derived,  will all  point in the direction of the truth.   From scarla-
tina, measles is much more  readily differentiated  by the macular or
papular elements of its eruption ; by their color ;  by their appearance
to a marked degree upon the face;  and by the absence  of the charac-
See Sternberg's Magnan's "Bacteria." New York, 1884. 
ROTHELN.                        133
teristic soi'e throat and usually intense febrile access of the first named
disease.   From the various forms of erythema accompanied by fever,
measles can  always be distinguished by the irregularity of the tem-
perature  record, as well as by  the  character of the eruption.   The
distinction between rubeola and rotheln is given later.
   The treatment of measles  should be strictly limited to a careful
hygienic attention to the invalid, including a restricted  " fever diet,"
and the use of such medicaments only as are especially indicated by
been followed by fatal  results M'hen employed as an antithermic, has
the complications or accidents of the disease.   Antipyrine,  M'hich has
been already superseded in cautious hands by antifebrin, which may
share a similar fate  when better understood.
   In the  May of local treatment, the skin should be anointed with a
bland, oily, or fatty substance, to relieve the pruritic sensations, espe-
cially after the sponging  of the surface once daily M'ith a weak alka-
line solution, which  may  be  used  cool without  fear of  producing
" repercussion " of the exanthem.  The chamber of the invalid should
be somewhat  darkened for the sake of the eyes, but pure  air should
be constantly admitted.
   The  prognosis is, in general,  favorable.  All  the complications
named  above increase, however, the gravity of the disease, M'hich is
also enhanced among  men crowded together  in  camps,  infants in
public charities,  pregnant women, the cachectic and greatly enfeebled
from other diseases, very young infants,  old men  and women,  and
residents  of islands that have  been long  unvisited by epidemics of
the malady.
   The disease has been demonstrated  to  produce itself by contagion
two to four davs  before the appearance of the rash, M'hile  the power
of such transmission is usually lost between the tM'entieth and thirtieth
davs after the exanthem is  fully developed.


                             Rotheln.
    (Rubella, German Measles,  Hybrid Measles, French Measles.)
Rotheln is a specific, feebly contagious,  febrile disorder, often epidemic,
               accompanied by a characteristic exanthem.

   The  disease  has an incubative period  lasting from fourteen to
twenty-one days, followed either by the eruption or by  brief pro-
dromes lasting from a few  hours to  a single day.   These are feelings
of malaise, cephalalgia, articular  pains, anorexia, and nausea.   The
occipital,  cervical, and  other  glands  may at this time become  large
and tender.   After a  pyrcxic  period, rarely lasting longer than  a
few hours and in many'cases entirely absent, the eruption appears,
occurring  for the most part  in the regions  affected  by measles; in
the form of  multiple, pin-point  to small  pin-head sized macules,
but smaller than the lesions displayed  in that disease, and  decidedly
lighter in  color.   The shade is rosy to  a crimson-red, rarely  lurid,
never of dark mulberry or  violaceous hue.  This color will, at times,
be perceptible beyond the line of the lesions, in a delicate halo, a 
134
DISEASES  OF THE  SKIN.
circumstance M'hich strongly distinguishes the  exanthem from mor-
billi.   The lesions, moreover,  are  seldom  arranged  in crescentic
outline, being  more often  grouped  in  roundish or  oval patches.
Often, indeed, the elements of the eruption are discrete and dissemi-
nated.  The fauces are occasionally reddened  in puncta.  The erup-
tion commonly  fades  in  from one to  two days, and there may or
may not be slight resulting cutaneous desquamation.
   The rash is to be distinguished from that of measles by the recog-
nition of the features described above,  particularly  by the  color,
contour, and  date of occurrence of the exanthem;  the transitory
character  of the fever M'hen the latter is present; and the rapidity
with which involution of the disease progresses.   By the temperature
record alone of the  patient, it may be differentiated from scarlatina,
though the rash is dissimilar in the two diseases.  It is also not to
be confounded with the erythematous affections of the skin.  One of
the most striking characteristics of the  disease can be  best recognized
in a ward filled with children, all of whom are simultaneously affected
with the disorder.   That characteristic is the  remarkable mildness of
the phenomena  displayed in every case.  The author has had under
observation at one time twenty little patients  all exhibiting the exan-
them, not one of whom  presented  the  peculiar facies of the sufferer
from  measles.
   After an exhaustive study of this disease, Atkinson1 concludes that
while its characters are so defined as  to justify a reasonable certainty
in its diagnosis,  it  has  no symptom that  is not often assumed by
measles.
   The disorder  should be treated  by rest in bed, a supply of fresh
air, and the usual  diet  of fever patients.   Medication by drugs is
almost never indicated.

                           Scarlatina.
                   (Scarlet Fever,  Scarlet Rash.)
Scarlatina  is a specific, contagious, febrile disorder, characterized by  a
  cutaneous exanthem, and by involvement of the throat  and other bodily
  organs.
   The  period of iucubation of scarlet fever varies between twenty-
four hours  and  a month  or more, the  average duration being about
eight days.  The reason  of this wide variation is to be sought, not in
any changeability in the mode of evolution of the disease, but in the
fact that its poison is less volatile and  less  rapidly dissipated than is
that of measles, the result being  that it may remain potential for
longer  periods in connection with articles through   the  medium of
which it is  transferred from one individual to another.  This incu-
bative period, like that described in connection with  measles, may be
quite unproductive of physical symptoms, or  be associated M'ith an
ill-defined malaise.
   The  prodrome of the disease in typical cases, is  marked by the
occurrence of a  rapid  and bounding pulse, an exceedingly dry skin,
1 Amer. Journ. of the Med. Sci., 1887. 
SCAR LA TI N'A.
135
 and a characteristic sore throat.   When examination of the mouth is
 made, the tongue is seen to be thickly coated, and its filiform papillse
 reddened  and prominent, producing the  so-called  "strawberry  ap-
 pearance."  The velum, pillars of the fauces, tonsils, and all exposed
 mucous surfaces are  engorged,  tumid,  reddened, and  often covered
 M'ith deep reddish puncta, M'hich unquestionably represent hyperemia
 of the perifollicular tissues.   Thirst is great, and deglutition often in
 the  highest  degree painful.  In severe  cases, the  mucous  surfaces
 named may speedily  exhibit finger-nail to pigeon's-egg sized, ashy
 ulcerations with a lurid halo at the  periphery.  In children, there
 may be syncope, delirium, convulsions, vomiting, or, when the poison
 has  been  intense, fatal  results  from shock of the  nervous centres.
 This prodromal  period usually lasts from twelve to  twenty-four
 hours,  though  it may  be  prolonged for two days more.   In this
 respect scarlatina is markedly distinguished from measles. This stage
 is terminated by the appearance of  the exanthem, but.the fever per-
 sists without abatement after the explosion ; and the other symptoms
 of the  disease are then in no wise ameliorated.
   The eruption  in scarlatina usually spares the face, however much
 the  latter  may display two damask-colored cheeks under the febrile
 flush, become tumid M'ith  the acceleration to it of the blood pumped
 through the throbbing carotids, or even  exhibit a few scanty lesions
 upon the  forehead and temples.   About  the mouth, the integument
 is ahvays pallid.  This is  far different  from the picture presented iu
 measles.   The eruption is first seen in the form of light or deep red,
 pin-head sized puncta, so closely agglomerated as to produce  upon the
 eye  the impression of  a diffuse  reddish blush.   It is first seen about
 the  neck and clavicular regions, but rapidly  spreads to the trunk and
 extremities,  including the dorsal surfaces  of the  hands  and feet,
 attaining complete development in the course of the second day of the
 eruption.   It is then of a distinctly scarlet color, M'hence the disease
 has  its name in the Latin, English, and German tongues, a coloration
 frequently compared to the appearance of a boiled lobster. Upon the
 limbs it is often developed in punctate form, M'hile the occurrence of
 a diffuse scarlet  blush is most  distinctly perceived by the eye in the
 examination of the trunk.  Here it is seen to fade under  pressure;
 and  the finger-nail draMii rapidly over the surface of the skin is fol-
 loMcd by  the  formation of  a  M'hitish  line, M'hich persists for an
 instant, a time sufficient to enable  one  to  describe a letter  upon the
 skin.  This period of efflorescence lasts  for  from one to tM'o days to
 an entire Meek, during which, as stated above, the febrile and other
 symptoms  continue unabated.
  The rash usually persists at its maximum of development for from
 one  to  three days, the  concomitant symptoms  continuing without
 noticeable  abatement.   Among the latter may be named the  occur-
 rence of albumen in a urinary secretion of diminished specific gravity,
 M'ith occasionally the presence of epithelium recognizable under the
 microscope as derived  from the lining membrane of the uriniferous
tubules of  the kidney. 
136
DISEASES  OF  THE  SKIN.
  Having attained its apogee, the eruption in favorable cases begins
to fade, the part first affected exhibiting earliest a lighter shade, while
the  other pathological  phenomena  diminish in  severity, the  sore
throat, especially in ulcerated conditions, alone persisting.  In  from
four to ten days longer the eruption disappears, leaving a brownish-
yellow pigmentation  of  the surface;  and simultaneously the other
symptoms of disease vanish.
  The desquamation which then ensues, as convalescence progresses,
is general and often proportioned in  extent to the severity of the
preceding eruption, though it  may  be generalized  after a well-nigh
imperceptible  exanthem.   It is more  pronounced and characteristic
in scarlatina than  in any of the  other eruptive fevers.   It may be
superficial and furfuraceous in  character;  or the epidermis may fall
in lamellated plates, the sheath of an entire finger, for example, M'ith
the  nail;  or that  of the entire palm.   In this  way sheets, ribbons,
and shreds of the horny layer of the skin may fall from its surface,
and  expose  beneath a new and often  tender epidermis.  The hairs
may be simultaneously shed.    When this  desquamation  is finished,
the stadium of the disease may be regarded as concluded, the entire
period lasting in uncomplicated cases from a fortnight to a month or
six weeks.
  The complications, anomalies, and remote sequelae of scarlatina are
so numerous as to furnish a vast array of facts for the study of the
pathologist.   The  reader need be merely reminded in these pages
that the usual incubative and prodromic stages of the disease may be
brief as to time, or so brusquely followed by eruptive phenomena as
to be indistinguishable.   The  latter may  also first occur upon the
extremities or trunk, and later on the neck and over the clavicles; or
at once cover the totality of the surface by a rapid explosion ; or be
extremely short-lived; or be altogether absent;  or be unusually pro-
longed and visible for even a fortnight upon the surface of the body,
appearing and well-nigh  disappearing  without  appreciable cause.
To a proportionate extent, the  stage of desquamation may be preco-
ciously or tardily  reached, and the exfoliating process be tediously
prolonged and of intense type, jeoparding in this manner the future
of the convalescent prostrated  by the fever which has passed, or the
sympathetic fever which  may thus be aMakened.
  The anomalies of the scarlatinal rash are numerous, but depend, in
general, less upon a variation in the intensity of the poison than upon
the  physical condition of the patient.   Thus, the affected surface may
be slightly elevated above the general level;  may exhibit irregularly
disposed mottlings and  maculations;  may be characterized by the
occurrence of miliary papules, minute vesicles, or  purpuric lesions
well defined against the general scarlet color of the skin by their vio-
laceous shade, and due to cutaneous  extravasation of blood.  The
rare  bullous, pustular, and urticarial lesions which  may appear upon
the skin, are accidental, and bear no relation to the specific history of
the disease.
  Malignant anginose scarlatina is  characterized  by the gravity of 
SCARLATINA.
137
the throat symptoms.   In such cases, a parenhymatous inflammation
of the tonsils, velum, and fauces supervenes at an early period, with
enormous tumefaction, involvement of the  submucous tissue  and
neighboring glands, and ulcerative, suppurative, and even gangrenous
results, which may prove speedily fatal.   Gastro-intestinal disorders
may  also prove dangerous.  An otitis externa,  media, or interna,
may perforate the tympanum, destroy the ossicles, induce caries of
the mastoid  process of the temporal bono, and  prove  fatal  by the
eventual production of meningitis or phlebitis.
   Another severe type of the  disease is that in which symptoms of
typhus are pronounced (Scarlatiniform Typhus). Here the patient
may perish M'ithin  a few  hours  after being attacked and before the
eruption appears, exhibiting comatose or convulsive symptoms indi-
cating the profound influence upon the nervous centres of the intensely
intoxicated blood;  or  the eruption  may have time to appear, often
livid,  hsemorrhagic, or petechial in type,  and be followed by albu-
minuria, meningitis, diarrhoea,  coma, and death.    Catarrhal  and
parenchymatous nephritis are justly dreaded during the desquamative
period of the malady, M'hen they may prove fatal after a relatively
benignant manifestation of  the disease in its prodromal  and eruptive
stages.   To this sufficiently grave list of  disorders which may com-
plicate scarlet fever, must be added pneumonia, pericarditis, pleuritis,
peritonitis, chronic  purulent nasal catarrh,  which  may  result in caries
of the nasal bones, destruction of the cornea as a result of severe
keratitis,  persistent adenopathy of  the subcutaneous  glands,  and
malnutrition in many forms, which  may  so impair the vigor of the
constitution as to leave the sufferer a physical wreck for the remainder
of life.
   The cutaneous lesions of scarlatina, like those of rubeola,  depend
upon hvpersemia and  a moderate degree of exudation.   The  latter,
M'hen it occurs, is limited  for the most part to the rete and papillary
laver of the  corium.   The signs of the  disorder are not apparent in
the dead bodv,  unless  there has been exudation of  blood and the
consequent formation of petechiae.
   The disease is produced exclusively by contagion derived from the
animal body affected M'ith scarlatina, either mediately or  immediately.
It attacks individuals of both sexes and all ages, children and  infants
more frequently, the aged more rarely, probably in consequence of
their respective conditions as regards immunity conferred by a previous
attack, since, in  general, the disease  occurs  but  once  in a lifetime.
Individual idiosyncrasy must account for  the cases in M'hich  unpro-
tected  infants exposed  to the disease fail  to receive  it, a fact noted
occasionally  in  all the exanthemata.   The contagious element is
volatile in "its nature, and  seems to be most active during the eruptive
stage of the disease.
  Pod-like bodies and mobile points have  been found by Rciss, Coze,
and Feltz in  the blood of  patients affected with scarlet fever;  and
injection of rabbits with such blood has proved fatal.  Drs. Jameson 
138
DISEASES OF  THE  SKIN.
and  Edington1  have lately recognized and  cultivated  the " bacillus
scarlatina?," measuring 0.4 mm. in thickness and 1.2-1.4 mm. in length,
forming long, jointed, and curved, motile leptothrix filaments.   Ex-
ceedingly interesting clinical facts as to the transmission of scarlatina
through the medium of the  milk of diseased com'S have been  lately
determined by some of the local health boards in Great  Britain.  The
disease at times  follows  injuries  and  surgical operations,  due,  as
Atkinson2 supposes, to diminished poM'ers of resistance to the disease.
Micro-photograph of the edge of a small colony of the bacillus scarlatina;.
          a. Central zone.  b. Outer edge of growth.
   The  diagnosis is  between  measles, rotheln, erysipelas,  and  the
erythemata; and is, in general, readily established.   The sore throat,
intense fever, punctiform  scarlet rash  reaching to  the border of the
inferior maxilla, and the distinct, M'hitish-yellow line traceable by the
finger-nail passed rapidly over the  surface, are all characteristic.   In
measles, the  macular character of the rash, and its crescentic arrange-
ment, in connection  with the catarrhal  symptoms, will usually  be
recognized.  From erysipelas, scarlatina  can ahvays be distinguished
by the absence of the peculiar, shining, smooth, or glazed and tumid
condition  of the affected  area.  From all other rashes, scarlet fever
can be distinguished  by the pyrcxic symptoms and resulting desquam-
ation.
   Great care should be taken not to confound  the medicinal rashes
having a scarlatiniform appearance, M'ith the specific disease under

                1 Brit. Med. Journ., June 11, 1887, and August 6, 1887.
                2 Journ. of Cutan. and Ven. Dis., vol. iv., October,  1886. 
VARIOLA.
139
consideration.  Thus belladonna, in doses of one minim of the tincture
every  hour to the extent of four doses, has  produced an abundant
scarlatiniform  eruption in children, a diagnostic point of importance
in vicM' of the fact  that the drug named  is employed popularly as a
prophylactic against the disease.  For the medicinal eruptions of this
sort due  to quinine  and other drugs, the reader is  referred to the
pages devoted to dermatitis medicamentosa.
   The  modern treatment of uncomplicated  scarlatina is purely ex-
pectant, after provision is made for an abundant supply of  fresh air,
disinfection, a proper regulation of food and drink, and the local use
of baths, tepid  or cool, for the purpose of reducing the bodily temper-
ature.   After each of these, the skin should be completely anointed
M'ith  a fatty substance, such as cold cream, scented almond or olive
oil; or, M'hat is most commonly used in this country, vaseline.   These
inunctions are  not only grateful to the patient, but, as the author has
again and again demonstrated by the thermometer, reduce the tempera-
ture to a slight degree.  All other treatment than that suggested above,
should be limited to the special conditions presented in each case, and
pertains to the field  of general medicine.   It includes the manage-
ment of disorders of the eve, ear, throat, kidneys, and other viscera,
M'hose involvement constitutes a complication  of the disease.
   The prognosis of the  malady  should  ahvays  be  established with
reserve.   It is largely based upon the relative intensity of the symp-
toms, the vigor and age of the subject, and the presence or absence of
serious complications.  Albuminuria is rarely absent, and not  per se
alarming; but anasarca and other evidences of profound interference
M'ith the renal  function, are to be  assigned due Meight,  In general, it
may be said  that a high  range of temperature; early and  ulcerative
throat lesions ; tardy development, rapid and untimely disappearance
or undue  prolongation  of the exanthem;  and  its admixture M'ith
petechia? to such an extent as to indicate extensive hemorrhagic ex-
travasation, are all formidable symptoms.  Finally, it  must not be
forgotten that the mildest and simplest forms of the disease, after the
fastigium is passed and convalescence actually established, may termi-
nate fatally  by the supervention  of urfemia, cerebral paralysis, or
even  meningitis, consequent upon secondary changes  in the  middle
or internal ear.
                             Variola.
                            (Smallpox.)
                         Lat. varus, a blotch.
Variola is a specific, contagious,  and febrile disorder characterized, when
   unmodified, by the appearance in  succession upon  the cutaneous  surface
  and occasionally also upon the mucous surfaces, of papules, vesicles, pus-
  tules, crusts, and cicatrices.
   The  variations of this  malady as to  the severity, character, and
duration of its  symptoms, are  so  great as to preclude its  complete
description within the limits here assigned to the subject.  The fol- 
110
DISEASES  OF  THE SKIN.
 lowing paragraphs  arc devoted to a brief sketch  merely of its more
 commonly recognized characters.
   The period of incubation of the unmitigated disease varies between
 ten and twenty days, occupying usually a fortnight.  It is character-
 ized by the peculiarities of that period recognized in all  the exan-
 themata, few and insignificant or no evidences of physical discomfort.
 The prodromic stage  is ushered  in generally by a vespertine chill,
 succeeded by fever, M'ith a temperature rising to 104°-106° F., M'hich
 is commonly associated M'ith severe and  characteristic pain  in the
 loins, headache, nausea or vomiting, and occasionally, in youug sub-
 jects, delirium and convulsions.  The fever continues, with alterna-
 tions of exacerbation and partial relief, or sensations of chilliness, on
 the second and third days.   At the same time there  may be faucial
 hypersemia and moderate dysphagia.  Occasionally, before the cuta-
 neous  exanthem  appears, minute reddish  papules  may be recognized
 upon the buccal membrane.
   On  the  second and  third days there appears, in some cases, espe-
 cially  in menstruating women  and in youug subjects, a cutaneous
 efflorescence, M'hose significance has been often  misinterpreted  and
 M'hich has led to  many errors in diagnosis.   It is to Hebra that we
 are indebted for  its distinct  recognition as a cutaneous  prodrome in
 variola.  It has been termed Variolous  Erythema,  and Vario-
 lous Roseola.   Its recognition is a matter of special importance to
 the diagnostician, as many have been  deceived respecting its nature
 and significance.   It is characterized by the occurrence of irregularly
 disposed and  distinctly outlined maculations, puncta, stria?, streaks,
 or a diffuse blush of bright or lurid reddish hue ; the invaded integu-
 ment being at times slightly tumid,  and thus elevated above  the
 general level.  It may be  also the seat of moderate  pruritus.   The
 blush  may fade under  pressure, but rarely does so perfectly.   One
 cannot by the finger produce upon it a visible whitish spot.   It occurs
 most  often about the groins, hypogastric  region, pubes, and  inner
 faces of the thighs; and, examining these parts, the physician will
 usually discover the evidence, in adult women, of recent or present
 menstruation, or  of the puerperal state.   It  occurs  also about  the
 axillse, the extensor faces of  the larger and  smaller joints, and  the
 lumbar and clavicular regions.  Often a broad area of the integument
 in these parts may exhibit a sheet or mask of dull  crimson erythema,
 upon which pin-head to bean-sized, dull-reddish papules may form,
 not losing their color under  pressure, more rarely petechiae, vesicles,
 and wheals.  All these are precursory phenomena, and are not  trans-
 formed into characteristic variolous lesions.  They fade  almost com-
pletely before the latter  appear.  Rarely, a few scattered papules may
be distinguished upon the face and arms before the variolous ervthema
fades.   Often the former in full development are even less profusely
displayed in the site of the precedent efflorescence.  The latter need
not be necessarily regarded as a symptom of portentous gravity.   The
author has  seen the entire surface of the belly covered M'ith a uniform
erythematous blush of dull crimson hue, confluent variola follow, and 
VARIOLA.
Ill
the patient ultimately  recover.  The physiciau, then,  in  face of a
deep red erythema of the regions named, especially of the groins,
loM'er part of the belly, and thighs of a menstruating woman affected
M'ith high fever, nausea, vomiting, and lumbar pain, should invariably
suspect the presence of variola.
   The period of eruption  is characterized, at  its earliest, by puncti-
form, subcutaneous disco]orations M'hich photography alone can reveal.
Commonly, after three days of prodromic symptoms, the patient will
be seen on the  morning of the fourth with the face and scalp covered
by pin-head  sized and larger, firm, conical papules, M'hose impression
to the finger is compared by most English M'riters to the feeling of
shot.   Later, these develop upon the trunk and limbs; and in well-
marked  cases every portion  of the surface of the  body is invaded,
including the palms and soles.   The lesions may be surrounded by a
narrow rosy  areola upon the trunk.  They may be unproductive of
subjective  sensations, or be slightly tender.
   As a rule, there is complete defervescence M'hen the  exanthem
appears, the patient experiencing such  relief that if an  adult  has
chanced not  to view the face in a  mirror nor  to be informed of his
appearance by those iu attendance upon him, he will  often regard
himself as completely relieved  of  his three days' illness.   In  other
cases, the febrile symptoms persist, M'ith a loM'ered temperature.
   During  the  first two days of the eruptive  period, the papules in-
crease iu number, and become  correspondingly agglomerated; while
those of earliest appearance become transformed into  vesicles  con-
taining a translucent serum, the roof-wall of many of them exhibiting
an umbilicatiou.  This  umbilication of  the vesicle is characteristic,
and slightly different from  that observed in   bullous  and pustular
lesions.   The  central  depression  is disproportionately  large, and
about it the  yet undistended epidermis is often  irregularly puckered
or fluted.  Even in this period, the lapse of a  feM' hours will produce
a lactescent appearance in  their formerly translucent contents.
   From the eighth to the twelfth day, the transformation  of these
lesions  into  pustules is effected, the process beginning,  as  in all  the
metamorphoses of the disease, in the vesicles  of greatest age; those,
namely, on the face  and  upper portions of the body.   The lesions
simultaneously enlarge  till  they are of the  average size  of a  pea,
and,  being fully distended, rupture the  centrally  placed  filament
which held doM'ii the roof-wall, in consequence of M'hich the umbili-
cation of the pustules is lost,   With this process of suppuration, is
awakened  the  so-called  secondary fever, a pathological process evi-
dently  not essential to the disease, as it does  not occur in mitigated
cases.   It  is  born of the extensive process of  suppuration occurring
in the skin and other organs, and  may be symptomatic, sympathetic,
or septicemic iu  character.   It thus varies  in different cases with
the character and severity of  the process by which it  is  excited,
beino- transitory in  mild cases, and in others  terminating only with
death.   At this time the patient is usually in  a most distressing con-
dition.   The skin of the face and  other  attacked regions is swollen, 
142
DISEASES  OF THE  SKIN.
thickly covered with pustules, and the features indistinguishable in
the tumid aud closed lids, the cedematous lips, disfigured nostrils, and
pus-obstructed mucous  outlets.   Deglutition becomes  painful  and
often impossible; the saliva flows from the lips;  and  the mucus of
the nares dries  with the pus upon the exterior of the visage.   The
pustules recognized  upon the integument are represented also  in the
gastro-intestinal tract,   Iu an autopsy  of a patient dead at this stage
of the disease, made by myself in company with Dr. McGill, of the
United States Army, during  the late  civil Mar in this country, we
discovered the entire  canal  from the mouth to the anus, as also the
genito-uriuary and  respiratory  passages, completely  covered  with
closely  agglomerated and well distended pustules.   The career of
those M'ithin the mouth  can be usually studied  by observation M'ith
the eye.   In this situation they rapidly lose  their epithelial roof-wall
by reason of the heat, moisture, and friction to which they are sub-
jected, and  then exhibit a  reddened  and excoriated   surface,  over
which there  is  reformation  of the epidermal layer.   Gangrenous
complications are rare.
  Betweeu  the  thirteenth and  fourteenth days  desiccation begins,
and  is usually completed M'ithin from  ten days to a fortnight  after-
M'ard; the pustules  rupture, and  the exuded pus  concretes into  yel-
lowish and  brownish, rarely blackish crusts, or the latter are formed
by the desiccation of the entire envelope and contents.  The pulse
usually at the same time diminishes in  frequency;  a secondary defer-
vescence occurs;  the tumefaction of the integument decreases;  and
at times  the peculiarly characteristic, and often intolerably fetid odor
of the patient is  less perceptibly exhaled.   In  from four  to  six
weeks the course of  the disease is completed.   The immediate  traces
of the eruption  are purplish  and  violaceous  pigmentations, which
slowly disappear.  When cicatrices result, they are slightly depressed,
dead-M'hite, lustrous, usually symmetrical  in disposition, and most
distinct upon the surfaces exposed to the light and air, as the  face.
Though  persistent, they  are rendered  somewhat less  deforming in
the progress of  years.   When  closely set together, they produce a
characteristic ridged  and  corded  appearance, due  to  the elevation of
narrow  bands of unaffected  integument betM'een the depressed sur-
faces  of scars.
  The several departures from  the pronouueed  type  of the disease
described above, present  variations differing widely from the most
benignant forms.  Brief reference only can be made to these.

  Varioloid, whether  occurring after vaccination or not, is a modi-
fied form of the disease.  With it should be classed all those forms
of the disorder  occurring in the human  subject, and  described by
authors under the title of "Swine-pox," "Horn-pox,"  etc.  In these
cases, there may be severe prodromic fever and a  scantily developed
exanthem; mild  fever, abundant exanthem, and rapid involution of
lesions; abortion of the  latter  in any of their several stages from
papule to crust; absence of secondary  fever; transmission of the 
VARIOLA.
143
disease in a mild or mitigated form, from one individual to  another,
so that an entire community, vaccinated and tin vaccinated alike, may
suffer from an epidemic disorder of this moderate grade M'ithout the
occurrence among  them of a single  case  of typical variola,   It  is
scarcely necessary to add that  the  patient  M'ith  varioloid, especially
during  an epidemic, may transmit to the  unprotected a malignant
form of the disease.
   Much more formidable, viewed from every standpoint, is Hemor-
rhagic A^ariola,  fortunately rare and too often confounded in the
past with  " black  measles."   When  cutaneous  haemorrhages occur
during the course of smallpox, they do not necessarily indicate that
the case  is one of the so-called varioliform  purpura, since these may
be accidents of the pathological process.  In  this malignant form  of
the disease, against  M'hose ravages  vaccination  seems  to present no
barrier, the prodromic  stage is folloMcd by a deep purplish redness
of the surface which is characterized  by pin-head to split-pea sized,
firm, closely set, papular lesions, suggesting the occurrence of measles
in a peculiarly severe form.   The febrile,  nervous, and other symp-
toms of the disease  are proportionately intense.   Ecchymoses appear
upon the conjunctival membrane.   Gradually the color of the exan-
them,  M'hich  at first disappeared under pressure,  refuses  thus  to
yield, and assumes  a bluish-black shade.   Ecchymotic patches may
be  intermingled with  these,  rapidly  widening  to palm-sized  and
larger  areas.  The  mucous surfaces share  in these colors, being also
infiltrated  M'ith effused  blood  ; and the muco-cutaneous orifices are
crust-covered  and exhale an extreme fetor.   Blood may escape  from
the boM'els, bladder, mouth, and vagina.  Signs  of grave  systemic
and visceral complications are ahvays present,   Vesiculation, pustu-
lation, and the typical transformations of the variolous lesions are all
Manting.   In the few cases observed by the author, death has ahvays
speedily supervened, either from shock,  coma, hemorrhagic infarc-
tion of the lungs, or rapid exhaustion.  Intermediate forms between
hemorrhagic  and  true variola are described, in M'hich the pustules
occurring  in  the latter form of the disease  merely fill with blood  in
consequence of  accidents possessing a  purely local significance.
   The Confluent is another severe  form  of variola, less malignant,
however, than that just described.   It is  characterized by intensity
of the prodromic fever, M'hich often scarcely abates M'ith the appear-
ance, of the exanthem.   The latter is  developed in deeply implanted,
firm papules,  closely set together, succeeded by vesicles and pustules,
M'hich, as they enlarge, fully occupy the entire surface of the integu-
ment, and accomplish a perfect  coalescence.  In  well-marked  cases
there is scarcely a  pin-head sized area of the entire  surface of the
body M-hich is not invaded.  The tissues become enormously edema-
tous; the deformity of the face renders the  features indistinguishable.
Hemorrhagic pustules and even  patches of a gangrenous pulp may
be intermingled  with the sheets of suppurating surface.  Phonation,
respiration, and deglutition are  proportionately  impeded  or  abso-
lutely  subverted by the tumefaction and  suppuration of the  mucous 
114
DISEASES OF THE SKIN.
membranes of the respiratory and gastro-intestinal tracts.   When the
patient survives till the  stage  of desiccation is reached, the  body
presents an aspect  as  revolting as that ever displayed by a living
being.  A  thick, brownish,  or  blackish-brown mask  envelops the
swollen head, trunk, and limbs;  and the odor exhaled from the  body
is intolerably repulsive.  All the  systemic phenomena are propor-
tionately  grave  and accompanied by one or more of the complica-
tions of the malady,  pneumonia, pleuro-pneumonia,  albuminuria,
diarrhoea, various motor and sensory paralyses, subcutaneous  furun-
cles, and abscesses.  The eyes may suffer from pustular and  ulcera-
tive chauges in the conjunctiva, cornea, and  deeper  tissues,  M'ith
resulting inflammation of every grade to panophthalmia, and resulting
loss of vision.  Often the patients, with surprising  powers of resist-
ance, will survive till extensive  sheets of crusts have fallen from the
surface, and then perish  slowly in  a typhoid condition  with low
remittent or continuous fever.  Every  such case does not, however,
conclude fatally.  The author has seen children rally from the severest
form of confluent variola, and enjoy afterward a vigor M'hich illustrates
well the wonderful  recuperative energy of the natural forces under
the most adverse circumstances.

                              Fig. 32.
  Vertical section of pustule at the beginning of pustulation.  a, umbilication at the site of an excre-
tory canal; 6, reticulum within the epidermis; c, reticulum of smaller meshes containing lymph-and
pus-globules.  (After Rindfleisch.)

   Variola is ahvays produced  as the result of  mediate  or immediate
contagion.  It is a disease which is  both contagious and infectious,
being  transmissible by volatile emanations from the victims of the
disease.   It is also artificially inoculable.   Wheu transmitted by the
latter  process, its period of incubation is someM'hat  shortened, and
often its successive manifestations become then less formidable.  The
history of inoculated human variola has, however, received  but little
attention  during the  last decade,  in which the practice  has  been 
VARIOLA.
145
properly  forbidden  by  law.   The disease is, to  a certain extent,
transmissible from  man to the loM'er animals, and the reverse.   It
attacks individuals  of both sexes  and all ages, including the  foetus
in utero,  M'hich may be  ushered at an untimely hour into the world
macerated or recently dead and covered with the lesions of variola.
The disease  in the  larger cities is decidedly more frequent in winter
than  in summer, possibly because in the  colder months the oppor-
tunities are greater  for spreading the contagion in  artificially heated
dwellings  where  numbers of  individuals  are  crowded   together.
Islanders long unvisited by an epidemic and unprotected by vaccina-
tion,  may suffer equally in the summer season.
                               Fig. 33.
 Vertical section of one-half of an undeveloped pustule, a, old epidermis; b, epithelia of rete above
the alveoli; c, new formed epidermis; d, alveoli filled with pus-globules; g, flattened and infiltrated
papilla) lying beneath the pustule.  (After Auspitz and Basch.)

  The  parasitic nature of variola  has not yet  been demonstrated.
Coze. Feltz,  Baudouin, Luginbiihl, Weigert, Hallier, and Colin have
recognized microorganisms, both bacteria and micrococci, in the blood
of variolous patients.   None of these have as yet  been utilized  in
the production of the disease; but Colin1 regards these parasites as a
twin race of the micrococcus vaccinas discovered in vaccine lymph. _
  The  difficulty attending  the diagnosis of variola  in its prodromic
and earliest eruptive stages, from  rubeola, has been already mentioned.
The general demand, indeed, upon  the physician for an exact and
definite  diagnosis  of every case before  its typical development, is
founded upon an erroneous conception of possibilities;  and the sooner
this is generally recognized, the better for all concerned. _ A delay of
even  a few hours  will often verify or remove a suspicion, and  the
author is confident that he has  seen fully as  much mortification on
the part of the  physician and damage to  the best interests of the
patient, result from an error in the oue direction as in the other.  The

                       1 See Magnan, loc. cit., p. 411.
                                 10 
146
DISEASES  OF  THE  SKIN.
wisest course in every doubtful case is to admit the doubt and to visit
the patient frequently for the purpose of observing the development
of the disease till that doubt is removed.  Typical cases of variola are
recognized M'ith ease from the character of the symptoms  presented.
Syphilis and acne are always distinguished by the  absence of fever
and their relative chronicity.  Two cases of suddenly occurring medi-
camentous acneiform rash, have come under the author's observation,
where a diagnosis of variola had been previously made.  In each, the
absence of a prodromic stage  and the subjective sensation excited,
Mere sufficient  to point to the nature of the disease M'hen considered
in connection M'ith the peculiar character of the lesions.
   The  prognosis of variola is largely dependent upon the  degree of
protection conferred by  previous  vaccination.  This  aside, the age
and vigor of the patient, the presence  or absence of an epidemic of
severe or  mild type, the extent of the  eruption, and the character of
the surroundings of the patient, are elements of prime importance.
Very young and aged  subjects, women  pregnant or in the puerperal
state,  and, as Hebra has shown,  those who have suffered from a pre-
vious attack of  the same disorder, are all unfavorably related  to the
final result.  Confluent and  hemorrhagic forms of the disease are,
naturally, the gravest.  Unmitigated variola is, under the most favor-
able circumstances, one  of the  greatest scourges of humanity; and
as such will probably always  destroy  a frightful  proportion of its
victims.   At the same time, the  conscientious physician needs to
be impressed M'ith the fact, that under the most discouraging circum-
stances, the patient, disfigured  to the greatest extent by an envelope
of blackened crust, and  in  a state of extreme physical prostration,
with many of his bodily functions almost completely suspended, may
even  from the  midst of such peril be won back to life and  vigor.
The assiduous  attentions of a gentle nurse, guided by the  inspiring
presence and counsels of a physician M'ho is himself fearless of the
malady, will  often achieve the  result.  Upon the  latter point, it is
interesting to note, that physicians in active practice who do  not
hesitate to expose themselves freely to the disease  in the  discharge
of the duties of their profession, rarely suffer in their own persons.
In the course of four  epidemics, during M'hich the author has had
the opportunity of observing the relations between many physicians
and their patients, he  has  never knoMn one of  the former to be
stricken down in the  actual performance of his  sacred  office among
the victims of the pest,

                           Varicella.
                          (Chicken-pox).
Varicella is a  contagious, febrile disorder of benignant and mild character,
                accompanied by a vesicular exanthem.

  The disease has an  incubative period lasting for about a  fortnight,
after M'hich there is occurrence of malaise, chilliness, and languor.
The patients are usually children M'ho may suffer thus from fever of
a moderate grade lasting from a few hours to two or three days, after 
VARICELLA.
147
M'hich defervescence is commonly complete.  With its onset, or M'ith-
out it, the rash appears, first on the head and trunk, in the form of
rosy macula?  or  slightly elevated  lesions lacking the  characteristic
"shot-like" feeling of the variolous papule.   These rapidly become
vesicular, the lesions being pin-head to pea-sized, limpid, superficial
in situation, differently shaped and very rarely umbilicated, puckered,
or "fluted"  as  in  smallpox.   They appear in successive crops  and
are often surrounded by a faint halo.   Their contents become cloudy
or lactescent rather than puriform, and desiccate often as early as the
second day, forming  thin, light, superficial crusts.  The lesions may
be  abundant  in  one region, as, for example, over the back  or the
chest; but are practically never both abundant and  generalized, and
never confluent.  Like the variolous lesions, they extend at times to
the mucous surfaces of the eyes, mouth, and genital regions.   Occa-
sionally they are productive of pruritic sensations.  Often the course
of  the disease is so mild  and the  exanthem so slight as scarcely to
attract attention.   Cicatrices result only  in places, chiefly  the face,
where the lesions have  been subjected to local irritation.
   Diagnosis.—It is well known that a number of German authori-
ties, following Hebra, have given  assent  to the doctrines  taught by
the  latter  that varicella is only a  mitigated  form of variola.   That
doctrine is  offensive to American  and English  physicians, who in
practice  find it vastly wiser to  distinguish carefully and  exactly be-
tM'een the diseases in question.   The settlement of the discussion  may
well be relegated to a date M'hen the probable parasitic nature of both
disorders can be exactly determined.
   In variola, the invasion period, of relatively fixed limits, the speedy
transformation of the lesions  into  minute, firm  papules, their  early
appearance on the exposed parts of the face and wrists, the age of the
patient, the thermic variations, the  prodromic rashes, and the speedy
transformation of the papules into umbilicated vesicles, are all impor-
tant diagnostic points.   In varicella, the  trunk usually exhibits the
greater number  of lesions, Mhich  appear also in successive crops.
Beside the characteristics of the cutaneous lesions, the catarrhal symp-
toms of measles and the  sore  throat of scarlatina, will point to the
nature of these disorders.   Fox's impetigo contagiosa is to be very
carefully distinguished from varicella, since the two affections occur at
times side  by side in one hospital ward; and occasionally the former
succeeds the  latter.   The lesions  of  impetigo  contagiosa  are  often
larger, generally more  persistent, the crusts bulkier, and the patients
may be of a more advanced age.

   The treatment of variola should, in  general, be limited to the indi-
cations presented in each case.   Xo remedies can be employed which
have the least  power to  abort the disease.   Kaposi  calls attention
to the striking fact  in  this connection, that in syphilis, for many of
M'hose manifestations mercury is a specific, we find a  disease M'hose
second  incubative  period is measured by weeks, and  yet  neither by
excision of its initial sclerosis  nor  by mercurials can the subsequent
manifestations of the disease be completely prevented.   Certainly, no 
148
DISEASES  OF  THE  SKIN.
specifics are recognized as of value in  variola.  The patient should
be  kept in  a relatively darkened room M'ith an abundant supply of
fresh air of a uniform temperature; and  antiseptic solutions should
be  constantly  at  hand  into M'hich  all the  ejecta  are  immediately
received.  He should be given ice when this is grateful to the palate,
cool water ad libitum, and his strength should be sedulously supported
by a liquid  animal diet.   The body may be sponged with or bathed
in cool or tepid water, as often as is grateful to the patient. In severe
or confluent cases, the constant immersion of the body in the continu-
ous warm water bath as practised in Vienna, is followed by the most
brilliant results in hastening the desiccation and fall of the crusts and
the subsequent repair.  A bath of this character given for merely two
or three hours in the day, is often of great value.  With and without
these external measures, gargles of chlorate of potash, myrrh, honey,
or carbolic acid, will be  found acceptable  to  the mouth and  palate.
Indeed, the  constant attention of  an efficient nurse bestowing assidu-
ous  care upon the mouth,  skin, and  eyes, may be regarded as  an
essential part of all sound treatment.
  As regards the  prevention of pitting, it  may be remarked that no
measures of a  therapeutic character  will prevent the  occurrence of
a distinct cicatrix whenever  pus  has eroded or otherwise destroyed
the  integrity of the papillary layer of the corium.  Every effort,
therefore, should be exerted to prevent the  extension of the suppura-
tive process  to the true skin.   The following are measures which have
approved themselves to the author as of practical value: first, the sick-
room should be moderately darkened, and  yet amply provided with
fresh air; second,  a solution  of the hyposulphite  of sodium (Squibb's
is  superior  to the ordinary preparations in the market) should  be
administered night and  day  in  the dose of  from fifteen to twenty
grains (1.-1.3) every three or four hours.   Certainly the variolous
lesions  pursue a milder course under  this .internal treatment, and
even, in cases, the vesicles  shrivel before pustulation is fairly begun.
Third, the skin of the face should be anointed with a bland fatty sub-
stance such  as vaseline, almond oil, or fresh lard, and over this may
be laid silk-enveloped compresses, dipped in tepid and weak solutions
of carbolic or boric acid, or thymol.  The author prefers the anoint-
ing of the surface before the application of the lotion, but, when more
grateful to the^ patient, the skin  may be constantly moistened  M'ith
the aqueous  lotion alone.  Here, again,  the assiduous attention of the
nurse is a matter of importance.  The author has never employed
the powder of iodoform topically in these  cases, but believes that it
might be often so used M'ith advantage.
  The edges of the eyelids should be daily anointed with freshly pre-
pared cold cream.  Puncture of  the cornea may be  required for the
relief of hypopion.  Diarrhoea and other  symptoms of visceral de-
rangement should  be relieved by  appropriate medication. As a rule,
the administration of narcotics for the relief of pain is objectionable.
Throughout all, the strength of the sufferer should be  supported by
a generous use of  animal broths or milk; and in typhoid conditions
a judicious employment of stimulants may  be necessary. 
VACCINIA.
149
                            Vaccinia.
                             (Cowpox.)
Vaccinia is a specific bovine fever, accompanied by a vesicular exanthem,
            which can be transmitted to man by inoculation.

   The  limits of these pages forbid  a discussion  of the interesting
questions which concern  the relations of cowpox  as it occurs spon-
taneously in the milch-coM', to human variola.   A careful collation of
the results obtained by the large number of vacciniculturists of later
days, renders it clear that it is a matter of great difficulty to transmit
variola  from man to the heifer;  that where this rare  result is
obtained, the  lymph derived from the lesions  on the udder or the
belly of the latter is  liable to produce variola M'hen  retransmitted to
man ;  and that spontaneous cowpox  alone seems to furnish  a  lymph
which is safely inoculable in generations  to the human race.
   Of greater importance  is it to note here that, either by arm-to-arm
vaccination, as was formerly extensively  practised, or by the use of
the animal virus which  has of late been  M'ell-nigh exclusively em-
ployed  in this country, there has been  conferred  upon millions of
human  beings a degree  of protection against variola M'hose value is
beyond estimate.   In both methods,  the  lymph is derived originally
from the female of the bovine race, preferably in the puerperal state;
and its  sources are the vesicular  lesions of vaccinia  spontaneously
arising  or artificially  cultivated about the teats, udder, and adjacent
parts.   The introduction of this lymph  into the skin of the  human
subject, is termed vaccination.
   The simple operation of vaccination is performed in  many ways,
but that which especially commends itself  to the prudent man is the
method which eliminates  to the largest extent the possibility of trans-
mitting any other contagious disease than  the  one intended.   AYith
this object in view, no better instrument  can  be devised than a clean
needle, one which has been properly disinfected and not previously
employed for any purpose.  The skin of the part  selected for vacci-
nation being  Subjected  to  slight tension  by the   left hand,  the
vaccinator should scratch or scrape off the epidermis  with the needle,
held in the right, by a scries of parallel and crossed  strokes, so as to
make three or four superficial erosions, at a distance  of three or more
inches apart.  Each of these multiplex wounds should have the size
of the little finger-nail, and should in no case bleed,  but  merely ooze
M'ith serum slightly tinged M'ith blood.   At such  points  the  lymph
is to be thoroughly and sIom'Iv  rubbed in, Mhether it be supplied in
a dry form upon ivory poiuts which  have  been dipped in the serum
oozing from vaccine lesions upon the heifer, or be  a fluid  obtained
bv crushing and dissolving in Mrater the crust taken  from the similar
lesions on  the arm of a  child  previously  unprotected and  recently
vaccinated.   In public charities, M'here, for the most part, such pro-
cedures are practicable.  It is  usually sufficient to  dip a needle into
the lymph flowing from  the arm of  the  vaccinifer and to plunge it,
thus charged, once  or  twice into the part  selected for the  operation. 
150
DISEASES  OF  THE  SKIN.
   Between the third and  fourth  days after a successful  vaccination
 of the  unprotected, a light reddish, pin-head  sized  papule rises at
 each inoculated point.   Between the fifth and sixth days, it becomes
 transformed  into a translucent, well-distended, occasionally umbili-
 cated vesicle.  This, when single, may attain the size of the finger-
 nail.  Springing  from  the multiplex  abrasions  described  above, a
 minute papule usually  forms at each  point  of  intersection of the
 crossed lines  produced  by the  scratching M'ith the needle, and the
 subsequent vesicles coalesce,  forming  thus a compound lesion  of
 rather peculiar aspect.   It appears often as a small coin-sized plaque,
 elevated to the extent of a line or  more beyond the  general  level,
 with a rim formed of numerous discrete or confluent vesicles, M'hich
 in either case are closely set together.   The  compound  plaque seems
 to  develop afteward as a single lesion, its centre being depressed.
 After the ninth day, the fluid becomes opalescent, aud desiccates in a
 reddish-brown crust,  which,  examined in section  by  a  good  light
 after it is completely dried, exhibits a smooth, homogeneous, shining
 appearance, with a color having the shade of amber.
   Fully as important as any of these metamorphoses of this lesion,
 is its rosy-reddish areola, in the absence of which some authorities
 declare that there is not proper protection.   It completely encircles
 the  compound vesicle in the form of a  halo having a diameter  of
 several inches,  the tissue  it invades  being  often  slightly  tumid.
 When the pathological  process in the focus of this areola is intensi-
 fied, either as the  result  of the irritant character of the virus, or from
 extrinsic  causes (undue  exertion  of the vaccinated  part), the areola
 may spread extensively  down the arm, or over the thigh or leg, and
 eventually cover  a dense, brawny, and deeply reddened integument.
 Dermatitis, erysipelas, lymphangitis, adenopathy, and severe grades
 of inflammation  of the subcutaneous tissues, may for similar reasons
 complicate the process,  which may terminate by central  sloughing,
 ulceration, slow repair, and the  production of an  atypical  cicatrix.
 Ordinarily, the subjective phenomena are limited to a mild or annoy-
 ing itching of the vaccinated surface; in other cases, severe  burning
 pain, a feeling of tension, and even sympathetic fever may be aroused.
   The acme of a  successful vaccination is usuallv  attained  between
 the tenth and the fourteenth days, after which the symptoms of the
 disorder gradually subside, the  crust falling,  if undisturbed, in the
 course of the ensuing week.  When "animal" virus is employed, the
 duration of each  of these stages of the disease is usually someM'hat
 prolonged.
   The cicatrix, at first  slightly reddened or pigmented, gradually
 assumes  the  dead white  appearance of  scars in  general.  When
 typical, it is slightly depressed, circular, not irregular, nor deformed
 by ridges, cords, or bauds, and  " foveolated,"  exhibiting  a  series  of
 peripheral pits or depressions, each  of which represents the site of a
 former  minute vesicle of simple type.  There is  strong reason to
believe that the degree of protection is based in part upon the multi-
plicity of typical  cicatrices, and, in vieM' of the  rarity of variolous 
VACCINIA.
151
 patients  M'ith four such  traces  of successful  vaccination upon the
 person, many are prejudiced in favor of the English method of pro-
 ducing multiple scars.
   The complications  of vaccination are due, first, to the character of
 the virus employed;  second, to the character of the soil  in  M'hich it
 is implanted ; and third, to the external accidents to M'hich the vaccine
 lesion is subjected.  Respecting the first of these sources, there are few
 contagious diseases M'hich  may be  transmitted  by vaccination, beside
 syphilis.  When this accident  occurs, it may be due either to the
 fact of syphilis  in the vaccinifer, or to the  use  of instruments soiled
 with infectious  secretions.   It is both asserted and denied,  that the
 lymph from a typical  vaccine  vesicle in a syphilitic vaccinifer, will
 necessarily transmit syphilis, if  it be accidentally commingled M'ith
 either blood or the products  of inflammation at the base of the pock.
 The demonstration of  any  such  fact requires a mass  of evidence
 exceedingly difficult to  collect, inasmuch as the  stage and intensity
 of the disease in the  vaccinifer are elements which cannot be ignored
 in  a decision of the question.  When  thus  transmitted, it will  be
 remembered  that the vaccine lesion  may complete its career during
 the incubative  period of the initial  sclerosis, whose existence at the
 site of vaccination is commonly declared  later by  induration, ulcera-
 tion, pigmentation, and  axillary adenopathy.   The  occurrence of a
 generalized  syphiloderm  before  the  chancre of  vaccination   is com-
 pletely healed, is often the first symptom to arouse suspicion.   Those
 further interested in the subject should study the cases collected and
 admirably illustrated by Air. Jonathan Hutchinson,1 of London.  It
 should be added, that the popular impression regarding the frequency
 of  this accident is greatly erroneous.   The  author has treated no less
 than nine physicians for  extra-genitsti chancre  of the fingers and
 eyelids,  acquired during the discharge of  their  professional duties,
 meeting in his entire experience  M'ith  but two  unquestioned  cases of
 syphilis transmitted by vaccination.  One of these accidents occurred
 to a negro infant, M'ho had a typical initial sclerosis of the arm fol-
 lowing vaccination, M'ith axillary adenopathy, and  a subsequent char-
 acteristic generalized exanthem.   In all such cases,  the possibility that
 the syphilis  might be hereditary, and its symptoms simply coincident
 in point of time M'ith those of vaccinia, should not be forgotten.
  Exceedingly dangerous is that  virus, however good its early char-
 acter, in which decomposition or  putrefactive changes have occurred
 after exposure, in a liquid form, to the action of heat and the atmos-
 phere.  Vaccination  M'ith  lymph  thus changed   has  been  rapidly
 folloMed  by  fatal  results,  in consequence of the  supervention  of
 pyicmia or septicaemia.
  (implications of vaccinia,  due  to the character or predisposition of
the tissues iu M'hich the virus is introduced by  the vaccinator, are
usuallv ascribed by the ignorant or prejudiced  to the causes just con-
sidered.   Post hoc ergo propter hoc is the sole logic of the uninformed.

                  1 Illustrations of Clinical Surgery. Phila., 137o. 
152                DISEASES  OF  THE  SKIN.
 In this way almost all other ills of the human  family have  been in
 turn ascribed to "impurities" and "humors" introduced by vaccina-
 tion.  The language and arguments used in support of these positions
 have been as extravagant as they were unreasonable, and have borne
 fruit in the refusal of many physicians of repute to perform vaccina-
 tion, and thereafter to assume the responsibility  of all the subsequent
 ailments  of the vaccinated.   The cutaneous symptoms which  may
 thus be awakened are numerous.  It will  be  remembered that the
 contents of the typical vaccine vesicle are  auto-inoculable, and  that
 thus the scratching of young patients may produce an abundant crop
 of typical or torn vesicles upon the arms, legs, thighs, hands, and
 fingers.    But  vaccination  may also awaken  in  the  patient,  as
 explained above, a latent syphilis, as also a list of cutaneous disorders
 not contagious  in  character.   Thus an  erythema (roseola vaccinia,
 vaccinola, etc.), eczema  in  many of its  forms,  and other exudative
 processes  may be first aroused in the integument by the turbulence of
 a successful vaccination.
   These rashes may  become generalized, and even assume a formid-
 able appearance.  They may appear at any time from the second  to
 the fourteenth day after vaccination.   A  scarlatiniform rash, diffused
 or  in patches, is described by some authors as occurring in this way,
 accompanied by mild fever, and  resembling German measles.   Simi-
 larly generalized eruptions, resembling erythema multiforme, psoriasis,
 urticaria,  impetigo contagiosa, varicella, and other cutaneous disorders,
 may appear for the first time within the limits named above.   They
 usually disappear within a brief time after the vaccine vesicle has
 completed its involution, and may be followed by slight desquamation
 or pigmentation.1
   Very rarely vaccinia is folloM'ed by purpuric symptoms
   Anomalies  of the  vaccine vesicle are occasionally noted  as to its
 shape, career, and resulting cicatrix which it is difficult to explain.
 Thus, the papulo-vesicle may not exhibit an umbilicated centre, or
 may complete its course within unusually short limits ; or a harmless
 ulceration may progress beneath  its crust, requiring a week, or even
 more, for complete cicatrization.   The so-called " raspberry sore" is
 explained by Robinson as resulting from coalescence of small papules,
 so as to form  a pigmented tubercle.   The scars resulting from many
 of  these irregular and non-protective  results of vaccination may in
each direction form a typical  cicatrix, being, on  the one hand, small
 palm-sized, deforming, corded, and representative of large tissue-loss ;
 and, on the other, feeble, irregular, and inconspicuous.
   Lastly, the complications of vaccinia due  to external  accidents of
the lesion are usually inflammatory in character.   The excessive use
 of the vaccinated arm in labor, and of the vaccinated leg in walking,
 standing,  and other exertion, may induce, as indicated above, every
grade of dermatitis, and even ulcerative  changes  in  the site of the

 1 An interesting paper on vaccinal eruptions was read by Dr. Gustav Behrend, before the Dermato-
logical Section of the International Medical Congress, in London, August 5, 1881. (See a translation of
his paper by Dr. Alexander, Arch, of Derm., No. 4, 1881, vol. vii. p. 383.) 
ERYTHEMA SIMPLEX.
15S
inoculation, as a  result of the  intensity of  the  process.  For these
accidents rest is essential, with the free use of a dusting-powder over
the inflamed surface.   In exaggerated cases,  lotions of lead-water and
opium  may be employed.   These  conditions  are  usually relieved
without difficulty, as soon as the part is  put to  rest.  The atypical
scar which results, seems to be  in such cases  as protective as others,
if only the accident  have occurred  to a typically progressing lesion
M'ith distinctly perfect areola.   Vaccine  cicatrices are to be  distin-
guished in anomalous situations from maculae atrophicae, the scars  of
syphilis, and of other scar-leaving disorders.
   Micrococci  have  been  recognized by Colin  in  vaccine-lymph.
These  have been named micrococci vaccinae, but their relation  to
similar  organisms discovered in the blood and  tissues of variolous
patients has not yet  been determined.  Wolff1 claims to have culti-
vated these organisms  through  fifteen  generations.   Strauss has
demonstrated their existence in the vaccinal pustules  of the calf.2
   Lipp, of Gratz, reported to the International Medical Congress in
London,  that  he had recognized  great  similarity,  if not  identity,
between the micrococci of vaccinia and variola, M'hich he  had culti-
vated to the  second generation, but had then been  unsuccessful  in
producing inoculation effects.  These organisms were  always arranged
in groups of four, or multiples  of four.

                       Erythema Simplex.
                         Gr. tpvOn/ua, redness.
Erythema Simplex  is a coloration  of the skin in various shades of redness,
  temporarily disappearing under pressure, the lesions differing in size and
  shape according to the  extent and degree of the hyperemia by which they
  are induced.
   Hyperacmia of  the skin, due  to increased velocity or amount of the
fluid in the cutaneous capillaries, results in increased coloration of
the integument.   The shades of this color vary from a delicate pink
or rosy hue to a dark  reddish  color.   Thus, hyperaemiae may  be
diffused or circumscribed, idiopathic or  symptomatic, and due  to
active or passive congestion of the vessels.

                       Idiopathic Erythema.
   Erythema Traumaticum.—Here  the redness  is the  result  of
friction, rubbing,  pressure, scratching, and similar external contacts.
It is observed, for example,  in the part pressed by the pad of a truss;
in the colored circle left about the leg where  a tight  garter has been
worn ; on the sides of the nose  where pressure is exerted by a  newly
applied pair of eye-glasses.   These traumatic hyperemias are readily
converted into  exudative affections,  if the traumatism be long con-
tinued.   Intermittent pressure upon the skin permits  restoration  of
1 Berl. klin. Wocli., January 22, 1883.                2 See Magnan, loc. cit. 
151
DISEASES OF THE SKIN.
the vascular equilibrium, and the skin responds to the demand  made
upon it, by increasing in thickness; continued pressure, on the con-
trary,  admits of no such  restoration;  and  the  integument fiually
becomes thinner, and  yields before the agent inflicting the injury.
Inflammation resulting iu ulceration may finally supervene.

   Erythema Caloricum.—Solar heat in excess  and extremes of
cold; very hot and very cold water; and other heat-conducting sub-
stances, are also sufficient to induce transitory redness of the surface.
In the erythemata induced by solar heat especially, there is frequently
an increase in the pigmentation of the  surface, as in the production
of freckles and "tan" in persons whose skins are  reddened by the
sun.  The darker, brownish,  and chocolate-colored stains  of the
hands and face are thus induced.

   Erythema Venenatum.—A number of  chemical substances,
dyes, and vegetable poisons are also capable of producing transient
hyperaemia of the skin.   Among these may be mentioned cantharides,
capsicum, mustard, aniline, chloroform,  ether, arnica, and  several of
the essential oils.

   Erythema Gangrenosum.—Under this title several  singular
affections  of the skin  have been described,  in M'hich erythematous
patches appeared  and  were folloM'ed  by more or  less  extensive
destruction of one or more of the several layers of the skin.   T. C
Fox, in  a description of  the  appearances in two cases  under his
observation,  concludes that these are  the symptoms of a feigned
disease, or oue produced artificially  for  the purpose  of  exciting
sympathy, etc.
                     Symptomatic Erythema.
   This may be of either  active or passive  form.   A long list of
physiological and pathological causes  operating upon the system at
large are capable of inducing active symptomatic hyperaemia of the
skin.  This may be generally diffused, or occur in surface  mottlings
and markings of various sizes and shapes.   Thus, the skin of the face
may be intensely reddened in  a paroxysm of rage; and that of the
limbs of a teething child covered M'ith rosy maculatious in consequence
of the reflection to the surface, through the medium of the nervous
system, of the irritation  induced  by a tooth.   In consequence of the
rosy tint  assumed  by several  of these  rashes, they have  long been
termed " roseola," a name which to-day is held to describe a symptom
rather than a disease.   The word " roseola" is still associated in the
minds of many with the earliest syphiloderm;  but that eruption is
now designated by the best  authors as  the erythematous or macular
syphilide.
   Several of the severer constitutional maladies betray their morbid
influence  upon  the central  nervous system by a  speedy efflorescence
of this character.   A lurid erythema of the axillary or  inguinal
region may precede by several days the  eruption of  confluent variola. 
ERYTHEMA  simplex.
155
Cholera, ccrebro-spinal meningitis, enteric and  other  fevers are thus
at times accompanied, preceded, or followed by rashes.  A study of
these is of the utmost importance to the diagnostician.   Children who
are really susceptible to the disease are often supposed to possess an
immunity from scarlatina, as the  symptomatic  erythema  they pre-
viously displayed Mas misconstrued.
   Symptomatic  passive  erythema  is  usuallv  characterized by a
cyanotic, purplish, or  darker hue of the integument, resulting largely
from accumulation  in excess  of carbonic  acid  in  the blood.  The
temperature of such  skins is  either  normal or below the  normal
standard, as in those  cases M'here gangrene ensues.  A long list of
conditions may be named in M'hich  these  symptoms may be noted,
including derangement of the bloodvessels from imperfect innervation,
direct pressure, or disease of the heart or vascular Malls.
   These erythemas may be either circumscribed in area or general.
The  term "livedo" is applied  to circumscribed regions of passive
erythema.   Sometimes the nose, cheeks, fingers, or toes  exhibit this
form of disease.  The so-called symmetrical gangrene of the fingers
belongs to the same category.   Cardiac cyanosis, or morbus caeruleus,
is a name given to a generalized dark blue discoloration of the entire
surface, due often to continued patency of the foramen ovale.
   Diagnosis.—If an erythema of the surface exists and is manifestly
unattended by exudative  symptoms,  the recognition of the condition
of the skin is  not difficult.  A more serious problem, however, con-
cerns the significance of  this symptom M'hen it occurs in connection
M'ith grave constitutional maladies.   A high  temperature,  severe
lumbar pain, great gastric or intestinal irritability, coryza, and injec-
tion of the ocular conjunctivae,  are symptoms M'hich  should always
put the practitioner on his guard in pronouncing upon the nature of
an erythema.
   On the other hand, patients  in a state  of alarm frequently seek
relief for an  idiopathic erythema, of the nature of M'hich they  are
ignorant.   Here the locality, contour, and general appearance of  the
eruption, taken  in connection with the history of the case, will usually
suffice to establish a diagnosis.
   Treatment.—The  symptomatic ervthemata  are usually  of such
trifling significance in  comparison M'ith the  constitutional disorder by
M'hich thev are  occasioned, that  the  removal or management of  the
latter becomes of the higher importance.  The idiopathic ervthemata
are  usuallv relieved at ouce by the suspension  of the cause.  Occa-
sionally cold Mater, weak  spirit lotions,  dilute  solutions of carbolic
acid, or one of the dusting powders may  be required.   The ordinary
rubber, adhesive,  or  lead plaster,  may be  applied  to erythematous
surfaces M'here  the friction must necessarily be continued (surgical
appliances,  orthopco-dic apparatus, etc.),  and in  those produced  by
constant pressure (nates and sacrum in low fevers or surgical confine-
ment), it  should  never be forgotten  that  the  hyperaemic is  also a
M'cakened skin.   Here stimulating applications  may be needed, alco-
holic, camphorated, etc., M'ith a view to the restoration of the tone of
the weakened capillaries. 
156
DISEASES  OF  THE  SKIN.
                     Erythema Intertrigo.

                   Lat. inter, between ; terere, to rub.

Erythema Intertrigo is an hyperaemic condition of those cutaneous and muco-
  cutaneous surfaces which are in constant apposition, and between which
  there is an hypersecretion or retention of sweat.

   Symptoms.—The erythema M'hich is  limited to portions of  the
integument which lie in contact with each other, is subject to certain-
modifications.  The sites of such contacts in the human body are the
axillae, the groins,  the  cleft between the nates, the  inter-mammary
and infra-mammary spaces  in women, the  superior and inner faces
of the thighs, the  scroto-femoral and the labio-femoral clefts  in the
sexes respectively,  the  flexures  of the joints, and in  especially fat
individuals, all those parts where the integument is thrown into fleshy
folds, as about the neck of infants, and even over the crest of the ilia
in fat women.   In these  localities  the disorder, beginning  as an
erythema traumaticum, proceeds by its irritative  effects to stimulate
the secretion  of sweat, which is freely poured out between the adjacent
folds  of the  skin, and  may there be temporarily imprisoned.   The
surface, heated and reddened, is also somewhat macerated  by  the
effused perspiration; and the latter,  when chemically altered, as it is
frequently under these circumstances, adds still further to the original
disorder.   The ground is thus well prepared for an exudative process,
but the  disorder may  be limited to mere hyperaemia with hyperi-
drosis, and disappear before  the supervention of actual inflammation.
   The sensations produced are those of heat and tenderness.   When
the parts in contact are separated, the surfaces are seen to be reddened
and chafed.  Here and there very superficial abrasions of the macerated
epidermis become evident.  One such is  ahvays especially significant.
It is the linear and superficial excoriation which  marks the line of
deepest contact of the two apposed surfaces of the skin at the bottom
of the angle formed by the tM'o.  An offensive odor usually proceeds
from  the part in consequence of the fluid secreted.  Fox, of London,
has called attention to the fact that the  secretions of an  intertrigo
stain, but do not stiffen the  linen of the patient, and thus differ from
the serous fluid poured out in an exudative dermatitis.
   Etiology.—The  disease is chiefly induced  by heat, friction,  and
moisture—these  causes, occasionally cooperating.   The heat may be
merely that of the natural  temperature  of the body, or  it may be
increased by that due to season  and  climate.  The friction also  may
be merely that originating between the surfaces  in apposition, or  may
be increased by clothing or other articles worn  next  the skin.   The
moisture which produces maceration of the epidermis  is that origi-
nating in the perspiratory  follicles, their secretion being  doubtless
stimulated by the heat and friction.   The interchange of operation of
these  three factors is, lastly, shown by  the fact that the  friction, if 
ERYTHEMA  INTERTRIGO.
157
severe, is capable of increasing the temperature of the part to M'hich
it is applied.
  As aggravating causes may be named other physiological secretions
and excretions, retained in contact M'ith the surfaces affected with an
intertrigo.   Thus, the feces of the infant left in contact M'ith its nates
upon the napkin ; the urine of the old man with paralysis of the
bladder, or with "overflow" from  prostatic disease; the milk of the
nursing woman  dribbling  over the breast to the infra-mammary
region ; retained  lochial,  menstrual, and  similar  discharges,  are  all
efficient in  this regard, and particularly  apt  to induce that form of
dermatitis  to M'hich  the  intertrigo then plays a subordinate  part.
Occurring in fleshy persons, these  conditions  find their most fertile
field.
  Diagnosis.—The recognition of a simple erythema  intertrigo is a
matter of no difficulty, if regard  be had  to the exciting and aggra-
vating  causes  enumerated above, and to  the  special localities where
such hyperaemia generally originates.   If an  eczema or dermatitis
supervene, the fact  will  appear from  increased subjective sensation
(usually a severe itching), from an infiltration of  the affected integu-
ment, and from the appearance of those lesions and discharges M'hich
are significant  of these forms of inflammation of the skin.
  The special sites of preference of an intertrigo are those also of the
disease named by Hebra  " eczema marginatum,"  or ring-worm as it
occurs upon the parts of the thighs covered  by the " reinforced" patch
in the trowsers of the cavalryman.  The disease  is properly named,
tinea circinata cruris, though  it is found also about the axillae, but-
tocks, and groins of both sexes.   Here  the disorder  is, however, of
the exudative type, and, moreover, is distinguished by a characteristic
"festooning" of  the elevated border marking the advancing limit of
the disease.  The microscope, by revealing  the existence of a fungus,
will, of course, put  an end  to any doubt.   In intertrigo the most
marked evidence of disease is to be distinguished in the deeper parts
of  the cleft between  the  two  adjacent skin surfaces,  while in tinea
circinata cruris the growth of the parasite is most active at the ad-
vancing border of the patch, which is, moreover, perceptibly elevated
above the sound  skin.
   Treatment.—Erythema intertrigo is an exceedingly common affec-
tion of the skin,  and occasionally  proves  of great annoyance to those
suffering from  it.  The skill of the young practitioner is often tested
early in his professional career by his management of just such cases;
and not a little may depend upon the success with which  he  may be
rewarded.
  The  affected surfaces should be gently cleansed by. ablution with
soap and warm water, and the offensive odor of the secretions reme-
died bv the addition to the water of a M'eak solution of carbolic acid,
or the dilute liquor soda- chlorinatae.   The  parts are then to be care-
fully dried M'ith a freshly laundried towel or soft handkerchief, and
afterward one of the dusting penvders very thoroughly applied.  To
be of service, these must be quite impalpable,  and, if compounded by 
158
DISEASES OF THE SKIN.
a druggist, be sifted through millers' fine silk  bolting-cloth.   The
articles chiefly  used  for  this  purpose  are:  bismuth, starch,  zinc
oxide,  French chalk, lycopodium, and, when an anti-pruritic effect is
designed, camphor.   Combinations  of several  of these are at times
effective.   The formula of M'Call Anderson is highly esteemed :

        R.  Zinci oxid. pulv.             J|ss;           161
            Camphorse pulv.             3jss;           6
           Amyli pulv.                  gj;           32|       M.
        Sig.  Anderson's dusting powder.

  The following is the formula for a dusting powder recommended
by Klamann.1
        R. Talc, venet. pulv.            3v ;           201
            Acid, salicyl.             gr. iij ;             2
           Magnes. ust. subtil, pulv.     3jss;           5|       M.
        Sig.  Dusting powder.

  The "Oswego gloss  starch" and  the "corn-starch farina" sold by
most of the grocers in this country, are finely bolted, and answer well
alone,  or in combination with some of the other articles named.  The
chief objection to the starch-containing powders is  their tendency to
form "cakes" or rolls M'hen wetted with sweat, these  masses further
irritating the tender surface of the skin.   Such an objection does not
apply to lycopodium, which not only under the  microscope exhibits
no salient angles, but on account of the oil it contains  is not miscible
with water.2
  The affected surfaces of the skin must also be separated in order to
prevent further friction.  A thin strip of lint, or the antiseptic cotton
now in the market, may  be used for this purpose; and must be
pushed well up to the deeper portions of the cleft M'here the secretion
chiefly forms.   Occasionally, it will be found useful  to  anoint  this
absorbent layer M'ith cold  cream or vaseline.   Where an astringent
effect is desired, the lycopodium or other dusting powder may be com-
pounded with tannin, alum, or similar substances.  The list of lotions
may be also at times consulted M'ith advantage.   Thus, cologne water,
weak spirit lotions,  tannin, and aromatic M'ine, or carbonate of mag-
nesium, may each be serviceable.   Lastly, the charron oil (equal parts
of lime-water and linseed-oil), spread thickly upon linen, will possibly
give more relief than the other articles named ; the chief objection to
it being the consequent soiling of the patient's clothing.

 i Hebam. Kalend., Obstet. Gazette, March, 1882.
 2 Unna's salve muslins and pastes will be found effectual and neat applications in many forms of
intertrigo. 
ERYTHEMA  MULTIFORME.
159*
                    Erythema Multiforme.

Erythema Multiforme is an exudative disease of the skin, in which appear flat
  or elevated lesions of an erythematous type in various forms, the exanthem
  being at times symptomatic of constitutional derangement.

  Symptoms.—In  this affection, M'hich is  usually of symmetrical de-
velopment,  erythematous  macula?, flattened papulae, and  even large
flat nodosities, very rarely vesicles, occur, usually upon portions of
the extremities,  the forearms, the legs, and the dorsum of the hands
and feet.  The eruption, M'hich  is much more generally recognized in
clearly defined patches, usually commences M'ith pin-head to finger-
nail  sized macules of a darkish-red shade, losing their color under
the pressure of the finger, M'hich in the course of some hours exhibit
tumefaction in various degrees, producing thus the papules, tubercles,.
and nodes already described.   The disease may persist for but a feM'
days, but iu severer grades it lasts for  several Meeks.  In the height
of the exudative  process, there is usually an efflux of the coloring
matter of the blood into  the skin M'hich is the site of the several
lesions; and thus  are produced the singular shades of reddish-black,
purple and  red,  blue and red, yellow and 'orange, M'hich are so char-
acteristic of simple bruises of the extremities when the  injury has
been sufficient to cause extravasation of blood.   The lesions occur in
various shapes,  sizes, and shades, and a number of names have  been
used to designate their several appearances, which require explanation
though they are M'ithout any practical value.

  Erythema Annulare is characterized by central paling of color
and peripheral extension of the erythematous patch,  in the form of a
ring.

  Erythema Figuratum occurs in gyrations formed by coalescence
of two or more  annular circles.

  Erythema Iris (Herpes Iris) is the result of successive new ery-
thematous  centric colorations, by M'hich  at times  several differently
shaded concentric rings are formed.

  Erythema Marginatum is that  form in M'hich a distinctly ele-
vated and defined marginal  band is left as the sequel of an erythe-
matous patch.

  Erythema Xodosum is regarded by several authors as a distinct
affection.   In it the characteristic  lesions are  of the dimensions of
semi-globular pea  to fist-sized tumors, pale red to livid  blue in color,
tender upon pressure, exhibiting in their  involution the variegations
of hue already described.  They occur at times, not only in the locali-
ties named above, but also upon the trunk and face.  Though occa- 
160
DISEASES  OF THE SKIN.
 sionally becoming so  soft to the touch that fluctuation may seem to
 be present, they never terminate by suppuration.

   Erythema  Papulatum  (or  Papulosum)  and Erythema
 Tuberculatum  (or  Tuberculosum)  are  those  forms  in  which
 occur respectively lesions of a papular or tubercular type.

   Erythema Urticatum is that form  in  which there  is  severe
 itching, and, as a result, scratching of the lesions, M'ith crusts of dark
 dried blood at the summit of each.   This crust is surrounded by the
 light red or bluish-red, flattened or elevated patch characteristic  of
 the disease.

   Erythema Vesiculosum and  Erythema Bullosum are  rare
 and  exceptional forms Mdiere the  exudation  is sufficient to raise the
 horny layer of the epidermis  into larger or smaller, serum-containing
 chambers.   These may  be, as regards the  erythematous  patch,  of
 central or peripheral situation;  and may crown the summit of papule
 or tubercle.   The fluid is usually removed by absorption, and is rarely
 set free by rupture of the vesicle or bleb.

   Robinson1 describes definitely an  Erythema Diphtheriticum,
 which is a rash of septic diphtheria.  The  early eruption is a diffuse
 erythema of the skin of the chest or of the belly, light red to pale red,
 mottled, scarlatiniform, or punctate, non-pruritic, disappearing under
 pressure, unaccompanied by fever,  and vanishing in one or  two days.
   The rash of septic diphtheria occurs only after several days of the
 disease, and is a limited or generalized erythema.   It begins as pin-
 head or larger sized erythematous  maculae, each of which spreads at
 the periphery,  and pales in  the centre, by which  process  rings are
 formed.  The  latter  increase  till  a diameter of several  inches is
 attained.  While these erythematous rings with  clearing centre  and
 red,  elevated rims are enlarging, new spots  continue to form, till the
 eruption has all the features of a multiform erythema.  Gyrate  and
 figured forms result from coalescence of lesions.   Occasionally, the
 centre of a ring is cyanotic.   The  eruption does not itch.   In fatal
 cases it persists till death.

   A number of medicaments, M'hen ingested  or externally employed,
 are capable of producing eruptions  identical  in appearance with the
 lesions of erythema multiforme.  For descriptions of these the reader
 is referred to the  chapters devoted  to dermatitis  medicamentosa  and
 dermatitis venenata.   Quinine, the iodine and  bromine compounds,
 arsenic, belladonna, chloral, salicylic acid, and other  substances, are
 often responsible for these symptoms.
  The name, multiforme, given to this disease by Hebra, is justified
 by the  singular diversity of lesions  which it displays.  These  are
 remarkable  not merely for their variety,  but  for their occurrence in
 such variety both simultaneously and successively, and  for their rapid
change from one type to another.
1 Journ of Cutan. and Ven. Dis., 1883, p. 83. 
erythema  multiforme.
161
  The subjective symptoms, save in the urticarial form of the disease,
are usually of a trifling character.  The slight sense  of heat  and
burning awakened by the lesions  is altogether  out of proportion to
the extent of development of the latter.
  The symptoms, however, indicative of a general disturbance of the
system may be of a marked character.   General malaise, fever, inap-
peteuce, pharyngeal   inflammation,  chills,  severe gastro-iutestinal
disorder, rheumatoid involvement of  the  articulations, and even
organic changes in the heart (valves, endocardium, and pericardium),
lungs, and  kidneys (Kaposi), have all  been noted as coincident or
causative phenomena.   In  many of these cases it is  clear  that the
exanthem belongs to the list of symptomatic erythemata, and is of
insignificance in  comparison with the grave general condition.  With
these exceptions, however, the prognosis is in general quite favorable,
as the disease may  terminate  in a few days, and rarely exceeds a
month in duration.
  Occasionally the mucous membranes are affected to a disagreeable
or even painful extent.  Thus  a sudden tumefaction of the  uvula
may supervene upon the cutaneous symptoms, even in cases sufficient
to impede  respiration ;   or  the  lining membrane  of the larynx be
involved, and the resulting aphonia in various degrees persist for tMO
or three days.
  Etiology.—"We are  in a  state of complete  ignorance as  to the
cause of these  erythemata" (Hebra).   We simply know that the
affection is more common in the spring aud autumn ; that it  occurs
in the young or  in the  early periods of adult life; that the papular
and tubercular forms are more common in men, and the nodose forms
in women ; and that in  many cases it occurs in those mIio are affected
with rheumatism.   There  cau  be but  little doubt that its etiology
includes  a  list of varying and widely differing  causes.   The author
has seen severe manifestations of  the disease in  a young woman with
extensive ulceration  of the cervix uteri.   Tilbury Fox noticed its
frequency in youug servants brought to town from the couutry.  It
is not rare  in young female immigrants who have recently made a
" steerage " passage to this country.
  Patholoe/i/.—Erythema multiforme is  essentially an  hyperaemia of
the integument  M'hich,  under  certain  obscure   influences, advances
more or less rapidly  to the  stage  of a  mild grade of inflammation
M'ith consequent exudation.   If, with  Landois and  Lewin, it be
accepted that the process is the result of vaso-motor nerve influence,
it cannot be determined  whether these nerves are irritated at points of
origin or distribution.   In the  case of erythema nodosum,  Hebra
advances what  he admits to be  an hypothesis, in saying  that the
morbid  process  is  essentially  an  inflammation of  the  lymphatic
vessels.   In some  cases it is  evident  that  there is extravasation of
blood from the vessels into the skin of the affected parts.
  Leloir1 discovered iu the papules,  tubercles, and bullae of the
i Bull, de la Sue. Anat, 1884, p. 294
         11 
162
diseases  of the  skin.
erythemata, only the phenomena of hyperemia and exudation limited
to the corium  and subcutaneous tissue ;  and Villemin1 simply con-
firms these facts.
   Diagnosis.—Erythema multiforme is always to be carefully distin-
guished from the traumatisms producing bruises, especially upon the
lower extremities.  This is  a point  which  may have an  interesting
bearing upon  certain  medico-legal questions, especially  iu  the case
of young children.2  The tendency of the disease here considered to
symmetrical  arrangement upon  the two sides  of the   body;  the
occurrence of  lesions evidently  dating  from  several  periods, M'here
successive crops appear ; and the  absence of  all history  of  external
injury, will usually suffice to establish a diagnosis.  Among the pre-
cocious  affections of the subcutaneous connective tissue in  syphilis,
Mauriac has described a lesion resembling somewhat the symptoms
of erythema nodosum; but in such  cases, and  especially in women,
mucous patches of the vulva, anus, or mouth, with coincident adeno-
pathy, Mould point to the real nature of the disease.
   Ireatment.—As the disease under consideration progresses naturally
to a favorable termination within the course of a few weeks, the duty
of the physician is usually limited to the question of diagnosis merely.
He should remember that the larger lesions seen in erythema nodosum
never  suppurate; and  thus be not  tempted to  open them with a
lancet.   Local treatment is rarely  called for;  and in any case should
be restricted to the application  of hot  or cold water, as found most
grateful  to the patient, M'ith possibly the use of a weak  lead lotion.
Internally such medication should be employed  as  is indicated by
the general condition of the patient.   Iron,  quinine, strychnia, and
the dilute hydrochloric acid  will be found beneficial in many cases.
Constipation and indigestion are to be corrected  by appropriate
measures.  When the disorder  is  evidently purely symptomatic, the
internal treatment is to be directed to the general condition present.
In  rheumatic  cases,  the indications  for  such  treatment are clear.
When the erythema produces extensive  oedema of the uvula,  incisions
may be requisite to prevent  dyspnoea and dysphagia.
   Prognosis.—It will be gathered from M'hat has preceded, that the
prognosis is always favorable.  The  fatal  cases  reported  are usually
those where the result was due to grave constitutional conditions, and
where the erythema multiforme was  an insignificant feature  of the
malady.   The  disease may relapse in susceptible individuals at those
periods of the year when it is most frequently observed.

 I Gaz. Hebdom., 1886, Nos. 22, 23.
 2 Since this paragraph was written, the author, in conjunction with a number of other physicians,
was summoned as a witness in a case where both parents of a lad who exhibited the lesions of poly-
morphous erythema, and who died suddenly, were charged with beating  their child to death.  They
were exonerated on the basis of the evidence of the experts. 
URTICARIA.
163
                            Urticaria.

                        Lat. urtica, the nettle.
 Urticaria is an exudative affection of the  skin in which appear ephemeral,
  whitish, Or rosy-tinted wheals surrounded by a reddish areola, giving rise
  to an intense pruritus.

   Symptoms.—This disorder,  popularly known as  the " Nettle-rash"
 or the " Hives," maybe ushered in by constitutional symptoms, such
 as inappetence, malaise, cephalalgia, or mild pyrexic symptoms lasting
 for a few hours or even for a day or more.
   With, and often without, such prodromic symptoms  the eruption
 suddenly appears  in  the  form of wheals upon the surface,  which
 frequently disappear with equal rapidity,  leaving behind no traces of
 their existence save a slight and transitory hyperaemia of the affected
 spot.  The lesions may be as small as a finger-nail or a coffee-bean,
 and are usually of this  size ; but in certain  rare instances " giant
 wheals" are seen, large tomato-sized  projections or flat elevations of
 broad areas of the integument, covering the greater part of the belly
 or the buttock.   In color, they are either rosy-red or whitish;  and
 are  usually surrounded  by an  hyperaemic areola.   They  may be
 isolated  and  few; or numerous  and  closely packed together ; may
 even coalesce so  that  individual lesions  are  scarcely recognizable.
 They are usually firm and semi-solid to the touch.   Rarely the horny
 layer of the skin is  raised  in fluid-containing  lesions  by the sudden
 effusion  of serum  beneath.   Iu contour, they are roundish or oval-
 shaped ; but a variety of curious outlines may result from the irregu-
 larity of their development. Concentric circles, lines, bands, and even
 figures, are in this way produced.   The finger-nail draM-n across the
 unaffected portions of the skin, in a patient M'ith urticaria, will often
 produce a linear wheal of extent corresponding to the  line of  irrita-
 tion,  ft is said  that in  this way the so-called  " medium" with a
 sensitive skin exhibits  written  characters  upon the  surface of  his
 body.
  The subjective sensations induced by these lesions are distressing
 in various degrees, according to the susceptibility of the individual.
 Every grade  of pruritic burning, tickling,  crawling,  pricking,  and
 especially stinging sensations  are thus engendered.   The efforts of
 the  patient  to secure relief  by scratching,  not only serve  still
 further to develop the eruption, but to irritate, tear,  and otherwise
 Mound those lesions  already  in  full  evolution.   In  this  way the
 serous effusions are  produced  at  the summits of the wheal; and in
 this  May, also, the  lesions really transitory in their course may be
 changed  to more persistent, deeply colored, flat, lenticular papules.
 Where the skin is delicate and thin, as that of  the  lids and prepuce,
 considerable oedema may result.
  All  parts of the body may become affected, and this irrespective of
age  and sex,  though children are particularly liable  to the disease. 
164
diseases  of  the  skin.
There are few very youug children with skins unwashed for an entire
month, who will not exhibit urticarial symptoms, if there be an added
irritation of the surface.
  The lesions may be numerically few, or so numerous as to cover
the entire surface  of  the  body.  Though more frequently acute in
course, they  may  recur  frequently  from  apparently insignificant
causes, or even become chronic.  In many cases  trivial, the disease
may become so aggravated as to make  the largest demands upon the
skill of the physician.
  The rapidity of appearance and disappearance of the lesions visible
upon the skin is  a characteristic feature  of the disease.  In some
instances but  a few moments are required  after the operation of an
efficient cause, to develop  a large number  of closely packed wheals
upon the  skin.   Even while these are  under inspection, it  can be
noted that there  is a change  in individual lesions, some fading or
completely disappearing, while others are newly developing.
  A number of names have been employed to designate the several
external peculiarities of the lesions as  they are presented  to the eye.
Thus U. Annularis occurs iu rings ; U.  Figurata, in gyrations from
union of several  lesions or patches of  lesions; U. Vesiculosa  and
U.  Bullosa, M'here there  is a vesicular or bullous development at the
summit of the lesion ; and U. Papulosa  (or Lichen Urticatus), M'here
there is a combination of the features of the wheal  and the papule,
the lesions being usually rape-seed to coffee-bean in size, and covered
with blood crusts M'here their apices  have been torn in scratching;
U.  Tuberosa, M'here  " giant"  wheals occur, some attaining  the  size
of a hen's egg; U. Hiemorrhagica  (Purpura  Urticata),  M'here  the
urticarial  element is  developed in a lesion produced by cutaneous
haemorrhage; and U. Evanida, or Perstans, where there is  respec-
tively a  rapid or slow  process of involution  in  the  characteristic
symptoms.
                      Urticaria Pigmentosa.

  In this form of the disease, characteristic M'heals in young subjects
are succeeded by peculiar pigmentations of the surface in dark-brown,
greenish-yellow, or chocolate-tinted spots, which persist from the  date
of one eruption to another.  The skin is highly irritable,  and the
most trifling causes are sufficient to induce an attack.   In Morrow's
case1 the mere removal of the clothing  and exposure of the skin of
the little patient to the air were sufficient, at the time the author had
the opportunity of observing the phenomena, to produce an abundant
crop of wheals over the surface.   The pigmentation in these cases is
probably due merely to the extraordinary sensitiveness of the integu-
ment, whereby repeated and rapidly repeated exudations occur in the
skin, and the resulting maculatious are proportioned in depth of color
to the frequency and  intensity of the process.
   Four  cases of this disease  were exhibited at the International
1 Archives of Dermatology, Jan. 1879. 
URTICARIA.
165
Medical Congress in London in 1881, by Mackenzie, Cavafy,and Fox;
and others have been reported by Nettleship, Beatty, and Crocker.
  In a case w here the lesions of this singular disorder were examined
by Pick, microscopically, hemorrhages were recognized  in the lesions.

  Baker1 reported a case of Urticaria Tuberosa characterized by the
presence of persistent, yellowish-red tubercles in various parts of the
body which proceeded to ulceration.  The parts most affected were
the knuckles, elbows, and cars.   These  tubercles are said  to have
begun  iu a manner similar to that M'hich characterizes the onset of
evanescent urticarial wheals and  tubercles.   A somewhat similar case
Mas observed by McCall Anderson.2
  Urticaria, like erythema, may be either idiopathic or symptomatic;
and  in either, the urticarial condition may underlie or  be superim-
posed  upon almost every elementary lesion noted  in the integument.
Its lesions may complicate (or be complicated by) the macule, papule,
tubercle, vesicle, bulla, and pustule.  It may spring from an excoria-
tion, or result in a fissure.   It is common in  traumatisms, and is a
prominent symptom in the skin bitten  by insects, reptiles, and the
domestic animals.

   Etiology.—Idiopathic urticaria ahvays results from the action of
external irritants.   The enumeration of these would require a recital
of all  the external agencies which are  capable of irritating the skin.
Prominent among them are the  bites and stings of  mosquitoes, lice,
fleas, bed-bugs,  flies, gnats,  Masps, caterpillars, and bees.   Contact
with certain species  of the jelly-fish is said to be also effective.  The
wounds thus inflicted  usually excite a  stinging or burning sensation,
bv M'hich the patient  is excited  to  rub or scratch the part.   Then
a wheal  is  rapidly formed  in the site of the injury, and the irrita-
tion thus set up is couveyed to other parts of the skin in  the vicinity,
so that, especially in children, a single traumatism by an insect may
excite an urticaria covering a much larger area.   Many medicaments
operate similarly, and it should  be added that some of them, though
applied externally without toxic effect to the mass of men, may pro-
duce urticaria in exceptional cases.  Thus a common flaxseed poul-
tice  M'hen made to cover  but  a small  portion  of the body  has
produced violent symptoms of the disease under consideration.  The
irritant action of the nettle (U. urens and U.  dioica)  has given the
maladv  its name.   Climatic influences,  more  particularly  those in
M'hich the surface of the body is  exposed  to cold air,  are very efficient
in the production of urticaria, as also of bronchial asthma, with the
symptoms of which the disease under consideration may often coexist
or alternate, in the case of adults.   Mechanical violence, the  applica-
tion  of leeches to  the surface,  and surgical  traumatisms may also
induce the disease.
   Symptomatic urticaria is chiefly of the variety named by  authors,

    ' Lancet, Aug. 1881, p. 153.                   2 Brit. Med. Journ., Dec. 8, 1883. 
166
DISEASES  OF  THE  SKIN.
ab ingestis, since it most frequently results from medicinal or dietary
articles taken into  the stomach.  ' Of the latter class maybe named
eggs, cheese,  pork, sausage,  coffee,  tea, cocoa, and confectionery;
crabs, lobsters, clams, caviar, and several species of fish-roe, oysters,
and  fish  generally; strawberries, cucumbers, skins of grapes, nuts,
dates, raisins, almonds, figs, prunes, gooseberries,  and  raspberries;
canned  fruits, meats,  and  vegetables; oatmeal, peas, beans, onions,
garlic,  and  "corn;"  pickles,  sauces,  honey,  mushrooms, pastry,
salads,  and  spinach.   Vinegar,  champagne,  beer, and  alcoholic
beverages in general are capable of inducing  a similar  effect.
   Among the medicinal  articles  capable of inducing urticaria  may
be named the balsams, the turpentines, quinine, glycerine, chloral,
valerian,  arsenic, hyoscyamus, cinchonidia,  salicylic acid and  the
salicylates, senna, santonine, and opium and its alkaloids.
   In the  case of children and infants, a severe urticarial  efflorescence
may be provoked by auy undigested morsel of food, or  indigestible
material of any sort, which may have been passed  into the stomach.
Thus a bit of orange-peel, or fragment of potato-paring, or the skin
of grapes, may be discovered to lie at the root  of  the trouble.  In
the case of adults also  who have  suffered  from repeated attacks of
urticaria,  and  have a  fully developed  sensitiveness of the gastro-
intestinal  tract, almost any unusual alimentary substance, if ingested,
may induce a return of the disagreeable symptoms.
   It must be borne in  mind that this undue seusitiveuess to the effect
of ingesta or external irritants  is often an idiosyncrasy peculiar to the
individual either on special occasions or at all times, and that, given
this susceptibility, the effect is  often great M'ith a relatively insignifi-
cant etiological factor.   Thus one may see cases in which a teaspoonful
of beer, one grain of quinine,  the smallest fragment of cheese, and
but a single strawberry M'ill  not  only induce  an  urticarial rash of
such extent as to cover the greater part of the  surface of the body,
but  will  do  the same on every  occasion when the articles named
are swallowed in the quantities given.   This, it is important to re-
member, is in general characteristic of the medicamentous eruptions.
The a priori  reasoning, that  the greater  the  quantity  of the  toxic
agent applied  or  swallowed, the graver the  effect, may lead to gross
errors.  It should always be remembered, in seeking the explanation
for an urticarial rash, that the  smallest amounts of  apparently inno-
cent substances may be responsible for the largest annoyance.
   Other causes of urticaria may  be cited, such as moral emotions
(fear, shame, anger); gastro-intestinal disorders, M'here  ingesta play
no part;  intestinal parasites;  malaria;  the exanthematous fevers,
particularly in their prodromal stages;  disorders of the  uterus, kid-
neys, and nervous centres; pregnancy,  dentition,  and  the irregu-
larities  attending the menopause; and,  lastly, the  following special
diseases:  asthma, pemphigus, prurigo (of Hebra),   rheumatism, and
purpura.
   Pathology.—The wheal of urticaria is produced by an interchange
of play between bloodvessels, muscles, nerves,  and tissues, under  the 
URTICARIA.
167
operation of a principle M'hich the French characterize as the choc en
retour.  There is, first, most probably under the influence of the vaso-
motor nerves, a clonic spasm of the capillaries in a limited area of the
derma, by which an acute oedema is produced with some serous exu-
dation.   The rapidity M'ith  M'hich  this occurs is greater  than that
with M'hich the tissues of the vicinage can accommodate themselves
to it either by imbibition  or more diffuse  tumefaction,  aud  there
results a counter-pressure upou the affected capillaries, by which their
lumen is still further restricted.  As the wheal is  not a purely  fluid-
containing  nor yet an  entirely solid lesion, but is semi-fluid in con-
sistency, the mechanical pressure is greatest at the centre and least at
the periphery.  Thus is explained the white  and relatively bloodless
appearance  of the centre of certain  wheals, and their rosy or reddened
outer border.  It  is confirmed  also by  the  fact  that generally the
most acute lesions, those springing into view most rapidly, are chiefly
characterized by this whitened centre, while  those more indolent or
even  chronic in  their career, have been less subject to the inter-play
of the forces described above, permit of more general vascular  injec-
tion, and have a light crimson or even at times a dull red centre.
Wheals have been excised and examined microscopically by  Neumann,
Poncet, aud others, with the result of discovering merely evidences
of infiltration.   According  to the  last-named author, the  lymphatic
vessels  are  also  choked  with " lymph clots."   Rohe1 explains  the
occurrence  of the wheal by supposing that  certain sensitive nerve-
fibres of the skin possess also a vasomotor function.
   The  process described, occurring as an epiphenomenon after  the
traumatisms  or other cutaneous lesions enumerated above, merely
adds its characteristic symptoms  to those previously apparent.
   Diagnosis.—The diagnosis of typical urticaria is so readily made
that the disease is often  recognized before the attention of a physician
is called to  it.  As usual, the atypical cases are those in which con-
fusion may  arise.  The chief points to be remembered are : the rapidity
of evolution of symptoms,  their ephemeral  duration, aud the char-
acteristic sensations they awaken.  The action of the animal parasites
and  insects  not parasitic should  not be overlooked, and the rash be
closely examined for the minute wounds  inflicted in this  May, often
covered  M'ith  a  minute  pin-point to pin-head  sized dried " blood-
scale."   The various  forms of erythema papulatum, tuberculatum,
and  nodosum are liable  to be mistaken  for  urticaria; but this is in
manv cases inevitable, as the intermediate forms between the  two
disorders are with difficulty assigned to either category.  Absence of
marked   subjective  sensations   and  persistence  of lesions  would
generally imply the existence of an erythema, while marked preva-
lence of  these symptoms would properly decide in favor of urti-
carial disease.
   In manv cases  the physician is consulted by a patient who gives a
history of well-nigh intolerable distress at night or at other capriciously
i Maryland Med. Journ., May 15, 1881. 
168
DISEASES  OF  THE  SKIN.
selected hours, M'ho  repeatedly and vainly endeavors to exhibit the
lesions as they appear upon the skin.   Being examined on occasions,
scarcely a trace of cutaneous disorder is  manifest.   Here the practi-
tioner has practically to decide upon the character of an eruption he
never sees.   The  task is rarely  a difficult one.   No  other  than the
urticarial eruption behaves  iu  this fashion.  Occasionally the physi-
cian will discover delicate, rosy, or deeper stained mottlings of the
surface where the M'heals have been but  are not.   At times also he
M'ill succeed, on the  flexor aspect of the forearm, or in some situation
M'here the skin is equally delicate, in producing the appearance of one
or more  typical lesions by the aid of his  finger-nail in  scratching or
rubbing.  These cases are more frequently of  the chronic or at least
relapsing class; and the  victims  of the disease may have a charac-
teristic facies, a worn look from loss of sleep or mental emotion.  One
is apt to discover in  this class those who are mourning over the death
of relatives,  loss of  property, separation from  home and friends, and
those harassed by anxieties.
  The several lesions of  erythema are larger than those of urticaria,
and do not develop  from characteristic M'heals; in erythema multi-
forme, the lesions are far  more persistent in type, and do not provoke
the characteristic subjective sensations of urticaria;  in erysipelas, the
redness is characteristic and the swelling more diffuse.
  Treatment.—Many cases of acute urticaria demand  no treatment.
The physician is summoned for  a diaguosis.   The patient and his
friends are alarmed by the dread  of variola or other severe affection,
and learning that perhaps a pickled cucumber  is alone responsible for
the disorder, they wait with  equanimity for the conclusion which is
always  reached.   Fortunately, the unusual,  severe, and  relapsing
forms rarely begin with acute symptoms.
  Naturally the first indication to be observed is the removal of the
cause, and  this, if possible, accomplished, the exclusion next of all
aggravating  agencies.   The discovery of  the  cause, at  times readily
effected, is often the  most serious problem  which is presented.   An
exhaustive and minute examination of  the person and history of the
patient, a study of his food, drink, medicine, regime, clothing, sleep-
ing apartment, habits, occupations of life,  and  mental state, are  here
essential.  When the disorder is recent, and is an urticaria ab ingestis,
a brisk emetic or cathartic may rid the stomach or bowels of offending
matters.   This done, it should be borne in mind that an idiosyncrasy
of the patient may at this  moment render the skin peculiarly sen-
sitive to the action  of other  ingesta, and the diet, for a few  days
certainly, should be  carefully prescribed.   In many cases the alkalies
are  indicated by an acid condition of the stomach, and then  the
preparations  of sodium, potassium, and  magnesium are useful.  Lax-
atives, such as  rhubarb, magnesia, the cathartic  mineral waters, and,
in the case  of  children, small  doses  of  castor-oil,  are  frequently
indicated when there is uo suspicion of irritating ingesta.   At other
times there is marked  atony of the digestive organs, when the mineral
acids, the bitters, and the  ferruginous tonics may be needed.  Ao-ain 
URTICARIA .
169
R. Atropias sulph.	gr- i;	0
Glycerin.) Aq.dest. j	_	2
	aa 3ss ;	
Gum. tragacanth.	q. s.;	
Ft. pil. No. xx.		
lactopeptine, pepsine, or the subcarbonate or the subnitrate of bismuth
may be exhibited with advantage  for the relief of the indigestion
M'hich may  be the prominent feature of the attack.
   Other remedies found useful in the  internal treatment of urticaria
arc sulphurous acid in drachm (4.) doses three times daily in sweetened
water (Da  Costa); copaiba; strychnia (Guibout); the  arseniate  of
sodium, employed by Blondeau in doses from one-thirtieth (0.002) to
one-fiftieth  (0.0013) of a grain; the fluid  extract of ergot in half-
drachm (2.) doses (Morrow);   the  sulphate of  atropia, given  by
Sclnvimmer in doses of one-sixtieth (0.001) of a  grain ;  and the sali-
cylate of sodium in scruple (1.33) doses.   The last named drug has
been  highly praised by a  number of  writers.  It is often given  in
one grain (0.06) doses every hour.  Pilocarpine, or the fluid extract of
jaborandi, is known to produce at times a powerful effect in relieving
surface congestions  of the  skin, by means of the excessive  hyperi-
drosis M'hich  it  occasions,  and in proportion to M'hich it may become
dangerous.
   Schwimmer endorses the folloM'ing formula for this affection :
                                                      01

                                                            M.

   The treatment of a symptomatic urticaria should have regard also
to that disorder of the viscera or general system to M'hich the cutaneous
symptoms  may  be attributed.   The  uterine  complaint  of a  woman
may require appropriate treatment, as also the diabetes of the patient
M'ith an affection of the kidneys.  Quinine is, of course, indicated in
periodical attacks, but its action in exceptional cases as a direct cause
of urticaria  should not  be forgotten.   The same, to a greater extent,
is true of arsenic, the  bromide and iodide of potassium, hydrate  of
chloral, aud gelseminum.    The larger number  of patients are best
treated without  the employment of these drugs.
   In the  local  treatment  of urticaria, M'hich is chiefly intended  to
assuage the disagreeable  sensations  experienced  in the  skin, the
greatest diversity exists in the  methods  employed.   This  is  to  be
largely explained by the fact that a similar difference is to be  uoted
in the relief experienced by different patients after the application  of
the same  medicinal agent,  Thus cold and hot Mater baths, baths
medicated by marine salt, aromatic vinegar, alcohol, cologne, camphor,
the alkalies, and sulphuric ether; compresses dipped in such solutions
and laid over the part affected ; douches and vapor baths will, any of
them, in the case of some individuals produce a marked  alleviation
of symptoms; and in others be either inoperative or actually serve to
aggravate the  symptoms in the highest degree.  Hebra  asserted that
several  of the baths named above are quite useless, while  Kaposi
recommends cold lotions medicated  M'ith aromatic volatile substances.
Fox prefers alcohol,'or cologne Mater to  M'hich beuzoic acid has been
added, dabbed over the part, and permitted to evaporate.  Hillairet 
170
DISEASES  OF  THE  SKIN.
and Gaucher employ in a similar way a solution  consisting of one-
third of ether and two of warm water.
   The alkaline bath should contain the carbonate of sodium, the bi-
borate of sodium, alum, or the bicarbonate of potassium, either singly
or in combination in the  strength  of about six ounces (P>2.) of the
salt to thirty gallons of water.   One or two ounces (32.-64.) of the
sulphuret of potassium  may be substituted  for  these.  The water is
made demulcent by the addition of starch or gelatine, or by squeezing
into it  a bag  of muslin containing  bran.   When  it is desired  to
employ the  acid  bath, half an ounce (16.) of either  the  muriatic or
nitric acid is added to the quantity of water given above.   The bath
of  this size  may also be medicated M'ith one drachm (4.) of corrosive
sublimate;  or this drug  may be used as a  lotion  in the strength of
from one-fourth  (0.0016) to  one-half (0.0033) a  grain  to the pint.
Carbolic, benzoic,  salicylic,  boric, dilute  hydrocyanic,  and dilute
nitric acids  in weak solution, are  also employed with advantage  in
some cases.   Other  external  applications are thymol, carbonate of
ammonium, bromide of potassium, ether,  chloroform, and chloral-
camphor in  the strength of half to one drachm (2.-4.) to the ounce (32.)
of ointment.  This last is prepared by rubbing  together  equal  parts
of camphor and chloral till a  semi-liquid substance results.  It is an
antipruritic  remedy of some value,  but will  increase the uneasy sensa-
tions produced, if not largely diluted.
   In other cases the oily or fatty substances will give  more  prompt
relief, especially if the eruption has  been  much irritated by scratching
and tends to persist.  Among them may be named the linimentum
calcis of the pharmacopoeia,  and cold cream  to M'hich  have  been
added a few drops of the fluid extract of grindelia robusta.
   Mention should also be made here of the dusting powders which
the reader will  find described in  the chapters relating  to  general
therapeutics and the erythemata.    They are the most  cleanly of all
external  preparations  in urticaria,  and are  often  the   only  local
measures required.  With internal  medication, as each  case may sug-
gest, the practitioner will be careful to note  that the clothing  of  the
patient is of a character that will  not aggravate  the  eruption, that
sleep is secured without an  excess  of bed-covering, and  that places
M'here the temperature is for any reason elevated are carefully avoided,
such as the  proximity to a  fire-place or drop-light, the opera-house,
the kitcheu,  etc.
   Among the Germans, sulphur, naphthol,  and  tar  salves  are
employed in the management  of the disease.
   One of the most effective and trustworthy of local applications in
severe urticaria is a starch solution.  The starch is first mixed with
cold water, and then boiled till the solution is of the consistency of
thin mucilage.  To  each pint of this a drachm (4.) of the oxide of
zinc,  and a  couple of drachms  of glycerine (8.)  are  added  before
ebullition is completed.   When cool,  and applied to the surface, this
often gives prompt relief.
   Such is the empirical treatment of  urticaria.  It Mill be  seen to be 
DERMATITIS.
171
founded upon no rational method of procedure, and this because the
very capriciousness of the disease demands and secures relief  in one
instance  by a treatment M'hich  should  be reversed in another.   It
must, be admitted that cases occur in M'hich all treatment seems abso-
lutely valueless, often really  injurious to the patient.  These cases
M'ill usually be  found to be of the relapsing or chronic type.   The
subjects of this form of disease are often plunged in morbid mental
states; dreading  by day the exacerbations of the  night;  brooding
over misfortunes experienced or anticipated; worn with loss of sleep;
fearful of a  generous regime  at the  table.  Here  the treatment  is
largely moral, and makes demands upon the  tact and courage of the
physician.   Travel, change of climate, variation in the routine of life,
neM' social  surroundings, are  here valuable.  The widow must  be
made to  lay aside  the  heavy crape veil beneath M'hich  her urticaria
plays;  the solitary  patient  must  secure  a  companion capable  of
diverting the nervous attention for a few hours each day.
   It seems probable that to these efficient agencies must be in part
ascribed the relief so often obtained at  the various mineral springs,
both in this country and abroad.  Thus the  Karlsbad, Vichy, Sara-
toga, and  White Sulphur Springs, have all  been  credited with the
production of beneficial effects in urticaria.
   Prognosis.—The prognosis of an  attack of urticaria is,  as may  be
seen  in  what has  preceded, exceedingly variable in  different  cases.
Simple attacks of  the  acute sort are trivial, and in a  few days the
patient may retaiu but the  slightest souvenir of the trouble.  In the
case of children, the attack  is often at an end in the course  of twenty-
four hours.
   It should, however, never be  forgotten that urticaria may torment
the life of a patient to the  utmost bounds of tolerance, and seriously
impair the general  health.  Persistent and rebellious chronic urticaria
may prove to be a more formidable affection  than  a mild attack of
syphilis.

                           Dermatitis.
Dermatitis is an affection of the skin characterized by the phenomena of  in-
   flammation, including heat, redness, pain, and infiltration, terminating in
   resolution, suppuration, or the occurrence of gangrene.

   Inflammation  of the skin  occurs  in a large number of cutaneous
affections.   Under this title, however, are grouped those  inflamma-
tions M'here the result  is plainly due to a direct  influence exerted
upon the skin by thermal, chemical, or  mechanical  agencies.   These
inflammations may be mild or severe.
   The milder forms  of dermatitis disappear without  leaving  behind
them persistent  lesions.  The graver forms_ may terminate in gan-
grene, or produce death by shock or exhaustion.
   Dermatitis, then, is that  idiopathic morbid state whose phenomena
are induced by the  action of certain special agencies,  such as heat, cold,
poisons,  and traumatism.  The inflammatory process may involve the 
172
DISEASES  OF  THE SKIN.
superficial or deep  portion of the integument, or  may extend to the
subcutaneous  tissues, or even deeper.   The  symptoms vary  with
the nature of the cause, the  extent and degree of its  influence, and
the circumstances attending its operation.  Hyperaemia  usually pre-
cedes and may.be followed by a fluid or plastic exudate, by the pro-
duction of one or more of the several recognized cutaneous lesions, by
diphtheritic deposits upon the surface, or by gangrene.   With these
there may be general symptoms of mild or severe grade, due to the
influence excited by the local process upon the general economy.

                    [A.] Dermatitis Traumatica.
   External violence, various in character and severity, is capable of
inducing dermatitis whose symptoms differ in  degree, though  their
career is, in general, the  same.  In this list are included the inflam-
mations produced by surgical  interference with the continuity of the
integument; excoriations caused by  scratching, by the friction  of
garments  and other articles  injuriously acting upon the skin; by
the  various implements handled  in  the trades;  and  by the  bites
and  stings of beasts, insects, reptiles, and fishes, when  the result is
traumatic and not toxic in character.   These  injuries may be in the
form of contusion,  bloM', concussion,  pressure, puncture, incision, or
laceration ; and the consequences are declared in heat, swelling, red-
ness, and pain; and in itching, burning, stinging,  or pricking sensa-
tious, with subsequent inflammatory symptoms varying in grade from
mild  and transitory hyperaemia and  exudation to severe grades of
inflammation  with  consequent production  of pus, granulation, and
repair;  or gangrene, and separation  of the  slough;  or, finally, by
repair without consequences.

                    [B.] Dermatitis Venenata.
   Certain  medicinal and other substances  applied to  the external
surface of the skin, are capable of exciting inflammation either by
operating  as caustic, irritant, toxic, or even  traumatic  agents.  In
this  list are included most of the strong acids and alkalies;  croton
oil;  cantharides; mustard; tartar emetic; mezereon; the compounds
of mercury; arnica; turpentine;  ether; chloroform; the tarry com-
pounds ; many of the dyes; several members of the rhus family (the
Rhus toxicodendron and  Rhus venenata, poison ivy, poison oak); the
nettle;  the  smart weed [Polygonum punctatum);  cowhage (Mmuna
pruriens);  and glass in fine powder or delicate filaments, such as are
thrust into the skin when handling certain articles  of Venetian glass-
ware.   The list might  be  indefinitely extended, as there are few
articles  which are  not  capable of producing  some irritation  of the
surface  of the skin, if applied to it M'ith sufficient vigor and for a
certain  period of time; and in some  it is difficult to decide M'hether
the effect is more traumatic or toxic.  An almost equally long list of
substances of animal origin might be also named having  poisonous
effects upon the integument, such as decomposed or ammoniacal urine,, 
DERMATITIS.
173
feces, ichorous pus, pathologically altered secretions from  the uterus,
eye, ear, nose, etc.
   The  symptoms of dermatitis  venenata are. substantially  such as
have been already described.   Numerous types of cutaneous lesions,
macules,  pustules, papules, vesicles, bulla?, M'heals, scales,  crusts, free
serous and puruleut discharges, subcutaneous abscesses, and even gan-
grene with  sloughing, may result from the operation of such causes,
the  result beiug  largely proportioned to the character of the agent
producing the injury.
   A few of the more common sources of such accidents may be briefly
considered.
   The  use of soap for laundry, toilet, or other  domestic purposes,
containing an excess of alkali, or even minute particles of bone, is a
frequent source of trouble, as are also several of the proprietary arti-
cles sold  in the shops for similar employment.   In these instances,
the  erythema, vcsiculation,  infiltration, or  other symptoms, will
naturally be distinguished on the hands, or the hands aud the face.
Stockings and other  undergarments dyed with aniline, picric acid,
chromium, and arsenic, the  leather liuing of the inside of the hat or
the  cap, and the painted toys to M'hich  the  lips of children  are ap-
plied, will beget  mischief in  the various regions of contact for each.
Duhring  reports cases where the dye-stuff in the  lining of shoes
penetrated the material of  the stockings  in  women,  and produced
dermatitis of the feet or legs.
   The  tincture of arnica, an article unfortunately much  used  as  a
domestic  application  for  contused and  incised wounds of a  simple
character, has  produced very serious annoyance  in some cases, two
such having been recently presented at the author's clinic.
   The  number of these accidents is annually increasing.   Cartier1
reports excessive erysipelatous SMclling, a phlyctenular eruption, and
submaxillary adenopathy resulting from the  external  use of arnica.
Beauvais  reported to the Paris Medical Society gaugrenous results in
one case.   Buchner believes this poisonous action  to be due to insects
(particularly the  atherix maculatus) found in the calyx of the arnica
flower.
   Other native plants, a large number of M'hich are enumerated in a
valuable work by Dr. James C. White,2 presented before the American
Dermatological Association in 1886, are similarly effective.  Wesener3
reports  that the Malacca bean tree (Anacardium Orientale) furnishes
a caustic  oil,  called card61,  or cordoleum  pruriens, M'hich produces,
after application to the skin, vesicles and vesico-pustules M'hich con-
tain cardol and  terminate by crusting.   He  reports  a generalized
eruption, beginning on the face, due to this cause.
  The antiseptic dressings of modern surgery are at times responsible
for eruptive troubles.   Among these may be named iodoform, which
has  produced erythema, vesicles,  pustules, and  M'heals.*   Carbolic

      ' Lv.m Mod., April 13, 1884.             2 Dermatitis Venenata, Boston, 1887.
      Dcntsch Arch. f. klin. Med., vol. xxxvi. p. 578.
      4 See paper of Dr. R. W. Tayior, read to the New York Academy of Medicine, 1887. 
174
DISEASES  OF  THE  SKIN.
acid and corrosive  sublimate dressings have had  similar effects.
Many of the articles employed therapeutically by the  dermatologist
should be placed in the same category.  Dr. N. E.  Green,1 of London,
reports severe oedema of the skin  followed by desquamation, resulting
from the application to  it of the ointment of ammouiated mercury in
the strength of tM'o drachms (8.) to the ounce (32.).
   Leszinsky reports a case of dermatitis following the use of a " triple
extract of heliotrope" as a toilet preparation over the face.
   An exceedingly common source of such dermatitis is  urine retained
upon underclothing in adults.   A persistent dermatitis of the scrotum,
perineum, or inner faces of the thighs in either sex, always calls for
a careful examination as to whether a few drops  of urine are  left in
contact   with  such  underclothing after each act of  micturition.
Fistulse, urinary incontinence, prostatic disease, " stammering of the
bladder," imperfect  finish of the coup de piston in  men,  especially
after a gonorrhoea, and  similar troubles, are all to be remembered.
   The eruption produced by the poison  ivy and other varieties of
rhus, is  almost exclusively an American disease;  and from its fre-
quency  in this country has  attracted a great deal of attention.   A
certain degree of susceptibility to the  poisonous action of the plant is
requisite for the  production  of  its effects,  as some individuals  can
handle the leaves  of the plant with impunity, and others are said to
be affected by its exhalations M'ithin a circle having a radius of several
feet.  It is,  hoM'ever, difficult to demonstrate the truth of the last
statement,  suspecting, as one  may,  that such instances are usually
cases  of contact with other  than the suspected  plant.   The parts
commonly affected are the hands and the regions to which the latter
are carried, such as the face,  genitals, arms, thighs, and neck.   Bare-
footed children suffer in the feet and legs.   Usually the  symptoms
are developed in the course of a few hours, and consist of erythematous
patches,  scanty or profuse vesiculation with abundant,  serous M'eeping
after  rupture of  the lesions,  SM'elliug,  oedema,  disfigurement, and
intense burning and itching sensations.   Serious effects are occasion-
ally produced.   The author  has seen deeply attached scars  result
from subcutaneous abscesses  of parts greatly swollen.   Occasionally,
in particularly sensitive skins, the eruption  spreads from the surface
affected  by the poison, to that  M'here  presumably none has been
applied.   It should  be remembered, however, that articles of clothing
may  for brief periods  of time certainly furnish sources  of further
trouble,  being worn at  the moment  of contact M'ith  the plant, then
laid aside, and, the occasion being  forgotten,  being subsequently
employed.  Thus a pair of undressed kid gloves after lying for two
weeks untouched  have  sufficed to reawaken the disease.
   A number of cases of dermatitis have originated in some parts of
the Orient from contact with the varnish employed in the finishing of
lacquered ware.   This is manufactured  from the rhus varnish   A
1 Brit. Med. Journ., May 3,1884. 
DERMATITIS.
175
 few instances of such dermatitis have occurred in this country from
 handling the newly imported articles of this class.
   Careful observation of a typical case, soon after the onset of symp-
 toms, Mill disclose the exact surface of contact, each being delicately
 outlined  by  a  reddened,  tolerably M-ell-defiued line, M'ithin  M'hose
 limitations will be seen a  slightly tumefied, erythematous surface, at
 times displaying closely packed, pin-point sized papules, which may be
 embryonic vesicles, or may proceed to resolution without serous effusion.
   The  diagnosis of the eruption will be aided.by recalling the features
 described  in  a  careful monograph on the  subject by Dr. White, of
 Boston.1   According to this  author, the lateral  surfaces  of the digits
 first exhibit  the symptoms of  the eruption; later,  the  dorsal  sur-
 faces;  and  latest, the thickened  palms.    The  efflorescence also is
 more irregularly  distributed,  more uniformly vesicular,  and  the
 vesicles less  transparent than  in  eczema.  These lesions are, more-
 over, more vesicular, and less  papular  at the  onset;  and, though
 suggesting papules by their situation in the pa]m, are  in that situation
 readily made to exude serum by puueture M'ith  a needle.
   Internal medication is  not required.   The local treatment is that
 of acute  eczema.  The application  of an  alkali for the purpose of
 neutralizing the poisonous volatile alkaloid  in the leaves of the plant
 (toxicodendric acid,  Maisch)  should evidently  be considered solely
 with a view to prophylaxis, as it is difficult to understand how such
 neutralization can control the inflammatory process after its onset.
 The black wash, solution of sugar  of lead, or oleated  lime-Mater,
 should  be employed at first, and be followed  later  by  the  dusting-
 powders.  The  late  Prof. Babcock,  of Chicago, a frequent  sufferer
 from the disease during his extended botanical excursions, first taught
 the value  of an ointment made by incorporating a decoction  of the
 inner bark of  the American spice-bush  (Benzoin odoriferum) with
 cold cream.   It certainly has afforded very  prompt relief in the cases
 in M'hich oue is  able to employ it, the difficulty lying in securing the
 bark of the shrub in its young and tender state.
   A long list of topical remedies have been vaunted as specific for the
 relief of this  disorder, from the brine of a pork-barrel to a decoction
 of the leaves  of the plant itself.  As the eruption subsides with satis-
 factory  results M'hen protected and not irritated by the local treatment,
 it is not difficult to explain these facts.   In this May corrosive subli-
 mate lotions; the tincture  of iron ; bromine, fifteen drops to the ounce
 (32.) of olive oil (Brown);  dilute nitric acid ; hyposulphite of sodium;
 bicarbonate of sodium ;  saturated solutions  of chlorate of potassium;
 and grindclia robusta, a  drachm  (4.) of the fluid extract  to  eight
 ounces  (250.) of water, have all  been found useful.

                      [C]  Dermatitis Calorica.
   Under this title are included those affections of the skin induced
bv extremes of  thermal variation.

 i Now York, D. Appleton & Co., 1878, from the March number of the New York Medical Journal of
the same year. 
176
DISEASES  OF  THE  SKIN.
   Unduly high temperatures produce in the skin some redness and a
slight degree of swelling, the color not completely disappearing under
pressure.   If the exciting agent be M'ithdrawn before further effects
are induced, the color first deepens, then becomes paler, and in twenty-
four hours the process is usually concluded M'ith a very delicate and
transitory resulting pigmentation.
   Rays of heat  and heated objects at a temperature above 125° to
175° F. produce immediately,  or  after  a brief interval,  first  an
erythema,  M'hich  disappears  M'hen  the  source of heat is removed;
second, after more prolonged exposure, the symptoms of active in-
flammation  and exudation.   Vesicles or bullae, isolated or confluent
according to the severity of the cause, may  rise from a reddened skin
M'hich is usually intensely painful.   These lesions  are persistent  or
transitory, and generally filled with a clear serum, M'hich exudes and
dries into crusts after  rupture of the chamber in M'hich  it was im-
prisoned.   At other  times  the  serous exudation  is so great that the
epidermis rises in broad plates,  from beneath which the serum  is
exuded.   This process  may terminate by  a free production of pus
from the  surface and gradual resolution.   Adenopathy is a frequent
concomitant symptom.   In such dermatitis of extensive areas of the
skin, the  intensity of the process may awaken a violent fever;  or
death may result from shock or exhaustion.
   In yet severer grades there is the production  of ail eschar, which is
dry, broMii, blackish, and destitute  of all  signs  of vitality ; or,  as
Kaposi describes it, dense, coriaceous, aud as M'hitc as alabaster, upon
M'hich, nevertheless, some vesicles may appear,  and  by their presence
suggest a false conclusion as to the vitality of the  tissues upon which
they rest.   In from  eight to ten days the  eschar is removed  by sup-
purative processes, and the scene is closed by the usual phenomena  of
granulation  and  cicatrization.   The  characteristics of the scar thus
produced are  its  great irregularity, its tendency to stellate radiation,
and the production of ridges, folds, pockets, and bridles.
   Burns involving one-third  of the surface of the body are of grave
portent, and those affecting  one-half are generally fatal, even though
for from twenty-four to forty-eight hours there may be little complaint
as to pain.  The causes of death in these fatal cases are often obscure,
as the post-mortem results are  usually negative.  Gastric and duodenal
ulceration are, however, often  recognized.  Overheating of the blood,
heart-paralysis, oligo-cythaemia,  and actual destruction of leucocytes
have  all been supposed to be effective.  In cases  M'here  life  is pro-
longed to the third day, the complications of pyaemia, erysipelas, aud
tetanus may arise.  Lastly, exhaustion folloM'ing fever, suppuration,
haemorrhage, and visceral affections may lead to fatal results.
   In the treatment of the simplest burns,  rest, lotions of  lead-Mater,
and cool water M'ith  the application of compresses, are usually suffi-
cient  to  secure relief;  occasionally the  dusting powders may  be
substituted advantageously for these.  In the cases  M'here the serum
is  invited  rapidly to the surface, M'ith the production of vesicles and
bullae, the  latter should be gently  punctured  to give relief to the 
DERMATITIS.
177
tension by the evacuation of their, contents, but the roof-wall should
be preserved,  as it may subsequently form an  attachment to the ex-
posed derma beneath.   The indication then is to exclude the air as
perfectly as possible and to prevent suppuration, indications admirably
met by the application  of carbolated  oil and  lime-M'ater M'ith  the
Lister dressing.  Continuous immersion in Mater of the temperature
most agreeable to the patient, as practised by Hebra in cases of severe
and extensive burning, produces  speedy and certain amelioration of
the pain, and  a favorable condition of the M'ounds, though it does not
avert a fatal issue in any dangerous case.
   The  strictest  antiseptic precautions  are  demanded M'hen the sup-
purative process in the skin  is both  active and  extensive.   Disin-
fection  M'ith a five per cent, solution of carbolic  acid, or a two  per
cent, resorcin  solution,  should be folloM'ed by the application of pro-
tective silk M'et M'ith a  five per cent,  solution of the sodic biborate, or
sodic  bicarbonate, and the  M'hole  enveloped  either  in  borax-lint,
antiseptic  (mercuric iodide)  M'ool, carbolized  gauze,  or salicylafed
cotton; over all, the impermeable rubber tissue should be Mrapped.
   Nitzsche1 first disinfects the surface thoroughly with carbolic acid,
                                           o  *                    J
having previously protected the blebs, after which  it is covered with a
thick varnish of linseed oil and litharge mixed  by the  aid  of heat
with five per  cent,  of salicylic acid.  When  this is dry, a second coat
is applied, and the M'hole  finally  covered M'ith  a thick layer  of wad-
ding retained in  place by an elastic  bandage exercising moderate
compression.  Cicatrization is said  to progress beneath the dressing
without changing the latter.  When suppuration does occur, the upper
layer of the  Madding is removed, and dried salicylic acid  in powder
is sprinkled over the surface,  the wadding being aftenvard reapplied.
   Skin-grafting may be required  to cover the extensive ulcers left by
the larger  burns.
   In Conoelatio, or dermatitis from congelation,  there  are  also
usually, in the milder forms,  circumscribed  erythematous patches or
plaques, generally recognized under the name of Pernio, or chilblain,
seated upon the digits  or, more rarely,  upon the face, and occasioning
a disagreeable sensation of heat, smarting, or itching, especially after
the  chilled part  has  again  been  Manned.   They are  bluish  or
purplish-red in color, and often seated on a slightly cedematous integu-
ment.   They  are often cool to the touch,  Mdien subjectively hot.
Authors have claimed  that anaemia  is  a  chief  predisposing  cause of
the complaint, but it  frequently  occurs  in perfectly healthy young
people.  Sir Erasmus  Wilson has intimated that some  cases  of so-
called lupus erythematosus of the hands belong to this category.
   In the second  grade of inflammatory reaction  from  the  state of
contracted  bloodvessels and pallid integument produced  immediately
by the action  of cold, bullae and vesicles  form,  with, in severe cases,
underlying ulcers.
   In the  third grade  gangrene  may  occur, with and  without the
i Deutsch. Med. Zeit., 1881.
        12 
178
DISEASES  OF THE  SKIN.
formation of bulke.   The frozen part may become insensible, M'hite,
and cold, without the circulation in it of blood- and  lymph-currents.
From this condition reaction occurs, with the formation of an eschar,
differing in depth according to the severity of the exposure  to cold.
If, however, over and beyond the interference with the circulation, the
tissue itself has been destroyed, the part falls at once  into gangrene
when reaction occurs; or bullae form larger than those described above,
filled with sanguiuolent serum; or the skin  is smooth, marbled with
bluish  lines, whitish,  cold, and insensitive.  Mortification ensues,
followed by the well-known phenomena of the " line of demarcation,"
and, in favorable issues, suppurative separation of the dead part,
granulation,  repair, and cicatrization.   As  the injuries  induced by
congelation are more frequent upon the extremities, the bones largely
participate  in the  losses  of tissue, especially those of the digits.
Septicaemia and a fatal result may follow.
  Chilblains are treated internally by the ferruginous tonics,  particu-
larly the tincture of iron;  externally by stimulant applications, such
as those containing iodine, camphor, carbolic acid, tincture of benzoin,
and balsam of Peru.  Kaposi recommends:
                                                      50
R. Pulv. camphorse	gr. x;	
Cretse prseparat.	,l.i;	30
01. lini	m-,	60
Balsam. Peruvian.	tt\,xx;	1
                                                            M.

   Frictions, with or without  medication, are generally useful.  The
parts are to be carefully protected from pressure and undue friction
effects.
   Dilute  nitric acid  and  peppermint water in  equal  proportions,
painted over  the part  for three or four successive days, have  been
recommended by Lapatin for the  treatment of frost-bitten  fingers
and  toes.   Hydrochloric  and pyroligneous  acids, lemon-juice, collo-
dion, and  acetate of lead,  both in lotions and poultices,  are also
recommended.   Meurisse advises in the management of both severe
ambustio and congelatio, that goldbeater's skin be applied over any
salves or lotions employed over the surface.'
   In cases of severe  congelation the circulation is to be cautiously
restored by friction in an  apartment where the air  is cool, in order to
prevent too energetic  reaction.   Friction with snow is employed with
safety in our own country, and in the  steppes of Russia where these
accidents are frequent and grave in consequences.   Perseverance for
hours in this course  is often reMarded M'ith success  in apparently
desperate  cases.  Antiseptic dressings  are  usually demanded when
sloughing and ulceration ensue.

                 [D.]  Dermatitis Medicamentosa.
   The importance of recognizing the  fact, that a given eruption is
produced  by an  ingested drug, can scarcely be overestimated from
the point of view of the diagnostician.   The errors committed in this
connection are so frequent and  so  annoying to the patient  that it is 
DERMATITIS.
179
 necessary for the physician to inquire very carefully, before treating
 any cutaneous disease, as  to  the  medicaments  previously SMallowed
 by the patient; and also to be prompt to connect any aggravation of
 a cutaneous disease with remedies ordered by himself for internal use.
 The  following is but an imperfect list of the  drugs whose internal
 administration may be followed by an exanthem;  imperfect, because
 without question many have  yet to be recognized as possessing such
 an action.   As to the  modus operandi of such  medicinal  agents, for
 the most part our knowledge on  this subject  is purely conjectural.
 Some, for example, the iodide of potassium, are eliminated in part by
 the glands of the skin, and presumably have thus a local effect upon
 such emunctories;  others, and  in  this class,  the author  believes,
 should be included quinia, induce an  urticaria  scarcely to be  distin-
 guished  from an urticaria ab  ingestis.   Some, possibly,  operate  in
 either or both Mays at different times or  in  different individuals.
 The absurdity of supposing that any disease can be "driven out" by
 the ingestion of such drugs, should be relegated to the specious ignor-
 ance which first framed such an  hypothesis.

   Aconite.—This drug is said to be productive at certain times of
 marked  diaphoresis with the occurrence of vesiculation and consider-
 able itching.  If so, it is possible that the diaphoresis in an irritable
 skin may be responsible for the trouble.

   Antipyrine.—Ernst1 has been folloM'ed by many observers  in
 recording rashes resulting from  the  administration  of antipyrine.
 The  symptoms are  discrete  and  confluent patches of  bright red,
 scarlatiniform, erythematous,  and pruritic macules or papules.

   Arsenic.—Erythematous,  vesicular,  papular,  and  much  more
 rarely pustular, bullous, aud  ulcerative lesions, occur upon the face,
 back, and  hands, after  the ingestion  of arsenic.   The well-known
 effects of the administration  of the drug in toxic doses, upon the
 mucous  membranes  of the  eyes, nose, and  mouth,  need  not  be
 described in  this  connection; nor yet the  grave, gangrenous  symp-
 toms, M'ith osseous necrosis, M'hich have been observed in the Morkers
 with the metal.
   The author has seen a bright red,  scarlatiniform blush M'ith few
 isolated  vesicles  cover both  shoulders of a  young woman with a
 delicate skin after taking three medicinal doses  of FWler's solution,
 the eruption  being present, but less distinct upon the face and hands.
 In  two cases the rash in polymorphic type was  limited to the  hands
alone.
  A number of young patients have  been sent to the author's clinic
from  that for nervous  diseases, who having taken arsenic in the
largest medicinal doses for relief of chorea, presented  as  a result, a
dark discoloration  of the skin of the  chest andneck chiefly, but also
i Ctlblt. f. Klin. Med., 1885. 
180
diseases  of  the  skin.
of other parts of the  body.  This Mas suggestive of the  bronzing
seen in Addison's disease.   In  some instances  there had  been no
other cutaneous symptoms.  Guaita and Liege have noted these phe-
nomena, usually in the fifth month after ingestion of the drug.
  By far  the largest number of such  rashes are, hoM'ever, produced
in those previously suffering from cutaneous disease, for whose relief
the drug is administered.  Here the toxic effect is declared either by
—first, increased  hyperaemia of the  skin visible  in an erythematous
patch, or  beneath the  scales of a squamous patch; or, as an areola
of bright red  hue about any  aggregations  of lesions; second, by
simple aggravation  of the  type of a disease already in existence
(recurrence of acuity in a subacute eczema); third, by rapid peripheral
extension  of a disease which had previously been well limited in
contour; fourth,  by converting  a disease exhibiting uniformity of
lesion into one characterized by multiformity.   Each of these results
might be illustrated by cases.
  In a series of eight cases of poisonous effects produced by arsenical
paper  hangings, and reported  by Dr. F.  H. BroM'n,1 there  M'ere,
curiously, no cutaneous symptoms.

  Belladonna, Atropia.—The M'ell-knoMii erythematous, scarlat-
iniform, or  reddish  efflorescence produced  by belladonna  and its
alkaloids, is usually limited to the upper segment of the body, but
may become generalized.  It  is  said  to  occur more  frequently in
children, probably because it has been administered largely to indi-
viduals of that age under the superstition that  it was useful  as a
prophylactic in scarlatina.  Very disagreeable and even  dangerous
results have  followed  the instillation  into  the eye of atropia  as a
mydriatic, the rash being accompanied  by constitutional symptoms.

  Boric Acid.—Modadewkow reports a case in which the pleura
was washed out with a five per cent,  solution of boric acid, a  part
of which was not removed.  There occurred  as  a result an erythe-
matous rash over the face, trunk, and extremities.

  Bromine and  its Compounds.—A full  and  valuable  account of
the cutaneous effects of this  drug and its compounds, when adminis-
tered internally, is contained in a paper on medicinal eruptions, read
by Dr. Arthur Van Harlingen, of Philadelphia, before the American
Dermatological Association in  1880.   Acneiform lesions, pustules,
macules, maculo-papules, papules, eczema-form  moist patches, fur-
uncles, urticarial  wheals, scales,  and ulcers have been induced by
swallowing  the bromides of potassium, sodium, ammonium, and
lithium.   By far  the  most  common are the acneiform and  pustular
lesipns, occasionally accompanied by pruritus, which appear upon the
face and upper portion of the trunk, though the  author has seen the
rash very distinct  upon  the genital region.   Duhring reports an
1 Paper read before the Boston Society for Medical Observation, March 6, 1876. 
dermatitis.
181
interesting observation of a case in which the eruption simulated very
closely the maculo-papular syphiloderm, the patient having  taken
the remedy for three  years.  The eruption first appeared within five
or six days after decreasing the dose.   Kaposi has observed a case in
a nine-months-old suckling, the mother having taken  one hundred
and twenty grammes of the bromide of potassium in two  months,
herself not exhibiting traces of eruption.   In one patient treated by
myself the eruption was generalized, but in no part exaggerated.  It
occurred in an adult male after three months' continual  employment
of large doses of the same salt.
   Mr. Browse, of Cambridge, England, recommends for relief of
these symptoms the  application of a  solution of salicylic acid, one
grain to the  ounce (0.066-32.) of water, frequently applied  on lint,
having  successfully treated in this way sores as large as the  palm of
the hand.
   T. C Fox and Gibbes report condyloma-form lesions in  the case
of an infant where the histology of the lesions was carefully studied;
and Fay, in a child eleven months old, also recognized lesions which
had been  mistaken  for molluscum  epitheliale.    These were un-
doubtedly  similar to the condyloma-form rash seen in children after
the administration of the iodide of potassium.

   Cannabis Indica.—The only instance thus far reported  of an
eruption produced by the ingestion  of this  drug was observed by
myself  in  the case  of an adult male, who Mas extensively covered
with papulo-vesicular lesions after swallowing a grain (0.066) of the
extract,1

   Chloral.—An erythematous  rash is  the most common of the
eruptions produced  by  chloral, though M'heals, red and yellowish
papules, vesicles, pustules, and petechial blotches have been observed.
It occurs upon the face, neck, trunk, and limbs, of the latter especially
on the extensor surfaces.  In  a man of advanced years, totally deaf,
who had slept only under the influence of chloral for four years, the
author observed .discrete scaly patches as large  as saucers over the
lower extremities, hands, and  feet.
   Martinet2 reports  an  erythematous and scarlatiniform rash,  occa-
sionally  commingled  with urticarial  and  purpuric lesions, occurring
upon the face, neck, front of the chest, the extensor surfaces of the
larger joints, and  the dorsum  of the  hands and feet.  There was no
pyrexia nor indisposition, but in cases dyspnoea and cardiac  palpita-
tion.

   Cod-liver Oil.—According to Farquharson,3 cod-liver oil after
being sM'allowed  is capable of producing an acne.  This can be true
onlv of  very  inferior specimens, such as are not rarely found in the
English market.

        1 N. Y. Med. Record, May 11, 1878.             2 These de Paris, 1879.
         8 Brit. Med. Journ., Feb. 22, 1879. 
182
DISEASES  of  the skin.
   Copaiba and Cubebs.—The ingestion of copaiba is occasionally
 followed by a vividly red rash, in the form of discrete macules, more
 rarely  maculo-papules, invading chiefly the lower segments  of the
 extremities and the skin  of the belly, but often completely covering
 the  surface.  The author  has  seen  the rash occur  in  dark  mul-
 berry-red petechiae; and  always in  his  experieuce accompanied by
 pruritus.  Inasmuch as the drug is often administered for the relief
 of a venereal disorder  not syphilitic, care should  always be taken not
 to confound the eruption  it may excite M'ith the early macular syphi-
 loderm.  Cubebs is much more rarely followed by a similar result.

   Cundurango.—Guntz1  reports the occurrence of  furuncular and
 acneiform lesions in twenty patients  out of one thousand who were
 taking  cundurango for the relief of syphilis.

   Digitalis.—In Behrend's treatise on diseases of  the skin2 refer-
 ence  is  made to  cases where  macular  and  maculo-papular  rashes
 succeeded the ingestiou of digitalis.

   Iodine and its Compounds.—The iodide of potassium is respon-
 sible for the larger number of all  eruptions in  this category.   The
 frequent  employment of this  drug  and the very marked influence
 which  it possesses over the skin, render  the  study of these morbid
 results  important.
   Unlike many of the other substances in  the list, the iodine com-
 pounds are followed by some  species of rash in  probably the  larger
 number of all persons who swallow them.
   The  resulting lesions may be macular, papular, vesicular, bullous,
 pustular, petechial, multiform,  or in the  form of circumscribed, sub-
 cutaneous abscesses.
   The  macular  rash  is  best  seen  fully developed  over  the  upper
 extremities, in discrete erythematous patches or in a diffuse blush.
 The  cases in which the  author has  studied  it,  all displayed  sym-
 metry.   The hands  were chiefly affected, and suggested  in appear-
 ance the dyed hands of the aniline worker.   It  is said to assume at
 times the papular type, a  transformation the author  has  not noticed,
 though  he has seen coexistence  of papules upon the face.
   Berenguier describes a scarlatiniform  rash of sudden  occurrence
 upon the surface  of which were numerous  minute  discrete  vesicles.
 Eczema-form eruptions M'ith   abundant serous  exudations  are  also
 reported.
   A number  of interesting cases are on record  where the adminis-
tration of the drug was followed by the production of bullae.   Bum-
stead, Taylor, Duhring, Tilbury Fox, aud  Finny, have described
such  in adults, and  the author has  seen several cases in children.3
Hallopeau* also reports a  case  in which  a bullous eruption followed

      i Vierteljahrscht. f. Derm. u. Syph., 1882.             2 Braunschweig, 1879.
      3 Arch, of Derm., Oct. 1870.  Journ.  of Cutan. and Ven. Dis., 1886, p. 383.
      * Union Med., March 25, 1882. 
dermatitis.
183
the ingestion of the iodide of potassium.   The patient died, and the
post-mortem appearances are reported in full.   The eruption occurred
chiefly about the head, neck, and the upper extremities.   The author
has called attention  to the  significant rarity of vesicular and bullous
lesious in acquired syphilis, and suggested that at least some of the
cases on record were those  of rashes induced by the remedy given
for relief of the disease.
   A careful analysis of these  bullous rashes leads to their division
into three categories: first, those occurring often M'ith fatal results iu
cachectic adult patients;  second, those occurring as part of the erup-
tive lesions  in a polymorphic group; third, those occurring in well
nourished children, taking on the appearance of molluscum epitheliale
and condyloma lesions, usually compounded of papulo-vesiclcs and
pustules.  Erythanthemata of a similar type have been also recognized
in infants after the ingestion of bromide of potassium.
   The pustules induced by the administration of iodine  compounds
are seen chiefly  upon the face,  neck, trunk,  and arms.   They are
usually seated upon a firm base, and may be followed by cicatrices.
Duhring has seen an annular patch upon  the forehead, made up of
minute vesico-pustules, M'hich eventually developed  into  a globular
violaceous mass, nearly two inches in diameter.  On  several  occasions
the  author  has  observed  large  cherry-sized,  tubercular  elevatious
abruptly rising from the surface of the integument, and presenting
a cribriform appearance, which showed the open ducts of several sup-
purating follicles (chin, cheek, nose).
   The purpuric rash occurs in petechial macules, discrete and miliary,
situated chiefly on the lower extremities.  In a case  reported by Dr.
Mackenzie (quoted by Van  Harlingen) a  single dose of two and a
half grains  (0.166) in an  infant, was folloMed by a  fatal  result after
the petechiae appeared.

   Jaborandi  and Pilocarpine  are capable,  when ingested,  of
inducing free diaphoresis, and erythematous macules, wheals, and pin-
head sized papules have been seen upon the surface  as a result.

   Mercury.—The statement that mercury M'hen ingested is capable
of producing an erythematous  rash upon the  surface of  the skin, is
made by several authors of reputation.   In view of  the fact that the
metal has been, in its various compounds, administered for so long a
period of time, and for so many various diseases M'ithout the produc-
tion of cutaneous symptoms, it is  a fair  hypothesis that the few
reported cases  are those in which there Mas coincidence rather  than
causation.   The author has had the opportunity of observing a large
number of individuals in M'hom the drug had been both properly and
very injudiciously employed  for long periods of time, and has not
been able in a single instance to discover any evidences upon M'hich to
base a belief in its power to produce a  cutaneous exanthem.   A
similar  statement Mas made by  Dr. White,  of Boston, M'hen this
subject Mas under discussion in the American  Dermatological Associa- 
184               diseases of the  skin.
tion.   Mercurials, wheu applied to the external surface of the body
are, as is well  knoM'n, capable of exciting, in various degrees, cuta-
neous irritation and inflammation.

  Opium and its Alkaloids.—Erythema, M'heals,  and occasion-
ally  intense pruritus,  M'ith oedema, and subsequent desquamation,
have followed the ingestion of opium and several of  its alkaloids,
notably morphia.  In its  mildest expression this cutaneous  effect is
limited to a  characteristic itching  about the nostrils, M'hich can be
perceived in a large proportion of all patients as soon as the  general
effect of the opiate becomes apparent.   In several cases the author has
observed an intense  and distressing  general pruritus without efflor-
escence;  and in some instances has been certain that the subsequent
urticarial efflorescence was induced by the free diaphoresis which the
medicament induced.  This  is a matter of some practical moment,
as the use of an anodyne for the purpose of procuring sleep  for a
patient tormented with a nocturnal  pruritus, would seem to be
occasionally indicated.   Inasmuch as chloral, the bromide of potas-
sium, and the  opiates  are all capable of aggravating such distress,
great caution is in such  emergencies  needful.  In  general, it  may
be said that the employment of these and similar remedies for  such
a purpose, should be interpreted as  a confession of weakness on the
part of the physician, who ought to  be able to alleviate the distress
of his patient by a judicious employment of topical  remedies.

  Phosphorus.—Hasse (quoted  by Van Harlingen) cites  the case
of a youug girl who exhibited a pemphigoid rash after the ingestion
of phosphoric  acid ; and, according to  Farquharson,1 phosphorus
itself is  occasionally responsible for purpura with  gastro-intestinal
derangement and jaundice preceding a fatal  issue.

  Podophyllin.—Winterburn2 reports that those who work  in
resinoid  podophyllin, are liable to suffer, as  a consequence of this
exposure, from a cutaneous disease of the scrotum.

  Quinine, Cinchona,  and  its  Alkaloids.—Morrow3 has col-
lected  in an  interesting paper, the  record of over sixty   cases  of
quinine  exanthem, and shows  that  its prevailing  type is  exanthe-
matous,  the  rash being  of  a bright vivid  hue,  disappearing on
pressure, and  resembling scarlatina.  Other  lesions  produced are
wheals, papules, vesicles, petechiae, haemorrhagic purpura, bullae, and,
in one instance, an intense  localized dermatitis  with commencing
gangrene of the scrotum.  In some  cases  the rash reappeared on
repetition of the dose, and even after recourse to the other alkaloids.
The subjects were mostly women.    As with most of the other exan-
them-producing  drugs, small  doses, M'here  the idiosyncrasy existed,
sufficed for the effect.  The author has seen the rash in an adult male,
        1 Loc. cit.                  2 Louisville Med. News, April 21, 1882
        3 N. Y. Med. Journ., March, 1880, p. 214. 
DERMATITIS.
185
   M'ho, after  taking  tMO grains (0.133), of  the  sulphate  of quinia
   for the first time in six years, exhibited an  efflorescence over the
   entire surface of the body, of discrete, finger-nail sized, salmon- and
   pinkish-tinted, scarcely elevated patches, accompanied by a moderate
   pruritus.   A repetition of the dose Mas folloM'ed by a recurrence of
   the exanthem.
      In several cases  desquamation  is reported  as resulting from the
   rash.  As to the occurrence  of  the general  symptoms  recognized '
   under  the title of cinchonism (tinnitus atirium,  etc.), these may and
   may not accompany the lesions.   Morrow makes the pertinent sug-
   gestion,  in  view of  the  frequent similarity  of the  rash to  that
   exhibited in scarlatina, that  many cases  hitherto recorded as recur-
   rent attacks  of that disease and measles, with  other anomalous cuta-
   ueous eruptions,  may have been instances of the  quinine exanthem.

      Salicylic  Acid  and  the  Salicylates.—Reports of  cases
   where these  substances after  ingestion  have  produced  cutaneous
   symptoms, have been  made by Heinlein, Wheeler, and Freudenberg,
   all cited by Van Harlingen.   The symptoms M'ere diffused redness,
   urticarial lesions, vesicles,  pustules, petechiae, and  vibices,  accom-
   panied by intense pruritus, and followed by desquamation.

      Santonink.—A  generalized eruption of urticarial lesions seated
   upon a reddened surface, and accompanied by  oedema, is reported by
   Sieveking as occurring in a child to whom santonine had been admin-
   istered as a vermifuge.1

      Sodium Benzoate—Robe2 reports two cases iu M'hich an erythem-
   atous rash,  M'ith well-defined border, accompanied  by itching and
   slight  desquamation,  occurred  during the  use  of the benzoate of
   sodium.   The patients  were a woman, aged thirty-five,  aud a boy
   M'ith diphtheria.  The eruption disappeared on the discontinuance of
   the remedy,  and Mas made  successively to appear and disappear by
   its alternate  use and disuse.

      Sodium Biborate.—Gowers3 reports the occurrence, especially on
   the arms, but also over the trunk  and legs, of an eruption  resembling
   psoriasis, after the ingestion  of the biborate of sodium.  Some of the
\ resulting patches were one inch and a half in diameter.   Three cases
   ft* all are collated.  In two the  eruption faded M'hen a  solution of
   arsenic was added to the sodium salt.

      Stramonium.—Dcschamps (cited by Duhring) reports an erythem-
   atous rash after the administration of the thorn-apple.

      Strychnia.—Skinner (cited by Van Harlingen) reports  a case
   M'here an eruption of  six weeks' duration  ensued upon the adminis-

                    i British Medical Journal, February 18, 1871.
                    '-' Maryland Medical Journal, June 15, 1881, p. 91.
                    3 Lancet, September 24, 1881. 
186
DISEASES  of the  skin.
tration of quinine and strychnia together;  the former in the dose  of
one and  a  half grains (0.10), the  latter  in  the dose of one-twenty-
fourth of a grain  (0.0025).

  Tanacetum.—A varioliform eruption produced  by the. ingestion
of a  drachm and  a half (6.) of the oil of tansy, administered for
abortifacient purposes, is reported by Porter.1  There were antecedent
clonic convulsions.   The result was not fatal.

  Tar and Turpentine.—Erythematous,  vesicular, and papular
rashes are reported as resulting from the ingestion of these substances.

  The diagnosis of the various medicinal rashes described  above does
not, fortunately, demand a recognition of the essential peculiarities
impressed upon each by the exciting cause, since in  many cases such
peculiarities do not exist.   The urticariae resulting from the ingestion
of "head-cheese," quinine, and  chloral, may be  absolutely indistin-
guishable.   But to establish the fact that a medicamentous eruption
is present in any given case, is a long step in  the direction of reaching
the precise cause  that  has been iu that case effective.   This fact
must  often be obtained from the lips of  the  patient.   The medicinal
rashes are in general remarkable for their sudden appearance, their
symmetry,  their  diffusion  over large areas  of the  integument, the
presence of pruritus, the absence of fever, and their existence alike
upon  exposed and protected surfaces of the skin, hinting  thus  at the
action of some cause not operating externally.  Excluding syphilis
and the exanthematous fevers, a generalized rash of sudden occurrence
should  always raise the  suspicion  of  a dermatitis  medicamentosa.
Similarly in cases of preexisting cutaneous disease,  syphilis, eczema,
or psoriasis, the sudden occurrence of lesions of a new type widely
diffused, or of rapid aggravation in situ, or of speedy extension as  to
area  of those already in existence, should awaken  the suspicion, if
there  be fever, of the exanthemata ; and, without a febrile process, of
the medicinal rashes.  Thus the author  has  seen two  patients with
eczema exhibit rapid rise in temperature, and subsequently develop a
generalized  variolous rash ; and  it is a matter of common experience
to examine patients on the  eve of a macular syphiloderm, or even long
past the  eruptive  stage of that disease,  showing their faces, necks, and
shoulders covered with an  acneiform rash produced by the potassium
iodide.   The practitioner cannot be too  strongly urged to view with
exceeding watchfulness the skin  of any patient affected with either of
the common disorders, eczema, acne, and psoriasis, when the eruption
in any instance becomes anomalous as to type, distribution, or  symp-
toms.   An  illustrative example has come under my observation since
the first paragraph of this chapter was Mritten.  A physician, on a trip
from Colorado to Chicago,  with a long standing eczema of the scrotum
and thigh,  suddenly exhibited tumefaction of both hands with small
i New England Medical Journal, October 15, 1881. 
DERMATITIS.
187
egg-sized, discrete, dull red plaques over the palms and clorsa ; and in
the centre  of nearly all  such lesions a firm, M'hitish, elevated wheal
accompanied  by severe  burning, tingling, and  pricking sensations.
He had been swallowing "bromidia," a proprietary preparation con-
taining the bromide of potassium, the hydrate of chloral, and cannabis
indica, each single drug  being capable of inducing an exanthem, and
yet he had not the slightest suspicion of the real nature of his symp-
toms, having been questioned by  a brother physician, to M'hom he
exhibited his hands, as to the possibility of syphilis.
   The medicamentous rashes, as a  rule, disappear rapidly after  the
withdrawal of the exciting  cause, aud require  no further  manage-
ment.  In  some cases the soothing lotions, baths,  and dusting powders
employed in the treatment of acute eczema may be required.
   It should not  be forgotten that the  patient M'ho exhibits these
lesions is usually oue M'ho has been suffering from the real or fancied
disease for relief of M'hich  the  drug M?as taken, and that condition
may require recognition and management.
   In Morrow's contribution to  this subject, it  is clearly shown that
the same drug  may produce a  variety  of eruptive phenomena, and
that the same  eruptive features may result from the ingestion of
different drugs.  He points to what he  concludes  to be the neurotic
origin of many of these rashes, and believes that the  proof is incon-
clusive that these are, to any considerable degree, brought about  by
elimination  through the cutaneous  glands, of  the noxious element
introduced with the  drug.  Tilden,1 however, calls  attention to the
fact that many of these eruptive phenomena  are of the nature of
angioneuroses,  similar  to Trousseau's " tache  cerebrate^ requiring
often increase in the irritability of the cutaneous vessels, with exuda-
tion of serum, outwandering of cells, and, in case of hemorrhagic
lesions, some change in  the vascular Malls themselves.

                    [E.] Dermatitis Gangrsenosa.

   Idiopathic and  symptomatic cases of dermatitis  terminating in
gangrene,  M'here no history  of external violence or caustic application
has been obtained, are reported by several authors.  Iu most of these,
single or  multiple,  circumscribed,  erythematous or  haemorrhagic
macules have been followed by superficial gangrene with sloughing,
the process being in some instances  attended with constitutional
symptoms of such"gravity as to result fatally.   In certain other cases
the affected patches presented at au early period the mummified and
alabaster M'hite aspect, noted at times  in  dermatitis  calorica.    In
establishing a diagnosis in such  cases, care should be taken to exclude
the forms  of senile gangrene occurring in  the  lower extremities as
the result of vascular calcification, M'hen the skin and deeper tissues
are alike invaded ; as also the cases  of simulated eruption  produced
by caustics upon the skin M'ith a view to deception.   Iu the latter
' Pathogenesis of Certain Affections of the Skin, June 9, 1885. 
188                DISEASES  OF  THE  SKIN.
class, a distinguishing feature of the lesions is their occurrence chiefly
upon those parts of the body most accessible to the  hands; and,  in
persons not ambidextrous,  upon  those parts  which  the hand pre-
dominantly employed can most readily reach.
   Cases  of "symmetrical dry gangrene  of the  fingers and  toes,"
multiple  ulceration terminating  in  gangreue, " asphyxia of  the
extremities," and others described under  similar titles, are annually
recorded.   Some of them appear to have a neurotic or augio-neurotic
origin ; some are peripheral symptoms of  diseases  of  internal organs
or of the  vessels; some are cases  of locomotor ataxia, the shrivelled
or gangrenous spots on the hands and feet beiug merely early symp-
toms of the perverted nutrition due to the spinal  sclerosis.  Atkin-
son's case,1 and that of Eichoff and C. Boeck, assigned by this author
to the group of affections termed  by Simon  " multiple cachectic gan-
grene," seem to  belong  to this same category which includes the
"symmetrical gangrene"  of  Raynaud,  or, as it is often termed,
"Raynaud's disease."  Mr.  Hutchinson  has  reported   instances
where the tendency to  this  disorder  appeared to  be  transmitted
through three generations, the  lesions not progressing in some indi-
viduals of the group  beyond the  " asphyxiated " condition to that of
gangrene.   Terrillon2 reports perforations of the  hand as preceding
symptoms of a disease of the central  nervous system supposed  to  be
locomotor ataxia, which resemble  the similar lesions  of the feet
reported by Atkin3 in  a case of undoubted ataxia.
   Petit and Verneuil4 have referred these disorders to a malarial
origin.
   Drs. Flynn and Clark, of New York,5 have also reported sym-
metrical gangrene of the extremities in men of advanced years.
   In many of  these  cases  the preliminary  stages  of  the process
either did not exist,  or  were  too transitory for observation.   The
first appreciable  external symptoms were the perforating  ulcer, the
shrivelling phalanx, the gangrenous patch, or the completely "asphyx-
iated" tissue.  For the relations of these to  a large group of tropho-
neurotic affections of the skin, the reader  is referred  to the chapter
devoted to the neuroses.
                          Erysipelas.

                   Gr. kpvdpdc, red;  iziXka, the skin.

Erysipelas is an acute and specific inflammation of the skin and subcutaneous
  tissue, characterized by diffuse, shining redness, pain, swelling, and elevated
  temperature of the affected part, terminating in desquamation, and usually
  accompanied by fever.

  Symptoms.—The disease is usually preceded by a prodromic period
of malaise, lasting for  twenty-four hours  or  less,  M'hich  may be

     1 Multiple Cutaneous Ulceration.  Amer. Journ. of the Mwl. Sci., 1884.
     2 Rev. Medical, June 13, 1885.                  » Brit. Med. journ., July 24 1886
     « Rev. de Chirurg., Nos. 1, 3, 6, and 9, 1883.         5 N. Y. Med. Record 1886 ' 
ERYSIPELAS.
189
ushered in  by one or several chills followed  by febrile  symptoms.
The latter are accompanied by anorexia and often  by vomiting with
general depression and headache.
   The  eruptive symptoms are generally first displayed at a given
point,  from which  the disease progresses.   It  is  commonly  first
noticed in  a  nut- or egg-sized patch, the integument of M'hich is
tumid, slightly elevated, irregular in contour, distinctly circumscribed,
and presents a rosy or crimson-reddish color M'ith a peculiarly smooth
and characteristic  shining or  glazed  appearance.   The sensations
awakened may be those of moderate pruritus, pain, heat, or burning.
To the touch, the affected part is  tender, moderately firm, and  per-
ceptibly hotter than  normal.   The color fades under  pressure to a
yelloM'ish-white.
   In typical cases, the erysipelatous blush aud swelling spread over
an area which  may be of the size of the palm,  or may even cover the
surface of an entire limb or region of the body.  In cases of moderate
grade, the inflammation attains a maximum  of extent and severity
M'ithin  a week,  remains  apparently  unaltered for  a  day or more,
and then  begins to  abate, M'ith amelioration of all  the  concomitant
symptoms.   The fever which  often precedes the  eruption, continues
unabated  during its  progress,  the temperature rising  to 10o° or 106°
F., with nocturnal exacerbation, cephalic and  lumbar pain, dryness
of the  tongue, gastric  distress, and occasional delirium.  As invo-
lution of the disorder is accomplished, the redness is replaced by the
brownish,  bluish-red, and  dirty-M'hite  shades often seen after  the
disappearance  of erythema multiforme, the epidermis finally desquam-
ating in various degrees  according  to  the extent of  the preceding
inflammation.
   In other  cases, where the exudation of serum beneath the epidermis
has been rapid, the  latter is raised  in the form of vesicles, pustules,
or bullae, more often the latter; and, precisely as  in  the severe forms
of  dermatitis calorica, M'ith M'hich erysipelas  presents  a  certain
analogy, gangrene of the skin may result in the part affected.  This
is  particularly apt to folloM' the disorder when it attacks the seat of
surgical wounds and injuries.

   Erysipelas Ambulans is a term used to describe that  form of
the affection in which the erysipelatous blush, after involving  a given
area, spreads M'ith greater or less rapidity to the parts in the vicinage,
either by direct extension and uniform  advancement  in one direction,
of the tumid and  distinctly  circumscribed  border;  or by linear,
digital, or irregular prolongations radiating  from the inflammatory
focus.  As  the blush and swelling advance in one direction,  there is
usually correspondingly rapid disappearance on the other.  At other
times/the disease, M'hile extending to a new area and abandoning the
old, is relighted in the latter, and thus an irregularly involved  and
irregularly  extending erysipelatous surface presents for weeks  the
varying phenomena of the disease.  In yet other cases again, chiefly
those in  M'hich there  has been  a  history of traumatism,  a  long
erysipelatous linear streak or  baud may spread from  the site of the 
190
DISEASES  OF  THE  SKIN.
traumatism in one direction  or another,  suggesting  the indurated
lines observed in lymphangitis.   In severe cases, the febrile, nervous,
and other symptoms are grave, including coma, delirium, meningitis,
and  the signs of serious involvement  of the  lungs, pericardium,
pleura,  and  bowels.   Metastatic  abscesses  may also  occur in the
cutaneous and subcutaneous tissues, the joints, peritoneal cavity, and
even in the viscera.   Death may result from these complications, or
from shock, exhaustion, or pyaemia.

  Surgical accidents aside, the face is the most common  seat of the
disease, M'here it may be  first seen  upon one  side of the nose, one
cheek, the lips, or the eyelid.   It often  attacks  the lobe of the ear
after the operation of piercing the lobule for the insertion of ear-rings
in women.  Thence  it may extend  over the whole face, inclusive of
the mucous linings  of the mouth and  nose, which  present a dry,
tumid, and glazed appearance, suggestive of  the symptoms displayed
upon the  skin.
  The inflammation may extend to the hairy parts, but in many cases
it exhibits a species of reluctance to transgress the limits there pre-
sented.   It may be noticed in cases of mild grade where no applications
have been made to  arrest a local progress, that the elevated border
spreads symmetrically to within a  few lines  of the male beard or
the hairs at the  edge of the forehead, and  there  spontaneously  rests.
In severer grades these limits are  readily surpassed;  and then, as a
rule, the extension is rapid and formidable.   In this way the entire
head may become enormously swollen, suggesting to a casual observer
that it is fully twice its normal size.   The patient may then be greatly
disfigured; his scarlet lips, swollen, parted, and permitting the escape
of saliva;  the ears, as usual when  greatly enlarged, projecting  in  a
marked degree from  the  side of the head; the lids ©edematous and
incapable of separation ; the face, disfigured  by bullae or crusts; and
the mind  disordered by  violence  of  the  fever or  the  accesses of
delirium.   AYhen recovery ensues, the hairs are apt to fall.
  All other regions of the body may be invaded, as  the vaccinated
arm, the  leg M'hose skin is  involved  in  venous varicosities, the
scrotum or umbilicus of the infant,  the genitalia of the newly deliv-
ered  woman, the breast  of the nursing mother, aud every  surface
which has been the seat of punctured, incised, contused,  or poisoned
wounds, or other accidents of  the integument.

  Several  authors describe habitually recurrent and Chronic forms
of Erysipelas,  M'hose identity with the disease here described, it  is
difficult to establish.   The diagnostician is sufficiently often consulted
in cases where an erythematous eczema of the face, an acne rosacea, or
a symptomatic erythema, is described by a patient as chronic or recur-
rent  " erysipelas."   The  lesions to which such  terms, however, are
restricted  by careful  writers, are often  forms  of chronic dermatitis
such,  for  example, as occasionally  follow dermatitis calorica.  In-
stances occur in M'hich the face, or parts of it, are the seat of  a low
grade of  inflammation with  local  heat, swelling,  redness,  consid- 
ERYSIPELAS.
191
erable infiltration, and some tenderness, the part being irritable and
worse after  exposure to a high wind or after excesses at the table.
But the most of such cases fail to exhibit the distinct imprint of
erysipelas;  they are not only chronic in course, but exceedingly indo-
lent, lasting  for years ; they are  unaccompanied by  fever; they are
distinctly limited in all accesses of aggravation to the  same part of
the face; they are never characterized by a bullous efflorescence; they
never completely disappear ;  many occurr in  the subjects of chronic
alcoholism.

   The febrile symptoms are, throughout, persistent and characteristic
of a specific  toxiemia.  The temperature, as has been  seen, may reach
105°-107° F.,  M'ith vespertine exacerbations and remissions;  it may
also become  subnormal.  If not relieved  in  the  course of seven or
eight  days,  complications may  be  expected.   These are  oedema,
abscess, phlegmonous inflammation, gangrene,  and inflammatory acci-
dents involving the membranes of  the  brain, lungs, heart, bowels,
kidneys, peritoneum, and joints.
   Etiology.—The modern view of the invariable origin of erysipelas
from some point,  however insignificant as  to size, where  a morbid
germ has  secured  access to the economy, is  generally accepted  and
adds  interest to the study of the  local manifestation of the disease.
Whether it be the slightest or severest traumatism, an erosion, a torn
pustule, or  a puncture by a pin, such lesions are now interrogated
whenever erysipelas occurs in any part of the body or in the course
of any other disease.
   In the face, catarrhal and ulcerative processes involving the mucous
membrane of the  mouth, ears, and  nose, are  often the cause of an
erysipelas, these processes occurring  in  a wide range of disorders
from syphilis of the nasal bones to  caries of the teeth.   Injuries of,
and surgical operations upon  the scalp not conducted with antiseptic
precautions,  and the  common  piercing  of the lobe  of the  ear in
M'oinen and  female children  for  the insertion of ear-rings, mav be
followed by the appearance of the disease upon the scalp, as a result
of M'hich  the hair  often falls.   Fistulae, vaccination, lesions  of the
tender umbilicus of the  newly born infant, and  railroad accidents
may be named as common causes of the disease in other regions.
  Predisposing  causes of this disease are to be  sought  for in cachexia,
epidemic influences, traumatism, violation of hygienic  rules, and occa-
sionally, the  recurrence  of  previous attacks.   Besides  these,  it is
alleged that  constitutional predisposition and particular articles of
diet may be  responsible for the disease (mussels).
  If  the  disease  be invariably the  result of  infection due  to the
presence of  a micrococcus, the essential  cause  lies  in  the specific
germ, in the  absence of M'hich none of the predisposing causes named
can be  effective.  It  is clear, however, that the predisposing causes
suggested  are those in M'hich the multiplication of such germs and
their entrance to the general  economy are most facilitated.
  The infectious nature of erysipelas  has been demonstrated by  clin-
ical proof, and the experiments of many observers, including Hiiter, 
192
DISEASES  OF  THE  SKIN.
  Nepveu, Wahlberg, Lukomsky, Koch, Orth,  Fehleiscn,1 and others.
  The micrococci  recognized  by them  were seen in great abundance,
  often  arranged in chains, in  the corium, subcutaneous tissue, and
  lymph spaces of erysipelatous skin, never in the bloodvessels.
    Other views as to the etiology of the disease have  been advanced.
  Hebra and Kaposi believed it  to be Hue to  the secondary products
  of local inflammation;  others  have held  to a "malarial"  origin
  (Cohnheim).   Among later observers, Tillmans concludes that the
  infection of the disease may be transmitted by fluids  both containing
  micrococci and without them.
    The  conclusion is  irresistible that  the disease is ahvays the result
  of the admission of specific bacteria to the human body by the avenue
  of a lesion  of  the surface, hoM'ever insignificant in  size.
    Women  are rather more subject  to  the disease than  men.  The
  disorder is also apt to occur in spring and autumn.
    Pathology.—Under the microscope,  the  skin  and  subcutaneous
  tissues are seen to be infiltrated, the  exudate being more serous and
  less rich in protoplasm than that observed in ordinary phlegmonous
  inflammation of the skin.   The bullae represent rapid exudation of
'  this same serosity to the congested  epidermis, and the  elevation of
  the latter in consequence.   The  elements of the rete  and connective
  tissue  are for the same reason swollen, the lymphatic and bloodvessels
  enlarged, and the cutaneous follicles engorged, the root-sheaths of the
  hairs  being occasionally  separated, necessitating thus  the temporary
  loss of the pilary  growth.  In proportion to the  severity of the
  exudative process, pus corpuscles may appear and  represent, for the
  most part, degenerative changes in the subcutaneous tissues resulting
  in abscess.   The phenomena are, in short, those of superficial or
  deep-spreading dermatitis.  After death, the skin which has  been
  the seat of the disease cannot  be distinguished microscopically from
  that of  another body.
    Diagnosis.—Erysipelas is to be distinguished from  the erythemata,
  from dermatitis of various grades, from eczema, and  from scarlatina.
  As  a  rule, its recognition  from  all is  readily effected, when the
  presence of the fever in erysipelas is had in vieM', as also the peculiar
  shining, swollen, and rosy-reddish to  damask hue  of  the  affected
  parts.    The redness is never produced as in scarlatina by multiplicity
  of reddish  puncta, nor is it  so M'idely  diffused as in  that disease.
  Erysipelas may be at  times  accompanied by a pruritic sensation, but
  the patch which it affects is never by any possibility scratched.  By
  this simple test alone  one may often distinguish an erysipelas of the
  face from an eczema of the same region in a child.   From a chronic
  dermatitis with thickening of the affected tissues and redness of the
  surface, erysipelas is to be distinguished by its tendency  to spread, by
  its acute career, by its frequent association M'ith bullous or vesicular
  lesions,  aud by the color, outline, and raised border  of the affected
  patch.   However, it  must be  understood that  to  these localized
  patches  of chronic dermatitis several authors  have given the  name,
Die Aetiologie des Erysipelas.  Berlin, 1883. 
ERYSIPELAS.
193
chronic erysipelas, the difference between the vicMS held on this point
being chiefly one of terms.
   Treatment.—Upon the continent of Europe, the therapeutic man-
agement of erysipelas  is in general limited to the employment of such
systemic and topical  measures as are  specially required in each case.
Quinine  is administered whenever  indicated  by  the temperature
record; and fhe erysipelatous  surface  is either left exposed  to  the
air, covered by dry compresses, moistened  by  cold  or hot aqueous
lotions, or anointed with unguents, simple, mercurial, or anodyne, as
suggested in each case.  Occasionally cataplasms are applied over the
inflamed surface.   Abscesses, M'hether subcutaneous or connected M'ith
a carious  tooth, are opened; the contents of all pustules evacuated;
and crusts carefully removed.   Kaposi lays stress upon freeing  the
nasal  cavities  of all  inflammatory  products, whenever the  face is
attacked.
   The method of treating  erysipelas  by  the administration  of the
tincture of iron internally has long been popularized among American
practitioners.   This preparation  is given in full  doses, from twenty
to fifty drops, day and  night every two to  three hours, irrespective
of the  febrile state.   When the erysipelatous blush  has a  distinctly
circumscribed  outline, the annular zone  extending for an inch or
more in width upon the souud and  affected skin is either covered
with  the  tincture  of iodine,  pencilled M'ith a crayon  of  nitrate of
silver, or painted with  a saturated solution of the same salt.  This
is done M'ith a vicM' to limit the extension of the disease.   It  is true
that these measures M'ill  not  ahvays  succeed, but  it  is  erroneous to
assert  with sonic authors that they always  fail.   Certain  it is that,
whether effective or not  in the production of the result,  the advancing
border of  the disease will often fail to  surpass the limits thus artifi-
cially described.  Collodion has been employed  for a similar purpose,
and  lately Darlin1 has written in advocacy of the revival of this
method of treating the disorder, basing its  claim on  the fact  that it
diminishes the temperature of the part thus protected, and that, by
the compression excited, it interferes with septic  absorption.   Heppel2
recommends the painting over the surface of a ten per  cent, solution
of carbolic acid in  alcohol, as  an  abortive treatment, for  M'hich
Braithwaite3 substitutes  a similar solution of tannin.
   Excellent results are occasionally reached in the local treatment of
erysipelas, first  by  attempting to limit the extension of  the disease by
the application of the tincture  of iodine over the peripheral zone;
and, secondly, by  retaining over  the entire  surface affected, neatly
applied compresses saturated with a solution of the hyposulphite of
sodium iu the strength of about one  drachm (4.) to the ounce (32.).
Dr. Spencer,  of the United States Army, has frequently seen  the
disorder upon  the  face  entirely relieved in this  way in forty-eight
hours.                              •
                   i Bull. Gen. de The>., 1881, vol. ii. p. 239.
                   2 Arch, of Derm., April, 1881.
                   a Brit. Med. Journ., April, 1881.
                                 13 
194
DISEASES  OF  THE  SKIN.
   With many judicious practitioners all attempts  to  limit the exten-
sion of the disease by local applications of an irritating sort (corrosive
sublimate, nitrate  of silver, carbolic acid,  tar, turpentine,  etc.)  are
condemned as positively injurious.   Dry heat is applied by the aid of
cotton or mooI ; or cold compresses are laid over the part;  or  iced
lead  lotions M'ith  intermissions of application ;  or  salicylic  acid,
boric acid, iodol, or iodoform, in powder,   llesorcin in solution has
been  followed in some cases by excellent results.
   Erysipelas  rarely  attacks a  patient  in  vigorous  health.   The
large majority of all the subjects of the disease are either those who
have  previously suffered  from  manifest  general  ill-health, or who
have  been  complaining of local  ailments, trifling wounds, nasal
catarrh, or surgical accidents.  It is these  precedent conditions which
often  demand the special attention of the physician or surgeon.
   It  is needless to add  that all  surgical indications are to  be  fully
met when these are present:  pus is to be evacuated, crusts removed,
and drainage secured.   The physician and  surgeon  alike should never
forget that the disease is infectious, that the patient is  to be  isolated,
and to be supplied with  an abundance of pure air; and that  fomites,
surgical instruments,  and even the  n on-disinfected  hands of the
attendants are capable of transmitting the disease.
   Finally,  there  are forms  of  erysipelas  vvhich  are  remediless.
These are usually septic in character.  The  scarlet blush  spreading
from  an irreparable injury of long duration, is often the last protest
of nature against the damage which  even her final  resort of gangrene
will not avail to repair.
   Prognosis.—Under  favorable  circumstances, erysipelas,  even of
severe grade and extensive invasion, terminates in complete resolu-
tion.   Reserve should be made, however, iu every case, as a serious
complication has often  transformed  the  simplest into the  gravest
forms of the disease.  The author has seen  an erysipelas of mild grade
originating in the irritation of the lobe of the ear by an ear ring, trans-
mitted to a child who died with gangrene of the entire mucous limno-
of the oral cavity.   The very young, the cachectic, the victims of
drink, the aged, the  inmates of hospital  Mards depressed by other
illness, and those mentally distressed by destitution and neglect, are
particularly liable to suffer from grave aud fatal forms of the malady.
  The patients who fill the beds in most lying-in hospitals are young
women, either unmarried or deserted by their husbands, and unpro-
vided with the necessities of  life  by those  upon whom such a respon-
sibility  rests.  The mental depression  thus originating in connection
with the septicaemic influences too common  in  all  large charities, is
responsible for much of the relation  which erysipelas often seems to
sustain  to the  puerperal state, as also  for  the appalling  mortality
which it may exhibit under these circumstances. 
FURUNCULUS.
195
                           Purunculus.

                     Lat. furuncutus, a petty knave.
 Furunculosis is a disease characterized by  the occurrence of one or more
   circumscribed, cutaneous or subcutaneous abscesses calied furuncles, which
   usually terminate  by necrosis of tissue in  the centre of the phlegmon, its
   expulsion in the form of pus or a core, and a resulting cicatrix.

   Symptoms.—Furuncles,  or Boils, commonly begin as  both tender
 and painful indurations in  the skin or its subjacent tissues, the sum-
 mit of which  soon becomes visible iu  the  epidermis  as a  reddish
 punctum.   It is the result of an active inflammatory process, limited
 to a definite area, and  of greatest intensity at the centre of the in-
 volved mass.  This centre is often represented by a hair-follicle, the
 pustule that forms subsequently being perforated by a hair.
   More or  less  rapidly thereafter these symptoms are succeeded by
 increased redness,  heat, and tumefaction, the  latter producing a nut-
 or egg-sized tuberosity,  well  projected  from  the  surface,  or fairly
 imbedded within  or beneath the  derma.   A  yellowish point in the
 centre of the erythematous swelling soon announces the occurrence
 of suppuration.    When accidentally or artificially opened at this
 summit, exit is given  to a thick yelloM'ish pus which  may be com-
 mingled with blood from the traumatism  of the neighboring capil-
 laries.   The small abscess may then, after discharging its purulent
 contents for a few  days, gradually close by granulation, or  may also
 expel  from its  cavity  a  tenacious, pus-covered,  yellowish-green
 slough, known as the  "core."   This evacuation is usually followed
 by relief of the tense  aud  throbbing pain which is the well-known
 subjective characteristic of  the furuncle.
   The  length of time requisite  for the completion  of this process
 varies, with the extent of tissue involved, from a few days to several
 weeks.   Boils  may occur in any part  of  the body, but are  most
 common about the  face, the auricular region, the neck, the armpits,
 the ano-genital region, the hips,  the buttocks, the breast,  and the
 extremities.  They may occur as single  or  multiple  lesions, or may
 succeed each other  in crops, especially about the buttocks, trunk, and
 thighs, for a period of  several months.   It is this succession of boils
 to which the term furunculosis is specially applied.   The disease of
 the skin, in such cases,  may produce a constitutional effect manifested
 in pyrexia.   This  is usually encountered when the furuncles are few
and short-lived, only in individuals of irritable constitutions.  There
 is  also a decided chloro-anaemia due to the pain, fever, purulent drain,
derangement of the nervous centres,  inappetence,  and  consequent
perversion  of nutrition.
   The sequelae  of boils are maculatious of a  violaceous tint, often
perceptible in the skin for  weeks and even months after their disap-
pearance ; and cicatrices, pin-head to coin-sized,  M'hich are permanent.
   Etiology.—The causes of furunculosis,  as also of a single furuncle, 
196
DISEASES  OF  THE  SKIN.
 are often exceedingly obscure; and it must be admitted that the sub-
 ject requires more extended study.   It  is true that both  conditions
 are encountered in typical subjects of " hospitalism," where anaemia,
 asthenia, marasmus, malnutrition, and  exhaustion  resulting from
 excesses, from grave general  disease, from low fevers, aud from ner-
 vous strain, play a prominent part.  But the reverse is also true. The
 author has recently, for example, had under his care a gentleman of
 superb physique, active habits of life, and large wealth, M'ho availed
 himself of all the resources of medical skill, and who had yet suffered
 for six months from a persistent furunculosis.  FeM' actively engaged
 practitioners have failed to see similar cases.
   On the other hand, scratching, eczema, scabies and other cutaneous
 diseases, lice, and external irritants of various sorts are responsible
 for  many boils, especially those that are few and not followed by
 similar  lesions.   When, however, such sequence occurs, it should
 never be forgotten  that  the  furuncles, if sufficiently numerous and
 large, are amply capable  of disturbing the  general economy.    The
 collar-button  at the back of  the neck;  the edges of an  unyielding
 corset, for one unaccustomed  to  it; a hard bench;  the saddle-tree;
 and many similar articles, may be the exciting cause of furuncles.
   Account should always be had, in cases of persistent furunculosis,
 of externally operating poisons.   In  this category must be included
 sewer-gas emanations, arsenical Mall-papers,  and the poisons handled
 in the trades, e. g.,  by dyers, lead-manufacturers, etc.
   Lastly, it is exceedingly common for patients thus affected to apply
 to practitioners for remedies  intended to " purify the blood;" and,
 inasmuch as the iodide  of potassium is often mischievously prescribed
 in response to this demand, the  original trouble is thus enhanced to
 a manifold extent.   Many cases of furunculosis are instances of boils
 resulting originally from  external irritation, M'hich have greatly mul-
 tiplied and finally profoundly affected the system under the impulse
 of the so-called " blood-purifying " process.
   Pathology.—Authors have  attempted to explain the phenomena of
 furuncle by supposing  the process to  be due to inflammation attack-
 ing a sebaceous follicle  in the derma; or a  pilary follicle  or sweat-
 gland beneath the skin ; or  the peri-follicular tissues; or the con-
 nective tissue  pedicle M'hich passes dowmvard from the fundus  of the
 hair-follicle to the subcutaneous tissue;  or the blood and lymphatic
 vessels  which  surround the  sac.   It is  reasonable  to  suppose that
 they are all in the right.   No one of these component parts of the
 skin is known to be exempt from the changes M'hich are induced by
 the inflammatory process.  It  is difficult to discover in the furuncular
 lesion any symptoms which  set it apart from the other  results of
 localized  inflammation,  its   phenomena differing   from  those  of
 ecthyma, acne, pustular eczema,  anthrax, etc., only by the seat and
 extent of the inflammation.   The  core of the furuncle represents a
necrosis  induced  by the violence of the exudation,  and so does the
gangrenous slough M'hich falls after a severe dermatitis calorica. The
core of the furuncle is  moist, yellowish, and puriform, because it  is 
FURUNCULUS.
197
completely immcshed  beneath the epidermis, and pus-soaked.  The
core or slough  of a gangrenous dermatitis may be as dry as a crust,
from desiccation  in  consequence of exposure  to  the  air, or  be in
various degrees moistened by  the  fluids escaping from the  tissues
beneath.   Where  there is no core in furunculus, this absence is prob-
ably due to the fact that the  purulent products of the inflammation
pass with readiness  from the peripheral  to  the central parts of the
phlegmon  without  having to  leak through or between, or  to be
pressed against, masses of centrally disposed  elements, whose vitality
is thus the more readily lost.  Inflammation of tissue in a practically
closed chamber, under tense pressure, under slight  pressure, exposed
freely to the  air, or in all grades protected from it, will always differ
in its phenomena.   It is wiser to  attribute these differences to the
circumstances under which it  is displayed than  to any peculiarities in
the nature of the  process itself.
  The contagious character and parasitic origin  of furuncles  have
been studied by a number of  observers.  Gingeot,1 Startin, Trastour,
Lowenberg,  Pick, Pasteur, aud others have, with  varying  success,
reproduced these lesions by  experimental inoculation.   The name
torula pyogenica has been given to  a vegetable parasite recognized in
furuncular products, which, however, in development, is to a marked
degree modified by the nature of the site iu M'hich it is implanted.
   It is M'ith these demonstrations in view that Gingeot suggests the
employment of parasiticides  in  the  treatment of furunculosis, the
acid nitrate of mercury, iodine  in tincture, carbolic acid, and borated
alcohol.  Internally sulphur and the hyposulphite of sodium in large
dilution are administered.
  Diagnosis.—Boils are to be  distinguished from carbuncles by the
exaggerated symptoms of the  latter, described below.  Circumscribed
furuncular abscesses of the groins and  axillae are not to be con-
founded  M'ith suppurating, sympathetic, or virulent  buboes of these
regious, associated M'ith geuital  or extra-genital, contagious, venereal
sores.   This goes without saying;  but many such errors have  been
made.   Furuncles of the anal  and  genital region may be significant
of surgical affections of the neighboring parts (perineal, peri-prostatic,
peri-urethral,  and scrotal  abscesses  in men;  suppuration  of the
vulvo-vaginal gland in women, etc.).
  Treatment,—The debilitated constitution  of many patients affected
with boils indicates clearly  the need of a tonic regimen, including the
administration  of iron,  quinine, and  strychnine, the mineral  acids,
and, contrary to the generally accepted opinion  of the laity, a gene-
rous diet of milk, cream,  eggs, and fresh meats.   To these, wines
and  malt liquors may be at times added M'ith advantage.   Change of
climate, of diet, of cooks, and of the habits of life is most service-
able in cases of prolonged furunculosis.  The mineral Maters, at some
of our health resorts, prove especially valuable for the debility M'hich
often results from  these  disorders.   The internal remedies which
1 Bulletin g6n de Therap., Jan., Feb., and Mar. 1885. 
198                DISEASES  OF  THE  SKIN.
possess  reputation in  this complaint  are  arsenic, sulphur, and  the
sodic sulphites, the alkalies,  tar, phosphorus, and the  sulphide of
calcium.
  The last-named is probably  more highly esteemed  by the larger
number  of practitioners  than  all other  internal remedies, and is
given in doses of one-fifth to one-tenth of a grain (0.0133-0.0066)
every three or four hours in the day.  In  lithaemia,  the acetate or
citrate of potassium is given  in large dilution ;  in gouty states,  col-
chicum and the alkalies, including the  sodic salicylate.   No one of
these articles, however, may be described  as an efficient  and certain
remedy for the complaint;  many cases will progress without hin-
drance from any or all of them.
  Attempts in the direction of aborting a furuncle may  occasionally
be made by the topical application  of the stronger alkalies (aqua
ammoniae)  or acids;  caustics  or cautery; ice, or premature complete
incision with the scalpel.   These measures will occasionally succeed ;
more often they fail.  Frequent renewal of hot poultices of powdered
slippery elm or flaxseed, to which an opiate may be added  for  the
relief of the acute pain, should be practised till suppuration is estab-
lished, and exit given to the pus or core.  For a brief time after-
ward, they may be  continued.   Subsequently  the treatment is by
carbolated  lotions and simple  ointments.
  Prognosis.—The future of the patient  affected with a prolonged
furunculosis is that only of M'hich there can be question.  Eventually
the worst  cases are  relieved when unaccompanied  by  systemic or
visceral disorders, and where the circumstances of the sufferer permit
him to pursue the most advantageous course (travel, diet, abstraction
from business,  etc.).   The  resulting  cicatrices  depend  upon  the
severity of the process.  Often  they are small, and in the course of
years scarcely distinguishable.   In exceptional cases they are large,
persistent,  and disfiguring.

                           Anthrax.
                       Gr. avOpa!;, a live coal.
Anthrax is  a circumscribed, cutaneous and subcutaneous abscess, usually
  larger than a furuncle, characterized by dense induration and sloughing,
  and terminating,  in  favorable cases, by the production  of a persistent
  cicatrix.

  The term anthrax is employed by several foreign authors to desig-
nate the disease known among the English as murrain, splenic fever,
or  malignant  pustule, the  charbon  of the French.    It  is  here
employed  solely in the description  of the  non-specific  carbuncle.
The malignant carbuncles due to the presence of bacteria  will be
described under the title, Malignant Pustule.
  Symptoms.—Carbuncles are often  preceded by  malaise, chill,  and
pyrexia of severe grades.   In cases M'here the anthrax is formidable
and  seated  upon or near the head, alarming symptoms of prostration,
stupor, somnolence, and even  coma, may be noted.   With and with- 
ANTHRAX.
199
out  these  concomitants,  a  dense,  dull-red, indurated, and  painful
phlegmon soon appears, varying iu size from a small lien's egg to an
orange and even much larger, involving  not only the skin, but the
tissues beneath.   Suppuration finally occurs; but the pus is not con-
fined to  a single  sac.   It  undermines the integument,  and often,
through  several apertures,  leaks out  indolently to  the free surface.
The fenestrated or cribriform  appearance of the skin covering the
carbuncle constitutes, in this stage, one of its most  striking features.
Through  these apertures may be  distinguished the whitish  or yel-
lowish pus-soaked sloughs,  or portions of  a siugle slough, M'hich can
be at times extracted through the orifice. Often the entire mass separ-
ates in a single slough, involving the skin and subcutaneous tissues,
leaving a crateriform ulcer of formidable size, which, in favorable
cases, proceeds to  heal  by granulation.   The resulting cicatrix is at
first of a deep violaceous tint,  and later  becomes blanched.   It is
indelible.
   The fever which usually  accompanies this process may be mild or
severe, or, more commonly in dangerous cases, of a typhoid character.
It results  unquestionably from  sepsis due  to unli berated  pus and
necrotic tissue, and  is naturally most grave in consequences M'here
the  patients are weakened  by previous asthenic disorders.  Under
these unfavorable circumstances, the carbuncle may  spread at  the
periphery,  with  islands  of necrotic tissue  and  ill-conditioned pus
separated by bridges of empurpled, infiltrated, and  yielding skin.
   The peculiar lesions of this  disease most often  appear upou  the
back of  the neck, the back of the trunk, and the  lateral aspect  of
the hips  and thighs, usually in single development,  though occasion-
ally two or even three carbuncles  of  small  or. medium size may co-
exist.  The  reason  for their appearance  in  the  localities named is
clear.  It is here that the skin  is  most thick and resisting, and, as a
consequence, purulent foci M'hen formed are covered in  by the most
voluminous layers of the connective tissue of the corium.
   Etiology.—Anthrax  is produced by the obscure  causes to M'hich
reference has already been made  as probably effective in the produc-
tion of boils.  The two may coexist; or the one follow the other; and
intermediate forms  occur M'hich might  be assigned to either class.
The disease is encountered more  often in men than in women, and in
later than in earlier life, simply because  the tissues constituting its
sites  of preference offer  in  these  individuals, and  at these ages, a
greater resistance to  the exit of pus.  The  bacilli M'hich may be recog-
nized in  many cases may sustain  an etiological  or  purely accidental
relation to the lesion.
   Pathology.—The  pathological  anatomy   of  carbuncle  is   mcU
described by  Warren,1 whose observations conclusively  show  that
the inflammatory process  here is one with that  seen in the simplest
pustule.   The peculiar symptoms of carbuncle are  due solely to  the
formation of the  phlegmon beneath the dense and  extremely thick
masses of fibrous  tissue  found  in the back  " for the  protection  of
1 The Pathology of Carbuncle, or Anthrax, Cambridge, 1881, p. 15. 
200
DISEASES  OF  THE SKIN.
that comparatively defenceless portion of the body."  The elements,
multiplying with the intensity of the inflammatory  process, first in
the subcutaneous adipose tissue, pass upward along the fat columns
described by Warren as columnae adiposae, crowd  these, push  along
their horizontal clefts  branching from  either  side,  infiltrating the
derma, pass along the edges of the hair-follicles, fill the papillae till
the latter "balloon" with pus, ooze to the surface through the cribri-
form apertures  in the undermined epidermis, and soak the bundles
of fibrous tissue, relatively intact, M'hich constitute  the undetached
mass of  sloughing tissue.
  It cannot  be  doubted  that  the general  symptoms in  anthrax,
pyaemic, septicaemic, sympathetic, are due solely to pus imprisonment.

                               Fio. 34.
           m                                  m
Vertical section of anthrax.  Dense network of fibrous bundles, with interspaces communicating and
                extending to the subcutaneous tissue. (After Warren )
          Fig. 35.
i-                                     i
                f          p                      mp
  Section of anthrax. Infiltrated papillae are seen at I, distended in balloon-shaped figures, between
which the rete is compressed; at p and mp columnas adiposae are seen; /, division of elements, the
fibrous bundles resolving into protoplasm.  (After Warren.)

   Diagnosis.—It follows from M'hat has preceded that carbuncle and
furuncle differ solely  inconsequence  of the depth of the starting-
point of the phlegmon, and the density and resisting  power of over-
lying tissue.   The former is therefore flatter, denser, less rapidly de-
veloped, larger, less tender, aud more  painful,  opens by many rather
than by one or  two apertures, and  is folloM'ed  by  larger sloughs,
ulcers, and cicatrices, and occasionally by fatal  results. 
ANTHRAX.
201
   Treatment.—Crucial and  other deep incisions  in  the  local treat-
ment of carbuncle are certainly inferior  in  results to the  method
advocated  by Wood1 and Talor,2 which are employed in  cases with
complete  success.  A  saturated solution  of pure carbolic  acid is
ifijcctcd through  the  several  apertures  in every direction into  the
sloughing tissues  by the aid of an hypodermatic syringe.   When the
orifice, are not sufficiently numerous, the point of the needle is thrust
through the thinned  integument  at the summit of the swelling in
several points.  The pain is severe, but short-lived; the  tissues  are
blanched, indurated, and destroyed ; the  slough  in a  few  days is
readily separated  after division of its  slender fibrous attachments;
and the ulcer rapidly  contracts M'ith  the sequel  of a smaller scar.
It  is necessary to use pure acid  in saturated solution  to  prevent
absorption of the injected fluid and resulting toxic effects.
   Relief is afforded in  many cases by opiated  hot cataplasms  and
fomentations, M'ith the requisite skill in the surgical dressing of  the
parts by  carbolated  lotions, extraction  of the slough  wholly or in
portions by the forceps,  aud the  subsequent employment of simple
or carbolated unguents during the  reparative process.  An excellent
method of withdrawing the purulent and sloughing  contents  of  the
carbuncle is to apply over it,  at  the  proper period,  an exhausted
receiver, such as a common cupping-glass.
   In many cases the  antiseptic treatment of a carbuncle furnishes
decidedly the best results as regards the comfort  of the patient and
limitation of the  disease.  Here there is absolutely no surgical inter-
ference M'ith the lesion, beyond the incisions made for the  evacuation
of  pus.  The violent squeezing and manipulation of the carbuncle
are interdicted.    It is freely powdered M'ith iodoform, and on it is laid
soft, felt cloth, thickly spread with any emollient and antiseptic salve.
Bulkley3 advises  the use of the ordinary zinc salve for this purpose.
Boric acid in powder, or iodol, thickly dusted over the carbuncle and
covered with antiseptic M'ool M'ill also be found a useful dressing.
   Internally calx sulphurata should be administered in  full doses.
It has an unquestionable effect in  diminishing the pus-formation.
  Other constitutional treatment  is that  demanded in the  case  of
furunculosis, including the liberal employment of tonics, a generous
diet,  a strict observance of the  rules of hygiene,  and  stimulants
M'hen indicated.   Pyrexie, septicaemic, pyaemic, and adynamic states
require the special management of such complications, including cold
sponging of the surface in fever, and the use of quinine  and  stimu-
lants, with artificially applied heat in the algid condition.
  Prognosis.—A  serious issue need be anticipated  only M'hen the
complications described above  are grave in  character,  or occur  in
asthenic constitutions.

  Pustules from Cadaveric Infection.—The lesions generally
known as dissection-Mounds usuallv occur upon   the hands of those
1 Toledo Medical and Surgical Journal, Dec. 1880.
'- Austral. Medical Gazette, Dec. 1, 1881.
3 Journ. of the Amer. Med. Assoc, May 16, 1885. 
202
DISEASES  OF  THE SKIN.
exposed to the danger of post-mortem examinations and dissections.
At  the point of inoculation, which may  be either  the site of  a
former abrasion,  rent, or  the mouth of an  open follicle, a painful
vesico-pustule, papule, tubercle, wart, furuncle, or hemorrhagic bulla
rises rapidly from an angry and indurated base, with hypersemic
areola  in dull red shades.   Suppuration, crusting, or ulceration  may
follow, limited to the seat of the lesion; or lymphangitis in various
grades with  consequent pyaemic or  septic-emic involvement of the
system.   Suppurative  and  non-suppurative  axillary  buboes  are
common.   Gangrene and necrosis of the soft parts and bones, especi-
ally the phalanges, may ensue, as also a fatal result from the systemic
disorders  named.  In a few  cases  a chronic  marasmus is induced.
Prophylaxis, by proper protection of the hands  and the immediate
cleansing  and disinfection of any accidentally wounded point, is of
the highest importance.  The treatment is to be conducted in accord-
ance M'ith the principles already  described.
  There is reason to believe that accidents of this kind may be pro-
duced by  absorption of the alkaloids engendered in the cadaver by the
decomposition of proteid  substances, called  ptomaines.   These were
first isolated and named  by  the late Professor  Selmi, of Bologna,
subsequent investigation  seeming to  prove that in chemical constitu-
tion they  do  not  differ from the alkaloids  produced by albuminous
decomposition in  vegetables.   Brieger has identified neuridine, cada-
verine, putrescene, and saprine in  the dead body, and, M'ith these  a
peculiarly toxic alkaloid to which he has given the  name  mydalein.
All these are capable, after ingestion or admission by other avenues
to the circulation, of inducing salivation, vomiting, diarrhoea, dysp-
noea, paralysis, and death.   The lethal issue in the case of lesions of
the character here designated, is  probably due to the fact that, at the
site of the pustule of irritation  or traumatism, one or  more of these
toxic alkaloids has  gained admission to the lymphatic circulation.
For further  reference to  this subject,  the  reader may consult the
chapter on Verruca Necrogenica.

   Pustules and Other Lesions resulting from Wounds In-
flicted  by Reptiles and  Insects are often  of an  insignificant
character.  Such are the trivial results of the bites  and  stings of
flies,  fleas, mosquitoes, ants, bees,  hornets,  etc.  At  other times,
however,  serious and  even fatal consequences have been  recorded.
The wounds produced by the tarantula and scorpion (M'hich frequently
lurk iu the clusters of tropical fruits iiomt imported to  almost every
part of this country), as also of the  venomous reptiles,  may prove to
be  grave.  Urticarial, vesicular,  pustular,  papular,  bullous,  and
petechial  lesions  may thus originate and  be  the  cause of a more or
less severe dermatitis M'ith toxic symptoms.   In the latter event, it is
common in this  country to administer  as remedial agents, alcoholic
stimulants as freely as they can  be ingested.

   Delhi  Boil,  Aleppo Evil, and Biskra Bouton.—These are
chronic endemic disorders characterized, for the most part, by the 
anthrax.                       203
 occurrence  of painful nodosities  upon  the  face, hands, and  other
 portions of the body.  The lesions are often  multiple papules, which
 subsequently become  purulent  aud ulcerate  indolently;  or become
 covered with scales.   They are often grouped in patches and followed
 by cicatrices.   The  exact  nature  of the  maladies  thus named, is
 unknown.  They  are quite fully described  by  Fox, Farquhar,
 Pollack,  Willemin,  and  other authors,  as occurring in India,  the
 region about the Euphrates and  Tigris Rivers, and along the northern
 coast of Africa, especially Algeria  aud Morocco.  The descriptions
 given of these diseases certainly suggest that, in some instances at
 least, several different disorders  have been included under these titles,
 such as the lesions of lupus, syphilis, and  the  frequently formidable
 symptoms produced in the skin by the vegetable  parasites in tropical
 countries.   The author has personally journeyed  from Arabia in the
 East, along the coast to six degrees below the  line in South Africa,
 and thus enjoyed a fair opportunity of observing the symptoms  of
 many of the endemic disorders  of that region.  In no single instance
 has the author been able to persuade  himself  that  the  numerous
 furuncular,  papular,  and  pustular affections  encountered,  differed
 from the  similar  lesions  observed  in temperate  climates, except  iu
 that they were greatly aggravated by filth, meagre diet, intense heat of
 climate, ignorant and vicious medication, and the  syphilitic diathesis.
   Laveran1 has lately described afresh the Biskra bouton.  It occurs
 not only in Biskra, but also in the adjoining  oasis, aud is plainly
 identical M'ith  the  Aleppo  boil.  It shoMS itself  as an  endemic only
 in the months of September and October, and continues till Decem-
 ber.  No  new  cases  appear in  January and February.  All  ages,
 both sexes,  the strong and weak, are liable  to it.   The  eruption
 affects the  face and extremities by preference,  sometimes  also the
 trunk.  It  ordinarily  attacks the same  person  but  once,  yet may
 recur.  So  long as the disease prevails, the least excoriation has a
 tendency to become Biskra button.  At first there is a reddish, pain-
 less elevation of the skin, the size of a pin's head; the centre of this
 soon dries, and a  brownish  crust forms, easily  removable.   Beneath
 this, there is a small round ulcer.   The papules may occur in patches,
 bearing thick  crusts M'hich  long resist.  The crusts are remarkably
 dry.  When  the latter are  removed and the ulcer left undressed, a
 new, less firm crust forms; M'hen dressed, the crust-formation is pre-
 vented and an ulcer of an  obstinate  character remains, which in the leg
 is not unlike a varicose ulcer. If the original crusts be not disturbed,
 these eventually fall and leave no scar.   Should, on the contrary,
 the crust be removed at the beginning of cicatrization, this is accom-
 plished   slowly, and   a  permanent scar  remains.   Lymphangitis,
 erysipelas,  and  phlebitis,  occur as  complications.   There are  no
 peculiarities  in the  crusts.   Epidermic  cells,  pus  corpuscles,  and
 bacteria, are commonly recognized by the microscope.   An expectant
treatment is the best.   Should the  crusts be removed or fall off, it is
advisable to  powder the ulcer M'ith  henna,  M'hich  favors the produc-
i Annal. de Derm, et de Syph., 1881, t. i. p. 173. 
204
DISEASES  of  the  skin.
tion of fresh crusts and cicatrization.   As  regards.its pathogenesis,
the  author  holds Weber's view, that the disease is  contagious and
inoculable, and perhaps  auto-inoculable.   The  virus  exists in the
crusts, but its  nature is not established.  .Carter's  opinion as  to its
parasitic nature is not tenable.                     -'»
   Dr. Altounyan, of Turkey,1 protests against the viCw, given above,
entertained  by Geber and others that the Aleppo tmtton  is a term
applied indefinitely to various cutaneous disorders.   In his view it
is a specific disease  beginning, independently of the, hair-follicles, as
a small acne-form papule, disappearing oh pressure and pinkish in
color.   Afterward it grows deeper, larger, and  harder', and becomes
more adherent and more vascular.   Still it.js livid, sensitive, smooth,
and  boggy to the touch.   Pus form* centrally and diies into grayish-
brown crusts which are rupioid  in  character.  -^>ei*eath is a spongy
ulcer,  with  ragged margin, ovoid  contour, and ichorous discharge.
Healing is by the production of a permanent and deforming scar, the
entire course of the disease lasting oue year.
   Dr. G.  R. Eliott, of New York, who made a  microscopical exami-
nation of  some specimens furnished  him  by Altounyan, reports that
the disease  was limited  to the epidermis and corium, and its  area
occupied  by  small  round  inflammatory  or  formative cells  and
epithelial  elements.   There was a distinct line of separation between
the  healthy and diseased tissue.   No cryptogams or other micro-
organisms were recognized.  The hair-follicles  and other glandular
structures M'ere intact.
   Altounyan  found the  best treatment to be  the painting of the
button with  the tincture of iodine;  and that one attack  furnished
immunity against a second.  He  believes the disease  to  result from
the bite or sting of an insect.


                     Phlegmona Diffusa.
                   Gr. ^leyfiovr], an inflamed tumor.
Phlegmona Diffusa is a grave form of non-circumscribed inflammation of the
  skin, in which the integument becomes livid, hot, swollen, painful, and apt
  for necrosis, this process occurring in one or many places to a considerable
  depth, and  accompanied by fever and systemic disturbance.

   The word phlegmon  is  employed by most English and American
writers to indicate a circumscribed inflammation of the skin, ter-
minating  naturally in suppuration, aud,  as to the tissues  involved,
larger than an ecthymatous pustule, and  yet not large enough to be
termed  an abscess.   Circumscribed  phlegmons are represented by
most furuncles, and, at one stage certainly of  their career, also by
carbuncles.
   In the disorder, however, under consideration, the symptoms, both
local and general, are far more serious.   The first evidence of trouble
may be a  severe chill, followed by high  fever and deep-seated ham-
Journ. of Cutan. and Ven. Dis., viii , No. 6. June, 1885. 
FUSTULA MALIGNA.
205
mering pain, felt in  the part M'hich is the seat of the disease.   This
is soon recognized as an (edematous area, of dull red  or  livid hue,
tensely infiltrated, of the familiar brawny  type  and  indeterminate
outline.  All of these symptoms rapidly increase as resolution is very
rarely attained, and  are  followed by suppuration  at  one or more
points.  In diffuse phlegmon, hoMever, the  brawny tenseness of the
inflamed skin has been so great that vascular thrombosis occurs, and
the  circulation  is greatly impeded,  as  a consequence, between the
points where pus forms, or  about a  single  point.   The tissues then
become more or  less  necrotic, both during and after the  formation
and evacuation of pus.
   The fever meantime may abate or  entirely remit,  or, in grave
cases,  steadily persist.  In the latter event, the subcutaneous tissue,
fascia,  periosteum, bones, joints, aud  ligameuts  may  be involved.
But in all  favorable cases the systemic condition is greatly improved
when  pus  is  no  longer deeply or extensively formed,  aud when the
gangrenous shreds and sloughs are M'ell  looseued or entirely removed.
   The "Acute Purulent ("Edema" of English authors  and the Gan-
grene Foudroyante of the French  may be regarded as severe types of
diffuse phlegmon.  In  most  of such cases the patients die septicemic
before the  complete evolution of the cutaneous inflammation has been
reached.   In  others,  the affected  part, suddenly losing its tense
brawny hardness, becomes emphysematous, or crepitates M'ith bubbles
of gas produced  by decompositiou.   The  patient may  then become
somnolent or delirious, or be the victim of an intercurrent and fatal
involvement of the kidneys,  lungs, liver, spleen, or bowels.
   The treatment of diffuse phlegmon  is largely surgical, and in  this
day simple.   Incision,  drainage, and  disinfection are the three essen-
tial  requirements.  These thoroughly assured, the systemic treatment
is by quinine, stimulants  M'hen indicated, and the accepted remedies
for the typhoid condition  generally, including rest in the recumbent
posture and a proper supply  of wholesome air and food.  Amputation
of limbs may be necessitated in order to save life.
   The prognosis rests almost entirely upon the extent, diffusion,  and
severity of the local inflammation, and the systemic condition of the
patient.  In a previously healthy subject, with good hygienic environ-
ment and  the absence  of thrombosis, pyaemia, septicaemia, and ery-
sipelas, the results M'ill generally be favorable.  With the reverse of
these conditions,  the outcome may be serious as  regards the loss of a
limb, deformity,  or a fatal issue.


                       Pustula  Maligna.
Malignant pustule is a grave  carbuncular  lesion occurring usually upon
  exposed portions of the body,  which may result in gangrene, accompanied
  by a specific fever, and usually resulting  from inoculation with a virus
  obtained from some of the lower animals.
   This disease in man is fortunately rare of occurrence, and is usually
derived from some animal affected with the specific malady variously 
206
DISEASES  OF  THE  SKIN.
 termed "Anthrax," " Charbon,"  "Splenic Fever,"  "Splenic Apo-
 plexy," or "Texan Fever."  The lesion under  consideration is  also
 termed Splenic Fever Carbuncle.  After inoculation with the disease
 from any infected  animal, the human subject may (a)  perish from
 systemic  poisoning wholly septicemic in character with  few external
 symptoms;  or, (6) when life is sufficiently prolonged, suffer from
 visceral  symptoms, and exhibit  subcutaneous tumors; or (c) exhibit
 the symptoms of the disease now under consideration.
   In from  twelve to  eighteen  hours after inoculatiou, a  painless
 macule is first manifested, usually upon the dorsum  or other parts
 of the hands or face to which the virus has had access.   This  is
 followed by  an inflammatory and  pruritic  papule, which is rapidly
 transformed into a flaccid  vesicle filled with a  bloody serum  and
 surmounting a firm indurated  " nucleus," or  a larger blood-filled
 bleb reposing upon a somewhat painful, engorged, and often densely
 indurated base.  One or more similar lesions  may follow in the  sur-
 rounding integument, coalescence  of which produces a large, angry,
 oedematous, and often  gangrenous  ulcer.  The involved  skin may be
 as large  as  a small coin,  or of the  size of the  palm of the hand.
 The lymphatic vessels and ganglia enlarge,  and  often suppurate;
 metastatic abscesses form; and  the constitutional  symptoms super-
 vening are those described in connection with equinia.
   If recovery ensues,  the grangrenous mass is sloughed  off as in
 favorable cases of  carbuncle ;  if the result is to be fatal, the process
 is rapidly aggravated by oedematous infiltration extending to a wider
 area and by  larger  quantities of tissue falling into necrosis.
   In some  cases  the  accompanying  fever is  high,  M'ith  marked
 delirium; in others, it is of a typhoid character.   Death  results from
 shock, septicaemia,  or exhaustion, though in cases where the lesion  is
 circumscribed  and  unattended by  constitutional  symptoms, recovery
 may ensue.1
   Etiology.—The disease is commonly induced by  infection from
 one of the  lower animals,  usually horned cattle, who  suffer from
 charbon  or splenic fever, and are in relation to herders, ranchmen,
 etc.  The susceptibility of the carnivora  to the disease is very much
 less than that of the  herbivora.  It is claimed that not only direct
 inoculation may produce the disease, but that it  may be  extended by
 the  medium of flies and other insects.  More recently  it is claimed
 that food, drink, and even inspired air may be the medium by which
 the disease is conveyed.
   Pathology.—Since the first investigations reported  by Davaine to
 the French Academy in 1864, Pasteur, Klebs, Koch, Carnevin,  and
 others have fully demonstrated that splenic fever is solely due to  the
 multiplication  in the blood  and tissues of a rod-shaped  bacillus, the
 bacillus anthracis, which  is  ahvays motionless.   Under  culture  the
 bacilli  may  develop long  filaments,  many times larger  than  the

  i A chromo-lithograph exhibiting the peculiar features of the malignant pustule in the neck will be
found in the British Med. Journ. of June 13, 1884, illustrating a paper by Mr. Morrant Baker.' 
PUSTULA  MALIGNA.
207
original  rods, with  a distinct sheath about a protoplasmic cylinder,
which after segmentation  furnishes oval and shining spores.   These
have been cultivated again and again, with re-
sulting germs that  have produced the disease         Fig. 36.
artificially in the lower animals.
   The pathological  anatomy of the malignant       «*^   #.
pustule is that of  carbuncle M'ith the added        ^  ^^oa
fact that specific bacilli  and spores are abun-    ^>^/^M ^#
dantly present  in  the  blopd and debris of       /  #\  ^ ,
tissue.                                             *    ^, ^jS
   In establishing a diagnosis, care  must be    f .^Jt-^ *»*
taken to  avoid one source of error.   Malig-      ''^ ^,'t£  ***&
nant pustule in  man is not of frequent occur-
rence in this countrv, but occasionally various   Malienant Pustule bacim and
                ..   *'      .  ,    ,  J      ,     pus corpuscles. About X 300.
cutaneous  eruptions are  induced  upon the
hands, after contact  with animals or hides upon  M'hich chemical solu-
tions have been applied  for the destruction of lice.  These solutions
usually contain  arsenic, corrosive sublimate, or other substances capa-
ble of exciting a localized dermatitis.
   The treatment is  to be conducted on the principles of general thera-
peutics.   Popper,1 an Hungarian physician M'ith a large  experience
in malignant  pustule, reports success by deep excision of the lesion,
extending the operation  to the subcutaneous connective tissue.   This
has always proved successful when practised before the occurrence of
general symptoms.
   A number of  other authors  have had similar successful  results
after excision.  Pitts, for  example (Brit. Med. Journ,, March 19,
1887), reports two  successful excisions of malignant  pustule  in the
case of brothers.  Hebra Mas not in favor of the early cauterization
of the malignant pustule,  and it may be considered as a questionable
method of procedure.
   A grave case of malignant pustule is recorded,2  in which recovery
ensued  after  the  hypodermatic injection of the tincture of iodine.
Three syringefuls of the pure tincture M'ere deposited beneath the skin
at the periphery of  the diseased  surface,  and lint soaked in the same
was applied  over the  slough.   Internally,  fourteen  drops  of the
tincture (1.) M'ith three grains (0.26) of the iodide of potassium, M'ere
also administered.  Normal  cicatrization  followed in this  and  six
other cases recorded.
   Crucial  incisions  M'ith the  free application afterward of pure car-
bolic acid have been followed   by  good results.   Mr.  Baker,  of
London, reports rapid and complete relief  after  excision, and the free
use of iodoform. Internally,  the hyposulphite of sodium and quinine
are  successfully employed.   The febrile, typhoid,  and adynamic
features of the; disease are to  be treated in accordance with the recog-
nized principles of general medicine.

    1 Ctbt. f. Chir., 1881, No. 33.                    2 Arch. gen. de M6d., Feb. 1883. 
208
DISEASES  OF THE  SKIN.
                             Herpes.

                         Gr. epneiv, to creep.

 Herpes is an affection of the skin  characterized by the occurrence of one or
  more vesicles filled with a clear serum, disposed in groups, limited to  a
  certain region of the body, and pursuing a definite career within a relatively
  brief period of time.

   The term herpes is  unquestionably  responsible for a great deal of
 the confusion M'hich has existed  with respect to contagious  disease.
 By the ancients it was employed,  as its etymology suggests, to desig-
 nate a disease creeping or extending gradually over the surface or
 within the substance of the skin.   By several  more  modern  authors
 the term has been employed in  a  generic sense in a futile attempt to
 distinguish a  series of so-called " herpetic diseases," and even  her-
 petic diatheses from those of a different complexion.
   The significance which attaches to the word in the minds  of the
 dermatological authors of  this day,  is  exceedingly  simple, and  is
 limited to the features conveyed in the definition given above.  It
 will be  seen  that the description thus embodied  is  largely  that
 of herpes  zoster, an  affection  which is  in  this  work considered
 separately.
   Symptoms.—The disease  is declared by  the occurrence of millet-
 seed to coffee-bean  sized vesicles, single or  relatively  few in number,
 and  in  the latter case grouped,  occurring as epiphenomena of a
 general  febrile  process, or  as  symptoms  of an idiopathic  disease.
 The lesions  are usually  short-lived,  surviving but  for a few days,
 and are filled  with a clear, serous  fluid which may become lactescent.
 After  accidental or spontaneous  rupture,  there  is  left a  slightly
 tumid, superficial excoriation, which at times  is characterized  by a
 circumscribed hyperaemia, slight  infiltration, or  oedema of the  base
 and  periphery.   The  subjective  sensations  are not  usually  severe,
 varying between moderate pain, itching, and  heat.  There  are occa-
 sionally  precedent chill and  pyrexia, but  no persistent lesion-relics
 result  from complete involution.

   Herpes Facialis.—About  the lips, mouth, and alae of the nose,
 rarely  upon any other portions of the  face, lesions occur  singly, or in
a group, possessing the characters described above.   Their frequency
about  the  lips has  determined the title Herpes Labialis, under
which  they are  described  by several  authors.   The tongue, buccal
 membrane, palate, aud larynx may participate in the morbid process;
and the lesions in such moist situations are represented by isolated or
grouped, dark-grayish patches of  epithelium, M'hich are sensitive and
exfoliate.  The functions of the mouth in articulation  and mastication
are thus rendered  painful.  The disease is common  iu acute pneu-
monia, malarial  and enteric  fevers.    In  these cases, as Kaposi has 
HERPES.
209
shown, the occurrence of the eruption  by no means augurs favorably
in every instance, as a fatal result may nevertheless follow.
   Often the lesions coalesce, forming a pea-sized bleb in an irregular
line of elevated epidermis, spreading along the vermilion border of
the lip and distended M'ith a clear serum.   The burning and itching
sensations M'hich accompany the lesions are often marked and  dis-
tressing.  In the course of two or three days, thin crusts form M'hose
exfoliation terminates the disorder.
   The  connection betM'eeu labial herpes aud rigors  has long been
recognized,  though  particular  attention has been  directed  to  this
relation by Hutchinson and Symonds.   Beside the trophic disturb-
ances of this nature,  traumatism, exposure  to  solar heat, unusual
fatigue, a simple corvza, exposure to a cool  draught of air, aud tem-
porary gastric disturbances may suffice to induce the disease.   There
are patients M'ho can produce the lesions at Mill by tickling the lips
M'ith  a  feather.   There  is  in  some individuals an  unquestionable
susceptibility to the disease.   The  disorder  is  ahvays short-lived
though often recurrent; and the superficial crusts  which  terminate
the process are never followed by scars.

   Herpes Progexitalis.—This disorder, also termed Herpes Pi;e-
putialis, is  characterized  by the appearance of one  or a group of
transitory vesicles occurring on  the inner  face  of the prepuce, espe-
cially upon its upper limb, on the glans, the balano-praeputial sulcus,
and the adjacent integument; in women, on  the  hood  of the clitoris,
the  labia  minora, the inner face of the labia  majora,  and adjacent
surfaces even as far removed as the buttocks.
   There is usually precedent pruritus or a sensation of heat, folloM'ed
by the appearance  of one or several  pin-head  sized vesicles seated
upon a tumid and hyperaemic base.   Within the praeputial  sac the
lesions  mav either rupture at an early moment, or assume the features
described as  presented  upon the mucous membrane of the mouth.
The resulting oedema of the prepuce is often displayed in an annular
tumefaction encircling  the glans, while the labia minora perceptibly
project from the general vulvar plane.   In these localities the floors
of ruptured  vesicles are particularly liable  to be irritated  (coitus,
caustic, etc.), and theu pus aud even blood may be exuded with much
angrier  excoriation and  resulting crusts of darker shade.  In the
course of a few days even these  crusts fall, and the disease is at an
end.   Recurrence is common.
   Often a first  attack  of herpes  in the male results in  an  extraordi-
nary  sensitiveness of the balano-praeputial membraue, which persists
for more than a year.   The patients are usually middle-aged men,
married, and virgin as to venereal antecedents.   The membrane is then
tumid,  tense, slightly glazed, and dark  red  to  dark purple in  hue.
Upon any undue sliding of the prepuce over the glans, a very super-
ficial  fissure occurs,  M'hence a drop of serum oozes.   The membrane
becomes so sensitive that the passage of the  finger over it is resented
                               14 
210
DISEASES OF THE SKIN.
as though the conjunctiva had been touched.   Unusual friction by
the clothing or the use of a stimulating lotion,  is follow cd  by intense
pain  and aggravation of symptoms;  and  the price of coitus  is a
M'eek's rest  in bed.
   Naturally the diagnosis of herpes progenitalis is between chancroid
and chancre.  The latter M'ill  be manifested  by  its induration, its
period of incubation, and its characteristic  double inguinal  adeno-
pathy.    The chancroid,  M'hether  iu  pustular form or inoculated
abrasion, is ab origine ulcerative  in tendency, capable of auto-inocu-
lation, and  often  accompanied  by sympathetic,  inflammatory, or
virulent  bubo of one  side.  Balanitis, with its puriform secretion and
superficial patches of reddened epithelium,  is readily  distinguished
by its symptoms, though the two disorders frequently coexist.
  The practitioner should never forget that  the patient M'ho exhibits
an herpes of the genital region to-day may have been inoculated at
the site  of  these  lesions which may to-morrow or later take on the
chancrous modification.   The  rule to be  followed, then,  is  very
simple.    No individual  Avith a progenital herpes  can be assured of
immunity against syphilis, till  the longest  period of incubation of
the syphilitic chancre  has elapsed since  the date of last suspected
exposure.
  Herpes progenitalis is almost  universally the  result of naturally
or unnaturally induced sexual  erethism.  Its  occurrence in an indi-
vidual virgin as to such antecedents may be due to the causes efficient
in the production of  herpes facialis.  Unna,1 in an interesting paper
on  the subject, has conclusively  shown that, though relatively rare
in chaste women, it is of common occurrence in prostitutes.
  Messrs. Diday and Doyon,2  who have  given special attention to
the subject,  believe that true herpes of the  genital region is always
of the recurrent type, and well  marked by its  special course, career,
and consequences.  All  others of a false  type  are divided bv them
into [1]  an  irritative  form, seen in  women as  the  result of vaginal
discharges, sexual irritation, etc.;  [2] a pseudo-membranous or diph-
theroid form, also occurring for  the most part in women, vesicular
and even bullous in its lesions,  M'hose rupture  is the signal for the
pseudo-membranous  transformation; [3] a neuralgic form, M'hich is
merely zoster of the genital region.
  Treatment.—The milder forms of herpes  occurring about the  lips
and genitalia require  the simplest treatment.   Sponging with pure
water, as hot as  can  be comfortably tolerated, is  best folloM'ed by
local use of a weak lead lotion, rose ointment, or zinc salve.   About
the lips it is well to protect the lesions with  flexile collodion or isin-
glass  plaster.  Occurring upon the genital region, the  lesions are to
be protected by the interposition of a pledget of lint or a borated or
salicylated dusting powder.   As a rule, ointments are  unsuited for
the moist mucous  surface of the genitals, the odorous emanations
1 Journ. of Cutan. and Ven. Bis., Aug. 1883.
2 Les Herpes Geuitaux, Paris, 1886. 
HERPES.
211
from most diseases of such parts being retained  disagreeably by all
grease-containing  compounds.   Lotions ansMer a far  better purpose,
and  these  may be  made stimulant M'ith  alcohol;  astringent M'ith
tannin, the sulphate of zinc, or the sulphate of copper; painless M'ith
opium or cocaine; and antiseptic with carbolic acid or corrosive sub-
limate.  Prophylaxis by the  local use of aromatic Mine, or tannin
and brandy, M'ith  continence, is a matter of importance.

                           Herpes Iris.
   The behavior of the lesions  in  herpes iris  differs someM'hat  from
that just described;  and this has led several authors to consider the
affection as a  separate and distinct disease.  As  there is, however,
some doubt respecting the question M'hether herpes iris should not be
relegated to  the  domain  of erythema  multiforme, it is  assigned a
provisional position in this connection.
   The symptoms  at the onset are the occurrence of  one  or several
vesicles or vcsico-papules, M'hich pursue their usual rapid career in
Iwo or three days.  Upon the hyperaemic ring which surrounds these
a second and even a third and  fourth  circlet  of similar lesions form,
each pushing the areola further to the periphery of  the patch.  The
older  are  in  full  retrogression while  the neM'er are in  process of
evolution; and the red blush which surrounds the  earlier is under-
going  color-changes from vivid to paler hues, M'hile the zone of the
latest vesicles is assuming its  intensest shade.  The lesions are pin-
head  to  pea-sized, rather persistent and firm; and terminate  more
often by resolution than by rupture and crusting.   The  concentric
and parti-colored  rings may make up a single patch an inch or more
in diameter, or several such patches may form upon  the surface of the
integument.   In the latter case the central disk of some of the patches
will be seen to be made of confluent lesions.   The eruption is most
commonly situated upon  the extremities, especially over the dorsum
of the hands and  feet, in M'hich situation, especially M'hen symmetri-
cally developed, it is ahvays, according to Kaposi, more nearly allied
to erythema multiforme.   It is, however,  also  rarely  seen upon the
face.   The subjective sensations produced are usually trifling. Atyp-
ical forms  occur M'here the lesions are  imperfectly developed  from
papules, and also  M'here, in consequence of an unusual exudation of
serum, bullae appear.
   The points  in M'hich herpes  iris most resembles  erythema multi-
forme  are : the variegation of the tints in the peripheral integument
(M'hence the name, iris);  its localization  upon the  extremities chiefly ;
its  occasional  symmetry; its  frequency in  young adults;  and  its
tendency to occur in  the spring and  autumn.   Per  contra, herpes
iris differs  from other forms of herpes;  in the absence of a precedent
febrile state or neuralgic pain ; in its  avoidance of regions near the
mucous outlets of the body (preputial orifice, vagina, mouth); and
in the behavior of the  vesicular  lesions   after  attaining their full
development. 
212
DISEASES OF THE SKIN.
   The affection is evidently one upon the border-line betM-een herpes
and erythema multiforme; and might be properly considered  under
either title.   Its existence is another evidence of the  impossibility of
draM'ing hard and fast lines between all the clinical  symptoms pre-
sented by different diseases.
   It can scarcely  be mistaken  for  other  affections, in consequence of
the elegance  with M'hich its  lesions  are  disposed.   Pemphigus
simplex  and  pemphigus foliaceus differ decidedly  in their career,
however much they may, at  the outset of  exceptional cases, present
certain points of resemblance.
   The affection tends to spontaneous recovery, and requires no treat-
ment.   A dusting poM'der may be applied  over the surface, if need
be, to protect the lesions from accidental rupture.

   Herpes Gestationis, or Pemphigus  Hystericus, is a name  M'hich
has been employed to designate erythematous, papular, vesicular, and
bullous lesions, accompanied  by marked pruritic and burning  sensa-
tions, occurring usually  upon  the  extremities,  but  also  upon  other
parts of the  body. The subjects are usually pregnant or  hysterical
women, who are said  to exhibit recurrent attacks in successive condi-
tions  of pregnancy or neurotic disorders.  Personal  experience has
led the author to accept  fully the vieM' of Duhring, that this disorder
should be included under Dermatitis Herpetiformis.

                        Herpes  Zoster.

          Gr. ^uarfjp, a girdle;  Shingles, Lat. cingulum, a girdle.

Herpes Zoster is an  acute exudative affection of definite career, characterized
  by the occurrence of groups of firm and distended vesicles, preceded, accom-
  panied, or succeeded by neuralgic sensations, usually monolateral in distri-
  bution, and followed in some  cases by persistent cicatrices, the cutaneous
  symptoms being always limited to an area of  the skin supplied by a twig
  of one or more of the cranial or spinal nerves.

   Symptoms.—This disorder is also termed Shingles, Zona, and Zoster.
The eruption is usually preceded, for a period lasting from  a few
hours to  days  and  even  weeks,  by malaise  or neuralgic  sensations
of moderate or  severe  intensity.    These  sensations are  usually
limited to the  area of the integument subsequently or  coincidently
displaying cutaneous  lesions ;  but there are exceptions to this rule,
as the paius  are  at  times experienced  elsewhere.    Often,  though
limited to the region  about to be attacked, they occur M'here pain  is
experienced  in  other neuralgias, at the points indicated by Romberg
as corresponding to the  regions where cutaneous branches are given
off by the nerve trunks.
   According to Fabre, the essential lesion,  ahvays present  even M'hen
vesicles are not seen,  is the first macular efflorescence  of the  disease.
This  appears  in  the  form of vivid  and brilliant-red  erythematous
macules, groups of which, from six to ten  in number, appear  in the 
HERPES ZOSTER.
213
tract supplied by the affected  nerve.   The vesicles (which are gener-
ally regarded as more characteristic of  the  disease)  appear afterward
in from a few hours to a day or  more, springing from the macules,
and are accompanied by a sensation of heat.  These typically perfect,
isolated vesicles vary in size, from a rape-seed to a coffee-bean.  They
appear in groups corresponding to the  groups of the  macules, from
eight to a dozen in a single cluster, and appear  successively,  the indi-
vidual members of each attaining maturity simultaneously  in  about
one week, while the succession of others may prolong  the period of
efflorescence to an entire month.
   The  lesions,  when fully developed, exchange their early  limpid
contents for those of a lactescent or puriform character.   They project
well from the widely hyperaemic  base  from M'hich  they spring;  are
tense from complete distention ; and have no tendency to spontaneous
rupture, so  firm  is  their  roof-wall.    When  abundant, they  may
coalesce.  Involution is accomplished by desiccation, and the forma-
tion of yellowish-brown  crusts, whose fall is succeeded in certain
cases by indelible scars.
   Several  variations from the type thus described require  notice.
The vesicles may be few and  typical;  numerous, abortive, aud transi-
tory ; or differ  in  type as they  may  be  transformed into  veritable
pustules or bullae, or become  filled M'ith blood from capillary haemor-
rhage.   In the latter event there  is still further departure from type
in their tendency to spontaneous  rupture and subsequent ulceration.
According to  Kaposi, it is in such  cases only that cicatrices form;
but  this statement, in view of many clinical observations,  must be
accepted with reserve.
   Authors  have  established a number of clinical  varieties of the
disease merely differing as to symptoms, such as acute febrile, apyretic,
subacute, and even chronic and  recurring  forms.   A bluish appear-
ance of the eruption in some parts has suggested  the name " black
herpes ;" blood in the vesicles, a  hemorrhagic  form ; and the occur-
rence of gangrene has added  an additional distinguishing term.
   The anomalies of nervous significance are: extraordinary persistence
of neuralgia after the involution of the cutaneous lesions; neuralgia
of an  intense and intolerable severity at   any  period of the disease;
painful anaesthesia of the skin ; paretic and paralytic phenomena with
resulting muscular atrophy ;  and, in zoster of the head, dehiscence of
teeth aud hair.
   The vesicles of herpes zoster are ahvays produced in  the areas of
integument supplied  by sensory nerves  proceeding from the cerebro-
spinal tract, a  circumstance which explains their usual  imitation to
a single lateral half of  the  body.   This limitation is rarely observed
exactly at the median vertical line of the  body, as  a few lesions can
usually  be seen surpassing  this boundary.   The terms zoster capitis,
zoster brachialis, zoster occipito-cervicalis, etc., are used to distinguish
the special regions involved in the disease.
   The fact  that the majority of  all cases  are  due to disease of the
ganglionic nervous system  and  not to disease  of the  spinal cord, 
211
DISEASES  OF  THE SKIN.
 explains the more frequent occurrence of zoster in the upper portion
 of the body.
   Individuals  are commonly  subject to but  one attack of herpes
 zoster in a lifetime, though, as usual for all general laMs, there are
 the few exceptions which prove the rule.  The same may be said of
 double attacks, those involving simultaneously the two lateral halves
 of the body, instances of which are  occasionally  recorded.  These
 may be complete and symmetrical, or multiple and not symmetrical;
 or bifid,  when there is simultaneous involvement of several branches
 of one nerve or of several nerves.
   Barensprung recognized the nine varieties  of this disease  named
 below, the difference in each having a purely local significance.

   Zoster  Capillitii depends upon involvement of  the  second
 branch of the fifth pair of nerves, and its lesions occupy the anterior
 and posterior portions of the scalp.

   Zoster  Frontalis occurs in the area supplied by the  supra-
 orbital nerve, which springs from the first branch of the  trigeminus.
 Its lesions extend from the upper eyelid to the  vertex, and are spread
 in a fan-shaped figure  over one-half of the brow, forehead, and scalp.

   Zoster Ophthalmicus may be a severe and  dangerous manifes-
 tation of the disease, being often complicated by agonizing neuralgia,
 formidable involvement of all  parts of the eye even  resulting  iu
 panophthalmia, ulcerative keratitis, pyaemia, meningitis,  aud  death.
 Typical  cases of zoster of this region may not,  however, exhibit  a
 single outward  symptom  of the disease.

   Zoster Facialis depends upon involvement of the sensory nerve-
 fibres of the trigeminus distributed  to the face, its lesions being
 displayed over  one cheek, the  side of the  nose, the half of the lip,
 or  of the chin.  The facial and  seventh  nerves  may  be chiefly
 affected.   Care  must  be  taken  in  cases of this  variety not to  con-
 found the disease upon the nose M'ith acne, or painful tertiary syphil-
 itic lesions, errors which  have occurred.   When  the lower jaw is
 involved, there  may be severe  toothache, dysphagia, and fall  of the
 teeth  with great resulting deformity.

   Zoster  Nuch^ seu  Collaris occupies the region extending
 forward from the cervical vertebrae to the clavicle, or upward toward
 the occipital region and the auricle.

   Zoster Brachialis occupies the region from the last  cervical and
 first dorsal vertebrae over  the supra-spinous  scapular region and the
contiguous  portion  of  the uper arm.  Rarely, even the skin of the
fingers, and  that over  the first  and second ribs  is involved.   It is
 a common  and  usually mild form  of the disease, and characterized
by a peculiar isolation  of the vesicular groups.   It occurs also  M'ith
lesions of exclusively brachial distribution. 
HERPES  ZOSTER.
215
  Zoster Pectoralis is the most frequent form of the disease, from
M'hich its common name "shingles" originated.  The eruption occurs
below the first dorsal, covering  the skin of the thorax as far  as  the
lumbar  vertebra1, extending from the spinal column behind  to  the
sternal region in front.   Two, three, or more of the intercostal  nerves
in this region  are commonly involved, and the neuralgia resulting  has
been frequently mistaken for the pain of a pleurisy.  Children  are
more apt to display this than any other variety of zoster.

  Zoster Abdominalis.—The area  here involved extends from  the
lumbar  vertebrae  to the median  line of the  abdomen.   It is  usually
much less pronounced in its features, and the exanthem less abundant
than in  the variety of the disease last described.  AY hen constipation
exists, defecation  may be attended with considerable pain.

  Zoster  Femoralis covers the buttocks and sacrum, and extends
along the  thigh, sweeping from  behind  forward and from above
downward as far  as the popliteal space;  in  some cases involving  the
leg  and  foot.  The  penis, scrotum,  labia,  vestibulum vaginae, and
anus may then exhibit unilaterally arranged vesicles.

  The  scars  left  by zoster are characteristic.   Not  only are they
limited  to  the seat of the origiual disease, but they have a peculiar
indented look, as  if made by  a nail-sett  and hammer.   They  are
particularly angular  in  outline, and  do  not exhibit the dead-white
color of many cicatrices.
  Etiology.—Herpes zoster occurs in  both sexes, and in the young as
well as the old, though it is rarely seen among infants.  It seems to
be somewhat under the  influence of  the seasons, as cold and damp
weather serves to increase its frequency in those susceptible to  it.   A
large list of other depressing agencies are  named as  effective in its
production, such as:  certain poisons, carbonic acid gas, belladonna and
atropine (Mackintosh), arsenic (Baker,  Dyce Duckworth, Hutchin-
son); pyaemia, carcinoma, fever (Gerhardt), pulmonary  inflamma-
tions (including phthisis), septicaemia, haemorrhages, traumatism, and
malaria.  Inasmuch  as no one of these causes can be  cited  as cer-
tainly effective in all  cases, it  can  merely be said that any influence
sufficient to induce inflammation of  a sensory nerve or its ganglion
mav be  folloM'ed  by the objective signs of the disease.
  Pathology.—The  researches  of  Barensprung,  Payer, AYagner,
Charcot, Kaposi,  and others have demonstrated with sufficient clear-
ness that in zoster there is always, at some point in the corresponding
nervous tract (cerebral or spinal centres, ganglia, or the nerves them-
selves), pathological changes.  These are: enlargements, hemorrhagic
effusion, separation, softening, or destruction of the nervous bundles,
with  hyperemia, infiltration,   and  multiplication of the elements
M'hich surround the latter.
  Sometimes the  ganglia and  nerves  are  both reddened and sMollen
at the site of the  inflammatory affection; at other times the ganglion 
216
DISEASES  OF  THE  SKIN.
alone  is large  and  soft, or  fatty from metamorphosis of its cells.
According to Curshmann  and Eisenlohr, the  process may begin  in
the bloodvessels of the nerve-sheath, as well as  the  peri-neural con-
nective tissue, the nerve substance being quite intact.  This is termed
acute nodose peri-neuritis,  as  small nodules were recognized by them
in one case along the  cutaneous branches of the .axillary  nerve.
Lassar,1 in a  post-mortem examination  of three cases, found the
nerves thin, flattened, and  of a transparent  reddish-gray color  con-
trasting with the normal M'hite.   There had been desquamation  to
the extent of replacing the normal  structure  M'ith connective-tissue
elements.   Similar changes M'ere  recognized in ganglion  cells and
fibres.
                               Fio. 37.
                                               d
e                                    d
 Longitudinal section of the third spinal ganglion of the right lumbar region from a case of lumbo-
inguinal zoster.  a,a, ganglion, the black points correspond with pigmented ganglion cells, the dark
lines to engorged vessels; a,b,c,d,e, fatty tissue surrounding the ganglion ; b,b, nerve filament divided
longitudinally at the points of entrance and exit; at c,c, divided perpendicularly.  (After Kaposi.)

   According to Biesiadecki and Haight, the cutaneous lesions  origi-
nate in the deeper portions  of the rete,  precisely as in other vesicular
diseases.   The exudate from the  hyperaemic  corium, especially its
papillary layer, presses upward into the rete, the epithelia of which
are thus  separated  and vertically elongated.    The  serous exudation
finally reaches a point where  the horny layer is forcibly raised from
its bed to form the roof of the  vesicle.    The mechanical destruction
of the papillary layer of the corium by the hemorrhagic or purulent
contents  of  the  lesions  results  in a solution  of continuity, which  is
healed only  by granulation and the necessary formation of a cicatrix.
   Robinson, also, studying the same phenomena  in the  skin, finds
the epithelia lengthening into bands  by tension, the lacune betM'een
them distended M'ith serum and a few round cells.   Often  the vesicles
form about the hair-sacs.   As the  exudation  increases, the rete cells
1 Ctblt. f. d. Med. MTis*eiisch., Dec. 1883. 
HERPES ZOSTER.                    217
are progressively separated, and finally discovered free in the exuded
fluid, though some, in changed form but still  connected, may be
found in the upper part  of the  vesicle.   Except at the margin, the
mucous aud horny layers are separated  by the exudation.   At first
many-chambered, the vesicle represents finally a single chamber filled
M'ith  scrum  containing rete-cells and a few pus-cells, the latter in-
creasing in number as the vesicle changes  its type.   Its base at first
rests  upon  the  lower portion of the mucous layer; later, upon the
corium  itself M'here all signs of papillae are absent.   In the vicinity
of the vesicle the papillae  and corium are infiltrated, and the vessels
dilated, this  peripheral change not extending  deeply iuto the corium.
Beyond this area, however, which is infiltrated in a columnar-shaped
region,  usually about a hair-follicle  dee-,) in the subcutaneous tissue,
Robinson has  recognized  a peri-neuritis characterized by a round-
celled infiltration within and around the neurilemma.
   Diagnosis.—The vesicles of herpes zoster are not rarely confounded
with those of eczema.  But the distinction  betM'een the two is ahvays
very readily established.   In eczema there is itching but no  neur-
algia ; vesicles which tend to rupture spontaneously, and never per-
sist as in zoster;  the eczematous lesions are  also smaller, more acu-
minate, and rarely distinctly limited to the lateral half of the  body.
Herpes  simplex  is frequently recurrent, herpes zoster almost never;
herpes  simplex is exceedingly  liable to spread around the  mucous
outlets of the body, and on either side of the  latter, while zoster only
reaches such regions  after extension from other parts, aud  is then
almost  invariably monolateral.   Its  lesions are,  moreover,  never
grouped in  the concentric circles of  herpes  iris.
   Treatment.—The indications to be met in the local treatment of
herpes zoster are the protection  of the vesicles from  rupture, and the
relief of pain.   These ends are best accomplished by thickly  dusting
the entire surface affected, M'ith an opiated powder, such as Anderson's
powder, with  the sulphate of  morphia, two grains (0.133) to  the
ounce (32.); lycopodium with powdered opium, etc.  Rupture of the
lesions  should never be practised.   Over the whole should be gently
laid a sheet of soft lint  or antiseptic cotton, its meshes also  filled
with the  powder, and a bandage, M'hen  practicable, smoothly bound
over  the whole.   In the  milder cases, nothing more than this is
needed  from first to last.    In others, where the lesions have rup-
tured and their  bases undergone erosive or ulcerative changes, the
oleated  lime-water with zinc oxide, belladonna and opium or morphia,
should  be applied and covered with  the Lister protective.  Carbolated
and anodyne ointments may also be used, especially toward the latter
part of the  history of the case.
   Lotions may  be employed of lead-water  and laudanum, or  the
"lead and opium wash."   Yau Harlingen recommends half an  ounce
(16.) each of the precipitated zinc carbonate, powdered zinc oxide, pow-
dered starch, and glycerine, shaken  up in half a pint (256.) of water.
   Duhring  speaks well of collodion M'ith morphia, in the strength of
ten graius (0.666) to the ounce (32.).   Kaposi warns against the use  , 
218
DISEASES  OF  THE  SKIN.
of the diachylon ointment.   Generally, it may be said that ointments
should  be the last resort;  but those  containing from ten to twenty
grains (0.66-1.33) of the aqueous extract of  opium or belladonna to
the ounce (32.) will  at  times give relief from  pain.   The oleate of
cocaine and menthol have been used  locally M'ith great advantage in
meeting the same indication.
  No  remedy, for internal use, is  known  to  have  the poM'er of
aborting or shortening an attack.   Quinine is certainly indicated and
does no harm; but  quinine and  strychnia alike in full doses have
proved quite inefficacious.    Other remedies  employed are the phos-
phide of zinc  in one-third  of a grain (0.022) doses, repeated every
three hours, and, if indicated, in combination M'ith one-sixth (0.011) of
a grain of the extract of nux vomica;  arsenic (Kaposi); and the tonics
in general.   Anodynes, orally  or by hypodermatic injection, are often
indispensable.   Inasmuch  as  many  patients consider  the attack  a
trivial matter, it is of some  consequence  that they be warned of the
possibilities of the future and be confined to an apartment of equable
temperature where  they are  not  exposed  to atmospheric changes.
This is of special importance in all the zosters of the face. A skilled
oculist should  be consulted  in all cases iuvolving the eye.
  Prognosis.—Zoster usually  runs  a benign course,  but it should
never be forgotten by the practitioner that the prognosis may be in
the highest degree grave.   Many severe  cases have occurred, M'here
the patients, after years  of  intense suffering,  have resumed the occu-
pations of life, physical  M'recks of  their former selves, their faces
indented with  profound scars,  and  the vision  of one eye impaired or
utterly ruined.   Rarely the termination  is fatal.

                   Dermatitis Herpetiformis.
Dermatitis Herpetiformis is a rare  but weil defined  febrile disorder, character-
  ized  by the appearance  upon the skin, of multiform lesions, ditfering in
  different cases, macular, papular, vesicular, pustular, or bullous  in  type,
  attended by subjective sensations of itching and burning, the disease at
  times being grave in character and fatal in termination.
   Dermatitis Herpetiformis should be named  Dermatitis Multiformis,
as the  latter term  is more descriptive  of its phenomena.   It  is  a
malady which, in one form or another and under different titles, has
long been recognized and described.   The credit, however, of clearly
establishing its identity, and of recognizing one  process as differently
expressed in the several observations of others, is largely due to Dr.
L. A.  Duhring, of Philadelphia.1
   It  should be  noted,  at  the outset  of the   study of this malady,
that, its identity  as a special  pathological  process having been only

  1 Dermatitis Herpetiformis; its relation to so-called Impetigo Herpetiformis.  Amer. Journ. of th&
Med. Sci., October. 1884.
  Dermatitis Herpetiformis.  Case of, caused by nervous shock, etc. Ibid., January, 1885
  Case of Dermatitis Herpetiformis, illustrating the pustular variety of the disease.  Journ. of Cutan..
and Ven. Dis., vol. i., No. 8.
  Case of Dermatitis Herpetiformis with peculiar gelatinous lesions.  The Med. News, March 7, 1885..
  Notes of a Case of Dermatitis Herpetiformis, etc. X. Y. Med. Journ., November, 1884.
  A Case of Dermatitis Herpetiformis (Bullosa)  N. Y. Med. Journ., July, 1884. 
DERMATITIS HERPETIFORMIS.
219
 lately established, much  investigation  is yet required before settling
 definitely many of the interesting questions it presents for considera-
 tion.   I hihring regards  its vesicular and bullous forms  as identical
 M'ith "herpes circinatus bullosus" (E.Wilson);  "pemphigus  pruri-
 gineux" (Hardy); "herpes gestationis" (Milton, Bulkley, and others);
 "pemphigus" (Klein);  "pemphigus  circinatus" (Raver);  "herpes
 phlvetaenodcs"  (Gibert); "pemphigus aigu pruriginosus" (Chausit);
 "herpes iris" (Jarish); "fatal pemphigus-like dermatitis" (Mayer);
 "peculiar   skin  eruption  recurring during  pregnancy"  (Oswald);
 "bullous eruption  of a  peculiar  character" (Leigh);  "pemphigus
 compose"  (Devergie); aud  "hydroa" (Jones, Bulkley, and  others).
   Symptoms.—The  disease is usually announced by malaise, sensa-
 tions of chilliness, decided rigors or alternations of cold and hot sensa-
 tions, with systemic  disturbances.   The  skin  usually is then  the
 seat of pruritic or burning sensations followed in the course of from
 twelve hours  to two days by the appearance of the exanthem.   This
 may be macular, papular, tubercular, vesicular, pustular, or bullous, in
 type; combinations  of these lesions  recurring  in  every variation.
 The lesions may be cutaneous, muco-cutaneous, or mucous in situation.
   The macular form  of  eruption appears in small-coin to palm-sized
 patches, irregularly  rounded,  coalescing, well or ill-defined as to
 outline, and slightly raised, suggesting the lesions of erythema multi-
 forme or urticaria.   Imperfectly defined maculo-papules, papules, and
 papulo-tuberculous  lesions, varying in shape, size, and firmness may
 also  spring from or  be  intermingled with  the  reddish maculatious
 described above.
   In typical  development the  disease, however, presents  cutaneous
 symptoms of herpetic type.   Flat, slightly  elevated, hard, angular,
 irregularly outlined  vesicles  may  appear,  pin-head to  bean-sized,
 tensely distended  M'ith their contents.  They may be pale-yelloM' or
 darker in color, and  M'ith  or without areolae.   When bullae form, they
 may  be sparse or plentiful, and beau-to egg-sized, with cloudy, lactes-
 cent, hemorrhagic  or purulent contents.   Pustules, when  present,
 are  single  or clustered,  pin-head  to bean-sized lesions, flat,  and
 surrounded by a livid  areola.   AVhen evolution is complete, segments
 of rings, or distinct  rings of* new punctate or large pustules surround
 those first  formed, which in less  than a week rupture and  become
 covered with  a crust, the latter  being flat, adherent, and yellowish,
 greenish, brownish,  or blackish in  color.   When there is coalescence,
 a  large coin-sized pustule and crust  may  result,  and  even large
 patches of such coalesced lesions.  The lesions may  number  from a
 score or fcM'cr to hundreds.
  The  imprint  of  the  cutaneous  symptoms is multiformity  and
 recurrence.  Vesicles, pustules, and bullae, without order or regularity
 of evolution or recurrence, appear  at one  and  the  same time, in
 rapid or slow succession, and without fixed intervals of appearance
 for months at a  time.   Generally, however,  a  prevalence of  one
special  tvpe of  lesions may be  noted during a single period of out-
break or recurrence.   This prevalence is  in the direction generally 
220
DISEASES  OF  THE  SKIN.
of lesions of an herpetic type, viz., the vesicular and  the bullous, iu
variously sized patches xvitli a tendency to coalesce.
  As a  result of the conditions described  above, a  peripheral  new
formation  of lesions  tends  to  produce marginate  patches  M'here
grouping occurs, the groups, however, being interspersed  M'ith  dif-
fusely disseminated lesions of various types.   The irregular, angular,
or stellate forms of the lesions containing fluid, are highly suggestive.
Pigmentation and infiltration of  the skin  are commonly noticed.
The subjective sensations of  burning, increase and diminish as cuta-
neous lesions are multiplying or disappearing.  The pruritus is  in
some cases more severe than  in eczema, and  the traumatisms  of
scratching add greatly to the multiform features of the disease.
  The disease lasts  for  months  and  years.   Duhring reports some
cases lasting for five to fifteen years, with  periods of relative or entire
immunity.
  Iu one of Duhring's cases  there were thumb-nail sized, raised but
flat, golden-yellow colored lesions, of very firm  consistency,  con-
taining a similarly colored, thick, consistent, gelatinous pulp.   The
author states that he has observed them before in several cases  of
this same disease.
  When  the oral cavity is invaded, pustules and bullae appear upon
the  mucous  surface which,  being macerated and sodden, rupture,
leaving raw erosions and unhealthy looking, even sloughing patches
of mucous membrane.  Crusts form  about the nares  aud lips, and
the stench of the patient becomes intolerable.   In the same M'ay the
vulva, anus, and prepuce may be surrounded by vesicular and bullous
lesions which form also on the mucous surfaces adjacent and pursue
a course  similar to that recognized in  the  mouth.
  In grave cases, as the skin symptoms exhibit a  marked  aggrava-
tion,  the systemic  condition changes for the worse.   After  a  low
fever alternating M'ith chills and accompanied  by progressive cachexia
and emaciation, an  intermittent  diarrhoea or pneumonia  may close
the scene.  The repulsive appearance of the patient at the  last is,  in
severe cases,  as formidable as in the fatal issues of confluent variola
or severe pityriasis rubra.
  The etiology, pathology, and proper rnede of treatment of this dis-
ease are  not yet fully understood.  In some cases disorders  of the
nervous  system  must be  admitted  as  efficient in  its production.
Duhring reports a typical case following nervous shock.  One  of my
patients  had  lost a  number  of children  by accident.   The disease
occurs in early and middle adult  life in both sexes, though in women
decidedly oftener than in  men;  and, among the  former,  preferably
among those  in the puerperal aud pregnant  states.  Unquestionably
the phenomena  of the disease in the later  stage of  fatal  cases are
septicaemia in origin.
  Internal treatment in general has been  directed to meet the indica-
tions presented.  Thus, quinine,  the  mineral acids,  ergot,  saline
laxatives, iodide and  bromide of potassium, arsenic,  and chloral, 
PSORIASIS.
221
have  all been administered  without appreciable  effect upon the dis-
ease.   Locally,  carbolic acid, tar lotions, the unguentum diachyli
albi  of Hebra,  mercurial  and  zinc salves have  all been employed.
One of Duhring's patients experienced great relief from the use of
a sulphur ointment.  Tmto  of my patients M'ere treated M'ith very
great comfort to the end in the continuous M'arm-M'ater bath.
  The  prognosis is always doubtful  and  generally grave.   It is not
certain that the disease is ever completely  relieved.   A male patient,
seen by me in  consultation  and then presenting  the typical features
of the disease, M'as reported  well  after one year.

                            Psoriasis.
                          Gr. ipupd, the itch.

Psoriasis is a cutaneous disease, acute, or, more usually, chronic  in course,
  characterized by masses  of whitish, lustrous, and adherent scales, in pin-
  head sized agglomerations  upon the surface  of the skin, or in larger disks
  resting upon circumscribed, usually  circular and  reddened patches of
  epidermis, which are readily  made to bleed.

  Symptoms.—In Psoriasis, also  termed  Lepra,  Alphos, and  Psora,
the primary lesion  is a punctiform macule of reddish-broMii  tint,
always, at the  earliest moment of observation, covered with a  deli-
cate,  whitish, epidermic  scale.   When this is removed even by gentle
scraping, one or more minute droplets of blood exude from the points
beneath M'hich lie the vascular papillae of the corium.  When several
or many such small points arc visible upon the surface, the disease is
called Psoriasis Punctata.
  Should the disease progress to fuller development, patches of larger
size form, ahvays m ith a definite contour, very slightly elevated above
the  general level  of the integument, and  covered  with whitish,
mother-of-pearl-colored  scales in abundance.   When these are about
the size of drops of water,  the disease is termed Psoriasis Guttata.
  In yet more  advanced  conditions of the disease other names are
employed, all from the external configuration of  the patches, none
having any pathological significance.  Thus  Psoriasis Nummularis
is characterized by coin-sized  patches ; Psoriasis Circinata or Orbi-
cularis, by patches where  the disease is actively exhibited  at the
periphery of a  circle, in  the centre of M'hich the scales have dis-
appeared; Psoriasis Gyrata and Figurata,  by coalescence and
extension  of several patches, forming thus fantastic figures covered
M'ith  gravish-M'hite,  imbricated scales; and  Psoriasis Diffusa,  by
much more extended and  uniform involvement of the skin in large
areas.
  The  greatest variation is exhibited in the progress of the disease,
and to this  point special  attention should  be directed.   Thus, in a
single individual the  eruption may appear upon  one or more regions
of the body in the form  of the punctate lesions described above, and
thereafter regularly progress through the degrees suggested  by the 
222
DISEASES  OF  THE  SKIN.
list of names given above, till the entire surface of the body is com-
pletely covered from the crown of the  head to the sole  of the feet.
This is fortunately rare.   More often  the eruption  tends to remain
stationary M'hen  one  or another of the  less extensively developed
phases of the disease has been displayed.   Thus the patches may be
at no time larger than a silver quarter  of a dollar, and though very
numerous, fail for years to extend beyond such  a limit.  They may
even persist for a longer period in even smaller dimensions, or, M'hat
is perhaps more common, occur in guttate forms upon the chest, and
in patches as large as the palm over the knee or sacrum.
   The sites of preference of the disease are over the extensor surfaces
of the extremities, especially about the elbow and knee, where it is
decidedly most  common.  After these  locations should be named in
order, the region  of the sacrum (M'here often the  largest patch upon
the body can be discovered), the upper surface of the chest, the seal]),
the face, the belly, and  the genitals; more rarely the hands and feet.
   The disease is essentially chronic in its  course,  is never contagious,
and the efflorescence does not usually awaken any subjective sensation.
Its features are so pronounced in typical cases that  its recognition is
facile,  after appreciating the number and distribution cf the patches,
their clean-cut outline, the unaltered integument between, the lustrous
and shining scales, and  the red border of the skin M'hich  may crop
out from beneath the squamous thatch above, or be completely hidden
by the latter.   Rarely a single isolated  patch betrays the existence of
the disorder.
   When  the disease  is  acutely spreading  over the  surface  it has
occasionally a different expression. This is often seen in young adults.
The patches are perhaps as large as the section  of a hen's egg ; dark
or  lurid-red over the whole;  covered  with  a  more uniformly con-
stituted, thiu, squamous film, or  sheet of  semi-transparent  delicate
membrane,  through M'hich the red glare  of  the  patch beneath  is
visible.  This condition  may also be seen in young  persons to whom
arsenic has been administered  for the relief  of the  disease, with the
production of irritative effects.
   In its indolent moods, the color of the  patch varies somewhat with
the hue of the patient's complexion.  Blonde women with flaxen hair
and clear tint of the integument, often exhibit singularly waxv-whitish
patches, decidedly differing  in color from those  occurring  upon the
muddy and greasy integument of  certain  dark-skinned men.
   The scales are usually abundant, and may adhere M'ith considerable
firmness to  the patch, or, more frequently,  be shed freelv from the
surface, in pronounced cases powdering the clothing of the patient or
the sheets of the  bed upon M'hich he reposes at night.
   There is never at any time in the course of the disease, the appear-
ance of other lesions or their sequelae, such as vesicles, pustules, crusts,
papules, tubercles, ulcers, or any discharge-feature.   The eruption is
dry from first to  last.   Exception only may be made in the  case of
patches occurring M'here motion of the  skin  produces fissure, an acci-
dental and by no means characteristic  complication.  The same may 
PSORIASIS.
223
be said of certain acute symptoms, especially developed in young and
tender  skins,  M'here considerable  redness,  occasionally  M'ith  an
erythematous halo, appears in and about individual patches, M'ith the
production  of itching,  heat, burning, pain, or  other disagreeable
sensations.
   The  involution of the disease is evident  in a  gradual cessation of
the scale-formation and  the exhibition of a normal  epidermis M'hich
gradually spreads from  the centre, or is  at  once  perceptible over the
entire surface of the patches.  No cicatrization results.
   Upon the scalp, plaques of well-defined contour, covered with thick
whitish scales, may  mat the hairs together, but alopecia almost never
results.   The dry condition of these scales contrasts M'ith the greasi-
ness of the crusts formed  in seborrhcea  of the scalp.  Often a fillet
or band of  diseased tissue, one or more inches in width, projects be-
yond the  border-line of  the  scalp and forehead.   When the vertex  is
bald from physiological  loss of hair, the patch  of  psoriasis usually
lingers  near the fringe of the hairs left at the sides of the head  pro-
jecting  thence to the regions of baldness.   On  the  face  as  Mell as
over the  genitals, the lesions are  usually both indistinct and small-
sized, displayed, as regards the former locality, over the cheeks, chin,
and nose, avoiding the parts  near the mucous orifices.  When there is
much vascular congestion, especially of the passive kind, the patches
assume a  violaceous or purplish  tint.   All forms of lesions are seen
upon the trunk, especially the  dorsum  and  near the sacrum ;  the
patches, in well-marked cases, encircling the  body in  ill-defined  par-
allels reaching from the  spine forward.   The hands, feet, fingers, and
toes are not often involved, and the palms and  soles only so rarely
as to throw doubt upon  a diagnosis based upon  the existence of the
disease  solely in these regions.   In severe cases, the  nails are second-
arily  involved, being thickened, eroded in points, irregularly lamin-
ated,  ridged, and  becoming  brittle and yellowish-M'hite or dirty-
whitish :n color.
   The amount of scaling varies greatly in different persons and in the
same individual; sometimes the scales are abundant and thickly heaped
up over even small areas;  sometimes they are sparse over large areas.
In acute febrile and other intercurrent diseases, the disorder may fade
or disappear.   Where the epidermis is thin, the scaling is less ; there-
fore, in youth, over flexor surfaces, near  the  mucous orifices,  and on
the back of the hands, the scaling is less than in advanced years, over
extensor surfaces, in  regions remote from the mucous orifices,  and on
the palms and soles.   The disease may be for years limited to two or
three  continuously existing  patches, or, what is  far  more common,
recur at irregular intervals and under varying circumstances.  As a
rule, it  is  worse in winter and in cold climates, though patients may
demonstrate the reverse of this rule.
  The scales may display instead of a lustrous M'hite, a deep yellowish
shade, and instead of being imbricated, form a thin continuous sheet
of exfoliated epidermis.  When the disease is disappearing, the scales
fall, leaving a pigmented or slightly discolored patch of integument. 
221
DISEASES  OF THE  SKIN.
  A rare  ultimate  termination  of the disease is  the formation of
verrucous  groMths  in the  psoriatic patches, M'hich  later become
epitheliomatous.1  At times the eruption is  the  source of excessive
annoyance, being the seat of intense  pruritic  aud burning sensations
of a persistent type.
  There can be no question  that intermediate forms betM'een eczema
and psoriasis occur, in which it  is difficult to  determine  M'hether
the two disorders  coexist,  or the  one has assumed  the  features
of the other.   In these cases, there is itching and infiltration of the
skin,  with vesicular and  other  lesions foreign to psoriasis, and a
catarrhal discharge.
  Psoriasis is not known to  affect  the mucous surfaces.  The lesions
of so-called "psoriasis linguae," are those of "leucoplakia buccalis,"
of  "smokers' patches," of  syphilitic disease of the mouth, or flat
epitheliomata.
  Etiology.—The causes of psoriasis are not known.  As no external
or internal factors can be demonstrated to be effective in its produc-
tion, it is safest to conclude that these unrecognized  sources of the
affection are limited  to the  skin  itself.  The  disease  is neither con-
tagious, hereditary,  nor limited  to either sex, occupation,  or  social
condition.   It  bears no relation whatever to syphilis, eczema, gout,
rheumatism, struma,  or  dyspepsia.   It  appears in  the feeble  and
delicate as  in the most superb specimens of manly vigor and womanly
beauty.  Though not occurring in infancy, it  yet usually first appears
in early life.   Kaposi reports a single case  in which the eruption
appeared in the eighth month, and  Eliot, a case of first appearance at
the eighteenth month of life.   Under these circumstances, the question
arises :  Is  this  affection  of  the integument,  M'hen uncomplicated by
the disagreeable symptoms named  above, a disease or  a deformity'?
Certainly in a very large number of individuals, displaying through life
unchanging patches  M'here the characteristic  symptoms are the same
year after year, the ailmeut would seem  to  be more properly classed
with the deformities than with the diseases of the skin.  In point of
frequency,  the eruption ranks next after eczema.
  Believers in the possibility of the  transmission of  the disease  by
inheritance  are numerous,  and some of  them careful  observers.
Robinson goes  so far as to say, that in the "majority" of all cases
there is an  inherited predisposition to  the disease.  Others conclude
it to be an inherited or transmitted  form of  syphilis,  struma, tuber-
culosis, rheumatism, or gout.  Weyl  thinks that inheritance may
possibly be the sole cause.   Bazin  admits the existence of both an
herpetic and an arthritic psoriasis.
  Bearing  in mind  the  relative frequency of psoriasis on the one
hand, and  on the other  the strict tests M'hich should be applied jn
order to prove that  a disease is actually transmitted by heredity, we
find that the doctrine of heredity in  psoriasis fails  of establishment.
It is putting a low estimate on the  actual figures to state  positively
1 See Dr. J. C White's paper, American Journal of the Medical Sciences, 1885. 
PSORIASIS.
225
that there are more than one thousand psoriatic  patients in this
country,  no one  of  M'hose ancestors,  so far as  known,  ever had
psoriasis,  syphilis, or rheumatism.   They furnish too large a body of
evidence to be either  ignored  or set aside M'ith a word.   Thousands
of their children are  living to-day free for  years  from any evidences
of disease.  They, too, call for further proof on this point.
   It has  long been known that iu psoriasic subjects lesions may be
artificially developed in  the  lines of mechanical  irritation.   In this
way, figures in the shape of anchors, crosses, hearts, etc., have been
produced on the  skin  of psoriasic patients, one  of which has been
ingeniously photographed by Dr. Fox, of New York.1
   The disease is rather more common in male than in female patients,
and appears to be rare in the negro races.  According to Greenough's
statistics, it represents about two and a half per cent, of all cases of
cutaneous disease.  It  has  followed vaccination, scarlet fever, and
other diseases.
   Dr. Gowers alone  reports the artificial production of psoriasis  by
the internal administration of the biborate of sodium.   Allusion has
been heretofore made to this circumstance in the chapter on dermatitis
medicamentosa (q. v.).   Further evidence would be required to estab-
lish the fact that these results differed to any appreciable extent from
those recognized in any  squamous dermatitis produced by an ingested
drug.
   Pathology.—The  observations of Wertheim,  Neumann, Auspitz,
Kaposi, and Robinson,  of New  York,  are  substantially in  accord
respecting the  general character of the changes occurring in the course
of the disease, though they differ upon the question M'hether it depends
upon an  inflammatory or purely hyperplastic process.  So far as this
problem  is illuminated by clinical facts, it would seem clear that both
views are correct, the disease being at times unquestionably the result
of a  circumscribed inflammation; at others associated with a  simple
overgrowth of the elements of the epidermis ; and again at times with
an inflammation M'hich  the  hyperplasia  has aMakened.  There is
ahvays abundant development of the  epithelia in the rete, and, in
recently formed patches, distention of the blood- and lymph-vessels in
the papillary layer of the corium beneath.   In older plaques the rete
either dips doM'nward to an unusual extent  between the papillae, or the
latter push upMard in the manner of Mart-like prolongations.  It is
 reasonable to conclude that at times both hypertrophies concur. The
corium is thickened  later by  an increase of its elements which may
 involve its entire M'idth as far as the connective tissue.   In the older
plaques also the connective tissue elements are often separated by  a
slight serous infiltration.  Hyper-pigmentation  is also noted. The
external  root-sheath  of  the hairs in direct connection  with the rete
 participates in the same process, thus explaining the defluvium capil-
1 In his admirable Photographic Illustrations of Cutaneous Diseases.  New Tork.
                          Li 
226                DISEASES OF THE SKIN.

litii of certain cases, and the resulting transient  or  permanent bald-
ness.   The  sebaceous  glands  are  secondarily involved in the scalp
only.
                              Ftg. 38.
 Vertical section of skin from a patch of psoriasis of long standing.  31P, Malpighian prolongation ;
                   C, corium ; L, leucocytes.  (After Jamieson.)

  Lang,1  of Innsbruck, has  attracted  notice by  his  alleged dis-
covery of certain  fungous elements  in  psoriasis, M'hich he claims to
be the cause of the disease.   These  he finds in the whitish pellicle
beneath  the  superficial squamous  layer,  to which  Bulkley had
already called attention.  After stripping this pellicle or a part of it
from the surface, and  subjecting it to  the action of a five per  cent.
solution of caustic potash, the epithelium becomes translucent, and
upon  and beneath the latter double-contoured and  highly refractive
spores become visible to him.   Lang considers this to be a fungus of
the lowest species, different from any previously  recognized upon the
skin.   He terms  this " epidermo-phyton."  In  his  treatment of
psoriasis the author proceeds  upon the principles  M'hich  govern the
management of the other dermato-mycoses.   He considers that the
value of the remedies hitherto found most useful in the disease, such
as tar, carbolic acid,  chrysarobin,  and  the mercurials, owe  their

                       i Viert. f. Derm. u. Syph., 1878. 
PSORIASIS.
227
 efficacy to their destructive  action upon the  fungus.   He has  used
 with ailvantage a topical application of rufigallic acid in a salve, one
 part in ten.
   Weyl, who believes that psoriasis is due to  "an inherited Meakness
 of the nervous centres," has seen  Lang's " brood-cells," and  regards
 them as "myelin-like exudations;"  but this  position is disputed by
 both Wolff,1 and  Eklund,2 who  confirm Lang's observations, and
 believe the disease to be of parasitic origin.   They explain the  arti-
 ficial production of psoriatic patches in the  psoriatic  skin, by  sup-
 posing  spores to  have  been deposited beneath the  skin, and  not
 previously awakened to activity in the  sites of such experiments.
   Lassar3 has succeeded in producing a disease of the skin in  rabbits,
 by rubbing into various portions of their bodies, scales, blood, and
 lymph  removed  from  psoriatic patches in  a  male  patient.   The
 disease  thus induced is  capable of transmission to other animals.
 Campana, Tommasoli, and other Italian observers, have repeated
 these experiments, with the result  of  reaching  the conclusion  that
 psoriasis  is produced by a parasite as yet unrecognized.
   Diagnosis.—The recognition of a pronounced case of psoriasis is
 made with ease, and often  by those unskilled in cutaneous  disease.
 As usual, it is the atypical forms  of the eruption M'hich occasion
 doubt.   It is to be distinguished from

   Eczema.—Eczema and  psoriasis  differ in  a striking manner with
 respect  to their sites of predilection, and  their extension from such
 sites in progressive cases.   Eczema,  from the  head to the toes, elects
 the anterior surface  of  the bod}-, the  neighborhood of the  mucous
 outlets, the flexor faces of  the joints and  limbs, the crevices, folds,
 pockets,  depressions,  aud  protected angles of the skin.  Psoriasis
 elects the posterior  surfaces of  the  body, avoids the vicinity of  the
 mucous  outlets, spreads abundantly over the extensor  aspect of the
joints and extremities, and  enjoys the regions of pressure and friction,
 as the skin over the  patella and the olecranon process of the ulna.
 Psoriasis, covering the vertex and scalp, lingers at the brow, where
 its scaly  thatch stretches from side  to side  close to the line of  the
 hairs, and creeps more  indistinctly  down  the face on  either side in
front of  the ear, reluctant to spread over the cheeks, nose, and lips.
Eczema  easily  escapes from the scalp to the nose, lips, or chin; or
lurks in  the folds of the  pinna of the ear.   Psoriasis will  cover the
back  and  reach  forward in front  by almost  symmetrically disposed
parallels  in the  direction of  the ribs, M'hile eczema sweeps betM'een
and  beneath the  breasts or around the nipple.  Psoriasis will cover
the belly  and spare the navel and pubes M'here eczema may  originate.
As before stated, the largest patch of psoriasis on the body M'ill often
be discovered  over the sacrum,  while eczema creeps upward with a
diminishing vigor from  the  anus  betM'een  the cleft  of the nates.
Psoriasis  often  spares the hands and  feet, M'hich eczema punishes.

   1 Viert. f. Derm. u. Syph., 18S4.                 2 Annal. dc Derm, et de Syph., 18S5.
   ;i Deutsch. Med. Ztit., 1885, No. 93. 
 228                DISEASES OF  THE SKIN.

   In  individual patches  eczema  will  be  recognized  by its  severe
 itchiug; the scratching it excites ;  the history of moisture, discharge
 and crusting; its  ill-defined outline;  its asymmetrical  disposition,
 except upon the similarly irritated hands and  feet; and the  fewer,
 more  yellowish, smaller,  and less  lustrous scales M'hich characterize
 its squamous varieties.

   Favus  of the  scalp might be mistaken for psoriasis of the same
 region, but the occurrence of its sulphur-colored, cup-shaped crusts,
 the existence of the  parasite, the lustreless and brittle condition of
 the hairs, and a possible history of contagion, will insure its identifi-
 cation.  In psoriasis, too, the  hairs  are usually firmly attached in
 their follicles, while they are loosened in favus.

   Lichen  Ruber, though a very much rarer disease than psoriasis,
 must in cases be carefully recoguized  as distinct from the latter.  In
 it the lesions are  papular, distinct, covered by few scales, and these
 yellowish in color, never  lustrous.   There is ahvays a  constitutional
 impairment of health, and, when the whole epidermis begins to  break
 up in scales, a condition of well marked marasmus.   When scratched,
 the patches of the disease do not bleed.   Finally, lichen ruber tends
 to a fatal termination.

   Lupus Erythematosus.—In any doubtful case where cicatricial
 tissue  is discovered  in  the site of  a patch where  the disease  has
 existed, the diagnosis is  clear,  since psoriasis  never leaves a  scar.
 Lupus prefers the nose, the cheeks, and  other parts  of the face, com-
 monly spared  by  psoriasis  unless it be very  abundant elsewhere.
 The lupus scales are scanty, firmly adherent, yellowish,  and  attached
 to the orifices of the ducts of the sebaceous follicles;  those of psoriasis
 are abundant, lustrous, and  shed freely from the surface.  Lupus is
 never, like psoriasis, a generalized eruption;  and is  always  much
 more chronic in course.   There is a bluish and violaceous tint to the
 reddish patch  of  lupus  erythematosus, especially as it  occurs upon
 the face, while the  highly  colored  patches  of psoriasis are rarely
 facial, being more commonly seen on  the trunk  and  extremities,
 while the out-cropping disks on the face are the least colored of  any
 on  the, body.

   Pityriasis  Maculata et Circinata.—In  this disease  the
 patches are more oval than circular, and the scales much finer than
 in psoriasis.   It is, moreover, much more rapid in its career and does
 not recur.   When the branny scales are  removed, the surface  beneath
does not bleed.  The centre of the patch is usually tawny or salmon-
 colored.  The thoracic surface may also  be exclusively involved.

  Pityriasis  Rubra.—If  psoriasis  be in any case generalized, its
distinction from pityriasis rubra would be difficult, if not impossible,
on the basis of our present knoM'ledge.   Indeed, any such distinction
would  have  but  little   practical  value.   A  few typical  isolated 
PSORIASIS.
229
 patches of a psoriasic character would point to the origin of the dis-
 ease in any doubtful case.

   Skborrhcea.—This disease could  only be confounded M'ith psori-
 asis of the scalp.  But the last named affection is, in the vast majority
 of cases, exhibited  also in patches upon  other portions of the body
 M'here seborrhoea  is never seen.   Seborrhcea of the scalp also occurs
 in usually diffuse forms, the surface  beneath the crusts  being rather
 anaemic and pallid iu appearance, not  bleeding readily, as in psori-
 asis.   The crusts, too, iu  seborrhcea, are distinctly fatty and greasy
 when rolled betM'een the fingers, and have a dirty-yellowish hue, never
 rec< tgnizecl in the whitish scales of psoriasis.   Lastly, seborrhceic crusts
 may fringe slightly the line of the hairs at the  brow, but never form
 a band  an  inch or more in width, like  a frontlet covering the upper
 half of the forehead, a not uncommon development in psoriasis.

   Svphilis.—Psoriasis  does in  many cases  greatly resemble the
 squamous and papulo-squamous  syphilides.  The  necessity for a
 clear recognition of either disease  occurring in suggestive patches, is
 often of the highest importance.
   In syphilis  the greatest aid M'ill be  attained by a history in both
 sexes of infection, adenopathy, aud mucous patches ; and  of abortions,
 miscarriages, or still-births in women.  Psoriasis is a singularly uni-
 form disease;   syphilis  decidedly multiform in  its manifestations.
 The syphilitic  patches are less symmetrical, more elevated at the edge,
 and the scales with M'hich  they are covered, feM'er, smaller, and dirty-
 M'hitish, rather than lustrous in color.  In syphilis, the eruption is less
 generalized, and shares M'ith the other syphilodermata in the  brownish
 and purplish hues of the skin beneath, lacking the vivid redness and
 pinkish-red  of many non-syphilitic  lesions.   The scales of many of
 the syphilides,  which  resemble psoriasis,  partake of the character of
 crusts, being agglutinated  by pathological exudations from the patch;
 they are rarely so exclusively squamous as in psoriasis.   In syphilis,
 the tendency of the patch is to exhibit  an affected  surface somewhat
 beyond the  line of the scales ;  in psoriasis, the scales more frequently
 reach  beyond  the border of the  affected epidermis beneath.  The
 squamous syphiloderm of the palms and soles often occurs in these
 localities only.   Psoriasis  is extremely rare in such situations, and is,
 almost never,  limited to  that region exclusively.  A  psoriasiform
 circlet limited to the region of the mouth, nose, or chin, will generally
 prove to be syphilitic.  The disease M'hich has for a long time persisted
 in the production  of squamous patches can generally be demonstrated
 to be  psoriasis; as syphilis changes its type in the course of months.

   Tinea Circinata.—Here the discovery of the parasite, the his-
 tory of contagion, and the frequent  limitation  of the  disease to  a
 single  patch (a feature exceedingly  rare  in  psoriasis), will usually
 suffice to establish a diagnosis.  In ringM'orm of the  body the scales
are bran-like,  and more  abundantly formed at the  margin  of the 
230
DISEASES  OF THE  SKIN.
 patch where the fungus is luxuriant; while in psoriasis, the scaliness
 is  usually equally pronounced over the entire  area  of an invaded
 patch, unless the disease is in process of involution.   The occasional
 occurrence of vesicles and  vesico-papules at the peripheral border of
 the patch in  ringworm, is  never observed in  psoriasis.   RingM'orm
 is never generalized symmetrically ; and upon the scalp or beard the
 discovery  of brittle  and  broken-off hairs  should  always  suggest
 examination for the parasite.
   Treatment,—As the precise cause of psoriasis is still unknown, all
 treatment for the relief  of  the disease must necessarily be limited  to
 the removal of its objective features.   This treatment may be internal,
 with a view to the indirect action upon the skin, of the drug selected ;
 or  topical, M'ith a view merely to the reproduction of a  sound epi-
 dermis in the patches of disease.
   Arsenic enjoys the highest rank in the internal treatment of psoria-
 sis.   What it is capable of accomplishing in other cases, it can with
 best effect accomplish here.  Whatever failures must be charged to its
 account in the attempt to relieve  other  cutaneous eruptions, cannot
 safely be ignored here.
   The facts are these:  arsenic administered  internally is assuredly
 capable of relieving a certain proportion of cases of psoriasis.   Given
 improperly in any case,  it may be either powerless or manifestly in-
 jurious.  In a certain proportion of patients, most carefully selected
 as  fit subjects for its therapeutic action, arsenic will prove utterly
 valueless in the most skilled hands.  It cannot  be demonstrated  to
 possess the power to prevent recurrences of the disease, and yet the
 latter must  be recognized as one  exceedingly  liable to recur.   Un-
 fortunately, the proportion of cases in which  it will and in M'hich it
 will not, exhibit its happiest effects, is not known.
   The following rules for its administration are to be in general ob-
 served.  It should be given with  or immediately after the ingestion
 of  food, so that it may be commingled with  edible substances in the
 stomach.   It  should  be given at first in small  doses, M'hich are to be
 cautiously  increased.   The possibility of the production of  toxic
 effects should be remembered, and on  the appearance  of these the
 remedy is to be given in a  smaller dose, and  not completely discon-
 tinued unless  such a  course be imperative.  If its administration is
 once determined upon, the  arsenic should not be hastily withdrawn
 and another remedy substituted  for it,  but persistence for months
 should be enforced if no serious  objection  exist, lest  the time be
 wasted which has been  already expended  in  the effort to relieve the
 disease.
   Arsenic is unsuited for all cases of psoriasis occurring with rather
 acute symptoms, such as subjective sensations and unusually vivid
 redness of the patches.  It should not be given when the disease  is
 in process of evolution, and, therefore, not  in  psoriasis punctata and
 guttata, unless the lesions have been  long  limited to  patches of the
 sizes to M'hich these names are given.  For the same reasons it is often
objectionable  in  the psoriasis of the  young, for, though the druo- is
usually rather M-ell tolerated in such periods of life, it is, unfortunately 
PSORIASIS.
231
 in these also M'here the disease  is most often  encountered in its pro-
 gressive stages.
   The remedial effect of arsenic, M'hen such is obtained, seems to de-
 pend upon  the impression it exerts upon the rete, and that part of
 it especially which lies in connection with the derma. When the metal
 is injected subcutaneously, its first effects, according to Jamieson and
 Nunu,1 are indicated by the appearance of a faint narrow band along
 the  base of the  columnar  epithelia  immediately  next the corium.
 This is due to a softening of the protoplasm M'hich separates  the
 epidermal  from  the  dermal elements.   Subsequently,  the remoter
 epithelia are involved, the protoplasmic threads becoming obscure, the
 characteristic arrangement of the epithelia less evident, and the natural
 features of the rete distorted, so that it remains attached to the derma
 by tags and the prolongations M'hich it sends  down to the cutaneous
 glands.   Jamieson suggests that arsenic stimulates the epithelia to
 exhaustion, that layer which lies next the bloodvessels containing the
 metal first appreciating its effects.
   The preparation usually  employed  is Fowler's  solution, the most
 soluble of all, M'hose exhibition  should  be ahvays begun in doses from
 half a  minim (0.033)  to  three minims (0.20);  this  amount to be
 contained in a solution  of fixed and  relatively large dose, such as a
 teaspoonful  of the infusion of peppermint;  the  M'ine  of iron ; or
 dilute syrup  of gentian  or of orange blossoms;  or  the  compound
 tincture of cardamom with Mater.  AVhen  only remedial  effects  are
 obtained, such as  diminution of the scaliness, the close may be steadilv
 continued without change for long  periods of time, and  usually with
 advantage for some time after the symptoms of the  disease  have
 entirely disappeared.  When, M'ithont  the production of toxic effects,
 the eruption seems quite unaffected by  the treatment, the arsenic may
 be, very carefully aud always   under the direction  of the  physician
 only, pushed till twenty and even  thirty drops of the Fowler's  solu-
 tion [the latter equivalent to one-third of a grain (0.22) of arsenic] are
 administered at a dose.
   The constitution of the Asiatic pill  has been given in the chapter
 on general therapeutics.   The pill is less likely to be as M-ell tolerated
 by the stomach as FoM'ler's solution, but cases are on record in M'hich
 the psoriasis which proved rebellious under the administration of the
 liquor arsenicalis, Donovan's solution, and  other  internal  remedies,
 yielded to the influence of the arsenious acid in pilular form.  Hebra
 has given two  thousand Asiatic pills to  a single patient  before  the
 disease disappeared; and  in no instance  has  he seen any ill effects
 produced.
   AVith regard to  the vulgar opinion respecting the arsenic habit which
 a long  familiarity M'ith this dosage has  been supposed to beget, the
 author  considers  it a curious  circumstance that  he  has never  yet
 encountered such  an instance in a psoriasic subject M'ho Avas consum-
 ing arsenic. Patients M'ho for several consecutive years have, M'ithout

 1 See the paper by the former on the Ilistolocy of Psoriasis, Edinburgh Medical Journal, January,
1879, p. 027. 
232
DISEASES  OF  THE  SKIN.
interruption, pursued an  arsenical course, thus barely succeeding in
keeping their cutaueous ailment out of sight, will in many cases affirm
that,  apart from any trifling  and accidental  toxic  symptoms, and
those evident iu the course of the eruption, they would not be sensible
of the fact that they had  taken the drug.
  With an enlarging experience, one views M'ith greater distrust each
year the benefits to be  derived from arsenic  in  any untried case of
psoriasis.   The great possibilities of its failure,  of the  repeated re-
currence of the eruption, of the necessity of continuing the medication
for one or two  years, and  even after that period of time, of even then
witnessing a generalized  development  of the disease to  an extent
quite equal to that  exhibited  at  the  outset,  all these considerations
should certainly  have  some weight  in  the mind of an ordinarily
prudent man. .  Is the ultimate result in  such cases worth  the cost by
which it is obtained ?  In such cases certainly it would seem not. In
the others, where, under  a  judiciously directed arsenical  course, the
eruption slowly disappears and fails to recur, the value of the  treat-
ment is incontestable.  As before stated, the proportion in which these
two classes of  cases are related, is not known.   The patients iu the
last-named category, in  all probability, decidedly  outnumber  the
others.
  The course which, under the circumstances, seems preferable, is this :
Instead of resorting first to the arsenical dose and afterward to other
measures, the order should be reversed.  That psoriasis which fails to
respond to other treatment, may be finally subjected  to  the influence
of arsenic.  He who, having vainly tried  other approved measures,
essays at last the virtues  of this medicament,  ought certainly to ex-
hibit  no impatience while testing his case with  it.   He should be
willing to  try  it  fully and  fairly, and be of all  men  least ready to
exchange it for a less valuable substitute.  No  reference is here made
to the effect of conjoined internal medication with arsenic and external
treatment  by topical applications   However desirable it  may  be, in
the management of any individual case, to arrive at the desired end
by the speediest method, it is evidently needful, in order to assign to
arsenic its exact therapeutical value, to understand what it can accom-
plish  unaided by topical measures.
  As to the other remedies  employed internally for the relief of the
malady, a very fair estimate of their  value can be made by remember-
ing that arsenic is superior to them all.  If arsenic fails so frequently,
what  remains to be said of the other articles in the list ?  Phosphorus,
tar, copaiba, cantharides, colchicum,  and pilocarpine, have at times a
feeble or transitory influence over the  patches of the eruption, but
their  employment M'ill disappoint far more often than satisfy.  Iron,
quinine, cod-liver oil, and the salts of the alkalies, will fill important
indications in the treatment of certain  classes of patients, but these
are in the minority, as the eruption is often seen in perfectly vigorous
and otherwise healthy subjects.
  After the use of any one of these remedies, it is rare to recognize any 
PSORIASIS.
233
decided effect upon the cutaneous symptoms, even m hen patients in
M'hose case they were indicated, improve under their use.
   The same in general may be said  of the  use of dietary articles in
psoriasis.   As no ingesta save the substances  already named are re-
cognized as  influencing the eruption to any perceptible  degree,  the
diet suitable for a patient may be in brief described as that M'hich is
both M'holesome and nutritious.
   Most authors agree  upon the value of  a greatly restricted diet.
Acids,  alcohol, and fatty  substances  should  be  excluded.    Meat
should  be  sparingly supplied;  cooked  vegetables  and fruits may be
freely eaten.  Coffee, tea, and tobacco should in general be interdicted.
  _ Passavant, of Frankfort, on the other hand, claims to have cured
himself and others, by an exclusive  diet of meat.
   The arseniate of sodium in pill form and arseniate of iron have been
recommended by  Biell.  Lipp  has  injected arsenious acid subcuta-
neously.  Robinson advises the liquor potassae, the citrate or  acetate
of potassium, or the bicarbonate of sodium in plethoric and rheumatic
patients.   In the  gouty state M'ith excess of urates iu the urine,  he
advises:

        R. Potass, acetat.                Jj;          321
            Spts. aether, nit.             f.T^s;          16
            Vin. colchici                f.^ij;           8
            Syr. aurantii               f SJss;          48!      M.
        A dessertspoonful three times daily in  water after meals.

   The  influence of climate in  inveterate  psoriasis should never be
ignored.  It  has  been  already  stated  that many  patients who suffer
from repeated relapses of the disease are worse in m inter, and either
better or entirely  free from the eruption in summer.  For the same
reason, in  a mild climate,  M'here the temperature is uniformly regis-
tered at or near a point of maximum comfort for the skin, the disease
Mill be both infrequent aud less severe
   McCall Anderson believes that sea-air and sea-water are generally
prejudicial to psoriasic patients, but the statement  is disproved in  the
cases of hundreds M'ho have removed from  an  interior climate to the
sea-shore, solely M'ith a view to the benefit to be thus received.
   The external or local treatment of psoriasis requires patience, care,
and a certain degree  of skill.  Properly  conducted, its  results  are
reasonably satisfactory iu a large majority of cases.
   The  first  indication to  be met is the  complete removal  of the
epidermic scales from the patches, and this is accomplished in various
Mays.   It  is preferable to secure first their  maceration in some fatty
substance,  such as  one  of the oils, or glycerine, or vaseline, after
M'hich they may be Mashed off  by the  aid  of  soap and  Mater, in a
general bath if the eruption  be extensive.   If it  be localized,  these
oily or fatty substances may be spread upon pieces of lint or cotton,
and thus retained by a bandage in  contact with the skin.  The scales
may also be  speedily removed with the dermal curette, if thcv occur
in few patches, or if the latter  are  to be  found in  totality or part 
231                DISEASES OF THE SKIN.
 upon some portion of the body  where the  disfigurement  demands
 special  attention, as upon the forehead and cheeks.   The squamous
 masses  are also removable by water alone, as after maceration  of the
 skin  in a bath,  or after a profuse diaphoresis, or even moderate
 exudation of sweat,  if evaporation of the  latter be  prevented by
 covering  the affected part with oiled silk or  rubber cloth.  Usually
 there is no difficulty in removing these scales, patients often declaring
 to their physicians that  they can themselves cleanse  the surface, if
 they can be shown Iiom' to prevent the recurrence of the desquamation.
   Baths play an important part in the subsequent treatment  of the
 disease.   They may be employed, as  by Hebra, so that the patient
 remains in the water for  from four to eight hours in the day; or be
 medicated by the  addition of sulphur, tar, or other substances, so as
 to combine  a medicative with a macerative effect. In private prac-
 tice, these baths are much  less  available than  in hospitals.   When
 the eruption  is generalized and  an  excessive macerative  effect  is
 desired, the rubber clothing ansMcrs a better purpose.   In such cases
 an  undershirt and drawers  may be worn, made of soft rubber cloth,
 of the  size  of the undergarments usually worn by the patient, the
 latter wearing these for several  hours of  the day.  The sweating is
 often profuse and debilitating to such an extent that the  psoriasic
 skin will rarely tolerate  the treatment for an entire day, or  for even
 that part of it in M'hich active  labor is  performed.  By this  means
 alone, it will  at times  be found  possible to secure complete disap-
 pearance of the patches.
  In other more  obstinate cases, or in  those where  for any  reason
 such  treatment is indicated, as upon the scalp and  face, the sapo
 viridis may be employed with advantage in the  soap and Mater treat-
 ment.   The spiritus saponis kalinus [two ounces (60.) of the soap to
 one (30.)  of alcohol] may be briskly rubbed over the patches  by the
 aid of a piece of flannel or sponge, and then immediately washed oft
 M'ith the oil and scales in  a surplus of hot water, or be left for  a time
 in contact with the part.  Hebra  and Kaposi make use of  a species
 of soap paste, made by rubbing into each patch a small quantity of
 the green soap to M'hich a little water is added till the proper con-
 sistency is obtained.  These inunctions are repeated  tM'ice daily  for
 six days.  The epidermis becomes then  brownish-colored, and in
 three or  four days afterward  exfoliates in lamellae.   Then a general
 bath  cleanses the  surface.  In the French  hospitals,  a somewhat
 speedier method is pursued.  On the evening  of the first day, the
 patient  is anointed with  the green soap M'hich  he retains upon the
 skin during the night.   In the morning he takes an alkaline bath, and
 immediately after is thoroughly anointed M'ith lard.  This is  repeated
on the  second and third days, after  M'hich  the patient  is usually
 ready for any  topical medication of the diseased parts.
  For the yet more obstinate  cases in M'hich the exfoliation  of the
epidermis is  not  readily induced,  still more energetic measures have
 been  adopted, such as the local use of salicylic  acid in  alcohol, one
 drachm (4.) to four ounces (128.), caustic acids  and alkalies,  scrub- 
PSORIASIS.
235
bing the patches M'ith nail-brushes, floor-brushes, etc., and the use of
clean, M'hite sand.
   Once ready for  topical medication, the patches  may first be  sub-
jected  to  the local action of tar, a remedy which has enjoyed the
highest reputation  for the  relief of the  disease.   It Mill, however,
accomplish the  result desired, only M'hen  applied  so that it  is  Mell
tolerated  by the  skin.   In  very young patients,  as also in  those
M'hose skins  are tender and  irritable, or who are  suffering from any
of the acute  phases of the disease, it may prove decidedly injurious
by aggravating the latter.   The rule should be, ahvays to employ it
at first tentatively over  a  relatively small portion of the surface,
upon M'hich the medicament should remain for several hours, as tar
will not in all cases promptly produce its  injurious  effects.   These
are, subjectively, a sense of heat and pain; and, objectively, heat to
the touch, redness, and tumefaction of the part.  Often black puncta
are visible  when  the tar is lodged  in the orifices of the cutaneous
follicles,  simulating thus, the "black  head" of the comedo, a  con-
dition termed by Hebra,  "tar-acne."
   Pix liquida, the oil of cade, or  preferably the oleum rusci may be
employed, in the  form of a  salve, a  drachm (4.)  of either  to  the
ounce  (32.)  of lard or other  fatty basis (lanoline,  vaseline,  etc.).
A thin  stratum  of such  ointment may be, several times in the day
or merely at night, painted over, or well rubbed into a patch denuded
of scales.  In Vienna, a  still  more energetic effect is secured by
using the soft soap freely over the patches M'hile the patient is in the
bath, then anointing him  with tar, and  finally returning him to  the
bath M'here he  remains for from four to six hours.  For localized
eruptions, the green soap in combination M'ith tar and alcohol, serves
an exceedingly useful purpose, either in the proportion of equal parts
of the three ingredients, or by combining them in other proportions,
as, for example:
R. Saponis viridis	Siv;	130
01. rusci | Glycerin, j	aa 5j;	30
Of rosmarin.	Hjss;	7
Spts. vin. rectif.	Oss;	500
Sig. For external use.		
                                                             M.

   Other combinations  of service are Bulkley's  " liquor picis  alka-
linus," the formula for which is given in the chapter on eczema; and
Wilkinson's salve, as modified by  Hebra, the latter  combining the
remedial effects of sulphur, tar, and soap, as folloM.s:

        R.  Sulphur, sublimat.       j - -  -  .           16
            Ol. rusci [crud.vel. rectif.] j  '  **  '
            Saponis viridis  ]           -- -•            ,,,,
            .  ■}• •          r           aa .-,1 ,           ou
            Adipis         j              ,JJ '
            Cret. praeparat.             ^ijss;           3.5     XL
        Sig.  Wilkinson's salve modified.

   Where the  sensitiveness of the skin  to the  action  of the tar has
not been  tested, or M'hen the skin is  particularly tender, a small 
236
DISEASES  OF THE  SKIN.
 quantity of the Wilkinson salve may be added  to any simple oint-
 ment,  or Spender's ointment  of tar (see  the chapter  on General
 Therapeutics)  may be substituted for it;  afterward a  drachm (4.)
 of the oil of tar, or oleum rusci, to the ounce (32.) of oil of almonds
 or of alcohol, may be employed.
   When toleration is established, the tar  may be  rubbed  over the
 patches in a pure state with a stiff brush,  a  procedure preferred in
 some parts of Germany, after which the patient either remains for
 some hours in  bed, or is powdered M'ith soapstone and bandaged with
 flannel, so  that M'hen the clothing is replaced it may not adhere to
 the tar.  Naphthalin, ichthyol, and carbolic acid  operate in psoriasis
 in the same way as the tars, but are decidedly inferior to it.
   Absorption  of any tarry compound applied externally may result
 in  general toxic symptoms, including  fever, vomiting,  diarrhoea,.
 strangury, and elimination of the toxic agent in secretions which are
 blackened  by its presence.  These symptoms are usually relieved in
 from twenty-four to  forty-eight hours  after the discontinuance of
 the drug.
   Kaposi1 was first to employ beta  naphthol, the formula of which
 is C10H8O in  psoriasis (as also in eczema).   It  may be applied in
 alcoholic solution.   Under the employment of  a  fifteen  per  cent.
 ointment,  the  author  reported  speedy  disappearance  of psoriasic
 patches.   It did not stain the skin, hair,  or nails.
   Balmanno Squire,2 however,  reports  that  the  naphthol was, in
 certain experiments conducted by himself, without appreciable effect
 when used in the strength of from ten to twelve per cent., and  that,
 when he increased the  quantity  of the agent till  the  ointment was
 applied in  the strength of twenty-five and  even fifty per cent., there
 was the production of merely irritative effects.
   By many practitioners, chrysarobin or  chrysophanic acid is  placed
 above all the tars in  the local management  of psoriasis.   It is  a
 crystalline  powder of  the color  of old gold,  insoluble in water, but
 readily dissolved in hot alcohol, acetic acid, benzol, vaseline, and hot
 fat.  It is  derived from the "goa-powder" of the East Indies, or the
 " araroba powder" of Brazil, whose employment in psoriasis was first
 recommended by Mr.  B.  Squire, of London,  Eng., in 1878.
   In 1880 the author collected specimens of  this powder  from the
 leading chemists of  Boston, New York,  Philadelphia, and Chicago;
 and  finding  these to vary greatly, both as regards the color  of the
 preparation and the therapeutical effects induced, he has since largely
 employed the Brazilian araroba em po3 with better results.
  The drug is  best applied in the form of an ointment, varying in
 strength from half a scruple (0.666) to a scruple (1.333) to the ounce
(32.) of vaseline or cerate.  It is occasionally used  in greater strength,
but,  with pure  specimens, it is liable in larger proportions to produce
disagreeable  effects.   These are  declared in  a hot, itching, swollen*

        1 Wien. Med. Wochensch., May 28, June 4 and 11, 1881.
        2 Brit. Med. Journ., Jan. 14, 1882.
        3 This article was obtained from Messrs. Silva, Liniaos & Co., of Bahiu, Brazil. 
PSORIASIS.
237
irritable, and erythematous skin, stretching from the surface of appli-
cation, M'ith tolerable uniformity,  in every direction.    It is, even  in
the strength named above, necessary to begin  its use M'ith caution,
testing it by application first to a limited area of integument.  These
excessive effects usually subside in a few days.   An ignorant woman
to M'hom a chrysarobin ointment was given  in  1879,  with  directions
to test  it  carefully at first  by application  over the  elboM's of her
daughter, stripped the latter before an open fire, and rubbed the oint-
ment over the  entire surface for  the  space  of  half an hour.  The
result Mas an intense erythema lasting for six days M'ith considerable
distress, and the complete disappearance of the psoriasis M'hich did
not fail to reappear in eight months.
   When  the drug produces its most  brilliant effects, the psoriasic
patch, previously denuded of its scales, assumes  a m hitish and normal
aspect, contrasting  thus  somewhat remarkably  with the chocolate to
brownish-black discoloration of the  normal skin  at  the periphery.
This coloration, when produced either by the ointment directly or by
a frequent transfer of its ingredients  to other  parts by the medium
of the clothing and hands, involves also the nails, hairs, and under-
linen of the psoriasic patient.  Its employment upon the face and
scalp is thus largely interdicted.   The  staining of the skin and its
appendages disappears entirely in  time, but always sIomIv.
   An improved plan of using  chrysarobin  externally has  been sug-
gested by Fox, of  New York.1
   A  soft paste is made by rubbing the  chrysarobin M'ith a sufficient
quantity of Mater,  and smeared upon the psoriasic1 patches,  the scales
of which have been previously removed by one or more hot baths,
with soap friction.   As soon as the paste has dried, M'hich  it does in
one or two minutes, a layer  of collodion should be allowed  to flow
over  each patch, and to harden into a protective coating.    This will
remain in place for several days, or longer,  according to the location
of the patches; and when it falls, or is M'ashed  off, the application of
the powder and the collodion should be repeated.  By this procedure,
the chrysarobin in full  strength  is kept in contact with the affected
skin, and  prevented from exciting undue inflammation  of surrounding
parts, or staining the clothing.    A mixture of the powder and the
collodion may  be used, but it is less efficacious.   A film of collodion
doubtless  interferes with the action of  the  acid upon the skin.   A
someM'hat similar  plan consists in the  use  of  gutta-percha tissue to
retain a strong chrysarobin ointment in contact M'ith psoriasic patches.
The edges of this tissue will adhere tightly to the skin if a small
camePs-hair brush, dipped in chloroform, be passed rapidly beneath
them.
   More  recently,  following Auspitz's  plan, this same author has
combined these articles in a convenient form, by adding ten parts of
chrysarobin and ten of salicylic  acid  to  fifteen of sulphuric  ether

                   i The Medical News, March 18,1882, p. 289. 
238
DISEASES  OF  THE  SKIN.
and one hundred of flexile collodion.   This rapidly dries over the
psoriasic patch, M'here its specific effects are produced.
  Pyrogallic acid, first suggested as a remedy for psoriasis by Jarisch,
is inferior to chrysarobin.   The fact that several  deaths have now
been reported as consequent upon its use deters many from making
trial of it in a painless and merely disfiguring disease.   It is used in
a ten per cent, vaseline ointment; is effective, though less rapid in its
effect than  chrysarobin; is cheaper; is odorless and painless;  and
discolors to  a less extent  the sound skin.   Both remedies are capable
of being absorbed from the surface, and of producing  constitutional
symptoms, pyrexia, strangury, and blackish evacuations.  But in the
case of pyrogallic acid only, so far as is known, have these symptoms
resulted fatally.
  Crocker,  of  London,  similarly uses thymol  in  ointment, half a
scruple to half a drachm (0.666-2.) to the ounce  (32.); aud  Wil-
liamson advises turpentine two  drachms (8.) to the ounce (32.) of
olive oil,  M'ith the odor corrected by the oil of lemon.  Charteris
treated thus a  single limb  of a psoriasic patient,  which was subse-
quently wrapped in wool,  with  the  curious result of relieving the
psoriasis of  the other limb, possibly in consequence  of the absorption
of the  remedy.  The danger of strangury in such  cases must not be
overlooked.
  The nitrate, as well as the iodides and oxides, of mercury is applied
by many practitioners in the form of ointment to  patches of psori-
asis,  usually few in number, aud  limited in extent.    The action of
these agents is, however, inferior to those already  named,  and the
range  of their  availability being  quite  limited,   they should  be
esteemed lightly in the local treatment of the disease.
  The local treatment of psoriasis of the scalp  and face by many, of
the articles named above is often  forbidden by reason of their dis-
agreeable odor or too energetic  action, or by the staining which they
produce.
  There is no better substitute  for them all in these regions than the
ammonio-chloride of mercury in ointment, from ten to thirty grains
(0.66-2.)  to the  ounce  (32.).   In  the same way,  the  tincture of
benzoin may be employed, half a  drachm (2.) to  the  ounce (32.)
of salve.
  Prognosis.—The permanent  relief of psoriasis is  not insured  by
any treatment of a grave case, though hundreds of cases are perma-
nently  relieved by even  the simplest treatment.   The disease often
recurs, and may do so repeatedly for the greater, part of a life.   Per-
manent relief, therefore, should  never be either predicted or promised
in any  case.   Once relieved, it should be the aim of the practitioner
to guard against all possible recurrences.   After relief of any obsti-
nate or recurrent attack, as also in all inveterate cases, the prognosis
is greatly improved by removal to a climate suitable for the psoriasic
patient. 
           PITYRIASIS MACULATA ET CIRCINATA.      239


              Pityriasis Maculata et  Circinata.

 Pityriasis Maculata et Circinata is a mild febrile disorder of specific character
  and  determinate course, in which appears a cutaneous exanthem in the
  form of  multiple,  circumscribed, superficial,  roundish  or oval-shaped,
  yellowish and reddish patches, covered with fine scales, and seated for the
  most part on the trunk.

   This disorder, also termed Pityriasis Rosea and Pityriasis Circinata,
 has been recognized and carefully described  by Gibert, Bazin,  Horand,
 and Duhring.
   It is a rare disorder, the expert seeing not more than from ten to a
 score of cases annually.   It is also non-contagious and benign in its
 course, lasting from a few weeks to three months.
   Symptoms.—The subjects are children, or more commonly young
 adults, but the author has seen it in middle life in both sexes.   The
 outbreak of the disease may  be preceded for  a variable  time by
 languor, lassitude,  inappetence, or a  feeling of chilliness.  Occasion-
 ally the first noticeable symptom is in the  occurrence  of mild fever,
 the temperature  rarely rising above 102° F.
   The eruption often escapes recognition  for a time after its appear-
 ance on account of its sparsencss, or the trifling degree of pruritus it
 arouses.  When fully developed, it is characterized by the conspicuous
 appearance over large surfaces of the trunk,  especially the integu-
 ment covering the clavicles, ribs, and scapulae,  of numerous pin-head
 to small coin-sized, circumscribed, roundish or  oval-shaped, slightly
 elevated, macular or maculo-papular lesions.   These may be discrete,
 closely set together, or confluent, and instead of  being elevated may
 be  either on  a level with  the  general surface, or even slightly de-
 pressed, with an annular  border.   They are dry, covered with  fur-
 furaceous scales,  and vary iu  color from a yelloM' or tawny shade to
 a deep red.    The infiltration is slight, and the patch is superficially
 situated.
   The oval contour is that more often  recognized as characteristic of
 a well developed lesion,  its  long axis  usually at  right angles to  the
 vertical axis of the  body, and  the terminal extremities of the oval
 slightly frayed by the irregularity M'ith M'hich the fine branny scales
 are here disposed.   The tawny, salmon-shaded hue of such patches
 is then highly characteristic of the disease, the patch slightly enlarging
 by  peripheral extension, and leaving a relatively clear centre.   The
 scales have often a silvery-grayish  hue.  The eruption may be toler-
 ably mcU generalized, but the  face and other exposed parts of the
 body usually escape, though the scalp may be  involved.   In  the
 latter event the hairs are unaffected.
  Etiology and Pathology.—The causes of this disease are  obscure.
 According to Bazin, it occurs in lymphatic and scrofulous  patients
 chiefly.
  The most of the  cases coming under the author's observation were
of patients  having  light  hair  and  delicate skins, who  had been 
210
DISEASES OF THE SKIN.
enfeebled by great physical fatigue or overtaxation in school.  Profuse
perspiration has been assigned as a cause by Horand.  Vidal  recog-
nized in the upper portions of the  epidermis minute spores in heaps,
chains,  and circles, called the microsporon dispar (s. anomaeon.) which
have unquestionably been  seen in other scaling diseases of the skm.
  Diagnosis.—The"disease is to  be differentiated  from ringworm of
the body by the absence of vesicles, the tendency to  symmetry of dis-
tribution of the lesions, their multiplicity, the characteristic yellowish
centre of the oval  rather  than  circular patch, and the constitutional
symptoms.   Psoriasis differs greatly in the color, quantity, and char-
acter of the scales present, and in  the contour of  the patch.   In the
scaling  syphilodermata, the region of the body involved, the presence
of plantar and palmar lesions, the constitutional symptoms aud history,
and the color of the patch, M'hich  is usually of a deeper  and dirtier
red than in the disease under consideration, M'ill point to the diagnosis.
In  the  macular syphiloderm ('•syphilitic  roseola")  the  closer prox-
imity of the  lesions will   point  at once  to the difference, since the
patches of pityriasis  maculata  et  circinata are, as  a  rule, far more
widely  separated.  The greasiness of seborrhoeic scales and the pallid
hue of  the integument beneath, when the former  are removed, differ
from the congested skin beneath the dry scale in the form of pityriasis.
   The  treatment  is expectant.  Quinine,  the sodic salicylate, and,
later, the ferruginous tonics are indicated in most cases.   Finally,
tepid bathing  in the alkaline or bran bath  is usually found grateful.
This is to  be  followed by  the application of a dusting powder.


                    Dermatitis Exfoliativa.
Exfoliative Dermatitis  is a  more  or less generalized,  cutaneous disorder in
  which, either in circumscribed  patches or over the  entire  surface of the
  body, the skin is reddened and covered with scales which are  freely exfol-
  iated  from the  surface.  The disease  may be accompanied by febrile and
  other general signs of systemic disturbance.

   Some confusion, both as to the names of diseases  and  as to the dis-
eases themselves,  has existed  in connection with the subject of all
 generalized  exfoliative  cutaneous  disorders.   More investigation is
 needed  before definite limits can  be established  for  several of  the
disorders  to  which authors refer under  these titles.   By some, the
term dermatitis exfoliativa is held to be synonymous M'ith  pityriasis
 rubra,  the disease next  to be considered.   In  these pages,  pityriasis
 rubra is, for the  present at least, distinguished as a distinct  disease,
and dermatitis exfoliativa is made to include the exfoliative and exu-
 dative  disorders  of the  skin not properly considered  in any other
 connection.
    Classing these latter together, as for the most part of acute type, and
 distinguishing them  from the chronic form of dermatitis exfoliativa

  1 See a communication by the author in the British Medical Journal, April 2, 1S87,  on the distinction
 between seborrhoea, pityriasis maculata et circinata, and lichen annulatus serpiginosus (Wilson). 
DERMATITIS EXFOLIATIVA.
211
represented  by pityriasis rubra, it may be said of them all that they
often present  features of wide diversity.   At one time the exfolia-
tive  dermatitis begins and ends in a single  patient as a well-defined,
distinct, and specific disease of mild symptoms, definite  career, and
benign type.   In another  case,  it  occurs  as a  sudden  or  gradual
change in a preexisting disorder, such as an eczema or  a psoriasis
(Gamberini)   Again,  beginning  in  one or another of the simpler
forms described above, it may become chronic, and, in its symptoms
and  course,  be indistinguishable from a  pityriasis rubra.
  It may be ushered in with mild febrile symptoms, which may have
been  preceded or not  by malaise, languor, or a  variable period in
which the  general health has been  impaired.   Often, however, all
prodromata are absent.
  The eruptive symptoms are a more or less shining and vivid red-
ness of the skin in one or several plaques which become in the course
of a  week the seat of numerous fiue bran-like scales.  Any region of
the  body may be affected,  though the  articular  folds of the  skin,
genital region, head, and trunk, are often the seat of the disease,
which may  involve consecutively one part after another till, in a week
or a fortnight, the whole surface is invaded.  It  may be limited to
one  region,  or, yet again, several  distinct regions  may be simultane-
ously involved, as the head and lower limbs,  or the thorax  and
external  genitals.  The  hands and  feet are  usually the last  to be
invaded.   The  eruption may appear in reddish  patches of  well-
defined or  very  indeterminate outline.  The skin affected  may be
slightly,  or  apparently not at all, infiltrated and raised.   The itching
may be slight or severe.    The redness  displayed  in the skin M'hich
is the seat of the scaling, may be of the brightest crimson, "erysipe-
latous," violaceous, or purplish shade, or with a faint  suggestion of
yellowness.   The scales are usually formed  in the greatest abundance
and  are commonly seen loosely covering the reddish integument upon
which they  rest, though they are also shed  in the  greatest profusion
when the surface is lightly swept with the hand.   They are always
whitish,  minute,  and bran-like, never  iu  the so-called pastry-crust
condition of the scales in  pemphigus foliaceus.
   In well-marked  cases,  the features may  be slightly  disfigured by
tumefaction of the lips, swelling of the ears, and puffiness of the lids.
In all cases, the  skin is  dry and  never  moistened by a pathological
discharge.  The  scales shed in  such abundance are always  white,
imbricated,  and silvery in hue.   They are usually  larger  and coarser
upon the lower limbs than over the neck, face, or chest.
   In the course of the  disorder, the hairs may fall; and, in some
cases, the resulting alopecia is general.   When the nails also are lost,
there is  rarely any special  preexisting onychia to  be noted.   The
mucous surfaces of the eyes, nose, mouth, aud throat, may participate
in the general disorder and become the seat of inflammatory and, in
rare cases, even pseudo-membranous and exulcerative processes.
   The itching may be entirely absent;  M'hen  present and in  severity,
it is relieved  even  before the complete  restoration of the integrity of
                                 16 
242
DISEASES  OF  THE  SKIN.
the skin.  It is apt to recur with each relapse, at which time also the
fever is usually relighted.
  In most  cases the  disease is terminated in the course of two or
three months, after which convalescence from the  emaciation and
possible complications (furunculosis, abscesses, etc.), may require^ an
equal length of time.   Pigmentation is always  left for some time
after the restoration of the health of the skin.
  Pathology.—Brocq1 has made a specially careful study of this dis-
order,  and  his results are more  or less confirmed  by  Vidal and
Baxter.  These observers recognized an infiltration of the papillary
layer of the corium with embryonic cells, dilatation of the papillary
and sub-papillary vessels, disappearance of the stratum  granulosum
and stratum lucidum  of the  epidermis, and appearance  of nuclei in
the cells of  the stratum corneum.   According to  Quinquaud,2 a dif-
fuse myelitis and parenchymatous  neuritis of cutaneous nerves may
be responsible for all these changes.
   Etiology.—According to Brocq, the disease affects patients who have
not  previously suffered from any cutaneous malady.  The disease is
rare; and is said to occur more often in adult male subjects.
   Diagnosis.—The  disease is to   be  distinguished  from pityriasis
rubra by the variety of  its symptoms and  course;  from  pemphigus
foliaceus by the absence of bullae and  grave systemic trouble; and
from scarlet fever,  by the absence of sore throat aud its much more
tardy evolution.  Though, in general,  a disease  having a cyclical
career  and  special  characteristics,  it may at  times  be lighted into
activity by  a diffuse psoriasis of acute  type, or a squamous eczema
becoming generalized.   In such cases the  diagnosis is  qualified by
the preexisting disorder.
   Treatment.—The  disease is unquestionably most  relieved by any
article which induces  profuse sweating; and, hence,  both jaborandi
and pilocarpine have been employed in it with even brilliant success.
Quinine, the sodic salicylate, and the mineral acids are often indicated.
The strength of the sufferer is ahvays to be supported by appropriate
measures.   Hebra's diachylon ointment, one part to four of vaseline,
with from five to ten grains (0.33-0.66) of salicylic acid to the  ounce
(32.) of the whole,  is usually most grateful to the skin.   One of the
combinations of lime-water, olive oil, and the oxide of zinc, described
in the treatment of eczema may, however, be well employed as a sub-
stitute for it.
   Prognosis.—The disorder  may  prove fatal  in exceptional  cases.
Generally,  however, recovery may be expected.  Often the conval-
escence is tedious,  protracted, and complicated by the occurrence of
furuncles and cutaneous abscesses.

   Dermatitis  Exfoliativa Infantum.—Under this  title V.
Rittershain3 and others have described an exfoliating non-contagious
disease  of the skin in  infants from six days  to five weeks old, the

     i Arch. gen. de Med., 1884.            2 Bulletin de la Societe Anatom., 1879
     3 Ctralztg. f. Kinderheilk., 1878, Bd. ii. 
PITYRIASIS  RUBRA.
213
disorder running from  seven to ten days.   It  is characterized by
dryness of the skin, from which branny scales are exfoliated, leaving
a  peculiarly dry, reddish, and fissured  integument  beneath.   The
angles of  the mouth and  mucous outlets  generally are  specially
involved.   Often buccal lesions are present.   The face and limbs are
the seat of the  chief features of  the disease.   The  malady occurs
more often in boys than in girls.   In  severe  cases crusts form where
the rhagades exist, and  there is considerable pain and constitutional
disturbance.  Occasionally the skin is attacked by furunculosis  after
the disease has existed for a week.


                        Pityriasis Rubra.
                          Gr. irirvpa, bran.
Pityriasis Rubra is a rare, chronic, and usually grave inflammatory cutaneous
   disease; as a rule, involving the entire surface  of the body, in whieh the
   skin is deeply reddened  and exfoliates lamellae of scales in large quantities.
   This disease is characterized throughout  its course  by a superficial
hyperaemia and  inflammation of the skin, declared by a diffuse red-
ness  of a  vivid  or lurid tint, and an abundance of  small  or large,
lamellated, bran-like scales,  M'hich are continuously exfoliated  from
the  epidermis throughout the course of the disease.    Patients rarely
present themselves for observation till a considerable portion of the
surface is  involved ;  but Kaposi states that in tM'o cases observed by
him the disease Mas first noticed iu the neighborhood  of the articula-
tions.  There are never at any time other lesions of the skin, betrayed
in vesiculation, pustulation,  moisture,  or  crusting.  The palmar and
plantar surfaces  are usually  less distinctly reddened than the face and
extremities, having  at times even  a pallid hue; but they are ahvays
covered M'ith a distinctly scaling epidermis.
   Under pressure with  the  finger, the redness subsides or assumes  a
yellowish  shade, while, as a rule, when  the integument is gathered
up betM'een the finger and thumb, no  thickening and infiltration can
be recognized.   Exceptions  to this have been,  however, noticed by
several observers, the  author among  the  number,  in an interesting
case made the subject of a clinical lecture.1   The temperature of the
skin  is slightly increased.  The exfoliation is, as the disease progresses,
one of the most striking of its characteristics, the scales accumulating
in large quantities about the coverings of the body of the unfortunate
patient, M'ho  is  engaged,  as a French writer has it,  in  the labor of
stripping himself involuntarily of his epidermis.
   The disease persists  for months and years, ahvays more severe in
expression as it advances, the papery scales being shed more  abun-
dantly, and in larger flakes, leaving beneath  them a smooth, shining,
occasionally purplish or even cyanotic skin.   In the cases observed by
Jamieson,2 of Edinburgh, and the author, the skin  Mas so dark-hued

             1 Pityriasis Rubra : Chicago Med. Journ. and Exam., Feb. 1881.
             ■ Edinburgh Med. Journ., April, 1880, p. 879. 
211
DISEASES  OF  THE  SKIN.
as to suggest the color  of the  mulatto.   Gradually  the patient is
conscious  of an increasing sense of chilliness, as if deprived of suf-
ficient bodily covering.   The itching  may be  absent, moderate, or
severe.  Later, the integument  seems to retract, as if insufficient to
encompass the body, and  becomes subject to  fissure from extension
and  contact, while the loM'er extremities  may even be  oedematous.
This  retraction  may be so marked  that  ectropion of the lid  may
ensue, and wide opening of  the mouth become difficult.  The hairs
and  nails lose their lustre, and  become friable, often  falling, though
at times escaping altogether.
   The influence of this gigantic, epidermal  catarrh, involving, as it
does finally, every portion of the surface, does not fail, toward the end,
to be perceived by the vital forces.  Alternating  chills and  febrile
processes,  pneumonias  of a low  grade, colliquative diarrhoea, tuber-
culoses, subcutaneous abscesses,  bed-sores,  and even gangrene of the
skin may  close the scene.
   Hebra  and Kaposi  have  together had  under observation  "about
fifteen" patients affected M'ith pityriasis rubra,  who,  with a single
exception, died from its effects.  It will be seen thus that the disease
is exceedingly rare.  A few interesting cases have  been reported by
English authors.  Among Americans,  Duhring, George H. Fox, of
New York, and the author,  have published  reports of cases.   The
disease is one of early or middle life, and preeminently of the male sex.
   Etiology.—The  causes of  the  disease  are  absolutely  unknown.
It M'ill be seen that the  small number of cases  which  have been
recognized,  furnish  but  an insignificant  field for  the study  of the
malady.   It  is  interesting, however, to note in this connection, that
the constitutional  symptoms of  each case seem to have been induced
by the disease of the skin, and not the latter by any internal derange-
ment of which the symptoms are  made manifest.   For not only do
these visceral troubles occur chiefly at a late period of the malady,
when common observation suffices  to  show that the cutaneous mis-
chief alone is sufficiently extensive to induce them," but it is also clear,
from  the  M'ide range of these disorders (bowels, lungs, etc.), that no
special visceral malady has excited the cutaneous disease.
   Pathology.—The researches of Hans  Hebra1 have demonstrated  in
two cases  that there is,  in the earlier period of the disease, an infil-
tration of the integument moderate in degree,  succeeded at a later
period by cutaneous atrophy, in M'hich the rete and  papillae of the
corium disappear.   The  connective tissue elements  undergo sclerosis;
and the glands and the follicles of the skin are destroyed.  Pigmenta-
tion  is abundant.  Both he and Fleischman have  discovered  coinci-
dent pulmonary, intestinal, or cerebral  tuberculoses ; and  Kaposi, in
one post-mortem examination, established an  atheromatous condition
of the arteries.
   Baxter,2 in a case examined  by him, discovered no trace  of the

              1 Viertel.jahr. f.  Derm. u. Syph., Hft. 4, 1876, p. 508.
               2 Brit. Med. Journ., 1879. 
PITYRIASIS  RUBRA.                  215
 stratum granulosum, nor Mas the stratum mucosum completely sepa-
 rated from  the stratum  corneum.   There M-as  a gradual transition
 from the polygonal  prickle-cells below, which readily stained, to the
 horny cells above, which remained colorless.  Flattened and  faintly
 stained nuclei lay parallel to the surface, and could be recognized  even
 in the enormously  hypertrophied stratum  corneum.   The papillae
 were enlarged; the inter-papillary projections of the rete had pushed
 deeply into  the corium.   The prickle-cells  of the  hair-sheaths  were
 multiplied.   The remarkable consistency of the  thickened corium at
 the  outset of the disease, was regarded by him  as chiefly  due  to a
 fluid exudate, M'hich M-as observed before death.
   Diagnosis.—It is  clearly necessary to add to the facts given above,
 that many cases loosely reported as instances of  pityriasis rubra, are
 not really such.  The misinterpreted symptoms are  often those of an
 unusually extensive  psoriasis or chronic squamous  eczema,  M'hich
 commouly terminates favorably in the course of a proper treatment.
 Experts are often summoned  to see such eruptions,  M'hose import has
 been misunderstood.
   In lichen  ruber the essential lesion is a papule, which even in the
 later extensive scaling of that disease  may usually  be recognized in
 some part or another of  the infiltrated skin.
   Psoriasis rarely extends over the entire surface of the body, but it
 M'ill  be at times thus generalized.  In these  very exceptional  forms,
 a long history of typical  psoriasic patches may  usually be obtained,
 while the bleeding surface beneath the scales, and  the character of the
 latter, will point to the true nature of the disease.   Psoriasis occurs
 in healthy,  pityriasis rubra   in  cachectic constitutions.  Extensive
 erythematous  or squamous eczema, apart  from all  other  symptoms,
 can  be recognized  at once by  the excessive distress occasioned  by the
 eruption.  The patient  lies  in bed nursing his or her tender limbs,
 back, or belly.  In pityriasis rubra, the patient rises, dresses himself,
 aud  moves about  M'ith  an  expression, not  of  pain  but of listless
 apathy.   His  scales  are  not scanty and adherent, but abundant and
 exfoliating freely.  There is, from first to last in  his case, no history
 of moisture.   In every generalized eczema, there will be ahvays, at
 one point  or another, a  surface M'hich weeps.  In its early periods,
 pityriasis rubra can  be distinguished  from  pemphigus  foliaceus by
 the absence of bullae, and of the intolerable stench  Avhich is then
 often emitted  by the sufferer.  When,  however,  there  is present
 merely a generalized  exfoliative dermatitis, the tM'o disorders may be
 Mell-nigh indistinguishable.
   Treatment.—Arsenic administered  internally  seems powerless  in
 pityriasis rubra.   Cases are on record of fatal  results after the exhibi-
 tion  of this drug in prodigious quantities for long  periods of time.
 Tar  externally  promises  no   better.   Kaposi reports a single case
 relieved by the  use of carbolic acid internally.
   A roborant treatment,  including the employment of coddiver oil,
 iron, orquiuia, is certainly indicated, M'ith the simplest bland unguents
externally.   Of the  latter, vaseline seems best tolerated.  It should 
216
DISEASES  OF  THE  SKIN.
be employed, not merely to soothe, but also to protect the skin.  The
clothing should be  ample and unirritating;  and the diet carefully
selected M'ith a view to supporting the strength.
   The prognosis is necessarily grave.


                        Lichen Planus.

                          Gr.  leixyv, moss.
Lichen  Planus  is a chronic and exudative affection characterized by  the
  appearance upon the skin, of multiple, usually symmetrical,  pin-point to
  split-pea sized, discrete or aggregated,  flat, polygonal, yellowish or pur-
  plish-red, smooth and glazed papules, having the appearance of umbilica-
  tion at the apex.
   Symptoms.—The first symptoms of the disease are the characteristic
papules, which are glazed, M'axy, umbilicated,  scaling at the  apex
only after they have existed for some time, pin-point to rape-seed in
size, and roundish, angular, or oval in contour.   They are usually
firm, and particularly well characterized  by the minute punctiform
depression of  the  flattened  apex, described as au  "umbilication."
They are at first irregularly disposed, but later tend to arrange them-
selves in groups about the flexor aspects of the wrist and knee, the
palmar and  plantar surfaces,  the lips, lids, cheeks, shoulders, penis,
and other parts, as of the trunk  and limbs.   Often, as  the lesions
persist, they  become flatter, assume a  characteristic purplish-red or
dark-brownish shade,  and surround themselves  M'ith  closely packed,
newer lesions  in  circlets  or parallel lines.   In this  May,  distinct,
sepia-tinted patches may form, whose  progressive involution leaves
dark-broM'n  atrophic  depressions in the skin, suggesting cicatrices.
The itching may be moderate or severe.   The eruption is chronic in
its course; tends to linger for  years within distinctly circumscribed
areas, and seems to exert upon  the constitutional forces little or no
influence.  As it is  amenable to treatment, it has been less studied in
its unmitigated features;  but  Kaposi thinks  that in the  majority of
cases it would, if unstayed, become generalized.   In one case  only
has he  noted  the occurrence  of  emaciation and other  symptoms of
disturbance of the general economy.
   Many lesions in the neighborhood of those M'ell developed are the
smallest papules recognized in diseases of the skin.   They are  no
larger than the points of  small  pins, scarcely if at  all  elevated, and
have either the color of the normal skin, or are whitish, lilac-tinted,
or yellowish.   They all, however, are, as Wilson first described them,
" smooth, shining, and flat."   The older groups may be either in
circles or bands of various lengths having a violet,  or bluish-red, or
even a coppery hue.
   The other special characteristics  of the papules are  their angular
outlines and the adherent horny covering of each.  As to the former,
the characteristic singularity of the sides is most conspicuous as the
papule  becomes developed; but even in the exceedingly minute pin- 
LICHEN  PLANUS.
217
point sized lesions with a glass one  may often detect the polygonal
outline which later on can be distinguished with the naked eye.   The
surface of each is  covered by a thin stratum  of horny  epidermis,
M'hich is not a true  mass of scales  since it does  not exfoliate.   In
some types  of the  disease, a  patch, whether band-like or circular, of
aggregated and well-developed papules may include also an infiltrated
interpapular skin, with a grade of inflammation M'hich  may result in
severe general scaling, and M'ith changes induced  by the traumatism
of scratching to relieve a consequent mild or severe pruritus.
  The course of the disease is decidedly chronic,  but its lesions are
never complicated  by vcsiculation,  pustulation, or by changes in  the
hairs and nails.  Upon the lower extremities, after it has existed for
a long time, a single band-like plaque of the disease may lose almost
all of the papular features, and come to  resemble a deep purplish
keloid-like elevation or flat tumor embedded in the skin, M'ith  whitish
miliary points or streaks at the border.   When  involution is  com-
plete,  there  is usually very deep pigmentation and at times slight
atrophy.
  Weyl describes the  whitish points and streaks referred to above as
visible at times  even in the  smaller lesions, the  horny scales  pro-
jecting from others like thorns, and  fantastic  groups on the body in
the form of  a cockade or in a whip-shaped curve.
  Under the title Lichen Ruber Monileformis, Prof. Kaposi1 reports
a curious form of  this disease,  iu M'hich the lesions  were nearly
symmetrically arranged  upon  the extremities, neck, and lower belly,
and  in which the papules were strung like  beads along definite linear
cord-like elevations.
  Lavergne divides all cases of lichen planus into three classes.   The
first is chronic lichen  planus, the disease as  it is  known in its most
common form.  The second is  acute  lichen plauus,  in  which  the
papules  rapidly develop,  and form extensive patches,  thickened,
painful, livid red, and abundantly desquamating.    The third  form
is the lichen planus corneus of A'idal, Founder,  Besnier, and Heguy.
It corresponds to  the  coin  or palm-sized,  bluish to blackish, scaling
and  rugous, tumor-like plaques, usually seen  on the anterior face of
the leg, briefly described above.
  Pospelow2 and  Thibierge3 have observed buccal  lesions occurring
in lichen planus on the mucous surface.  Wilson, Hutchinson, Kaposi,
and  Crocker have described similar lesions, M'hich are to be carefully
differentiated from the  patches of leukoplakia  buccalis (so-called
"psoriasis buccalis"), epithelioma, and the mucous  patches of syphilis.
The plaques are whitish, thickened, and  uniform elevations of the
mucous surface, grayish-white, or resembling in  color  the places  to
M'hich the nitrate of silver  has been applied, with  irregular contours,
often horizontally disposed betM'een the teeth.   These may be due to
confluence of pin-head size papules  of lichen planus.

        i Viertel. f. Derm. u. Svph., 1SS0, 4 Hft., with chromolithographic illustration.
        2 Viert. f. Derm. u. Syi'.h., 18S5, p. 533.
        3 Annal. de Derm, et de Syph., 1885, p 66. . 
218
DISEASES  OF  THE  SKIN.
  Etiology— The  causes  of the  disease are obscure.   It is^ seen in
both sexes, and at all ages, but is decidedly more common in early
and middle adult life.   Debility, digestive  disturbances, and neuras-
thenia have all been named as effective causes;  but it is seen in very
fleshy middle-aged women and strong men.
  The evidence that connects this disease more directly M'ith the
nervous system  is of great value,  and annually  accumulating.  In
some  cases, distinct  coincident neuralgias  of the head and  lumbar
region are reported.   In  yet others  the  papules  have  been noticed
distributed in the  areas supplied  by given  nerves, or occurring after
injury of such nervous branches.1
  Pathology.—Robinson first clearly  showed the pathological distinc-
tion betM'een  lichen ruber and lichen  planus.   His observations have
been confirmed by those of Boeck, Kaposi, Touton, Weyl, and others.
  The first changes noticed in the skin are increase in the lumen, and
a sinuous  condition of  the capillaries supplying the  one  or two
papillae concerned in a single papule.   The papillae, thus largely filled
with dilated  capillaries, also contain  a network  of  fine connective-
tissue fibres, and dense, round cells, which proceed to multiply.  Later,
more papillae are concerned in this process and also the epidermis.
In the places where the M'hite points are exhibited, granules of kerato-
hyalin become visible.   In some portions of a lichen  papule of
medium development, the stratum corneum exhibits an external, dark,
narrow, and firm layer, and beneath it two to four rows of translucent
cells forming the stratum  lucidum ; but in other parts, and when fully
developed in all parts, the stratum corneum  breaks up into definite
lamellae, a phenomenon seen in other disorders  attended  by derange-
ment  of the kerato-genetic function of the skin.  The external layer
is dark, when stained, and  firm ; next below it  is a wider layer of
swollen cells  with nuclei scarcely visible or  relics of liberated nuclei;
and, still deeper, a narrow and solid layer beneath which the stratum
lucidum becomes visible.
  In Robinson's sections, the horny layer Mas almost entirely absent
over the region occupied by the cell-packed papule, below which the
corium was normal.  The rete M'as hypertrophied  centrally, especially
in the  region of the sweat-ducts; its  cells above the affected papillae
horizontally  flattened, and  the granular  layer  thickened.   In  some
places  it was difficult, in consequence of these changes, to distinguish
between the rete and the corium beneath.    The cell-infiltration, com-
posed  largely of  embryonic M'hite blood-corpuscles,  extended  more
deeply into the corium  in the neighborhood of the sweat-ducts.
  Briefly, it appears that the papule  of lichen planus is the result of
a primary  hyperaemia of the  papillae of the corium ;  a  secondary
thickening of the lower part of the rete;  a tertiary flattening of the
papule by reason of the resulting pressure, producing thus the appear-
ance of umbilication ;  a proliferation of cells in the granular layer, as
a result of  M'hich  the deposit of kerato-hyalin in whitish points or
1 See Report of Two Cases, by Dr. Stephen Mackenzie, Journ. of Cutan. and Ven. Dis., 1885. 
LICHEN  PLANUS.                   219
sheets occurs sufficient to produce the clinical peculiarities having that
appearance (not due, as Neumann supposed, to changes in the SMeat-
glands); and coloration  of lesions due to both vascularization and to
escape of blood corpuscles.
  Diagnosis.—The diagnosis rests  on the characteristic shape, size,
color, grouping, disposition, and umbilication of the papule of lichen
planus;  which are not found  in any other papular disease.   Thus, in
its size, apex, color, aud  course, the  papule of papular eczema is quite
different from  that described above,  being brighter,  redder, more
acuminate at the apex, and much more often  followed  by or accom-
panied by catarrhal symptoms.   In psoriasis punctata, the scales are
abundant and  readily removed ; the individual lesious  also  increase
rapidly by peripheral extension, far beyond the fullest development of
the papule of lichen.  The papular syphiloderm  is  not pruritic, not
flattened when  minute, not polygonal  in  shape,  not covered M'ith  a
closely adherent horny  scale, and  always  occurs in patients M'here
careful investigation  will disclose  other  symptoms of the  disease
(mucous patches, adenopathy, etc.).
  Treatment.—Roborant treatment by quinine, the mineral acids, the
ferruginous tonics, and cod-liver oil, is frequently indicated.  Though
it is claimed that arsenic  actually aggravates the disease, the author
agrees with Hebra, Wilson, Duhring, and  others, in ascribing to it
the most brilliant results obtained in the treatment of lichen planus,
results far more consistent than  are obtained  from the  same drug in
the  management  of  psoriasis.   Boeck  and Taylor  give fifteen
grains (1.) of the chlorate of potassium in four ounces (128.) of Mater,
fifteen minutes after eating,  followed  in  a quarter of an  hour by
twenty drops of the dilute nitric acid, swallowed  in a Mineglassful of
water.  Robinson, in  generalized and hyperaemic  cases, praises  the
alkaline  diuretics (acetate of  potassium with sweet  spirits of nitre),
well diluted after  meals; and  Fox regards mercury as valuable in
the  chronic forms of the disease,  for M'hich also he administers
asafoetida.
  Finally, Koebner has  injected  both  pilocarpine  and  arsenic  sub-
cutaneously with success ; Unna has used one part of corrosive subli-
mate, twenty parts of carbolic acid, and five hundred of  the benzoated
oxide of zinc salve ; Vidal employs baths of vinegar, one litre to the
bath ; and the  external  application of one part of tartaric acid to
twenty of the glycerine of starch; and Wilson employed a mercurial
salve two grains  (0.13) to the  ounce (32.).   Tar, ichthyol,  thymol,
iodine, and chrysarobin may also  be successfully employed  topically.
Weyl has employed caustic applications; as also  one to two  parts of
p naphthol to ninety of rectified spirits of wine, and  ten of glycerine.
  Prognosis.—The prognosis  is ahvays favorable, as  the disease, even
when chronic, tends to spontaneous disappearance. 
250                DISEASES  OF  THE  SRIN.
                         Lichen Ruber.
                           Gr. heixvv, moss.
 Lichen Ruber is an exudative cutaneous disease, characterized by the appear-
  ance of firm, millet-seed to split-pea sized,  reddish, conical, discrete, or
  confluent papules, whose evolution may  be  accompanied by a moderate
  degree of itching, the eruption having a marked tendency to generalization
  and the induction of a fatal marasmus.
   Under the  term  Lichen Ruber, Hebra M'as first to describe the dis-
 ease M'hich is now  recognized under this title, and which was, at one
 time, thought to include lichen planus, the two diseases being merely
 different  expressions of a single  pathological process.  It has been
 already shown that lichen  planus,  M'hich is much the more common
 of the two, has no relation with lichen ruber.   Very few cases, indeed,
 of the last-named  disease  have ever been  reported in this country;
 and  there are authors who deny its  existence as an independent affec-
 tion, claiming that the conditions described under the  name should
 be properly assigned to other categories.
   Symptoms.—The disease is first  characterized  by the  appearance,
 without  prodromal symptoms, of isolated, pin-head  sized, conical,
 reddish,  and scale-capped papules of considerable firmness, bright red
 or livid in hue, and disseminated  over the  belly, chest, genitalia,
 extremities, and other portions of the body.  In another form of the
 disease, these  lesions are lighter  in color, with  a smooth surface, a
 small central depression  at the apex, and a waxy appearance.  It is
 these latter which  have suggested that lichen planus is a variety of
 this  disorder.   The itching excited may be mild or severe.   It bears
 no relation to the extent of the exanthem.
   The papules rapidly multiply, forming patches  which by aggrega-
 tion  eventually cover entire regions  of the body, and, lastly, its entire
 surface.   Throughout all, the individual papules do not enlarge at the
 periphery, but persist as such till they are lost in a diffuse, dull-red,
 infiltrated patch, covered with thin, papery, grayish, non-adherent
 scales, beneath which the  orifices of the hair-follicles are seen to be
 dilated.
  Occasionally at the borders of a patch thus formed, isolated, shining
 flattened, or umbilicated papules persist or form circles of densely
 packed lesions, surrounding groups  in which involution of the lesions
 progresses, leaving pigmented and atrophic areas within.
  Whether in the form of  the lesions last described, or after irregu-
 larly disposed disseminated patches have been developed, the entire
 integument  becomes eventually  the  seat  of extensive  infiltration,
 reddening, and scaling   As  a  consequence fissures form;  and tthe
distress of the patient increases.
  The skin  of the face cracks; the lids are  everted  or thickened ;
the skin  of the palms aud soles is converted iuto leathery tissue; the
nails become friable and irregular ;  motion  at the joints is excessively
painful, on account of the inelasticity of the skin  covering the articu- 
LICHEN  RUBER.
251
lations ;  the hairs are thinned and fall; the extremities are mainfa'ned
in a position midway between flexion and extension.  The integument
is now universally reddened, covered  M'ith innumerable delicate or
coarser scales, aud, especially upon the palmar and  plantar surfaces,
thickened  by dense infiltration.   Over the deeper fissures, extending
to the corium, blackish and blood-containing crusts form.  Emacia-
tion progresses pari passu with the invasion of the disease; and death
may result from  exhaustion, an intercurrent diarrhoea,  or a  pneu-
monia.
   Etiology.—The causes of  the disease  are  unknown.  The sexes
seem to suffer in equal proportion, though it is claimed that more men
than women  are affected.    The disease is  neither  transmitted  by
heredity nor contagion.   In  those who display the symptoms of the
affection, external irritation  is capable of aggravating  the eruption.
The disease is  chiefly encountered  in  middle life from  the tenth to
the  fortieth year, but has been observed as early as the eighth month.
   Diagnosis.—In psoriasis the discovery of  a typical scaling patch,
often M'ith  a clearing centre, should suffice  for  recognition  of that
disease.  The scaling also in diffuse psoriasis is much more abundant.
In  papular eczema, the lesions  do  not persist as such.   AYhen these
two affections  are generalized,  it is claimed by French observers
that there  is ahvays  some one  area,  however small, of unaffected
integument.  This is not true of generalized  lichen ruber.   But, in
such generalized cases, the distinction between that disease, pityriasis
rubra, and  dermatitis exfoliativa may be extremely difficult, if at all
practicable  or possible.  At an earlier period,  papules are not seen in
either of the two last named disorders.  The  papules  of syphilis
never scale  so generally as those in  lichen ruber;  they, moreover, in
cases, increase to double their original  size; and  are ahvays accom-
panied by some other symptom of that disease.  In  the scaling stage
of pemphigus foliaceus, there are bullae present or a history of such
lesions preexisting.
   Pathology.—According to  Robinson, lichen ruber is a paratypical
keratosis.   It is characterized by hypertrophy of the stratum corneum
and  incomplete corneous transformation of the individual elements of
that  layer,  M'hich are  larger and more  polygonal, a  feature most
noticeable about the sweat-ducts and  hair-follicles.  The rete is in
places eularged  and in places normal.   The  upper portion  has  an
uneven appearance as the interpapillary portion pushes slightly clown-
Mard  and  the  increase  in  size  of the  other parts is more marked.
The papillae are increased in size; their bloodvessels  dilated and
surrounded  by emigrated corpuscles.   The Malls  of the sweat-duct
are formed  of large cells with  vesicular  nuclei;  corneous cells  are
heaped also about the orifices of the hair-follicles :  the muscle-bundles
are much hypertrophied.
   Treatment.—Arsenic is of greatest value and can be employed M'ith
large chances of success  in lichen  ruber.  The  drug is to be early
given, persistently pushed iu the  face of new crops of lesions, till the
desired result is obtained, aud continued for several  months after all 
252                DISEASES  OF  THE  SKIN.
 signs of the disease have disappeared.  Tonics when indicated, should
 ahvays be exhibited.   The diet should be generous.
   The external treatment is naturally employed  chiefly for the relief
 of any pruritic sensation.  Here  the dusting  powders and ointments
 prove* serviceable.   The local  remedies  employed in  corresponding
 stages of eczema may, in brief, be here used with advantage, such as
 the alkaline, starch, or bran bath ; and followed by inunction of the
 skin  with salves containing thymol, salicylic acid, zinc oxide, bismuth,
 carbolic acid, or benzoin.
   Prognosis.—The prognosis of  the  disease, M'hen it refuses to yield
 to  treatment  and tends to become generalized, is necessarily grave.
 Treatment  after the occurrence  of marasmus,  will often prove in-
 effectual.  The disease is said to be occasionally amenable to energetic
 treatment before it  has advanced to  the  stage of inducing systemic
 exhaustion.

                             Eczema.

                        Gr. en feu,  to boil forth.
 Eczema is a non-contagious, acute, or more frequently chronic, inflammatory
  disease of the skin, beginning as an erythema, or by the appearance of iso-
  lated or grouped papules, vesicles, or pustules, either singly, simultaneously,
  or in succession, resulting in redness, catarrhal symptoms, scaling, crusting,
  and infiltration of the skin, accompanied by more or less  intense itching
  and burning sensations, and leaving, after complete resolution, no cicatrices.

   Symptoms.—Eczema  is one  of the diseases of the  skin of most
 frequent  occurrence.    In the statistics gathered by medical men, it
 would seem to rank first in the order of  frequency.   But it is only
 true as regards  those diseases for which  the physician is commonly
 consulted.  It  is easy  to become convinced  that acne is a more fre-
 quently encountered affection  than eczema, by observation of the faces
 of individuals on the streets of any large  city, eczema being of more
 frequent occurrence  in  this  situation  than upon other parts of the
 body,  Many persons  are  the  subjects of acne M'ho never deem  it
 necessary to submit to treatment for its relief, and the records of such
 cases  do not figure in dermatological  statistics.   This  being  noted,
 eczema  may be  regarded as the disease of the skin for which most
 frequently the practitioner of medicine is  consulted.  By as much as
 inflammation  is the most common accident  of other  organs of the
 body, by  so much is its enveloping organ  subject to the same patho-
 logical process.
  The surgical signs of inflammation  of any given tissue are usually
 named as increased heat, redness, pain,  and swelling.   These are
 essentially the  symptoms of an eczema;  and it will be necessary, in
 order to study the disease intelligently, to inquire  how these pheno-
 mena  are modified  by  the  anatomical peculiarities of  the organ in
this case affected  A typical eczema is ahvays betrayed by an  eleva-
tion  of the temperature of the surface,  and by a greater or less 
ECZEMA.                         253
degree of SM'elling.   Redness, in various shades, is also  true  of the
eczematous skin.  Pain here is represented by a sensation usually  of
itching, which may vary from slight annoyance to an almost intoler-
able distress.    The  variation in the sensation which accompanies
inflammatory  disorders of the skin and other organs is merely due
to the fact that the former is  exposed to the air, and its increase  in
bulk is  not opposed by other contiguous  parts, as, for example, the
inflamed  bone  in  contact  M'ith periosteum, or  the pathologically
enlarged  prostate within  its fibrous  capsule.   Inflammation  of the
inner skin of  the body, as of  the lining  membrane of the stomach  or
of the intestines, is generally characterized by the occurrence  of in-
creased  heat, redness, swelling, and severe pain.
   Inflammation of tissues constituting  other  organs of the body
usually terminates either in resolution, in the free production of pus,
or in the occurrence  of gangrene.  And so an inflammation  of the
skin may terminate either by  resolution, or by the free production  of
pus on  its surface, the living  matter rapidly multiplying as the in-
tensity  of the  process may determine.   Gangrene is not a  classical
result of eczema, chiefly because of the freely exposed position of the
organ affected.
   The  great variety  of expressions  assumed by an eczematous dis-
ease, and the frequent interchange of these, the one for the other, are
to be accounted for in the  same way.   The atmosphere which sur-
rounds  the body is but one of many external influences capable  of
affecting the skin.   Thus it is rubbed and scratched, exposed  to the
friction of the clothing and the incursions of insects, and subjected
to innumerable injurious contacts  in  all the various trades and occu-
pations  of life.   If the inflamed skin could be as perfectly protected
from the outer M'orld as is  the spleen, we should find the history  of
this  affection much simplified.
   Clinically, several types of eczema can be recognized.  These require
separate description.   It should not be forgotten, however, that each
may prove to  be not a variety, but a stage of the disease, which may
speedily give place to yet another.

                   [A.]  Eczema Erythematosum.

   In this form of the disease the conspicuous symptoms are heat,
redness, and swelling, with a variable degree of itching,  usually less
severe than in  several of the other phases of the malady.  The pro-
cess may begin with acute and intense symptoms, to be soon followed
by one of the varieties of the disease to be subsequently described,
or, M'hat is perhaps  more commonly the case, may continue indefin-
itely as  a subacute or even  chronic affection.  In  color the skin  of
the part involved varies  from a light  to a darker shade of red; and
inasmuch as the process is more frequently observed in middle-aged
adults,  M'ith darker  hue  of the integument than in early  life, the
color of the part is frequently noticed to be of a dull shade.  In
consequence of the swelling, the affected surface is notably elevated 
251
DISEASES  OF  THE  SKIN.
above  the level of the unaffected  contiguous  skin, and  the  line of
demarcation between the two  can be  more readily traced than in
several of the  other varieties  of eczema.    The  surface  is usually
uniformly and  occasionally symmetrically involved.   Lesions, other
than the erythema, which is the prominent feature of the attack, may
not be observed;  and, as  a  consequence, from  the beginning to the
end of the disease, there may be no history of moisture.  But in many
cases, minute poppy- to rape-seed sized papules become visible on close
inspection, still more rarely with a very minute vesicular apex filled
M'ith a droplet of clear serum.    The localities chiefly thus involved
are the face, the palms, the soles, and the regions about the genitalia,
though any portion of the  body  may  be  affected.   Resolution is
accomplished after the occurrence of a very fine superficial desquam-
ation of  the epidermis, or by  very gradual diminution of the red-
ness and swelling without the production of scales.   In either event
the termination of  the  process  is often announced  by  significant
changes  in the involved surface, as by the fading  of  color, the ap-
pearance of islets  of sound skin  between  affected  patches, and by
perceptible relief  in the subjective symptoms.
  Such is the course of a typical erythematous eczema.   Variations
from  this type are, however, numerous and important.   Thus  the
disease may be limited to a patch  as small as a finger nail, or may
extend over large  areas, especially after  subjection to irritation.  At
times the coloration is irregularly distributed, producing a mottled
appearance, brighter at one point and darker at another, while again,
as has been indicated,  the variety described may  coexist with, or be
followed by, the weeping, excoriation, and crusting which are charac-
teristic of other manifestations of  eczema.   Scratching of the part
involved produces a change  in  the symptoms which the skilled eye
will promptly recognize.  Minute superficial losses of tissue are then
visible here and there upon the surface;  the fresher with a reddened
floor possibly hidden beneath a thin blood-scale, the older surmounted
by a light yellowish-red crust,   The scratch-lines, so often recogniz-
able elsewhere, are here less frequently evident.
  Like all the  other varieties of eczema, this is extremely liable to
recrudescence and  relapse.  In advanced  life, the traces of the dis-
ease may be visible for years.

                    [B.]  Eczema Papulosum.
  Under this  title are classed all those  forms which have long been
described as Lichen  Eczematodes,   Eczema  Lichenodes,  etc.
" Observation  of the natural course  of an attack of eczema," says
Hebra, "furnishes the most  unassailable  proof of the connection
between its various forms.   In  oue case an eruption of vesicles begins
the series of symptoms; in  another, it is preceded by the appearance
of red scaly patches or groupes of papules; or vesicles and papules
are developed together, some of the former  rapidly changing to pus-
tules,  and forming yellow gum-like crusts by the drying up of their 
ECZEMA.
255
contents."   It is of the greatest importance that  there  should be a
distinct aud more  general  recognition of the fact, that eczema may
exist  from  first to last as  a dry infiltration of the integument, for
there is perhaps  no one of the various manifestations of the disease
that is so frequently mistaken, and  confounded  M'ith  other M'idely
different affections.
   The poppy- to rape-seed sized  papules M'hich are developed in its
course, are usually  seated upon a reddened  and thickened base, and
are themselves colored  in various shades of red to a dark lurid shade.
They are  usually  discrete,  though  often closely set together; are
accompanied by a severe form of itching m hen irritated by scratching,
and of all eczematous lesions are most apt to be thus irritated.  Their
summits are torn, and  often to such  au extent as  to bleed, the blood
drying in reddish crusts over the area involved, or limited to minute
blood-scales on the apices of  individual lesions.   The extent  of sur-
face affected  varies, as  usual in the  other  varieties, being  in  cases
largely diffused  in patches over various portions  of  the body, or
limited to small and  single patches no larger than a silver quarter of
a dollar.    Such patches, covered  M'ith a single or several groups of
reddish papules, may continue to torment the patient for long periods
of time, or, being at one time  relieved,  recur M'ith each aggravation
of the part by the exciting cause.   Papular eczema is the dry mani-
festation of the disease, and is thus most frequently noticed upon the
drier  portions of  the  integument.   These are  the surfaces  of the
limbs, the back of the body, andj in particular, the scrotum.   In the
latter region, the lesious giving a name to this variety of the disease
are most fully developed.   If  the  moist forms of eczema are most
frequently seen in early life, it is none the less true that the dry forms
are most common in adult life or advanced  years.
   It should not, however, be forgotten, that the papules here described
may develop into  minute or larger pustules, or may exhibit minute
vesicular summits  when there is free  exudation  beneath the surface.
It should be added, that a patch of papular eczema, M'here no vesicula-
tion nor pustulation has been observed, will, if sufficiently scratched,
ooze M'ith  moisture, the serum escaping  from the  abraded surface.
There are,  in fact,  feM' scratched eczematous surfaces which  M'ill not
moisten a dry handkerchief applied to the  part.   This weeping con-
dition attracts the attention of patients themselves, who M'ill complain
of it in describing their symptoms to a physician.   A certain species
of relief for  the pruritus is thus obtained ; and in aggravated cases
patients M'ill  scratch,  or rub, or  otherwise irritate  their  diseased
patches, not merely for the purpose of gratifying the intense desire to
assuage this symptom, but also to induce the serous exudation for the
sake of the  relief it affords.  The  secretion M'hen in contact M'ith
linen  cloths  stains and  stiffens them,  very  much  as  seminal fluid
leaves its traces upon the clothing.
    Resolution of papular eczema is accomplished  after  the formation
of scales, the tissue  beneath the latter assuming  more and more the
appearance of healthy  skin. 
256
DISEASES  OF  THE  SKIN.
                    [C]  Eczema Vesiculosum.

   This variety of the disease  is, as  its name implies, characterized
at an early period by the formation of minute vesicles.   It is a matter
of importance, however, to recognize the fact that the vesicular, like
the erythematous, is but one of several manifestations of this singu-
larly protean affection.   Long  after the appearance of the treatises of
the early English dermatologists, the term eczema Mas very generally
limited by physicians to the vesicular phases of the disease;  and it is
to the Vienna school that we are largely indebted for the recognition
of the fact that these simultaneous or successive features,  presented
often in the same individual, really belong to one and the same malady.
To limit the name eczema to-day to its vesicular  variety alone would
be to relegate the student of diseases  of the skin to the misty uncer-
tainties of the last half century of dermatology.
   The clinical features of vesicular eczema are chiefly due, first, to the
acuity of the inflammatory process present;-and  second, as the result
of the former, to the free exudation of the serum of the blood  from
the  vascular plexus immediately  below the pars papillaris of  the
corium.  The involved surface usually feels at the outset hot, itchy,
or particularly sensitive, and soon after becomes more or less intensely
reddened, the  hyperaemia producing  this  effect  in the  course  of a
true exudation  which may last  for  one or several hours.  Poppy- to
rape-seed  sized vesicles then become visible on  this reddened  base.
The lesions may be closely packed together, or  discrete, or may be
so abundant as to  coalesce, a frequent  behavior  of  all  vesicular
lesions.  Each is filled  with  a droplet of clear serum, imprisoned
beneath the most superficial layers of the epidermis.   The  vesicle is
readily ruptured, and, if this does not speedily occur as the result of
accident, it bursts spontaneously, and its limpid contents are then
poured  out upon the  surface  of the integument.   The quantity of
the fluid thus exuded is in excess of  that originally contained in  the
small vesicular chamber.  This is  due to the fact that the elevated,
macerated, and broken  epidermis no longer presents  an obstacle to
the outflow of the serum from the engorged vessels beneath.  Minute
and  even  large drops of a clear fluid of  syrupy consistency can  be
seen forming  at  the points  where the solution of continuity  has
occurred.   If with a slip of bibulous paper the first drop be removed,
its place is visibly filled by a second.  Crops of  new vesicles succeed
the  first, each followed by  the train of symptoms described.   The
weeping at many points of the surface thus  affected, is so prominent
a  feature of the disease  that it has  led several  authors to describe
eczema  as  invariably  a catarrhal  disease  of the  skin.  There are,
without question, forms of the disease where the history is throughout
entirely different from  that  just  described, where no evidence  of
discharge  can be appreciated from first to  last, aud  yet  where, by
artificial measures, the so-called catarrhal features can be readily pro-
duced.
   The subjective symptoms of the vesicular forms of eczema are more 
ECZEMA.
257
or less intense itching and often burning.  In the very acute forms
there is considerable soreness, the patient  managing the affected  part
with  as  much  care  as if it were a  fractured limb.  In exceptional
cases, more frequently observed in children,  there is sympathetic
febrile disturbance of a mild grade.
   The discharge from the  broken  epidermis, whether directly from
the vesicles, or from the vascular elements, dries rapidly when exposed
to the air, in light yellowish crusts, M'hich are rarely  bulky.   The
extent of surface involved is variable, and the contour of the affected
patch or patches is seldom well defined, these portions  imperceptibly
shading  into the sound  skin.  The color of the area  thus diseased
varies according to the  stage of the process, being at one time of a
bright and vivid red, at another yellowish, and when  covered  M'ith
crusts or scales, undergoing a corresponding change of hue.  Infiltra-
tion of the skin occurs rapidly, so that  M'hen a portion  of the affected
integument is pinched  up between the finger and  thumb, it is found
to be thicker and less elastic than before.
   As resolution approaches, all the  symptoms described above grad-
ually decline in severity: the  serous discharge diminishes,  the redness
fades, the  limits of the  involved area are less distinct,  the  crusts
loosen and fall, aud it can be seen that  beneath the scales M'hich  have
taken the place of the oozing  and broken epidermis, a neM' and tender
epithelial  covering  has been produced.   As  a rule, for  weeks  after
the process has  completely ceased, the newly  formed epidermis has a
slightly  reddened and tender appearance, though complete resolution
is followed by  no permanent  sequelae.
   Such then being the typical -phases of vesicular eczema,  it must not
be forgotten that clinically the picture may be quite  different  from
that described.   The  types  here given are convenient for analysis
and study, however they may be commingled and obscured iu the
inflamed integument.   Like the erythematous, the vesicular forms of
eczema may precede the others, and becoming chronic, torment the
suffering patient continuously for long  periods of time, or yield,  only
to reappear at irregular intervals.

                     [D.]  Eczema  Pustulosum.

   This variety  of the disease may originate in one  of the other forms
of eczema, which, in  consequence  of the severity or  acuity of the
process,  changes from  an erythematous, papular, or more commonly
vesicular type, or the pustular lesions may rapidly form at the onset.
Usually a crop  of minute  vesicles is  first seen of  the sort  just
described,  which, after enlarging to the size of a coffee-bean, become
distended M'ith puriform contents.   These either accidentally or spon-
taneously burst, and the  fluid with  which they were distended  dries
into velloM'ish-green or darker-colored and friable crusts.   In aggra-
vated cases the  purulent  matter seems to  form directly  upon the sur-
face involved.   If the process be long  continued, infiltration occurs ;
and the itching, M'hich  in  all varieties of the  disorder is a  charac-
                                 17 
258
DISEASES  OF  THE SKIN.
teristic feature, is  awakened  as  an accompanying symptom.   It is,
hoM'ever, rarely of the peculiarly aggravated type M'hich accompanies
the erythematous and papular phases.   Pustular eczema is most fre-
quently encountered  in  the regions of the head, and in constitutions
where there  is a pyogenic tendency.   When existing on the scalp
and face there is most commonly an involvement also of the sebaceous
glands, M'hose secretion, altered  by the  periglandular  inflammation,
is  added  to  that  naturally produced   by the  exudative process.
Singular shades of mixed yellow and green, and even black, are then
to be  distinguished in the resulting crusts, M'hich later desiccate and
fall, leaving a reddened  and tender new  epidermis beneath.
   Pustular eczema, as thus observed, has been described under a great
variety of titles.   Its identity as a form of eczema was first accurately
distinguished by Hebra, in his experiments on the artificial produc-
tion of the disease upon the  surface by the external application of
croton oil.  It has been called Impetigo Figurata, Mellitagra,
Porrigo Larvalis, and other singular names, which suggest the
attempts of the  early astronomers to designate  the constellations by
their  resemblance to  the figures of animals.   These,  and many other
useless terms, have been  finally dropped  from the  nomenclature of
modern dermatology.

   The four types of eczema considered above are, as has been  stated.
sometimes encountered  in practice as distinct and unmingled forms
of cutaneous  disease,  some  of  them more commonly than  others.
To present, however, a picture of eczema as  it  is seen clinically, it
must be understood that these several 'forms, useful in the analytical
study of the disease, often become, in actual observation, well nigh
inextricably commingled.   It is this untiring interchange of features
which distinguishes all  the  results of  manifold  causes operating in
nature at one and the  same time;  and  it is  this which  gives the
inflammations of the human skin, exposed to almost every external
influence, such a manifold physiognomy.
   Like  all other inflammations, eczema may be acute or chronic.
Like all  others, too, the acute may precede, aud the chronic follow ;
or the reverse  may occur, the disorder, originating in  subacute or
insidious forms, may become chronic, and then, as the  result of fresh
or more severe irritation, develop into the acutest symptoms.   Thus
the name
                         Eczema Rubrum
has been given to the red  and angry form  of the disease,  which,
because of the free exudation of serum from its surface, has been also
termed Eczema Madidans.   In this form, the intensely red and
wounded integument pours out freely upon the surface a thick gummy
or syrupy fluid, which, if artificially removed, leaves  behind  it the
SM'ollen, angry,  and  still discharging skin, or, being  permitted to dry
where it has formed, concretes into the  thick, dark-colored and often
blood-stained crusts  already described.
   Again, the scales which usually form on the eczematous skin  toward 
ECZEMA.
259
the conclusion of the process just described,  may  prove to be the
most characteristic feature of the case from the first,  Thus on the
back of the  neck an eczematous patch  may often be seen, where the
skin  is infiltrated and covered M'ith a stratum  of thin, M'hitish scales,
the latter  having developed  rapidly upon an  erythematous surface,
and continuing for a long period as a scaly disease.   It is to this and
similar forms that the term

                        Eczema Squamosum
has  been applied.  Again, in the  regions about the  hand, the move-
ments of that organ develop  often fissures or cracks in the inflamed
and infiltrated integument, and to these fissured forms the term

              Eczema Eissum, or Eczema Rhagadiforme,
has  been applied.   They are observed wherever an eczematous dis-
order has so impaired  the elasticity and extensibility of the skin, that
its necessary movements, especially about the joints, tear and stretch
the torn integument.  It is thus seen not only on the hands, but also
on the feet  and about the ankles, the resulting  rhagades being, at
times, the  most painful of  all  the  complications  of the  malady.
Occurring  upon the bodies and the hands of those M'ho are compelled
to come into contact with irritating substances, this form of the dis-
ease finds its severest expression.

                         Eczema Intertrigo
is a name applied by several authors to that form of  intertrigo M'hich,
surpassing the limits of hyperaemia, results in an exudative process.
Reference was made to this possibility in describing  the symptoms of
erythema intertrigo, in  a preceding  chapter.   Here the  symptoms
are usually those of diffused redness of surfaces of  the skin in  close
apposition, macerated by previous  transudation of sweat, and M'eeping
with the serum which oozes from the several abraded  points or patches.

                       Eczema Verrucosum,
                                  •
or the Mart-like form  of the  malady, is occasionally observed,  espe-
cially upon the lower extremities, in  middle life or advanced years,
as the  result of long-continued disease.   The integument  becomes
thickened and so hypertrophied as to suggest the appearance of warts
closely packed  together in a circumscribed patch.

                        Eczema Sclerosum
is a  form of the  disease most frequently observed upon  the palmar
and plantar surfaces, a condition referred to in the paragraphs relating
to asteatosis.   Here is  presented  a  densely thickened inelastic in-
tegument, suggesting  the condition  of tanned leather, without the
occurrence  of any of the  other lesions of eczema described  above. As
a consequence, the perfect extension of the digits is impaired. 
260
diseases  of  the  skin.
   Most authors agree in considering eczema  as  it occurs in its acute
and  chronic manifestations.   These are,  as has been seen,  inter-
changeable conditions, the types of which possess, however, a clinical
distinctness.
                         Acute  Eczema.

   In certain cases an acute attack of the disorder is ushered  in  by
malaise, chilliness, or the  recognized symptoms of the  febrile state.
With or without these prodromata, the affected portion of the surface
becomes the seat of a burning sensation which is soon  succeeded  by
redness and swelling.  This may  occur  upon one or several portions
of the body at the same moment of time, and the disease throughout
be limited to this single area or those several  spaces; or it may extend
from one  or all to other regions.   This extension  may proceed  by
continuous development of the disease along the  surface, or an eczema
of the thigh be suddenly followed by an eczema  of the face, and this
by an  eczema of the scrotum.   According to Kaposi,  extension of
eczema by the last-described method is due to the extraordinary sen-
sitiveness  of the  skin when involved  in  an acute attack,  in con-
sequence of which the slightest friction, and  even reflex  irritation  of
the bloodvessels, produces a new focus of the disease at a distant point.
   This is  a consideration of special importance.  Patients will fre-
quently point to an acute eczema  upon several portions  of the body
widely separated, the one from the other, and urge this as an irrefutable
argument in favor of the fact that they suffer from some " poison in
the blood."
   The  tumid  and  erythematous  surface  already described  soon
assumes the features of either papular or vesicular eczema, which need
not be again detailed.  In this manner the evolution of the disease
occurs, and  may continue  for weeks, the patient, if unrelieved, tor-
mented by the itching; and, if the disease  be  extensive, prevented
from attending to his usual avocations.  Acute eczema of severe grade
will  frequently prostrate a  strong  adult, confining  him to his bed-
chamber and often to his bed.  When there is a simultaneous febrile
process, the emaciation and adynamia are proportioned to its severity.
Weeks and even  months  may*elapse  before recovery  can  be pro-
nounced complete, subacute patches of the disease lingering here and
there upon the surface, crust-hidden, scale-covered, occasionally oozing
from recrudescence of symptoms.  Recovery, even M'hen complete,
leaves the patient, it should  never be forgotten,  with a skin sensitive
to irritation and mote prone to a fresh attack  of the disease than one
long virgin of an inflammatory process.
   Such is  the  course of an attack of acute  eczema of severe grade.
Needless to say that a circumscribed patch of the skin may exhibit all
the  features  of vesicular  eczema in  an acute form; and, under the
influence  of an appropriate  treatment, be  satisfactorily relieved in
the course of a few days.  Lastly, acute eczema may be followed  by
chronic forms  of the disease, the  one passing into the stages of the
other by scarcely definable gradations. 
ECZEMA.
261
                         Chronic Eczema.
  The symptoms and pathology of chronic eczema are largely those
of the acute form of the disease.   The chief differences  to be noted
relate  to diminished intensity of the inflammatory action, or marked
tendency to  recurrence and persistence of the process,  and a pre-
ponderance of scaling and  infiltration  as  contrasted with the active
secretion and crusting of the acute phases.   It is, however, important
to remember that chronic eczema  is not only the frequent sequel of
such acute phases, but is particularly prone to recurrent exacerbations
of acute grade, during which the serous discharges, consequent crusts,
and  angry  aspect of the affected  surface,  do not  fail to reappear.
The itching so characteristic of the malady in  all its manifestations
is here also  a tolerably constant symptom.
  Chronic eczema may involve a  limited surface of the skin, or
invade  the  entire surface of the  body from the head  to the feet.
Rarely thus generally developed, it is more  frequently observed upon
circumscribed patches of the integument, as, for example,  the scrotum
or flexor surface of a joint, in which situation it may linger for years,
or even for a  lifetime, now  better and now worse, or disappearing
for brief periods only to  return with each recurrence of its cause.

  Etiology.—Eczema is a disease of both sexes and of all ages; and
is,  moreover, neither contagious  nor inherited.   The study  of its
etiology is thus to a degree  simplified.
  In manv  cases no cause of eczema can be discovered, beyond those
which operate  exclusively M'ithin the skin-organ, and  are proper  to
itself.   These are necessarily obscure, and will remain  so until we
are in  possession of far more  knowledge as to  the  complex  and
inscrutably  delicate processes by M'hich inuervatiou,  nutrition, and
new formation of the living matter of the  skin, are  both conserved
and impaired.  The  autonomy  of the integument  must be conceded
to the  extent  recognized in  other organs of the  body.   There are
diseases of  the liver which  are  neither referred  to the blood, the
nerves, nor  the action  of poisons.  There are diseases of the  heart
which can  be induced by neither rheumatism nor syphilis.   When
the etiology of the disorders  of all the viscera  is perfected, that  of
the skin displaying  the  lesions of eczema will  be  assuredly  more
distinct.
  These remarks are justified  by clinical  facts.   Eczematous affec-
tions occur  in  the persons of individuals  who are  in every respect
superb examples of good health, M'here the most thorough and careful
examination fails to reveal  for the disorder either an external or in-
ternal cause.  Eczema  occurs also in  persons who are affected with
every form of bodily ailment; those suffering from acute  and chronic
disorders of every viscus  and system of the  body;  and   even  those
affected with other disorders of  the skin.   This is only what a study
of established facts would suggest, having in view the probable pro-
portion of eczematous attacks in every thousand individuals   Such
coincidences would, however, scarcely furnish a satisfactory etiological
basis  for  the disease, unless a  certain degree of constancy  betM'een 
262
DISEASES  OF  THE  SKIN.
 eczema aud  these  disorders could be  established.   Thus eczema  is
 often  seen  in patients affected  with  rheumatism,  gout, dyspepsia,
 malaria, obstinate constipation, anaemia, scrofula, and pulmonary dis-
 orders, a  list of affections exhibiting  surely very  wide  pathological
 differences.   Yet he would prove to  be a  physician of exceedingly
 limited experience who could not select from patients under his own
 observation,  tM'enty individuals affected with any one of the diseases
 named, no single person of the entire  number having ever exhibited
 symptoms of eczema.   If figures alone were to decide  the question,
 these, and a larger list of maladies which have been named in similar
 connection, would  be  excluded in the study of the etiology of the
 disease.
   As  predisposing causes,  those operating by  inducing  systemic
 debility, many if not all the diseases named above, may be effective.
 In this way, chlorosis, albuminuria, tuberculosis, struma, gout, rheu-
 matism, uterine disease, dyspepsia, hepatic disease, constipation, and
 other gastro-intestinal disorders may  lay the foundation for a per-
 sistent eczematous attack.   In a similar May it is possible that a pre-
 disposition to this disease  may be  inherited, but, as distinguished
 from all the diseases known to be transmitted by heredity, it may be
 asserted that no child  was ever born  into the world with an eczema.
   Eczema seems, in exceptional cases, to bear some relation  to spas-
 modic asthma, sometimes coexisting with that disease in one person,
 or its  attacks alternating quite regularly with the  asthmatic parox-
 ysms.   This  may be due to the  exquisite sensitiveness of the skin,
 mucous membranes, and nervous system exhibited in some patients.
   The so-called internal causes of eczema must be, for reasons given
 above, considered  for  the  most part as  either coincidences or condi-
 tions which favor the development of diseases iu general, eczema not
 excepted.   By interference either with innervation, nutrition, develop-
 ment, excretion, or the performance of the important functions of the
 body, as M'ell as by reflex irritation of the  surface, they operate by
 inviting, aggravating,  or prolonging an eczematous attack.   Among
 these may be named :  not merely the diseases enumerated above, but
 also as physiological  states, pregnancy,  lactation, and dentition ; as
 associated with the habits of life, occupations necessitating inordinate
 fatigue of body or  mind, especially with the exclusion of sunlight;
 and lastly, as originating in the irritative  action upon the mucous
 surfaces,  of  substances foreign to the body, dietary and medicinal
 articles capable of exciting  cutaneous rashes, intestinal parasites, and
 instruments inserted and fluid injected into the mucous canals, as, for
 example, the male urethra.
   This much  premised,  it  should be  added that  every phase of
 eczema can be artificially produced upon the surface of the skin by
 the action of external irritants.   Several authors, notably those of
 French nationality, take  exception to  this  view,  claiming that the
 induced disease iu such instances is au  artificial dermatitis, but  they
 fail to point  out  the  distinctive  objective differences  betM'een  such
dermatitis and eczema.   They content themselves with observing the 
ECZEMA.
263
subsequent evolution  of the  malady, and  pronounce that to be an
eczema  which  fails to respond promptly to treatment; and that, a
dermatitis  which  is capable  of speedy relief.  The climax of such
absurdity is reached when they are shown obstinate cases of eczema
of artificial origin, and  the response is, that the induced dermatitis
gave rise to an eczema in a predisposed subject,
  One  step further and M'e are in position to estimate the approxi-
mate value of the etiological factors in eczema.  The large majority
of all  generally  recognized  and externally operating  causes of the
complaint, fail to have such an  effect in the mass of individuals.
Wdiether  any one of them be necessarily followed by the disease is
open to some question.   Even the poison ivy, a fertile source of the
disorder in  susceptible  individuals,  will fail to  influence  others.
The late and eminent  Professor Boeck, of Christiania,  when he last
visited America rubbed the tender leaves of this plant over his hands
and face in repeated efforts to produce  the disease in his own person,
aud utterly failed of the desired end.
  Respecting the numerous  agencies operatiug thus externally and
capable of producing the disease under consideration, it  is  to be re-
marked that they can  all be referred to either: solar light  and heat;
contact with foreign bodies in various vaporous, fluid, or solid states;
toxic agencies of a  widely differing nature;  traumatisms in varying
degrees; and the action of parasites.  Many of these cooperate ;  some
include others ;  and some become effective by aggravating a disease
which  others have engendered.  The reader is referred to the chapter
on general etiology for fuller consideration of this  subject.   It  will
be sufficient to note here that acids, alkalies, antimonial and mercu-
rial compounds,  mustard, sulphur, castor oil, capsicum, arnica, tur-
pentine, chloroform, ether, alcohol, and a long list  of other medica-
ments  are  capable of producing eczema M'hen applied  to the skin
externally.   The same is true of articles manipulated in many of the
trades—those,  for  example, handled  by  the grocer, the baker, the
confectioner, the seamstress,  the  ink-manufacturer, the mason, the
cook, the gardener, the laundress, the painter, the dyer, the printer,
the tobacconist, and the chemist.  Then, too, the eczema of the person
exposed to intense cold, or intense solar  light and heat, aided by re-
flection from the water, or even  by excessive artificial  heat, as the
fire of a furnace, illustrates the action of other causes named.  Pres-
sure and friction-effects are exhibited in the eczema  produced by the
contacts with gaiters, cuffs, trusses, saddles, crutches, and corsets.
  Scratching is a fruitful cause  of  eczema when the skin is  affected
with pruritus as a distinct disease, or as a symptom of other cutaneous
disorders.  Thus it  is  efficient in  urticaria, scabies, and  the prurigo
of Hebra; in the skin  bitten by  lice, insects,  bed-bugs,  and fleas
(which even without such interference  are capable in many cases of
inducing the disorder); and in the lower extremities, where the skin
is distended by varicose veins.
  Water is capable of exercising an injurious effect upon the skin to
the  extent  of producing  an  eczema, whether it proceeds  from the 
261
DISEASES  OF  THE  SKIN.
sudoriparous glands in an excessive exudation of sweat M'hich is not
duly removed by ablution, or be applied externally as a fluid in ex-
cessively cold or hot temperatures, or  in the vapors of the popular
Turkish and Russian baths, or yet again be rendered irritating by its
saline or other constituents.
  The external sources of eczematous  trouble named  above should
be regarded simply as  suggestive illustrations.  It should  be borne
in mind that every contact with the external world, sufficiently severe
or prolonged to aM'aken the resentment of the healthy skin, may be
followed by the protest of the latter in the shape of an eczema ;  and
the same may be true M'hen even the most trivial external  accidents
occur to the sensitive skin of certain  individuals particularly prone
to the disease.
  Pathology.—The pathological  changes in  eczema are those of in-
flammation  of the skin,  varying somewhat M'ith the  acuteness or
chronicity of the process, and the character and career of the exudate
furnished in  each  expression  of  the disease.  In all cases there is,
first, a  circumscribed  or  diffused  hyperaemia of  the  affected part.
This results from a series  of more  or  less rhythmical  and alternate
dilatations and contractions  of the vascular capillaries,  the  apogee of
which is persistent vascular  distention, blood-stasis, and the  condition
generally  recognized  as  engorgement  of the affected  parts.   This
engorgement becomes visible to the eye in various shades of increased
redness.   Then occurs an exudation, by M'hich a material in various
degrees of fluid  or solid consistency is added to  the tissues.   This
process is also coarsely appreciable, either by the  free ooze  of serum
from the surface, or by the imprisonment of such exuded fluid in the
chambers of  the  vesicles which  it produces, or by  an  increased
thickening of the various constituents of the skin, perceptible when
these are pinched up between the finger and thumb, or, lastly, by the
appearance of various solid  or semi-solid projections concerning the
skin proper, or, secondarily, its glandular appendages, which visibly
spring from the  involved  area.    Thus are explained the  various
erythematous, vesicular,  pustular,  and  papular  manifestations of
eczema.
  A history of the many doctrines which have been held regarding
the part played in these phenomena by  the  bloodvessels, the nerves,
and the tissues would simply exhibit  the several  steps which  have
been taken in arriving at the facts now demonstrable. The researches
of Heitzmann serve  to throw light upon this inflammatory process
in the skin in a highly satisfactory M'ay.
  As to the part played  by the epithelium,  Heitzmann1 shows  that
the initial step of the inflammation is declared by an increase of the
living matter, both M'ithin and between the protoplasmic bodies; the
former produces a coarse granulation of the epithelia due to increase
of living matter.   This increase  is evidently due to augmented afflux
of nutritive material in the stage of hyperaemia.   It is declared at
1 Transactions Amer. Derm. Association, Fourth Annual Meeting 
                             ECZEMA.                          265

the points of intersection of the protoplasmic network (the formerly
so-called granules)  by their  enlargement,  and by the shining  and
solid condition of that part of the network called  the nucleus.  The
increase of living matter between  the protoplasmic bodies is declared
in a  thickening  of the  threads  traversing  the  cement-substance.
Every particle  of the  living matter,  either M'ithin  or between the
epithelia, is capable of producing  a  new formation of epithelial ele-
ments.   Thus  is  explained  the part  played  by  the  epithelium in
the thickening  of the skin,  the  production of scales in  squamous
eczema, etc.

                               Fig. 39.
 Chronic eczema—vertical section of the skin of the forearm, a, epidermis ; 6, thickened rete;
c, hyper-pigmented layer of rete; d, enlarged papillse ; e, atrophied sebaceous gland; /, atrophied hair-
follicle; g, infiltrated corium.  (After Kaposi.)
   In connective tissue, the first manifestation of the inflammatory
process is the dissolution of the basis-substance, and reappearance of
the protoplasmic condition; by this process, and the new formation
of medullary elements which  may start from  any particle of living
matter, the inflammatory infiltration is  established.   The sum total
of the inflammatory elements which remain united with  each other
by means of delicate offshoots represents an embryonal or medullary
tissue.   In the case of erythematous eczema, the new formation of
medullary elements is scanty, and resolution is accomplished by refor-
mation of the basis-substance.
  In papular  eczema  the papillae of the  skin  are  enlarged in all 
266
DISEASES  OF  THE  SKIN.
diameters, partly owing to a dilatation and enlargement of their capil-
lary bloodvessels, and partly to the peculiar connective-tissue changes
already described.    Plastic formative inflammation may be  accom-
panied  by the  accumulation of a larger  amount of serous or albu-
minous exudation in the epithelial layer as in vesicular eczema.
  Suppuration in the epithelial layer of the  rete mucosum is pro-
duced  by the accumulation of an albuminous  or fibrinous exudate,
in consequence of which a number of epithelia are destroyed,  and by
a new formation of pus  corpuscles from the  living  matter of the
epithelial elements themselves.   Epithelial suppuration of this sort
is not followed by a cicatrix.   This is the pathology of eczema pus-
tulosum and eczema  madidans.
  The elevation of the temperature in the inflamed skin is somewhat
proportioned to the rapidity of the process.  In acute eczema, such
elevation may exceed 105.5° F. (11° C), while in chronic eczema it
can scarcely be appreciated.
  The fluid exuded in eczema, whether taking part in tumefaction
of any portion of the skin,- as in vesiculation, or  in a free discharge
from the surface, is ahvays identical.  It is a yellowish-white, sticky
and  syrupy  liquid, feebly alkaline in its reaction, depositing albumen
in abundance when treated  by heat  and  nitric  acid, and exhibiting
the characteristic features of the serum of the blood under the micro-
scope.   Exposed to the air, it desiccates in light yellowish to brownish,
friable crusts, M'hich  resemble honey or gum.
  Increase in the pigment particles distributed to the epithelia of the
rete  is characteristic of the chronic  forms  of eczema, and more espe-
cially of those  where the  circulation is  somewhat impeded  by  the
influence of  gravity, as, for example, in the lower extremities.  This
is true, however, of all diseases accompanied by an augmented afflux
of blood to  any part of the body, as, for  example, over the surfaces
of joints to  which for many years stimulating embrocations have been
applied.
  Diagnosis.—Eczema is such a protean disease  in its manifestations,
and  is, moreover, of  such frequeut occurrence,  that it  is necessary to
establish a  differential diagnosis between it and  a large number of
other cutaneous disorders.   The more important of these are named
below in alphabetical order for convenience of  reference, the distinc-
tive  differences of each being briefly appended.   It must  be remem-
bered, however, that the identity  and characteristics  of eczema  are
made clear only after a close study of all its features; and that is the
surest basis  for an accurate diagnosis in every case.

  Acne.—Acne occurs chiefly on the face, neck, and back  of the
trunk,  and its  pustular forms might  be  mistaken for eczema of the
same localities.   But pustular acne is  usually accompanied by a
deeper-seated infiltration than the similar lesions of eczema; and this
infiltration is also generally limited to the sebaceous glands or peri-
glandular tissues.   In eczema the itching is often severe,  while in
acne the subjective sensations are those  of heat or burning; come- 
ECZEMA.
267
dones intermingled M'ith the pustules of acne M'ill aid in distinguishing
the two.
   Erythematous eczema of the face is to be distinguished from Acne
Rosacea by its more generalized infiltration, its production of itching,
and its greater  diffusion  over the face; while acne rosacea is mo*re
often limited  to the  cheeks, nose, brow, and  the regions adjacent  to
these parts.   The patch of erythematous  eczema is  " hot;" that  of
acne rosacea " cold "  to the touch.   The former is  seen  in infancy ;
the latter is rare in that period of life.  Acne rosacea is also in many
cases readily distinguished by the development of visible bloodvessels
in the skin of the cheeks  or  nasal region.   Lastly, in erythematous
eczema, the lids are apt to suffer, M'hile in acne rosacea this  is the
exception.  In  severe forms of acne the sub-epidermic pus formation
and the resulting scar M'ill prove significant.

   Dermatitis.—Dermatitis, of artificial origin, is to be distinguished
from idiopathic eczema rather by its history than  by special  differ-
ences in the appearance or evolution of lesions.  In many cases the
two affections are indistinguishable.  A history  of traumatism or of
the externa] application of irritant  or toxic  articles will often serve
to distinguish the two.  Dermatitis of artificial production is usually
sudden in  its  onset, the date of M'hich  M'ill  nearly  correspond with
the time of the operation of the exciting cause.  The subsidence  of
the symptoms after the withdrawal  of the cause will also point to the
nature  of the affection.   Eczema is also much more capricious in its
distribution and career.

   Erysipelas.—Erysipelas  is  generally accompanied by  febrile
symptoms, and  iu many cases by bullae.  The affected surface  is red-
dened,  much  more  swollen  than in eczema, and exhibits besides a
characteristic shining appearance, which is ahvays absent in erythema-
tous eczema.  The line of demarcation between  the  affected and un-
affected portions of the skin is usually distinctly defined in erysipelas,
ill defined  in eczema.   Erysipelas spreads from one  point to another
M'ith a  rapidity  M'hich is  never noticed  in  eczema, the latter disease,
moreover,  exhibiting under a glass its minute papules or vesicles.  In
eczema  also, M'hen occurring upon the face in  the erythematous form,
the scalp is usually spared, M'hile erysipelas tends to  invade the scalp
and the regions covered by the beard.

   Erythema.—Eczema is  to be distinguished from the forms  of
erythema which are  due to hyperaemia only, by the presence of an
inflammatory process.  The  erythema  simplex M'hich  advances  to
exudation, at once transgresses the artificial line of distinction between
the purely congestive and purely exudative disorders.  It must there-
fore be  remembered that many eczemas begin as erythemata, and that,
clinically, the latter may represent but a stage  in  the disease process.
The discharge iu erythema  intertrigo results from  imprisoned  or
chemically altered sweat, aud M'ill not stiffen linen, as does the  serous 
268                DISEASES OF THE SKIN.
exudation of vesicular eczema, for example.   Erythema multiforme,
an affection  really on the border-line  between the two pathological
classes here sought  to be distinguished,  will  be recognized by the
absence of severe itching, and the recurrence of the disorder at certain
special seasons of the year; while E. papulosum, E.  tuberosum, and
E. nodosum, display solid elevations  of the  surface much exceeding
in size the minute lesions of papular eczema.

   Herpes.—Eczema is, in the minds of many, so associated with the
occurrence of a vesicle, that other vesicular disorders  are apt  to be
confounded  M'ith it.   But in  herpes  febrilis the vesicles are usually
grouped  about the mucous outlets  of the  body, and when  actually
under  observation exceed in size the minute  and transitory lesions
of vesicular eczema.  In herpes zoster  M'ith the limitation of the
eruption  to one  side of the body,  there is also a history of precedent
neuralgic pain.  The subjective sensation  is a decided burning rather
than itching, and there is a possibility of the subsequent production
of scars.

  Impetigo and Impetigo Contagiosa.—In these  forms of disease
the pustular lesions are usually isolated, do not  spring from an in-
filtrated surface  where other lesions may be visible, and are unaccom-
panied by the  intense pruritus which is characteristic of eczema.  The
pustules, moreover, are larger, and  the resulting crusts, as a  rule,
bulkier and darker colored than in eczema.   Again, in  pustular
eczema the cutaneous affection usually occurs in one or  more patches,
while in  impetigo a dozen or more isolated pustules may be irregularly
scattered upon the entire surface of the body.  In the contagious form
of impetigo, there may be a history of the extension of the disease
from one member of a family to another.

  Lichen  Planus.—In  this disorder  the papules never become
vesicular as  in eczema; while those  of the last-named  disease never
assume in any stage the peculiar sepia-tinted hue of the similar lesions
of lichen planus.  The latter, moreover, are  often umbilicated, are
chronic in development, frequently  symmetrical in disposition, and
are scaly at  the  flattened summit.

  Lichen  Ruber.—Here the  dull red, non-excoriated  papules,
covered  with  minute scales,  unattended  by  severe itching,  could
scarcely be mistaken  for the vivid, angry, and scratched papules of
eczema, which, moreover, are often  accompanied by secretion  from
the surface.  When the scales  covering patches of coalesced papules
in lichen  ruber are removed, the orifices of  dilated  hair-follicles become
visible.  This is never true of papular eczema.  But the important
symptoms of a grave disease in  lichen ruber, such as marasmus and
the indications of a fatal termination, M'ill not fail to attract attention. 
ECZEMA.
269
  Lupus Erythematosus.—Lupus erythematosus greatly resembles
certain forms of squamous eczema.   The greater chronicity of lupus;
the firm attachment of the scales;  the symmetrical distribution of
certain patches upon the face; the association of the disease with the
sebaceous glands; the definite border  of each involved area; and,
above  all,  the discovery of the  cicatrix M'here  it has  existed, M'ill
sufficiently distinguish the disorder.  In eczema there is usually itching,
often vesiculation, more rapid extension of the borders of a  single
patch,  and scales much more  loosely attached, than in  erythematous
lupus,  which are never provided as in the latter disease M'ith stalacti-
tiform plugs on the inferior surface.

  Lupus Vulgaris.—Lupus vulgaris is readily distinguished from
eczema by  its more chronic career, its larger papules and tubercles of
dark reddish-brown hue, and by every  one of its destructive pro-
cesses, none of which is ever recognized in eczema.

  Pediculosis.—As eczema is often induced  by lice upon the head,
pubes, or clothing, it is ahvays necessary to exclude the operation of
such causes both for diagnostic and therapeutic  purposes.  Eczema,
limited to the pubic  region  or  existing  there,  and elseM'here only
about the axillae, should suggest careful examination of the skin and
hairs for the  discovery  of the  crab  louse.   As  for  the pediculus
corporis, it should  be the  rule  of the physician,  invariable and
never to be forgotten (whatever the social position or refinement of his
patient), to search for evidence of the parasite upon the under surface
of the  clothing worn next to the  skin, at the  instant  of its removal
and while the patient supposes him  to  be busied with  the inspection
of the cutaneous lesions.  The excoriations produced  by scratching
Mounds inflicted  by body lice are usually out of all proportion to the
amount of skin disease present; and this is the most significant of all
symptoms  next to the  discovery of the corpus delicti.   Head lice may
precede or follow eczema of  the scalp, but  either they or their ova
(nits),  clinging in numbers to the hairs, will be visible to him who
looks carefully for them.

  Pemphigus and Pityriasis Rubra.—The large  isolated bullae
of pemphigus  vulgaris are  never  seen in  eczema.   In pemphigus
foliaceus the lesions are  succeeded by  the formation  of pastry-like
crusts, scaly exudation, superficial soreness, and the eventual produc-
tion of an extensive and usually fatal  exfoliative dermatitis.  The
marasmus becomes then rapidly conspicuous, M'hile, as a rule, itching
and infiltration are  not present.   The  disease known as pityriasis
rubra  is equally rare  and fatal; aud, though unattended M'ith the
production of bullae, is characterized by an equally abundant epidermic
exfoliation, itching aud infiltration being either entirely Manting or of
insignificance in comparison M'ith the other symptoms present.  The
scales  too are  papery, large, and thin;  there is no vesiculation and
moisture, aud little, if any, infiltration of the skin.   The latter  is, 
270
DISEASES  OF  THE  SKIN.
moreover,  of a uniformly reddish hue.  Both pemphigus  foliaceus
and pityriasis rubra are particularly liable to be  complicated with
chills or uncontrollable diarrhoea.  Without question,  many of the
reported cases of so-called pityriasis rubra are instances of squamous
eczema.  Here the localization of the disease to one or more patches
upon the body, the severe itching, and  the distinct infiltration of the
patch, M'ill point to the eczematous character of the disease.  Observa-
tion of such patients will finally convince the observer, in many cases,
that there is occasional weeping from the surface.

   Prurigo and  Pruritus.—In the prurigo of  Hebra, a disease
exceedingly rare in this country, there are infiltration, intense itching,
and numerous minute papules.  But the disease usually occurs within
a year or two after birth, and lasts for a lifetime, extending generally
over the greater part of the  body, sparing only the palms and soles
(which eczema does not), and is accompanied by inguinal adenopathy.
In pruritus, often  confounded with prurigo, there is itching without
disease of the skin save that  induced by the nails to relieve the sensa-
tion.  Hence, pruritus without scratching will not reveal a cutaneous
disease; while the same disorder  with  scratching will  exhibit either
excoriations, or an eczema induced  by the  attacks  made upon  the
skin.  The last is, however, rarely noted.   The distinction will  be
clear when  it is   remembered, first, that pruritus is usually of a
paroxysmal character, worse regularly at  certain hours or  seasons;
second, that pruritus not originating in a cutaneous  lesion, but in-
directly producing the latter  by the medium of the nails, never ex-
hibits as much  cutaneous excoriation as the skin  bitten by lice or
attacked with eczema.  The impressive symptoms here  are always the
disproportion between the complaint of the patient and  the visible
symptoms, and  the vast preponderance  of all lesions, when the skin
has been scratched, in those regions of the body most accessible to the
hands, such as the anterior  faces  of the  limbs, the genital region,
loM'er belly, etc.

   Psoriasis.—Psoriasis  and eczema in typical forms are distinct.
Variations from type in the direction from one to  the  other furnish
many obscure cures.
   The following are the chief diagnostic points in  psoriasis : Sharp
definition of contour of patch ;  abundance and lustrous hue of scales ;
absence of  moisture; vascularity of tissue beneath  the scales; sites
of election  on posterior  aspect of trunk  and  extensor surfaces of
limbs; chronicity   in  course;  uniformity  of  lesions; and usually
absence of itching.   In eczema: there is  an ill-defined  contour;
usually scanty scales not having a nacreous hue; a  preference for the
flexor surfaces of the extremities, though the  disease  may occur in
any portion of the body ; generally, at some period in its  course, a
history of moisture; polymorphism, as regards lesions;  and a marked
intensity of subjective sensations.   Upon the scalp, psoriasis is partic-
ularly apt to extend  beyond the  hairy border  in a fillet stretching 
ECZEMA.
271
across the upper portion of the forehead and thence irregularly down
in front of the ears;  M'hile eczema of the face, when the scalp is also
invaded, departs boldly from the hairy parts  to the lower limits  of
the forehead, the lips, nose, cheeks, or  chin, regions which are rela-
tively  spared by  psoriasis.   Finally, the two diseases, in doubtful
cases, will  generally  be  distinguished  by carefully  searching the
entire surface of the  body, upon  some  part  of which, in psoriasis,
there M'ill usually  be  discovered a  tell-tale patch of typical  appear-
ance.

   Scabies.—Scabies is really an  artificial eczema induced  by the
incursions  of the  acarus scabiei, and its  lesions  are  thus those  of
eczema.  In scabies, hoM'ever, the  pruritus is intense and the several
papules, vesicles (these  much less  closely set  than in  eczema), and
pustules are more  likely to be coincident than successive, exhibiting
thus the multiformity characteristic  of the disorder M'hen produced
by the parasite.  The discovery of the presence of the latter, especi-
ally  if there be a history of contagion and  the localization of the
disease in its sites  of preference, will at once determine the diagnosis.
Scabies never attacks the  scalp.   Its sites of  preference are, in both
sexes, the  fingers, hands,  wrists, and axillae; in women, the breast
and  the nipple; in  men, the penis; aud, in  children, the buttocks.
The presence of the acarian furrow, if the  disease has existed for
some time, aud the appearance  of minute blackish dots or points
upou or about the lesions, usually  suffice to establish the real nature
of the disease.

   Scarlatina.—This  disease  could  only  be  confounded with
certain of the varieties  of  eczema exhibiting  an erythematous type.
In scarlet fever, however,  the elevation of temperature, the  appear-
ance  of the  tongue  and  fauces,  and  frequently the  history  of
contagion,  serve to distinguish  the disease.   The  peculiar  " boiled
lobster " appearance  of the skin, and  its symmetrical distribution
over the surface of the  body, with gradual extension from the head
and trunk  to the lower extremities, are  never  seen  in  eczema.   The
finger-nail  drawn across the skin of the patient affected with scarlet
fever is  usually followed by the occurrence of a M'hitish  line corre-
sponding with  the impression made M'ith  the nail, which  is highly
characteristic  of the eruption.   Lastly, a generalized eruption  of
eczema  will never disappear M'ith the rapidity of the scarlatina rash.

   Seborrhcea.—Seborrhcea and  eczema  may coexist, either disease
preceding  the  other.   Typical  forms  of each are  readily  distin-
guished.   In  eczema  there  is  infiltration  and  much consequent
itching; in seborrhcea,  neither.   The scales of seborrhoea are more
voluminous, greasy, freely shed  from the surface, and seated  usually
upou an integument  of scarcely altered hue.   In  eczema the scales
are drv, scanty, and  more  firmly  attached to a usually  hyperaemic
base.   Seborrhcea  of the hairy  parts  is generally  symmetrically 
272
diseases  of the  skin.
diffused ; eczema, though occurring with ill-defined contour, is rarely
as symmetrical, usually more acute, and seldom followed by alopecia.
Upon the non-hairy portions of the body the same  distinctions can be
to a great extent observed.  The crusts of eczema removed  from the
face  generally disclose beneath  them  an  oozing  surface, while  the
under surface of these crusts  never exhibits  the  stalactite-like pro-
longations M'hich pass from the under surface of the seborrhceic crusts
into  the patulous orifices of the excretory ducts  of the  sebaceous
glands.

   Sycosts—Both the parasitic and the non-parasitic forms of sycosis
are limited  to the  region of the beard, M'hile eczema  of the hairy
portions of the face will usually be found to affect  other regions.  In
eczema the itching is severe, the exudation spreads  beyond the limits
of the beard, and the discharge is characteristic, while in both forms
of sycosis there is  no oozing, and  the  subjective  symptoms  are
trivial.   The  discovery of the parasite in the root or shaft of the
hair  will at once distinguish the  parasitic  forms of the disease.  Iu
sycosis,  each pustule is perforated by a  hair.   Eczema limited to the
region of the beard  is even rarer than  the two varieties  of sycosis.
The  circumscribed  indurations  and tuberculations of the  affection
produced by the trichophyton, as M'ell   as the loosening of  the  hairs
in their follicles, constitute further distinctive differences.

   Syphilis.—There  can be  no question that  several   syphilitic
eruptions resemble certain forms  of eczema.  In the eruptions due to
syphilis, however, there is usually a history of infection; of involve-
ment of the glands and mucous surfaces ;  of ulceration and cicatrices
in advanced periods; and, especially in the case of infants with an
eczema-like  eruption,  a  history of snuffles.   It  should  always be
remembered that the intense itching of eczema is characteristic of no
one of the syphilides; and that the  latter are remarkable for their
tendency to occur with a circular or partially circular outline, and to
be covered with  bulky crusts of an offensive odor. A point partic-
ularly worthy of uote is  suggested  in  the  diagnosis  of chronic
eczematous affections.   A syphilitic eruption  limited  for  an  equal
period of time to one locality will often ulcerate or exhibit evidences
of repair by scar tissue, no such lesions occurring in eczema.
   Syphilis of the palms and soles exhibits very distinctly limited
outlines in the usually circular, circumscribed  and deeply infiltrated
patches  present,  which  are often symmetrical  in development, or at
least situated on both sides of the body, even if more fully developed
upon one limb.  Syphilitic pustules   upon the  scalp  usually  rise
above well-defined ulcers.   Syphilitic  eruptions encircling the mouth
in children are less angry-looking and formidable than severe eczema
of the same region, being often  made  up of flattened  papules,  moist
or scaling, grouped in  circles about the lips, with mucous  patches at
the angles. 
ECZEMA.
273
  Tinea Circixata.—In ringworm  there  should be a history of
contagion, microscopical discovery of the vegetable parasite, distinct
contour of all separate patches, absence of marked subjective sensa-
tions  and of  discharge.  These  are not symptoms  of eczema,   In
ringworm of the scalp the hairs are  usually either brittle or actually
broken at a short distance from the  scalp; the scales are fine, dirty-
white, and not torn from the surface by the finger-nails.   In eczema
the hairs are unaffected, and their  extraction  from the  follicles is
accompanied by pain.
  In  ringworm  of the body the patches are distinctly circular; more
scaly  or papular at periphery than centre; and, moreover, yield M'ith
exceeding promptness  to the  action  of a parasiticide.   Occurring
about the thighs and ano-genital  region, the disease may be compli-
cated  by eczema, but the characteristic "festooning" of the advancing
border of the patch downward along the  thigh, or upward over the
pubes, will suggest a microscopical examination of the  scales scraped
from  the surface.

  Tinea Favosa.—The cup-shaped, friable, yellowish crusts  of
favus in the scalp might be mistaken for the crusts of eczema of the
same  part; but  here the exudation is slight; there are no pustules of
eczema, and hence no history of  discharge.  The odor, moreover, is
characteristic.   In case of uncertainty the microscope Mould indicate
the parasitic nature of the disorder.

  Tinea Versicolor.—Iu this disease, also, the microscope M'ill
reveal, beneath the epidermal plates, the spores and filaments of the
vegetation M'hich produces  the ailment.   From eczema it is easily
distinguished  by the absence  of infiltration  and  of any history of
inflammation, by the very slight  subjective sensation it  produces;  by
its peculiar fawn to chocolate-colored, slightly yellowish patches, M'ith
superficial furfuraceous  desquamation, limited often  to the  anterior
surface  of the trunk, and readily removed by the action of a para-
siticide.

   Treatment.—It  is  proposed to describe  here  the  treatment  of
eczema in general, reserving the consideration of the treatment of the
forms occurring in  particular localities  of the body  to  the pages
M'hich follow, and M'hich are  allotted  especially to such  local mani-
festations of the disease.
  In  acute eczema, as well as iu  many of the chronic  forms of the
disease,  the first and  most important  requisite is  that M'hich is the
simplest, and, perhaps, for that reason most  commonly overlooked.
This requisite is the exclusion of a el sources of irritation.
  This  completely secured, a  large  number of cases of the disease
will proceed to a prompt recovery without any other treatment what-
ever.   Failing this,  acute  become chronic  phases of the disease; or
there  is  a history of exacerbation, recurrence, or development of the
disorder  in  new" and perhaps  distant portions of the body,  from
                                is 
274                diseases of  the skin.
reflex  irritation or augmentation of the sensitiveness of the skin  to
other sources of mischief.
   The  exclusion of all sources  of irritation  necessitates,  first, the
withholding  of all harmful internal  medicaments.  The number of
patients  presenting themselves for treatment of this disease, both  in
dispensaries,  hospitals, and  in private  practice, who have aggravated
their eczema  by the medicaments they have  swalloMed, is incredibly
large.   Men  and  women, infants and  adults, those M'ho have been
under the charge of physicians, and those M'ho have purchased their
drugs  of the  apothecary at the suggestion of the latter or of their
friends, exhibit  patches of acute  or chronic eczema, intensely aggra-
vated by the  injudicious use of arsenic, iodide of potassium, bromide
of potassium, Donovan's solution, and other harmful preparations
contained in  the various  "blood-purifying" remedies sold in the
shops.  The  practitioner whose  patient  comes to him after making
trial of any such remedies, is strongly urged to set aside carefully the
operation of such mischievous agents, and to watch the eruption care-
fully, M'hile their effect is  vanishing.  The result is often marvellous.
   The exclusion of all sources of irritation necessitates, in the second
place, the avoidance of all  injurious  external  contacts.  Only gross
ignorance or carelessness M'ill overlook the fact that  the  inflamed
skin, like the inflamed bone or the inflamed bladder, calls imperatively
for rest.  The  prevalent  idea is, however, that the patient w ith  an
inflamed joint  retires to his couch  or bed, M'hile the patient with an
eczema, unless his disease  is so formidable as to necessitate temporary
withdrawal from the pursuits of business or pleasure, belongs always
to the peripatetic class.   He consults a  physician, swallows  some
medicine, anoints his eczematous skin with a salve, and  returns  to the
vocation where his complaint was begotten,  just as the man with a
gonorrhoea will  occasionally solace himself by embracing the source
of his affliction.  The baker goes to his baking; the seamstress still
pushes her Meary needle through the dyed fabrics which first injured
her hands; the man with an  eczema of the thigh M'alks  the  street
with his troM'ser leg rubbing the affected surface; the nursing mother,
with an eczema of the infra-mammary region, still suffers  the milk,
chemically altered in the heat of the summer, to flow over the tender
surface  of the breast;  or,  in the  case of her  infant  affected  with
eczema, stuffs the  folds  of a coarse  diaper,  half laundered or yet
covered M'ith  the dejections from the bowels, betM'een  its thighs and
over the anal region.
   Next is involved the exclusion of all topical irritants in the hands
of either physician or patient, designed to relieve the disorder but
having a precisely opposite effect.   The number and variety of these
articles are far from being  commonly appreciated.  Some are  useful
in advanced stages of the disorder, and  harmful in its earlier periods.
These are generally ordered by persons with a  limited experience in
diseases  of the  skin, and include a  long list  of stimulating and
astringent ointments.   Some are employed in sheer ignorance of their
effects, as,  for example, crude petroleum, strong acids and alkalies, 
ECZEMA.
275
nitrate of silver, turpentine, and concentrated solutions of corrosive
sublimate, intended to "burn out" the disease.
  Lastly, the exclusion of all sources of irritation necessitates saving
the involved  surface from the excoriations  and  other traumatisms
produced by scratching, rubbing, and excessive M'ashing of the eczem-
atous skin.   In the case of adults  some restraint is here needed; in
the care of  infants, this restraint may need to be enforced.
  This is the only proper treatment  of eczema.   That which is con-
ducted M'ithout regard to  this, is unworthy of the name.  The methods
of treatment  about to be described in detail, are  to  be regarded as
entirely auxiliary to the  measures and precautions suggested above.
If the latter could be perfectly secured in every case, no other treat-
ment M'ould be required.   If the patient protest that he must continue
his vocation ;  the  hands of the  sugar-baker returning to their accus-
tomed manipulations; the feet of the busy pedestrian to the frictions
incident to his daily locomotion, then let both, physician and  patient
distinctly understand the facts  of the case.   The former advises the
speediest method of relief; and the latter elects  a slower and more
uncertain course.   In  doing this he should  be  made to understand
that the responsibility is, to that extent, to be borne by himself. What
competent   surgeon  consents to  be responsible  for that fracture in
which the extremities of the bone are daily subjected to movement
on  the part of the patient?
   The  great  importance  of rest and freedom  from irritation of all
sorts in eczema  is Mrell illustrated by two classes of cases.  There is,
first, the newly born infant, whose sensitive skin responds  early to
its first  harsh acquaintance M'ith the outer world, by an explosion of
eczema.  But it is a fact  of singular importance that no child is born
into the world eczematous.  If the  nervous system Mere responsible
for eczema,  such a result  might occur, for that system is not  only
capable in intra-uterine life of producing club-foot and other deformi-
ties, but also of influencing skin  disorders.   The author has reported
a  case  of  pigmentary moles  at  birth, and other observers  have
described similar  facts M'here the lesions were distributed exactly in
the situation  of herpes  zoster of  the trunk, along the  lines of the
intercostal   nerves.  If the  blood  were responsible for  eczema, the
foetus  surely might display its lesions, as it  does those of syphilis.
Animal poisons, as those of variola and scarlatina, do not spare the
unborn child.   Nor is it  exempt from certain diseases of the integu-
ment which are generally regarded as due solely to  tissue  changes,
since newborn infants are occasionally seen  affected  with ichthyosis
or sclerema  neonatorum.
  Why is the tender  skin  of the foetus  saved  from  every form of
eczema, and the tender  skin of the infant accessible  to all  by such
various approaches ?  Will it be responded that the child has begun
to respire and digest for itself; that it has  become suddenly strumous,
dartrous, rheumic, arthritic, gouty, or  herpetic;  that  its standard of
health is impaired ; that it is suffering from assimilative, nutritive or
nervous debility, or from  any one  of the other numberless perturba- 
276
DISEASES  OF  THE  SKIN.
 tions to which eczema has been  ascribed?   For him M'ho can divest
 himself of all prejudice, there can be  but a single ansM'er  to the
 question.   The difference between the  child  unborn and the child
 born is, as regards eczema, a difference  solely  of skin protection and
 skin exposure.  The former  enjoys M'hat Dr. White has aptly termed
 a "prolonged, placid, subaqueous life."  Anointed with unguent and
 immersed in  its water-bath of grateful  temperature, its  skin cannot
 be  fretted to  produce  an eczema.  The latter,  abruptly and  often
 rudely brought into contact with the  outer  world, may  speedily
 exhibit the most formidable symptoms of the disease.
   The second class of cases to which  reference is  made, exhibit the
 reverse of this  picture,  and  are best observed in  hospital  practice.
 Attacked with such severe symptoms of the disease as to justify admis-
 sion to these charities, eczematous patients, usually impoverished  in
 their resources  and often injured by exposure during severe bodily
 toil, rarely fail to  improve greatly during the  course of a few days,
 when no treatment of an active sort has been adopted.  In the larger
 number of cases, while  waiting to study the evolution of the disease,
 one is limited  to the observation of its involution.   The mere rest  in
 bed in a recumbent position, with a proper regulation of the  diet and
 exclusion of all sources of irritation, has  here been sufficient to secure
 relief.
   If any apology  be  needed  for the space devoted  to this part of an
 exceedingly interesting subject, it must be based upon the great fre-
 quency of the  disease; the  wide  diffusion of erroneous doctrines
 respecting its  nature  and  the  method  of its management;  and the
 mischief resulting  from the too common aggravation of the disease
 in its earliest manifestations.
   The dietary allowed the eczematous patient should be limited to the
 most digestible articles of food, and  should exclude those known to
 be capable of exciting cutaneous irritation,  a  list of M'hich is  given
 in the chapter on urticaria.  A moderate use of fresh meats, cooked
 vegetables,  and  fruits may  be permitted,  but  starchy articles in
 excess, hot breads and  cakes,  pastry, confectionery, cheese, pickles
 and  pickled meats, cucumbers, cabbage  both raw and cooked, pars-
 nips, turnips, beans,  oatmeal, cracked wheat,  peas, celery, shell-fish,
 salted fish  and meats,  pork and veal  should be avoided.  Milk,
 when not the source of constipation, may be drunk.   Coffee,  tea,  and
 cocoa, are  in the doubtful list;  as these are positively  injurious to
 some patients,  and apparently  without effect in  others.  Tobacco
 should always be cut off from male patients suffering from anything
 like  a serious  eczematous attack.  Alcohol in every form is  contra-
 indicated save  in such conditions as debility or  previous habitual use
 iu moderation by persons of advanced years.
  Internal treatment,—In  the management of acute eczema, cooling
draughts are useful; and  in  all cases occurring in patients  M'ho are
plethoric, who are constipated, or who suffer  from other symptoms of
imperfect excretion, aperients and catiiartics are needed.  Often a brisk
mercurial purgative may be ordered at the outset in the form of blue 
ECZEMA.
277
mass or the compound cathartic pill.   The rhubarb and soda mixture
answers well in some cases.   Podophyllin, irisin, and eupatorium may
be substituted for these.  The saline cathartics, M'hether employed in
medicinal formulae, or in natural mineral Maters, such as the Hathorn,
Hunyadi Janos, or Friedrichshall, are  exceedingly useful in the man-
agement of  most cases.  The  following is  a valuable combination
often advised for cases M'here both iron and  the sulphate  of  magne-
sium arc indicated:

        R. Magnes. sulphat.             Jij;           64
            Acid, sulphur, dil.          f'3ij ;            8
            Ferri sulph.                 £)ss;             66
            Sodii chlorid.                 3j;            4
            Cardamom, tinct.  comp.       f3j ;            4
            A q. dest.                 adOs's;          256      M.
        Filtra.  Sig.  A tablespoonful before breakfast in a tumblerful of
                  cool or hot water.

   in some cases of renal  derangement, the alkaline diuretics  are
indicated, such as the potassium acetate, carbonate, or citrate, adminis-
tered with nitre, squills, caffein, or the benzoate  of lithium in three
to five grain (0.26-0.33) doses before meals (Piffard);  and, in gouty
cases, colchicum, Vichy water, etc.  In patients  suffering  from acid
dyspepsia, the liquor  potassae, sodium bicarbonate, or  ammonium  car-
bonate  may be required.
   Aloes and iron, or aloes aud ergot  are often indicated in special
cases.   The late Dr.  Tilbury Fox employed  in cases  M'here diuretics
and  alkalies were both indicated, a formula of this kind :

        R. Magnes. sulphat.            ^ss;           161
           Magnes. carbonat.            3j;           4
           Colchici. tinct.              f3ss;           2
           Menth. pip. ol.              rri^ij;             2
           Aq. dest.                   fijvj;          192       M.
        S.   Two tablespoonfuls in a wineglassful of water every three or
                  four hours.

  Cod-liver oil is indicated  in all  cases of struma and tuberculosis;
phosphate of lime in bronchitis; steel in anaemia and chlorosis.
  In fleshy children affected m ith eczema capitis, calomel  internally
is a  valuable remedy, one  to two  grains  (0.06-0.133) of calomel,
with  two to  three (0.13-0.26) of rhubarb  rubbed up  M'ith  five of
calcined magnesia (0.33) may be given once  in the day to  an  infant;
or one-twentieth of a grain  (0.003) of calomel rubbed up  M'ith sugar
of milk, may be given three  times daily, for ten or tMelve days.  Van
Harlingen  advises small doses of the unspiced syrup of rhubarb, with
or M'ithont magnesia, for the constipation of infants, or from one to
three drachms (4.-12.), each  of poM'dered rhubarb and the bicarbonate
of sodium in four ounces (128.) of peppermint M'ater, of M'hich a tea-
spoonful may be  administered  tM'o or three times daily.   Quinine,
strychnia, the syrup of the iodide of iron, and the wine of iron may
also  be  used M'ith  advantage M'hen indicated in these little  patients.
  Beside the articles  enumerated above may  be named the following, 
278
DISEASES  OF  THE  SKIN.
which, after internal administration, have  been reported as efficient
in the hands of various authorities :   Calx sulphurata and  viola tri-
color (Piffard);  hyposulphite of sodium, ichthyol,  chrysarobin, tar
(for adults, two drops of purified pix liquida mixed with one-eighth
part of rectified spirit, gradually increased—Anderson); carbolic acid,
sulphur, aud hydrocotyle Asiatica.
   If the remarks which  have preceded are justified by the clinical
and pathological history  of eczema, it folloM's  that  there is no con-
stitutional  treatment of  the  disease,  save that M'hich excludes all
sources of irritation, a point  to  M'hich attention  has  been already
called.   Once fully persuaded of  this important truth, the physician
should be capable of managing the complaint without mental bias in
the direction of futile experimentation with drugs.
   The treatment of the  patient, however, may be in one  sense re-
garded as the treatment of his disease, though a very large number
of eczematous patieuts are,  except as  regards the skin, in conditions
of health.    Constitutional  treatment, to meet any  general conditions
of ill  health, should be,  in short, such as is  made familiar to the
physician in his experience  as a general practitioner of medicine.
   Mention has been made of but few of the  disorders  in  the long
list  M'hich may coexist M'ith  eczema.   Some  male  patients M'ith  a
gleet have  an eczema of the thigh, kept  up by the discharged secre-
tion, M'hich calls for treatment calculated in a very indirect manner
to relieve also the cutaueous disorder.   The same may be said of an
otitis externa ivith a purulent discharge, and  of other local  and con-
stitutional  ailments which the skilled  physician should be competent
to recognize and treat.   Be it clearly understood the while, that all
such  treatment  will not  relieve an eczema.    It simply places  the
patient in the most favorable condition for getting rid of local trouble.
If  one has  had the  opportunity of observing a large number  of
eczematous patients of every social class  treated by internal medica-
tion of the character approved by those who still cling to a  belief in
the constitutional nature of the disease, he will see that the statements
here  made  are  based  upon a conscientious study of this experience,
and of the results of personal experiment in the same direction.   He
who desires to  build  solidly will  not  lay  his corner-stone upon  the
shifting sands,  M'here so many have been disappointed before him.
   Bearing in mind the fact that  an  eczema M'ill occasionally vanish
under even the worst mismanagement, the value of arsenic adminis-
tered internally for its relief should be duly estimated.   It  is an un-
certain remedy in all cutaneous diseases ;  it is as uncertain in eczema,
and has unquestionably aggravated as many cases as it has relieved.
Its value in chronic and persistent forms  of the disease is attested by
men of distinguished reputation ;  and upon such authority it mav be
conceded a position among  the  internal remedies for the malady of
possible value.    It  is  indeed  not as  remarkable that a few patients
annually recover under its administration, as that more do not attain
the same fortunate end; for it is the favorite dernier ressort in chronic
scaling diseases  of the  skin with  physicians of every grade of pro- 
ECZEMA.
279
fessional proficiency; and,  having in view  the  large percentage of
eczematous  erases M'ith  which they are confronted, it is a  curiously
suggestive fact that the position of arsenic in eczema is  yet open to
discussion.  If arsenic, which certainly does  possess an influeuce over
the skin, cannot to-day be demonstrated to have  therapeutic value in
the large proportion of all cases of eczema, what can be said for the
host of other drugs, too commonly employed for a similar purpose,
which are inferior to arsenic in their cutaneous  effects ?   Sunlight,
fresh air, suitable  clothing, and due  regime as to pleasure  and busi-
ness—these must be, for many patients, controlled by the physician.
They do not cure eczema.   They may do much to aid in its manage-
ment; they may  do more,  if neglected,  to furnish sources  of its
aggravation.
   External treatment.—The most  soothing applications M'hich  can be
made to the skin affected with acute eczema are, in various propor-
tions and combinations, water, oil, dusting powders, and occasionally
ointments.  These M'ill be separately considered, but two important
circumstances must be remembered in  their employment—first,  that
au article which will be grateful to the skin of one patient may prove
irritating to another, the two being to all appearance similarly affected;
second, that M'here the  surface is  broken, from  rupture of vesicles,
excoriations, abrasions, or fissures,  an applied  fluid should  be of
greater specific gravity  than the serum which is  exuded, since  other-
wise endosmosis and exosmosis will  occur, and the surface in  conse-
quence become more tumid aud painful.
   Olive or other bland oils may be  poured  over the surface, applied
upon folded pieces of lint, or used by iuunction.  Even these sub-
stances are  at  times, hoM'cver, the sources of irritation.   They are
made more  soothing by combination with an equal  part  of  liquor
calcis, as iu the Carrou oil, constituted  of equal parts of  linseed oil
and lime-water.   For the linseed oil it is frequently advantageous to
substitute cod-liver oil, palm oil, oil of sweet almonds, neat's foot oil,
olive oil, or lard oil, flavored very slightly with bergamot or lavender
to correct the disagreeable odor.  In combination with equal parts of
lime-water,  one of these may be gently smeared over the surface, M'hile
a piece of lint, saturated with the same preparation, is also applied.  In
many  cases the value  of this  dressing  is greatly enhanced by  sur-
rounding the whole with oiled silk or other impermeable tissue.
   The dusting powders, described in the chapters on General Thera-
peutics and the Ervthemata are available  in many cases where the
surface of the skin is, or is not, broken.  These  may be composed of
lycopodium, magnesium, boric acid, bismuth, talc, the oxide of zinc,
and camphor M-hen au  anti-pruritic effect  is  desired, in combination
M'ith finely powdered starch.  The Anderson powder, the formula for
which has been already given, is a  useful combination  of  camphor,
starch, and zinc.   In their preparation it is of prime importance  that
they be made perfectly  impalpable by sifting them carefully through
silk bolting-cloth, as they are sources of irritation M'hen  they contain
grain-like  particles of untriturated material.    The  finely  bolted 
280
DISEASES  OF THE  SKIN.
" Oswego gloss starch," " corn starch farina,"  and rice flour, sold by
the grocers, either  singly or in combination with the other articles
named, are generally accessible, aud prepared at hand.   It M'ill often
be of advantage, where exercise in  the day is not  to be prohibited, to
employ one of the  oily preparations  during the night, which can be
removed in the morning by a M'eak alkaline  bath containing borax
or the sodic bicarbonate, while the  patient employs a dusting-powder
in the daytime.   This can be  freely dusted over the surface, as also
over the  soft lint in contact  M'ith the eczematous skin, the stocking,
gloves, or suspensory bag being also M'ell protected by the powder on
its inner face.
   Water is of value in many  cases when properly applied.   Excessive
M-ashiug  of the eczematous  surface  is  not only  disagreeable  to the
patient,  but irritating  to the inflamed  skin.  Hot water,  applied
either as a  lotion,  bath, fomentation, or  by sponging, is frequently
grateful and alleviates the itching.   If employed at all, its use should
be immediately followed, as  soon  as the part is  carefully dried, by
the other medicament selected for topical application, such as an oily
or fatty substance, or a dusting-powder.
   Cold Mater is of service only M'hen it can  be continuously applied,
as its intermittent employment is followed by a vivid reaction in the
skin capillaries, whereby the itching  is greatly increased.  Thus are
explained many of the nocturnal exacerbations of  the disease, notably
those occurring soon  after the patient retires to his or her bed.   A
cold bathing of the part before retiring has  beeu  followed  by a tem-
porary calmative effect, the blood  being  driven from the capillaries
by the contraction of the tissues.  The  return of the circulating fluid
in excess has then been aided by the  Marinth retained by the bed and
the bed-clothing.   The continuous application of cool or cold water
requires  a  constant supply  of the fluid from a reservoir of fixed
temperature, and the  exposure to  the  air of the part to which the
dressing  is  applied.  Thus evaporation is not checked;  and M'hat is
intended to be a continuous  cold dressing is not  transformed into a
hot fomentation.
   Such fomentations are, however,  frequently grateful to the patient's
skin, and at times fulfil a good purpose.   They are applied by dipping
pieces of soft  cloth in  hot  water, applying them  neatly over the
affected  surface, and  covering them  with oiled silk, rubber cloth, or
the " protective material" employed  in antiseptic surgical  dressings.
Poultices of flaxseed, elm bark, or other bland materials  operate in
a similar manner, but are chiefly useful  in  softening crusts or other
morbid concretions upon the surface.  When too  continuously or too
frequently employed, they are productive of harm in their macerating
and relaxing effect upon the skin, M'hereby its  natural tonicity and
instinct of self-repair (if such a term be permitted) are to a degree
obtunded.   They are hence but little used in eczema.   The combined
employment of M'ater and fatty substances is an exceedingly valuable
method of soothing the eczematous  skin, but, with  the means accessible
in the private practice of many physicians, can rarely be secured.   It 
ECZEMA.
281
certainly approximates most closely the sebaceous envelope and  warm-
water bath of foetal life.   The eczematous skin is first anointed  gently
M'ith a bland  unguent, such  as mutton tallow, suet, cold  cream, or
vaseline, and is then immersed in a  bath of Mater kept continuously
at the  temperature of the blood.   In the case of the Wer extremities
this is accomplished without great difficulty.   Less perfect than this
is the anointing of  the surface and the subsequent application of a
warm  fomentation,  by strips of soft  lint dipped in the M'ater,  super-
imposed with neatness, and subsequently covered M'ith the protective
gauze.   Imbibition of fluids by  the skin is prevented  by its careful
anointing;  and,  M'hen immersed  in  the Mater, the pressure is both
uniform and gentle.1
   Medicated water in  baths and  lotions plays an  important  part in
the treatment of acute eczema.  The liquor calcis  with calomel, half
a drachm to one drachm (2.-4.), and  pure glycerine or mucilage half
an ounce (16.) to the pint (512.) ; the lead and opium wash ;  glycerine
one drachm  (4.) to liquor plumbi  subacetatis four  ounces (128.); car-
bolic acid  one drachm  (4.), and  glycerine two drachms (8.) to one
pint (512.) of camphor  or lime water; a decoction of opium, made
by boiling  five to ten grains (0.33-0.66) of  powdered  opium in  a
pint (512.) of  Mater, M'hich is strained  and  rendered demulcent with
mucilage;  sulphate of zinc ten to thirty grains (0.66-2.) to  the pint;
dilute  hydrocyanic acid two drachms (8.) to the pint of water;  these
and  similar lotions, the ingredients  of which are changed to suit the
indications of each case, often  serve to alleviate the itching, and in that
proportion to  diminish the  intensity of the disease.   Dr. White,  of
Boston, after bathing  the parts for  several minutes  with  the  lotio
nigra,  dilute or in  full  strength, gently smears  the surface  with a
small  quantity of  the oxide  of  zinc ointment, or, in M'inter, four
scruples (5.) of powdered zinc  oxide to half an ounce  (16.) each  of
cold cream  and vaseline.   Dr. Taylor,  of  New York, has suggested
the following::
. Liq. plumbi subacetat.	3i.i;	s
Opii tinct.	Su;	64
Carnphone tinct.	li;	32
Glycerinse	3u;	64
                                                               M.
         Sig.  To be mixed with a quart of water and applied on lint.

   To this solution, a greater  astringent  effect  can be  given  by the
addition of the subuitrate of bismuth, or  oxide  of zinc, half an ounce
(16.) of either to the pint (512.) of the lotion.
   Dr.  Duhring, of Philadelphia, has greatly popularized the use of
the fluid extract of grindelia robusta in the proportion of one part to
four of water, as a lotion in eczema.  Many patients will in this way
secure relief M'hich  they cannot otherwise obtain.

 1 A convenient method of making the applications described above, is by the aid of spongiopiline
The eczematous surface is first anointed with a bland, neutral unguent, and then covered with a piece
of spongiopiline, cut to the required size, sewn to a somewhat larger sheet of oiled silk or Lister pro-
tective, so that the edges may project on every side. The whole is retained in place by a flannel or
muslin bandage, to which the edges of the impermeable material are attached by stitches. The spongio-
piline is moistened with  pure or medicated water, as desired, of a  temperature uearly that of the-
Btomach, and may be re-moistened from time to time. 
282
DISEASES  OF  THE  SKIN.
  Other useful lotions contain finely levigated calamine, one to two
ounces (32.-61.) to the pint of rose-water, with a  small  quantity of
glycerine, and, if the itching be severe, in addition  half a  drachm  (2.)
to* one drachm (1.) of dilute  hydrocyanic acid.   Boric acid, one to
two  drachms  (1.-8.) to the pint of an opiated wash ;  thymol,  one
part to one thousand ;  and borax or the bicarbonate of sodium in the
same proportion, containing, besides au equal  proportion of alcohol,
spirits of camphor,  or chloric ether, is also available.  With any of
these it is proper to  moisten frequently the soft lint upon which they
are applied, and this after ablution with  hot,  pure or slightly  medi-
cated, water, for the purpose of relieving the itching.
   Van  Harlingen uses also poultices made of crumbs of bread mixed
with ice-cold lead water, M'here the skin is oedematous.
   From M-hat has preceded, it will be clear that the chief end in the
treatment of an acute eczema, is the relief  of the subjective sensation
of itching, and the exclusion of all irritants, the two being practically
one.  That M'hich is not  grateful to the skin of a patient thus com-
plaining, had better be, for the time at least,  abandoned.  So great
is the difference between different patients as to the toleration by the
skin of various topical remedies,  that it is  well, as  a rule, at the time
of the first consultation, to order an alternative treatment, the one to
be  immediately  substituted for  the other,  if such necessity  arise.
Especially is this true in cases where the epidermis is wounded,  and
where the patient can sometimes  M'ith comfort  to himself exchange a
dusting  poM'der for  a  lead  wash, or a weak carbolized oil and lime-
water lotion, M'hile his eczema is tormenting him in different degrees
at different hours of the day.
   The  necessity for this relief is so imperious that at times  it over-
shadows all other symptoms of the disease.   He who has  never
studied the case of a man or woman possessed  with a furious impulse
to relieve an intense eczematous  pruritus, has  not yet completed an
education  in  medicine.   The fury,  for such  it really is, has been
likened to the sexual orgasm, with which  it is undoubtedly allied, as
the  two are not rarely coincident M'hen there is severe anal or genital
itching.  The features  of the patient are  drawn ; he  is but  half
conscious of  his  ejaculations  and surroundings;  with  his nails or
other object which he  employs  he attacks  the  too vulnerable skin
with an  incalculable  savagery.   In  these  exaggerated  paroxysms,
nothing but  blood  M'ill suffice for his relief.   Not till  the torn and
wounded surface oozes with red drops at every point does he emit the
sighs which indicate that his desire  is satisfied.   Men  and  women
forcibly withheld from doing themselves  this  severe damage, will  at
times, exhibit muscular spasm, facial expression,  and movements  of
the  body, scarcely distinguishable from the symptoms of an epileptic
seizure.   This brief outline of a picture  familiar to those M'ho have
had experience of exaggerated cases, will serve to  enforce the need of
the utmost care  in  selecting a topical remedy in  acute eczema, the
greatest gentleness in its application, and  the  nicest provision for the
special needs of each individual patient. 
ECZEMA.
283
  In proportion as the disease progresses to a subacute or  chronic
stage, the various topical  medicaments employed  may be changed in
character so as to produce au  astringent or stimulating effect upon
the part.  The utmost  skill and  prudence, however, are needed at
this juncture;  and M'hen uncertain  as to the proper course, it is M'ell
to continue the  dusting powder,  oleated lotion  of  lime-M'ater,  or
whatever other article may be externally employed.  For it is at this
time that the disorder is readily awakened to renewed activity, a turn
of affairs M'hich is especially annoying  to the patient,  and  particu-
larly so to the practitioner if there be a suspicion (truth to say, often
too well founded) that the aggravation has been due to the treatment.
It goes M'ithont saying, that the routine practice  in eczema has  long
been to order an application of  the benzoated oxide of zinc ointment,
irrespective of particular features of the  malady in  any individual
case.   Now no greater error in this special direction could be  com-
mitted.   The  acutely  inflamed skin will rarely tolerate the  most
perfectly medicated ointment;  and  as this acuteness  subsides, such
tolerance is first to be carefully tested, as, for example, by applying
a weak  ointment  to a part only of the affected  surface.  The  term
rarely is, hoMever, here used advisedly.   AYith  that singular capri-
ciousness M'hich distinguishes the  eczematous skin of different  indi-
viduals, the zinc ointment occasionally affords very great relief in the
severest forms of acute vesicular disease.
   In  the application of such  ointments  it should be  remembered
first, that they must  be sweet and freshly and carefully prepared;
second, that they can be advantageously applied by gently  rubbing
them into the  part  by the tip of the fiuger, after M'hich soft lint in
strips, spread with the same  material, may be neatly superimposed ;
third,  that an ointment, if selected, need not necessarily be applied
to every part of the inflamed skin, since a little pad or  circlet of lint
may be  applied only to an oozing or pustular patch;  lastly,  that the
debris of one dressing should be  carefully removed before another
application is made.  Strata of any ointment, the older  next to the
skin possibly  rancid and  having imprisoned beneath  them pus or
other  products of the disease, are positive sources of harm.
   The most soothing ointments for use at this stage are  the benzoated
oxide  of zinc salve M'hich may be reduced M'ith cold cream one-half or
more for extremely sensitive conditions of the skin ; Hebra's diachylon
ointment, described later, of M'hich one  part  may be combined with
three  or four parts of vaseline or  cold  cream and from five to ten
grains (0.33-0.66) of salicylic  acid added to each ouiice (32.) of the
whole; or the oleate of bismuth, prepared according to the formula of
McCall  Anderson  given below.
   Appended  are a  few formulae for ointments useful in this stage of
the disease:
         R. Zinci oxid.                  3ss;
            Hydrarg. ammon. chlorid. gr. v-^ss ;
            Camphor, pulv.           3ss-3j ;
            Ungt. aq. ros.                 J;j;
2-4
 32
33-66
M. 
284
DISEASES  OF THE  SKIN.
  For the oxide  of zinc  may  be substituted  the  subnitrate or the
subcarbonate of bismuth, or from two to four grains  (0.133-0.266) of
the red oxide of mercury, or from four to ten  grains (0.266-0.666)
of the mild chloride, or from ten grains to  half a drachm (0.66-2.) of
the ammonium chloride.   The cold cream makes an agreeable basis for
these  ointments,  though  lard, simple  cerate, lanoline,  vaseline, or
equal  parts of vaseline and the other preparations answer a good pur-
pose.   The cerates are made sufficiently soft for gentle manipulation
by adding a  drachm (4.) or two  of glycerine  to each ounce (32.) of
ointment, and may be flavored M'ith lavender, rosemary, or bergamot
to suit the taste.
  The oleate of bismuth  or zinc is  prepared  by rubbing up  one
drachm (1.) of the oxide of either  metal M'ith eight (32.) drachms of
oleic acid, which is then allowed to stand for two hours.  It is after-
ward heated in a water bath, M'hen ten drachms (40.) of  vaseline and
three  (12.) of Max are dissolved in it, the  whole to be stirred  until
cold.   It is especially useful in the papular forms of eczema.
  The well-known diachylon  ointment of  Hebra occupies a foremost
place  in all  lists of articles useful at this  period of the disease, and
even later.   It is prepared as follows:
  Fourteen  ounces of the best olive oil are added to two pounds of
water, and  heated to boiling in the water  bath.  Three  ounces and
six drachms  of an equally good  article of litharge  are dusted over
the fluid in  ebullition, M'hich is  constantly  stirred throughout, in
order to prevent the formation of fatty acids.  During the cooking,
water is occasionally  added as  required.  The stirring is to be con-
tinued till the ointment is quite cold.
  Duhring has lately modified this ointment as follows:
  One  part of freshly precipitated (from  acetate of lead) pure M'hite
hydro-oxide  of lead  is rubbed doMii M'ith two parts of water, and
well mixed M'ith six parts of the best Lucca olive oil.  Stir the mix-
ture for about two hours  over  a hot-water  bath  near the boiling
point, and then cool with constant  stirring until  the proper consistence
is obtained, and  while the mass is cooling add  one drachm  of the
oil of lavender to each half pound of ointment.   The preparation,
according to Eisner, a Philadelphia chemist, is said to contain the
oleo-stearate of lead.
  When properly prepared this  ointment is  perfectly homogeneous,
of a light yellowish color, and of the consistency of butter.   It has
been modified by Piffard, and after him by Kaposi, in combining equal
parts of lead  plaster and vaseline.   It is commonly  flavored with the
oil of lavender.  It is technically known as the unguentum diachyli
albi of  Hebra.  It may be imitated  fairly well by  melting together
two or three  parts of olive oil, and four of diachylon plaster, stirring
till  cool.
  This  valuable ointment, though useful  often in  full strength aud
even to the exclusion of all others, is yet with such  others often com-
bined with manifest advantage.   Thus a drachm  or tMO (4.-8.) of it
may be added to the  ounce (32.) of lard,  cold  cream, or cerate, with 
ECZEMA.
285
 or without  the addition of another drachm  or two (4.-8.) of the
 oxide of zinc  ointment, or even  one of the tarry preparations to be
 mentioned later.
   For the management of acute  eczema many rely to-day upon the
 salve muslins, glycerolates, pastes, etc., M'hich "are fully described in
 the  chapter on General Therapeutics.  Uuna's paste is prepared  by
 mixing  one ounce (32.) of zinc oxide with two ounces (64.) each of
 glycerine and  mucilage.   To it one per cent, of carbolic acid or sali-
 cylic acid may be added,  and the  mixture then applied with a brush.
 Veicl recommends as a mull for the face and genitals

         R. Emplast. plumb, simpl.  )  .. _..
            Sebi benzoinati        {aa^ijss;          10J
            Adip. benzoinat.             3ss;           21      M.
   [To make benzoinated sebum :
         R. Seb. taurin.                3ijss;          10]
            Benzoes. subtil, pulv.      grs. xv;           l'      M.
         Digere in balneo vapor, per horas duas et cola.
   To make benzoinated lard :
         R. Adipis                   3ijss;           101
            Benzoes subtil, pulv.       grs. xv;            l|      M.
         Digere in balneo vapor, et cola. |

   With these  may be named the  glycerole of starch, cucumber oint-
 ment, the emulsion of sweet almonds, the decoction of Irish moss, and
 the salicylatcd  paste made by combining half an ounce (16.) of vase-
 line or lanoline M'ith two drachms (8.) each  of  zinc oxide and starch,
 and  ten grains (0.66) of salicylic  acid.
   in chronic eczema it is necessary at first to  remove from the sur-
 face  all  dried  products of the inflammatory process M'hich usually
 remain upon the surface, such as crusts, scales, and masses of effete
 epidermis.  For this purpose oil is to be freely used,  and care should
 be taken that it is rubbed gently into every part of the affected patch.
 A species of oil poultice  may also be applied by saturating pieces  of
 flannel or layers of antiseptic cotton with either  cod-liver  or  olive
 oil, and covering these M'ith protective silk gauze and a light bandage.
 As soon  as the  inflammatory products are softened thcv are removed
 by Mashing M'ith  soap and M'ater, using for this purpose  either the
 ordinary  toilet soap, or, where the skin will  permit, the spirit  of
 green soap, described in the chapter on General Therapeutics.
   The Sarg glycerine soap is an admirable substitute for these articles
 when the skin  is tender, and M'here an elegant toilet  preparation can
 be ordered.   The crusts and  scales once removed, subsequent topical
application may be made as required iu each case.
   The acuteness  of the disease having  fairly  subsided, not only  as
regards the question of  time, but more especially as concerns the
question  of what the skin  M'ill tolerate, the tarry and allied prepara-
tions  become for the first  time worthy of consideration.   Valuable
indeed M'hen such toleration  has become experimentally established, 
286
DISEASES OF THE SKIN.
they are sources of positive injury when the acuteness of the inflam-
matory process has not completely subsided.
  The articles of this class most commonly employed are pix liquida
(pine tar), oleum rusci (the oil of M'hite  birch), oleum cadinum, and
terebinthina  Canadensis  (the  balsam of  fir).   The oil  of cade,  as
found in most of the shops, is inferior to  the  oleum rusci, M'hich  is
certainly the better of the two articles.  They are best applied in the
form of ointments, but are occasionally painted over the surface with
a camel's-hair brush in a liquid state.  From one-half to two drachms
(2.-8.) of the tar, in combination with a suitable quantity of the sub-
carbonate of potash, are sufficient to  add  to a single ounce (32.)  of
ointment, the proportions  suggested being varied to suit the require-
ments of each case.  In attempting to  meet such requirements, it may
occasionally  be  found  useful  to  combine  with these ointments the
oxide of zinc, the mercurial compounds, or the  diachylon ointment
of Hebra, already described.
  The following formulae  are illustrations merely of the manner  of
compounding these articles :
R. 01. rusci (vel. cadini)	3ss-3jss;	1-6
Potass, subcarbonat.	9j-3ss;	.66-2
Unguent, aq. ros.	Ij;	32
Ft. ungt.		
                                                             M.

  For the  potassic subcarbonate one-half to one  drachm (2.-4.) of
the zinc oxide may  be  substituted, or  from  two  to four  grains
(0.133-0.266) of the red oxide of mercury, or yet  half a scruple
(0.666) of  the  mild chloride.   The vehicle also of such  ointments
may be vaseline, lanoline, simple cerate,  or  half an ounce  (16.) of
either in combination with an equal quantity of diachylon ointment.
  Of the fluid preparations may be mentioned alcoholic solutions of
tar, half an ounce (16.) of the* latter to the pint (512.) of  alcohol;
and in cases M'here the detersive action  of soap is also needed, the
sapo viridis may be added as follows :

        R. Picis liquidae              f&HJ;       32-64
            Sapon. virid.            f3Jss-iij ;       48-96
            Glycerin.                   Q\;          32
            Spts. vin. rectif.           f.lviij;         256
            01. rosmarin.               f"3ss;            2       M.
        Sig. To be rubbed gently into the skin with a flannel rag.

  Dr.  Bulkley, of New York, has devised an alkaline  solution of
tar and caustic potassa, which  is especially serviceable, as it is  mis-
cible with  water in all proportions.   It is constituted as follows:
        R. Picis liquidae             .   f^jj ;          64
            Potassa? causticse            '3;j •          32
            Aq. destillat                 ^v;         160       M.
        Dissolve the potash  in  the water, and add slowly to  the tar in a
           mortar with friction.
        Sig. " Liquor picis alkalinus."  To be used diluted as a lotion.

  A drachm (4.) or more of this solution may be added to  a  pint
(512.)  of M-ater; and,  as an ointment, the same quantity to the ounce 
ECZEMA.
287
(32.) of cold cream, lanoline, or vaseline.  It should be remembered,
however, that the caustic alkali renders it exceedingly irritating to a
sensitive skin, and  it should be employed M'ith caution upon any un-
tested surface.
  The formula recommended by Spender and described in the chapter
on General Therapeutics, is a useful  means of testing the efficacy
of tar upon  an eczematous surface.  When fluid or semi-fluid com-
pounds of tar are needed upon the scalp, a drachm (4.) of the article
selected may be rubbed up w ith  an equal  quantity of glycerine, and
added to six  ounces of  Cologne M'ater (192.).
  Hebra disclaimed any special value for sulphur in eczemas uncom-
plicated  by the acarus scabiei, but in AYilkinson's and other oint-
ments, it has certainly served a good purpose.  The folloM'ing formula
supplies an ointment rather less severe, which  has practical efficacy
in chronic eczema :

        R. Picis liquid,  (vel. ol.  rusci)    ijiv ;          128
           Adipis                     ' /jj;          32
           01. olivse                   ^ss;          16
        Misce et adde
           Terebinth. Canadens. {     .. z.
           Sulphur, flor        }     aa & >          *k      M.
        Sig.  To be applied three times daily with a soft brush.

  To this  may  be  added the  green soap, if a  stronger effect is de-
sired.
  Olive or cod-liver oil  may  be  rubbed  into  the eczematous skin,
after combination M'ith  equal  parts of one of the tarry preparations;
and carbolic  acid in lotion and  ointment, M'ith  the balsam  of Peru,
though less effective, ansM'ers well  in many eases.
  Ichthyol, in ointments of the  strength of ten per cent, and  less, is
useful in  localized  patches  of  the  disease, especially of the papular
and scaling varieties.   The ammonium sulpho-ichthyol is preferable
to the natrium compound.    Its influence  upon the skin  seems to
resemble  both  that of the tars  and of chrysarobin, and cannot  be
regarded as greatly, if  at all, superior to these agents.
   Whichever article be selected,  it should be thoroughly rubbed into
the affected surface  several times in the day, after a small portion of
the skin has  been  attacked to  test its susceptibility.   Should the
redness,  itching, secretion, and  infiltration be  aggravated  by  such
application, it M'ill   be  needful, for a time at least,  to  exchange the
local treatment for  one  less stimulating.  Should, however,  the tarry
or other similar application be well borne, it should be reapplied till
it is no longer Mashed away by the ooze from the skin.   Sometimes
it is M'ell to permit  the  former  to accumulate till it is naturally  shed
from the surface by exfoliation, a course M'hich M'ill be indicated by
the absence of  all  local distress.   The new epidermis which forms
beneath such a coating, should be  for  a time protected by a dusting
powder.    Occasioning  no  further  subjective sensation, it  speedily
loses its redness and assumes a normal appearance.
  In  other cases, indicated by local  distress and exaggerated  secretion, 
288
DISEASES  OF  THE  SKIN.
 it will be found useful  to  remove the tarry application completely.
 After  saturating it for a feM' hours  M'ith oil, the surface may be
 cleansed  with a M-eak alkaline lotion, aud the tar compound then
 reapplied to the oozing skin with flannel  or a camel's-hair  brush,
 according as recourse is had to an ointment or solution.
   Hebra  used  to employ in  chronic eczema of obstinate  kinds a
 remedy M'hich  he claimed  to  be  his  ultimum refugium, and  which
 "cures every case without exception," the concentrated liquor potassae.
 The objections  to its use are, however, grave.   It produces  severe
 pain, and in inexperienced hands it is dangerous.  As a consequence,
 this distinguished dermatologist adopted  two methods M'hich  he  re-
 garded as partial substitutes for it.   The first Mas the inunction of
 the body thoroughly and firmly with  green soap, wliich was not  re-
 moved by washing, but left in contact M'ith the skin for several days,
 while the patient Mras wrapped in blankets.  The second was his M'ell-
 kuoM'ii method of  treating more  circumscribed patches of chronic
 eczema with soap washing and ointment, the process being described
' below in nearly his own language:
   A piece of green soap, as big as a walnut, is spread upon a flannel
 rag, and rubbed into the eczematous part for several minutes, pressing
 firmly the M'hile, aud from time to time dipping it into Mater in order
 to produce a better  lather.   The part is then washed free from suds
 with water, carefully dried, and the oil or ointment selected for topical
 use immediately applied  on  strips of muslin.  These are neatly ban-
 daged to the part.    The soap must be rubbed in at least twice every
 day, so long as any  excoriated points appear after its application.
 Soap rubbed into the healthy skin M'ill not be followed by such effects,
 the part  feeling clean,  smooth, and comfortable after it  has been
 washed off  with water.  The  contrast this offers to the eczematous
 parts is very striking, the latter presenting numerous  intensely red,
 raw, and moist spots.  These are all caused by the action of the soap
 in softening and destroying the layer of cuticle which was  before
 undermined by the  eczematous fluid so as to form coverings  for vesi-
 cles.  Each, therefore, represents the floor of a vesicle, the roof being
 removed.   The appearance of these red, shining, moist points after
 the first inunction suggests to  the inexperienced eye that the malady
 has been aggravated;  but they become fewer in number after each
 application,  and finally entirely disappear, the eczematous surface
 being then no more affected by the soft soap than is the surrounding
 healthy skin.
   For the production of marked effect upon different  patches  of  the
 eczematous  skin—those, for  example, upon  the  palms  and soles
 characterized by callosities, thickening, or even verrucous growths—
 a ten per cent,  salicylic acid salve  can be used after the shampooing,
 or Unna's salicylated gutta-percha plaster mull.
   Energetic effects  are also  obtained by the use of naphthol, chrysa-
 robin,  and  pyrogallol, in  the strength of from  one part to ten, to
 one part to  thirty of  salve.    It is M'ell to begin M'ith a strength  not
 exceeding one to two per cent., and gradually increase. 
ECZEMA.
289
  Frazer1 speaks highly of the application of iodoform to eczematous
patches.    It  is  employed in the form of an ointment, containing
from ten to thirty grains (0.66-2.) of poM'dered iodoform to the ounce
(32.) of cerate.
  Other stimulating articles have been found useful in the treatment
of eczema.  Among these may be named cantharides, employed as a
blister, the nitrate of silver in crayon or solution, and iodine in com-
bination with  carbolic acid.   The following formula should furnish
a clear vinous-red fluid, M'hich may be applied pure or in dilution:

        R.
Sis
Todin. tinct. 3ss;	2
Acid, carbolic, (cryst.) 3j ;	4
Glycerin.	
Alcoholis aa 3ij ;	8:
Aq. destillat. ad fjj;	3^
Iodized solution of carbolic acid.	
M.
   In cases M'here there is considerable pruritus, especially in obstinate
patches of papular eczema, the iodized  phenol of Bellamy may be
substituted for this.  The formula is:

        R.  Iodinii cryst. )             - -  _ .             .
            Acid, carbol. j             lia  3 J;            4,
        Combine with gentle heat and add an equal part of glycerine.
        Sig.  Iodized phenol; to be applied twice daily with a glass rod.

   Balmanno Squire, of London, has  suggested a substitute for the
diachylon  ointment, in  the glycerole of  the subacetate of lead.
It is certainly a valuable preparation iu many cases,  but not superior
to the other ointment named.   The "stock"  is prepared as follows :
Take five parts of the acetate of lead, three and one-half of litharge,
and tMenty of  glycerine; heat for half an hour in a boiling glycerine
bath, constantly stirring, aud  filter in a gas-oven or other kind of
heated apartment.   From one-half  a  drachm  to two drachms (2.-8.)
of this stock, added to  the  ounce (32.)  of pure glycerine, are suffi-
ciently  strong  for  application  to  the  oozing surfaces  of eczema
rub rum.
   Lassar2 recommends  that the part affected should be at  first well
soaked M'ith antiseptic oil, of M'hich  a considerable quantity  is ab-
sorbed by the  skin.   A muslin bandage, soaked in oil, is then ap-
plied, and covered M'ith oil-silk.   The oil may be rendered antiseptic
by the addition of one  to two  per  cent,  of carbolic or  salicylic acid,
or one and one-half per cent, of thymol.   Sometimes the carbolic
acid can only be borne  for a short time, as it will of itself produce
eczema.   Rape-seed oil may be used iu place  of the more expensive
olive oil;  but drying  oils, such  as  linseed  oil, are to be avoided, as
they may  cause inflammation.   In  chronic eczema, especially  in in-
fants  aud  in eczema of  the face, he recommends an ointment.   The

                   > British Medical Journal, July 10, 1881, p. 80.
                   - Annal. de Derm, et de Syph., Sept. 1881.
                               10 
290
DISEASES  OF  THE  SKIN.
formula for an ointment which cannot be rubbed off during sleep, in
eczema of the face, is :
R. Acid, salicylic.
   Zinc. oxid.
   Amyli
   Vaselin.
3ss;	2
3yj;	24
3vj;	24
ay;	64
M.
   Wyndham Cottle1  has employed chaulmoogra oil, or gynocardic
acid, in a large number of cases of eczema occurring in persons M'ith
delicate skins, and over such exposed surfaces as the face, hands, and
arms.   In both acute and chronic forms he has employed these sub-
stances in the  form of ointment, in the strength of from  fifteen  to
twenty-five grains (1.-1.5) to the ounce (32.) of vaseline.   The oint-
ment is applied several  times  in  the  day, and, if possible, kept  in
contact with the part  on  rags over M'hich it has been spread.
   Other mercurial preparations than those named above have long
been  in  favor  for  application to  localized patches  of the  disease.
Among  these  may be  named corrosive  sublimate,  the  ammonio-
chloride, the iodide and  biniodide, the two oxides, and the nitrate.
   Calomel, which is exceedingly useful in the strength of a scruple
to a drachm (1.-4.) to the ounce (32.) of zinc, lead, or simple ointment,
can  be  often  advantageously  employed  also as a powder  in full
strength, or diluted M'ith bismuth or starch.   In localized patches of
papular eczema, M'here such a dressing can be tolerated, marked re-
sults follow this dry  dusting  of calomel over the part, followed by
alternate superposition of neatly adjusted  strips of Maw's surgeon's
plaster—the whole  kept  in situ by means of a neat bandage.   If the
itching is alleviated by such a dressing, it can be reapplied for a week
as soon  as  it is loosened, when the redness and infiltration  M'ill  be
found greatly reduced.
   Other surgical  appliances used in the  local treatment of eczema
are Martin's solid rubber bandage, Fox's tubular bandage of  rubber,
and other dressings composed of starch, gutta-percha, and  plaster of
Paris, intended to support  the extremities when the integument is
Meakeued.  None of  these are equal to rest in the recumbent posture.
The most  useful  purpose  subserved by rubber in the  treatment  of
cutaneous affections is as an  impermeable outer dressing for watery
and oily applications.   Here  the mackintosh  and silk protective  of
the Lister dressing answer all the indications.
   Prognosis.—The  greatest  uncertainty  attends the prognosis  of
eczema, so far as  regards the duration  of the  disease and the proba-
bility of the recurrence of a relapse.   AATith  respect to the questions
most frequently asked, those relating to contagion, heredity, and per-
sistent lesion-relics,  naturally  a favorable response can  be made.
But the fact remains that some forms of the disease are  insignificant,
some persistent, and some peculiarly liable  to relapse from very slight
provocation.    Only after careful weighing of all the conditions ex-
hibited by the  skin and by the  other organs of the patient can a
1 British Medical Journal, June 35, 1881. 
LOCAL VARIETIES  OF ECZEMA.
291
reasonable probability as to the future be estimated.   All this is un-
satisfactory, and must be so.   Eczema is truly a curable disease, but
unfortunately one not only exceedingly common, but one  open to
aggravation by causes well nigh innumerable.    AVere the physician
ahvays in position absolutely to insure his patient the exclusion of all
sources of irritation, the prognosis would  be much more satisfactory.
In hospital patients, M'here such  control is more perfectly attained,
the results of treatment  may be predicted with some confidence.
   In general, it may be  said  that acute eczema is  more readily re-
lieved  by proper treatment than the chronic  forms of the disease;
that eczema M'ith a  discoverable cause is  more manageable than one
whose etiology is obscure; that eczema of the very young and of the
very old is at times  particularly rebellious;  that the non-discharging
phases of the disease are rather more persistent  than  those accom-
panied by secretion; that eczema lingering at the mucous  outlets of
the  body (auditory  canal, nostrils, mouth, nipple, anus, vagina)  is
more obstinate than M'hen it affects the skin of other parts (shoulder,
neck,  lumbar region);  that  eczema  M'ith constant aggravation  or
complications (fissure of the hands, varicose veins of the leg, appa-
ratus for anchylosis  of knee) is more  stubborn  in proportion as those
complications or aggravations cannot, from the  circumstances of each
case, be set aside; and, finally, that an eczema which has long existed,
or repeatedly  recurred, as, for example, M'ith every season of extremely
cold or hot m eather, is, after relief, extremely liable to return.

                THE LOCAL VARIETIES OF ECZEMA.

          Eczema of the Scalp.  [E. Capitis.  E. Capillitii.]
   AVnen the scalp is affected with eczema, the symptoms differ some-
what,  accordiug to the age of the patient.    In  adults, the erythema-
tous  and  squamous  varieties of the  disease  are  more common;  in
infants and  children, the pustular.    In the former the eruption is
usually circumscribed and in patches; in the latter it is more diffused.
In the same proportion also the former is generally asymmetrically
and the latter symmetrically developed.
   In  infants  and children,  the pustules  rupture early; and  their
contents dry into dirty-M'hitish, yellowish, or greenish crusts, matting
together the hairs, serving as foci for dust accumulation and nests for
lice, superimposed upon a reddish, oozing, pus-covered, or occasionally
indolent skin, often foul-smelling, and  usually  complicated  by  a
seborrhcea.  The  so-called  "milk-crust" is usually a compound  of
dried pus and altered  sebum.  The  itching is not so intense as in
some other  forms of the disease.   Post-cervical, pre-auricular, and
occipital adenopathy are common, and in strumous children suppura-
tion of the affected  glands  may  occur, though  this is rare.   The
causes of this  form of the disease are evidently  associated M'ith local
conditions.  The rapidly  growing hairs  of the scalp are in intimate
association M'ith the numerous and large sebaceous glands of the same 
292
DISEASES  OF  THE  SKIN.
part, which  unquestionably respond  at times to the physiological
stimulus they feel, by an exudative process.   The acne of the young
man M'hose beard is growing, illustrates the same fact.  Local  irri-
tants are not often Manting to push the disturbed  equilibrium  into
the scale of disease.  Dr. White calls attention to the common neglect
in removing the " pre-natal cap of cheesy material," as well as to the
rude and unskilful  attempts to accomplish the same end.   Extremes
of temperature, friction, excess, neglect, and absence of endeavor to
wash the scalp, all  these contribute to originate or aggravate the dis-
order.
   The affection when complicated  or induced by lice, is more common
in children than in infancy, doubtless in  consequence of the greater
independence  of the former and  their gregarious habits.   In girls
M'ith relatively long hair, the ova, or nits, of the parasite are readily
distinguished, adhering closely to the  hairs  and accumulated espe-
cially  about  the occipital region.   The itching is usually  more
annoying than in pustular  eczema not thus complicated.
   The erythematous and squamous forms of the disease, rather more
common in adults, originate frequently in seborrhoea, M'hen scratch-
ing or  irritant applications have been made.  The eruption here
usually occurs in asymmetrical patches, or may be limited to a single
patch tolerably well-defined in outline, and  this often upon one side
of the scalp, not as in infancy preferring the vertex.   Reference is
made in the chapter on seborrhoea to a form of eczema of the scalp
occurring in adults  where finger-nail sized, circular, oozing or slightly
crusted patches are generally disseminated  over the surface.  They
result, as a rule, from  the scratching  of an obstinate  seborrhcea  in
"nervous" women; and suggest traumatism, in their reddish friable
crusts, the  color being due  to exuded blood.
  The diagnosis of these forms of disease has been already considered.
  In the treatment of the eczema of the scalp in infants and children,
the first indication to be met is the removal of the accumulated crusts.
When this is  harshly  accomplished, it  becomes  a fruitful  source  of
further mischief; it is, therefore, necessary to  proceed  M'ith  great.
gentleness, and thus  the  thorough softening of the crusts is  all
important.   For this purpose it is necessary to soak them in oil and
to retain this substance in intimate contact with the scalp.  Olive or
cod-liver oil may be selected, and,  if needful to correct the odor or for
other purpose, one drachm  (4.) of  carbolic acid may be added to each
pint (512.) with two drachms (8.)  of the balsam of Peru.  A neatly
fitting skullcap should be then smoothly applied, constructed of the
Lister protective or flannel, and fastened in place by a light bandage,
never  by elastic rubber bands.  After  several hours of soaking, the
crusts should  be removed by warm water and  spirit of soap washing,
and the entire process  be repeated till the crusts are completely
detached.   In selecting  an article for  subsequent medication of  the
scalp, it should always be remembered that even infantile eczema will
proceed to a  natural involution  if unirritated.  Heuce the oleated
lime-water, or oil of sweet almonds alone, M'ill  often answer better 
                LOCAL VARIETIES  OF  ECZEMA.            293

 than au ointment, aud, even  where there is considerable acuity of the
 inflammatory process, lime-M'ater aloue, with possibly a small quantity
 of glycerine  added.  In  other cases  the  lime-water  can be  better
 medicated M'ith calomel  or the oxide of  zinc.  At times, also, it is
 well, even M'hen these applications are kept in constant contact with
 the scalp, to order that a small pea-sized  mass of one of the ointments
 described above [such as the  benzoated  oxide of zinc ointment with
 cold cream,  or one  medicated with  a mercurial  compound, e. g.,
 calomel,  twenty grains (1.33); or white precipitate,  ten  to  twenty
 grains (0.66-1.33); or the subnitrate of  bismuth half a drachm (2.)
 to the ounce (32.)], be applied at  the  time of the dressing.   This is
 to be gently rubbed in the surface M'ith the tip of the finger, and the
 skin afterward protected as before.
    It is rarely needful to cut the hair unless nits be  found, though in
 public charities it certainly is a more expeditious method of arriving at
 the end,  M'hen a nurse has to dress the heads of several children in a
 single ward.  In  adults, especially in women,  the hair should be
 spared, while the patient is warned that the loss of  the growth upon
 the scalp may be  considerable.  As a sequel of obstinate seborrhcea
 such an eczema may be succeeded  by alopecia; in the absence of the
 former, the  hairs  are  usually reproduced.   It is  rarely necessary to
 employ the  skullcap  in adults, since one can  succeed in insuring the
 necessary applications by directing the attention of the patient to the
 necessity of care and thoroughness.
    Lice when present may be  destroyed  by the application of petro-
 leum.  Nits are removed from hairs M'hich it is not desirable to cut,
 after the  petroleum dressing, with alcohol or cologne Mater.
    As the disease in both classes of patients  advances  to  a subacute
 or chronic stage, the treatment may be changed so  as to include the
 various stimulating applications already  described, such as ointments
 and spirit lotions containing tar, oil of cade, balsam of fir, pyrogallol,
 alcohol, and sulphur.  In the case of infants, however, such stimu-
 lating topical remedies are very rarely to be  employed.   An  eczema
' of the scalp M'hich has once entered upon resolution, in an infant or
 child, should be generally soothed and  protected.
   Many little  patients thus affected are in excellent general  health,
 and require no internal  medication.   Others, however, demand the
 interposition of the wisdom of the physician to protect them from
 the ignorance  or folly of  those to M'hose charge they are intrusted.
 Here is not space for a discussion  of the  pressing questions relating
 to the nutrition of the infant deprived  of the  breast and starving on
 the "proprietary"  diet purchased  of a chemist, or an equally  vicious
 aliment compounded  by lime-water, and imbibed  through a tube by
 M'hich it is flavored with  India-rubber  and  the chemically  altered
 casein of milk several  days old.   A  word to the M'ise'is sufficient.
 Fresh pure milk, animal broths, cod-liver oil, must  not be neglected.
 This concerns the health of the child, and has indirect connection M'ith
 the eczema.   A record of one  hundred infants dead of artificial foods 
291
DISEASES  OF THE  SKIN.
and marasmus in a  public Charity of Chicago, includes in the list
not a single case of eczema.
   Lastly,  patients of both  classes  are to be saved  from  mercury,
arsenic, and the iodide of potassium.

                 Eczema of the Face.  [E. Faciei.]

   Erythematous eczema of the face in adults is projected prominently
among  the varieties  of the disease by its  uniformity of type.   It
occurs  in  early and middle  life  and  advanced  years;  and  is  a
particularly intractable ailment.  In well-marked cases, the forehead,
cheeks, eyelids, and  nose of the  patient are involved, exhibiting an
infiltrated, usually dusky-red, often symmetrical patch of disease, the
affected surface being slightly elevated  above the level  of the sound
skin.  This surface is uniformly smooth and reddened ; occasionally,
near the root of the nose and about the lower  line of the forehead,
minute, closely set papules are visible.   Very slight ooziug, especially
after irritation, may be noticed.  At the height of the  disease or in
its  involution, exceedingly fine scales form, which are scarcely  per-
ceptibly shed  from the surface.  The lids, especially  the lower  lids,
in advanced years become puffy.  The line  of demarcation is unusually
distinct, and  rarely invades the scalp-border  or the  region  of  the
beard.   Itching is at times intense, the patient complaining of this
bitterly, and usually preferring  to  rub the face with the hands or
pieces of cloth.  Sometimes, however, the face is well scratched M'ith
the nails, and excoriations and blood-crusts disfigure the countenance.
Patients of intelligence usually describe the itching  as paroxysmal,
and starting at the root of the nose, whence it travels upward over
the forehead,  and laterally  to the  brows, often in the line of  the
supraorbital nerves.   Certainly at the root of the nose, the exudative
process is of the most marked character.  The eruption also is seeu in
asymmetrically disposed patches of various sizes, with islets of sound
skin  betueen.  In  resolution  of  the symmetrical   form,  this  is
commonly observed.
 ^ Patients thus affected  are often those whose faces have  been espe-
cially exposed to irritation, such as  locomotive engineers, wheelsmen
of sea-vessels, mechanics in trades M'here the hands are soiled with
irritants and  afterward  applied  to  the face, and  women spending
hours  of each day over the laundry-tub  or the kitchen-stove.   In
eaph class the operation of the cause is made manifest  by the exacerb-
ation of the disease after exposure.
  The affection is  most commonly mistaken for erysipelas, a disorder
from which it is readily differentiated by the chronicity of its course.
The latter feature is particularly characteristic of this form of eczema.
It is rarely completely relieved after the age of sixty M'ithin a twelve-
month ;  and, when it has existed for a  long period of time, is partic-
ularly obstinate under the best treatment, recurring with exasperating
frequency upon exposure  of the  face to atmospheric  changes.   The
great vascularity, abundant supply  of  sensory nerves, and necessary 
LOCAL  VARIETIES  OF  ECZEMA.
295
exposure of the face, probably explain this peculiarity.   In its treat-
ment the dusting powders fulfil au important part.   Soothing appli-
cations should  ahvays be  first  employed.  The more stimulating
applications may be tried later.
   In patients  of younger  years  the face is apt to display vesicular
and  pustular phases of the disease, forms more often of acute eczema,
and  correspondingly  more manageable.   The itching, and especially
burning sensations, are apt  to be severe; crusts form rapidly ; and in
infants the picture presented is often that seen  in the scalp, except
that the hairs are not matted  into the crusts; and there is often a
reddish blush at the  edge of the  crust;  or, when the latter has been
removed, a redness  of the oozing surface somewhat  more marked
than the similar patches on  the less vascular  scalp.  The scratching
in these, little patients is severe ; crusts are torn off in part or wholly;
blood-crusted excoriations are common.  The area of surface involved
is in this  way clearly extended ; sleep is greatly disturbed; and the
irritability and  fretfuluess of the  child, thus produced, bear heavily
upon  its general  nutrition.  In  severe  cases of  long standing the
mental tone of the little sufferers becomes singularly perverted, and
the character unquestionably changed.  They will  occasionally, when
permitted, pick off and devour the crusts M'ith voracity, and undergo
nervous crises M'hich are but a step removed from convulsions, and
doubtless allied to the petit mal of the epileptic.1
   This chain of formidable symptoms, M'ell linked together, M'ill often
bid  defiance to the most skilled efforts to impart ease to the tormented
skin.   In such cases the harness employed by Dr. AVhite, of Boston,
fills an important  office.  The skullcap, described above, and made
of firm old cotton or  linen cloth, is  closely fitted to the calvarium,
and  a mask of the same material is shaped to the face M'ith exactly
placed apertures for the eves, nose, mouth, aud ears.   It is  gathered
in beneath the chin, and laps over two inches at the back of the head.
This may be used only during sleep, or in aggravated cases, also during
the  hours of  wakefulness.   A  species  of strait-jacket  is  made by
passing the head of the child  through a  hole in the closed  end  of a
small  pillow-case, which  is then   drawn down  over  the body  and
arms, and the latter confined at the sides by stitching the case together
betM'een the trunk and the upper extremities, or  accomplishing the
same end with safety-pins.   The jacket is finally secured by similar
means betM'een the thighs.  "When it is necessary to imprison the
lower extremities, these are similarly secured  by pins M'ithin the case;
and  the outer  edge of such trousers can be fastened to the bed or
cushion on M'hich the child  reclines.  Of course  this treatment  does
not  preclude the employment of the Mashes, ointments, etc., M'hich
are to be neatly applied next to the skin  beneath  the "trousers" or
"jacket."   The result is that rest is  given to  the tormented skin,

  1 Among the criticisms elicited by the appearance of the first edition of this treatise, it wascharged
that the picture given iu this paragraph is exaggerated.  The experience of the critic, however had
been too narrow. The accuracy of the description given above has been more than once confirmed in
the observation of the author since these lines were first written, and they are left standing to-day as a
hint of the truth. 
296
DISEASES  OF  THE  SKIN.
which is not suffered to be exposed to a single scratching even during
the dressing  of the parts;  and its  natural tendency to repair soon
brightens up the case.
  In  the treatment of these cases,  the black Mash  and zinc salve
treatment will  be found  valuable, as  also the diachylon salve, lead
lotions,  and  the glycerole  of starch.   Van  Harlingen gives  the
folloM'ing :
R. Pulv. zinc. oxid.	3j;
Sevi purificat.	3ij;
Adipis	3iv;
Pulv. ulmi flav.	q. s.;
16
M.
   To protect the face from the cold air he also employs half an ounce
(16.) each of glycerine and gum tragacanth, half a drachm (2.) of
borax, and Mater sufficient to make a paste.
   In obstinate cases tar should be employed.  It is well to remember
in the management of any case, that while a tarry application may be
well tolerated over one part, as, for example, on the cheeks and near
the nose, in another, as, for example,  over the lids, a zinc salve may
be better employed in the same individual.

                Eczema of the Lips.  [E. Labiorum.]

   Reference has been already made to the obstinacy of eczema occurring
near the mucous outlets of the body, a  result due, probably, to the
secretion furnished by the adjacent mucous tracts.  The lips furnish
an  illustration  alike  of this pertinacity and  aggravation.   Their
frequent motions in mastication and articulation aggravate an eczema,
M'hich is,  moreover, apt to be teased by a no less frequent thrusting
of the tongue out of the mouth, where there is no beard, to wet the
parts with mucus and saliva.  One or both  lips may be involved,
vesicular, pustular, squamous, and erythematous lesions occurring at
one point, or along the entire line of either, with  frequently resulting
crusts and  fissures.  The  vermilion  border  of  the  lips commonly
participates in the process.   The lips become hot, sometimes  much
thickened by the swelling and infiltration, their  mucous faces  being
rarely implicated.  Scarlet, dull red,  and other peculiarly purplish
hues  of the vermilion border become visible.   The  parts  are more
picked than scratched, though the  itching is  at  times  severe.   The
pustular and vesicular forms are  more  common  in  children.   The
erythematous form, its reddened outline  roughened bv  scales, evenly
projected  beyond the vermilion  border, is  rather  an  affection of
maturer years.   In young children the  disease  is frequently aggra-
vated by nasal discharges M'hich flow over the lip, giving the latter
an elephautiasic aspect or even the appearance of an animal's snout,
a condition noted  also  in later life.   Occurring  upon lips covered
with  the  hairs of the moustache,  the  disease  exhibits the  usual
symptoms of eczema barbae.  In  these  male patients, the  pipe, the
cigarette, the cigar, and the tobacco  chewed  and expectorated may
aggravate the  malady.  In all  cases it is  obstinate,  and calls  for 
LOCAL VARIETIES  OF ECZEMA.
297
 either emollient,  stimulating, or  protective applications.  In  cases
 displaying acute and painful symptoms, frequent fomentations of the
 part M'ith soft rags dipped  in hot mucilaginous  and alkaline waters,
 will aid in controlling the swelling and alleviating  the pain.   In
 chronic cases, where stimulation  is demanded, this can  be effected at
 the time of dressing, the parts being subsequently protected by collo-
 dion or other material.  Carbolic  acid aud  the nitrate of silver are
 often needed  for  such dressiug.   Iu eczema of the hairy  lip  it is
 often of great service to remove  the  moustache by shaving.
   Fox suggests the use of thymol, five  grains (0.33) to the  ounce
 (32.)  of  cold  cream.  Van Harlingen applies  equal parts  of dilute
 phosphoric acid, glycerine,  and syrup ; and  to  the outer edge of the
 lip, two scruples  each (2.66) of  zinc oxide  and  honey, six drachms
 (21.) of the  oil of sweet  almonds, and  two drachms (8.) of  mux.
 Veiel paints the lips twice daily  with soft soap.   Taylor's application
 of the tincture of benzoin, each ounce (32.) containing one to two
 grains (0.06-0.13) of corrosive sublimate, is a valuable solution for
 painting over the  cracks and fissures near the angles of the  lips.
   The diagnosis is betM'een  sycosis parasitaria, herpes  labialis, and
 epithelioma, the points of difference having been already suggested.
 The first is accompanied by loosening of the hairs, and caused  by a
 parasite;  the  second  is vesicular  in lesion, brief in  duration, and
 trivial in severity;  the third  'is a disease of advanced years, rather
 than of early and  middle life, and is never accompanied  by itching,
 but usually by more or less ulceration.   Syphilis is fond of the angles
 of the lips; in most cases when  thus limited, typical mucous patches
 of the mouth can  be discovered.
   The lesions of syphilis  at the  angles  of the mouth are seldom
 linear fissures, but more often irregularly  outlined erosions, secreting
 a puriform  mucus.

                Eczema of the Nostrils [E. NariumJ

 is  naturally often  associated with a chronic coryza.   Inasmuch  as
 one of the common symptoms of hereditary syphilis is the "snuffles"
 of the child, the physician should carefully exclude the possibility of
 such disorder  in every  instance M'hen an  infant M'ith coryza exhibits
 an "eczema"  of the nares or lips.   The age of the little patient; an
 inspection of its anal region (M'hich should never be omitted in infan-
 tile eczema); and the history of the case will  throw considerable light
 upon  this important question.
   Whether occurring  in the adolescent or child,  the disease  may
 linger  only upon  the alae in pustular or  squamous forms, or block
 up the nares  M'ith crusts.   In infants this  enforces respiration  with
 an open mouth,  and the grasp of the nipple  by  the lips is thus inter-
 rupted either  by respiratory acts  or cries of agitation.   The Schnei-
derian membrane participates  in the inflammatory process, and pours
out its secretion upon the  eczematous skin.   The membrane when
inspected is seen  to  be either raw and succulent, or in a condition 
298
DISEASES  OF  THE  SKIN.
analogous to that seen in the pharyngitis sicca of authors, dry, glazed,
and  free from  discharge.  The nostrils are often thickened in con-
sequence of infiltration or fissured, especially at the lines of the nares
laterally and  interiorly.   In severe cases, and when the lips partici-
pate in this process, the pouting, swollen, and distorted organs suggest
the snout of the lower animals.  Adults as a result frequently suffer
from non-parasitic sycosis and  furunculosis.
  Care should be taken to exclude  syphilis in making a diagnosis,
bearing in mind the fact, that  the pustular  syphiloderm (which see)
frequently selects the furrow on either side of the nares for its evolu-
tion.
  In treating these cases all crusts should be removed, and the parts
carefully  protected.   Picking  the  nose in children should be pre-
vented if needful, by the "strait-jacket."   Pencillings M'ith the com-
pound  tincture of benzoin,  iodized  phenol, nitrate of silver,  and
collodion will  often  prove serviceable.  In  softening crusts, oil may
be freely used.  For this  purpose the warm carbolized spray of the
atomizer  answers well,  medicated with   resorcin  which  may  also
be  efficiently  employed  for  the relief of the nasal catarrh, often
responsible for the disease in adult cases. Unna  recommends drainage
tubes in such patients, M'rapped with lead ointment mull, and, after
the  softening  of the crusts, painting  every  second  day M'ith  yellow
precipitate ointment.  In  the  same way  a weak citrine ointment or
M'hite precipitate  salve may be  used.   AVhen the disease extends well
up  the nares,  Neumann employs bougies made by combining  two
grains (0.138) of zinc oxide with sixteen  (1.06) of cocoa butter.

                 Eczema of the Ears.   [E. Aurium.J

  The  ears are  affected with  eczema both in  infancy and maturer
years, rather  more often in women and  children, the disease being
limited to the whole or  part  of the   organ, or extending  backward
over the post-auricular  region, or downward over  the  ramus of the
superior maxilla.   It may be acute  or chronic,  and  originate  in
chronic  or catarrhal discharges from the external auditory meatus;
in exposure to temperature changes,  especially M'hen aided by high
winds; in frost-bite;  in the  irritation set  up by pediculi  and by
the  auricular limb  of the frame  of  spectacles ; in the toxic effect
induced by the hook of  cheap  ear-rings and  dyed bonnet ribbons;  in
the  traumatism of ear-piercing; aud  in  the habit of  unnecessarily
picking the ear to relieve it of wax or trifling sensations of irritation.
  The pustular and  moist forms are common at the superior, inferior,
and posterior boundaries of the pinna,  where a linear fissure is apt to
form in the  line of the angle made by the auricle M'ith the plane of
the  adjacent  integument.  The  motions  impressed  upon the ear by
handling it,  placing the hat on the head and tying hat strings over
it, always tend to aggravate the disorder.   Long hairs worn over the
ears may have a similar effect  by the  production of friction and the
retention of heat.   The lobules  are apt to display  the erythematous 
LOCAL VARIETIES  OF  ECZEMA.
299
and  scaly phases of eczema, becoming infiltrated, having a deformed
appearance, a lurid red color, and indolent course.   The lobules alone
of both ears in young women may be similarly affected, and exhibit
these phenomena for consecutive years.   Often the chronic inflam-
mation  may  lay  the foundation for a keloidal growth, an accident
of several  inflammatory processes  in other parts.  At other times
the entire auricles present a similar appearance, uniformly dark red,
infiltrated, alternately  Meeping and  scaling,  and  projecting to  a
noticeable  extent from the side of the head iu consequence of their
increase in bulk.   The itching is usually  more annoying than severe,
being accompanied by  a characteristic  sensation of tenseness and ful-
ness of  the part.   Like the eczema M'hich occurs at the other mucous
outlets of the body, the affection  in these parts is particularly obstinate
when it assumes a chronic form.  Symmetry to the extent of involving
both ears, though commonly to  a different degree in  each, is rather
the rule than the exception; and is doubtless due to the simultaneous
operation of effective causes.
   The diagnosis  is betM'een erysipelas, seborrhcea (M'hich occasionally
occurs in the concha  of the  auricle), erythema simplex aud multi-
forme, aud dermatitis  calorica.  The mouth should ahvays be care-
fully examined in these cases for sources of trouble.
   The  treatment should be at first soothing and protective by the
zinc salve or diachylon  ointment; afterward  stimulating.   A firm
bandaging of the ears  to the  head may  be required  to support  the
parts, to  prevent irregular pressure (head  upon the pillow), and to
secure contact with external  medicaments.  In chronic  cases, stimu-
lant applications  are often well tolerated, and the tarry ointments here
play an important part.  Treatment appropriate to the otitis externa
may  be required.  Bulkley recommends a  tannin ointment,  one
drachm (4.) to the ounce (32.), deeply and thoroughly passed into
the  meatus on  a  camel's-hair  brush.   French authors generally
recommend small tampons smeared with  an ointment  and left in the
canal.   Burnett  employs two drachms (8.) of the oil  of tar  to  one
ounce (32.) of alcohol.  Great  benefit is derived from pencilling the
indolent surfaces  M'ith solutions of the silver nitrate.   The intractable
forms almost invariably affect adults, and in them  there is  usually a
history  of improvement under  treatment,  then, in men, exposure,
as, for  example,  to the M'iud, or, in  women, excessive dancing, etc.,
and subsequent aggravation.

              Eczema of the Lids.   [E. Palpebrarum.]

   Here the free edge of the lid, or  the skin over the orbital margin
of the tarsal cartilage, may be  chiefly affected;  and either, both in
children  and adults.  When  the free edge of the lid  is involved,
there is  a species  of  sycosis n on-parasitica present, the hair-follicles
becoming inflamed and furnishing a  purulent discharge which may
agglutinate the lids.   Th'e latter are thickened and swollen, become'
the scat of a moderate itching, are picked rather than  scratched,  and 
300
DISEASES  OF THE SKIN.
exhibit minute  crusts between, or glued to, the hairs.   The disorder
is often accompanied by a seborrhoea of the Meibomian follicles, and
is described by oculists  under the designation of "blepharitis"  and
"tinea  tarsi."   Inasmuch as  the  facial  expression is quite charac-
teristic  when the lids are thus involved, the patients exhibiting  this
form of eczema are usually set  down as " scrofulous,"  though  it
occurs in  many individuals M'ith no other sign of struma, and eczema
surely is not such a sign.
   Fissures  occasionally form at the commissure  of the lids.   The
disorder may complicate eczema of the other  parts of the face.   In
the  erythematous eczema faciei of adults, there is usually swelling
with puffiness, especially of the lower lid.  The conjunctiva may, or
may not,  be implicated.   A chronic granular condition of the lids is
not  noted as frequently  as might be suggested by a  priori reasoning.
   The  edges  of the lid should be carefully  cleansed M'ith a weak
alkaline solution and soft  camel's-hair  brush M'henever the lid itself
is involved, then as carefully dried and anointed with  cold cream.
In acute cases the closed lids  may be  frequently bathed with warm
alkaline solutions;  and strips of soft lint, soaked in the same material,
or a very dilute glycerine  or carbolic acid solution, may be laid over
the closed lids for as long periods  during the day as  they are com-
fortably tolerated.   In chronic cases the red oxide of mercury oint-
ment, one grain to ten (0.066-0.66) to the ounce (32.), has always
been held in  high  esteem.  Oculists, in the  treatment of this affec-
tion, are  fond of using an   ointment  of the yellow  sulphuret  of
mercury.    In  place of these, the unguentum  hydrargyri nitratis,
one  part to six of cold cream, may  be applied.  Epilation of the eye-
lashes may rarely be  necessary.   Pencillings with  solutions of the
nitrate of silver in various strengths are also useful in chronic cases,
but these  must be carefully confined to the lids, and not suffered  to
come into contact with the conjunctiva.  Excessive use of the  eyes
must be prohibited.
   In the  diagnosis, care must  be  taken to exclude syphilis, lupus,
and  pediculi.   The author has seen but one instance of piedra of the
eye-lashes.  Instead  of  the ordinary nits  of the lash, there were in
this  case jet-black, small pin-head sized masses of ivory-like hard-
ness attached to the  hairs.

                 Eczema of the Beard.   [E. Barbae.]

   Eczema may involve the region  of the  beard  only,  or may spread
to such parts from those in the vicinage, or may, finally, extend from
the beard to other parts of the face.   The first is common, and fur-
nishes,  perhaps, the best type of  the disease;  the second is also
common,  but usually subordinate  iu importance to other trouble of
the facial region.  The last is decidedly the  rarest.   It is indeed a
matter of surprise that an eczema should, as it often does, endure for
•years, limited exclusively to  the region of'the  beard and never for
once transgress these limits. 
LOCAL VARIETIES OF ECZEMA.
301
   This fact furnishes a convincing argument in favor of the local
origin and of the frequency of local sources of aggravation of eczema.
Rarely M'ill one see a picture more suggestive to the  uneducated eye
of "scrofula" or "humors of the blood" than the face of a middle-
aged  man, M'ith long-standing eczema of the entire region covered by
the beard.  The hairs  are thinned, and  fail  to hide  completely  the
reddened surface beneath, covered  here  and  there  with pustules or
floors of  broken pustules, dried inflammatory products, yellowish and
greenish scales and crusts.   Beneath the crust the surface is smooth,
not lumpy, as in parasitic sycosis.    The hair-follicles are not solely
involved, as in the non-parasitic form of sycosis, but evidently they
and also the integument  between them.    In recent eczema the hairs
are not loosened in their follicles, but in  chronic cases such loosening
does  unquestionably  occur, and  there is a  true  defluvium capillitii.
The  disorder is evidently one primarily involving the skin of the
region of the beard,  and secondarily the hairs,  extending  smoothly
over  that surface, as smoothly as an eczema  on the cheek of a woman.
There is commonly a certain degree of symmetry,  to the  extent at
least  of involving the beard in different degrees  on both cheeks at
once, or the chin on both sides;  often the symmetry is perfect.  This
is rare in the parasitic  affection of  the same part.
   The disease is accompanied by itching, rarely as severe as upon the
smooth parts'of the face,  is particularly obstinate, and extremely dis-
figuring.   AVIien extending into the region of the  beard from other
parts, it is usually associated with eczema of the ears.  AVhen limited
to the region of the moustache, it may be  connected M'ith an eczema
of the nares aud a  chronic nasal  catarrh.
   The explanation of the obstinacy of eczema of the region of the
beard is to be found iu the hairs M'hich cover it.   Whether the latter
be long or short, feeble or strong, each during the twenty-four hours
acts to a certain extent as a lever in motion upon the portion of  the
integument in M'hich  it is implanted.   In conditions of health,  the
skin tolerates M'ell this  motion;  in disease it becomes a positive source
of trouble.   Multiply by thousands the impression produced upon
the healthy skin when a single hair or group of  hairs is moved by a
strong current of air,  by the fingers, by a brush,  or by  any other
externally operating cause, and some idea may be had of the extent
to M'hich this force  may become effective.   But the best evidence of
the fact is to be found in  the results which folloM' the  removal of the
beard,  ('lipping short the hairs of the face M'ill not answer,  though
generally preferred by the  patient  as exposing  to  a  less degree the
unsightly surface beneath.  Nothing short of shaving, and continual
shaving  every second day, M'ill effect the desired result in chronic
cases.  A^ soon as the disease is reduced practically to an eczema of
the non-hairy parts, it  improves, in proportion to its distance from
the mucous outlets of the  body.   AVhen limited to the bearded cheeks,
the most  obstinate  cases  may be in  the course of a single month
robbed  of one-half of their  unsightliness.   It may  be needful to
employ the usual methods—oil, hot M'ater, and soap—to remove the 
302
DISEASES  OF  THE  SKIN.
crusts before the first shaving,  and any imprisoned pus  should be,
evacuated.   The patient should be encouraged by reminding  him
that usually it is  but the first step which costs; each succeeding re-
moval of the beard  is accomplished with  greater comfort to himself
physically and  mentally.   After each  shaving, the skin  should be
bathed in M'ater as hot as tolerable,  and, if at night, a lotion may be
used, or an ointment, or the latter after the former.  The salves most
useful for this purpose are sulphur, one drachm to the ounce (4. to 32.);
the diachylon  ointment with salicylic  acid, five to ten grains to the
ounce (0.33-0.66 to 32.),and the zinc ointment.  Best of all, however,
is the dusting powder; and, as soon as practicable, the patient should
limit himself to this application.   The shaving should  be continued
for months after the disease is at an end.   It is indeed surprising to
note in such cases how quickly the " scrofulous" look disappears, and
the evidences of a " humor of the  blood " are no longer  evident in
the face.   The  longer the limitation of the disease  to the region of
the beard, the more brilliant, as a rule,  is the result.  It is not often
necessary to resort to the tarry applications in this form of the affec-
tion.   When complicated by eczema  of the post- or infra-auricular
region, stalactite-shaped crusts depending  from the  infiltrated lobule
in consequence  of the unintermittent drip of serum from above, eczema
of the region of the adjacent M'hisker is less  readily managed.
   Flat epitheliomata of  the bearded cheek are not to be confounded
M'ith eczema barbae.   The points of difference  have been previously
noted.  It should be remembered also that the age of the patient, the
career of the disease, the possible eversion of the neighboring lid, or
agglutination of the  adjacent  lobe  of the ear, distinctly high eleva-
tion, or ulceration of tissue, absence of itching, and distinct localiza-
tion of the disease are all characteristic  of this form  of carcinoma.

          Eczema of the Genital Organs.  [E. Genitalium.]

   Here the disease is remarkable for  the severity  of the subjective
sensations it occasions;  for its tendency to persistence, recrudescence,
and nocturnal exacerbation, and for the liability to the production of
the  sexual orgasm by the act  of  scratching.   In  men  the surface
most often involved  is  the anterior, posterior, or lateral faces of the
scrotum where they meet the thigh, though the surface  of the penis,
as also that of  the pubes and perineum,  ma}' be  involved.   In
women, the labia majora, more rarely the labia  minora  and vestibule
of the vagina are affected, M'ith  occasional extension of  the disease to
the same contiguous  parts as in men.
   Eczema thus located  is, as a French writer  has  M'ell said, " a dry
disease in a moist locality."  Vesicular and  pustular forms are much
rarer than the  erythematous, the papular, the papulo-squamous, and
the erythemato-squamous.  In women, the moister forms are  more
frequent, doubtless because of the  wider mucous outlet, and the  more
extensive mucous tract in the vicinage.   The labia are then heightened
in color, oedematous, agglutinated by crusts, and often torn viciously 
LOCAL VARIETIES OF ECZEMA.
303
 by the finger-nails.   Blood-crusted  excoriations are seen in  most
 severe cases.   Au eczema intertrigo at the  labio-femoral angle  is
 common.  Over the M'hole may be poured the secretions from uterus
 or vagina, normal or pathologically altered.  The disease is, however,
 sufficiently common after the menopause, when there is physiological
 atrophy of the uterus.
   The  typical  disease  in  men is  recognized  in  the thickened,
 reddened, perhaps slightly scaling integument of the scrotum, M'hich
 may also be fissured, excoriated by  the nails,  or covered by blood-
 crusts.   Torn papules,  often  closely packed  together, may be seen
 with a peculiarly lurid, even purplish hue.   In exaggerated cases the
 infiltration is so great as to deform the parts, increasing the thickness
 of the scrotal integument  to many times its normal dimensions, pro-
 ducing thus an elephantiasic appearance. In eczema of the penis the
 prominent symptoms are also oedema, itching, and redness, M'ith slight
 scaliness.
   In  both sexes, as before  stated,  the   attempts  to relieve the
 itching are often as severe aud  prolonged  as  they are ingenious.
 Commonly no relief is obtained till a serous sweating or M'eeping of
 the thickened tissues is induced  by the friction.  Inasmuch as the
 latter is in severe cases frequently repeated, the physical dangers are
 obvious.
   Apart from this, however, the disorder has a marked tendency to
 disturb the mental tone and the general health.  Shame deters many
 from seeking speedy relief, so that  cases of long standing are those
 more  commonly  registered  by  the physician.   Though  entirely
 unconnected  M'ith venereal disease of every  kind, there is, for the
 many, a special dread of an eczema of these parts, precisely because
 of its  location.   With sleep disturbed, the mind agitated, and the
 nervous system  teased by au intolerable pruritus, oue  can scarcely
 wonder at the eloquence  M'ith which many patients  describe  their
 sufferings.   It is a disease of middle life and advanced years.   It is
 rare to see a  Mell-marked, obstinate case in a child.
   The causes, exciting and aggravating, of eczema of the genital
 region are to  be sought  in  heat,  moisture,  and friction.   These
 primary  factors are favored—first, by the effect of gravity, the organs
 in question being situated, M'hen the body is in the erect position, at
 the inferior apex  of the double cone forming the trunk, and  being
 thus subject to the force of gravity ;  second, by the  arrangement of
 the clothing  in  both sexes, by M'hich  heat  and  friction  effects are
 heightened ; third, by uncleanliness,  the secretions  and discharges
 from the adjacent mucous tracts being suffered to accumulate upon
 the person ; fourth, by a long list of sexual  errors which operate by
 obstructing Avhat  may well be termed the  sexual ebb—that is, the
 natural reflux by which  each periodical  physiological congestion  of
 these organs is by a natural process relieved.  That the  skin of these
organs participates in  such  periodical congestion is a fact  demon-
strable to  the eye.  The  abundant  supply of bloodvessels, lymph- 
304
DISEASES  OF  THE  SKIN.
 atics, and nerves to the parts, furnishes all necessary elements for the
 explanation of the formidable series of symptoms often displayed in
 eczema genitalium.
   In many eczemas of the surface, especially of the genital organs, the
 urine will be found to contain albumen or sugar, and these conditions
 have been supposed to lie at the root of the eczema.   One author has
 even prescribed  a diet for the eczematous patient  M'ith saccharine
 urine.  The explanation  of the phenomenon  is, however, sufficiently
 simple.  It is the eczema M'hich causes the elimination of the sugar
 or albumen, aud not the reverse.   Sugar and albumen are known to
 be producible in urine  by external irritants, and, among the latter,
 by cutaneous diseases.   Merely varnishing a portion of the  skin has
 been followed by these effects.   If patients with saccharine urine and
 severe genital eczema can be kept in  bed, in the  recumbent  position,
 for a few days, while any soothing application productive of comfort
 is continuously applied  to the  tender and  excoriated  surface, the
 sugar M'ill often  rapidly disappear from the fluid  excreted from the
 kidneys.  These renal  symptoms  are  in part reflex, resulting  from
 the extraordinary irritation of the  nerves distributed to the  involved
 surfaces.
  The so-called diabetides genitales of  French authors may include
 some geuital eczemas occurring in diabetic patients.  But it is certain
 that many cases of very extensive and  severe eczemas of the genital
 region in both sexes occur in patients in whom the most careful and
 repeated examination  of the urine fails to reveal traces of sugar.
 The practitioner is urged never  to  omit such  examination in his
 treatment of a typical case.
  The treatment is to be conducted on  the general principles hereto-
 fore enunciated.   Sponging of the  genital region with alkaline water
 as hot  as  can be  well tolerated,  followed by the blander   oils and
 ointments at night, and the use of anti-pruritic dusting  powders  in
 the daytime, must not be omitted.   In eczema  of the scrotum, the
 suspender lined with  lint which is wet with a lotion, smeared  with
 an ointment, or thoroughly covered with a powder, can  be usually
 employed to  good advantage.  The  habit  of scratching must be
 broken up at  all  hazards.  In chronic cases, the treatment by soft
 soap and diachylon ointment will  be found useful.   Caustics, solu-
 tions of the mercuric  bichloride and other mercurials, carbolic  acid,
and especially the tarry compounds, are often necessary.
  Finny, of Dublin, uses  the following formulae, M'hich are useful in
allaying the irritation :

        R. Liniment, calcis            fgiv;          128
           Belladonn. extr.          gr. xij ;
           Zinci oxid.                  3ij ;            8
           Glycerini                   f^ij;            8
           Aq. calcis                  fgiV;          128       M.
        Sig.  " Lotion to be applied at night after bathing the parts in hot
                water." 
LOCAL VARIETIES OF ECZEMA.
305
R.
*'£
Lin. calcis.	f.Siv; 12*
Acid, hydrocyanic, (dil.)	t'3j; 4
Liq. plumbi subacetat.	f3ij; 8
Glycerin.	f.=5ij; 8
Aq. ros. ad.	f^viij; 256
" Cream, for application	on strips of old linen."
M.
   Exceedingly obstinate eczema of the pubic region is benefited by
shaving and subsequent appropriate  treatment.   When  complicated
by intertrigo, the latter condition requires special relief by the  inter-
position of soft lint spread with an ointment.
   The diagnosis is between ringworm of the genitals, acne, pruritus,
pediculosis,  the venereal  disorders,  aud  herpes progenitalis.   The
first named  may occur alone, or induce, or be grafted upon the eczema.
It will  be recognized by the  discovery of the trichophyton, and is
clinically distinguished by the crescentic edge of the spreading patch,
with its convex border looking away from the genital centre.   The
"follicular  vulvitis" of gynecoolgical  authors is a genital acne, and
manifestly limited to the glands and peri-glandular  tissues.   The
same is true of bromine and iodine acne, which may be developed in
the  same situation in both  sexes.  Genital pruritus may beget an
eczema  by scratching, but is accompanied by no proper skin  lesion.
The pubic  louse is visible to the eye,  as  are also its reddish excreta
and  nits.   The ulcers and  sclerosis of the chancroid and primary
syphilis are not accompanied by pruritus, and  though  occasionally
multiple, never exhibit diffuse patches  of disease.   The syphilo-
dermata are  recognizable  by their characteristic features, and by the
history  of an infectious disease.   In herpes progenitalis there are pre-
cedent burning, smarting, or neuralgic sensations, the occurrence of
vesicles or groups of vesicles (lesions rare in eczema of the genitals),
and  frequent limitation of the disorder to the mucous surfaces or the
muco-cutaneous lip by M'hich such surfaces are bounded.   In eczema
such boundaries are usually respected, and the disease is much more
strictly  cutaneous.

            Eczema of the Anus and Anal Region [E. Ani]

in its etiology and characteristics is  closely allied to the same disease
in the genital region.   The  presence of ascarides and haemorrhoids
occasionally induces or aggravates the disorder; though this is rarer
than is commonly supposed, since multitudes of men and women who
suffer from  piles never complain of eczema.  The eczema may occur
in erythematous, squamous, or papular form, in the order named;
thus exhibiting here, as  in  the genitals,  " a dry disease in a  moist
locality."
   The redness, infiltration, and itching, may be  limited to the  verge
of the anus, radiate from  the latter in stellate  lines, creep upward
between the nates  in the cleft, sweep  forward  over  the perineum  to
the genital  region, or extend laterally M'ith intermediate intertrigo
over the inner face  of each thigh.   Rarely the buttocks are covered
with the same lesions.
                                20 
306               DISEASES OF THE SKIN.
  The disease is  common  in  infancy,  M'here want of care in the
removal  of the napkin  is a fertile source of mischief; and  also in
middle life and advanced years, M'hen it becomes particularly intract-
able.   The itching is intense in  the latter class, with frequent noc-
turnal exacerbation.  Unfortunately the scratching  is often reflex,
aud practised during the unconsciousness of sleep, from  which the
patient is often roused by his or her manipulations.   Pollutions fully
recognized, or  occurring during  profound sleep, or, more usually,
in states of semi-consciousness, complicate certain cases;  defecation
becomes  painful.  The  harassed nervous system of the  sufferer  is
often  in a deplorably wretched  condition.  In cases of  long standing
the usual congested, thickened, infiltrated, and  almost elephantiasic
appearance is presented, with  exaggeration of the natural furrows
and occasional fissures.   The part may simulate in aspect the formid-
able conditions  discovered in  passive pederasty.  Excoriations are
common  around the anal verge.
  The diagnosis is that of eczema of the genital region.
  In  the treatment of these cases the  use of very hot  M'ater by
sponging, and  the subsequent  application of ointments, has yielded
the best  results.  In  the  case of  infants the dusting powders and
blander  ointments are alone to be employed; in adults, especially in
chronic cases, the  tarry applications  are especially valuable.   Here
the tincture of tar may be freely painted over the surface, or one of
the tarry ointments, such as  the Wilkinson  salve, of sufficient firm-
ness to retain its form  as an unguent when subjected to the heat of
the part.  Caustics are useful when  there  are fissures.   Corrosive
sublimate, one-half to one-quarter of a grain (0.033-0.016)  to four
ounces (128.) of  the milk of almonds;  Squire's glycerole of the
plumbic subacetate, half a drachm (2.) in two ounces (64.) of glycerine
and water, or, as  a substitute for the latter, the soft soap and dia-
chylon plaster,  are here of special service.  Van Harlingen recom-
mends almond oil containing twenty  per cent, of carbolic  acid.
When defecation is painful the stools should be semi-liquid in  order
to insure non-aggravation of the local disorder;  not, it need  scarcely
be remarked, with a view to eliminating any materies  morbi by purga-
tion.   Small tampons of cotton may be  smeared M'ith an emollient
ointment, and gently inserted  for  a short distance within the anus.
Kaposi recommends  butter  of cocoa suppositories,  containing  zinc
oxide with belladonna or opium.   AVhen complicated by true fissure
of the anus the sphincter ani must be stretched, divided,  or dilated
with  medicated bougies.
   Besnier recommends the use of a clyster after each bowel  movement,
the fluid being retained for but a short time.  At night, a cataplasm
is applied.   The  parts  are frequently washed with tepid  water, and
the anal tampons are smeared M'ith cocaine.   During  the day,  the
oxide of zinc salve,  thirty grains  (2.-32.) to the ounce of vaseline,
is applied, and the parts are also  thoroughly  sprinkled with  equal
parts of  the zinc  oxide and subnitrate of bismuth in fine powder.
   Van Harlingen suggests after the use of the hot bath, M'ith the 
LOCAL VARIETIES  OF ECZEMA.
307
addition of starch and glycerine, an ointment  composed  of one part
of cod-liver oil to two parts of suet.   A^eiel prefers the cautious use
of chrysarobin to tar,  employing  the latter  either in the form  of
spirits or as a tar diachylon, one part to twenty, gradually increased
in strength.   Carbolic acid aud glycerine, a  few drachms of each  to
the pint  of elder-flower water or almond emulsion, are specially indi-
cated in fleshy women when the disorder, as is often the case,  is com-
plicated with intertrigo.

      Eczema of the Nipple and Breast of Women [E. Mammae]

is common in nursing women from either the irritation produced by
the  mouth of the infant, or,  more commonly, in  consequence of a
galactorrhcea.  Eczema intertrigo is common beloM' and  between the
breasts.   The eczema  here is vesicular, erythematous, or squamous
in form, with fissures of the apex, side, or  base of the nipple.  The
serous ooze from the infiltrated areas dries as  usual into light-colored
crusts.   There  are  the characteristic burning  and itching.  The
disease may  occur on  one or  both breasts^ and, especially  M'ith a
galactorrhcea  in summer, may spread  extensively,  covering both
breasts, the surface of the belly, and the intermammary region. The
circumscribed forms occur also in pregnant or unmarried  women, and
are to be distinguished  from scabies, which in women is  apt to occur
upon the breast.

   "Paget's Disease of  the Nipple," or "malignant papillary derma-
titis," the so-called eczema of the nipple and cancer of the breast, is
designated by  Thin1 as a destructive or  malignant  papillary der-
matitis.   The mammary tumors here formed are found to originate
in the epithelial lining  of the lactiferous ducts, the elements of M'hich
undergo, at an early  period of  the  disease, a  cancerous  transforma-
tion.   Clinically, there is usually observed in such cases  a  sunken
nipple, its  site occupied by a bright red  or livid infiltrated patch of
distinct  outline, differing thus  from the irregular definition of the
contour of the eczematous area.  In all cases of subcutaneous tumor
or coincident axillary adenopathy, the physician should  be  especially
careful in the matter  of prognosis.

   The treatment is in general that described above.  In  severe cases
with galactorrhcea, nothing short of weaning the child  aud  a cessa-
tion of all demands upon the breast will  insure relief.   Every effort
should be made in milder cases to avoid  this dernier ressort.   At
first, scrupulous care; peucillings of fissures  with a crayon of silver
nitrate or the tincture  of myrrh;  gentle anointings with  emollient
zinc, thymol,  or carbolic acid  ointments, which should  be carefully
washed "off before the child is put to the breast;  and, finally,  dusting
powders, with soft lint retained between and  beneath the breasts, are
measures to be tried.   Later, the sublimate solutions, diachylon oint-
ment or naphthol, two per cent, in alcohol, may be employed.  Veiel
1 London Lancet, Ainer. ed., p. 533, June, 1881. 
308
DISEASES  OF  THE  SKIN.
recommends the application to all fissured nipples of Lister's borax
salve:

        R. Acid, boracic. subtil, pulv.)  --       .        ^
           Cerae alb.               }    g '    '
           Paraffin.     \               -,- -          2
           01. amygdal. J               a'l3as'        J       M.
  Fournier recommends a breast-plate of caoutchouc.  When limited
to the nipple and areola in nursing women,  the  glass and rubber
apparatus sold in the shops may be tried in the  hope of saving  the
nipple from the  mouth cobtacts in nursing.  Sometimes they answer
admirably;  often they fail utterly.
  Paget's disease of the nipple should be treated as a carcinoma, and
may eventually  require removal of the breast.

              Eczema of the Umbilicus.   [E. Umbilici.]

  This local variety of the disease is briefly described in the chapter
devoted to  seborrhcea.   In most  cases it is either  induced  or aggra-
vated by a local  seborrhoea fluida, which gives origin to the peculiarly
nauseating odor  characterizing the disease.   Generally a reddish and
infiltrated,  more  or less  annular  patch  surrounds  the  umbilical
depression,  which may be filled with crusts.   Syphilodermata, pedi-
culosis, and scabies  in women are  to be carefully excluded in  the
diagnosis.   The liquor sodae chlorinatae, carbolic acid  solutions, and,
in chronic cases, iodized phenol M'ill be required in its management.
Care should be  taken that the dressing  of the  navel in the newly
born infant, the improperly adjusted apparatus for retention of an
umbilical hernia, and the corsets or  "uterine supporters" of  women,
do not occasion  or aggravate the disease.
  Anderson reports  that in typical cases, especially of those  affected
with scabies, the navel is swollen and projects  in the form of a  small
tumor.

          Eczema of the Superior and Inferior  Extremities.
                  [E. Membrorum.   E. Crurale.]

  The flexor surfaces of the extremities, especially in the vicinity of
the joints, are particularly prone to  exhibit symptoms of the disease.
With  these should  be properly included  the axillary and inguinal
spaces.   In all  such localities the alternate tension and  relaxation of
the  integument  serve when the limbs are  in  motion, to increase the
pruritus, and, correspondingly, to  aggravate  the  disease.   Often  a
certain degree of symmetry can be perceived, the two popliteal spaces,
for example, being simultaneously affected, though  each to a different
degree.  The parts most favorable for the complications of intertrigo
are those  nearer the  trunk M'here  the moisture and heat are greater,
as  the groins and  axillae, while the elbow and  popliteal spaces are
more frequently dry, exhibiting papulo-squamous  ridges in  lines at 
LOCAL VARIETIES OF ECZEMA.
309
right angles to  the  axes of the limbs, with hyperaemic patches on
either side.
  Upon the legs, where the force of gravity is more potent than in
other parts of  the  body, exaggerated  forms of  eczema are found
complicated with varicose veins and  oedema, with  dense infiltrations
and  indurations.  In ancient  cases the frequent elephantiasic aspect
is significant, one  limb  being  by several inches larger in circumfer-
ence  than  its fellow, covered from  knee  to ankle with  enormous
patches of eczema  rubrum of an  intensely angry appearance, moist
and  crust  covered; or  dry, glazed, and of a lurid reddish hue; or
dry,  horny, and ridged with irregular projections surmounted by
scales resembling the rough bark of a tree;  or, again, M'ith or M'ithout
oedema, tense, inelastic, seamed with scars of old varicose ulcers, and
deeply and  irregularly  pigmented, a condition with great difficulty
distinguished from syphilitic ulceration of the same region.  At its
onset, eczema of these parts may assume any one of its known forms.
In  infants with long clothing, where the lower extremities are sub-
jected to  a higher temperature than  in adults,  the vesicular  and
pustular forms  are  common.   The  exceedingly  obstinate forms of
eczema of  the legs, especially those complicated M'ith varicose veins,
are,  of  course, those encountered in middle life and advanced years.
  The diagnosis is, in general, to be established  by considering  the
points heretofore discussed.  The chief difficulty lies in  distinguish-
ing the eczema associated with ancient varicose cicatrices of the leg,
from syphilitic scars of  the same locality M'hich have resulted  from
degenerating tubercular  syphilodermata or gummata.  In some cases
when no distinct history can  be obtained, there M'ill be  a  necessary
doubt, as  the force of gravity upon  the vessels, even without  vari-
cosities, produces  certain common features  notably  deep pigmenta-
tion in  both classes of cases.    In women,  the sexual history is  all-
important, including the order of abortions, miscarriages, and viable
infants.  In both sexes, the discovery of other lesions, and  especially
of characteristic cicatrices elsewhere, must be attempted.   It M'ill be
remembered that the syphilitic ulcer tends  to the shape of  a circle
or segment of a circle, and though occasionally existing as the sole
lesion upon one leg, it  is frequently multiple, or  may involve both
extremities, the pigmentation  in old cases occurring chiefly at  the
periphery of the scar.   Very  extensive pigmentation about ancient
cicatrices, especially  disposed  between  irregularly defined scars, is
truer of eczematous forms, as the pigmentation due to syphilis, though
long-lived, is yet the more ephemeral.   With periosteal nodes  the
diagnosis is clearer.
  The treatment of  eczema of the extremities does not differ from
that described  above, except  as regards the indications  to  be  met
relative to support of the parts,  thus counteracting the effect of gravity.
Excellent results are here obtained  by the use of the  pure rubber
bandage, applied immediately  next the skin, especially in cases com-
plicated by (edema, ulceration, and venous varicosity.   The  method
of applying the well-known Martin bandage has been made generally 
810
DISEASES  OF  THE  SKIN.
 familiar to the profession ;  and for details respecting its availability
 in eczema of the leg, the reader is referred to the essay on Eczema
 and its Management, by Dr. Bulkley, of New York,1 who is enthusi-
 astic in its praises.
   Such treatment, however, deserves only subordinate  rank in com-
 parison with the essential rest of the affected limb in the horizontal
 position.   With a grave eczema  of the lower extremity, such rest
 should be enforced ; and patients whose limbs have proved rebellious
 under the rubber (for  such there  are) may thus be relieved.   The
 local applications to be made meanwhile are those adapted to the
 particular features in each case present.
   To a  less degree, the same may be said of the  arms.  In  these
 localities, it is rarely necessary to  resort to elastic pressure.  In all
 cases, however, a neatly applied bandage over the dressings will add
 the  effect of pressure and  support, and generally contribute to the
 comfort of the patient.  A favorite dressing, in dry, papular, erythem-
 atous, and squamous patches of the disease, is applied  as follows :
 The parts are first bathed with hot alkaline water for several minutes
 till the itching is relieved, and then carefully and  thoroughly dried.
 The patch is theu completely covered with a dusting powder, which,
 according to the indications of the case, is either emollient, astringent,
 or stimulating.   Finely powdered tannin with French chalk ; or even
 pure calomel; or bismuth, zinc, and starch, may be thus used.  Over
 the whole, strips of MaM''s surgical plaster are alternately and neatly
 superimposed in the manner some years ago recommended by Baynton.
 A snugly fitting rubber bandage encompasses the whole.  The dress-
 ing  is left in situ as long as it is comfortable, often for two or three
 days, when it can be removed.   In properly selected cases, the itching
 is relieved, the infiltration reduced, and  the patch  soon loses its
 hyperaemic aspect.  Occasionally no other treatment will be required.
   Nor should it be  forgotten that with care and patience, the starch
 bandage of the leg, the plaster-of-Paris dressing over folds of Canton
 flannel arranged so that it may be removed at pleasure in the manner
 in which  it is used  by  some surgeons in the treatment  of diseases of
 the joints, these and  other immovable dressings may accomplish even
 more in obstinate cases than elastic  apparatus.
   For the exudative phases of eczema of the leg, the forms so often
 seen here  of eczema rubrum, the gelatine medicated plaster meets the
 indications well.  Morrow makes  this by  adding two  hundred  and
 fifty parts of glycerine to one thousand of gelatine, and  two thousand
 of water medicated with ten per cent, of the oxide of zinc and  one
 per cent, of carbolic acid.   It may be left in situ several  days and
 furnishes  a smooth, elastic, and uniform coating.

    Eczema of the Hands and Feet.   [E. Manuum.  E. Pedum.]

   No more striking illustration of the significance of the etiology of
eczema can be adduced than that to be discovered in the hands.   By
1 G. P. Putnam's Sons, N. Y., 1881. 
LOCAL VARIETIES  OF  ECZEMA.
311
these organs man toils to earn his bread, and the eczema they display
is their protest against the rude contacts which  are thus necessitated.
Unfortunately, in too many of such patients the imperative necessity
of bread-winning  forbids consent to the best method  of relief, viz.,
temporary disuse  of these  organs.   The feet  may  or may not be
similarly attacked, and for similar reasons.   All forms of eczema are
here seen, erythematous, vesicular, papular, pustular, and squamous,
involving the  entire surface, or limited to the wrists, ankles, inter-
digital spaces,  palmar or plantar surfaces, or one or more  digits on
either face.   The  motions of the part are so free, that fissures are
common and often exceedingly  painful.   The itching may be severe,
and  the parts of one hand or foot extensively rubbed, torn, or abraded
by the other.  Vesicles are more  frequently encountered upon the
more delicate portions of the skin, as over the dorsum and interdigital
spaces, M'hile in the denser  palm and  sole they are  represented  by
sub-epidermic points from which by puncture a clear serous or cloudy
fluid may be  evacuated.  Usually, however,  in the  regions  last
named, there is a dry, dead-whitish or  hyperaemic, uniformly indu-
rated and thickeued integument, M'hich may be fissured or produce
such a tense inelasticity of the surface that the fingers are semi-flexed
into the  palm, or, much  more rarely, the toes rendered  considerably
less  extensible.
   Circumscribed patches of  eczema, with fairly defined outline, red-
dish in color beneath crust  or scale, subacute in  course, and accom-
panied  by paroxysmal itching,  are  of  common  occurrence on the
dorsum, and also  in  the palm or sole.   In  the latter situation, they
may be  traversed by one or more  painful  fissures, the  same being
true of the dorsum of the fingers and toes.   Upon the  back of the
hand, these circumscribed patches are apt to assume an indolent course,
improving temporarily  under appropriate treatment, and  becoming
aggravated by every exposure to the causes by  M'hich they Mere first
induced.
   The long list of etiological factors M'hich may here be efficient can
scarcely be  enumerated.  Several  have already  been  considered  in
discussing the causes of eczema iu general.   The influence  of all
articles handled in the trades, occupations, and  professions of life,  as
M'ell as  of the action of toxicants  and dyes, must be  remembered.
Thus  printers, bakers, and niasons suffer  in  the  hands;  and the
wearer of dyed stockings, and coarse, ill-fitting shoes and boots in the
feet.   Because needle-women  are  often  overworked,  nervous, pale,
and  thin, their digital eczema, really due to the implements and stuffs
they handle, has been erroneously attributed to their  general condi-
tion.  The poor seamstress starving for sunlight, nutritious food, and
open air  exercise, may return  to her weary routine with her eczema
quite relieved.
   In the matter of diagnosis, it should be remembered that an eczema
of the hands  mav be induced by the Rhus toxicodendron, the disease
beino- then liable"to a transfer by contact  from the hands to the face
and  o-enital  or mammary regiou.   Scabies  of the  same region is in 
312
DISEASES  OF  THE  SKIN.
this country much rarer than eczema  manuum.   In scabies the vesi-
cles are firmer, more often unruptured, fewer,  more  isolated, more
intermingled with crusts, pustules, and  even bullae, which latter are
rare in eczema.  The discovery of the parasite and a history of con-
tagion will aid in  removing doubt.   Abundance of pustular lesions
in young subjects  is, however, according  to Hebra, most commonly
produced by the acarus.
   The characteristic burrow  made by the parasite, an irregularly
curved, thread-like, beaded, or dotted line, about one-quarter  of an
inch in length, either running at a tangent from the unruptured vesicle
or across its summit, is proof of scabies only second in value  to the
discovery of the parasites themselves.  The occurrence of the erup-
tion elsewhere  on the body is  also to be expected in the last named
disease,  M'ith  respect to which   it should  be remembered that the
burrow may not be visible, and  may be wanting when  the parasites
are present.   Psoriasis  of the palms  and soles is always accom-
panied by the presence of patches in other parts of the body,  M'hose
typical characters should throw light on  the local disorder.  They
are dry, non-discharging lesions, very rarely fissured as  is the eczema
of the hands, have  a distinct contour, and are covered M'ith  more
abundant  and more lustrous  scales.   The scaling syphilodermata of
the palms and  soles occur early and late in the disease, and usually
after  a distinct history of infection.  The lesions in   syphilis are
usually  isolated,  firm,  deep  infiltrations,  circular in  outline,  with
very  sharp  definition, and may  be covered by  dry, adherent,  dirty-
white scales,  beneath which the brown and red  hue of  the persistent
lesion can be discovered.  Superficial or deep circular excavations of
tissue are visible, single or multiple, with punched or  ragged  edges.
The eruption  is rarely,  like eczema, accompanied by itching or dis-
charge,  but painful fissures may form.   It occasionally affects the
dorsum of the hand  or foot, favorite sites of eczema  manuum, but
almost invariably has in such cases swept  thither from the palm or
from the sole.
   In  both syphilis and  eczema of the hand, the  right organ in  right-
handed  laborers is invariably most  involved,  even when  there is
apparent symmetry of distribution of lesions.
   The treatment demands, first,  rest for  the organs, and a simulta-
neous discontinuance of the exciting causae.   In the trades, the result of
the latter can be usually demonstrated by  the patient, who notices the
difference between the condition of the skin on  Monday morning after
a  Sunday's  rest, and that which M'as distressing on  the preceding
Saturday night.  When practicable, protection during labor must be
secured by the use of gloves, finger-cots,  rubber-stalls,  or bandages,
neatly applied and retaining dressings to the part  of the hand or foot
which is the seat of the disease.   For circumscribed, non-discharging
patches on the dorsum of the hand or foot, the  dressing described in
connection M'ith eczema of the extremities may be applied.  When the
nature of the labor performed  is such as to render it  impossible to
secure protection of the hands or fingers in this way, something may be 
LOCAL VARIETIES OF ECZEMA.           313
accomplished  in a few cases by directing that the hand be frequently
dipped  into a protective  solution, or powdered during the hours  of
labor.   Thus  printers  may dust their  fingers with lycopodium, and
those compelled  to  retain their hands in irritating solutions, can
anoint  these  organs occasionally Avith an oily or  fatty substance.
Cenerally it may be said that  an eczema of the hands is  too fre-
quently washed, and the  ill effects of such practice are made evident
not only in  laundresses, but  in mothers who personally attend to the
dressing of  young infants.   The local applications made to each case
may be those  described above as suitable to each stage of the disease.
When extensively  involved, the hand  should  be carefully dressed,
each finger  being separately wrapped in soft linen rags smeared M'ith
camphorated  or  carbolized,  pure or  diluted,  linimentum calcis  in
acute cases  ; or, later, with a bismuth, zinc, or mercurial ointment.
The tarry compounds  are here very useful; and the caustics more
than  ever needful  when  there  are fissures.   Protective flexile collo-
dion  plays  an admirable part  about  the nails where irritable seams
and fissures form M'ith overhanging  fringes of a  torn and  ragged
epidermis, bordered with  red.   In all painful eczemas of this region
the immersion, particularly  at  night, of the entire  hand or foot  in
hot  water  should  be practised, followed  by  careful  drying and
anointing M'ith a salve or an oleaginous  semi-liquid.   This  should
be spread thickly upon pieces of muslin, wrapped neatly about each
finger separately, and other affected  parts, and the whole  covered
with  waxed paper.   The Lister protective gauze, or a pair of rather
large undyed  gloves M'hich can be readily drawn over the M'hole, may
be substituted for the former.
   When the epidermis of the palm is greatly thickened, it should be
shampooed  at night M'ith green  soap, pure or in spirit, by the aid of
hot Mater, folloM'ed  by a salve containing either the white precipitate,
ten to twenty grains to the ounce (0.66-1.33 to  32.), or the Wilkinson
tar salve.   For  intractable  cases, caustic potash, in the strength of
twenty to thirty per cent, solutions, can be  mopped mcU into the
thickened palm, aud followed by a salve-application.  ATau Harlingen

                                                      1133
                                                      2
                                                     10
suggests:		
R.	Hydrarg. aminoniat.	?y,
	Adipis	oss;
	Sevi benzoinat.	9viJ;
	01. ainygd. dulc.	"lx;
	Vaselin.	ad 3vi;
24
66
M.
  For the fingers and hands, Unna's mull plasters fill very perfectly
every requirement.    These may be cut  into strips, and applied M'ith
neatness to every digit.   The zinc oxide, tar, and ichthyol mulls are
all available for this purpose.

           Eczema as it Affects the Nails  [E. Unguium.]

  There is nothing characteristic of eczema  in  its effects upon  the
nails.   These  horny plates participate  in the diseases M'hich affect 
311
DISEASES  OF  THE SKIN.
their matrices, and thus exhibit nutritional changes.  There is, there-
fore, no eczema of the nail proper, but  only an eczema of the digit
by which the nail is affected.  In well-marked cases, one, several, or
all of the nails of either hands or feet  may lose  their polish,  or
become  rough, punctate, furrowed  laterally, and clubbed, or present
au appearance suggestive of worm-eaten surfaces.    They  lose their
uniformly smooth attachment beneath, and become tilted  on their
beds, with marked friability of their tissue.  In such cases, an eczem-
atous condition of the skin at the margin may be detected, M'here
the usual redness, infiltration, and scaling, M'ith a sensation of itching,
point to the nature of the trouble.   Rarely the nails are shed.  The
most misshapen will be succeeded by smooth and natural growths of
nail-substance, if the  disease of the matrix be completely  relieved.
The treatment, therefore, is  the  treatment of the cutaneous  disease.
Care must be taken to exclude ringworm of the nails, M'hich end can
be reached by microscopically examining the scales scraped from the
nail-surface.
  The zinc oxide and tar salves will  be found most effective for the
larger number of cases.   Often the organs may be with advantage
protected during  the daytime by  the  combination of gelatine  and
glycerine described in the management  of  eczema of the extremities.

   Eczema of the Tropics (Prickly  Heat).  [E. Solare.  Lichen
                         Tropicus, etc.]

  Under these titles have been described a number of disorders, some
of which are more closely related to the forms of sudamen described
in connection with  the functional  derangements of the sweat appa-
ratus, some of  which are instances of papular eczema, associated or
not with profuse sweating under the influence of high temperatures
(solar heat, tropical climates, hard labor in the heated  air of engine-
rooms, etc.).   The disease is aggravated by all external and internal
sources of irritation, including  alcoholic  beverages, opiates, flannel
garments worn next  the skin, undue exertion in a heated medium,
fatigue, and obesity.
  Etiology.—The disease is  more common in those subjected to rapid
and intense fluctuations in the temperature of the atmosphere than in
those long accustomed  to a relatively  hot climate.   It  is thus ex-
ceedingly common in the northern parts of our own country, where
the absence of  a regulating  Gulf stream ushers the inhabitants sud-
denly from the rigors of a  severe winter to the prostrating heats of
summer.   It attacks alike individuals of both sexes and  all ages,
being often particularly severe in the obese  and  in  infants, whose
delicate skins,  no less than  their bowels, resent sudden and severe
thermal changes.  It moreover affects equally those  who are vigorous
and the debilitated.
  The disease is characterized by the occurrence of pin-point to pin-
head  sized vesicles, bright-red papules, vesico-papules, or the two as
coincident and commingled  lesions.  They are exceedingly numerous, 
LOCAL VARIETIES  OF  ECZEMA.
315
and may in severe cases  cover almost  the entire so-called non-hairy
surface of the body, though they may be much  more limited in their
diffusion.   Thcv  are  usually acuminate and discrete, though  often
very thickly set together.   They are  rapid  of  occurrence, but  may,
in consequence of persistence of the cause, be  slow  to disappear or
recur repeatedly.  Whether vesicles be or be not present, the affected
region is usually bathed  in sweat.   The eruption is  accompanied by
characteristic sensations  of  tingling,  pricking,  and  burning;  its
lesions, even though generalized, may  be  most vivid or  most dis-
tressing about the trunk, axillae, head, neck, or  extremities.   It may
last for but a few days, or be severe for a week or more.   It is un-
questionably seen in the severest  grade  among  fleshy Europeans, or
Americans emigrating to tropical climates who are habitually ingesting
alcoholic beverages in excess.
   The  local treatment of prickly heat  is, in brief, that  of the cor-
responding stage of eczema.  Unguents are generally to  be avoided,
as the skin  rarely  tolerates them, and  the same  may  be said of plas-
ters and very cold baths.  Baths  or  lotions, tepid, warm, or  moder-
ately cool,  as  the  feelings of the patient may decide  to be  most
grateful, medicated with alkalies, bran, gelatine,  or starch,  M'ill be
found useful.  After each, the  skin  is to be dried,  not by rubbing,
but by gently pressing dry cloths over the surface, and is then to be
thoroughly protected by a  free use of one  of  the dusting poM'ders.
When large tracts  of the skin  are involved, aud general baths have
been ordered, a package of "  corn-starch farina " will often be found
sufficiently  well suited for such  topical employment.
   Lotions  may also be  employed,  composed  of lead, or lead and
opium,  or  the black wash, or alcoholic and ethereal solutions con-
taining camphor and glycerine  in the proportions given when con-
sidering the subject of acute  eczema.   Modifications of the  oleated
lime-water are serviceable in severe cases, as, for example :
         R. 01. lini                    fgij;          64
            Paraffin      j           -a  gij           64
            Sapon. Castil. j              ° J '
            01. bergamii               q. s.;         q. s.
            Aq. calcis                 ad Oj;         500|      M.
        Sig.  For external use.
   This makes  a  demulcent  creamy solution  which often  proves
exceedingly grateful to the  skin ; and to  it may be added the zinc
oxide or dilute hydrocyanic acid, as may be required.
   The general  treatment of  the patient is a matter of  importance.
The cause must be removed if possible.  Withdrawal from the light,
heat, and labor of the day ;  unstimulating  food  and  drink, unirri-
tating apparel, and rest,  are of the greatest  importance.   The saline
and  acidulated  beverages are usually acceptable  to  the palate, and
useful if not drunk too cold.   The chief value  of Apollinaris water,
lemonade, Vichy,  and Kissengen, lies not in their action  as medica-
ments, but as supplying  the  water demanded  by the cutaueous loss
through evaporation. 
316
DISEASES  OF  THE  SKIN.
  Prognosis.—The disorder may be trivial and severe, and last but for
a few hours, or for as many months.  It is usually relieved without
difficulty, and often by domestic measures alone.   It is most annoying
and severe  when complicated by the exudative process in other parts
of the skin than the sweat-ducts and their immediate vicinage.

                            Prurigo.
                        Lat. prurire, to itch.
Prurigo is a chronic, exudative, cutaneous affection, commonly beginning in
  infancy or early childhood, and continuing through life, characterized by
  the  occurrence on the extensor surfaces of the extremities and also on the
  trunk, of minute, pale or reddish, millet to hemp-seed sized papules,  with
  extensive  infiltration and intolerable pruritus.
  Symptoms.—In  this  affection, pin-head to rape-seed sized, firm,
whitish or  reddish-white  papules form, chiefly and  primarily upon
the extensor  faces of the extremities, but from  these localities
extending gradually over the entire surface of the body.  The itching
they occasion is of the severest type.
  The earliest symptoms are usually displayed in  the latter portion
of the  first year  of life, in the  form of an urticarial rash, which
persists and is finally succeeded  by typical papules.  The  latter are
minute, often sub-epidermic, and become rapidly covered with blood-
stained  crusts  in  consequence  of the  induced scratching.   Then
ensues  a long  train  of symptoms, including  pustulation, fissures,
excoriations, dense infiltrations, crusts  formed of exuded serum  and
dried blood, oedema, diffuse dark-brown  pigmentation of the surface
in large areas,  and consequent adenopathy.   Fully  developed, the
disease  presents in general the same physiognomy in different patients
of different ages.   The lower extremities ahvays exhibit the severest
manifestations of  the disease, especially the thigh  and leg as distin-
guished from the  foot; though  the trunk,  forehead, cheeks, neck,
arms, and  head may be also involved.   The protected surfaces, as of
the axillae  and  groins, except as regards  adenopathy, are  free from
the disease. The general health of the patient manifestly suffers from
the insomnia  and  nervous agitation  induced  by the  state of  the
integument. Emaciation,  malnutrition, and cachexia  are common
sequelae.   The mental  and  moral tone of the patient  thus harassed
from  early childhood  throughout an  entire  life  is  necessarily  pro-
foundly impaired.   Insanity  and  suicide are reckoned  among its
remote  consequences.
   Mild and severe forms of the  disease are distinguished  under the
terms Prurigo Mitis aud Prurigo  Ferox, or Agria.   Incessant
care, judicious treatment, climatic influences, and the comforts of life
commanded by wealth, seem to determine  the difference between the
two.
   Etiology.—The disease occurs  chiefly in  Austria, few cases being
recorded elsewhere. A patient was, however, exhibited at the Inter-
national Medical Congress  in  London,  whom  both  Kaposi  and H. 
PRURIGO.                        317
Hebra recognized as affected  with prurigo.   Wigglesworth, Camp-
bell, and others, have reported cases in this country.  It  is needful
to remember that the term prurigo is here employed' to designate the
disease recognized by some authors as the "true prurigo of Hebra."
It should  never be confounded  M'ith pruritus, M'hich, under various
usages, may be the title of a mere  symptom of a disease.   Prurigo is
more often encountered  in the  male sex ; is  never contagious; and
never induced by lice; but, according to Hebra and Kaposi, may be
grafted upon an hereditary predisposition.  " Scrofula," tuberculosis,
malnutrition, "misery,"  poverty, anaemia,  and filth,  are held  to be
severally favorable to its development.  Unquestionably the superior
resources  of  the poorest  classes in America will long protect  them
from the incursion of this  inveterate malady.
   While the typical prurigo ferox, as described by the Vienna school
of authors, is of such rarity that  probably less than a  dozen cases
have been  observed in  this  country, the opinion is gaining ground
that the same  disease with  milder manifestations (prurigo mitis) is
much more  common here than  has at times been believed.   Two
patients with severe prurigo treated  by Hebra  himself,  found their
way to the author's clinic M'ith unmistakable symptoms of improve-
ment after a residence in this country;  and almost every expert in
America has observed cases of the  milder type.
   Pathology.—Kaposi  practically  admits that, striking  as is  the
clinical portrait of this  disease,  its anatomical features are indistin-
guishable  from severe forms of  obstinate papular  eczema.   The
microscope reveals merely an hypertrophy of the various elements of
the  epidermis  and derma, deposits of pigment in  the corium, thick-
ening of the root-sheaths of the  hairs, enlargement of the  cutaneous
muscular elements (erectores pilorum), and a  consequent atrophy of
the integument M'hich has long been the seat of the disease.
   The hairs are thinner, the  root-sheaths loosened, and young cells
are collected in abundance about the follicles.  Schwimmer calls atten-
tion iu  this  connection  to the  fact that many prurigo nodules  are
pierced  M'ith a  hair.  Auspitz  believes  that  the  disease is in  fact a
sensori-motor neurosis M'ithout essential lesion.  Riehl1 regards it as
a chronic form of urticaria.   Morison2 regards the prurigo papule as
formed by  an infiltration beginning around the  upper plexus of vessels
in the corium, which thence spreads to the papillary vessels, enlarging
the papilhe, elevating the epidermis, which at  an early stage becomes
thickened  above them.   Finally the latter is  penetrated, and within
its  strata  a vesicle forms,  containing serum, blood, and  lymph-cells.
The regions of infiltration about  the hair-sheaths and sM'eat-ducts are
regarded by him as secondary, and not  as an essential part of  the
process.  The color of the  papule does  not at first differ  from that
of the skin  in  the  neighborhood,  on account of the depth of the
slight infiltration  by which  it  is  characterized, and for  the  same
reason it can be distinguished by the touch before it becomes visible.
1 Arcbiv. f. Derm. u. Syph., 18S4.
2 Amer. Journ. of the Med. Sci., 1883. 
318                diseases of  the skin.
  Diagnosis.—Remembering the extreme rarity of prurigo in America,
it is to be distinguished chiefly from the various  forms of papular
eczema  by the location of  its lesions,  the* course of the disease, the
age of the patient when it is  first developed, the great extent of the
eruption, and the uniform type of its lesions.   In prurigo, also, the
fingers and toes, flexor aspects of the extremities, and  face are more
or less spared.   Under treatment eczema commonly yields at  least  in
some portions of the skin M'hile prurigo does not.
  From pruritus, prurigo is readily diagnosticated by  its  general
physiognomy and history; its peculiar pigmentations aud infiltrations;
and  by the special  region  chiefly affected.   But, both diseases  may
complicate prurigo, especially eczema,  M'hich is then  ordinarily  of
artificial origin.   In  pediculosis corporis, the parasites will  usually
be found  upon  the underclothing, M'hile the lesions induced by the
nails never form closely packed  papules.  There is something highly
characteristic in the  widely separated  excoriations,  puncta  from
wounds of the insects, and inflamed papules  seen  upon louse-bitten
patients.
  In scabies, the characteristic burrows of the parasites will  usually
be recognized, as also vesicular and pustular lesions.  Urticaria can be
mistaken  for prurigo  only in  the earliest stage  of the  last named
disease.
  Treatment.—In Vienna, sulphur, tar,  green soap, baths, and fre-
quent anointings with oily and fatty substances  have occasionally
served to ameliorate the severe  symptoms of the disease.  Mercury,
carbolic acid, boric acid, the  diachylon, and  zinc ointments may also
be employed upon different portions of the skin when indicated.
  The Wilkinson salve, representing  a combination of tar, sulphur,
and  green soap, has proved  of  special value in many cases.   Vle-
minckx's solution (q.  v.), followed by hot bathing and corrosive sub-
limate baths one drachm (4.) to thirty gallons, has also been recom-
mended  Internally, arsenic has proved valueless, M'hile  carbolic
acid has occasionally seemed  beneficial.  Cod-liver oil and the ferru-
ginous  tonics with the bitters,  M'ill  naturally be indicated in many
patients suffering from malnutrition.  A generous diet  and  tonic
regimen are essential  to the  management of most  cases, the patients
afflicted M'ith prurigo being usually  found  in  the most wretched
hygienic conditions.
  Prognosis.—The disease usually persists through life.   The most
favorable conditions are those where the  patient is quite youug aud
surrounded by circumstances which permit of untiring provision for
all  his  needs.   Many authors to-day  pronounce the disease entirely
curable in the early years of life. 
ACNE.
319
                              Acne.
                         G-r. axp.r/, a point.
Acne is  an inflammatory disease of the sebaceous glands, in which appear
  usually multiple,  and painful, firm, reddish, pin-head to  small nut-sized
  nodules, which  may result in suppuration and the formation of cicatrices.
  Symptoms.—Acne is probably the cutaueous disease of most com-
mon occurrence, not excepting eczema.   The latter affection occurs
upon the face as often  as  upon other parts  of the  body, and is yet
seen upon the street M'ith  far less  frequency.  Eczema, however, is
more distressing in  its symptoms, and for that reason  physicians are
more often consulted for its relief,  the disease thus acquiring a statis-
tical preponderance.  Acne is more tolerable, and therefore more
tolerated and  less treated, especially among the poor.
  The disease is characterized in general by the occurrence of several
and usually  numerous, light red, dull crimson,  or violaceous, pin-
head to small nut-sized, circumscribed, ill-defined  papules, nodules,
tubercles, or non-projecting indurations of the skin, often commingled
with the lesions of  comedo and  seborrhoea sicca.    They are usually
both slightly  painful  and tender, though upon this point there is  a
wide range  of difference in different individuals,  some patients toler-
ating with a  surprising equanimity the  most extensive  invasions of
the disease.   The inflammatory process, M'hich manifestly involves
the sebaceous  glands and periglandular tissues, may result in suppura-
tion of one or  several adjacent  follicles, as a consequence of M'hich
coalescence  occurs and pea- to large nut-sized, cutaneous and subcuta-
neous abscesses  may form.   In the larger number of cases, hoMever,
the suppuration is limited to the area of the individual nodule, every
feature of the entire process being displayed at the  same moment in
an  affected individual.  Under circumstances of  special  aggravation,
the disease  may occur in  acute  forms, but it is  commonly chronic;
and such acute phases are usually accidents of the general process.
   The disease occurs chiefly upon  the face, but is seen also upon the
neck, the back and front of the chest, the genitals, and the extremities,
the palms  and soles alone  excepted.  It is emphatically a disease of
the early puberal  epoch in both sexes, though  occasionally seen in
middle aud  later life.   It usually lasts,  when unrelieved, for years,
being  during this  period  subject  to  occasional  exacerbations  and
remissions;  but  commonly  spontaneously  disappears  as the  full
maturity of the body is attained.   In  severe cases, it leaves indelible
traces of its ravages, in the  scars M'here  suppuration has been ex-
tensive.   It occurs also in very mild and severe forms.   The  various
terms used  in the description of the  forms of the disease refer chiefly
to its external features.
                         Acne Artificialis.

   Various substances, either applied topically to the skin  or ingested,
are capable of producing acneiform lesions.   Among them may be 
320
DISEASES  OF  THE  SKIN.
named tar, which may prove  such an  irritant, whether employed
externally or internally, and, far more frequently, the salts of  iodine
and bromine after ingestion.   Tar  acne  occurs  both among workers
in that substance, and in those subjected  to its action for the relief of
other cutaneous disease.   Pin-head to pea-sized reddish-brown papules
then form, at the apex  of which is perceptible a  minute  blackish
punctum, produced  by the lodgement of a minute particle  of  the
medicament in the orifice of a sebaceous  follicle.   Pustular  and fur-
uncular lesions are, however, also produced; and the same is true of
bromic and iodic acne.  In the latter, Adamkiewicz and others have
demonstrated the presence of the drug in the contents  of the  pustular
lesions.   Chrysarobin and a number  of other  medicinal  substances
are capable of exerting a like effect.

              Acne Atrophica and Acne Hypertrophica

are terms employed to designate merely the lesion-relics of the dis-
ease.   In the former, there is  complete atrophy of the gland-tissue,
indicated by a minute sunken pit in the  site of the former orifice; in
the latter there is, in consequence of the periglandular exudation, a
thickening of the tissues about  the  acini, and a projection from the
surface of persistent, pea-sized, and indurated masses.

                       Acne Cachecticorum

includes the symptoms encountered  in the  subjects of struma, scor-
butus,  marasmus,  chloro-anaemia,  and  tuberculosis.   The lesions
more often develop on the trunk and extremities than over  the face,
and are papulo-pustules, pin-head to bean-sized, particularly indolent,
and remarkable for their livid, purplish,  lurid-red, or violaceous tiut.
The  lesions are rarely indurated; more often they are seen as softish,
pus- and blood-containing nodules, sluggish of career, aud leaving
minute  cicatrices.  Their features are  due entirely  to the general
cachectic condition of the subjects in whom they occur.

                          Acne Indurata.

   This is a form of the disease less frequently observed than several
others, but one which possesses certain distinct clinical features.  In-
duration of  the base of the acne papule  may be noted in many cases
of the simple form of the malady;  but in others  the glands seem
generally to be distinguished as minute, very firm  nodules, with no
tendency whatever to suppuration.   The surface of the skin is often
without  marked  change in color  or heat, the  individual lesions
indeed exhibiting at times an unnaturally whitish aspect.   They  are
felt when the finger is passed over the surface as dense, often conical
projections, occasionally painful, and giving to  the  touch a sensation
suggestive  of the nutmeg-grater.    Comedones may  be  often  dis-
tinguished intermingled with the papules.   The disease, M-hen well
marked,  is apt to be extensive, occurring M'ith characteristic expres- 
ACNE.
321
sion among brunette, hairy male patients well advanced to the twenty-
fifth year.   It  is often generalized over the  forehead, cheeks, chin,
and the back of the neck.

                          Acne Papulosa.

   Here  the lesions are of a papular type, ranging in size from a
millet-seed to a coffee-bean, M'hitish or reddish in color, and varying
in the amount of firm induration at  the base.   They are evidently
due to hyperplasia of the periglandular tissue, and are often com-
mingled with  pustules, papulo-pustulcs,  and  comedones.   At  the
apex is often distinguished the blackish point  characteristic of acne
punctata, or a minute, greasy, yelloM'ish-white spot, which represents
the non-pigmented extremity of an inspissated sebaceous plug.

                          Acne Punctata.

   In this variety, the acne papule is  formed about a comedo.  When
examined, its apex is  discovered exhibiting the characteristic blackish
punctum of that hsion.

                          Acne Pustulosa.

   This  is probably the most frequently observed of all the forms of
the disease.   The lesions, as usual,  are  apt  to  be commingled with
papules, comedones, and intermediate phases between the functional
and  exudative disorders  of  the  glands.    The  pustules may  be
large or small, containing  merely a  droplet of  pure pus, or, when a
true  furunculosis ensues,  a teaspoonful  or  more of the  same fluid
mingled M'ith blood  and  serum.   This may be speedily evacuated
artificially or accidentally, be absorbed, or remain  for a long period.
of time in a species of cyst-like loculus, M'hence it  can  be finally ex-
 pressed.   In aggravated  cases, Uxo  or more of these pustulo-furun-
cular depots may coalesce, forming nut-sized abscesses, or, not rarely,
become  united by fistulous tracts, through M'hich there is free com-
munication of the fluid contents of two or more chambers.

                        Acne  Varioliformis

is  the term employed, by the French  especially, to designate the
lesions elsewhere described as molluscum epitheliale, the name being
selected in  consequence of the resemblance of the latter to the um-
bilicated pustules of  variola.

                          Acne Vulgaris

is  a  term  applied by  several authors to the composite eruption
 M'hich is common to  many clinical cases.  Here the various  lesions
described above are  associated, usually on the face and  over the
shoulders, each in several  degrees of development, often  in conjunc-
tion with the scars left by a prior eruption.
                                 21 
322
DISEASES  OF  THE  SKIN.
    Etiology.—The  causes  of acne are  in  many  cases  exceedingly
  obscure and are  probably numerous.   It is  common to describe the
  puberal changes in both sexes as a frequent cause of the disease, but
  one should be slow to regard a physiological crisis as a disease-factor.
  It can merely be  asserted with safety that, with the growth  of the
  hairs in both sexes at the period of puberty, there is  an unusual
  activity of the sebum-producing function, and that this physiological
  is then the more  readily perverted to a pathological activity.   Need-
  less to say that tens of thousands escape acne  who  survive  puberty.
  The disease, however, is apt to  appear first at this time of life, and,
  if not improperly treated, to disappear  spontaneously when the full
  maturity of  the body  is attained.
    Inasmuch also as there is a close physiological connection between
  the genital function and organs, and the appendages of the skin, not
  only in man, but in the lower animals (antlers of the stag, plumage
  of birds, etc.), it  seems reasonable to  conclude, a priori, that the dis-
  turbances of the  former may be reflected to the  latter.   Many facts
  support such reasoning.   The effect of castration upon  the male  of
  many animals is displayed in the appendages  of the skin.   In the
  same way, perverted sexual instincts and habits, or a poorly regulated
  sexual hygiene, and uterine disease (which  is  indeed often traceable
  to the causes just named) are often associated with an acne.   To the
  same category belong the disturbances of the gastro-intestinal tract,
  including  constipation, dyspepsia, malnutrition from various causes,
  and the  struma,  tuberculosis,  etc.,  which  are responsible  for acne
  cachecticorum.   The medicinal agents capable  of producing artificial
  acne, either  by ingestion  or after external application, have been
  already named.
   It should not, however, be concluded that any one of these condi-
  tions can be recognized as efficieut in the majority of patients.   Many
  cases of acne occur in perfectly healthy young people of both sexes.
  A careful record of cases of the disease, preserved upon blank forms
  in which is space for noting irregular performance of function in the
  other organs, will exhibit no ailment  common  to the larger number.
  In these, therefore, it is proper to believe that the causes of the dis-
  ease are  entirely  local, such as  suffice  merely to induce primarily
  alteration in  the  consistency, quantity, or chemical character  of the
  sebaceous secretion, and, either as a cause or result of this, an adenitis
  or periadenitis.
   Apart from the local causes to which reference has been made, one
  should not forget that the use of cosmetics ; neglect of soap,  or the
  use of the cheaper and irritating varieties;  excessive shaving  on the
  part of the young man; friction from hat-bands; "frizzes," "bangs,"
t  and dyed veils; too frequent fingering  of  the face (Wigglesworth);
  improper compression  of the neck by tight collars ; and a long list of
  other  agencies may  prove  the immediate or remote cause  of the
  disease.  It  is  believed  that blondes of both sexes are the  more
  frequent  sufferers.  But this observation may have been suggested
 by the circumstance that in the  light complexions the symptoms  of 
ACNE.
323
the disease are more conspicuous and disfiguring.   It certainly seems
that young brunettes, M'ith thick skins and abundant growth of dark
lanugo hairs, furnish the most obstinate cases.
  The distinct cause of acne is the mechanical irritation set up by the
inspissation of the secreted contents of the gland.  The next efficient
cause is perversion of the glandular function, in consequence of M'hich
the secretion is changed in character.
  Pathology.—The  microscopical appearances are briefly those of  an
inflammatory process with  exudation  involving the peri-glandular
tissue of the sebaceous glands  and hair-follicles, and that about the
common excretory duct.   There  is the usual vascular engorgement,
the multiplication of protoplasm  within and  M'ithout the focus of the
phlegmon, its metamorphosis into pus  often mingled with blood, the
destruction  by suppuration of the sebaceous gland, and  often  the
preservation of  the hair-follicle though the  latter  may  also  be
involved in the destructive process.  According to Kaposi, there is no
question that the first stage of the disease is always an anomalous
performance of secretion or excretion in the sebaceous gland.  Visible
cicatrices rarely result,  unless the destruction of the elements of the
derma  surpasses  the original limits  of  the  gland itself.   Where
suppuration docs not occur, there is generally  relief of tension  by
extrusion of  the inspissated gland-contents and  resorption of the
plastic or fluid exudate in the periphery.
   Diagnosis.—The  typical  facies of acne vulgaris  is readily recog-
nized by the  characteristic features already described.  The reddish
papules, pustules, comedones, and "lumps" in the skin of the face of
a young subject; the evident involvement of the sebaceous glands;
the  history of a chronic affection destitute of itching  and quite
uuscratched;  the occasional  blood-crusts  M'here lesions  have  been
squeezed or incised,  are all significant facts.  The pustular  syphilide
of the face is not only to be differentiated  by its share in the history
of an infectious disease, but  by the occurrence of characteristic crusts,
its selection by preference, of the regions  about the  nose and mouth,
its evolution in groups, and its sequelae  in the form  of superficial or
deep ulcerations.   Nevertheless, and  this  is  a  matter  of prime
importance as regards diagnosis, simple acne is exceedingly common
in syphilitic subjects.  The iodide of potassium is so largely adminis-
tered for the  relief of syphilis, and in so large a majority of cases
induces its artificial  acne, that the latter eruption often precedes the
evolution of the macular syphilide, and also M'ith surprising frequency
masks  the  latter  by a  commingling  of lesions.   Simple  acne is
common also among those who are veterans of syphilis.  Acne does
certainly at times resemble variola, and  cases of  the former have
actually been  mistaken for the latter.  In  most instances, the absence
of fever and a brief delay  M'ill soon put an end to any doubt.
   Treatment.—Acne is an entirely remediable disease  in every case
properly managed from the first.  Scars  of ancient ravages of the
affection are, it is true,  indelible ; but even these are smoothed down 
324
DISEASES  OF  THE  SKIN.
in the progress of time, so that they become yearly less  conspicuous
and disfiguring.
   An important consideration, at the outset of treatment of a patient
affected with acne, relates to any local  or internal medication which
has been previously employed.   A very  large proportion  of all
patients first claim the attention of the physician after ingesting drugs
or making topical applications which have decidedly aggravated  the
original trouble.  With or without the advice of  others, such persons
have  often  been engaged for months  iu  swallowing the iodide of
potassium, " red clover," and various nostrums calculated to " drive
out"  the disease; or in rubbing over the skin equally noxious pro-
prietary substances.   In every such instance the skilled  physician
should delay active treatment of the affection until the artificial acne
has subsided, and the real condition of  affairs  can be  clearly recog-
nized.  The  patient should  be directed  to discontinue  his or  her
former practice, to bathe the affected part in hot Mater at night, and
after  it is dried to apply  any  bland  unguent.   By these simple
measures alone,  many cases can be very greatly improved, aud some
completely  relieved.  Their  simplicity should  commend them  to
every reader of  these pages.   It  is a good  thing  to  know what  not
to do.
   The constitutional treatment of acne  rests for its success upon  the
discovery of the cause of the disease.   Many cases certainly require
no such management, being entirely relieved by local treatment only.
A thorough investigation of the habits  of living,  food, diet, bathing,
occupation, and  bodily functions  of the patient, such as  is described
in the chapter devoted to General Diagnosis, is essential at the outset.
   Since dyspepsia and constipation are frequent causes of the disease,
it is necessary to correct  these M'hen present; also any conditions of
acidity of the stomach, distention  of the transverse colon (Jewell),
or marked anaemia.
   Some modification of Startin's acid mixture, such as the following,
will be found suitable for many cases :
R. Magnes. sulphat. Acid, sulphur, dil. Sodii chlorid.	3u; f3ij; 3j;	64 8 4	
Ferri sulph. Cardamom, tinct. co.	gr. v; f3j;	33 4	
Aq. dest. Filtra.	ad fj viij ;	256! M.	
Sig. A tablespoonful in	a tumblerful of water before		breakfast.
  Other cathartics, saline and alterative, will often prove serviceable.
It is rarely found necessary to  resort to arsenic, although this  metal
is  highly recommended  in  acne  papulosa, by both Duhring and
Taylor.  The internal employment of ergot in full doses for the relief
of acne, as  suggested  by  Denslow, has,  without question,  been
frequently  followed by  excellent  results.   Coddiver  oil, iron,  the
mineral acids, and the  bitters  will prove valuable in  chlorosis and 
ACNE.
325
 cachexia.  The sulphide  of calcium, in quarter of  a  grain (0.016)
 doses, is of decided benefit in obstinate cases.
   Glycerine in teaspoonful  to tablespoonful doses  three  times daily
 has also proved  valuable (Gubler).  The  mineral waters, Hathorn,
 Hunyadi Janos, oftener  Racoczy or Kissingen, a tumblerful  before
 breakfast, are exceedingly  valuable in  cases of habitual intestinal
 torpor.   When there is an acid  form of dyspepsia, the rhubarb  and
 soda mixture,  or the acetate of potassium in half drachm doses (2.),
 Mill be serviceable.
   Temperate gratification of the sexual instinct in a happy marriage
 is conducive to good results; and  such a condition  should generally
 be recommended as favorable for the  future of  young  adults.
 Uterine disease should receive proper treatment when such compli-
 cation exists ; and  this,  far less  by topical  applications,  than  by
 attention to the general health, as the patients of this class are more
 often chlorotic young M'omen with menstrual derangements, leading
 sedentary lives,  or  overworked  at  the school-desk, the  sewing-
 machine, or  the shop-counter.   The  diet should be carefully regu-
 lated, and the rules of hygiene enforced.
   As  to the former, hot  breads and  cakes, sweets, pastry, oat-meal,
 uncooked vegetables, and  all alcoholic beverages should  be scrupu-
 lously avoided;  while fresh cooked meats, fish, and vegetables, fresh
 fruits, and tea and coffee  in  moderation should be permitted.
   In all cases, whether previously treated  or not, which have been
 purged of suspicion of an artificial element, the local treatment is of
 prime importance, and in the  perfection with which its details  are
 observed, lies the key to success.  It is not the selection of one of the
 several remedies of the many advocated for  the relief of  the disease,
 nor yet  the  successive substitution of oue  for  another to meet any
 transitory indications in  each case, which conduces  to  the happiest
 result.   It is rather  the use of a single method of recognized  value,
 and its skilful  adaptation to  the changing conditions of the disease.
   It is  first  necessary to evacuate the contents of all pustules, to
 express  from the  summits of papules where are the orifices of seba-
 ceous ducts,  all densely inspissated  plugs of sebum, and  to  remove
 any comedones  which  are  present,  by the  aid  of  the  comedo-
 extractor.  For the  purpose of opening the superficial and smaller
 purulent collections, the  long  needles  used  by gynecologists  are
 decidedly preferable; and for the larger aud deeper furuncular lesions,
 a bistoury M'ith a delicate and very narrow blade.  A slight degree of
 skill will here repay the operator.  Piffard's acne-lance is useful  iu
 this same connection as is also Volkmarin's  spoon as modified by
 Auspitz, M'hich may be employed in  removing pathological debris.
 By counter-depression with the fingers the whitish-yellow  or blackish
 orifice of the duct may be detected, and at  that point precisely the
 needle or bistoury should be thrust sufficiently deep  to insure the
 removal  of pent-up pathological accretions.   Should blood  flow  in
droplets  from  any of  these slight wounds, it  is rather to be  en-
couraged  than  repressed,  as relieving  the hyperaemia and  engorge- 
326
DISEASES  OF  THE  SKIN.
 ment of  the  small  peri-glandular phlegmon.   In  one  or several
 sittings, all lesions  requiring  such interference  should be  carefully
 attacked,  and immediately after each, preferably M'hile the pus and
 blood are still oozing, the part is to be bathed for several minutes in
 M'ater as hot as can  be borne M'ith comfort.   For many reasons, the
 hour before retiring is  preferable, though not alM'ays practicable, in
 treating such cases, as  then a  bland ointment can  be thoroughly
 applied and permitted to remain till the following morning.
   When  one or several of  such operations have completely relieved
 the  skin  of its  engorgement and retained inflammatory products, a
 systematic use at night, of the spiritus saponis viridis with hot water,
 should  be for a time practised.  Let it  be noted here, however, that
 many  cases  which  do  not require the  minor  surgical  operation
 described above, should  be  from  the first treated  in this manner.
 As  the face is the most common seat  of the disease, it  may be, for
 the purpose of description, considered as the affected part.
   The  patient is seated  before a  basin of water, as  hot as can be
 tolerated  with comfort, and M'ith a  pad of white  flannel or soft
 sponge, bathes the  face till the skin is thoroughly moistened and
 softened by the heated water and steam.   From ten minutes to half
 an hour may be well employed  in this way, and it is a fertile source
 of the improvement  which follows.  Then, while the face is still wet,
 all pustules M'hich have formed are emptied, and a sufficient quantity
 of the spirit of green soap is poured over the flannel or sponge, and
 the face thoroughly scrubbed with it.   Finally the surface is cleansed
 with a  surplus  of the  water,  carefully dried, and anointed with a
 sulphur ointment.
   Some range may be observed in the employment of the two articles
 named.   Thus the spirit may  be diluted with cologne or rose-water,
 one half or more; or the soaps employed, in less  imperative cases,
 may be the best toilet, Sarg's glycerine, or sulphur soap.  The oint-
 ment, too, may be  compounded by  adding  half a drachm to two
 drachms (2.-8.)  of the flowers of sulphur to  the ounce (32.) of cold
 cream  or  vaseline.   In the  morning, the face is to be washed with
 cold water.
 #  This  operation of steaming,  soaping, and  anointing, is  to be con-
 tinued, according to  the severity of the case and the tolerance of the
 patient, nightly, twice in the day, or on alternate nights, till the face
 is  free from papules and  other  inflammatory lesions.   At  this time
 it  is usually  unsightly,  reddened, slightly tumid, and  often  mod-
 erately furfuraceous,  but free  from acneiform lesions.  To the patient,
 it  feels tense, slightly painful, and as if made of leather.   This accom-
 plished, the  spirit,  or  other preparation  of soap  may  be for the
 time discontinued.   The improvement which follows is marked and
 speedy; and usually quite  satisfactory to the  patient.   When this
 is  reached, a wider latitude of treatment is permitted.
   Gradually the  hot ablutions  may  be withdrawn, and the use of
lotions and ointments other than those containing sulphur, may be
advised.   The last-named substance, having  the highest reputation 
ACNE.
327
in the disorders of the sebaceous glands, is a constituent of many of
the lotions thus employed.
  Taylor1 advises the following:
R.	Sulphuris loti Camphorae spts. Sodse biborat.	3nj; f3»j; 3ij;	12 12 8
	Glycerin. Aq. fontan.	f3vj; ad f§iv;	24 12S
                                                             M.
        Sig.  Shake  well and apply freely, leaving a thin film of powder
               over the face.

  Various combinations of sulphur with alcohol will be found useful.
Thus Kaposi recommends a paste composed of:
R.
Sulphur, praecip.
Spts. vin. rect.
Lavand. spts.
Gl veer in.
 3ijss
 f'.!jss
fSjiss
 n\,xx
M.
Sig.  To be spread over the face and retained during the night. Or,
R.
Sulphur, flor.
Spts. sapon. virid.
Lavand. tr.
Peruv. bals.
Camphor, spts.
Bergamot. ol.
gijss:
 f3v;
 f|ij;
ir\,xx;
n\,xv;
 n\,v:
M.
      Sig.  To be applied over the face at night.

Duhring recommends the following :

      R. Sulphur, praecipit.            3y ;
         Glycerin.                   f3ij;
         Alcoholis                    f^j;
         Aq. calcis                    f^j;
         Aq. ros.                    f|ij;
      Sig.  Sbake the vial before using.
M.
.^ix;	288
Z/y,	192
5J;	32
  Occasionally  the rumex  ointment may  be used  M'ith advantage
as the basis of sulphur and  other salves  in acne.  It is prepared
according to the following formula :

        R.  Rum. crisp, rad.
            Adipis
            Cerae flav.
            Aq.  pur.
        Wash and  bruise the roots;  boil for two hours; strain; evaporate
          to four ounces (128.);  gradually add the wax and lard in a melted
          state; and stir till  cool.

  The English  hypochloride of sulphur, in ointments of the strength
of those given  above,  and  the snlphuret of potassium, half to one
scruple (0.66-1.33)  to the ounce (32.)  of  lotion or  ointment are
effective, but objectionable on  account of  their odor.
  Ararious  cosmetic ointments will be found  useful in superseding
those described  above,  as the  case  progresses.  Among these may be
named, the  oxide of zinc,  the subnitrate of bismuth, and freshly
1 Amer. Clin. Lectures, vol. Hi. Xo. 10, New York, 1878. 
328
DISEASES  OF  THE  SKIN.
levigated  calamine in the strength of from  one-half to  one drachm
(2.-4.) of one or more of these substances to the ounce (32.) of cold
cream, to  which, as required, the tincture of benzoin, glycerine, oil of
roses or bergamot, may be added in suitable  proportion.
  For mild cases an excellent lotion is obtained by adding a drachm
each (4.)  of the simple  tincture  of benzoin and glycerine to four
ounces (128.)  of distilled water, to which, where  a more stimulating
effect is  desired an ounce (32.) of  cologne M-ater or rectified  spirit
of wine may be added, or a scruple (1.33) of the sulphuret of potas-
sium.  The  folloM'ing is the  formula  of  the  "Oriental  Lotion,"
according to Hebra:
        R.
Hydrarg. chlor. corros. Aq. destill.	3j; 3iv;	4 16
Ovorum iij albumen Succi citri Sacchari	3"j; %y>	12 32
                                                            M.

  The  bichloride of  mercury  is  very generally employed  in  the
strength of from one-eighth to one-half a grain (0.008-0.033) to the
ounce (32.) of emulsion of bitter almonds as a lotion;  and the prot-
iodide,  biniodide, and  ammonio-chloride of the metal are similarly
applied in both lotions and unguents;  the first two, in the strength
of from five to ten grains (0.33-0.66) to the ounce (32.); the last-named,
in the strength of from half a scruple to a scruple (0.66-1.33).   One
should be careful not to make use of the mercurials at the same time
with a  compound of sulphur, lest  a chemical  combination occur by
reason of M'hich the sulphuret  of mercury is precipitated upon the
skin and produces  the appearance of comedo.   Heitzmann  highly
recommends the solution of Vleminckx.1
   Kaposi recommends also mercurial plaster applied on strips of linen
iu obstinate cases,  for  which may be substituted  iodated  glycerine,
five  parts each of pure iodine and the iodide of potassium to ten of
glycerine, applied with a brush tM'ice daily  till  from  six  to  twelve
applications have been made.
  Van  Harlingen's favorite prescription is one drachm each (4.) of
the sulphuret of potassium aud sulphate of zinc to four ounces (128.)
of rose water.  Fox  applies half a drachm (2.)  of chrysarobin to
the  ounce (32.) of  collodion.  Taylor advises  five  to twenty-five
grains (0.33-1.6)  of the  iodide of zinc to the  ounce (32.) of vase-
line.   Veiel employs the uncertain unguentum Rochardi:
R. Hydrarg. chlor. mit.              £j;        1
   Iodi. puri.                    gr. vij ;
Leni igne fusis adde
   Ungt. rosae aq.                   gij;       64
M.
  The  use  of caustics  in acne,  though recommended  by several
authors, should  be discountenanced as quite needless.   In extreme

 1 The formula is :
            V- Calcis,                Sss;             1G;
              Sulphur sublim.          Jj;             32
              Aq. dest.               Sx;            3>0|   M.
            Coque ad gvj [192.] deinde filtra.
            Sig. " Vleminckx's Solution." 
ACNE ROSACEA.
329
induration of the lesions, they may be rubbed with fine pumice-stone
till the desired effect is produced.
   The powders employed  in the milder  forms of the affection, are
finely poM'dered sulphur, which may be freely dusted over the face;
and  those compounded, in  various  proportions, of starch, rice-flour,
zinc  oxide, and the subcarbonate of bismuth.
   Finally Sherwell, Denslow, and others in this country report relief
of acne in young male patients after the passage of the urethral souud
and, in  both sexes, by  hot  and cold water injections of vagina and
urethra.

                        Acne Rosacea.

Acne Rosacea is a chronic disease of the skin, chiefly of the face, often devel-
  oped from, or associated with, the lesions of acne vulgaris, characterized
  by hyperaemic maculae, patches of diffuse, dull red erythema, telangiectases,
  inflammatory papules, or vegetating masses, which may attain the size of a
  hen's egg.

   It is  usual to describe three grades  of this disorder,  also  named
Gutta Rosea, or simply Rosacea, which  is most ofteu displayed upon
the nose,  though it may also affect  the cheeks, lips, chin, and, rarely,
the lateral regions of the neck.
   Symptoms.—In the first grade, there is a more or less diffuse and
uniform,  pinkish or dusky, but transitory redness, involving the ex-
tremity of the nose and its contiguous parts, M'hich may extend from
this  part in a somewhat symmetrical figure over the cheeks and chin.
The parts give  rise to  little or no subjective sensation.   Under the
finger, the  color disappears under  pressure, the surface  seems  cool
rather than hot, and  the sebaceous  glands are  seen to be affected, as
there is usually  present either a seborrhoea oleosa or an accumulatiou
of yellowish-white, moderately  inspissated  sebum  in the  patulous
orifices of the gland ducts.   When the  redness has existed  for some
time, minute bloodvessels can be seen ramifying over the erythem-
atous surface.
   This  disorder  varies greatly with the general condition of the
patient.   At times, it may be scarcely  perceptible; again after the
stimulation produced by ingested food or alcohol, after mental excite-
ment, a paroxysm of coughing or laughing, or exposure to external
irritation, the lesions  may be even conspicuously deforming.   This
may endure  for  months or years, and then disappear or be succeeded
by the second stage of the malady.
   In this second grade of the disease, the redness becomes permanent,
the  capillaries dilate passively  aud appear as conspicuous, tortuous,
straight or anastomosing lines of reddish color about the nose, cheeks,
chin, or forehead.
   Firm,  purplish-red, painless, pin-head to  pea-sized  nodules  or
papules often rise  from the erythematous  surface, and either display
minute  superficial  and tortuous bloodvessels in the integument by
which  thev are  covered, or project  from  a base  about which such a 
330
DISEASES OF THE SKIN.
 telangiectasis has been very irregularly developed.  The lesions are apt
 to be intermingled with those of eeborrhcea  oleosa or  acne vulgaris.
 When fully  developed, this stage of the disease, though generally not
 productive of marked subjective sensation, produces an  exceedingly
 conspicuous  deformity.
   In the third stage, which  is  the  most pronounced of the three,
 roundish,  sessile,  or pedunculated,  lobulated  or pendulous,  firm,
 elastic, pinkish-red, bluish, livid, or violaceous vegetations, traversed
 by finer or larger networks of bloodvessels, slowly develop about the
 affected  part of the face, chiefly the  nose.  These may be single or
 multiple, and, in the latter case, isolated, or so closely united as to be
 scarcely distinguishable from each other.  The acneiform lesions seen
 in the second grade of the disease, may here also be apparent.   In
 other cases,  there  is a uniform,  symmetrical, and elongated  hyper-
 trophy of all the soft parts of the nose, which  may thus attain colossal
 proportions.   It is  these consequences  of acne rosacea to which  the
 term Rhinophv^ma1 has been applied.
   The  course of the disease  is very slow, and in by far the largest
 number does not produce  the exaggerated types of the  second  and
 third grades.  The lesions may persist indefinitely as indolent symp-
 toms of the  malady in any one of its stages, or, in the cases where
 there has been  no  new growth  of vessels or tubercles, proceed  to
 spontaneous  involution.
   Etiology.—The first and second grades of acne rosacea are common
 in women either at puberty or near the period of  the  menopause,  in
 those M'ho are pregnant, or who suffer from  utero-ovarian disease,
 frequent miscarriages, sterility, irregular performance of the menstrual
 function, and chlorosis.  It is,  however, seen in men of early and
 late adult life.   In both sexes, it may occur  in anaemic and asthenic
 states.   In both, also,  its association with dyspepsia and the immode-
 rate  use of alcoholic drinks, beer, wines, and  spirits, is a matter  of
 common observation.   According to  Kaposi, the  rosaceous  nose  of
 the wine-drinker  is  bright red; of  the beer-drinker, cyanotic  or
 violet; of the spirit-drinker, smooth, supple, fatty, and  dark blue.
 The  new growth of vessels and tubercles, with the rhinophyma  of
 the advanced grade of the disease, is much more common in men
 than in women.   In those M'hose faces  are bronzed by exposure  to
the weather,  the telangiectasic condition  of the cheeks rather than  of
the nose, is of frequent occurrence.  Veteran sailors and  soldiers are
thus commonly affected.  Persons who  have  frozen the  nose or the
cheeks on one or more occasions, are similarly liable to the telangiec-
tasic development.  Any  externally  or  internally  operating cause
which tends  to retard  the capillary circulation in the superficial por-
tion  of the skin, is capable of inducing the result.  It  is at times
conspicuously displayed in the mulatto.
  Pathology.—In the first stage of acne rosacea there is merely passive

De^Vs^n^fsaTrHft Wjft,(C0??l! a ValuaWe PaPer ^ Hans Hebra> in the Vierte«- f-
of the di'seaTe              ' lllu8trated *>? cuts SivinS tb-e gross and microscopical appearances 
ACNE ROSACEA.
331
hyperemia.  The circulation of the blood in the superficial capillary
plexus of minute vessels is retarded.   Persistence  of this condition
for long periods of time  results in paresis of the capillaries, M'ith
their consequent dilatation and hypertrophy, phenomena which char-
acterize the second stage, the  sebaceous gland disorder being a com-
plication of the process.   In the third stage, the nodules are found
to be composed of new-formed gelatinous  elements,  which  become
formed  by organization.  According to Biesiadecki,  there  are  also
dilatation and hypertrophy of the  sebaceous glands, with dilatation,
hypertrophy, and new groM'th of the superficial vessels, and enlarge-
ment  also of those trunks which ascend from the corium.
   Diagnosis.—Acne vulgaris is  distinguished from acne rosacea by
the absence of  telangiectasis,  and of  the hypertrophic growths M'hich
characterize the developed lesions of the  last-named disease.   The
tubercular syphiloderm is  recognizable by its tendency to  ulceration
and crusting, and by the entire absence of telangiectasis.  When the
tubercles of syphilis are limited to the extremity of the nose, and are
unusually small in consequence of the  influence of  treatment, they
often  degenerate into characteristic, split-pea sized,  irregularly  cir-
cular  ulcerations, superficial in seat, and frequently isolated.   They
leave  similarly shaped and sized, depressed  cicatrices  at  the tip  and
neighboring parts of the nose.  As the process is much more rapid
than in acne rosacea,  these  lesions, considered in connection with the
absence  of telangiectasis,  furnish  the  most significant diagnostic
symptoms of the disorder, for they often occur  late in the history of
syphilis, in individuals of middle life, and in varying shades of a dull
reddish color, circumstances  particularly favorable for confusion re-
garding the identity of the two diseases.
   A  case  of zoster  from involvement of the superior  maxillary
branch  of  the  trigeminus, with  diffused redness of one side of the
nose  and  efflorescence  of vesicles over its tip and ala,  certainly
strongly resembles acne rosacea with pustular lesions.   Here the
painful character of the disorder, its limitation to one side, its transi-
tory career, and its vesicular  lesions are sufficiently characteristic.
   Lupus vulgaris, like syphilis, M'hen occurring upon the nose, is to
be  recognized  by the  tendency of its  papulo-tubercular  lesions to
ulceration and  crusting, the absence of vascularity, and the frequent
presence of characteristic cicatrices.  Unlike syphilis and acne rosacea,
however, the history of  lupus vulgaris usually extends to early child-
hood.   Lupus  erythematosus is yet more readily differentiated, as  it
is not only unaccompanied  by vascularization and  ulceration, but  is
characterized by scaling and  symmetrical  diffusion over much larger
areas, commonly extending from the bridge of the nose well on to
the cheeks.
   Treatment.—As far  as  there  can  be  said to be any internal treat-
ment  of acne rosacea, it is that of acne vulgaris, but in neither dis-
order  can such be confidently described as effective in the dispersion
of the local lesions.   The treatment is that of the patient rather than
of his disease.   When alcohol has been in  any  degree productive of 
332
DISEASES  OF THE  SKIN.
 the local effects, the use of spirits, Mines, and  beer  is to be  inter-
 dicted; but as regards confirmed rosacea, this will prove to be of but
 little avail.   The disease,  M'hen resulting from spirit-drinking, may
 persist after five years of total abstinence.
   The diet  should be  of  the simple character  described above as
 proper for the patient M'ith acne.  All imbibition of hot liquids, even
 tea and coffee in excess, should be restricted as tending to congest the
 bloodvessels of the face.   Everything having the same result in the
 habits, occupation, or clothing  of  the patient should  be,  as  far as
 possible, deprived of influence, as, for example,  the wearing of tight
 collars and corsets, the working  over hot fires, etc.
   All  gastro-intestinal  sources  of mischief should  be  also,  when
 practicable, set aside.    In  acne  rosacea, even more than in acne sim-
 plex, dyspepsia and  constipation are conspicuously effective  factors.
 Here it is well  nigh  imperative  that there be a daily evacuation of
 the bowels.
   The local treatment of the  first  grade  of acne rosacea is substan-
 tially  that  of acne vulgaris.    Stimulating  lotions  of green  soap,
 alcohol, bichloride of mercury,  or sulphur  in connection with  ablu-
 tions by hot water, are of the highest value.   In addition, the various
 ointments containing sulphur, the mercuric oxide and iodides, and
 the continuous  application of mercurial plaster should be employed
 if necessary.
   A^an Harlingen reports rapid  results from the application, several
 times in the day, of a lotion composed as follows:

        R.  Sulphuris praecipit.            3j ;           4
            Pulv. camphorae            gr. v;
            Pulv. tragacanth.          gr. x;
            Aq. calcis ]               __ -_ .            on
            Aq.rosae j               aaf3j5           32

   Fox, of New York,  applies  chrysarobin in traumaticine, half a
 drachm (2.) to the ounce  (32.), but this  should  certainly be re-
 served for intractable cases, as it may have severe  results.  Even,
 however,  after  the production  of these  severe  effects, the  benefit
 secured may be appreciable for months after.
   When the diseased condition is that of the second grade, the indi-
 cation  is the destruction  of  the superficial  capillaries,  as well as. the
 removal of the other indications  present.    HardaM'ay, of St. Louis,
 was early in destroying the vessels by single or multiple puncture of
 each with a  fine cambric-needle attached  to the negative pole of a
galvanic battery, with six  to ten elements  in the circuit.   This is
 better than the knife, which has repeatedly failed.   The  operation
may be regarded to-day  as  the established  and  effective  method of
removing all blemishes produced by dilated  bloodvessels in this  stage
of rosacea.   It is  simple,  readily executed, requires  no  anesthetic,
and is  in many ways superior to  all other methods, which now should
be relegated to a second grade in the list as only to be proposed when,
for any reason,  electrolysis cannot  be employed.  The author has
33
66

      M. 
ACNE ROSACEA.
333
operated in many  cases, with the  result of destroying the vessels
completely M'itbout the production  of a cutaneous cicatrix which, in
the course of a few months, could be recognized by the unaided eye.
   For details of this  simple  and elegant operation the reader is re-
ferred to the chapter on Hirsuties, M'here it  is more fully described.
For the cambric-needle  mav often  be substituted  M'ith advantage a
fine jeweller's brooch,  annealed in the flame of a  spirit-lamp.
   The vessels may be  entered in  one or .several places, and the opera-
tion repeated till the  last thread-like evidence of their existence  has
disappeared.  The number  of cells  brought into the circuit must be
somewhat  graduated  to the requirements  of  each  case  and  the
locality of the  skin operated  upon.    FeMer can be tolerated for the
lip and  alse of the nose than for the root of it, the cheeks, or the
forehead.
   Next in value after this operation  may be named :
   Brushing the part cautiously M'ith solutions of caustic potash, ten
to thirty grains (0.66-2.) to the  ounce (32.)  of Mater;  and the local
use of pure carbolic,  chromic,  pyrogallic, and  glacial acetic acids,
acet urn cantharidis (Taylor), iodide of sulphur, and the pernitrate of
mercury.   Before  any  of  these, however,  is employed,  an effort
should be  made to produce exfoliation, by spreading over the part a
plaster made of green soap.   Unna's mercurial plaster-mull is simi-
larly applied    Kaposi  highly recommends the solution  of iodated
glycerine employed by him in acne  vulgaris (q. v.), M'hich is painted
over the part eight to twelve  times  daily for three or four successive
days, and immediately covered with gutta-percha paper.
   Multiple scarification  of all  new growths after the manner  of
attacking  lupous  nodules;  erosion  M'ith the  dermal  curette, or
Braun's spoon ; and surgical  ablation or decortication of tumors by
ligature  and knife, are also available.   After  any destructive attack
upon the diseased portions of  the skin, the soothing lotions, fomenta-
tions, or ointments should be  regularly applied.
   Prognosis.—A favorable  prognosis can be established only in cases
where the disease  is presented in its mildest forms.  In those com-
plicated  by marked telangiectasis  and  hypertrophy, the results  of
treatment are not in the highest degree encouraging.  In spite of the
most  energetic  procedures, the  vis  a tergo of  passive hyperemia,
involving often the deeper and unassailed  bloodvessels, works its
sIom- progress.   For women, the  future is in  general more promising
than in the case  of  men.  With  the most unfavorable  prognosis,
however, it is  to be remembered that, after all, the disease is one of
deformity rather than  of physical discomfort. 
334
DISEASES OF THE  SKIN.
                             Sycosis.
                           Gr. cvkov, a fig.
Sycosis is an acute or  chronic non-contagious inflammatory affection of the
  surfaces provided with relatively long hairs, in which the follicles  and
  perifollicular  tissues are involved  in an  exudative process, producing
  papules, pustules, tubercles, infiltrated patches,  and crusts perforated by
  hairs.
   Symptoms.—This affection, also termed Mentagra, occurs upon the
face, involving one or both  cheeks successively or  simultaneously,
the chin, upper lip, eyebroM's, scalp, axillae, and pubes.   It is, how-
ever, almost always a disease limited  to the  region of the beard  in
men.  In this respect it differs from acne and other disorders of the
sebaceous glands of the  face  M'ith  which  authors have sought  to
identify it, since not only is it as a rule strictly limited  to the region
of the beard, but the more hairy portions of  the face of the patient
are free from comedones,  acne lesions,  and  other  symptoms of a
cutaneous disorder.
   When seated upon the upper lip the first symptoms may be a nasal
catarrh; elsewhere  an  eczematous attack  may precede  the  onset of
the disease.   It may be ushered in with  such  acute symptoms as are
found in the early stage of some of the forms  of eczema,  tumefaction
accompanied by a  sensation  of heat and burning;  but often a few
isolated and indolent  lesions M'hose  presence scarcely awakens atten-
tion, are the first traces of  the  disorder.   Soon may be recognized a
larger or smaller number of discrete,  flattened  or conical, reddish and
painful papules, tubercles, or pustules, whose anatomical  seat is dis-
tinguished as the hair-follicle  by the penetration of each by a filament
of hair.   These lesions may persist, and when typically discrete and
visible at the part where the hair makes its exit from the duct of the
follicle, have  suggested the  appearance  of the surface  of  the fig,
whence the disease has its name.  They are apt to occasion a burning
and  at  times  a decidedly pruritic seusation M-hen, being picked or
torn open by  the fingers, the  pus concretes into  a crust at the base of
the hair.   In severer cases these  lesions while not coalescing, are so
closely  set together as to  form a patch of continuous  infiltration.
These patches may be weeping or  crusted;  in the latter case the
crusts are apt  to be  small  aud  numerous, each  being limited to the
shaft of a single hair, and  leaving when removed  a  minute  crateri-
form excavation at the mouth of the  follicle.
  Involution of several lesions may  be followed by fresh crops, and,
sooner or later, distinct patches of disease are thus formed.  When
fully developed, the surface of the skin  is reddened, swollen, infil-
trated, and thickened; covered irregularly here  and there with papules,
pustules, crusts, scales, and  often with excoriated surfaces.  The dis-
ease  is apt  to  lapse into chronic conditions,  usually as the result of
improper treatment; and in ancient cases the  deformity is character-
istic  and  totally unlike that  produced  by the vegetable parasites. 
SYCOSIS.
335
The hairs are usually fixed firmly in their follicles, but from those
M'here active suppuration is in progress they may be plucked without
occasioning much  paiu.   In the cases M'hich  have  been treated for
years,  the  hairs are thin and decidedly lacking  in vigor.  There is
no parasite to be discovered.
   In typical  neglected  cases of long standing, where the region of
the beard is involved, an important clinical feature is the symmetrical,
general, and uniform involvement  of the entire surface.   The picture
of one cheek  is  very  nearly  that  of  the other.  The thin hairs
scarcely serve  to  disguise  the reddened, tumid,  painful  surface
beneath, displaying the several lesions of the malady.   Furuncles,
abscesses, cicatrices, vegetations, and eczema of the ears may compli-
cate the process.   It is occasionally acute in its course, but more
often chronic and rebellious.   A typically chronic and untreated case
of the malady rarely terminates  by spontaneous involution.
   The thinning of the hairs described above as a consequence of long
persistence of  the disease is far more characteristic of it  than any
distinct resulting alopecia.  The latter,  however, very rarely occurs
but is then remediless.  The same may be said of resulting  cicatriza-
tion, which is one of the very rarest of consequences.
   The absence of  certain symptoms  in this disorder is as significant
as the presence of others.  Adenopathy of the cervical glands is very
rare, and when  present should  awaken suspicion of another malady.
The disease when  of longest  persistence  as  to  time, produces great
unsightliness, but no deep-seated,  subcutaneous, small- or large-nut
sized nodules or tubercles, forming the " lumps" so characteristic of
trichophytosis of the beard.   It is a disease of chronic course, which
may last for years  and be characterized by relapses and aggravations,
but it  is entirely curable and it is only in  neglected and badly treated
cases that such persistence may be expected.
   Etiology.—The exciting causes of the  disease are obscure.   It is
encountered  chiefly  among men  after puberty,  and  these in  all
social  conditions and grades of health.    It  is  non-parasitic, non-
contagious, aud not transmissible by heredity.  Shaving is not known
to produce it.   At times, the immediate cause  of the disease  can  be
recognized, as M'hen the upper lip is constantly irritated by the dis-
charge from a profuse nasal catarrh.   One such patient Mas  seen  by
the author two years after Hebra first  assumed charge of  his case.   In
others again, all the causes of eczema  may be invoked in explanation
of the result.
   A careful study of many cases, however, suggests that the hairs
themselves are the aggravating  causes of  the disease and the sources
of its peculiar obstinacy.  In health the motions of the free shaft of
the hair do not irritate the follicle in which it is  set.  In conditions
of disease it is quite different.    Each free hair  operates like a lever
upon the inflamed ring of tissue which encircles  it on its escape from
the follicle beneath, and this whenever by the touch of the  hand,  by
the action of brushing, by currents  of air, or by any agency what-
ever, a movement is  imparted to it.    Every such  movement must 
336
DISEASES OF THE  SKIN.
tease to a variable degree the surface  beneath, already irritated;  and
when estimate is made of the hundreds of such movements to M'hich
each hair  is subjected during a period of twenty-four hours, the
relative importance of this  apparently insignificant factor may be
appreciated.
  Pathology.—The disease is due to an inflammatory process, M'hich,
whether originally follicular or peri-follicular in its seat, may extend
unquestionably either  toward  or  from the follicle.   Sometimes the
extraction  of the hair is folloM'ed by a drop  of pure pus,  which
exudes from  the follicle; and the root-sheaths  of the hair are seen
to be altered in  consequence of the circumscribed follicular abscess.
At other times, the follicle itself is free from disease, and the exuda-
tive process has  evidently expended itself upon the peri-follicular or
even the inter-follicular tissues, in which case the papillary layer of
the derma exhibits the usual  phenomena of hyperemia, infiltration,
and multiplication of protoplasm, with abundant vascular dilatation.
  According to  Robinson, the disease  ahvays begins as a peri-follic-
ular  inflammation,  under the influence of  M'hich transuded  serum
penetrates the follicle.   Maceration  and eventual  destruction of the
root-sheath of the hair result M'ith the ultimate  production of pus
within and without the follicle.  The  pus, when the hair remains in
the follicle, finds its way to the surface by breaking through the epi-
dermis near the  hair; occasionally exit is obtained between the shaft
aud the follicle-sheath.
  Diagnosis.—The most important consideration here is the distinc-
tion  betM'een the parasitic  and the non-parasitic forms of  disease of
the region of the beard, upon which naturally the microscope finally
decides.   Still the clinical features of the disease are quite distinct.
The  non-parasitic form is recognized  (a)  by the  greater redness of
the involved surface; (b) by the extension of the disease in  advanced
cases to larger areas of symmetrical involvement; (c) by  the more
superficial  character of the lesions, and (d) by the firm implantation
of the hairs  in  their  follicles in the  earlier periods of the disease,
aud their  relative freedom in  all cases  from fracture and relics in the
form of stumps.   The parasitic disease of  the  hairs  is peculiar, in
consequence of  (a) decidedly less redness  of the surface  attacked;
(6) its frequent limitation to a circumscribed area,  or to several such,
irregularly dispersed over a large region;   (c) the peculiar " lumpy,
tubercular,  nodular,  and  uneven" characters of the patch, upon
which  Duhring  has laid significant emphasis;  and (d)  the earlier
loosening  of the hairs  in their follicles, as also of the occurrence of
fractured hairs and  stumps, exhibiting  usually at the bulb unmistak-
able  evidence of the  nature of  the disease.  The malady is often
mistaken  for  syphilis,  chiefly on account of its deformity, but the
pustular syphiloderm is very much less chronic in its course, is never
limited for years to the face exclusively, and, when long persistent in
one locality, is characterized by ulceration and the  production of very
characteristic crusts.
  Eczema may complicate non-parasitic sycosis;  but typical instances 
SYCOSIS.
337
of the two  disorders  may be recognized by  the  occurrence, in the
former case, of a discharging disease not usually limited to the region
of the beard, characterized by a more intense itching, aud with marked
absence of the papulo-tubercular lesions described above.
   The lesions, moreover, in eczema are not invariably perforated  by
hairs.   Erythematous eczema of the  shaven face is reddish in color,
and desquamates, after full evolution of the disorder, M'ithont pustu-
lation.
   Treatment—In  all cases of sycosis, the  essential and important
step is the continual removal  of the  hairs which, as indicated above,
an; the chief sources  of aggravation of the disease.   This is best
accomplished by shaving, an act M'hich, though often painful at the
onset, is soon well tolerated by the sufferer.  The majority of patients,
however,  object to the removal  of the  beard, far more on account of
the consequent greater exposure to view of the deformity induced by
the disease  (then no longer partly masked by the hairs)  than  on
account of the distress  occasioned by the operation.   To these  objec-
tions there is but one response.   The shaving is essential; the defor-
mity is rapidly  reduced after its successful initiation; the discomfort
diminishes whli each repetition of the process.   For the disease in
patients positively  refusing to have  the beard removed M'hose  cases
are so severe as to require it, the  practitioner will do well to decline
to be responsible.   There is no  limit to the tedious and obstinate
course of the malady in the  one case; and in the other, the results
are speedily satisfactory, often in the course of a few weeks.
   When  there  is  much tenderness,  pain,  swelling, pustulation, or
crusting, the hairs  may first be clipped short, and a bland poultice
of oil, elm-bark, or bread and milk applied.   The practice in Vienna
is to substitute for  the latter strips  of soft muslin or linen spread
M'itlrdiachylon ointment, and firmly  bandaged over the cheeks, chin,
or lips for from twelve to twenty-four hours, after  which the razor is
passed over the entire surface.
   The integument which thus becomes visible, is usually a reddened
infiltrated area,  with  pustules, papules, pustulo-papules, aud  some
crusts dispersed here and there over it.  This is best treated bv very
hot M'ater lotions, pure  or alkalinized, after exit is given to all  puru-
lent collections; and then a bland ointment is to be applied  at night,
and a dusting powder in the morning.  The subsequent treatment is
largely  that  of eczema  of equal grade  of  severity.  In the  more
acute periods, the oleated lime-Mater, medicated M'ith calomel or zinc
oxide, half to one  drachm (2.-1.) of either to the  pint (512.) may
often  be employed  M'ith benefit;  or for this  may be substituted tM'o
ounces (64.) each of linseed oil, castile soap,  and  paraffine, to  the
pint (512.) of aqua  calcis.  Later, ointments may  be  used, particu-
larly  cold cream, to M'hich either sulphur, the zinc oxide, or, less
preferably, one  of the mercurials may  be  added.  Lotions  of the
mercuric  bichloride, sulphur,  alcohol,  cologne  water, or  iodated
glycerine, may be useful in stimulating any indolent patches of infil-
tration.  The treatment of these is indeed that of chronic eczema.
                               22 
338
DISEASES  OF  THE  SKIN.
  In Vienna,  epilation is successfully  practised for relief of the
disease; and, by many, severer methods are employed, including the
use  of green soap, tar,  cauterization with  acetic and  even  nitric
acids.  Erasure with the curette is to be named in the same category.
It is possible that these measures have been employed in much more
aggravated  cases than  those  commonly  observed here; but as the
disease is certainly curable in a majority of eases  M'itbout having
recourse to these heroic methods, they are to be regarded in the light
of a dernier ressort.  It is not necessary  in the immense  majority of
non-parasitic forms of sycosis, either to epilate or  employ caustics.
By repeated and frequent use of  very  hot  water,  and the  milder
stimulants,  with constant shaving, the desired result is always within
reach.   Shaving  should be continued for nearly oue year after all
traces  of the disease have disappeared; and it is a point of some im-
portance to substitute  a  continuously applied dusting powder for  a
fatty application, so soon as the  skin M'ill tolerate the persistent use
of the former.
   Van Harlingen advises for acute cases a wash composed of half a
pint (256.) of rose Mater, to M'hich one drachm each (1.) of precipi-
tated carbonate of zinc and oxide of zinc  in powder have been added,
M'ith two drachms each (8.) of glycerine and dilute liquor plumbi sub-
acetatis.   Veiel recommends a solution of pyrogallol,  one part to fifty,
for painting over the part affected, followed in the day by emollient
cataplasms, and in the night  by diachylon or weak tannin ointments.
Sycosis of other portions of the body is to be treated as described for
the region of the beard.
   Internally, treatment is of minimum  value, and  when  indicated,
should be of the kind demanded by the wholly accidental constitu-
tional  condition  of the patient.   It is  a  matter worthy  of special
attention,  however, to purge every previously  treated  case  of all
suspicion  of an artificial  element,  by withdrawing for a proper time
all internal medication.   The  disease  is so  disfiguring  that  many
patients swallow the iodide of potassium, arsenic, and other  deleterious
drugs  for months before consulting one M'ho is M'iser than they in
these matters.  Exposure of the face to dust, smoke, M'ind, and other
sources of irritation should be for a time avoided.
   Prognosis.—The disease is  entirely curable, and will, in the large
majority  of all cases, either disappear entirely or  be very  greatly
improved  by judicious treatment.   The latter requires  the personal
supervision of the physician and close attention to details.

                   Dermatitis Papillaris  Capillitii.

   Under this title Kaposi describes a disorder characterized by pin-
head sized, isolated, or confluent elevations of the surface,  M'ith inter-
spersed pustules, M'hich finally form cicatriform plaques over which
the  hairs are either clustered in tufts or  totally absent.   The pilary
filaments are atrophied yet firmly fixed  in  their follicles, and suffer
elongation or fracture before M'ithdrawal.  The disease is encountered 
SYCOSIS.
339
chiefly upon the  nucha, occiput, and vertex.    Papillomatous vegeta-
tions, crust-covered, hemorrhagic, and M'ith a foul-smelling secretion,
sometimes form,  and eventually retract into a sclerotic tissue.
   The author has seen and  described  tM'o typical cases  of this dis-
order,1  and  each  concluded with  the production of a  keloid-like,
cicatriform,  irregularly shaped,  but  circumscribed elevation  of the
surface.   This feature is that  by M'hich it specially differs  from all
other sveosiform disorders.   The disease  seems to be due fully as
much to inflammatory processes in the subcutaneous tissues between
the  unyielding pericranium and the  thick scalp as to the  derma
proper, and  is not, therefore, strictly speaking, a dermatitis.   Punc-
ture, for example,  of one of the pin-head sized pustules, commonly
gives exit to the usual quantity of pus; but pressure upon the scalp in
the  periphery  will  at once  be followed by the appearance of a still
larger quantity of similar pus, which evidently is expressed from a
circumscribed  subcutaneous  abscess.   When  by such pressure  the
abscess cavity is  emptied, it slowly fills M'ith venous  blood, and pro-
duces a firm, semi-solid elevation of the surface, which subsequently
undergoes sclerosis, and the starved hairs above behave in  the manner
Mell described  by Kaposi.   The papules and plaques are  formed in a
similar way, by the abundant supply of venous blood.   The case of
one  of the author's patients (presented at the clinic) had been erro-
neously diagnosticated by a surgeon as aneurismal in character.  Punc-
ture of all such  semi-solid, cicatriform lesions is invariably followed
by oozing of venous blood  in abundance.   The disease is chronic in
character, particularly liable to relapse in crops of pilary or peripilary
pustules and papules, and extends from nucha to vertex,  curiously
avoiding  the frontal and  temporal regions.   Over the bald or par-
tially bald keloid-like elevations there is seen, iu some cases, a species
of seborrhcea in the form of more or less adherent, fatty  crusts, M'ith
occasional characteristic tufts of hairs.    None of these hairs Mas
invaded by a parasite,  though  repeatedly examined M'ith  the micro-
scope M'ith a view to such discovery.
   The disease  seems to OM'e its special  character to the anatomical
peculiarities of its location.   It occurs preferably at the points where
the venous supply of the scalp is not only greatest, but in  most direct
connection M'ith the large vessels beneath, aud where an inflammatory
process in the derma or subcutaneous tissues invites with readiness a
pathological  afflux of blood.   Such a focus, limited  beneath by the
dense calvariuin, and M'ith  the relatively  thick scalp above, readily
undergoes organization aud sclerosis, the subsequent behavior of the
hairs aud hair-follicles  being an accident of the process.
   Sangster (in  a  paper read before the International Medical  Con-
gress in London, 1881)  described a pigeon's egg-sized tumor of the
scalp, which Kaposi, M'ho Mas present, recognized as a case of derma-
titis  papillaris capillitii.
   The method  of treatment to be employed in this rare  disease can

 1 See a paper on this subject by the author, published in the Journ. of Cutaneous and Venereal
Diseases, vol. i., No. 2, p. 33. 
340                DISEASES  OF  THE  SKIN.
scarcely be described as established.   The affected surfaces are first
freed from all subcutaneous abscesses by puncture and expression of
the contents.   Then the patch is  washed with hot carbolized Mater,
dusted with boric  acid  or iodoform,  and  a compress,  moistened
with an antiseptic solution, such  as corrosive sublimate wash, rather
firmly bandaged  over  the part.    When  the  pathological fluids no
longer form under the scalp, the  patch is best epilated, and anointed
with a salve containing one drachm (4.)  of precipitated sulphur to the
ounce (32.)  of  scented vaseline, which may also  be kept  constantly
over the part.   When crusts form, they may be removed by sham-
pooing with green soap.
  Generally, internal  treatment  is suggested  by  the constitutional
condition  of the patient, and this should often  include cod-liver oil,
the ferruginous tonics, and a roborant regimen.


                           Impetigo.
                      Lat. impetcre, to rush upon.
Impetigo is an acute inflammatory affection of the skin, in which discrete,
  roundish, and acuminate or globoid vesicles,  of the average size of a coffee-
  bean, form and rapidly fill with pus,  which, being set free after rupture of
  the lesions, desiccates in characteristic crusts.

  Hebra  has  distinctly stated that the  pustular, cutaneous affection
described  by authors under the name Impetigo has no existence as an
independent disease.  Unquestionably a long list of disorders hitherto
described  under  this  term have  been, in  fact,  forms  of pustular
eczema; and there are good grounds for believing that the symptoms
detailed below  are not those of a  disease having  a  special identity.
The reasons for retaining the name given above and  for assigning to
it certain  peculiar eruptive features, are based upon  the simple fact
that the latter, probably in consequence  of the  operation in a similar
way of similar causes, reproduce themselves again and again, so as to
exhibit the same  clinical picture  in different patients.   With a  larger
experience,  it must  be admitted that the convenience  of the  name,
impetigo,  as descriptive of a  group of cutaneous symptoms, is more
and more apparent.
  Symptoms.—The disease is sufficiently  common  in practice, being
observed  chiefly in children  and  youug adults of both  sexes.   In
such  patients,  one  to twenty or  more isolated  and  often  widely
separated  minute vesicles or vesico-pustules usually acuminate, ap-
pear upon the surface either simultaneously or  in rapid succession
occasionally after a slight access  of fever.   They are speedily trans-
formed into split-pea sized or larger pustules, so rapidly, iii fact, that
often the  early vesicular phase is  not manifest, the lesions  showing
as minute pustules from the  first.    When fully developed, they are
globular,  yellowish-white in color, discrete, well distended with their
puriform, rarely  bloody contents, and projected clearly from the sur-
face on which thcv rest.  They may be surrounded by an erythema- 
IMPETIGO.                       341
tons areola, or be  simply superimposed upon au integument of un-
altered color.   They may persist as such or burst, and their contents
dry into a yellowish crust resembling honey, or into brownish-tinted
concretions M'hich adhere with firmness to the superficial and circum-
scribed  base, M'here a slight weeping can be determined.   They are
much more commonly  observed upon the face, but are recognized
elsewhere, ahvays sparsely upon the  trunk and  extremities.   The
eruption  is never in any sense generalized, its characteristic feature
being  the fewness  of the lesions, which  rarely exceed  tMenty in
number,  M'hich  are scarcely ever  grouped,  and which  occur in
capriciously selected locations.  The subjective sensations are slight,
and the eruption is more picked than  scratched.  It  is common in
dispensary and hospital  patients;  and since these are often the vic-
tims of neglect and the subjects  of vices  of nutrition, it  has been
considered the appanage of scrofula.  But the disease is also encoun-
tered in well-nourished  and  rosy-cheeked children.   In the  latter,
when well cared for, the eruption proceeds regularly to its natural
resolution, while,  in the former, it  is prolonged and often aggravated,
thus attracting to a  greater degree  the attention of a physician.   The
pustules are never umbilicated, never  seated upon ulcers, never fol-
lowed by cicatrices,  and are incapable  of transmitting the disease to
another individual.
   Etiology.—The causes of the disease are not clearly recognized, but
there is some reason to  believe that it originates exclusively in local
irritation. • It occurs rather at the age of childhood  than in infancy
and adult life, a period M'hen the hands are first brought into habitual
contact with the face; and these are, quite suggestively, the two sites of
election.   The lesions are very rarely scratched, more often torn M'ith
the nails in picking, so  that  the crusts may be  a little blood-colored.
There  is reason to believe  that the  habit of picking the  nose and
other parts of the face  and body  M'ith unwashed hands, is the sole
source of the mischief.   In  later  life the  habit of refraining  from
carrying the  hands  to  the face when  the former are soiled, becomes
instinctive.   Before this instinct is well established, that is  in child-
hood, the hands will convey to the head any particle of filth or dust
M'ith M'hich they may have been brought into contact.
   Pathology.—-The lesions  have  been examined microscopically by
Duhring aiid others, M'ho have thus been  able to establish  clearly the
purulent character  of the  contained  fluid.  Plainly,  each  is  but  a
distinctly circumscribed and superficial pea- to bean-sized abscess, the
sources of the pus being the horny layer of the epidermis.
   Diagnosis.—In order to establish the identity of this affection, it
is necessary to  define its exact differences  from eczema .pustulosum.
These  are/first, the  absence of infiltration of the tissues affected;
second,  the absence of itching; third, the failure of the  lesions to
form patches;  fourth, the  isolation and wide separation, each from
the other, of  lesions distinctly pustular; fifth, the large development
and rather persistent character of individual pustules;  and sixth,
after involution of the latter, the  evident  termination of the disease, 
312
DISEASES OF THE SKIN.
 which does  not,  as  does eczema in  many cases, progress  to form a
 freely discharging and crusting surface, the  pustular  being but the
 initial stage of a  distinct  disease process.  Manifestly, however, an
 impetigo of the sort described is  not incompatible M'ith an eczema
 which is often originated by less irritating causes.
   In ecthyma, the pustules are much  more formidable in appearance,
 in  consequence of their  size, depth,  inflammatory base, areola, flat,
 dark, bulky crust, and erosive action  upon the skin.
   From impetigo contagiosa, the disease is distinguished chiefly by
 the absence of the evidences of contagion.  The lesions of the latter
 are also, at  first,  strictly vesicular,  not vesiculo-pustular or pustular,
 there is often umbilication, and the pus is auto-inoculable.  The lesions
 may also coalesce.
   Treatment.—The individual pustules  are  to be  opened with  a
 comedo-needle; the purulent contents gently removed by  M'ashing
 M'ith tepid water and soap, and the floor smeared M'ith any mild oint-
 ment, such as five grains to half a scruple (0.33-0.66) of ammoniated
 mercury to the ounce (32.) of cold cream, or the subnitrate of bismuth
 half a drachm (2.) to the ounce (32.),  or the benzoated zinc salve
   Van Harlingen  recommends, after  the application of salve on bits
 of muslin, the covering of  the M'hole  with M'axed paper.   A dusting
 poM'der  containing calomel  may be substituted for the salve or  em-
 ployed afterward.   The disease tends  to spontaneous recovery, if  the
 lesions are not irritated.  When they are situated within reach of a
 child's tongue, which is constantly thrust out of the mouth to moisten
 them, they may linger  obstinately, and require protection by flexile
 collodion.

                     Impetigo Contagiosa.

 Impetigo  Contagiosa is  an acute, inflammatory, contagious disease, character-
  ized by the formation of multiple, usually isolated,  flattened or slightly
  umbilicated, roundish or ovalish, split-pea-sized and larger, vesicles, vesico-
  pustules, or blebs, which terminate by the production of yellowish, slightly
  adherent crusts.

   The disease is  also termed  by Pontoppidan, Pemphigus Acutus
 Contagiosus Adultorum.
   In 1862,  Dr. Tilbury Fox observed and described the  disease now
 under  consideration,  to M'hich he gave the name by M'hich it is most
 generally recognized to-day.
  Symptoms^—The eruption, occurring  in infancy,  childhood,  and
 early adult life, is often preceded by a febrile process, and appears in
 the form of rarely numerous, isolated vesicles, vesico-pustules, pus-
 tules, or  bulla;, usually about the face, but also on the neck, buttocks,
 hands, or feet.   In severe cases these are surrounded by an areola.
 The lesions  are roundish, flat, have the average size of a  split-pea,
and become  covered  in the course of a few davs with dry, o-ranular,
straw-colored crusts,  which adhere  closely to  the slightly  reddened
base on  which they rest.   Very  superficial erosions "are* to be  dis- 
IMPETIGO CONTAGIOSA.
343
covered  beneath,  M'hich  become  rapidly covered  with  epidermis.
They occasionally  coalesce,  and their complete involution requires
from a week to a  fortnight.   When  of the dimensions of bullae, a
pseudo-umbilication may be observed at the apex, produced solely
by flaeeidity of the roof-wall, M'hich is never tied down as in variola.
The contents of the lesions  are inoculable  and auto-inoculable, the
disease thus spreading from one member of a family to another, and
also from  one part of the  body of an individual to  another.   The
mucous surfaces are said to  be occasionally invaded.  The subjective
sensations  are mild, the itching  being rarely severe.  The disease
runs a  tolerably definite  course, being usually at end  in a fortnight.
It  may recur.  Kaposi states that it  is at all times accompanied by
submaxillary  adenopathy.
   Etiology  and Pathology.—Kaposi,  Piffard, and Geber  have all
described a microscopic fungus M'hich they  discovered in the crusts
of the disease, but neither they, nor Tilbury Fox, nor observers who
have succeeded them, have ever been able to demonstrate the existence
of a parasite  in the contents of the lesions.  Plainly,  a  parasitic
vegetation on  the exterior crust can have no etiological significance
in this connection.    The eruption often  occurs during convalescence
from a  more or less actively contagious disease.   The antecedence of
some fever iu many cases is admitted  by all  observers.   Duhring and
Fox himself have seen it follow vaccinia; and the former admits that
some connection between the two  seems probable.   The  author has
seen it occur typically in four children, each of whom was convales-
cent from  varicella; and in one interesting case,  that  of  a  young
woman convalescent from confluent variola, the lesions sprang  from
an integument where the pigmentation of the scars  of the last-named
disease  had not begun to disappear.
   Stehvagon, in 1883,1 making a new study of the subject, reports
only six cases out of eighty-eight observed  by him following vacci-
nation,  and concludes that the disease is non-parasitic,  but  an acute
specific  contagious  exanthem, with  cutaneous lesions  pursuing a
definite career.
   Pontoppidau, in  1885, found, as had  many before that date, only
epithelial  cells, blood-corpuscles,  aud detritus in  the  crusts,  never
any indications  of a parasite  capable of explaining the  etiology of
the  disease.
   Dewcvre2 reports a number of successful inoculations and auto-
ino;'illations practised  with the contents of the vesico-pustule,  with
finely powdered impetiginous crusts and M'ith the products of scraping
the subjacent  erosion.    He reports finding reticulated mycelial tubes
of  the 'thickness of three  thousandths of a millimetre  in the  rete
mucosum beneath the lesiou.
   In 1S81, the author succeeded in producing au  almost  typical
vesico-pustule upon his left forearm  by inoculation,  all due precau-
tious observed,  with the moistened debris of crusts.   This was done

                 1 Mod. Recorl, Deo. 22. 1881.
                 2 Arch, de Med. et de Pliarm. Mil., Sept. 16, 1885. 
341
DISEASES OF  THE  SKIN
in the Dermatological Clinic, the crusts  being taken  from  typical
lesions upon the face of a youug  girl inoculated M'hile  under  obser-
vation from the lesions  of exactly similar character on the  face of
her twin sister.   The lesion  on the forearm produced a characteristic
crust, M'hich in seven days Mas also used  for the inoculation  of two
students then present at the Clinic, in one of whom  there Mas no
result, and in the other an abortive lesion.
   The disease is  contagious,  and its lesions  inoculable  and auto-
inoculable;  but  whether it be a specific  exanthem,  or  due to a
purely local parasite, or other  cause,  must  be regarded as an  unde-
termined question.
   Diagnosis.—Impetigo contagiosa  is distinguished from impetigo
by its frequent pyrexic symptoms;  its  flat, yellowish, superficial,
friable crusts; its vesiculo-bullous  rather  than distinctly pustular
lesions, and its contagiousness.   In pustular eczema, there are itching,
infiltration, profuseness  of  discharge, indefiniteness  of duration,
coalescence of lesions, and extensive bulkier crusts.   In varicella,
the lesions are small, much  more widely distributed  over  the body,
and are  vesicular only, never bullous.    In pemphigus and herpes
iris, the  seat, character,  and  period of evolution  of the lesions  will
suffice to establish the diagnosis.
   Treatment.—The crusts are removed and a salve applied consisting
of cold cream or vaseline with from  five to ten grains to  the ounce
(0.33-0.66 to 32.) of ammoniated mercury.

                    Impetigo Herpetiformis.
Impetigo  Herpetiformis is a cutaneous disease of women, frequently compli-
  cating the puerperal state, characterized by the occurrence upon the skin
  and mucous  membranes of concentrically grouped pustules, and by a
  febrile condition which usually  terminates fatally.

   Symptoms.—Our  knowledge of this rare disease  is limited  to the
reports of thirteen cases observed in the Vienna clinic by Hebra and
Kaposi; one in New York, by  Heitzmann; one by Pataky; and a few
scattered cases recorded  by others.   Of the Vienna patients, tM'elve
were women, and these usually  in  the  puerperal  state.  Pin-head
sized  pustules, usually closely  packed together in groups, filled with
an opaque  or yellowish-green  fluid, are discovered  upon the  surface
of the  groins, navel,  axillae,  breasts,  and other  portions  of the
body.  A dirty brownish colored crust is formed by the rupture or  '
desiccation of these  lesions,  and  about this, single, double, or triple
concentric  circlets of neM' and similar lesions appear in succession,
each series undergoing  a similar process  of involution.  The erup-
tion thus extends till the circlets from different  foci of origin  unite;
and  extensive areas  of  the  skin  are involved.   Beneath  the  crusts
the skin is reddened, infiltrated, smooth, aud covered with a new epi-
dermis, moist as  in  eczema,  or exhibiting a denuded corium.   It is
never in a state of ulceration.   In the course of three or four months,
the eruption  is M'ell  nigh universal, the skin being swollen, shining, 
ECTHYMA.
845
and  crust-covered, or seamed with excoriations here and there  sur-
rounded by  circlets  of pustules.   The lingual mucous  membrane
exhibits grayish, centrally depressed patches, well-defined in contour.
Alternate rigors and febrile accesses mark the periods of recrudescence
when new pustules form.   Delivery  seems  to  have  no  favorable
effect upon the course of the disease occurring in pregnant women.  An
endometritis M'ith peritonitis Mas discovered, post-mortem, in a single
case.   Two women  only, of the thirteen Vienna patients, survived;
and one suffered  from a  relapse after several weeks of  improvement.
   The etiology aud pathology of the disease are necessarily obscure,
having in  view  the relatively  small number of  reported cases.
Duhring describes a much milder malady of similar type, occurring in
women not pregnant, and has latterly included impetigo herpetiformis
in the  list of diseases covered  by the title, dermatitis herpetiformis;
but Kaposi, in  the last  edition of his treatise, refuses  to admit any
such reduction of impetigo herpetiformis to a class of other maladies.
Robinson  also has described  a case supposed  to represent one of the
mild  manifestations of the disorder.  Kaposi is  inclined to associate
the disease M'ith a pathological  condition of the uterus.   Heitzmann
thinks  it  related to pemphigus.   Besnier and Doyon conclude the
disease to have a septicemic origin.
   The diagnosis of the disease is between herpes, dermatitis herpeti-
formis, and pemphigus.
   In herpes, the purely vesicular character  of the  lesions and the
cyclical career of  the disease  indicate its nature.    In  dermatitis
herpetiformis there  is commonly a  distinct multiformity of lesions;
and the subjects of the disorder are not, in such great preponderance,
pregnant  women.  In pemphigus, the  size of the  bullae, and  their
distribution in other than concentric groups, will indicate the character
of the disease.
   The  treatment is conducted on  general principles, including anti-
pyretics, and the  local employment of alkaline, or carbolated baths;
starch  and other dusting  powders ; anodyne, carbolated or simple
salves;  and a mixture of plaster and coal-tar.   The uterus should be
relieved of its contents.
   The prognosis is necessarily grave.


                            Ecthyma.
                   Gr. EnOvfia, a  pustule; kudbu, I burn out.
Ecthyma is an inflammatory disease of the skin characterized by the forma-
  tion of few or many,  large, discrete pustules, implanted upon  a dense,
  deeply situated base, the pus of which dries into dark colored, firm, bulky,
  and attached crusts, beneath which there may be superficial ulceration and
  resulting scarring.

  Symptoms.—Attention has already been directed to the position of
Hebra in denying the existence of ibipetigo and ecythma  as distinct
diseases.   Ecthyma is, however, entitled to separate consideration, for 
346
DISEASES  OF  THE  SKIN.
the clinical reasons whose importance appears after a careful study of
a feM' typical cases.
   The disease is  characterized by the  occurrence of one or several,
roundish, bean- to filbert-sized, yellowish or reddish pustules, which
are the  result of a distinctly circumscribed, inflammatory  process,
limited to the  base of  each lesion,  or extending  from  it  at the
periphery in a diminishing hyperemia.  This process is distinguished
by the formation of an indurated phlegmon at the base of the pustule,
which is converted into  a loss of  tissue involving the corium.   The
purulent or sanguinolent contents of the lesions dry in dark colored,
thick, rough, adherent crusts, the color being  somewhat dependent
upon the quantity of the blood with which they  are commingled.
On the removal of this concretion, a minute, shalloM', and circular pit
is discovered, invading  the  true  skin to various depths, and lined
with a tenacious, puriform, and often  blood-stained product.  When
carefully wiped clean, this solution of continuity, which really con-
stitutes a minute  ulcer, is seen to have a floor reddish or grayish in
color, and indolently granulating.
   The pustules may  be acutely  or  indolently developed,  aud be,
M'hen  multiple, coincident  or successive.   They occasion  rather  a
sensation of heat, burning, and pain, than of itching, the latter being
usually more distinct M'hen the lesions are healing under their crusts.
Their formation may be preceded  by mild general pyrexia.  They
occur at all ages and in  both sexes, usually upon the extremities, but
also upon every portion of the body.
   Etiology.—The causes of the disease are practically those of eczema
and dermatitis (traumatism,  heat, scratching, parasites, etc.), but these
usually operate in excess, or in subjects affected M'ith  other diseases,
such as  anaemia, asthenia,  struma, variola-convalesceuce,  and men-
strual disorders.   Filth aud neglect are most common aggravations ;
in other words, that circumscribed cutaneous ulcer will be the angrier
and the deeper, which occurs in the victim of any depressing disease,
whose skin is scratched  M'ith nails begrimed with dirt, and is covered
with the effete products of the excretory processes.  The pus thus
produced may be  in various degrees  inoculable aud auto-inoculable,
as is the product of many inflammatory processes of similar grade.
   Pathology.—The pustule of ecthyma differs in no respect patho-
logically from the pustule of eczema or the pustule of impetigo, save
in the severity of the exudative process by which it is produced, aud
in its limitation to the exact site of external irritation.   By the ex-
tension of that process to the corium, there is au actual loss of some
of the elements constituting the papillary layer; and the result is  a
cicatrix, M'hich contracts as it groM's older, and is, in milder cases,
finally barely visible as  a minute cicatriform  punctum.    One M'ho
frequently examines the skin of the entire body with care can usually
detect the ancient sites  of  these  lesions by  their  indelible though
insignificant relics.
   Diagnosis.—Ecthyma is  liable to  be  confounded M'ith  the other
pustule-producing exudative affections, but as the distinction between
• 
ECTHYMA.
347
them is largely artificial, and based  upon the severity of the inflam-
matory process, there is small danger in the consequence.    Kaposi
well expresses the truth in his  suggestion that there can be but little
objection to the employment of the  term ecthyma when it is desired
to characterize precisely the pustular grade  of any cutaneous inflam-
mation at a given time.  The pustules of variola are " ecthynia-form,"
and  many of those seen in syphilis  possess  similar characters.   But
in each the history of the  general affection  should throw light upon
the identity of the cutaneous  disease.   In  the latter,  moreover, the
ulceration at the base of the lesion  exhibits the pronounced features
of the syphilitic ulcer in  its secretion, floor, edges,  base, crust, aud
career.
   The  crust,  in particular, of the flat pustular syphiloderm  has
the rupioid conical appearance  M'hich suggests the shell of the ovster,
and  its underlying ulcer is larger and deeper than in ecthyma.   In
the furuncle there is usually a central core;  in impetigo, the pustules
are not deep-seated, and there is no  ulceration at the base.    In  im-
petigo contagiosa the crust is superficial, yellowish, firmly adherent,
and  the lesions are more numerous.
   Treatment.—The general treatment  of patients  affected with ec-
thyma is a matter of some importance.  A proper regulation of the food
and  hygienic surroundings is  not to be neglected.   Tonics are  fre-
quently indispensable, including iron, quinine, and strychnia.   The
destruction of any pediculi, and the cleansing of the skin by soap and
M'ater will often be sufficient to effect a great change.   This is  M'ell
illustrated in hospital  practice, where the little patients  rapidly im-
prove  after a bath, followed by inunction  M'ith vaseline, and a few
substantial meals of a nutritious character.   When the lesions  are
abundant, the treatment is in general that of pustular eczema.  Crusts
are to be removed after soakings M'ith oil or  fat;  and the floors of the
former pustules,after Mashing with carbolated water,should be dressed
M'ith an ointment  containing ten to  fifteen  grains (0.666-1.) of  the
amnionio-chloride of mercury to the ounce (32.) of lard.  If the minute
basal ulcers are sluggish, they may be, after careful cleausing, touched
M'ith a small swab dipped in a solution of the bichloride  of mercury
in the tincture of benzoin, one  grain (0.066) to the ounce (32.)  Car-
bolic and boric acids or iodoform  may  be employed  for  the  same
purpose.   For the salve  mentioned above  may be  substituted one
containing ten grains (0.66) of calomel, or half a drachm (2.) of  the
subuitrate of bismuth to the ounce of salve  basis.
   In every case  of the disease  it is  desirable to inquire whether any
medicines have been ingested prior to the appearance  of the eruption,
since these may be  responsible for the lesions.
   The prognosis is ahvays favorable. 
348  '
DISEASES  OF  THE  SKIN.
                          Pemphigus.

                       Gr. irkpfi%, a bladder.
Pemphigus is an acute or chronic disease of the skin, often characterized by
  febrile and other symptoms of constitutional disturbance, accompanied by
  the production of a series of pea- to egg-sized bullae, irregularly distributed
  over the surface, and distended with serum or blood.

  Symptoms.—The cutaneous  lesions in  this  disease  are  usually
preceded by febrile symptoms; and the disturbance  of the economy
is declared in cardiac, respiratory, and gastro-intestinal derangements
of function.   The  fever may  be  continuous,  remittent, or  inter-
mittent, and is usually exaggerated  just  before the  appearance of a
fresh crop of blebs.
  The eruption first appears in reddish  maculae  of rather vivid hue,
in the centre of  each of which  appears  later a whitish  elevation of
the  epidermis suggesting a wheal.   Either upon these or  unaffected
points  of the skin, tense,  well-rounded bulla? subsequently  form,
varying in  size  from a pea to a hen's egg and even  larger, and in
number from three to six only, to a hundred and more.  They are
usually irregularly distributed (Pemphigus Disseminatus), but may
be clustered in groups, or very rarely be found the younger  encircling
the  older lesions, so as to form  a circinate appearance (Pemphigus
Circinatus) ; their contents are serous, bloody (Pemphigus H.emor-
rhagicus), or later  purulent,  with color  corresponding to  these
fluids.   Whether  ruptured or not,  the  involution  of the lesion is
accomplished by desiccation and crusting, the crusts  being usually
found to contain blood, pus, epithelial debris, and the  exudate from
the  base of the bleb.   Beneath  such a crust  a new epidermis  forms,
which  is  usually violet, purplish, or bluish-red in color, and, later,
displays  a broM'nish  pigmentation  which may for several   weeks
survive the disease.
  Occasionally the affection occurs with very mild  and even  insig-
nificant phenomena (Pemphigus Benignus).   There may   be  no
fever, and a very few blebs appear;  in some  cases but  a single  lesion
can be seen (Pemphigus Solitarius).   In other instances, the fever
is intense;  the  eruption  abundant; the skin  oedematous, painful,
pruritic, excoriated, and the underlying lymphatic glands enlarged.
This general condition with exacerbations and remissions may persist
for  months, and  the eruption then disappear never to return or to
recur, as it often does, in the future.
  The term Pemphigus Vulgaris is applied to the  more common
clinical forms of the malady, but it is also employed  generically by
many  authors to  include all varieties  of the disease.   Pemphigus
Diutinus designates that pemphigoid eruption in which the charac-
teristic lesions follow each other with rapidity, fresh bullae appearing
each day.    Fortunately, all forms of the disease are relatively rare.
  The lines technically draM'n betM'een many  conditions of  disease are 
PEMPHIGUS.
349
quite artificial, however useful and necessary for systematic study and
classification.  Clinically, many of these distinctions disappear.   This
is especially true of the varieties of pemphigus.  Between the benign
processes just considered  and the grave form of pemphigus foliaceus
described  in another chapter, several intermediate  gradations can be
observed, and  even the most benign may at times unexpectedly assume
the most malignant phases.   Pemphigus Malignus is a name given
generally to those  intermediate varieties of the disease, most of M'hich
are  distinguished  by  persistent and prostrating  fevers;  cachexia,
especially in infants;  the occurrence of diphtheritic patches upon or
about the lesions, with infiltration of the derma and slough  of its
superficial layers;  or extensive crusting, and even subsequent ulcera-
tion.  A form is described  by Hebra and  Kaposi, in M'hich vegeta-
tions and fungosities rise  from the  base of the blebs.    Pemphigus
Pruriginosus is  another grave form of the  disease, in which the
lesions give rise to an intense pruritus, under the scratching induced
by which  they are torn, excoriated, and commingled m ith the  crusts
and  exudations of an  artificially  engendered eczema.   Several of
these malignant and intermediate forms may terminate fatally.
   In all varieties of the disease, the  lesions may be  exhibited upon
the mucous membrane of the accessible outlets of the body.
   An important distinction,  which has been established only M'ithin
late  years, should be made between acute  and chronic pemphigus.
   Acute pemphigus occurs in adults, children, and  infants, more fre-
quently among  the very young.  It may be epidemic  in  hospitals
and  other public institutions. With or m ithout an  antecedent febrile
movement, the blebs may appear  before birth  or within a  fortnight
after, in infants  which are either well  nourished or  cachectic, more
often the latter.   In favorable cases, the  evolution  of the disease is
completed  in  three or  four  Meeks.  Any  part of the body may be
affected, but, what is important from a diagnostic point of vieM', the
face, hands, and feet are often exempt.  The conjunctiva and mucous
lining of  the  mouth  may,  however, become implicated.   In some
cases the pemphigus may be  of hsemorrhagic type.   Underneath the
lesions, the rete is  exposed, and has a reddish, glistening look.   The
termination may be fatal.  Acute  pemphigus  of adults is still  rarer.
As in the case of infants, there may be  marked febrile antecedents
and  systemic  disturbance.   The eruption of pea-  to large nut-sized
bullae may be  sparse or abundant, covering in cases the entire  body,
and  attacking  the  mucous surfaces.  The vesicles  or bullae may be
tense, flaccid,  and  filled  with clear, serous,  or puriform  contents.
Beneath may be seen a smooth, raw, mucous layer  or a diphtheritic
exudation.   According  to Weyl, Bulkley's Herpes Gestationis is an
example of acute pemphigus adultorum.
  Chronic  pemphigus exhibits the greatest variation both as to its
symptoms and the  period of their efflorescence.    There may  be a
week or mouth of immunity, followed  by benign relapses, or  by
malignant and rapid recurrences.    The  bullae may form  upon  an
unaltered or deeply hyperaemic  skin, in all sizes from  a pea  to  an 
350
DISEASES  OF  THE  SKIN.
orange, invading the skin and mucous surfaces including the vagina,
the lesions at the base exhibiting the several features described above.
The eruption is rarely  generalized, and throughout  not more than
half a dozen lesions may  be at any one  moment visible  upon the
surface of the skin.   The contents 'may be removed by evaporation,
absorption, or rupture,  leaving a crust  M'hose color is  largely deter-
mined by the contents of the bleb.
   Etiology.—The  causes of pemphigus vulgaris are  so obscure that
they may"be said to be  unknown.   The disease is more frequently
encountered in infancy and childhood, because, it would seem natural
to conclude, the powers of resistance at a  tender age are inferior  to
those of  a maturer epoch.   The disease is  in  general observed  in
debilitated patients,  who are  variously described as suffering  from
"nervous prostration," "mental worry and  exhaustion,"  "neuras-
thenia,"  "general debility,"  visceral disorders, and impairment  of
nutrition.   Occurring  in a  vigorous, rosy-cheeked, strong-limbed
adult, the disease would certainly be  regarded as a curiosity.   It  is,
therefore, safe to conclude that those  states in which there is  marked
impairment of bodily vigor are particularly favorable to the develop-
ment of the disease.
   Kaposi relates one case in which the disease seemed to be inherited,
as the patient's mother,  sister, mother's  brother,  and  some of the
children  of the latter had been affected with the  malady.   While,
however, this author admits such  association  of nervous disorder
with the disease as occurs in hysteria  and pregnancy, he  concludes
that there is little  if any etiological  significance in  the fact.   I  have,
however, observed one case in an adult where pemphigus of typical
appearance occurred after  mental depression, which was so greatly
increased by the appearance of the exanthem  as to  lead to suicide.
   There is good reason to believe that, at  least  in some of  its forms,
the  disease  is  contagious.   The bullous  lesions,  however,  seen  in
syphilis,  lepra, and other  similar  disorders,  should not be  here
included.
   Pathology.—Kaposi  and Weiss found anatomical changes in the
spinal cord of but one out of nine fatal cases  of pemphigus.  In this
there was diffuse sclerosis, but the case was complicated with cancer.
Jarisch discovered swelling of the processes of the  ganglion-cells and
interstitial fibrous deposits in a similar case.  Dejerine and Leloir
found changes in the peripheral  nerves due to degeneration in a case
of pemphigus.
   The contents of the bulke of acute pemphigus were  found to con-
tain bacteria  by Gibier in 1882.  The microbe recognized by him
Mas, when mature, arranged  in  chaplets,  each  containing a series  of
joints.   His observations were confimed by Vidal and Rceser.   Eiehl
in 1883, discovered both conidia and spores in the  layer of epidermis
beneath  the lesions of an infantile pemphigus.  Demme,1 in  1886,
found cocci  both in the contents of the bullae, and in the blood.
i Viertel f. Derm. u. Syph., 1886, p. 636. 
pemphigus.
351
  On the other hand Thin, of London,1 after full trial of all methods
of staining  and cultivation  now employed,  had  entirely  negative
results in his attempts to discover microorganisms in  the contents of
the bullae of pemphigus.
  Diagnosis.—From M'hat has preceded it M'ill be inferred that pem-
phigus is a name given to a disease, and  not merely to bullous lesions
upon the surface of the skin.   It is of some importance to remember
this fact, as several  authors have used  the term in a purely descrip-
tive sense, the fact  being that bullae are manifestations of several
disorders, including syphilis, lepra, pemphigus  foliaeeus, herpes iris,
and erythema multiforme.
   At the outset, consequently, the blebs of pemphigus can scarcely
be differentiated from those of  other diseases.  It is necessary for its
recognition that proper consideration be had of  all the cutaneous and
other phenomena present in the disease.   In syphilis, such lesions
are rare  in the adult, and relatively more frequent in infants heredit-
arily diseased.   With the latter, the blebs are usually seen at birth,
often upon the palms and  soles, and are frequently superimposed
upon an exulcerated base.  The coexistence of mucous patches of the
mouth, vulva, and anus with the evident polymorphism of the lesions
and signs of grave cachexia, will usually indicate the nature of the
disease.   The cutaneous  symptoms of  such infants are improperly
designated as pemphigus.  Such an eruption is a bullous syphiloderm.
   In the bullae of  lepra, there is usuallv coexisting cutaneous anaes-
thesia, and the involution of the bleb is  followed by a  strikingly
characteristic atrophic patch, usuallv pigmented aud insensitive.  In
pemphigus  foliaeeus, the extraordinary  and  usually generalized des-
quamation M'hich ensues,  is sufficiently distinctive, though it must be
borne  in mind,  as heretofore stated,  that  the several  varieties  of
pemphigus may be  transformed, the one into the  other, by M'ell-nigh
insensible gradations.   Among its graver forms  susceptible of such
transformation may  be named,  impetigo herpetiformis,  pemphigus
cachecticus, pemphigus diphtheriticus, and pemphigus pruriginosus.
   In herpes iris, the lesions  are  more vesicular;  much more tran-
sitory; subject to a concentric arrangement and variation M'ith respect
to  color; and  are  situated more  frequently upon  the  extremities,
especially the backs of the hands.  The bullous  lesions occasionally
seen in urticaria and erythema multiforme, are to be recognized  by
the  other characteristic symptoms of those diseases; in the former,
more particularly,  by their intermingling M'ith typical  M'heals; and
in  the  latter, by  the location of the  eruption, and its climatic or
seasonal significance.   Some  of the  reported contagious  forms  of
pemphigus, epidemics  of M'hich  have  been described by Besnier,
ilervieux, and other French authors, were possibly, as Duhring sug-
gests, instances  of  impetigo contagiosa.  This  inference is  sustained
bv the frequent allusion of the M'riters named to the "varicella-form"
appearance of the lesions.

                        1 Lancet, May 30, 1886, p. 981. 
352
DISEASES OF THE  SKIN.
   Some of the ingested medicaments are capable of producing bullous
 lesions, for example, the iodide of potassium ;  and such a possibility
 should always  be borne  in  mind  M'hen establishing a differential
 diagnosis.  Scabies in infants and children is occasionally character-
 ized by the formation of blebs, in M'hich case the other lesions present,
 as also a  history of contagion and the discovery of the parasite, will
 point to the real nature of the disease.
   Lastly, the external application  of  cantharides,  mezereon, the
 stronger  acids, alkalies, and other  chemicals may  be followed by
 blebs produced either by accident or intention with a view to feigning
 disease.   The intentional production of such  symptoms  is  usually
 effected  upon the anterior faces of the  lower extremities,  regions
 within  easy  reach of the  right  hand.   Erysipelas  and  dermatitis
 calorica are also diseases iu M'hich blebs  appear, always, however, of
 minor significance as compared with the other symptoms of disease
 present.   The same may be  said of the bullae which form  upon a
 gangrenous integument.
   Treatment.—The internal  treatment  of pemphigus is a matter of
 importance, as will be suggested by even a brief consideration of the
 constitutional  states in which it occurs.    Mr. Jonathan Hutchinson,
 of London, Eng., in his valuable Lectures on Clinical Surgery,1 dis-
 tinctly asserts his  belief that "arsenic is a specific  for the state of
 health upon which relapsing  pemphigus  depends."   In  many years'
 trial of this remedy,  he declares that, in his  own  practice,  he has
 never recorded a single failure, though he makes exception, properly,
 of many  infantile cases supposed to be  syphilitic.   The remedy is
 certainly  a valuable one,  but should  be employed  M'ith the  same
 caution and  in  accordance with the  rules already prescribed in the
 chapter on psoriasis.   Kaposi,  however, declares  that he has  been
 unable  to obtain  favorable  results from  its  employment.    Iron,
 quinine, ergot, strychnia, and the mineral acids are certainly indicated
 in many  cases,  in conjunction with a  particularly  nutritious  diet.
 Cod-liver oil  and the malt preparations  now in the market  should
 not be neglected.
  Not infrequently the treatment should  be directed  to the relief of
the anomalous performance of the sexual  function in women, as the
disease has been found to  occur in the hysterical and chlorotic states
sufficiently common as a result of such disorder.
  The local treatment of  the lesions should consist, first, in a punc-
turing of 'each bleb with a fine  needle,  in order to  give exit to its
contents, which should be carefully removed from the skin  by the
aid of cotton-wool.  Then the parts are to be thoroughly enveloped in
an inert dusting  powder.   When there is considerable pyrexia  M'ith
heat and  distress  in the skin, the surface may be treated as in acute
eczema, with  oleated  lime-water, containing also opium  or dilute
hydrocyanic acid in some  such proportions  as those already detailed.
1 London, .|. & A. Churchill, 1878, p. 49. 
cutaneous  hemorrhages.             353
  The ordinary lead and opium Mash, M'ith or without the addition
of the oxide of zinc, will also answer a good purpose.
  in  Vienna, the  continuous hot-water bath still  enjoys the highest
favor.   Kaposi has kept one patient day and night for eight months
M'ith his body thus immersed, to the  great advantage of the latter.
Such a course is often impracticable outside of a large hospital; but
the author has, in  two cases of grave pemphigus,  employed the con-
tinuous hot-water bath in private houses, with the happiest results.
  Prognosis.—The prognosis in mild  cases of pemphigus, though
much less grave than in the malignant forms of  the disease, should
ahvays be formulated with  caution.  Unlike  several of the diseases
heretofore considered, the affection is one not  frequently encountered
in persons of fair general health.  The constitutional condition of the
patient must be carefully considered; nor should it be forgotten that
the disease is not only one liable to relapses, but also one in M'hich
the graver may succeed  the  more benign manifestations.  A flaccid
summit of the bleb, sanguinolent or  ichorous contents, an abundant
efflorescence, and a rapid succession of new after the involution of
more ancient lesions, are in  general  unfavorable symptoms.   The
same may be  said of degeneration of the floor  of  the bleb, after
rupture and discharge  of its contents.
                       CLASS  III.

                        HEMORRHAGES.

                  Cutaneous Haemorrhages.

Cutaneous Haemorrhage is characterized by the issue of a part or all of the
  constituents of the  blood from the cutaneous  or  subcutaneous vessels,
  with and without rupture of the vascular walls.

  Hemorrhage into the skin may be active or passive, idiopathic
or symptomatic, and may vary greatly in extent.   It may be limited
to but a small area of the integument, or may  be symmetrical and
universal, or coexist M'ith similar blood  extravasations in the mucous
membranes, and the investments and  parenchyma  of  the  viscera.
It may result from undue  infra-vascular  pressure, as in violent
effort with  extraordinary demand upon  the circulatory system.    It
mav occur  with a  normal intra-vascular pressure  M'hen  there is
lessened extra-vascular  atmospheric pressure, as  after ordinary exer-
tion in high altitudes.  It may result  from  disease  of the vascular
walls, as in malnutrition.   It  may  occur after traumatism of the
latter, or  bv diapedesis  through  the Malls of uninjured capillaries.
It may result also from lack of support;of the vessels due to various
disorders of peri-vascular tissues, as  in the case M'here the epidermis
                                23 
351
DISEASES  OF  THE  SKIN.
is artificially removed, or M'here au abscess cavity is evacuated of pus,
and the sac immediately fills with blood.
  Idiopathic haemorrhage  into  the  skin and  neighboring  tissue  is
usually the result of traumatism, and accomplished through rent of
the vascular wall.   The discolored  patches M'hich result from con-
tusions of  the surface of the body are illustrations  of  this condition.
Examples  of symptomatic  cutaneous haemorrhages are to be  found
in the  course of  such general  diseases as septicaemia and  variola,
and of such cutaneous disorders as herpes, pemphigus, and erythema
multiforme.

  Bulla  Hemorrhagica are globoid, bean- to egg-sized  eleva-
tions of the epidermis, filled M'ith a sanguineous or sero-sanguineous
fluid, giving such lesions a  reddish, brownish, or purplish shade.

  Ecchymomata  are nut-  to egg-sized,  and  even  larger,  firm or
fluctuating, flattened or elevated tumors, filled with  blood, and having
a cutaneous envelope.

  Ecchymoses are small  coin- to palm-sized,  and even larger, light
red to dark purplish, irregularly shaped, macular colorations of »the
skin, not fading under pressure, aud due  to circumscribed cutaneous
haemorrhage.

  Petechia are  pin-point  to small  coin-sized, light red  to  dark
purplish macular colorations of the skin, not fading  under pressure,
and due to circumscribed cutaneous haemorrhage.

  Vibices are  linear  maculations  of various lengths, due to the
diffusion in the skin of extravasated blood in the form of streaks or
bands.   They are often commingled  with petechiae and ecchymoses.


                            Purpura.

                       Gr. iropfyvpeoc, purple.

Purpura is a disease characterized by the appearance in the skin, of reddish-
  purple or livid maculae, varying  in size, usually not clustered, and not
  wholly disappearing under pressure, which may be associated with systemic
  symptoms.

  Some confusion  has existed in  connection M'ith the term, Purpura,
in consequence of the fact that it  has been employed indiscriminately
by authors in the designation of  both  symptoms and diseases.  The
following disorders are commonly included under this title:

                      [A.]   Purpura Simplex.
  In  this  form of cutaneous haemorrhage, pin-head to pea-sized
light red  to dark  purple  petechiae  and small ecchvmoses,  usually 
purpura.
355
multiple and symmetrical, of sIom' or sudden occurrence, appear upon
various portions of the surface, chiefly  over the lower extremities,
and here doubtless by  preference, because of the greater effect of
gravity upon the column of blood.   They usually aM'aken no sub-
jective sensation, aud may occur iu  persons  of apparently unaltered
health, though rigid examination M'ill often disclose some facts having
a bearing upon the etiology of the disease.  The subjects of the dis-
order  are frequently asthenic, and complain  of unwonted lassitude
and malaise.  The disease may last for  a  fortnight, and in exceptional
cases be  accompanied  by a febrile rise of temperature.   Lesions of
this sort may be due solely to an ingested medicament, such as arsenic,
salicylic acid (Freudenberg), or quinine.    The author has seen the
lower extremities  completely covered  M'ith petechiae,  induced  by
the  ingestion of the iodide of potassium,  a fact  reported by other
observers.
                         Purpura Urticans

is that form in M'hich there is an  irritability of the skin sufficient to
produce  M'heals, urticarial lesions  accompanied by itching in various
degrees, M'hich have the purpuric hue in consequence of circumscribed
cutaneous haemorrhage.

            Purpura Rheumatica.   (Peliosis Rheumatica.)

   This is a variety of purpura which  has a striking analogy to ery-
thema multiforme, and is probably au  exaggerated form of some of
the  conditions recognized under  that  title.   It  is preceded  by the
usual febrile or other premonitory symptoms associated with arthritic
pains, especially of the knees and ankles, M'hich may become swollen,
or be affected M'ith an hydrarthrosis.  In a few  days,  petechial to
ecchymotic, light red to dark purplish maculations appear upon the
extremities, trunk, or the entire surface of the body, fadeless under
pressure,  and  usually  M'ith coincident relief of the  arthritic  pain.
The subjective sensations are ordinarily trivial.   In a fortnight, the
eruption may subside, its color undergoing  the usual variations from
greenish to  orange and light yellow; but relapses are common in  the
course of weeks, with recrudescence of  the fever, return of the rheu-
matoid symptoms, and progressive asthenia.   Kaposi describes cases
in M'hich  there Mas coincidence of  purpura rheumatica M'ith  renal
haemorrhage, albuminuria, and gangrene of the soft palate in conse-
quence of its over-distentiou M'ith blood.    Cases  are  also on record
M'here there were cardiac involvement  and  grave  disorder of other
viscera.   According to Mackenzie,1 the disease occurs in both sexes,
more frequently in women however, aud  between the  ages of twenty
and  thirty,  though  also at earlier  periods  of life.   The purpuric
spots observed  by him usually made their appearance regularly in
the afternoon or evening,  sometimes daily, and  often  with  several

                  i Brit. Mtd. Jouru., March IS, 1882, p. :)S3. 
356
DISEASES  of  the skin.
days' interval, accompanied  by pain, stiffness,  and sMclliug of the
joints.   The maculae  Mere at first of a bright  reddish  hue,  but
became purplish by the ensuing day.  The  site of predilection  m as
the extremities, but the eruption  in  his cases M'as  sometimes more
generalized.
   The lesions displayed this amount of symmetry :  if they occurred
on one extremity, upper or loM'er,  they Mould generally be found on
the other.  As a rule, there were not profuse sweats,  unless the attack
occurred M'ith  rheumatic  fever;  the joint affections and pyrexia,
though  distinct, M'ere  not severe.   Sometimes  there  was a certain
amount  of erythema  accompanying the  haemorrhages;  often  the
eruption was purely haemorrhagic.   The attacks  were frequently very
protracted, lasting even some months, and were liable to recur.
   The  disease occurs  in  both sexes, though more often in young
women, and is to a certain extent influenced by the changes of climate
and season.  Its diagnosis, in consequence of its marked characteris-
tics, coincidence of  petechiae and ecchymoses M'ith rheumatoid pains,
is  readily effected.   Duhring  calls attention  to the danger of con-
founding it M'ith the  macular  syphiloderm,  the lesions  of which,
however, fade under pressure.   The  prognosis  is in general  favor-
able, though  the disease may persist for  long periods of time, and
may, in rare cases, terminate fatally.

   [B.]  Purpura Hsemorrhagica.   (Morbus Maculosus Werlhoffii.)

   This  disorder, called  also land-scurvy, is usually ushered in M'ith
phenomena of a febrile  character, accompanied by  symptoms of
general  depression.   Subsequently, ecchymoses appear upon the  ex-
tremities and trunk, both spontaneously and at points  M'here  the
integument has been  specially  subjected  to  pressure and friction.
Usually petechiae appear simultaneously upon the  nasal, laryngeal,
buccal,  and other  mucous surfaces, M'hich may also be  the seat of
exhausting haemorrhages, resulting rarely in fatal collapse.   A symp-
tomatic fever is usually awakened.   The disease occurs equally in
the robust  and feeble  of all  ages, and, though usually as a sporadic
affection, it may assume an epidemic form.   The disease  is sIom' in
its course,  but commonly terminates favorably after the lapse of
several  months.
   The lesions commonly appear first on the upper extremities ; then
over the trunk, and finally over the lower extremities.    They are
usually  dark  red or purplish in hue, varying in size  from  a pin-head
to  a bean, but may  be  of the size of the palm.
   It is  distinguished  from purpura scorbutica,  or " scurvy," by the
absence  of distinctive  premonitory symptoms of the  latter disease,
and its  invariable occurrence among  those suffering from improper
alimentation, vitiated air, and lack of exercise. 
PURPURA.
357
                  Purpura Scorbutica. (Scurvy.)

  This disorder is peculiar to those who are compelled to subsist for
lengthened periods of time on improper food, more particularly that
from  which  fruit and  fresh  vegetables are excluded;  to  respire a
vitiated air; and to endure  such confinement as precludes the  pos-
sibility of duly exercising the body.   The disorder  is hence  more
common among sailors, prisoners, Arctic voyagers, and men similarly
situated.
  The cutaneous lesions are, as in so  many other forms of purpura,
preceded by an almost characteristic sense of lauguor aud depression.
One or several joints may  then enlarge.    There may be, however, a
distinct febrile action.
  The haemorrhages M'hich  result are quite like  those of purpura
haemorrhagica;  and the cutaneous lesions  are  petechiae, ecchymoses,
and painful  ecchymomata, usually first  appearing  on the lower ex-
tremities,  M'hich may fluctuate, open, and  result in offensive ulcera-
tions reaching to the  bone.  Simultaneously with  the cutaneous
eruption,  the  gums  become  involved, and show as tumid, heemor-
rhagic,  or ulcerative  fungositics,  smeared with a dirty  yellowish
secretion,  and having a fetid exhalation.    The subcutaneous connec-
tive tissue, muscles,  fasciae, and viscera become  also involved.    The
disease  is accompanied by febrile and other general phenomena of
asthenia, and, when  the causes are persistent, results  fatally.   It is,
hoM'ever,  remediable by proper  treatment, though convalescence is
usually tediously prolonged.

                         Purpura Pulicosa

is the result  of the traumatisms produced by fleas, lice, and  bugs.
The lesions are  punctiform, and due to the welliug up of blood into
the minute punctured wound, surrounded  usually  by an hyperaemic
halo M'hich is the  result of the irritation.   AVhen the latter fades,
the central haemorrhagic point usuallv for a brief time persists.   The
disease is  characteristically manifested  upon the filthy skins of indi-
viduals long  bitten  by  bugs, and covered with excoriations and dark
colored crusts, the result of scratching.   Such cases  are often  pro-
nounced scorbutic.

  The  symptoms of  cutaneous  haemorrhage are  also observed in
other conditions besides those named  above.   Petechiae and ecchy-
moses are also in cases noted upou the lower extremities of the  sub-
jects  of tuberculosis, cancer,  aud the  plague.   In  Hamophilia, a
disease occasionally of hereditary origin,   aud  characterized  by the
facility with M'hich trivial traumatisms  of the  surface  are followed
bv  incoercible haemorrhages, purpura  may  be the first signal of the
predisposition.   A  young man M'ith  purpuric  lesions of both lower
extremities, and otherwise  in apparently good health, lately presented
himself at the Dermatological Clinic  for the relief of the  difficulty. 
358
DISEASES  OF THE  SKIN.
There Mas at the time no suspicion of  haemophilia, but two weeks
later, as  the  result of a vaccination, he  bled continuously for eight
days.
  Pathology.—Many cutaneous  haemorrhages,  not resulting from
traumatism, however  manifestly  and  immediately  due  to  morbid
conditions  of  the  vessels, are by  many authors believed to  have  a
neurotic  origin.   Purpura  haemorrhagica,  for example,  in  conse-
quence of the frequent absence of lesions of the vascular walls suffi-
cient to  explain  its phenomena, is by Wagner, Henoch, and others
explained  by supposing  either abnormal excitation of the  sympa-
thetic system, or paresis of the vaso-motor centres.   Cavalier1 reports
a case of purpura alternating  M'ith paralytic symptoms.   The fre-
quently symmetrical disposition of the lesions has received a similar
interpretation.  Tyrrell2  reports cases induced by marsh-miasm, and
Satterthwaite,3 of  New York, a similar case, in M'hich the eruption
followed a chill lasting three-quarters of an hour.
  In all these cases,  the  haemorrhages occur  chiefly in the derma,
though often  in the subcutaneous connective tissue, a fact well illus-
trated by the drawings made by Variof4 of sections of the purpuric
skin of a patient dead of haemoptysis.   In this case  there M'as nu-
merical  diminution of the red corpuscles in life, as demonstrated by
the hematimetre, M'itbout any change in their form, volume, or color.
Inflammatory complications  in these conditions are rare.  The color
of the several lesions induced is,  without  question, derived from the
haematine,  M'hich not only stains  the environing fluids, but also the
tissues themselves where the extravasation occurs, and appears, when
absorption of  the fluid portions of the clot has been accomplished, in
the form of variously sized granules.  In this way, the color-changes
between  red, orange, yellow, purple, and  violet in the resolution  of
petechiae and  ecchymoses  are to  be explained.   The  persistence  of
the pigmentations varies with the quantity of the effused blood and
its  seat.    In mild cases, especially of lesions  involving the upper
half of the body, all traces of the haemorrhage may be removed in the
course of a few Meeks.   Dark pigmentations resulting from purpura
scorbutica, affecting prisoners at Andersonville  during the late civil
M'ar in this country, are still, in some  persons, perceptible upon the
lower extremities.
  The explanation of the diapedesis of blood  through the vascular
walls by supposing changes to have occurred in the fluid  itself, has
been made by dial vet, Andral and Gavarret, and others.  The pale
and watery appearance of the fluid, the increase in the proportion of
fibrine in the  clot, the diminution in the  number of the  red  blood-
corpuscles, and the loM'ered specific gravity of the blood have all
suggested this view.  Kietschy has called attention  to irregularity in
the shape and metamorphosis of figure in the red blood-corpuscles.

  1 Bull. Gen. de Therap., 1879.              2 Pacific Med. and Surg. Journ., June, 1876.
  3 Med. Gazette, Jan. 14, 1882, p. 14, cited by Duhring.
  * Journ. do l'Anatom. et de la Phys , Nov., Dec, 1881, p. 520. 
purpura.
359
   Wilson, Fox, and  others, again, have  recognized  lardaceous  or
inflammatory  changes  iu the  vascular  walls,  with  embolism  or
thrombus in others.   Watson Chcyne1 discovered in a case recorded
by Russell, some of the capillaries in the neighborhood of the haemor-
rhages plugged with bacilli, and  colonies of the same in the blood
effused after rupture.
   Treatment.—The  treatment of these various  forms of  cutaneous
haemorrhage M'ill clearly depend upon the nature of the cause in each
case.  In general it may be said that internally the use  of ergot,
of the chloride or other salt of iron, and of quinine  is  advisable.
The oil  of turpentine, the tincture of the muriate of iron, the acetate
of lead, and  dilute sulphuric acid, have all been employed at times
with  marked  success ; at others,  without;  in the treatment of these
cases.   Hypodermatic injections of Bonjean's ergotine, one part  to
two of distilled water, repeated every second day, have been speedily
followed  by favorable results.   A  generous  diet, the use  of wines,
malt liquors, aud  even spirits, and strict  observance of the demands
of hygiene, are often essential methods of relief.
   In  the May of local treatment, the  gums often require an applica-
tion of rhatany, one part of the extract  to fifty or sixty of lotion ;
or equal parts-of the tincture of cinchona and tincture  of myrrh,
diluted  as required.
   Rest  in the recumbent position is advisable, and, if haemorrhage  be
actually in progress, the free use of haemostatics will be required M'ith
local application of ice.  For those M'ho are convalescent from systemic
disorders accompanied' by purpuric lesions of  the loM'er extremities,
resorption of  the  extravasated blood  may be hastened by the local
application of stimulating spirit  lotions M'ith friction; and the pres-
sure of the blood column may be partly relieved  by elastic bandaging
of the extremities.
   The  prognosis  has  been given, as  far as might  be, in connection
with each disorder named.
i Brit. Med. Journ., Sept. 1, 1883, p. 416. 
360
DISEASES  OF  THE  SKIN.
                        CLASS  IT.

                        HYPERTROPHIES.

                       1.  Of Pigment.

                            Lentigo.
                         Lat. lens, a freckle.
Lentigo is that condition in which occur pin-head to bean sized, yellowish to
  brownish, circumscribed, and usually multiple maculations of the cutaneous
  surface, due to an excessive deposit of pigment, most often seen on the face
  and dorsal surfaces of the hands.
   Symptoms.—This condition, termed also Ephelis, is  due to exces-
sive and irregular deposit of pigment in  the  skin, producing  the
pin-head to  bean-sized spots  of circinate  or  irregular  outline,
frequently grouped and even confluent, which are commonly desig-
nated  as " freckles."   They are  most frequently seen symmetrically
distributed on the parts of the body ordinarily exposed to the light
and heat of the sun and atmospheric influences,  such as the face,  the
neck, and the backs of the hands in persons  of both sexes.  In those
whose bodies are to a  greater  extent similarly exposed, they occur
upon  the chest, the back, and over the extremities.  In other indi-
viduals,  they may be seen upon  parts not thus exposed, such as  the
penis,  the  scrotum, and the  inner faces of  the  thighs, a fact M'hich
indicates that they are not ahvays the result of  the operation of  the
agencies  noted above.   They vary in color from light yelloM',  salmon,
and red to the  deepest  brown; and are most noticeable in  persons
having red hair and a delicate skin.  They occur rarely in infancy,
partly, perhaps, on account of the infrequency of out-door exposure
in tender years ; and are usually seen first  about the age  of six to
eight years.  They are commonly observed in mulattoes, individuals
of  a race particularly disposed to the  anomalies of pigment distribu-
tion.   Once  developed, the lesions  may persist through life  without
marked  alteration ;  or fade  with each recurrence of the  season of
winter;  or, in  milder cases, entirely disappear.   They  usually share
in  the atrophic  changes of old  age, and,  M'hen  persisting  to that
period, may then  spontaneously disappear.  They are not the source
of subjective sensation.
   Etiology.—Freckles are, without question, produced and aggravated
at times  by the action of the  light and heat of the sun,  as a common
experience declares; but it is evident that these forces must act upon
a susceptible skin.  Of a hundred sailors exposed in  precisely similar
situations on a  long cruise, some of the number will  be uniformly
" tanned,"  and  others deeply " freckled."  Attention has been called
to the  occasional occurrence of lentigo in the  protected parts of  the
skin.   Dr.  White, of  Boston, in  an interesting paper on melano- 
CHLOASMA.
361
 derma,1 calls attention  to the fact  that  exposure to sea-air and fog,
 M'ith obscuration of the sun, is sufficient to produce the result.
   Pathology.—Freckles are due to an increase of deposit of pigment
 in definite areas of the epidermis, never in the corium.  Lesser urges,
 with strong probability in his favor, that there is always a congenital
 predisposition to these  pigment formations M'hich requires certain
 external conditions for development.
   Treatment.—The treatment of  lentigines  is that of chloasma and
 other pigmentations  of the surface.   Prof. Wertheim,  of Vienna,
 advises :

         R . Hydrarg. ammon. muriat.   gr. lvj ;            3 7o
            Bismuth, magister.         gr.  lij ;            3 50
            Ungt. glycerini              3j;           32       M.
         Sig.  To be applied only every other night.

   Bulkley employs:
         R. Hydrarg. chlor. corros.     gr. vj ;
            Acid, acetic, dilut.           f 3ij;
            Boracis                    ^i'j;            2 66
            Aq. ros.                   fjiv;          128       M.
         Sig.  To be applied night and morning, at first with gentle brush-
           ing; afterward by rubbing.

   Hard a way touches each freckle with a rather stiff needle  connected
 with the negative pole  of a galvanic battery, and finds  the results
 satisfactory.
   Most of the secret methods employed by charlatans for the removal
 of freckles depend for their success upon thorough blistering of the
 surface.  Inasmuch as  by this process the  epidermis is  removed, it
 is evident  that the  pigment of its cells is also removed with it; and
 the  new epidermis is for a time quite free from blemish.  But in
 all such cases the ultimate result is a deeper and more  persistent
 pigmentation than that  which was previously visible.


                            Chloasma.
                    Gr. xloaZo, to possess a greenish color.
 Chloasma is that condition in which occur yellowish to blackish,  finger-nail
  to  palm-sized,  circumscribed, diffuse,  and  ill-defined maculations of the
  cutaneous surface, due to an excessive deposit of pigment.
   Symptoms.—In this affection the skin is either diffusely discolored
 in various  shades, or  the maculatious occur in patches larger than
those of lentigo,  fairly well-defined, and irregular in contour, the so-
called " liver-spots."  In color they vary from a  scarcely perceptible
staining of the skin,  M'hich requires a strong  light for its detection,
to a deep yellow, a yelloM'ish-green,  a chocolate-broM'n, or a blackish
shade  (Melanoderma).   They may be either idiopathic or symp-
tomatic in  character.

                1 Boston Med and Surg. Journ., May 16, 1878, p. 624. 
362
DISEASES  OF  THE  SKIN.
  The idiopathic varieties of chloasma are produced by all externally
operating agencies, in consequence of which an undue afflux of blood
is persistently determined to any portion of the skin.   It is largely
from the blood  that  the  pigment is derived, and hence the  stains
produced by the latter are,  to a certain extent at least, proportioned
to the hyperaemia, stasis, or extravasation of the  vascular  fluid.
Among these  externally operating agencies may be named, pressure
and friction (as over the part covered by the pad of a truss); trauma-
tism (as after the severe scratching of the skin  affected with lice,
eczema, or  scabies);  heat (as  in  diffuse "tanning" of the face,  or
"sunburn" following exposure  to the solar rays); and the toxic or
irritating effect  of externally applied substances,  such as mustard,
capsicum, cantharides, and other articles capable of producing either
vesication  or  pustulation  of the surface.  The  physician should
alwavs  remember the possibility of producing long, persistent,  or
even permanent  pigmentations of the skin upon the face, shoulders,
and bosom of young women especially, by the repeated application of
such topical medicaments.
  The symptomatic varieties of chloasma are  the results of disorders
either  systemic  or involving  the internal  organs.   They  occur  as
either  circumscribed  or  diffuse, localized  or  generalized,  spots,
mottlings, stainings, or " masks "  of the skin ;  and vary in color from
the lightest to  the darkest shades.   One of  the most common, and
at the same time the most marked of these, is Chloasma Uterinum,
so called because of its frequent association with certain physiological
or pathological  conditions of the uterus, both among  married and
single  women.   Thus  in pregnancy, sterility,  hysteria,  chlorosis,
ovarian disorders, and tumors, and  functional derangements  of the
uterus, there can be observed at times a facial  discoloration extending
equably over the forehead and reaching nearly to the line of the hairs
at the  scalp, in  the form  of a faint  or  decidedly yellowish, reddish-
yellow, or  deep brownish tinge.  At other times, the discoloration is
macular and asymmetrical, involving the lids, the cheeks, the lips, or
the chin.   When the chloasma  assumes the  mask-like form, it is
usually most  pronounced over  the  forehead,  but  may involve the
M'hole facial region,  being  less distinctly defined  below than  above.
Similarly,  the well-known changes occur in the areola of the nipple,
along the linea alba, and about the external genitalia.

            Melanoderma, or Chloasma, Cachecticorum

is another  of  the symptomatic  pigment  disorders,  characterized  by
the changes in the color of the integument of the subjects of tubercu-
losis, syphilis, cancer, chronic alcoholism,  malaria  (e. g.,  " Chagres
fever"), and other disorders.
  The peculiar bronzing of the skin in Addison's Disease, formerly
thought to  be due  exclusively to lesion of the supra-renal capsules,
is of the same nature.   Overbeck and  Greenhow have shown that
the capsules may be completely destroyed without changes in the 
CHLOASMA.
363
skin-color resulting.  The pigmentation  maybe general or  partial;
and  in the latter case is without definite lines of demarcation.   It is
commonly  most  pronounced  over the face, neck, scrotum, groins,
axilla-, and nipple and  areola   The  hairs  become coarse and dark;
and dark patches are at times visible over the mucous surface of the
lips, gums, and other parts of the mouth.   The bronze or mulatto-
like  color of the skin is intensified  by stimulation or erosion of the
cutaneous surface.  In these cases there is generally marked asthenia,
with a feeble pulse, M'ith anorexia and other signs of gastro-intestinal
disorder.   When the result is  fatal, there may or  may not be recog-
nized pathological alterations of the supra-renal capsules.
   Among the cutaneous disorders capable of producing skin pigmen-
tation  may be named scleroderma, lepra,  angioma pigmentosum et
atrophicuni, eczema,  especially e. venis varieosis;  and general exfolia-
tive  dermatitis.
   From all of the discolorations named  above, which are due solely
to deposition in excess  of coloring matters normally existing in the
skin, it is necessary to distinguish the various dyschromiae which are
owing to the introduction into the integument of coloring substances,
either supplied by other portions of the body or entirely foreign to it.
 rhus,  in icterus,  the  bile may color the skin from a light yelloM' to a
dark chrome color, the  duration and  severity of the cutaneous symp-
toms depending upon the nature and gravity of the hepatic disease.
It is frequently accompanied by pruritus in various grades of severity,
the exact causes of which are obscure.
   In Argyria, the bluish,  bluish-gray, slate-colored, or  bronzed
coloration of the skin results  from the introduction from without of
the nitrate of silver.  It is most commonly the result of the adminis-
tration of the drug in the treatment  of epilepsy, but  is said also to
have resulted from the  topical  application of the silver crayons to the
throat, to the conjunctivae, and even to the skin.   Under M-hat form
the  silver  produces  this effect, whether  as an albuminate or  other
salt, is not known.   The  deposition, hoM'ever, occurs in the form of
minute particles of the metal in the  connective tissue  of the derma.
The discolorations are most evident upon  the  parts  of the  skin ex-
posed to the light, as  the face and hands; but the author has  seen the
chest and lower extremities similarly stained.  The connective tissue
of the viscera  is also at times involved, showing thus that the action
of light  is not essential to the production  of the dyschromia.   Two
cases are reported as  relieved  by the  administration  of the iodide of
potassium.
   The administration of arsenic in full  doses for relief of  nervous
disorders in  children  has  been  followed by  a characteristic  dull
brownish or dirty-colored discoloration of the skin  of the  neck and
chest.  Several cases of this sort have been presented to  the  author's
observation in his clinic by Dr. H. X. Mover.
   Bv the process of tattooing, lastly, several  mineral and vegetable
substances  are directly introduced  into   the corium by  means  of 
364               DISEASES OF THE SKIN.
needles, for the production in the skin of various devices in colors.
Individuals whose entire integument has been thus artificially covered
with figures of different patterns by tattooing with indigo, vermilion,
and cinnabar have been from time to time exhibited iu this country.
The results are indelible.   Post-mortem,  these pigments have been
discovered not only  in the derma,  but  iu the  lymphatic  ganglia
nearest the site of their introduction.
  Pathology.—The lentigines, ephelides, and chloasmata are all  due
to excessive deposit of the natural pigment of the body  in  the  rete
mucosum of the epidermis.   Restoration  of the normal color of the
skin is usually proportioned to the extent and depth of the deposit,
but the process is always very gradual.  It can be M'ell studied in the
slow bleaching of the pigmentation of syphilitic cicatrices upon the
lower extremities.  In the dyschromiae due to the introduction of
coloring matters foreign to the body or foreign to the skin, the corium
and subcutaneous connective tissue are commonly stained.
  Diagnosis.—The diagnosis of the cutaneous pigment hypertrophies
is readily effected by observing the persistence  of the discoloration
under pressure;  the absence of all symptoms of hyperaemia, inflam-
mation, aud secondary  changes in  the  skin, as also by the charac-
teristic  shades of color presented  to the  eye.   In  tinea versicolor
there is  usually slight furfuraceous  desquamation, and the'existence
of a vegetable parasite is readily demonstrated by the microscope.
The rare pigmentary syphilide is  usually seen  upon  the neck  and
shoulders of infected women in the  form of yellowish to brownish
maculatious, often arranged in  an irregular network.   It is, indeed,
one of the symptomatic chloasmata.
  Treatment.—In all the symptomatic pigment anomalies, the indi-
cations for treatment are  presented by the  disease which begets the
cutaneous disorder.
  The  local  treatment  of both  the idiopathic  and  symptomatic
varieties of the disease demands  the use  of external applications
which will hasten the physiological reproduction of the epidermis,
substituting thus new and unpigmented for old and pigmented  epi-
thelia.    This must also  be accomplished without the artificial pro-
duction of such  an hyperaemia  as will  tend to add to the  very
coloration which it is attempted to relieve.   The substances  used for
the  slow accomplishment  of this end are  muriatic and acetic acids,
borax, sulphur,  tincture  of iodine, potash,  aud soda (including the
soaps of these alkalies), aud the mercurials.   None  of these is more
generally employed than  corrosive sublimate, which constitutes the
basis of most of the cosmetic lotions sold  in the shops.
  The following are. formulae given by  Dr.  White1 for  use iu the
evening.  The preparation in each  case should be left upon  the  sur-
face during the night, and removed by a  soap and water washing in
the  morning.  They are to be used for weeks in succession, but only
after a cautious preliminary testing of the  sensitiveness of the skin
Loc. cit. 
CHLOASMA.
365
to their action.   In order to avoid the possibility of error, the prac-
titioner Mould  do well to order a poisou-label upon all  vials con-
taining- the sublimate :
R. Hydrarg. am. chlor. ]
   Bismuth, magister.  j
aa 3ij;
Amyli Glycerin	}	aa ,5ss;	16
R. Ammon.	muriat.	3ss;	2
Aq. colognien.		f'sj;	32
Aq.		Oss;	256
R. Hydrarg	bichlorid.	gr- YJ;	
Acid. niur. dil.		f3j;	4
Glycerin		f3j;	32
Alcoholis	}		
Aq. ros.		aa f^ij ;	64
Aq.		f'.-jiv;	128
M.
M.
M.
The following arc formulae for ointments given by Kaposi

                                                  16
      R. Hydrarg. ammon.
         Sodae biborat.
         01. rosmarin.
         Unguent, simpl.

      K. Acid, boracis 1
         Cerae alb.    J
         Paraffin.
         01. amygd. dulc.

Van Harlingen recommends

      R. Hydrarg. chlof. corros.
         Zinci sulphatis
         Plumbi subacetat.
         Aq. dest.
aa 3ss;
gtts. x;


 aa 3j;
   3ij;
gr. vss;
aa 3ss;

  f^iv;
M.
M.
128
M.
Sig.  Lotion, for external use, morning and evening.
   The  rapid  removal  of pigmented  patches  is accomplished, in
Vienna, by  covering the part  with strips  of linen dipped in an
aqueous or alcoholic solution  of corrosive sublimate of the strength
of four grains (0.-6) to  the ounce (32), with M'hich  also the dressing
is  occasionally moistened.   Aresiculation  is usually accomplished in
about four hours,  w hen the serum is evacuated by puncture, aud the
detached epidermis covered M'ith any inert  dusting powder.    The
resulting crust falls in about eight days.    The procedure is attended
with the danger of producing, in the end, the  precise deformity which
it seeks to  remedy, a danger explained above.
   The  internal administration  of  the iodide of potassium,  recom-
mended for the removal of argyria, has in my hands failed  of any
good results.    Yandcll's two  patients, one completely and the other
partially relieved,  M'ere both syphilitic.   One of my patients was a
veteran syphilitic,  fifty years of age. 
366               DISEASES OF THU  SKIN.
     2.  Of Epidermal and Papillary Layers.

                          Keratosis.
                         Gr. Kepac, a horn.
  The term Keratosis was first applied by Lebert  to hypertrophic
lesions of the epidermis.   It  has since been made to include changes
in both the epidermis and corium; and is employed by some authors
in a generic sense to embrace  a number of both localized and general
hypertrophies, including  callosities and corns.   In the classification
of  the American Dermatological  Association,  however, it includes
merely the two disorders described below, the others  embraced by
authors in the same  category being  in these  pages  separately con-
sidered.
                      [A.] Keratosis Pilaris.
Keratosis Pilaris is a disorder,  chiefly of the extremities,  characterized by
  multiple, millet-seed sized, whitish, grayish, or slightly reddish aggregations
  of epithelium, about the orifices of the hair-follicles.
  Symptoms.—This condition,  termed  also Lichen  Pilaris, and
Pityriasis Pilaris, may be a  mere temporary and functional dis-
turbance of the skin, awakening no subjective sensation, inappreciable
by  the patient, and apparent  only to the careful  observer, or it may
really constitute a disease.  Its symptoms are the occurrence of pin-
head sized, pointed elevations of the surface, which may be described as
papules, though, strictly speaking,  they are  not such, constituted by
an accumulation of horny epithelia and a small quantity of inspissated
sebum about the lanugo hairs of the extensor surfaces of the extremi-
ties and trunk.   These aggregations of material are usually of a dirty
M'hitish or grayish  hue, and  pierced by a  lanugo hair implanted in
the follicle about which the abnormal condition  exists.   Occasionally,
however, the hairs  are of the finer and shorter kind, and are often
coiled in or otherwise covered by the little heaps  of epithelial debris.
The skin of the individual thus affected is generally harsh, squamous,
and dry to the touch ;  being also, in the majority  of cases,  long
unwashed.  The color  of the quasi-papules   also differs  M'ith the
complexion of the individual; at times they have a distinctly reddish
tinge.   They are often surmounted by a scale.
  The condition is  sufficiently common in  skins  long  uucleansed by
ablution, and can thus be artificially produced.    In some individuals
it persists for long periods of time,  and awakens no concern.  In
others, and especially in children,  it speedily becomes the source of a
pruritus, and each lichenoid papule may be then  transformed into an
urticarial wheal, M'ith distinct and  sometimes very annoving, pricking
and tingling sensations, the  entire trouble being at once relieved  bv
a bath in warm water with soap.   In other cases, especially in adults,
an  exaggerated form  of the  disease can  be recognized, the skin pre-
senting a roughness  to  the touch suggestive  of the nutmeo--o>rater 
KERATOSIS.
367
and exhibiting numerous fine, conical, grayish, horn-tipped filaments,
M'hich several  dermatologists  are  disposed  to  regard as a form  of
ichthyosis.  Here, there  is doubtless  a true  hypertrophy  of the
epidermis.  In the  former case,  there  is  scarcely more  than  a
mechanical  accumulation  of effete organic  material.  There can  be
little  doubt that  the  malady, simple  though it be in character at
the onset, may become the first stage of a series of chronic cutaneous
disorders.   Tilbury Fox has reported four cases in which the disease
Mas well marked, under the title Cacotrophia Folliculokum, the
name  being employed to  designate its peculiarities as to wide distri-
bution over the body, implication of the deeper portion of the follicles,
and its congenital history.  In  these cases, the reddish  tint of the
lesions is distinctly shown.
   Pathology.—The disease is  produced  by the  accumulation of the
cells  of  the horny layer  of  the epidermis  and sebaceous material
about the orifices  of the hair-follicles.  In some cases the result  is an
irritation which produces  a more or  less persistent hyperaemia of the
periglandular tissue.
   Etiology.—Puberty aud uncleanliness have  been assigned  as a
cause  of the  disorder;  and both conditions may be in some patients
effective.  A careful study of a group of exaggerated cases, hoM'ever,
occurring in adult men  and women,  suggests more essential reasons
for the  disease.   In  such exaggerated  cases, the outer faces of the
limbs and  even the entire face of  the  belly may be covered  M'ith
faintly pinkish or bright reddish firm papules, many of them scale-
capped, all seated at the orifice of a  hair-follicle.  In these patients
there  may  be  a  history of regular  ablution and persistence of the
 malady long after puberty.  But in  general they M'ill be seen to have
peculiarly thick, coarse, usually dark colored skins,  and also to be
persons of marked muscular vigor and  unusual development of most
of the other bodily tissues.  In brief, the  disorder seems to  be due
often  to  marked  inherited predisposition  in  persons  of vigorous
constitution.   The  varieties  of keratosis pilaris seen  in cachectic
 hospital patients,  and in persons M'ho have aggravated the disease by
 inducing a medicamentous rash upon the person, belong to a different
 category.   Patients in the two last-named classes may be so perfectly
 relieved that there is no predisposition to return of the disorder, a
 relief not ahvays  to be secured by  the others.
   Diagnosis.—The disease should   be readily recognized   by the
 peculiarities of its seat, its course, and  the nature of its symptoms.
 From ichthyosis, it can  be  distinguished  by  its  limitation to the
 orifice of the  hair-follicle; from  the transitory condition known as
 "goose  flesh," by  its  persistence after  the  surface of the  skin is
 thoroughly Manned ;  from papular  eczema and the other lichenoid
 eruptions, bv the relatively insignificant character of the lesions and
 their evident association with follicular inertia.
   It is a  matter  of very considerable importance to distinguish this
 disease from the  papular syphilodermata,  siuce many male patients
 have  for  vears  swallowed medicaments for  relief of  a supposed 
368
DISEASES  OF THE  SKIN.
 syphilis whose sole symptom is a keratosis pilaris.   But  the papular
 syphilodermata are not persistent  year after  year, not  persistently
 symmetrical, and not limited largely to the outer faces of the limbs,
 especially of the thighs.  They are preceded by a history of infection
 and invariably accompanied by some other manifestations of the dis-
 ease.  They are not limited to the orifices of the  hair-follicles, and
 are  not capped by the  peculiar  horny scaling tip of the  papule of
 keratosis pilaris.
   Treatment.—For  patients affected with this disorder in its typical
 forms it is not sufficient merely to order a bath.   The bathing should
 be conducted systematically for years at a time.
   As soon as it can be well tolerated, the patient should  be urged to
 bathe the  entire surface of the  body every morning, by the  use of
 the sponge and cold water, following this M'ith brisk friction by the
 aid of a coarse towel  or flesh-brush.   The daily and habitual  use of
 this cold bath continued for  years, in persons who can tolerate it
 (and  patients affected M'ith keratosis pilaris are usually of this  class),
 accomplishes results of the most satisfactory character, exerting as it
 does, a  profound influence on the nutrition and healthfulness of the
 skin.
   For immediate treatment, however, of the most of these cases the
 hot  bath with the soap is desirable.   This may be  repeated as often
 as required to  remove the lesions, and  followed, in the more urgent
 cases, by inunction M'ith the  fats  or  oils.   In  the congenital and
 severer  cases, such as those described by Fox, cod-liver oil, internally,
 should be ordered.

                      [B.]  Keratosis Senilis.
   The  senile changes in the  skin are commonly  of the  character
 studied  by Neumann, in which granular opacities appear in rows in
 the corium, giving it a dull  greenish-yellow or  saffron-colored hue.
 Later, the  fibrillae  of  the corium  are  almost entirely replaced  by
 finely granular  masses, the remaining  fibres becoming  swollen and
 gelatiniform, reverting thus to an embryonic type.
   Side by side M'ith these degenerative changes, but also M'itbout the
 latter, the  skin of the aged  may become  harsh, dry, and unusually
 cornified either  diffusely or in certain definite regions, such  as the
 hands, feet, or extremities.  This may be regarded  as  the  simplest
 form  of keratosis senilis.  The skin of the entire  body, or  of the
 region affected,  is then dark  in  color,  dry to  the touch,' occasionally
covered with fine, rather adherent scales representing merely attached
and cornified cells of the horny layer of the epidermis, and notably
 unprovided with the natural unguent of the skin.
   In  a  more advanced grade  of this affection, the skin undergoes
changes  which are closely allied  to epithelioma, and which  indeed
often  both  furnish the  first  symptoms of that affection  and also
coexist M'ith its gravest destructive effects.   The skin, in  these cases
more  commonly  of the  face,  hands, or forearms, less  often  of the
feet, legs, and genital regions of the aged, is covered with thin, horny, 
MOLLUSCUM  EPITHELIALE.
369
often greasy looking, pin-head to nail-sized and larger, dark yellowish
plates or scales, between M'hich the integument which has undergone
the atrophic changes in the senile skin, is visible.   Pigmented puncta
aud maculae may also appear, scattered irregularly over the surface,
with rough,  dirty yellowish to dark brownish,  granular accumula-
tions  upon  the  skin of certain regions, such as the clefts beside the
ahe of the nose, the temples, etc.   The appearance is quite suggestive,
in some cases, of a seborrhcea  sicca of the face.   In many  of the
patients  exhibiting  these features a fully developed papillomatous,
superficial, or deep epithelioma may be  present.   In other cases  one
or more varieties of the senile wart may ba visible, as described in
the chapter on verruca.
   Viewing the subject of senile keratosis in the light of the knowledge
had upon the subject to-day, it must be  admitted  that the boundary
lines between it  aud epithelioma are not well established.   Unques-
tionably the exaggerated lesions of the  former disease are frequently
the first stages  of the latter, and the  treatment of the  skin  of the
aged, conducted  on the general principles already set forth, should
never  lose sight of the possibly serious consequences in  one or more
regions of the skin affected.

                    Molluscum  Epitheliale.
                         Lat. molluscus, soft.
Epithelial Mollusca are smooth, globoid or acuminate bodies, situated either
   within or upon  the skin, and in the latter case either sessile or peduncu-
   lated, varying in color from a yellowish-white to a dark pink, and in size
   from that of a pin-head to that of a bean.

   Symptoms.—Molluscum Epitheliale,  a disease first recognized  by
Bateman, in 1817, under the title Molluscum  Contagiosum, is to
be distinguished  from auother, known  for a long time as molluscum
fibrosum.  The two disorders are quite distinct, and no longer to be
confounded  by a similarity in their names.
   Typical mollusca are firm, roundish  bodies, averaging  in size the
dimensions of a pea, and in color varying from  a M'axy whitish hue,
nearly that  of the integument, to the  dark red tint of all injected
masses.  They are either imbedded in the skin,  or project from it in
semi-globular tubercles, sessile  or pedunculated.  Usually a  dark-
colored aperture can  be detected  at the apex  or side of the lesion
from  M'hich, on  pressure,  milky  and curd-like, semi-fluid contents
can be  made to  exude.  Occasionally  inspissated, or even horn-like
masses  project from  these orifices, as though  forced out by a vis a
tergo.  The disease is rare, aud the lesions usually single and isolated,
though  hundreds may appear upon the person of one  individual.
Thcv consist of semi-fluid collections derived from that portion of the
rete M'hich either lines the sebaceous glands or penetrates  betM'een the
papillae of the derma ; or are actual transformations of the glands into
cornified amorphous deposits, surrounded by thickened parietes.   They
mav be artificially removed ;  or be shed spontaneously;  or inflame,
                                 24 
370
DISEASES  OF  THE  SKIN.
suppurate, and  result in circumscribed abscesses; or  terminate by
ulceration.  Most often they are insidious and slow of  development;
and may persist for years without producing annoyance or subjective
sensation.  They  occur on  the  face, the  side of the  neck, and the
nucha;  on the penis  and scrotum of men, and the breast and labia
of women; on the trunk; on the flexor surfaces  of  the extremities,
and the dorsal surfaces of the hands and feet.   They are most com-
mon in children.  In consequence of the depression  of the centre of
the little tumors (M'hich Hutchinson has aptly  likened to small pearl
buttons),  they may suggest  the lesions of variola,  and are hence
described  by French writers under the term, A^arioliform Acne.

                             Fig. 40.
Molluscum Epitheliale. (Alter Allen.)
   Hebra, Virchow, and Nicolaysen have reported colossal  mollusca,
as large as an orange or a small cocoanut.  Microscopical examina-
tion of these  gigantic lesions demonstrated their identity with the
smaller tumors.   Similar smaller bodies have been found interspersed
among epitheliomata.
   Etiology.—Iu England, M'here the disease M'as first recognized and
where, according to Hutchinson, it is far more frequent than on the
continent  of Europe, the belief in its contagiousness is quite o-enerally
accepted.  Excellent  authorities are,  hoM'ever, divided  upon  this
question.  At present, therefore, it can  only be definitely stated  that 
molluscum  epitheliale.
371
the contagiousness of molluscum is not yet established.  If contagious,
the lesions certainly possess this power of transmission in a feeble and
imperfect degree, one much inferior certainly to other lesions  recog-
nized as contagious.  Ketzius,  Vidal, Peterson,  and "Wigglesworth
succeeded in producing the disease  by inoculation of the contents of
molluscous  tumors.  Allen,  in an  interesting  communication upon
the subject,1 reports an abortive result from an inoculation practised
in two places  upon himself by Dr.  Bulkley.   He reports fifty cases
observed  among children in an infant asylum of New York City,
and  expresses himself strongly in favor of the contagious character
of the disease.   Experiments with inoculation  have been, however,
often unsuccessful.  The proofs of contagion rest chiefly upon  the
circumstance of lesions observed simultaneously  or successively on
the breast of a  mother aud  the mouth of her  nursling, as observed
by both Bateman and Allen, or upon the successive development of
mollusca  in  several members of  one  family.  These  are  possibly
explicable as coincidences.  Fox, of New York, has called attention
to an interesting relation  which would seem to subsis tbetween mol-
lusca and verruca,  or  ordinary Marts.   If simple  warts are ever
shown to be in  a feeble degree contagious, it can scarcely be doubted
that a demonstration of the contagiousness of mollusca will soon
follow.  According to Kaposi, eczema, sweating, pruritus, and macera-
tion of the skin, predispose to their occurrence.
   There are not sufficient grounds for assuming that, in adults, they
are ahvays  associated M'ith venereal disease.   They  are  not  rarely
seen in large numbers upon  the scrotum of youths M'ho have  never
exercised the sexual function.
   Pathology.—Upon section, a typical molluscous  tumor is found to
contain either a  thick caseous fluid, or a mass of smooth, M'hitish, and
roundish bodies, M'hich are often clustered about a short stalk.  Micro-
scopically, these are seen to be composed
of epidermal  masses, -fat globules, and
peculiar  bodies  of oval shape, partly or
wholly contained in an  epithelial  pod,
the so-called "molluscous corpuscles."
   The origin and significance of these
corpuscles have been  the subject of  a
great deal of careful investigation  M'ith
no little  divergence of opinion as to the
result. The disease has been consequently
regarded  by many authors as one  con-
cerning  the sebaceous glands, and  the          (Alter Kaposi.)
fluid or more or less solid contents of the
tumors as the result of the various metamorphoses M'hich the pent-up
secretion of those glands  underwent.  By such authors, the disease is
termed "molluscum sebaceum," " contagiosum," etc., and is classified
with the sebaceous gland  disorders.
1 Journ. of Cutan. and Yen. Dis., August, 1886. 
372
diseases  of the  skin.
   But the later studies  of Petzius,1 Lukomsky,2 Kenaut,3  Vidal,4
 and Thin5 make it clear that the disease is one which concerns chiefly
 the  rete  mucosum of  the  epidermis.   The  name molluscum  epi-
 theliale, first  suggested in  this conuection by Virchow, in the  title
                                        i          •   •   1   1  •
 epithelioma molluscum, is hence seen  to  be appropriate in the desig-
 nation of the disease.
   Molluscous tumors may evidently take  origin either in the portion
 of the mucous layer whose involution forms the lining membrane of
 the sebaceous gland, or in  the prolongations  of the rete downward
 between the papillae of the corium where there is no follicle.   In
 either situation, the molluscous elements are earliest recognized as
 simply enlarged epithelia  which assume, as a consequence  of this
 enlargement,  a globular form.   In  the  midst of these,  there are
 certain individual elements which acquire a granular appearance, the
 granular  masses finally giving place  by union to a globoid or oval-
 shaped body,  large, shining, and stratified or homogeneous.  This is
 the molluscous  corpuscle which represents a  colloid  metamorphosis
 of the original epithelia.   According to Ranvier, the stratum  granu-
 losum of the epidermis is composed  of  elements  M'hich  contain
 minute particles  of  a  substance  called  eleidiue, the  keratogenic
 material by whose transformation  the stratum  corneum is actually
 produced.  This substance Renatit declares  to be abundantly de-
 posited in the enlarging corneous globes characteristic of molluscum;
 and  the process is by him shoM'n to be identical with that occurring
 in the transformation  of the elements of the mucous into those of
 the horny layer of the skin.   The pathological resemblance of  cer-
 tain  molluscous bodies to  epithelioma is thus very clearly suggested.
   According to Thin,6 the internal  root-sheath of  the lanugo follicle
 is the original  source  of the disease, whence molluscous elements
 pass to inoculate, at various points about the follicular orifice,  the
 adjacent epidermis.  The  coalescence of these points forms the tumor,
 in the course  of the development of which  the lanugo hair is shed,
 and the sebaceous gland disappears.
   Auspitz denies that the transformation of the prickle-cells  of the
 epidermis into molluscous bodies has  anything in  common with col-
 loid  or amyloid degeneration,   Robinson classes the disease with the
 new  groM'ths.    At present, we must be content with recognizing the
 molluscous corpuscle as the result of a transformation undergone by
the prickle-cell.
   Diagnosis.—Mollusca  resemble the lesions of variola more than
any  other cutaneous phenomena.   They  are, however, readily dis-
tinguished from the latter  by  their chronicity, their semi-fluid con-
tents, the  absence of febrile symptoms, and the career of the vario-
lous  pustules.    From  Marts  they  are  also differentiated by their
contents, hemispherical  shape,  and  the dark punctum almost invari-
ably  present on  one part or another  of the lesion.

   i Viertel f. Derm, mid Syph., iv. Hft. 3, 1877.          2 Virchow's Archiv, Bd. lxv.
   3 Lyon Med., July 25, 1880.                      4 goc. de Biologic, 1877-1878.
   5 Journ. ot Anat. and Puys., vol. xvi., 1881; arid Brit. Med. Journ.,  Jan. 15, 1881.
   0 Loc. cit. 
MOLLUSCUM  epitheliale.
373
  Molluscum epitheliale in no May suggests molluscum  fibrosum,
M'ith M'hich it has only been confounded in consequence of  the simi-
larity in the  two names.   The tumors of molluscum fibrosum are
Fig. -J 2.
        The author's rare form of molluscum verrucosum. (From a painting in oil.)

solid  iicm'  growths, usually occurring  in great numbers  upon the
trunk of individuals in adult years.    They  may attain enormous
dimensions of several pounds weight, and though  in  cases they de- 
374
DISEASES  of  the  skin.
generate by ulceration, they never have  the  curdy contents of mol-
luscum sebaceum.
   Papillary  warts are to be  distinguished  from mollusca, though
without question lesions are to be occasionally seen of a type  inter-
mediate between the tM'o forms.   Warts are to be recognized by their
general papilliform character, and their evident relation to the papil-
lary layer of the corium overlaid  by a thickened stratum corneum.
   Physicians  are occasionally consulted  by patients  M'ho  have dis-
covered mollusca upon the genitals, and who suppose these  lesions to
be  of venerea]  origin.  Au  error  in this respect  can scarcely  be
committed by the expert.    Neither the  solid  papule of the initial
lesion of syphilis when observed  on the skin of the jienis, nor the
pustule and resulting  ulcer of the chancroid are ever  characterized
by the particularly waxy look of  genital mollusca  with  their de-
pressed puncta.    In  such  cases,  the  inguinal glands should ahvays
be  carefully  examined,  remembering,  however,  that  a  forcibly
squeezed and cauterized molluscum may be accompanied by a sympa-
thetic adenopathy.
   Treatment.—Molluscous  tumors  may  be removed  by  ligature,
scissors, knife, curette, or the needle  in contact M'ith the negative pole
of a galvanic battery, their contents having been previously expressed.
When desired, the surface  may be  first  chilled or  frozen  with the
ether spray, to diminish the pain  of the trifling operation.   Bleeding
is easily arrested by a pledget  of  lint.   Occasionally the  point of a
crayon of nitrate of silver  may be  introduced, after their  removal,
either to  check haemorrhage or  to insure destruction  of  the  cvst.
According to Hebra, the return of the complaint, when it  occurs at
all, may be expected at points M'here no tumors have been removed.
   When the lesions are small and numerous, they may be made to
exfoliate by the local application of green soap.   Removal of the
larger lesions  may be followed by minute cicatrices.
   Prognosis.—The disease can always  be terminated by removal  of
the tumors—the process to be repeated in case of recurrence.   Cica-
trices, M'hen these result, are of trifling moment,


                           Callositas.
                       Lat. callus, hard flesh.
A callosity is a whitish-gray, yellowish-gray,  or brownish, semi-transparent,
  localized and circumscribed thickening of the epidermis of the skin, due to
  hypertrophy of its horny layer, most  commonly occurring upon the hands
  and feet.

  This condition is also termed  Tylosis, and the callosity  itself,
Tyloma.  Callosities are superficial, circumscribed, dirty M'hite, yel-
lowish-white or darker, flattened, thickened, and horny patches of epi-
dermis, dense  in structure aud usually insensitive.   A section of the
plaque shows it  to be largest at the centre and least at the periphery.
They vary in size from a finger-nail to a section of a hen's egg, being at 
CALLOSITAS.
375
times larger; and occur chiefly upon parts of the integument subjected
to long-continued intermittent pressure, as the hands and feet; also
upon parts stretched  over osseous  prominences, as those over  the
ischia.  They  may be  complicated  by  hyperemia,  fissure,  acute
inflammation, or erysipelas;  and readily  serve as foci  of cutaneous
disease  (eczema,  psoriasis, etc.).  They are commonly  encountered
among mechanics, carpenters, shoemakers,  etc.; among persons wear-
ing  ill-fitting shoes (heel,  ball,  or  big toes), stockings, or surgical
apparatus;  among workers  in  metals, acids,  or  heated substances;
and  among musicians (harpers,  banjo-players, etc.).  They are  pro-
duced by such external  causes as pressure, friction, chemical agents,
and  heat.   By careful  consideration, they can be readily distinguished
from eczematous,  psoriasic,  and ichthyotic  patches,  being always
limited to the sites of external contact,
   They are said to be  so characteristic of the several professions and
trades, that by their locality alone they point in many cases  to the
occupation of the individual who exhibits them.   Often they  are, iu
these cases, essential  to the prosecution  of such  work; and their
removal would only expose a tender  epidermis  to the operation of
an injurious pressure or friction.
   They are, pathologically, pure hypertrophies of the stratum corneum
of the  epidermis, the  deeper layers  of the latter as also the corium
and  subcutaneous tissue being quite unaffected.
   Callosities  require treatment  only when  they are sources of pain
or discomfort.  They  may be removed ; surgically, by the  knife;
chemically, by the destructive action of acids or alkalies ; rationally,
by disuse of the  part to  an extent  sufficient to interfere with the
operation  of the cause.  When painful, they may be poulticed.   A
nightly soaking of the  part with M'arm oil, kept in contact with the
thickened  epidermis during  the hours of sleep, by a  compress of
flannel  saturated M'ith  the same substance, will  in the  end ahvays
soften the induration.

   Callositas of the  Hands, mtth  Unusual Complication
[reported  by Dr. Morrison,1 of Baltimore], is illustrated by the case
of a  negro  M'ho Mas engaged in stoking the fires of a steamer.   In
this  instance the  combined  effects of heat  and friction resulted  in
ulcerations beneath the callosities which eventually produced necrosis
and  fall of some  of the phalanges.   This patient recovered as soon
as the  hands Merc properly protected, a fact M'hich seems  to justify
the assignment of this and similar cases to a  class  apart from those
which follow.

   Perforating  Ulcer  of the  Foot [Malum  Perforans Pedi;
Mal Perforant du Pied].  This disorder, first named by Vesigne, has
been studied by Messrs. Savory  and Butlin,2  Mr. Treves,3 Duplay,4
Michaud,5 and others.
1 Journ. of Cutan. and Vener. Dis., Jan. 1886.
> Lancet. Nov. 20, 1884.
& Lyon Mod , 1876.
2 Med. Chir. Trans., vol. lx., 1879.
* Arch. gen. de Med., 1876. 
376
DISEASES  OF  THE  SKIN.
   The name is an uufortunate one, since many cases to be  classed
 only in this category, have neither ulcerative nor perforating symp-
 toms.
   The first symptom is a  proliferative thickening  of the epidermis,
 like  a corn, usually single, occasionally multiple,  appearing  over  a
 point of pressure (first  or fifth  metatarsophalangeal  joint, etc.).
 Inflammation  and suppuration proceed  beneath  this  thickening,
 spreading first to the soft parts of the sole and  then to the bone
 itself.  Gradually a sinus forms, reaching  from the side  of the corn
 to the deeper parts involved.   Meantime  the skin in the neighbor-
 hood becomes greatly thickened, heaping  itself especially  about  the
 sinus.  The ulcer  which  eventually forms is roundish, deep, and at
 times very destructive in  its effects.
   Thus far, the lesion might be supposed  to be the result merely of
 a  greatly  irritated corn,  but  other phenomena exhibited  in these
 cases are quite inexplicable in  this  M'ay.  The nails are altered ;
 superfluous hair groM'S on the dorsal surface of the foot and the skin
 of the involved extremity; pigmentatiou,  erythema, or eczema may
 occur; and the parts become affected with  either anidrosis or hyperi-
 drosis.   These disorders  have, again, been noted  as  the result of
 spinal  injury, congelation,  posterior spinal  sclerosis,  anaesthetic
 leprosy, and, in animals, after section  of the sciatic nerve.  Among
 the most common symptoms in typical cases are anaesthesia, neuralgic
 and  rheumatic pains, hyperidrosis,  and coldness of the feet.
   The author has had the opportunity of studying this disorder in a
 group of cases which illustrate  both extremes of its symptoms.  The
 perforating ulcer occurred in the following case :
   In the centre of a dense callosity M'hich  had formed  over the right
 first   metatarso-phalangeal articulation of  a young man, there  was
 exposed  the orifice of a  sinus  which could  not  be made to close.
 The   course of the disease was  exceedingly indolent, the parts being
 the seat of little pain.   The M'eeping from the sinus was  scanty, and
 it was not  surrounded by granulations.  It was more an annoyance
 at first, than a serious disease.  Finally, by the aid of a fine probe,
 it  M'as discovered  that  the sinus  beneath  led to exposed bone.  A
 deep  incisiou  was made  at  this  point,  and  the osseous  surface
 thoroughly scraped, after  which antiseptic dressings  were applied.
 The   sinus, however, reformed  in time; and it  became finally neces-
 sary  to amputate the toe and remove by the gouge  a large portion of
 the head  of  the  corresponding metatarsal  bone.  This  operation
 proved successful in relieving  the patient.
  The case next described represents a group in M'hich typical symp-
 toms  of the disease were  marked without  a  tendency  to  ulceration.
 A  servant maid, twenty-two  years old, kept  under* observation in
 hospital  for  more  than a year, had for several years  previously as
 also  while under   treatment,  suffered  from  symmetrical  recurrent
 tylosis of the soles  of the two feet only, the  hands  being  spared.  A
 dense, thick, yellowish-gray cast of the entire sole of  each  foot Mas
regularly shed every four  months, leaving behind a soft,  tender, and 
CALLOSITAS.
377
irregularly mammillated epidermis.  Persistent maceration of the feet
for weeks  at  a time, poulticing, absolute disuse of the organs for
months, mopping with from ten to thirty per cent, solution of caustic
potash,  applications of Hebra's diachylon  salve, mercurial  and tar
ointments, were all futile  in preventing the recurrence of the tylosis.
After the cast of each foot M'as formed, the use of the organs Mas
almost  interdicted  in  the act  of walking, on account  of the pain
which Mas induced.
   The nail of each toe of both feet Mas roughened,  scabrous, friable,
and tilted up from  the matrix so as to approach the vertical  position.
The hands Mere the seat of a persistent hyperidrosis, being constantly
clammy and macerated with the sweat that poured from them.  The
pulse was slow, ranging from fifty to sixty beats a minute.  All other
functions of the body Merc properly performed.
   In the group of cases to M'hich  reference is made  above, there
was  always a  symmetrical involvement  of the  entire sole  or palm,
either of both feet,  or both hands and feet.  The patients M'ere young
adults.   The  palms when involved  never exhibited the translucent,
yellowish,  wash-leather-like appearance  of the same  condition of
the soles, but  rather suggested the dry,  scaly features of the palms in
certain  forms  of erythematous eczema of these parts,  but always
without  itching, and ahvays with coincident  plantar tylosis.  The
soles, however, always presented the typical appearances of callositas
throughout the entire region, the callosity reaching somewhat upward
over  the  heel, and in  some cases relatively sparing the instep.   In
some cases the nails were  not involved.   The feet were ahvays as cold
to the touch as in pernio.
   Pathology.—The disease  is, M'ithont  question, a trophoneurosis.
Histological  examination has  shown destruction of the  myelin  and
axis cylinder  of twigs of nerves  supplying the affected parts.  Ac-
cording to Messrs. Savory and  Butlin, the sensory and nutrient fibrils
of the involved  nerves degenerate  in consequence of pressure exer-
cised  upon them  by increase of the endoneurium,  the  motor fibrils
escaping, OM'ing to their  large size and thicker  medullary sheath, a
view  plainly  untenable for ail cases.
   Diagnosis.—The diagnosis is between  tuberculosis and simple cal-
lositas, a  distinction readily established by the evident neurotic phe-
nomena seen  in the so-called perforating disease of the foot.
   Treatment.—Apart from the surgical interference called for by one
class of cases, a roborant  treatment, including the  internal adminis-
tration  of iron and  arsenic, has been followed by most favorable
results.
   The Prognosis is doubtful. 
378
DISEASES OF THE  SKIN.
                             Clavus.

                          Lat. clavus, a nail.
 Clavus, or Corn, is a circumscribed callosity usually found upon the toes,
   due to epidermal hypertrophy, and provided with a conical spur of horny
   tissue beneath, which is projected into a corresponding depression in the
   corium.

   Corns  are hypertrophies of the horny layer of the epidermis,  with
 the   peculiarity  of presenting  inferiorly a  coniform  prolongation,
 which, being pressed from M'ithout inward upon the sensitive papillae
 of the  corium, excites pain in various degrees.   They vary in size
 from peas to large chestnuts, and are dense and callous when occurring
 upon  those  prominent  parts of the  foot where  the  boot, shoe,  or
 gaiter,  exercises its  greatest pressure.  When occurring  upon the
 lateral  face of a toe  in apposition with another, the corn originates
 usually from pressure through the medium of the neighboring digits.
 It is  then softer, from exposure  to greater heat and moisture.   Corns
 are often  weather-sensitive, being unusually painful before, during,
 or after the  occurrence  of storms, and should therefore not be con-
 founded  with  gouty or rheumatic deposits beloM'  the skin.   They
 are composed  of superimposed,  and  often  concentrically  arranged,
 layers of epithelium, between which  are occasionally found  minute
 haemorrhagic extravasations.  They are occasionally seeu  upon the
 palms of  the hands.
   At the  periphery of the corn the corium is  unchanged,  but at the
 point where its central cone is pressed  into the deeper structures, the
 papilla? are either atrophied or quite absent. -
   Corns  are rationally  treated  by disuse of the feet, or  the adjust-
 ment of properly fitted coverings for  the same.   They usually  fall
 spontaneously after an attack of paraplegia and in  the case where the
 lower extremities are confined for a few weeks in surgical apparatus
 for relief  of a fracture.   They may be softened by prolonged macera-
 tion  in water,  poultices, or, best "of all,  oil, as in the  treatment of
 callosities.  Erasion and excision may be practised, if demanded by
 an exigency.   Where the sufferer must necessarily continue the use
 of the foot, the simplest and best  treatment is  as follows:   The part
 is  thoroughly macerated for half an hour, with water as  hot as can
 be tolerated.   Then  the projecting callous  portion of the corn  is
gently removed by cutting or scraping, till, as   nearly as may  be, the
surface  is level with the plane of the adjacent skin.   The part  is
then dried, and the entire surface, both of the seat of  the corn  and
the adjacent  integument, is completely covered  with many narrow,
short, aud nicely adjusted  strips of Maw's moleskin plaster.  AVhen
the trifling operation  and  dressing are complete, the patient  should
bear  firm  pressure over the corn M'ithout flinching, and  walk M'ith
perfect comfort.  The plaster remains till it separates spontaneously,
 which is usually  in the course of a few days.   The corn is then macer- 
CORNU  cutaneum.
379
ated at night M'ith an oil poultice, as described above, and the dressing
afterward reapplied, usually the second time by the patient.  Persist-
ence iu this course is followed  by complete relief if the coverings of
the feet be properly fitted.  Caustics, employed by many, are usually
unnecessary when there is no ulceration of the hard corn; and are in
this situation frequent sources of great distress.   They are chiefly
valuable  in  the treatment of the soft variety; but should always be
applied with a skilled hand.
   For this purpose, the crayon of nitrate of silver or acetic acid may
be employed.   The proprietary  "corn  salves" sold  in the  shops
commonly contain  the ointment  of  the nitrate of mercury, which
also is a useful application to  the soft variety of corn.   The latter
should be protected by the interposition  of  absorbent cotton or wool
from contact with adjacent digits.
   As a rule, the ringed corn-plasters sold in the shops are inferior to
the dressing with the moleskin plaster described above, which is made
to cover  the entire corn.   Anderson recommends  the emplastrum
salicylici  for a similar purpose.


                       Cornu Cutaneum.
                          Lat. cornu, a horn.
Cornua, or cutaneous horns, are circumscribed hypertrophies of the epidermis,
     forming irregularly shaped, spur-like excrescences of different sizes.

   Cylindrical, conical, straight or  twisted, angular  and  otherwise
irregularly shaped and sized  corneous eminences, single or multiple,
are occasionally seen projecting from  the scalp, forehead, nose, lips,
ears, penis, aud extremities.  They are named from their resemblance
to the similar appendages in horned cattle, but widely differ from  the
 latter, which are ahvays  implanted upon osseous tissue.   They are
formed of dense and massed columns of epithelia, often resting upon
somewhat prolonged papillae.   Occasionally, on section, they exhibit
the concentric arrangement of the epithelia  seen in  corns, but, unlike
the latter, have reentrant basal depressions into which  the papillae
below penetrate.   At  times  they are implanted in a dilated follicle,
 in M'hich case the glandular elements participate in their formation.
 At times, also, they represent a corneous transformation of the epi-
 thelia M'hich  constitute warts..  They are seen  in all colors, but  are
often betM'een  a  yelloM'ish-brown and  a  brownish-black, M'ith  a
 fissured   or M'rinkled or  longitudinally grooved exterior, like  rough
 bark.  They  may  be  painless, or, like  the other keratoses, become
 the seat of inflammation in various grades.   They may be short or
 several inches  in  length.   The  largest  specimen  ever under  the
author's  observation Mas  seen by  him in France, on the forehead of  a
 man, M'here  it had  existed for  fifteen years.   It  measured  three
inches in length.   A few cases have been recorded in Chicago.   They
 may be shed spontaneously, never to  return  or shortly to reappear.
They occasionally develop into epitheliomata, as has  occurred once 
380               DISEASES OF THE  SKIN.

under the author's observation, in a gentleman over sixty years of
age, whose epithelioma developed from a horn on the dorsum of the
right haud, projecting about three-fourths of an  inch.

                                       Fig. 44.
Varieties of cutaneous horns.
   At the  meeting of the American Association of Genito-Urinary
Surgeons in 1887, Dr. Brinton, of Philadelphia, exhibited an ante-
riorly curved horn one and seven-eighths  of an inch long and three-
eighths of an inch in circumference, removed by him from the glans
penis of an elderly patient, no  member present having then seen a
similar growth in that locality.  Only fourteen cases are on record
of a similar growth in this situation.
   In a horn growing from the lower lip of an elderly man exhibited
at the author's clinic in  1886,  the growth Mas longitudinally fur-
rowed, and also at somewhat regular intervals transversely furrowed
presenting then the appearance of the joints of the sugar-cane. 
VERRUCA.
381
  Pathologically, these hypertrophies are first developed either M'ithin
a closed atheromatous  cyst, or from remarkably  elongated  papillae
of the corium.   They are made up of cornified and hypertrophied
epidermal cells.
  Horns  may be removed by extirpation, after M'hich the surface
upon  which they were implanted  should be carefully aud completely
cauterized.

                            Verruca.
                    Lat. verruca,  an excrescence.
Verruca, or Warts, are pin-head to bean-sized and larger, soft or hard, cir-
  cumscribed elevations due to hypertrophy of both the epidermis and papillse
  of the skin.

   Warts are cutaneous excrescences; sessile or pedunculated; pointed
or flat; smooth, rugous, or having a cauliflower  appearance;  pig-
mented in various shades, or  of  the natural color of the skin;  con-
genital or developing after birth.   They may be single or multiple,
aud occur upon  the  hands, feet, face, scalp, neck, genitals, and  other
parts of the body.   They may develop slowly or rapidly, and per-
sist for vears, or disappear without apparent cause.   They may be
soft, dense, or even corneous to the touch.
   The  several  names  given  to the 'various  forms of  warts  have
chiefly a descriptive value.

   Verruca Acuminata (condyloma) is a filiform, papilliform, or
cock's-coinb-like vegetation.   They are single or multiple;  at times
hundreds coexist upon the genitalia, and  neighboring regions.    In
size they  vary from  a pin's point to a hen's egg, and  may be larger.
They are  apt to be moist and secreting, being frequently covered with
a puriform mucus of exceedingly nauseating odor.    Upon the  geni-
tals, they are encountered upon  the glans, around the fraenum, and
 over  the  prepuce of men ; aud  in  women, about  the clitoris, labia,
 vagina, and anus.   They are  usually of a bright red  color in  these
 situations.  When occurring upou  the integument, they are firmer,
 drier, and exhibit a feebler  tendency to  luxuriant vegetation.  In
 this  form they  may be  recognized  about  the  axillary regions, the
 umbilicus, the interdigital spaces of the feet, and even the face.   Dr.
 Heitzmann once informed the author that  he had seen them covering
 the side of the chin.

   Verruca Congenita and Verruca Acquisita are terms  used
 to designate the lesions discovered at birth or later.

   Verruca  Filiformis.—This variety of wart  differs  somewhat
 from the  others, not onlv pathologically, as is noted below, but  in its
 clinical features.    They are slender, thread-like, often pedunculated
 masses, usually  covered with a smooth and apparently unaltered epi- 
382
DISEASES  OF  THE SKIN.
dermis, occurring upon the neck, eyelids, chest, and ears of women.
Kaposi concludes that they represent minute fibromata.1

   Verruca Glabra is distinguished by its smooth surface.

   A7erruca Plana is the flattened or globoid, smooth or rugous
formation like a plaque or button, usually pigmented, and occurring
upon the back.

   Verruca Senilis vel Plana.—These are bean- to coin-sized,"
smooth, and softish  growths developed  upon the  face,  trunk, and
extremities of persons of advanced years.  They  are flat, u.sually
pigmented, and have a granular aspect.  They are readily separable
by the finger-nail, and are then found to rest upon a reddish granular
base.  As  the result of external  injury (caustics, traumatism) they
may become the starting-point of an epithelioma.

   Verruca Vulgaris  is  the form most frequently seen upon  the
fingers  and hands,  as pin-head  to pea-sized, usually  discolored,
papilliform excrescences.

   Of  the  several varieties of warts it may be said, in general, that
they are most frequently observed either  on the hands  or over  the
genital region;  that they are  usually discrete but  may be confluent
aud form palm-sized and larger elevated plaques;  that they may be
soft, hard, smooth, rough, pointed, flat, brush-like,  or  like the comb
of a  cock; that  they may vary from  a pinkish to a  blackish hue;
that they may persist, occur in crops,  or spontaneously disappear ;
and may grow with great rapidity [Verruca  Acuminata] to a large
size and involve any portion of the body.
   Dr. Fox, of New York,  has figured  an interesting case in which
warts occurred in lines tattooed on the skin of a young man.
   Etiology.—The causes of warts are unknown ; but in early  child-
hood, a period in which they are most frequently  encountered, it  is
reasonable to conclude that they result from external  contacts.   It is
when the child  begins to handle  everything  within reach, that they
usually first appear, and then  about the hands.  The acuminate or
condylomatous warts are chiefly induced in  parts moistened M'ith a
blennorrhagic secretion, but unquestionably may originate from con-
tact with  the leucorrhceal  or  pathological, non-venereal discharges
from the female genitals.   They are rarely seen in virgins of  either
sex.   The senile warts are more probably due to obscure changes in
the nutrition of the  integument.
   Pathology.—Warts on section exhibit, microscopically, an  hyper-
trophy of the papillary layer of the corium concerned in their growth,
with corresponding  development of the vascular  loops rising from
the  superior vascular plexus of the corium.   Above these papillse
the rete is usually largely developed, the epithelia being multiplied
not only on the sides of  the prolonged papillse, but immediately over
1 See Dr. Taylor's observations as epitomized in the chapter on Fibroma. 
                             VERRUCA.                         383

their apices.  In all  the  dry varieties  the stratum  corneum  is also
hypertrophied,  but  this  more especially over  the  summit  of the
excrescence.  The filiform warts  are composed  chiefly of a slender
fasciculus  of connective  tissue springing from the  bundles  below,

                                Fio. 45.
     Vertical section of the summit of a pointed wart,  a, papilla containing vascular loop;
              c, stratum corneum ; d, hypertrophied rete.  (After Kaposi.)

enclosing a vascular loop and covered M'ith an epidermis which is not
apparently altered.   Beneath all forms of Marts there may be a sub-
stratum of sclerosed connective tissue, constituting the firm base upon
which  they rest.
  The diagnosis  of warts  is  usuallv  readily made, but  great  care 
384                DISEASES  OF  THE  SKIN.
 must be had to distinguish the moist variety from syphilitic condylo-
 mata.   In the  latter  there  is usually a history of contagion  M'ith
 other syphilodermata  upon the surface,  such as  mucous  patches,
 palmar  lesions, or  papules  of the  face.   Fibroma, or  molluscum
 fibrosum, generally occurs in tumors of greater number,  firmer con-
 sistence,  and  larger  size.   The  tumor  of  molluscum  epitheliale
 greatly resembles  a  M'art, but the waxy-M'hitish appearance of the
 lesion and its dark punctum at one  point  or another,  sufficiently
 distinguish it.
   Treatment.—AVarts may be removed by excision, erasion, or caustics
 (nitrate  of silver, alkalies, acids, perchloride of iron, corrosive sub-
 limate, etc.).   The larger growths upon the genitalia are often highly
 vascular, and may demand  the prior application of a ligature when
 they  are peduuculated.   Even the  slender filiform  M'arts  will  be
 found to contain a small vessel in the pedicle which requires cauteri-
 zation after the excision.   When the warts cannot be  more readily
 removed  by the knife or curved scissors, the  Paquelin  cautery may
 be used.  The blackened eschar which is  left prevents hemorrhage,
 serves as the best subsequent dressing, aud  is  less apt to be followed
 by a return of the growth.   In some cases, it  is a  useful  expedient
 to transfix the lesion in several directions with the long needles used
 iu gynecological practice, previously  dipped iu a fifty per cent, solu-
 tion of chromic acid.
  By far the simplest and most elegant method of removal, however,
 is to transfix the  base  of the wart a sufficient  number of  times with
 a needle connected with  the  negative pole of a galvanic battery, the
 positive being connected  with the body of the patient by the aid of
 a moist sponge.
  The formula, according to which are made several of the proprie-
 tary  " wart cures" sold in the shops,  is as follows :

         R. Acid, salicylic.              3ss;           2
           Cannabis indie, extr.       grs. v;             33
           Collodion                   3ss;           16      M.
        Sig. To be painted over the wart with a camel's-hair brush.

  For patches of  warts, Van  Harlingen recommends attacking one
part at a time cautiously with the following paste :

        R. Pulv. acid, arseniosi        gr. vj ;             |40
           Ungt. hydrarg.   )      aa  q. s. ad
Emplast. hydrarg. j           3ij ;
M.
   For warts not requiring operative removal, local treatment often
answ.ers  well.  Those about  the genital  region often disappear if
persistently washed with a solution of tannin in alcohol, one drachm
(4.)  to three  ounces (96.), after  which  they are  dried and  thor-
oughly dusted with  boric or  salicylic  acid  with lycopodium;  or
burnt alum and rosin; or,  what is most popular, dry calomel.  Alum
and lead lotions may also  be substituted  for the tauniii and  alcohol
and for a time kept over the parts as a compress. 
VERRUCA.
385
  Prognosis.—Warts are benignant growths; and  in childhood and
early adult life need not suggest grave sequelae.  It is far different
in advanced  years, for, though  these excrescences  possess even then
no  malignant  character, they  are  the  too frequent precursors  of
epithelioma.   While it may be  urged justly that the early lesions in
such cases M'ere really epitheliomatous  and not verrucous; the fact
remains that many warty formations of  apparently benign character
do in advanced years, especially  under the teasing of frequent cauteri-
zation, undergo a cancerous transformation.

  Multiple  Cutaneous  Tumor  Accompanied by Intense
Pruritus.—Under this  title Dr.  AV. A.  Hardaway,1 of St.  Louis,
describes  a rare  disorder characterized  by the occurrence of about
sixty pea- to nut-sized, dense  tubercles and  tumors covered by a
thickened, scaly, and  excoriated, often hsemorrhagic skin.  In some
situations coalescence had occurred, forming thus  long  aud narrow
plaques of nearly the width and  half the length of the  finger of  an
adult.   The  lesions were seen  upon the  outer aspects of the arms
aud legs, the palms and  soles,  the  sides of the fingers,  and around
the ankles, wrists, and elbows.  The accompanying pruritus was
intense and  intolerable;  and,  having lasted for  twenty-two  years,
was naturally associated  with  the degree of pigmentation  often
observed  under similar conditions.  The patient was an unmarried
woman, fifty-one  years  of age,  and declared  that the  lesions first
appeared  as " blisters."
  Specimens of these tumors, examined by Dr.  Heitzmann micro-
scopically, exhibited hyperplasia  of the epithelial  and connective
tissues.   The papillse were longitudinally elongated, branching, and
provided  with narrow capillaries.   Numerous  nests, greatly varying
in  size,  aud  containing  inflammatory  elements  M'ith considerably
enlarged  bloodvessels, lay close  beneath  the papillary layer of the
corium.   These  elements showed  all stages of transition into basic
substance.  The deeper layers  of the derma were built up  of very
coarse bundles of  connective tissue  and numerous elastic fibres.

  Papilloma.—This  term has been  loosely applied  to  a large
numberof cutaneous growths widely differing  from each other, both
histologically and clinically.   It   has  been  made  to  include the
vegetations of syphilis, the neoplasms of nsevus, and even the tuber-
cles of lupus.
  The designation, papilloma, is properly limited  here  to such  cir-
cumscribed hypertrophies of portions of the skin as correspond with
warts  in  their pathological significance.    They may be defined  as
excrescences from  the cutaneous surface,  of a size considerably  larger
than all  the varieties of  the wart with the exception of the condy-
loma, usually presenting  a luxuriant vegetation composed of elon-
gated  papillse, bloodvessels,  and enlarged rete, covered externally
with a smooth epidermis like a pellicle, or, more commonly, branched

                     1 Arch, of Derm., April, 1880, p. 129.
                                 25 
386
DISEASES  of  the  skin
and tufted with the cauliflower aspect, and then usually covered M'ith
a  puriform mucus.    The  tumor  increases rapidly till it attains a
maximum size, and then  indolently persists.   It is benign in char-
acter, and bears no relation to struma, carcinoma, syphilis, or lupus.
It may occur upon any portion of the body.  The cases observed by
the author all occurred in women who were either pregnant or at the
period of the menopause.

                    Verruca Necrogenica.
Verruca Necrogenica is a vesiculo-pustular or wart-like lesion situated usually
  on the hands, resulting from contact with the bodies of the dead, which
  may induce grave constitutional symptoms.
   This lesion, also known as the " Post-mortem Tubercle,"  " Dis-
section Tubercle," or "Anatomical Tubercle," was first named
by Wilks,1 verruca necrogenica.   It commonly occurs ou the fingers
of those engaged in the habitual handling or dissection of cadavers,
and is  said to result both  from such habitual contacts, and also from
dissection wounds.  Cases are reported M'here  the  lesion has  had  a
non-cadaveric origin.    It begins at the site  of  an abrasion or wound
as a vesico-pustule, with  deep-seated  base  and reddish or reddish-
purple areola.    This is productive of a burning,  smarting, or pru-
ritic sensation.   The lesion  accomplishes a period of bursting and
crusting, which may be followed by complete involution.   But when
the typical so-called "anatomical tubercle" forms, the tissue becomes
indurated and horny, and a pigmented verrucous papule or tubercle
very slowly forms, which  may become fissured at one or more points.
                       The characteristic  lesion  is the thickened,
                       indolent, more or  less pigmented and fis-
                       sured, split-pea to beau-sized wart, usually
                       single, found on the finger of the  auatomist.
                         In other  cases,  grave  symptoms  result
                       either in the  involvement of the deeper tis-
                       sues (subcutaneous,  thecal, tendinous, peri-
                       osteal), or  in the  production of erysipelas,
                       pyaemia, septicaemia, or gangrene.  Surgeons
                       divide these  cases  into mild and acute va-
                       rieties, according to the symptoms exhibited.
                       The records  of the  medical profession in
                       almost every one of the larger cities of this
                       country contain the names  of one or more of
                       its eminent representatives whose lives have
                       been sacrificed in this manner.
                         It is probable that some one or more of
                       the  ptomaines, described  on a  preceding
                       page, may be  responsible  for some  of the
                       results here mentioned.
                         Out of  more  than  fifty-eight thousand
cases of cutaneous diseases  collected  by  the  statistical  committee
Fig. 46.
Verruca Necrogenica.  Model
    Guy's Mus. 19350.
Guy's Hospital Bep., 3d series, vol. viii., p. 263. 
N^IVUS PIGMENTOSUS.
387
of the American Dermatological Association, but one instance M'as
reported of verruca necrogenica.   This  does not, however,  exactly
represent the frequency or, better, the iufrequency of the lesion, since
the majority of all  such accidents occur in the persons of anatomists
and surgeons, who destroy their lesions themselves without consulting
others on the subject.
   The treatment of verruca necrogenica is  destruction of the lesion
M'ith acid nitrate of mercury, nitric acid, or caustic potassa.
   The prognosis is not necessarily grave.

                     Nsevus  Pigmentosus.
                         Lat. naevus, a mask.
Nsevus Pigmentosus is a congenital, circumscribed pigmentation of the skin,
  in single  or multiple  deposits, either with  or without textural cutaneous
  change, or associated  with the development of warts, plaques, tumors, or
  pilary hypertrophy.

   Abnormal congenital pigmentations of the skin vary in color from
a  light yellow or  chocolate-brown  to  a blackish hue, and  may be
single, or multiple  and very numerous.   They are commonly termed
Pigmentary Moles.  They vary in size from a pin-head to tumors
of considerable volume; and are either ovoid or circular in  contour,
or so irregularly shaped as to present a fanciful  resemblance to parts
of the figures of  the lower animals, whence the  popular belief as  to
their origin in maternal impressions.  They occur in both sexes; and
upon the  face, neck, trunk, thighs, buttocks,  and external  genitals.
The term N.evus Spilus is applied to  those which occur in a smooth
and otherwise unaltered skin ; N.evus Verrucosus, to those which
are irregular and M'art-like;  N.evus Pilosus, to those surmounted
by a growth of shorter or longer,  stiff or downy, dark-colored hairs;
and N.evus Molluscifoumis, or Lipomatodes, to the soft or firm,
more or less elevated and projecting tumors.
   They may be, M'hen multiple, symmetrically or asymmetrically
developed  upon the  surface  of  the body; and in either case  may
exhibit in  their arrangement the controlling effect  of the nervous
system.  In a  case reported  by myself1 there were multiple mono-
lateral pigmentary  nsevi distributed over the left side of the trunk in
the course  of the intercostal nerves, and in such a manner as strongly
to suggest  to the  eye their correspondence  in  site with  the lesions
of zoster  of the same region.  De Amicis2 had previously reported
a somewhat similar case.
   The course of pigmentary nsevi, after obtaining their full evolution,
is to persist unchanged for a lifetime.   Their increase in tender years
is occasionally characterized by a relative rapidity.  The author has
seen a pilarv naevus upon the cheek of an infant extend over nearly
double its original  area in the course of tMO years.
1 Chicago Med. Journ. and Exam., October, 1877.        2 Lo Sperimentale, March, 1876. 
388
DISEASES  OF  THE  SKIN.
    The lesions of this sort seem to occur with equal frequency  in  the
 two sexes.   It is possible that they may  be acquired after  birth, as
 claimed by some authors, but it is  much more probable that such
 presumably acquired cases Mere  instances  of rapid development from
 minute congenital pigmentary moles.
    A case of unusually large congenital nsevus lipomatodes associated
 with multiple pigmentary nsevi of several forms occurring in a child,
 was observed by the author in  1883, the report of the case made
 subsequently being illustrated by a chromo-lithograph.1  (See frontis-
 piece.)
    Pathology.—Anatomically, pigmentary moles are readily separable
 into two classes: first, those in which the  pigment only of the skin
 undergoes hypertrophy (nsevus spilus); second,  those in M'hich both
 epidermis and corium are hypertrophied,  forming verrucous, pilous,
 mollusciform, and other lesions.   The distinction made by V. Biiren-
 sprung, Gerhardt, and others, between these two classes and still a
 third, M'here the lesions are limited to the cutaneous regions supplied
 by one or several nerves (Naevus Unius Lateris, Papilloma Neuropath-
 icum) is more apparent than real: for a close study reveals a tropho-
 neurotic influence exerted in all  cases, even  in the enormous tumors
 of a  mollusciform  type.  According to Demieville,  the  pigment
 accumulation occurs in the corium as well as in the epidermis, in the
 form of ribands stretching along the  lines  of the bloodvessels.
   Pigmentary moles  very  rarely disappear spontaneously.   Their
 removal may be accomplished  by excision, or  by destruction with
 caustics, M'ith the Paquelin  knife, or with the needle by electrolysis.
 The last-named  method  is applicable  only  to the smaller and more
 superficial growths of this class.   Fox2 calls attention, in connection
 with  this subject, to the need of passing the needle no deeper than
 the epidermis, sufficiently deep merely to " blister the surface of  the
 black spot."

                            Xerosis.

                           Gr. typos,  dry.

 Xerosis is a congenital dryness and roughness of  the epidermis accompanied
            by a moderate degree of furfuraceous exfoliation.

   Xerosis,  also termed  Xeroderma,  is  a  term which has been
 applied to the disease sometimes  known as xeroderma pigmentosum,
 or the melanosis lenticularis progressiva of Pick.   In these pages that
 disorder  is  described, in  accordance  with the  nomenclature*5 of  the
 American Dermatological Association,  as  angioma pigmentosum  et
 atrophicum.
   The term xerosis, or xeroderma, has also been employed to designate
a simple asteatosis.   It is also used by some authors as practically
equivalent to ichthyosis.   It is sought "here to limit its application to
1 Journ. of Cutan. and Vener Diseases, July, 1885.
* Electricity in Removal of Superfluous Hairs, etc., Detroit, 1886. 
XEROSIS.
389
the description of a distinct and easily distinguished morbid condition
of the integument.
   Symptoms.—The sole  symptoms  found in  xerosis are cutaneous.
The skin of the body, in some regions more than others but at times
universally, is to the touch of another, dry, harsh, rough, and desti-
tute of natural moisture and unguent.   Closely inspected, the  surface
is seen to be scaly, the exfoliation being of the character described as
furfuraceous.   In some cases the hand passed briskly over the surface
of such a skin will cause a moderate separation of a few of the scales
in a scanty shower; in yet others, while the surface seems quite fit
for the furnishing of such free flakes of epidermis, one is surprised to
note that the  free flakes are more or less attached, and the clothing of
the patient is not, as in some forms of psoriasic and pityriasic disease,
covered  with  epidermal scales.   In brief, there is  not  in progress  a
catarrh of the horny layer, as in some of the other disorders named;
but merely an unusual keratinic transformation  of the elements of
that layer.
   The parts  chiefly involved  are the  extremites, more  particularly
the hands, feet, forearms, and legs; but all parts of the skin may be
involved, including the face, temples, cheeks, and even the lips.
   The disorder is met with  in  all grades, from the mildest  physio-
logical dryness of the skin, almost suggestive of the so-called "goose-
flesh," to that state in which the exhibition of the face only, suggests
an abnormal condition of the skin.  The color of  the latter iu Mell-
marked cases  is always of a  dirty yellowish or dirty brownish shade,
suggesting the unwashed  condition of the integument, and in extreme
cases of  older patients becomes rather deeply pigmented.  It is seen
in both sexes  and at all ages, being a congenital condition whose first
appearance is  only clearly indicated after variable periods of time after
birth.   Red-haired individuals perhaps  furnish the larger number
of well-marked  cases.   The general health is uuaffected.   Before
puberty  the affection, in  northern latitudes, will  often  be  inappre-
ciable  in summer, and distinct in winter.  As maturity is  reached,
however, the condition becomes more or less permanent.
  This disorder  may be,  as described by some authors, a variety of
ichthyosis simplex, but the following are excellent  reasons for  giving
it a separate consideration :
   1. The  disease does  not furnish the typical  plate-like  scales of
ichthyosis.
  2. One child affected  M'ith  what appears at first to be merely
xerosis, may exhibit a typical ichthyosis  before puberty, M'hile an-
other will go through  life,  the xerosis of his childhood  becoming
simply the exaggerated xerosis of mature  years, but never an ich-
thyosis.
  Xeroderma may therefore  be regarded in one sense as a variety of
ichthyosis, but cannot be described as a stage of the latter disease.
  The disorder  is congenital, and may be inherited from  parents.
It is readily distinguished from all furfuraceous scaling diseases of 
390
DISEASES  OF  THE  SKIN.
the skin by the absence of inflammation.   The treatment and  prog-
nosis are those of the disease next considered.

                          Ichthyosis.
                          Gr. lipdv^, a fish.
Ichthyosis is a congenital  deformity of the skin, developed first in early
  infancy, and manifested in a general scaliness, in the formation of regularly
  outlined polygonal plates, or in the growth of larger masses of a corneous
  consistency.
  Symptoms.—The disorder, also  termed the "Fish-skin Disease"
and  "Xeroderma,"  is one which  displays  a  wide  variation in its
symptoms.  To the extremes in either direction two names are given,
ichthyosis simplex and ichthyosis hystrix.

  Ichthyosis Simplex.—The  earliest and mildest form of ichthy-
osis simplex is, by many authors, held to be the condition of xerosis,
fully  described  in the preceding  pages.   It  will be remembered,
however, that  such a  xerosis may persist through  life without  the
production at  any time  of the peculiar symptoms of the ichthyotic
skin.   In these earlier manifestations of the disease then, the skin of
the patient can merely be described as unusually harsh to the touch,
moistureless, and covered with adherent or exfoliating, fine  scales.
The latter are not massed, imbricated, nor displayed in plaques, and
are usually of a dull yellowish-white color.  It is rare that the prac-
titioner is consulted for the relief  of this disorder; it is usually discov-
ered M'hen the skin is exposed for other purposes (exploration, vac-
cination,  etc.).  In  a still more  advanced degree,  the  scales  are
massed together, forming grayish and whitish, polyhedral elevations
or  plaques, regularly outlined  and closely set together, especially
upon the extremities and certain  portions  of the trunk.   Elsewhere
the scaliness  described  above may be present  in  a more marked
degree.   Variations  occur, in  consequence  of which the plaques,
bordered distinctly by the natural  lines and furrows of the skin, are
even depressed, centrally or  completely, or assume darker shades of
color than those described, brownish and greenish-broM'n.

  Ichthyosis Hystrix.—With and M'ithout the symptoms detailed
above, the hypertrophy of the skin may, in circumscribed patches or
larger areas, produce  irregularly shaped, verrucous, corneous, corru-
gated, M'rinkled, or rugous masses,  usually much darker in color than
the patches seen in the simple variety  of the disease, and more often
also discovered in adult  years.   The  resemblance is here rather to
the rough bark of a tree than to the scales of a  fish.  In other still
rarer cases, the excrescences assume a spinous, acuminate,  or horn-
shaped form.   The hand passed over the surface perceives not only
the excessive roughness,  but also the dryness of the skin.  Perspira-
tion is imperceptible  in the  parts affected.   The  nails are friable
and indurated; the scalp scaly, aud covered with hairs of exceeding 
ICHTHYOSIS.
391
harshness.   The palms and soles are often spared   Kaposi described
certain diffuse callosities occurring in the palmar and  plantar regions
differing from the ichthyotic patches elsewhere.   The face is usually
spared,  but, when involved, only the slighter manifestations of the
disease  appear there, minute, superficial, scaly patches  of a grayish
tint.

   Ichthyosis  is accompanied by  insignificant subjective sensations.
The skin,  indeed, of these patients  seems  inapt for  the eczematous
and other complications of the less  diffuse  keratoses.   The  author
has treated four ichthyotic patients for syphilis, and noticed in all  a
decided tendency to the production of lesions  of the  mucous surface
M'ithout cutaueous efflorescence.   The extensor  are usually more
implicated  than the flexor surfaces of the extremities.
   Singular variations from the types described  above are  noted by
observers.   Hilbert,1  for example, in a case of congenital circum-
scribed  ichthyosis in  a young woman, discovered a growth of thick
hairs over  the left shoulder and arm, one centimetre long.   AVeisse2
exhibited to the New York  Dermatological Society a boy, ten years
old, M'ith hsemorrhagic fissures in an ichthyotic skin, double ectropion,
corneous opacities, claw-like fingers, attachment of the ears to the
sides  of the  head, and  a generalized condition of the  skin, M'hich
became very red when warm, some  doubt,  however, existing as to
the diagnosis.
   The most exaggerated types of ichthyosis are seen  in the so-called
"Porcupine," " Phinosceros," or "Hedge-hog"  patients.   In these
unfortunate beings, the entire  skin is converted  into a  rugged,
bristling, Marty, quilled, or horn-like envelope, suggesting the integu-
ment of the  animals  named.  Such conditions are  represented by
Air. Henry Baker's case, described by Anderson.
   The terms, Ichthyosis Serpentina, Nacrea, Nigricans, are employed
to designate  those conditions respectively in  M'hich is  recognized  a
snake-like  appearance of the  skin, silvery whiteness of  the  scales, or
a dark pigmentation.
   Viewing the  disorder as thus in various  Mays  exhibited, it is seen
to be a congenital deformity rather than a disease.   It  may be par-
tial or general, though usually the  latter, M'ith intense manifestations
over  the extremities, especially  over  their  extensor  aspects, and
relative immunity of  the face, axilla?, groins, flexor aspects of the
limbs, the palms and soles,  the glans penis, and prepuce.
   Like xerosis, the deformity is rarely visible at birth, but usually
becomes apparent before the completion of  the first year of life.   It
is  first manifested iu the region of election named above—i. e., over
the elbows and knees—and here also, as in xerosis, may be for some
years only apparent in  this latitude  in winter,  disappearing  almost
wholly in the  summer season.   In maturity, the deformity has been
knoM'ii  to  disappear also temporarily under the influence  of inter-

 1  Virchow's Archiv, Bd. 99, Sept. 3, 1884.       2 Journ. of Cutan. and Veil. Dis., 188M, p. 49. 
392
DISEASES  OF  THE  SKIN.
current disease (variola).  One patient is said  to have regularly cast
a slough of his integument in the autumn.
  The general health is usually unimpaired.

  Ichthyosis Congenita.—This exceedingly rare deformity occurs
as an  intra-uterine modification of the skin of the foetus, which  is
usually brought into the world as a  non-viable monstrosity.   The
skin is represented  by a thick, horny cuirass, deeply furrowed, and
resembling  plates of armor.   The ears, lids,  and  lips are  usually
wanting, and replaced by corneous folds suggesting  in appearance
the  corresponding features  of a mummy.    The  fingers and  toes
resemble talons and claws.   Death usually occurs in the course of a
few  days  from  both inability to secure  nutrition by the act of
sucking, and  by imperfect  development of other organs  than the
skin.

  Etiology.—Ichthyosis is unquestionably a congenital disease, though
its first manifestations are only apparent  during the second year of
life.    It is  said  to be  generally hereditary, but this should be
accepted M'ith some reserve for every individual case.   One of my
ichthyotic patients was married to his own cousin, and  had by her
five  children  entirely free  from  cutaneous disease.   None of his
parents or  grandparents was  similarly affected.  The  disease occurs
equally in  both sexes, and is  liable  to aggravation in cold climates
aud  the season of winter.   The general vigor and development of
patients  thus deformed  are,  as a rule,  quite  unimpaired.   Kaposi
says :  " The cause appears to be a local auomaly of the nutrition of
the  skin, especially involving its epidermic and fatty elements;" but
this  scarcely meets the requirements of etiology.
  Thost1 describes ichthyosis  occurring  in four generations.   Ac-
cording  to the  ascertained  genealogy, the ancestor first known to
have suffered from this affection had five male children who inherited
it, while one girl and one boy were  spared.    One of  these diseased
children had himself five children, of whom three males showed the
disease, while one boy and one girl remained free.  Another brother,
of the second generation, had  five male and  three  female children;
of these, four boys and two girls became affected.   One of the latter
(of the third generation) bore four children, of whom three girls
inherited the disease, while the fourth, a boy, escaped.   It appeared
that the affection  always showed itself within a  few Meeks after
birth,  in the  form of a roughness of the palmar and plantar sur-
faces.    With the groM'th of the patient,  the condition constantly
increased in severity, the epidermis shedding in large shreds until
the disease reached its maximum by the fourteenth year.  There was
a marked  disposition to  excessive SM'eating, particularly in the dis-
eased localities; the sensibility of the skin remained normal.  Micro-
scopic examination showed, in addition to the  hypertrophied  papillae,

              1 Inaug. Diss. Heidelberg, 1880; Cbl. f. Chir., No. 10, 1881. 
                           ichthyosis.                        393

great development of the  sweat" glands, with marked thickening of
the ducts.   Treatment failed to give more than partial relief.
   In the Molucca Islands and  some other isolated regions, ichthyosis,
on account  of its  unusual prevalence,  has been  regarded  as  an
endemic affection.  But instances of this kind are readily explained,
without referring to climatic influence, by  the operation  of the laws
of heredity with  intermarriages.

                               Fio. 47.
 Ichthyosis hystrix, vertical section; a, masses developed from the stratum corneum ; 6, cones formed
by the rete ; c, hypertrophied papillse with dilated vessels; d, dense connective tissue of corium,
exhibiting numerous vessels transversely divided. (After Kaposi.)
  Pathology.—The  diseased,  or,  better, deformed,  skin is  found
microscopically to  be hypertrophied in  various  degrees according to
the development of the  malady,  the  proliferation  of its  elements
occurring in connective tissue, papillae,  stratum corneum, and blood-
vessels.   In well-marked cases  of ichthyosis  hystrix, the elongated
papillae are surmounted  by dense cones  of the horny layer of the
epidermis, more or less concentrically disposed,  M'ith  sclerosis of the
connective  tissue,  and  a  relatively  unchanged  rete.   In  this  last
particular, the dense plaque of ichthyosis differs in texture from the
M-art.
  The polygonal ichthyotic plates  are composed for  the most part oi 
394
DISEASES  OF THE  SKIN.
corneous epidermal cells, their long axes parallel with the surface  of
the skin, with an unusual  accumulation of pigment granules between
the strata.   The interpapillary cones are enlarged;  the horny layer
greatly thickened, the hair-follicles indurated, the papillae elongated
but not branching,  and their bloodvessels dilated.    The sebaceous
glands are frequently converted  into cyst-like bodies, the coil-glands
distended,  and the panniculus adiposus diminished in size.
   Diagnosis.—Ichthyosis  not only  presents  features which are  so
characteristic as to be unmistakable, but also those which can be well-
nigh perfectly portrayed in plates.   In this respect it differs from a
long list of cutaneous maladies.1
   AVhenever necessary, aid of au important character can be gained
in the history of the disease and in the entire absence of the lesions
and lesion-sequelse, exhibited in the exudative and scaling affections
heretofore  considered.   The  most conspicuous characteristic of ich-
thyosis, as distinguished from psoriasis, lichen ruber, and pityriasis,
is the absence of inflammatory phenomena.
   Treatment.—The younger the patient applying for relief, the larger
are the chances  of improvement and possible recovery.  Ichthyosis
hystrix of  mature years is practically incurable.  Internal treatment is
valueless.   External treatment is directed to softening, macerating, or
anointing the skin, and, as far as practicable, preserving  it in a softer
state.   This is  accomplished by frequent  baths, alkaline, vaporous,
or combined with the use of soap or green soap, and generally fol-
lowed by an anointing  with vaseline, dilute glycerine, or lard.   The
French, after the removal of the denser layers of the horny plates by
the aid  of soft soap and Mater, anoint the body by friction  with the
glycerolate of starch. Almond, cod-liver, neat's-foot and linseed oils,
or lanoline may be used after the bath.  Only by the most assiduous
perseverance is a desirable result obtained  and permanently secured.
In the severer hystrix varieties, the  most  annoying projections and
rugosities   may be removed  by excision, the Paquelin knife, or, less
preferably, by the aid of caustics.
   Subcutaneous injections of one-third of a  grain  (0.022)  of pilo-
carpine have been practised in ichthyosis, in order to induce sweating,
with a view to the maceration of the skin.  Van  Harlingen recom-
mends the  following for use when the epidermis begins to shed  after
the external application of soft soap:
R. Potass, iodid.                 £)j ;            1
   01. pedis bubuli)         .. -             ,.
   Adipis        }         aa3ss=           16
   Glycerin.                    3j;            4
33
M.
  Anderson  recommends  the M'earing  of pure  vulcanized  India-
rubber garments, a method of treatment M'hich the author has found
too exhausting for all cases.
  Taking a general  survey of the therapeutical management of ich-
 i The admirable representation of the ichthyotic skin in plate F, of Duhring's Atlas, is faithful i:
its exactness. 
ONYCHAUXIS.
395
thyosis  and its results, the course  to be advised for the majority of
patieuts is very clear.   AYith but few exceptions1 the subjects of  this
deformity are either entirely relieved, or greatly better in hot weather
and  moist atmospheres.   Under  these  circumstances, and having
regard to the essential fact that the deformity is life-long in duration,
patients should ahvays, M'hen  practicable, select for permanent resi-
dence a climate most conducive to the comfort of the skin.   There
is no step which the ichthyotic patient can take at all comparable in
value with the important selection  of a suitable environment.
  Prognosis.—Having in view the facts set forth above, it M'ill be
clear that in no case can a favorable result be anticipated with respect
to a  "cure" of the deformity.   Treatment, persistent, prolonged,  and
properly directed  in connection with suitable climatic influences may
do much  to improve  the condition  of the skin.

                          Onychauxis.

                    Gr. bw$, a nail; av^su, to grow.
Onychauxis, or Hypertrophy, of  the nails is an abnormal  development of
              these appendages of the skin in any diameter.
  Symptoms.—The  nail  substance may be developed  to an unusual
extent either as an idiopathic  or symptomatic affection, and in each
case may be simply increased in volume, extent, or number, or
exhibit such  increase in connection M'ith secondary changes.  Thus
the  nail  may develop  to  an extraordinary  length or  breadth, pre-
serving its general character as regards texture, color, and  position;
or it may also be changed in any  particular, becoming opaque,  dis-
colored, dirty yellowish, and blackish or brownish; rugous, furrowed,
horny, and  rigid; thickened in one part and  thin, vitreous, and ex-
tremely fragile in another;  tilted to one side or another on  its bed;
or projected  backward in recurved, irregular lines.   Finally,  the
matrix may be inflamed, suppurating, hemorrhagic, and  the seat of
an excruciating pain.   One or more of the nails may be affected; in
some cases the entire twenty are similarly involved.
  The diseases in M'hich these changes occur as symptomatic lesions
are  numerous, since  it is evident   that the matrix, from which the
nail  is produced, would scarcely enjoy immunity in the case of pro-
found  alteration  of the skin  in its vicinage.   Thus  eczema,  lepra,
psoriasis, lichen ruber, syphilis, scarlatina, perforating disease of the
foot, variola, and  other diseases are attended  by changes of various
grades of severity in both matrix  and nail.
  The condition termed Paronychia, is that in  which one or both
lateral borders of the  nail  bury  themselves  deeply in  the tissues
adjacent, producing  thus an exquisitely tender and painful state of
the  soft parts, M'hich may suppurate or surround the attached limb
of the nail  with  exuberant  granulations.  This is  more frequently

  1 While these pages are in preparation, the author has been consulted by an intelligent patient who
positively asserts that her ichthyosis is always aggravated by warm weather. 
396
DISEASES  OF  THE .SKIN.
observed  in the nails of the toes, as the appendages of the skin are
liable  to  injury from the pressure of ill-fitting  boots,  gaiters, and
shoes.   In the condition described as Onychia, the  matrix is not
only inflamed, but the nail substance is, as a consequence, texturally
changed.   No strict  line of demarcation, however,  can be described
betM'een the two conditions.  The term Onychocryptosis has been
employed to  describe the contorted  deformities  which  cause  it to
resemble a claw.
   Onychomycosis is the name given to that condition in which the
nail substance is invaded by vegetable parasites.   In such cases, the
nails  become  opaque, discolored, and thickened, with a noticeable
friability at the projecting border.
   In Syphilitic  Onychia, one or several of the nails may become
affected, though it is quite  characteristic  of the disease to exhibit
limitation to the extremity of a single digit.  In such cases, there is
usually a very marked  involvement of  the peripheral  soft parts,
which  may be infiltrated with  gummatous  material.   The bullous
syphiloderm, of the congenital  manifestations of the disease, M'ill at
times  form beneath or quite near the nail, and  thus endanger its
integrity.   In both forms, ulcerative results are common,  M'ith secre-
tion of a foul discharge.
   Iu  the affection termed  perforating disease of the foot, alb the
nails of the feet may exhibit a characteristic onychauxis.
   Traumatism (constant  or intermittent  pressure  of shoes)  may
augment the size of the nail in one  or another  diameter; and the
deformed  talons resulting from gross and  long-continued  neglect
(East Indian devotees, etc.) are illustrations of another type of hyper-
plasia.  Supernumerary  nails   may  be  found  on  supernumerary
fingers and toes;  or double  organs on a single digit;  or in unusual
situations as over the  scapula (Tulpius);  or on a  digital  stump ; or
iu an ovarian  cyst.
   AVith respect to  onychauxis proper, two forms are recognized.  In
the first, the nail-cells are more closely set together aud the resulting
hypertrophy is declared, not in changes in bulk of the nail, but in a
dense,  thick,  opaque,  glossy, grayish-white transformation of the
organ.   It is perceptibly increased  in weight  and becomes so  solid
that it cannot be cut by ordinary  implements.   It  may be  also,
though not changed in bulk, altered in shape, its free border curved
downward or upward.
   The second form represents a  visible hypertrophy  iu bulk, the nail
being enlarged in one or  several  diameters.  Enlargement in a trans-
verse diameter ne«essarily involves the soft parts adjoining.  Vertical
hypertrophy results in any one  of  the claw- or talon-like forms of
onychogryphosis.
   Etiology.—Onychauxis may be congenital or acquired;  idiopathic
or symptomatic; and due to inflammatory changes  in the corium or
matrix of the  nail; to traumatism ;  to defective hygienic  care of the
general surface of the skin  including the  nails; and, perhaps, in
exceptional cases, to senile influences. 
onychauxis.                      397
   Pathology.—According to Geber,  there  is in  gryphotic nails  a
 tolerably uniform consistence superficially;  and in the deeper strata
 a harder or  softer substance arranged in  fan-like lavers.  In  the
 former region, the nail  is made  up of small, roundish, or flattened
 cells containing variously sized dark granules.   These have a  linear
 arrangement along the longitudinal axis, and, in places, as along the
 higher transverse ridges, are more closely aggregated.   More deeply
 the  cells are irregularly grouped.   According to VirchoM', they con-
 tain, centrally, horizontal masses of horn,  M'hich descend  laterally,
 including  the so-called " medullary  spaces."  These are  sharpiy
 defined loculi filled  with a homogeneous, lustrous, yellow, or finely
 granular mass; and in them may be found epidermal cells in process
 of keratinization.
   AVhen the nail is lifted off,  the  bed looks short, arched, and
 narrow.  Beneath the epidermis accumulated upon the surface, the
 hypertrophied ridges, longitudinally  arranged  anteriorly, and  the
 papillse more particularly,  become visible, the latter containing large
 vascular loops surrounded by a small-celled infiltration.
   Treatment.—The treatment of  the disorders of the nail described
 above, is largely that of the maladies in which they occur.   Arsenic
 aud iron are  often indicated in these affections ; and  their  influence
 upon the nutrition of the nail  cannot be questioned.   In syphilitic
 onychia, the constitutional treatment of the disease is essential.   The
 cutting, scraping,  and trimming of the nail  by the aid  of the useful
 instruments found in the chiropodist's case, supplied by most surgical
 instrument makers, are important measures in many cases.
   The treatment of ingrowing  toe-nail varies with the extent of the
 disease.   In mild  cases, soft threads of charpie are insinuated between
 the offending  border of the nail and  the tender granulating surface
 upon which it presses.   Counter-pressure by plaster and the local use
 of the crayon of  nitrate of silver, may be  at times employed with
 advantage.  In severer cases, the  nail  may be removed, though this
 is generally unwise.  The method of treatment devised by Agard, of
 California, often produces the speediest results.  The soft parts are,
 by him, completely removed from the side of the nail by means of a
 thin-bladed bistoury; and  the nail  permitted to groM' down  upon
 one side of the extremity of the distal phalanx, thus  protecting  the
 cicatrix and radically preventing the recurrence of the disease.
   The proper dressing of  the feet in onychauxis of the toes is a
 matter of great importance.  The shoes and  socks,  or  stockings,
 should be adjusted  both as  to  texture and shape  to the special
 requirements of each case.  After the hypertrophied tissue is largely
 removed by cutting or scraping, the phalanx may be enveloped  in a
 plaster-mull or salve-muslin  of diachylon ointment, or with mercurial
 plaster, and the whole covered with a  leather or  rubber cot.
   The Prognosis in  these disorders  of the nails rests entirely upon
 the nature of the malady  in  M'hich they  occur.  Idiopathic  and
 localized changes,  as also those occurring in transient cutaneous dis-
eases (e. g. the exanthemata), often terminate favorably.  In  severe 
398
DISEASES  OF  THE  SKIN.
constitutional or grave cutaueous diseases, the outlook is less promis-
ing.  The diseases  of the nail are usually more obstinate and  less
amenable to treatment than the similar affections of the softer parts.
In cases M'here  there is congenital disease of the  nails, a prognosis
should be made with reserve.

                        Hypertrichosis.
                    Gr. ii-sp, in excess; dpl%, hair.
Hypertrichosis is a development of the pilary filaments, exaggerated as to size
  or number, or unusual either with respect to the location of the growth, or
  the age, or sex,  of the individual in whom it is displayed.
   Hypertrichosis, Hypertrophy of the hair, Hairiness,  or Hirsuties,
may be  congenital,  and  this in various  grades.   It is sufficiently
common to see infants at birth provided  with extremely long hairs
of the hairy parts of the body, such a groMth being  usually replaced
later by shorter  filaments.   Universal congenital  hirsuties is a rare
deformity, the entire body being then covered with longer or shorter
downy hairs  of various colors.
   Acquired  hirsuties may be partial or universal,  much more com-
monly the latter.  Thus the  hairs of the  scalp or beard  may acquire
an enormous vigor and length, reaching fully to the ground when the
figure is in the erect position;  or  the hypertrophy of the hairs  may
affect the face of the child or woman, and in this sex, either the upper
lip, chin, cheeks, or  all portions of the body usually covered by hairs
in mau, be provided with a vigorously and symmetrically developed
pilary growth.
   Remarkable instances of universal  congenital hirsuties are occa-
sionally observed.  The so-called "Russian dog-faced man" (Andrian
Jeftichjew) and  his  son, lately  on exhibition  in  this country, were
noteworthy illustrations of this anomaly.   In most cases the influence
of heredity is usually distinct  and  often  accompanied  by defective
dental development,  such as entire absence of molar or  canine teeth.
In  all cases  of hypertrichosis, whether  congenital  or  acquired, the
parts normally unprovided with hair, such as the palms, soles, ungual
phalanges, prepuce, glans penis, upper eyelids, and vermilion  border
of the lips, are not the seat of the  pilosis.
   As the growth of the beard in man  is more or less associated with
the maturity  of the sexual organs, so we often find  the hypertrichosis
of women and children related to a precocious, perverted, or arrested
function of the generative organs.   The  reported instances of men-
struation in female infants aud children usually iuclude  a description
of  abnormal pilary  development about  prematurely developed
pudenda; and after the climacteric period, M'hen some women  con-
spicuously begin in  external appearance  to resemble individuals of
the opposite sex, either isolated, thick, bristle-like hairs  develop over
the chin or lips ; or the extreme hirsute  condition  may be reached. 
HYPERTRICHOSIS.
399
Duhring1 has reported one such case, which is illustrated by an excel-
lent lithograph representing the face of a woman  provided M'ith a
superb beard.
                              Fro. 48.
The Kussian " Dog-faced Man "
   The influence of the sexual organs in the hypertrichosis of women
 is well demonstrated in the following case coming under the author's
 observation.
   A married woman, thirty-three years of age, weighing one hundred
 and fifty pounds, mother of three healthy children,  applied, in 1883,
 for relief of a general and facial hirsuties which had resulted in the
 growth  of a full beard and  moustache.   She had not menstruated for
 more than a year, and had  been pronounced by an  expert  past the
 climacteric.   During the years 1884 and 1885 the author removed in
 successive operations the hairs of the face by the electrolytic method
 described below.   Menstruation  began while she Mas subject to the
 influence of the galvanic current in the operating-chair, and continued
 thereafter irregularly, at times with intense pain and even  menor-
 rhagia.   In 1886, after  the last of the operations  on the face, she
rather  suddenly lost in weight, decreasing  to  one hundred pounds,
and  began  to  mcnstiuate  regularly  and  painlessly.  The hyper-
trichosis of the general surface then disappeared by  a simple fall of
hair.  In the latter part of the year she again conceived, and in
1 Arch, of Dermatology, April, 1877. 
400
DISEASES  OF  THE  SKIN.
March, 1887, being then quite free  from any form of hirsuties, she
brought a healthy male child into the world.
  As the result of  the local application of stimulating and oily lini-
ments persistently  and over a single region of  the  body (scapula,
sacrum, sciatic notch, etc.) a growth of long and  numerous hairs is
often produced.   Care should be had in the management of cases of
acne and rosacea in  the persons  of dark-skinned young women with
luxuriant hair upou the head, lest this  growth be precipitated  upon
the chin, cheeks or nose."
  In cases  of hypertrichosis the  hairs may  be variously colored, and
the hypertrophy of downy hairs be purely numerical, or result  in
increase in  the actual size of the shaft of the individual filaments.
In neither  case do the hairs  present any anatomical peculiarities  of
structure.   The localized congenital  form of hirsuties is often charac-
teristic of certain moles, known as N^vi Pilosi ;  and the surface of
pigmentary moles  (N^eyi  Pigmentosi) is often  very  extensively
covered with hairs  of a dark color.   Singular anomalies  have been
figured  by  a  number of dermatologists where extensive regions (one
or several limbs, the entire back, even the greater part of the  body)
were  the  seat  of enormous  pigmented moles,  covered M'ith  warts,
fibromata,  and  other  benign  tumors,  and  clothed  with  a   thick
covering of longer or shorter hairs.1  All such cases exhibit a striking
development in either symmetrically or asymmetrically disposed areas
of distribution of cutaneous nerves.
  Under the name Plica Polonica was formerly described a  condi-
tion supposed to be a disease peculiar to the Poles (whence its name),
but which  has long  been recognized as a result merely of persistent
neglect, filth, the invasion by parasites, and consequent exudative dis-
orders of the scalp.  AVhen it  exists, the hairs  form a huge  matted
mass on the crown  of the head.   Hebra has devoted some interesting
pages to the superstitious awe with which this accumulation of hairs,
lice, and filth has been  regarded.  Dr. H.  M. Bannister, lately con-
nected with  the  U. S.  station  in Alaska,  informs  me  that  he has
seen a number of cases of plica  among the  natives of that region.
A typical case of this curious deformity was lately presented  at  the
author's clinic.
  Under the title Neuropathic Plica, Le Page2 describes a casein
which tangled "lumps" and "festoons" of hairs, flat, curled, looped,
and intertwined, appeared on one side of the head of a girl  seventeen
years old, who had previously suffered from  neuralgic pains  in  the
site of the growth.
  Etiology.—The causes of hypertrichosis  are  practically unknown.
It is clear that whatever determines the blood  in excess to any  one
region of the body, may be  indirectly the  cause of hypertrophy of
the  hair, a fact demonstrated  in the  patients who, after applying
sinapisms or liniments for years to the skin over the seat  of a rebel-

  1 See the author's case of naevus lipomatodes in a child, the pilary growth being at that age unde-
veloped. Journal of Cutan. and Ven. Diseases, July,  1885.
  2 British Medical Journal. January 20, 1881, p. 160. 
hypertrichosis.
401
lions  neuralgia, exhibit au  abundant  growth  of hair, often  several
inches in length, over a scapula or a buttock.   In women, whose sex
renders the anomaly most deforming and distressing, it is chiefly noted
as has  been  observed, in precocious,  perverted, or arrested activity
of the sexual  function.    The  neurotic  conditions  accompanying
certain  varieties of hirsuties may be inappreciable; or evidently due
to traumatism;  or exhibited in paralyses, muscular atrophy, etc.
   Treatment.—To Hardaway, of St. Louis, Americans are indebted
for the popularization of the method  of  removing superfluous  hairs
by electrolysis, first devised by Michel, of his city.   After him  most
American dermatologists have with success removed extensive pilary
growths without subsequent reproduction  of the hairs.  A fine needle
is introduced into the hair-follicle aud  pushed  well down to the
papilla at its base.  This instrument  is connected with the negative
pole of a galvanic battery containing six or more elements, the  posi-
tive pole of M'hich is  in  connection with a sponge electrode held in
the patient's  hand ; the latter being thus  enabled to  make or break
the circuit  at  M'ill.  AVhen the current is  passed,  a few  minute
bubbles of gas escape from the orifice of the follicle,  and, when the
hair-papilla  is  destroyed, the  hair itself  is readily extracted.  The
dexterity acquired by practice is requisite for the proper performance
of the  operation,  with  a view particularly to  the insertion of the
needle at the proper angle  into the follicle.  Few patients complain
of pain.  The number of hairs removed at a sitting varies M'ith the
sensitiveness of the patient's skin.   The resulting  scar  is either
quite imperceptible or far  less disfiguring than the hirsuties, sug-
gesting the appearance of the male beard  after shaving.  Transitory
macuhe, papules, pustules, and wheals occur  at the site of puncture.
Care should be  taken not to insert the needle too deeply in the par-
ticularly vascular  regions of the face, as an aneurismal tumor might
be produced as a consequence.
   Every detail  of this exceedingly simple operation has now  been
carefully studied  by  American  operators, and the results, as  con-
firmed by the author's experience, may be given  as follows :
   1. As to the battery, any good galvanic battery  may be employed.
The author uses habitually the forty-cell stationary battery made  by
the Mcintosh Galvanic and  Faradic Company,  whose switch-board
is so arranged that any number of any selected cells may be brought
into the circuit.   The number of cells employed should  be different
for different individuals, different parts of the  face, and  on different
davs M'ith the same individual—e.g., a smaller  number  is required
M'hen a patient previously operated upon returns  after a somewhat
long period  of rest.  Two to  four cells only may be tolerated over
the tij) of the nose or upper lip  near  the septum  nasi.  Twelve to
twenty  may be M'ell borne, after some  experimenting, on  an  insensi-
tive chin.
  2.  The  best needle is a carefully selected, exceedingly fine jeweller's
broach, its shaft and  point  annealed  by rapid passage through the
flame  of an alcohol lamp.   It is often useful to have the point also
                                L'15 
402
DISEASES OF THE SKIN.
well rounded on an  emery-M'heel.   The irido-platinum needles are
useful, but  inferior for general work to  the well  annealed, carefully
selected broach.
   3. The needle-holder  should  be simply a  convenient  insulated
handle, sufficiently long to  protect all  the points of the  operator's
right hand  from  the current.   The author employs  Prof. White's
long handle.  Duhring's1 is of the shape of a thin lead pencil or pen-
holder, and is about four inches in length.  The handle or stem is of
hard  rubber, through which passes  a metallic rod, acting  as a con-
ductor for the transmission  of the current.   The needle is inserted
into the needle-holder proper,  M'hich  is  slotted, the  needle being
clamped immovably by means of a screw-nut.   On the  other end of
the stem  there is  an  insulated iuscrting-pin  attached to  the  cord
leading to the battery.   The instrument is of proper Mcight, conve-
nient to handle, and altogether M'ell adapted for the operation.
   4. As to  further details of the operation it is M'ell  (a) to  make the
connection only after the needle is in situ; (6) to introduce  the latter
with a gentle manipulation acquired only by skill—it is M'ell charac-
terized  by  Hard away  as a  "catheterization"  of the hair-follicle—
observing a  certain degree of parallelism with the hair-shaft as the
needle enters;  (c) to operate leisurely, making sure that the current
is uot broken by the separation of the hands of the patient,  before the
hair is completely free  in the follicle.  This last  can be ascertained
by gentle traction  on the shaft  in from ten to twenty seconds after
the insertion of the needle;  (d) to operate in succession upon  con-
tiguous hairs M'hen practicable, not selecting one here aud  one there,
the latter course being  productive of greater pain ;  (e) never to use
the positive pole in connection with the needle, an error M'hich results
in the  production  of unsightly pigmented blemishes on the surface
of the skin.
   The previous employment of preparations of cocaine both hypo-
dermatically and by inunction—e.g., the  oleate of cocaine—in order to
relieve  or diminish the pain of the operation, may be followed by
exceedingly unpleasant consequences.  The author has seen a derma-
titis thus induced present for months.
   Dr.  Prince, of Boston,2 lays stress upou the accurate regulation of
the current  by the aid of the absolute galvanometer, which the author
has  found  in  his  practice useful but  not essential.  Dr.  Fox,3 of
New  York, reports  a gradual decrease  in  the  number  of hairs
returning after operation, proportioned  to the improvement in the
instruments and skill of the operator.  There can be no question that
the percentage  of such returns varies with these conditions.
 ^  All patients affected with hirsuties are not to be advised  the opera-
tion.   The  author  has  declined to operate in many cases which Mere
uot deemed  to belong to the class in M'hich  the best results of the

   1 Amer. Journ. of the Med. Sci., July, 1881.
   2 The exact measurement of the electric current, and other practical points in the  destruction of
hair by electrolysis.
   3 The use of electricity in the removal of superfluous hair, etc.  Detroit, 188G. 
HYPERTRICHOSIS.
403
operation may be expected.  Young and vigorous women, usually
unmarried, may  point  out hairs to be  removed M'hich are merely
fully developed  filaments of a  thick downy growth,  all of whose
individuals are rapidly pushing to equal  maturity.   Here the opera-
tion itself, by inducing hyperaemia of the skin, may simply hasten
the  hypertrichosis  actually in progress, aud  thus aggravate  the dis-
order.  In most  cases M'hen an operation  is undertaken, both parties
should  fully understand  the  possible issue.  It may also be a ques-
tion M'hether it lies within  the legitimate  sphere of the physician to
remove superfluous hairs from the habitually covered breast and  arms
of  women.
   Hairy nsevi are best removed  by complete excision.
   Depilatories for the  removal  of superfluous hairs operate by the
destruction of the filament  without obliteration of the papilla.   The
consequence  is that  the hairs are reproduced in the course of about
a fortnight.  Most of the compounds used for this  purpose contain
either the sulphate of calcium,  sulphate of arsenic, or sulphide of
barium, made into a species of paste with hot water.   This is applied
over the surface  with a spatula,  and  permitted to remain till it dries,
a  period usuallv requiring ten minutes.   It  is theu rapidly removed
by scraping  M'ith the  spatula, and  the surface thoroughly cleansed
M'ith warm Mater, after M'hich it  is anointed with cold cream, or other
similar unguent.
   Of these depilatories Duhring recommends the following:

         R. Barii  sulphis.                3Ij;           8

           SSv. a"'  }        «**          12      M.

   The following are formulas devised by French authors.
         R. Sudii  sulphat.               3iij;          12
           ?lcir   i       t         aa3x;          40 j      M
           Amyli pulv.     j                           !      31.
        To be finely triturated, and when used, to be made into a thin paste
          with water.  (Boudet.)
         R. Calcis                      3j;           -4
           Sodii  carbon.               S.jss;           6
           Cerat. adipis                s.j ;          32      M.
        To be applied as a depilatory in the manner of a paste.

   All of these  require caution  in their  use, and  should never  be
intrusted to unprofessional hands.
   Shaving may  be practised  upon the  hirsute face of women, and,
M'ith a similiar'end in view, epilation also; the latter, particularly in
cases of hypertrophy  of the  hair, limited iii  extent.  Partial  suc-
cess has attended the  thrusting  into the follicles of  needles,  pre-
viously dipped in  various  caustic solutions, or heated in  various
degrees, but these methods are all far inferior to electrolytic destruc-
tion of the hair-papilla. 
404
DISEASES  OF  THE  SKIN.
              3.   Of Connective Tissue.

                    Sclerema Neonatorum.

          Gr. cKkripdq, hard ;  vkov, lately; yevvdu, to bring forth.
Sclerema Neonatorum is a disease of early infancy, induced by changes in
  the capillary circulation, accompanied by a progessive fall of temperature,
  and characterized by blanching, oedema, and even mummification of the
  skin.

  Symptoms.—The disease  occurs, as a rule, in from three to six days
after birth, and is characterized by a progressive cooling of the surface
of the body,  with an increasing and extending oedema, first most notice-
able in the lower extremities.  The skin is blanched, marbled, mottled,
or more rarely of a yellowish, reddish, or  violaceous hue, pits upon
pressure, and later is indurated, firm, tense, aud shining.  The con-
dition becomes more or less rapidly noticeable over the other parts of
the body,  the face, upper extremities, and  trunk.   As a consequence,
motion is  impeded, the features are stiffened,  suction of the nipple is
rendered  difficult or impossible,  and the  infant  reclines helpless,
motionless, rigid, cold to the touch, and  displaying  the  signs of a
waning vitality  merely  by  its  moans and  superficial respiration.
Death usually occurs within a brief time.
  The respiratory and circulatory systems are in such cases always at
fault.  The  disorder is common after capillary bronchitis, the  pneu-
monia of infants, and the  gastro-intestinal disorders  which prevail
in premature, imperfectly nourished, and neglected infants of a tender
age.
  Etiology.—The causes of the disease, whose cutaneous manifesta-
tions seem to be largely symptomatic, are to  be sought in every sys-
temic disorder of early infancy which is accompanied by retardation
of the respiration  aud circulation.  For several years the author had
the opportunity of studying the changes which precede a fatal issue in
a large proportion of the  abandoned aud diseased foundlings cared
for in the infirmary of  the Chicago Home  for the  Friendless, and
in several were  distinguished unmistakable symptoms of sclerema
neonatorum.  Three of these M'aifs  had been, significantly, abandoned
at the door of the  institution in very cold  weather, and had there
remained  for several hours exposed and  unnoticed.   In  none M'as it
necessary  to seek for causes any more profound than  those which the
history of each case suggested.
  Authors have, however,  regarded the disease as produced by atelec-
tasis pulmonum, cardiac disorders, and  unknown constitutional con-
ditions.
  Pathology.—Post-mortem, there is discovered  no  hypertrophy of
the cutaneous elements.  The tissues are simply distended M'ith yel-
lowish-white serum—iu other words, are oedematous.   This fluid, often 
SCLERODERMA.
405
containing fat globules, flows forth after  incision of the parts, more
or less stained by the coloring matters of the blood, which Mas during
life in a state of partial stasis.  The stearine-like deposit found in the
panniculus adiposus, is mere coagulated lymph, whose movement has
been arrested and whose temperature has been lowered simultaneously
with that of the  blood.  The subcutaneous  tissue is usually so iufil-
trated that it is readily  separable from  the fascia? and aponeuroses
beneath.   The brain, lungs, kidneys, and serous membranes are often
found coagulated and  infiltrated  with fluid.
   Diagnosis.—The disease is  readily recognized by its characteristic
features  exhibited in  very early infancy, and in subjects  suffering
from  any cause which  strongly depresses  the respiratory and circul-
atory activity.  It is  to  be distinguished from sclerema adultorum,
in M'hich there is a hide-bound condition  of the integument of very
slow progress and rarely generalized.   The latter disease is due to a
true hypertrophy of the cutaneous elements.
   Treatment.—The treatment should be  exclusively directed to the
restoration  of warmth, the stimulation of  the respiratory aud  cir-
culatory centres, and  the proper  alimentation  of the little patient.
Massage  and cutaneous frictions, with  artificial heat applied exter-
nally, are serviceable.   The prognosis is grave.   Infants are said to
have  been saved after exhibiting these symptoms.   The author has
seen none such  recover.   In the discussion, however, of a case pre-
sented by Dr. Robinson to the New York Dermatological Society in
1883, several cases of recovery Mere reported.


                          Scleroderma.
                   Gr. aKiripde, hard; Sepfia,  the skin.
Scleroderma is a chronic affection; characterized  by a circumscribed or rela-
  tively diffuse induration, rigidity, fixation, and subsequent atrophy of the
  skin, the affected parts being yellowish-white, waxy, or pigmented in color,
  and either elevated or depressed, the disease-process enduring for a series
  of years, and, in certain cases, terminating  fatally after the induction of
  marasmus.
   The disease, also termed Scleriasis and  Sclerema, is manifested
either as a  partial  or  general change in  the  structure of  the skin.
The former, much more commonly encountered, is termed by French
authors,  sclerbne en placards.
   There can be little question  to-day that morphcea and scleroderma
are different names for one and the same  disease,  though  the two
have been separately considered by many  authors.  In the following
pages, adhering to the nomenclature of the American Dermatological
Association, the conditions indicated by each name are for the present
separately described,  a temporary provision looking to more exact
knowledge of the entire subject.   Under the title, Morphcea, will be,
therefore, found a description of the localized forms  of scleroderma,
to M'hich that name has long been applied. 
406
DISEASES  of  the  skin
   Symptoms.—In both the partial and  generalized forms, the disease
 is first manifested in irregularly defined roundish or ovalish, coin or
 palm-sized patches, in elevated or depressed, yellowish-M'hite or waxy,
 ribbon-like bands, or iu a more extensive ahd uniform  involvement
 of the skin, usually that of some  part  of the  upper segment of the
 body.   The affected areas in both of the forms  named  may be ele-
 vated  slightly  above the level  of the  adjacent normal  integument,
 or to an  equal extent  depressed  below it,  or both, the depressions
 being  irregularly distributed  among the elevations, or,  especially in
 the ribbon-like form, bordered on  either side by dense ridges.  In all
 fully developed cases, the most prominent feature is the  sclerosis, the
 skin being shining, indurated, brawny, tense, pigmented,  and immov-
 able upon,  because adherent to,  its underlying structures, as the
 muscles, aponeuroses, and periosteum.
   For this reason, there is at  times  interference M'ith the movements
 of the trunk in respiration, as also of the lips and other parts of the
 face in the expression of the emotions, aud  of the fingers in the
 grasp  of  the hand.   The disease, in  short, produces the condition
 often described as " hide-bound."   The skin of the  affected parts is
 usually yellowish-white, dirty yellowish, waxy, or like  alabaster in
 color; is often slightly desquamating, and may be pigmented in various
 shades  from yellow  to  brown  and bronze.   There is usually no
 alteration in the subjective sensations, temperature, glandular  secre-
 tion, nor, in the early stages of  the  disease, in the general  health  of
 the patient.   The malady begins insidiously, but may,  however, be
 rapid in its development, and accompanied by pyrexic or rheumatoid
 symptoms.   In its subsequent  progress, it ahvays pursues a chronic
 course.
  There is no strict line of demarcation between the sclerosed and
 unaffected portions of the skin.  The  temperature of  the affected
 part may  be at times slightly subnormal.
  After  the  complete evolution of the disease,  when the  sclerosed
 patch has attained a maximum of induration and  thickening, the
 disease may disappear by resolution,  or marked atrophy result.   This
 atrophic process may involve both the  skin aud its underlying struc-
 tures.   A dead-M'hite, thinned, pinkish, slightly pigmented, or dirty-
yellowish membrane may then be seen tightly stretched  over a joint
 or a projecting  osseous surface.
  The course, therefore, of the disease may be either toward definite
 resolution, persistent cutaneous atrophy, or  the final induction  of  a
 fatal marasmus.  But little is known of the concluding  stage of the
 affection, patients, before arriving at that term, usually drifting from
 the  observation  of  practitioners.    Nearly  twenty  fatal cases are,
 however, on record.   The skin may be entirely restored to its normal
 condition, but often such restoration is succeeded  by a return of the
 disease in the part originally affected, and by the involvement of new
 areas.
  The sites usually involved are:  the  head,  trunk, and upper ex-
tremities,  including  the mamma of women.   It is occasionally of 
SCLERODERMA.
407
symmetrical development.   When  occurring upon  the  face, an  ex-
ceedingly characteristic symptom  is the resulting  immobility of the
features, head, thorax, digits, and even the limbs.
   Its lesions are accompanied at  times by other cutaneous disorders,
such as eczema, erysipelas, melanoderma, canities, anidrosis, morphcea,
zoster, and  acne.
   Exaggerated forms  of the disease  have  been  noted  by several
authors, where, to  a varying extent, the surface of the lateral half
of the face has been involved, the resulting condition being described
as Hemiatrophia Facialis.  Here not only the subcutaneous tissue,
but the  aponeuroses, periosteum, and  bones may participate in  the
atrophy,  a  fact M'ell illustrated  in the case  of Robinson's patient,1
whom the author had the opportunity of examining.  In  this instance
there Mas also a distinct sclerodermatous lesion on the face of one
thigh.
   Scleroderma is exceedingly rare;  and the preceding description is
based upon  the notes of the few  cases which have fallen  under  the
author's observation.   In one male patient, the surface of the entire
chest  was symmetrically involved to the extent of inducing marked
dyspnoea, and the  general condition  was  that  of decided asthenia.
His skin Mas tightly bound in undulating ridges to the ribs beneath,
and colored in a  dirty-yellowish shade.    The  other  patients were
much less seriously affected; one  had symmetrical scleroderma  of a
part of the  skin of the thorax in  irregular patches;  another, a band-
like deep yellow depression between  dense ridges M'hich  fastened a
part of the  forehead firmly to the frontal bone;  the fourth, a limited
M'hitish patch at the back of the neck ; aud the  fifth, a diffuse sclero-
derma of the  cutaneous  envelope of the  left  mamma, the patient
dying in a neighboring State one year after  my examination of her
person, of what her physician pronounced to be "sarcoma" of the lung.
   Finlayson2 has observed in one case symmetrical  gaugrene of the
extremities, a complication related without doubt to the " symmetrical
asphyxia of the extremities'' described  by  a  number  of  English
authors.  The so-called "Glossy  Fingers" and the "Sclerodactylia"
of symmetrical distribution may belong to the same category.
   In  many of the  asymmetrical forms of the disease,  and in others
also, the sclerosed  patches occur  in the areas definitely  supplied by
certain  nerves, or  in  the lines of nerve trunks.   The  lilac-tinted
border, described more  fully in connection with morphcea may dis-
appear  as the disease  progresses.  In exceedingly advanced stages
the pigmentation may be deep and extensive.  The  complications of
such  stages are naturally associated M'ith circulation disturbances;
and   may be  erysipelatous,  gangrenous,  or ulcerative.  Amyloid
degeneration of the viscera may also complicate any case.
  Etiology.—The causes  of the disease are obscure.   It is observed
in about two-thirds  of all cases in  the  female  sex, a fact which
certaiulv points to  some  other cause than  rheumatism as effective in

                1 Anier. Journ. of the Medical Sciences, Oct. 1878.
                - Mid. Chronicle, Jan 18S0 
408
DISEASES OF  THE SKIN.
its production, since men are more  exposed than women to changes
in atmospheric temperature and humidity, M'hich agents are generally
admitted to  have an etiological  importance in  rheumatism.  The
disease occurs at all ages, chiefly, however, in adults.  Cruse observed
one case in a child two years old.
  The etiological importance of the nervous system is, in the explana-
tion  of many cases, too obvious to  require demonstration.   This is
much more distinct in  the  localized manifestations of the disorder
where a region supplied by a single  nerve or traversed  by a nervous
trunk  is solely involved.  Harley,  Schwimmer,  and others  have
recognized  cardiac  and  gastric disturbances; Westphal and  Eulen-
berg, central and peripheral changes in the nervous system;  Heller
demonstrated in  one case a closure of the thoracic duct.   Bancroft1
repeatedly  recognized filarise  iu large  numbers  in  the blood  of a
young girl  in Australia  affected with a characteristic scleroderma.
  The disease is regarded to-day by  the greater number of observers
as a  trophoneurosis.
  Pathology.—The confusion which  has  existed in  relatiou  to the
question of the identity of scleroderma and morphcea is due to various
causes.  By several authors  similar symptoms are described under
each of the two names: and  the symptoms described as  peculiar to
each are occasionally seen  either  simultaneously or successively in
the same individual.
  Microscopical examination  of the tissues involved in the disease
has  proved unsatisfactory.   The connective tissue  of the  skin has
beeu found,  according  to  Kaposi,  condensed and  thickened;  its
elastic fibres  multiplied at the expense of the  panniculus adiposus;
its muscular tissue hypertrophied ;  the pigment in  the  rete and
corium increased ; the sweat glands dilated ;  the lumen of the blood-
vessels diminished, and  their walls  ensheathed in accumulations of
what he terms " lymphatic cells."
  Schwimmer and Bates found vascular changes including a narrow-
ing  of the vessels, thickening of the tunica  media and intima.   In
the atrophic sequela? of the disease the new elements disappear.
  Diagnosis.—A  differential diagnosis  between  scleroderma and
morphcea involves, as  has been already shown, chiefly a distinction
between the partial and general manifestations  of the disease.
  Scleroderma   is  occasionally  symmetrical,  usually  insidiously
developed,  void of subjective sensations, and  indeterminate  in out-
line.  Morphcea  is usually  asymmetrical,  often  accompanied  by
pain or tingling,  and exhibits a  particularly well-defined contour.
Scleroderma  may affect large areas  of the integument M'hich are at
some time  densely rigid and  firm, and may not  exhibit to  the eye a
structural change.  Morphcea is of much less exteusive development,
produces a soft, somewhat elastic  or "cushiony" feel to the touch,
and  alters the skin  so that the eye  can take cognizance of the change.
The  former commences as a cutaneous sclerosis; the latter as a patch
of altered  color,  the change of hue being due to a greater or less
1 Lancet, Feb. 28, 188G, p. 380. 
M0RPH03A.
409
degree of vascularity.  Lastly, in scleroderma there is no telangiec-
tasis,  nor punctate atrophy.
   Treatment.—The treatment of scleroderma, though empirical, should
be persistently enforced in the hope of improvement.   Locally, baths
(cold, hot, sea, vapor, Russian), massage, frictions with fat  and  oils,
and  possibly  the  hypodermatic injection  of pilocarpine  (Besnier,
Doyon) may be advantageously tried.  The inunction of mercurial
and iodized unguents has proved futile.  Internally, quinine, iron,
arsenic, cod-liver oil, and the usual hygienic and tonic regimen, are
in different cases severally indicated.
   In  some cases the galvanic current has been employed with marked
benefit, applied locally to the patches of disease,  and in the direction
of the  trunks of nervous  supply, aud  over the nervous centres.
Rasmussen  applies locally an ointment of the black oxide of copper,
tM'o grains (0.133) to the ounce (32.).
   Prognosis.—The outlook for the  patient affected  M'ith  extensive
scleroderma, especially of the trunk, is decidedly unfavorable.   Much
more  limited expressions of the disease may be regarded as less grave.
Recovery in cases is  said to have been perfect.   Atrophy once estab-
lished, is final.   Contracture of mouth, fingers, or costal  region may
prove serious.   Patients yielding to marasmus are naturally those to
whom little can be  promised.  Even after  slight manifestations of
the disease, the future may be portentous.


                           Morphcea.
                     Gr. [iop<j>r/, by metathesis, form.
Morphoea is a cutaneous disease characterized by the  occurrence  of one or
  several discrete, well defined, firm, and smooth points,  patches,  lines, or
  bands, often  slightly elevated  or depressed, and surrounded by a delicate
  violaceous or lilac-tinted  halo, whose involution  may  be  followed by
  macular, punctate, or striate atrophy of the skin.

   Symptoms.—This disease, once known  under the misleading  title
of "Addison's Keloid," is to-day best regarded as a local manifesta-
tion  of  scleroderma.  The  folloM'ing is a brief description of the
most  typical form of the disease observed by  the author :
   The patient Mas a vigorous, Mell-nourished girl, sixteen years old,
with  a  patch upon the outer face of the left thigh, as  large  as a
breakfast plate and almost  as  perfectly circular.  It was slightly
elevated  in its centre above the adjacent level, and thence declined to
the periphery by a gentle curve quite perceptible M'hen viewed  from
the side.  It was firm but not  indurated, feeling to the finger like a
densely padded cushion set  in  the  skin.   With  some difficulty it
could  be gathered up betM'een the fingers.   Sensibility was slightly
impaired over its surface.  Its outline was so distinct  that its limits
could  have  been traced by  a  pen.   The surface Mas  exceedingly
smooth, and colored in a shade between  alabaster and yellowish Max.
Regularly dispersed  over the surface of this circular cushion, were 
410                DISEASES  OF  THE  SKIN.
discrete,  slightly pigmented,  atrophic  puncta, separated  from  each
other by an inch or less of  the shining substance constituting the
patch.  * About  it Mas a delicate,  elegant, and very  regularly dis-
played halo of a violaceous tint, which on close inspection could  be
seen to be produced  by a plexus of minute capillaries.
  Of the few cases of this rare disease M'hich the author has had the
fortune to see, no one Mas comparable M'ith that described above, as
respects the size of the patch, and the classical type of the features.
In  another  case, observed lately in private  practice, a female child
exhibited  a small hen's egg-sized patch on  the left temple, the in-
volved part projecting to a marked extent above the level of the sur-
rounding skin.   The same violaceous halo surrounded the part, made
up, as was evident on close examination, of a delicate  vascular plexus.
  Other  forms  in M'hich the  disease  is manifested are one or more
coin- to  palm-sized  patches  approximately circular,  either at  the
general level  of the  integument or slightly depressed below  it,  in
which the tissues are either natural, or unusually firm, tense, and sug-
gestive of a tightly stuffed cushion.   The surface may be rosy pink,
M'hitish, yellowish, lardaceous, purplish, mottled,  or  pigmented.   It
may resemble  marble, alabaster, wax, bacon, or a piece  of tanned
leather.  Occasionally there is superficial desquamation.  Often minute
bloodvessels  ramify  over its surface, or in the areola,  beyond which
also the  skin may be  pigmented in various shades.   The centre is
often partly anaesthetic.  After existing  for months and even years,
these lesions may undergo  involution, leaving an unaltered integu-
ment where once they existed, or, more commonly,  a contracting
cicatriform  atrophy of the  skin and  often also of the subcutaneous
tissues, the resulting scar becoming agglutinated to the structures lying
beneath it.
  The lesions may often also  be first  observed as punctate or striate
atrophic depressions.  Au exaggerated form of the latter is the more
or less broad, grooved streak, or furrow, in the sunken floor of M'hich
is a glazed, white, firmly attached, and insensitive epidermis, bounded
on  either side by hyperaemic, pigmented, or otherwise altered, smooth
edges or ridges.  Whether, however,  in the form of patches, puncta,
striae, furrows, or broad grooves, these changes must in many cases
be  sequela?  of the  insidious deposition of lardaceous  material  to a
corresponding extent,  whose resorption has  been unnoticed.  As in
the case of striae et  maculae  atrophica^, mauy  of these  lesions are
mingled  M'ith, or surrounded by, variously colored, pigmented, hyper- .
aemic  or telangiectasic patches,  streaks, lines,  or mere  shadows.
Often a delicate, yellowish,  or violaceous  streak can  be distinguished
in  the immediate proximity  of these curious lesions, and the  most
careful scrutiny will fail to  define either its outline or character.
  The disease occurs asymmetrically, aud often unilaterally, upon the
face, back  of the neck, surface of the  trunk,  including the breast of
women, the belly, the arms, and the thighs.    It is said, also, at times
to select  the areas supplied  by certain nerves, a feature by no means
distinctive of the disease.    Tilbury  Fox, for example, M'rites that 
MORPHCEA.
411
"M'hen  morphcea occurs on the forehead, it takes the course of the
supraorbital nerve;" but  I  have certainly seen  one  perfect frontal
groove,  M'ith pigmented, yelloM'ish edges, terminating fully an  inch
from the supraorbital notch.
   Etiology.—The causes  of the disease  are unknown.  It rarely
occurs in men, a large proportion of all  patients being women.   I
have, however, seen an  oval patch two inches in length upon the back
of the neck  of a young man.  All  my patients, one child only ex-
cepted,  Mere individuals in early adult life, though it  is said to occur
at all ages.   The subjects of the disease are both vigorous and weakly.
   Pathology.—The  studies  thus far made  of  the microscopical
anatomy of the disease have neither sufficed to demonstrate its iden-
tity as distinguished from scleroderma, nor to explain satisfactorily
the polymorphism of the affection.  Duhring, in one case, established
shrinkage of the upper and  condensation of the  lower layers of the
corium ; while Crocker,1 beside noting the usual phenomena of mul-
tiplication of the elements  of the derma and secondary changes in the
rete and skin glands, thought there Mras also a fibrous  metamorphosis
of the protoplasm, lending color thus to  the  view of Fox, that the
disease is essentially a'fibroid degeneration  of the  skin.
   The neurotic explanation of the disease,  suggested  by Hutchinson
and others, may be said to have generally  commended  itself to late
observers.   Morphcea,  in  fact, is a localized  scleroderma,  and  its
position will probably be oue day fully established among the tropho-
neuroses of the skin.
   Diagnosis.—For the distinctive differences between morphcea  and
scleroderma, M'hen such are recognizable, the reader is referred to the
details presented in connection with the  diagnosis of  the  last-named
disease.  From the patches of vitiligo those of morphcea are readily
distinguished by the entire absence of all structural cutaneous changes
in the former, aud their characteristic milky-white color, the  hairs of
the  part being also  blanched.  Both  the  pigmented  macules and
atrophic patches of lepra are  remarkable for their anaesthetic condi-
tion,  and their  coincidence M'ith, or sequence  from, other readily
recognized symptoms of the disease, such as tubercles, bullae, ulcers,
and involvement of the hairs, nails, eyes, aud other organs.
   Treatment.—In many of the milder cases of morphcea, especially
those existing upon portions of the surface concealed by the clothing,
there is no indication for treatment.  The patient's general  health is
unimpaired, and the  local disorder  unproductive of either present
discomfort or a menace for the future.  AVhen the disorder is facial,
and atrophy  has already occurred, the resulting disfigurement may be
regarded as  remediless.   For the  earlier stages of the disease upon
the face, and for those  lesions in other situations M'hich, from their
size, number, or progress, are portentous, general  and  local treatment
mav be  required.  The former  includes  the  use of iron, quinine,
arsenic,  cod-liver oil,  strychnia, and phosphorus, M'ith  the  usual
i Lancet, November 22, 1870. 
412
DISEASES  OF  THE  SKIN.
roborant regimen aud diet.  The latter  involves  the  application of
the various simple stimulants, frictions with oil, spirits, and  soaps,
singly or in combination ; lotions with the  mercuric bichloride, mas-
sage, and  the employment  of the galvanic  current.  In pregnant
women treatment should be deferred till after delivery, when involu-
tion may be more speedily obtained.   Young girls, chlorotic, anaemic,
and suffering from  menstrual  derangements, should be  taken from
the school-desk and the  piano-stool, and  sent to the  riding-gallery,
the gymnasium, or the dairy-farm, where they can  swallow a goblet
full of pure, fresh milk after each meal.
  Prognosis.—The disease may terminate by spontaneous and perfect
restoration of the part.  Adherent  atrophic striae or  patches  are
remediless.   The progress of the disease is  exceedingly indolent, and
may continue for a  lifetime.  Occasionally  grave sequelae  may be
anticipated.

                         Elephantiasis.
                        Gr. eM<j>ac, elephant.
Elephantiasis is a chronic disease of the cutaneous and subcutaneous tissues,
  usually limited to certain regions of the body, preceded by the occurrence
  of some inflammatory process in the blood- and lymphatic vessels of the
  affected part, and resulting in an  enormous increase in  its  volume, with
  hypertrophy of the structures of which it is composed.

  Symptoms.—This  disease, long  known as  Elephantiasis Arabum,
Pachydermia, Bucnemia Tropica, and Elephant Leg, or Barbadoes
Leg, is  encountered  more  frequently in and  near the  tropics, but
sporadic cases occur in all  countries.   Perfectly typical  instances of
the malady have  been  noted  in  almost every part of  the United
States.
                              Fig. 49.
Elephantiasis of the foot and leg.
  Its most frequent seat is the lower extremity of one side, where it
involves the  foot and  leg, though the thigh of the same limb  may 
ELEPHANTIASIS.                    413
also  enlarge.   The  penis  and scrotum  of the male, the labia and
clitoris of the female, the upper extremities, the face, and portions of
the truuk may likewise become involved.
  The disease is insidious  in its approach, and remarkably chronic in
its career.   Usually, localized inflammations precede, as an erysipelas
or a dermatitis, with or M'ithout some involvement of the lymphatic
vessels and glands.   At the same time there is a condition of general
fever.   To this succeeds a defervescence, M'ith abatement of  the local
inflammation ;  its sequelae becoming manifested  in a  more or less
persistent  oedema of the  part  lately inflamed.   After  intervals  of
days, M'eeks, or months, the pyrexia  recurs M'ith still greater involve-
ment of the swollen tissues which, with each access of fever, increase
in volume aud gain  in density.   When  the elephautiasic condition is
fully developed, the  skin  is found to be tense, glossy, aud blanched
or discolored in various shades.   Pressure upon  the oedematous part
is followed by  pitting, but the tissue  beneath is felt  to be brawny and
indurated.   The parts beneath the skin are perceptibly increased  in
volume, especially the subcutaneous tissue ; and the circumference of
a limb  thus diseased may be several times larger  than that of  its
fellow.   A lymphangitis  is usuallly declared  by  painful, cordlike,
linear indurations of the part,  associated  M'ith adenopathy of the
Fio. 50.
Elephantiasis scroti.
nearest ganglia.  In older cases, the skin loses  its glabrous aspect,
and  exhibits eczematous, verrucous, papillomatous, seborrhceic, and
even ichthyotic changes.   Pigmentation, even to a blackish tint, may
ensue; scaling, Assuring, and furrowing are common; and the accum-
ulation  of altered  sweat  aud  sebum  in these depresssions  is  the 
414
DISEASES  OF  THE  SKIN.
source of an  offensive stench.   During the course of the  disease
almost all of the elementary lesions of tiie skin may be displayed  by
the skin, maculae, vesicles/papules, tubercles, pustules, blebs, ulcers,
crusts, scales,  excoriations,  and  fissures.  Warty  growths form as
large as those seen in ichthyosis  hystrix, aud in some cases reddish-
colored tumors spring from the hypertrophied integument.
  When fully developed in the  lower extremity, the unwieldy limb
with  the  foot, ankle,  and leg  massed into  one  huge,  cumbrous
cylinder, bears a  striking resemblance to that  of the elephant, from
\vhich circumstance the malady first received its  name among  the
Arabs.  Locomotion is then greatly impeded, or rendered impossible.
Xo less striking is the similar deformity induced in the female labia
or male scrotum,  the latter at times hanging far  below the knees.
In  its rugous folds the penis disappears, aud the urine is  passed
along a gutter formed of skin transformed  into quasi-mucous mem-
brane.  As  a consequence of the fissures  and  excoriations  M'hich
form, the lymphatic channels are finally opened, and a true lymphor-
rhoea  results.   After similar  processes  the  ear may become  largely
pendulous by the side of the neck.
  Subjectively, the  disease  may be regarded  as productive  of  less
discomfort than would be suggested by its formidable features.  Paiu
is occasionally experienced, and, during  the  exacerbations accompa-
nied by pyrexia, there is corresponding malaise.  The chief subjective
sensations are those induced by the M'eight and consequent  tension,
inseparable from the enormous masses of hypertrophied tissue.
  Etiology.—The  causes  of elephantiasis  are exceedingly obscure.
Predisposition  of races or individuals, heredity, climatic influences,
malaria, fatiguing labor with  the feet and  legs immersed in water,
aud filth in connection  M'ith "misery,"  have all been cited as favor-
ing conditions.  To these  should  be  added  the  local disorders
especially common  in the lower extremities, M'hich  have in cases
proved to be the points of departure of the elephautiasic hypertrophy,
such  as obstruction to the blood or lymphatic currents by pressure
of  tumors,  pregnancy,  or  neoplasms ;  ulcers,  cicatrices, and  the
presence in the blood of the filaria sanguinis hominis.
   LeM'is and others have demonstrated  the presence of embryos  and
filaria, adhering to the  walls  of both lymphatic and bloodvessels in
elephantiasis of the tropics; but the occurrence of the malady M'here
such  parasites do not  exist is  to be explained on other grounds.
The disease  is especially prevalent in  the East  and West  Indies,
Egypt, Arabia,  Abyssinia,  Africa, Malabar,  Barbadoes,  Brazil,
Mexico, and parts of China.
   Pathology.— Fvcu macroscopically, the elephantiasic mass is  seen
to  be  built up of hypertrophic elements representing all the  tissues
of  which the part is composed.  The knife with  difficulty divides
the  homogeneous,  whitish,  and  lardaceous  mass, from  which on
pressure exudes a fluid  of similar color.  The subcutaneous  connec-
tive tissue is found relatively much more enlarged and sclerosed than
the epidermis aud derma ; though when the section is made through 
ELEPHANTIASIS.                    415
the rugous and Marty skin described above, all the elements of the
papillary layer, rete, and stratum corneum are seen to participate in
the changes described  in connection M'ith  the pathology of verruca.
lb-re and there are loculi filled with a fluid  lymph.   The sheaths of
the bloodvessels,  lymphatics,  and nerves, the bones, muscles, and
aponeuroses are also thickened, solidified, and occasionally aggluti-
nated, so as to be almost indistinguishable in the mass of uniformly
sclerosed  tissue.   The  pigmentation of the  derma  is marked:  the
nuclei of the connective-tissue cells are multiplied; aud the cutaneous
glands  intact,  hypertrophied  in their epithelial linings  and invest-
ments, or, at a later stage, atrophied.
   It  is evident that in  many cases, as YirchoMr has pointed out, the
earliest of the changes to be noted occur iu the lymphatic glands and
vessels, the whitish  and yelloM'ish lymphatic fluid M'hich then accu-
mulates in the tissue, resulting  from obstruction of some of the  lymph
channels.   In some of the remarkable cases on record the lymphatic
obstruction is the prominent feature of the disease;  and the elephauti-
asic enlargement  subordinate  in gravity to  the  former condition.
Such are, for  example,  the noteworthy  instances in M'hich the  lvmph
distends multiple  cutaneous vesicles, after rupture of one or more of
which that fluid streams away to a dangerous extent.   For a fuller
description of this interesting class of eases, the reader is referred to
Busey's careful  monographs on  Occlusion  and  Dilatation of  the
Lvmph Channels.
   J) i a gnosis.— The striking deformity, which characterizes elephanti-
asis, M'ill  ahvays suffice for its recognition.   In the earliest stages of
the disease, M'hen  merely an erysipelatous or eczematous  condition of
the skin can  be  determined, it would be difficult, if not impossible,
to decide as  to  the future of the disorder, especially in a  locality
where only sporadic cases occur.   A  symmetrical  hypertrophy of
both  legs  and both feet developing in  this  country, even  though
described as "elephantiasis," should be most carefully studied before
a diagnosis is made  of  the  particular disease  here considered.   The
same might even be said of elephantiasis of but one inferior extremity.
The author Mas once requested to examine a  patient with extensive
deforming induration and enlargement of  the right leg and  foot, ac-
companied by pigmentation and a M'ell-marked Marty condition of the
skin.  M'ho had been pronounced the victim of idiopathic elephantiasis
Arabum.   It M'as discovered that the patient had had  a fracture of
the upper third of both  bones of the same  leg during the previous
year,  and had since constantly  worn a  tight  bandage, encircling  the
limb  at the seat  of the injury.  The deformity rapidly  disappeared
under the application  of a roller  bandage  extending from the toes
upward.
   A peculiar and  rare, though  characteristic, deformity of the labia
majora  of women—most commonly the labium majus of one  side—
results from a tertiary,  syphilitic, gummatous infiltration  M'hich must
be distinguished from elephantiasis.   In such cases the history of the
disease and  the relative inferiority as to bulk of the affected  organ, 
416                DISEASES  OF  THE  SKIN.
points to the nature of the disease.  The syphilitic  labium rarely
exceeds the size of a large fist.
   Treatment.—In the early stages of elephantiasis, the febrile condi-
tion of the patient aud the localized cutaneous inflammations, are to
be treated  by the measures appropriate for the relief of these condi-
tions.   Quinine, especially in  malarial  districts, is  of  the highest
importance.   When the elephantiasic development is established, if
the genitals are  involved, the  knife of the  surgeon  offers the best
prospects.   The result of such interference, both in the genitalia and
extremities, has  been in  many cases  brilliant indeed,  though  the
mortality of such severe operations is necessarily great.   When the
lower extremity is involved, it should be maintained  in a  horizontal
position, its ulcers if possible  healed, its excrescences removed, its
circumscribed inflammations  resolved, aud then  elastic compression
be carefully and skilfully maintained by means of the rubber bandage.
The toes are  first separately enveloped; then the foot  and ankle;
and lastly the leg.   The results are sometimes highly satisfactory.
   Ligation and digital compression  of the main artery supplying the
elephantiasic  leg,  have  been  occasionally  followed  by  transient
improvement.   Instrumental compression  has at times resulted  in
severe ulceration, and a reawakening of the  erysipelatous affection.
Multiple punctures  and incisions, made with a view to  giving exit
to the fluids contained in the mass, have  been attended by no greater
success.  The main obstacle  in all these surgical procedures, is the
lymphangitis which so frequently complicates  the situation.  None
of them promises so well as nerve stretching,  which, in a few isolated
cases, has been followed by noteworthy results.  Excision also of a
portion of the sciatic nerve has been followed  by satisfactory changes.
The use  of the galvanic current  has, when  long continued, accom-
plished resolution of engorged masses of.tissue.  Elastic compression
in the  horizontal position for all  cases not warranting nerve stretch-
ing, may be regarded as  the wisest course  M'hen the extremity is
involved.  For the local treatment of the pachydermia proper, green
soap, mercurial ointment, and bathing in hot or cold lotions, may be
advantageously employee!.  For patients whose  disease  is acquired
in countries where the deformity is  prevalent, a change of climate is
of the highest importance; and, having  in view the social  surround-
ings and habits of most victims of the disease, it is scarcely necessary
to call attention to the need  of a proper hygiene, diet,  and  tonic
regimen.
   Prognosis.—The future of a  patient affected with the disease may
be  regarded  as most favorable when  the latter exhibits an  early
tendency to respond  favorably to appropriate  treatment, and  when
circumstances  permit  of  a resort to the best  therapeutic  measures
which  can be adopted, such as change  of residence,  persistent and
careful dressing of the affected part, aud the removal of any exciting
cause of  the disease, such as a neoplasm,  indurated  cicatrix, etc.  In
the severer cases, a fatal result may be precipitated ; but usuallv  life
is  prolonged, burdened  by  the inconvenience   of  the  enormous 
ROSACEA.
417
 elephantiasic mass  in  comparison with  which  the  rest of the body
 often seems to serve as a mere appendage.
   Lymph Scrotum, Varix Lvmphaticus, or Naevoid  Elephantiasis,
 fully described by  Wong, Carter, Fayrcr,  Mausou, and  other East
 Indian observers, is that condition in which the inguinal and femoral
 glands become  large and soft, and  the scrotum covered with vesicles
 aud distended with dilated  lymphatic vessels all filled with coagu-
 lable lymph.   As  in  elephantiasis  of other organs, there  may  be
 preceding fever, chills, erysipelas, and other localized inflammations.
 The disease  is  produced solely by the filaria sanguinis hominis, and
 may be associated often with chyluria on the one hand, and elephan-
 tiasis of other organs on the other.


                             Rosacea.

                            Lat. rosa, rose.

 Rosacea is a chronic cutaneous disorder, chiefly of the face, characterized  by
   irregularly disposed, rosy or  reddish maculatious often produced  by telan-
   giectasis of  the skin  capillaries,  or forming split-pea sized and  larger
   hypertrophic nodules most commonly seated upon or about the nose.

   The condition of telangiectasis described  under this title, is almost
 identical  as  regards its clinical  features with acne rosacea (Gutta
 Rosea,  Copper-nose), to which the  reader is  referred.   In what fol-
 lows, it is attempted  to portray the  affections of  this class which
 maybe properly described  as hypertrophic in  character; relegating
 the acneiform cases  to the chapter devoted to Acne Rosacea.

                        [A.]  Erythematosa.

   Symptoms.—The  eruption  is usually displayed  in middle life  or
 later, and chiefly upon the face  of both sexes.  In these, the nose
 (tip, alae, root), brow  (especially near the  root of the nose),  chin,
 cheeks, temples, or  lips, may  be the seat of reddish or rosy blotches.
 The effect is a marked unsightliness for M'hich  chiefly or  only the
 advice of the physician is sought.   These maculations are  usually
 unproductive of subjective sensations, or of  objective feeling of heat.
 They may be so numerous as to implicate all the regions named above
 to a great degree, or be limited  to  one or  tM'o adjacent regions, or,
 lastly, be  spread very profusely over the entire  face in  minute blem-
 ishes not more developed at  oue point than another.
   The very greatest  irregularity  may  be noted as  to  their contour,
 the spots being pin-point to uail-sized,  roundish, radiating,  stellate,
 linear, tortuous, or in any  fantastic outline.   The colors vary from a
delicate rosy  pink to a  deep purplish crimson.  Viewed M'ith  care all
are seen to be produced by a  double  process of dilatation, and new
formation of the skin capillaries.
   This condition  is subject to marked aggravation,  or at  least  tran- 
418
DISEASES  OF  THE  SKIN.
sient  change of features after  the operation of any cause tending to
congest the vessels of the head, such as dietetic stimulation, coughing,
laughing, sneezing, active  exertion, the  application of hot water to
the surface,  exposure  to  the sun,  etc.   After  such occurrence,  the
blood  will visibly distend the vessels of the  face, the color deepen
and spread, and all features of the disorder become decidedly con-
spicuous.   Often  a  coexisting acne, or seborrhcea faciei participates
in these changes.   The disease is seen with almost equal frequency
in both sexes, but women  rarely exhibit  the succeeding stage of  the
disorder next described.

                       [B.]   Hypertrophica.

  After a longer or shorter continuance of the condition described
above, a  new formation  of connective  tissue  with cell  infiltration
proceeds pari passu M'ith  the telangiectasis.  In  this way small or
large  pin-head to  egg-sized tumors are developed, more particularly
about the tip or alae of the nose, reddish or purplish in color, till  the
stage  is reached which is  elsewhere described as  rhinophyma.  The
absence of inflammation is in these cases marked.   The nose is often
cold to the  touch  when bright red in  hue, and  may be  of a pecu-
liarly oily or greasy appearance in consequence of a seborrhcea oleosa
of the  part.  The  so-called  "brandy-drinker's," "M'ine-drinker's,"
and "whiskey-drinker's," noses are of this  class.
  Etiology.—The disease in its milder manifestations  is  common
to both sexes,  the hypertrophic forms  being rarer and  practically
limited to the male sex.  The causes of the disorder are numerous,
but always operate by producing at first active or passive distention
of the bloodvessels of the upper portion of the body.  Among these
effective causes  may be named gastric  dyspepsia (especially though
not exclusively associated with intemperate use  of alcoholic  stimu-
lants, including brandy, whiskey, wine, and  beer);  articles of clothing,
surgical apparatus, tumors, etc., compressing the larger vessels at  the
root of the  neck;  the  long-continued action  of heat and cold upon
the face,  as also the local effect of chemicals, aud the  influence of
certain trades and occupations of life tending to  produce congestion
of the  face, as, e. g.,  among cooks, cab-drivers,  swimming teachers,
etc.    In some  cases there is a distinctly inherited tendency to  dis-
tention of the  capillaries of the skin of the face;  iu yet others, the
rosaceous blemish is  congenital.    Disease of the uterus and other
viscera may be the remote sources of the trouble.
   Pathology.—The hyperaemia usually  begins as a transitory  phe-
nomenon in the more deeply seated plexus of vessels and, after  per-
manent distention has resulted, the vascular elements of the more
superficial strata of the corium, and those  surrounding the sebaceous
glands and  hair-follicles  become  involved.   In  the  hypertrophic
lesions, there are  new formation of connective tissue, enlargement of
all portions of the corium, hyperaemia and  telangiectasis of the  ves-
sels, and  dilatation of the sebaceous glands. 
FRAMBCESIA.
419
   Diagnosis.—Acne rosacea  is to be  distinguished from uncompli-
 cated  rosacea  by its  characteristic lesions, comedones, papules, pus-
 tules,  cruets, etc.   In uncomplicated rosacea, there is only a macular
 lesion due to hyperaemia or telangiectasis.   The two disorders, thus
 artificially  distinguished, are often found the one complicating the
 other, an acne being the  origin of the hyperaemia, which is the first
 rosaceous stage.   The hypertrophic lesions of rosacea are also often
 thus associated with acneiform symptoms.    Lupus, carcinoma, and
 syphilis of the regions affected by rosacea are commonly productive
 of ulcerative or destructive consequences which point to the nature
 of those affections.
    Treatment.—The treatment of rosacea is  practically  the  same as
 that of acne rosacea, to the chapter devoted to which  the reader is
 referred.    The vessels producing  the rosaceous blemish are to  be
 destroyed,  preferably  by electrolysis;  but the  result  may also  be
 accomplished  less  elegantly and perfectly by incisions,  followed  by
 cauterization;  by curetting, by the  Paquelin knife, by  Brun's sharp
 spoon, Vidai's lancet, or B.  Squire's  multiple scarificator, the last-
 named instrument being  only available for the larger lesions.   The
 hypertrophic forms of rosacea are best remedied by the plastic opera-
 tions of modern surgery.
   Prognosis.—The lesions of rosacea, limited in extent,  even though
 quite  numerous,  may be  elegantly  and permanently  removed  by
 electrolytic methods.   The scars left after operations upon the larger
 lesions are  usually superficial, and  not disfiguring.   The prognosis,
 after ablation of the largest hypertrophic lesions, is proportioned to
 the  resources of surgery.   In no case does general disease result.


                           Frambcesia.
                       Fr. framboise, raspberry.
 Framboesia is a disease of the African race chiefly, manifested in pin-point to
   egg-sized and larger  papulo-tubercular  lesions,  appearing mostly on the
   face, resulting in discharges and crusts, and in cases followed by systemic
   symptoms.
   This disorder,  termed by  Charlouis,  Polypapilloma  Tropica, is
encountered  chiefly among the negroes  residing along  the  African
coasts, in  the West Indies, and in  South America, where it is also
known as Yaws  and  Pian.   By Alibert it  Mas  termed Mycosis
Framdcesioides.   The  contributions to the  literature  of this sub-
ject  have been  made chiefly by Drs. Milroy, Nicholls, and Imray, of
Dominica, and Dr. Bowerbank, of Jamaica.  The malady is said to
be characterized at first by the occurrence of brownish-red, pin-head
to pea-sized, flat maculo-papules.   In  these, one or more yellowish
or whitish  puncta  become visible,  which  gradually develop  into
roundish papules or tubercles, resembling pea-sized and larger pus-
tules of yellowish-red  color.   When the integument M-hich covers 
420                diseases  of  the  skin.
 these  gives  May, a  fetid, sero-purulent  fluid exudes, aud a dirty-
 yellowish, spongy mass projects  from the  rent, and enlarges subse-
 quently, till it appears as a yellowish-red, crusted vegetation, an inch
 or more in diameter.   This  may degenerate  into an offensive ulcer,
 whose destructive processes are accompanied  by progressive emacia-
 tion and systemic disturbance.    Instead  of this retrogressive  meta-
 morphosis, the tubercle may shrivel iuto a dark-colored, crusted, and
 withered  excrescence, yielding a fetid and ichorous discharge.   The
 eruption occurs upon the face, neck, extremities, ano-genital region,
 and, rarely,  upon the trunk.
   The lesions are seldom the seat of subjective  sensation.   They
 have been considered contagious,  and not susceptible of transmission
 by heredity.   The course of the  disease  usually  extends through
 from two to four months.   It is  also said  to occur at all ages and in
 both sexes, one attack conferring  immunity against another.
   The constitutional  symptoms  of the  malady include fever, osteo-
 copic  pains, gastro-intestinal  distress, arthritic troubles  M'ith ulcera-
 tions about the joints  resulting in deformity, and eventually cachexia.
   The disease  is both inoculable and  auto-inoculable.   Inoculation
 results in the formation  of  a  crust-covered ulcer, followed in from
 seven  to  fifteen days by  a general eruption.   The result is rarely
 fatal, the disease being concluded  in most cases after a period of from
 three to four months duration.
   Most of the authorities who have personally studied the disease as
 it occurs in the African race,  believe that frambcesia is a disease  sui
 generis.   Certain it is that in both  syphilitic and non-syphilitic sub-
jects, who have never visited the countries where it is claimed that the
 disease is  endemic,  similar  symptoms  have  been recognized  and
 described.   An interesting case of framboesioid lesions in a syphilitic
 woman is reported by De Amicis ;* and the  author has personally
 treated three patients whose lesions corresponded very closely to those
 described above, no one  of whom was syphilitic.   It can be readily
 understood  that a  vegetation occurring  upon  the filthy skin of an
 unwashed  negro in the tropics, might assume features which would
 be scarcely recoguized as classical, in the clientele of most practitioners
 in this country.
   It is safest  at present  to  regard the term framboesia as largely
 descriptive in scope, and as including certain papillomatous and other
 vegetations projecting from the surface of the body as a result of filth,
 syphilis, tropical temperatures, and possibly  of other unfavorable
 agencies operating upon the skin  of a  negro.   A sufficient commen-
 tary upon these  considerations is afforded  by the admission of the
 West India surgeons,  that mercury and  the iodide of potassium are
 regarded  as  specifics  for the  disease as it exists in those islands, and
 that cleanliness is of  prime importance.
1 Cf. a translation of his paper by the author in the Archives of Derm., October, 1879, p. 39. 
FRAMBCESIA.
421
                             Parangi.

  Kynsev  has presented  a report upon  the  nature  of the disease
which is thus designated in Ceylon, where it  prevails.   It appears
to present  mixed features of syphilis, land  scurvy, yaws, pellagra,
lupus,  leprosy,  scrofula,  and less severe disorders, existing  as an
endemic in certain provinces of the island.   It is clear,  from the
description of the symptoms  recorded, that the nature of the disease
has  not yet been recognized.  It was  first  described by  Loos in
1868, and is now regarded as due to  numerous causes,  such as mal-
nutrition induced  by impure food and Mater, wretched hygienic sur-
roundings, and infection from the discharges from ulcers.
  There is, according to Christie,1 an incubation period  of  from two
to eight weeks,  followed  by the appearance  of an ulcer  over any
bony prominence—the initial  sore.  This is followed by malaise and
pyrexia, the premonitory  fever lasting from two to eight days, and
followed by the exanthem M'hich appears first over the face, aud later
on  the  body.   This eruption  may be  vesicular,  pustular, pustulo-
tubercular, or squamous, superficial ulcerations forming M'hich become
subsequently crusted.  Pupioid, furuncular, aud psoriasiform features
are common in the course of the malady.   Condylomata may appear
at the anus.  Ulcerations succeed later of a  more formidable char-
acter, involving the  nose, palate, and cheeks;  the  digits may be lost
by gangrene;  blebs occur; pricking pains are experienced; there may
be anaesthesia of some part of the surface, associated  with bronzing
and glazing  of the skin.  The patient  may  perish of some inter-
current disorder or from exhaustion.
  The duration of the disease is said to  be from two to eight years.
Treatment has been  successful M'ith the cautious employment of mer-
cury and the iodide  of potassium, and strict observance of the rules
of hygiene.

  Doxda  Ndugu  (" brother ulcer," or " ulcer that clings")  is a
disease existing in Central and Eastern Africa.   Dr. James Christie,2
M'ho first described it, believes it to be identical M'ith that from which
Livingston suffered in 1870.
  The disease is confined to the lower extremities,  and occurs among
the natives chiefly iu the  rainy season after a march toward the
coast.
  It is characterized by the appearance of M'hitish  papules  springing
from a boggy swelling, seen often near  the toes, heel, or dorsum of
the foot.   When  iucised, an  extensive, deep-seated slough is  found
beneath the healthy tissue, bathed in au  ichorous discharge.   Severe
rapidly-spreading ulcerations  and death  may ensue.  Livingston ex-
tracted the ova of a  species of maggot from such lesions in  his  own
person; but Christie failed to discover them in his cases.  The treat-
ment is local, by the use of antiseptics after incision.
1 See Anderson's Treatise on Diseases of the Skin.
2 Loc. cit. 
422
DISEASES  OF  THE  SKIN.
                         CLASS  V.


                          ATROPHIES.


                       1.  Of Pigment.

  Absence of the pigment of the  skin, giving  rise to conspicuous
disfigurement,  is  naturally most  frequently encountered  iu those
races of mankind whose skins are most abundantly provided with
such pigment.    The absence of pigment  may  be congenital or ac-
quired, and partial or universal.  Some confusion has been  produced
by the arbitrary distinction established by authors between the names
intended to designate  these several varieties of achromatia or leuco-
pathia.   In  the  following pages, leucoderma is the name employed
to designate the  pigment atrophy  Avhich is partial  and congenital;
albinismus, that  which is universal  and congenital;  vitiligo,  that
which is acquired.

                         Leucoderma.

                    Gr. 2.EVKO?, white;  depma, skin.

Leucoderma is a partial  congenital absence of pigment in the skin, most
  commonly observed in the  colored races, and characterized by whitish
  patches or bands having an irregular border, the evidences of disease in
  such parts being  limited to the changes in hue of the skin and hairs.

  Symptoms.—In these cases, the  patients  being most  often  of the
colored  races,  one or several  whitish  or  rosy-whitish pate lies or
bands, varying as to size, outline,  or situation, may be seen at birth
unprovided with  pigment.  These may have a symmetrical arrange-
ment, in which case they commonly observe the areas of distribution
of one or more cerebral or spinal nerves, or be asymmetrical in  dis-
tribution.   They are  usually of  circular outline, and may  be found
upon the  scalp, face,  nipples, breast, and genital region.  The hairs
found upon such  parts are equally destitute of  normal color, being
usually  white.    Negroes thus marked  are generally  termed " pie-
bald,"  and the integument  similarly affected in  persons of other
races has  long been recognized  as the  " pied" or " piebald  skin."
These blemishes,  wheu symmetrical, like pigmentary naevi, exhibit a
striking analogy   with  the  symmetrical arrangement of the spots,
bands, and stripes to be recognized in the furs of many of  the lower 
ALBINISMUS.
423
animals.  The outline of the patch may be abrupt, or may gradually
shade into that of the adjacent integument.  At times, islands of
pigmented skin are visible within the non-pigmented areas.   The
changes  in these patches during  later life may be  insignificant, or
they may individually increase in size M'ith  age, or even multiply.
Pa rely they regain pigment in later  life.   Iu  no case  is there an
excess of pigment deposited at the border of the patch.
   This  condition is practically remediless.


                          Albinismus.

                          Lat. albus, white.

Albinismus is a congenital  cutaneous achromia, characterized by universal
     defect of pigment, unaccompanied by textural changes in the skin.

   Symptoms.—The term albinismus is limited to the congenital con-
ditions  of  achromia induced  by  universal failure  of cutaneous
pigment.
   This  deformity  is peculiar  to  individuals  known as Albi noes,
isolated instances of  this  anomaly occurring in all  races, but more
frequently among those having normally a hyperpigmentation  of the
skin, such as  negroes.  In  the subjects of this anomaly,  the skin
has a milky-M'hitish, transparent,  or  rosy tinted hue, and is usually
of delicate texture;  the  hairs  are silky and yelloM'ish, whitish, or
snowy-white in color; the iris, transparent or pinkish ;  and the pupil,
in consequence of the defect of pigment in the choroid, is also reddish
or pinkish.  There is, as a result, nyctalopia and heliophobia with
frequent  nictitatiou, pupillary variatious,  aud  the  semblance of
myopia.
   The pinkish hue of the skin is, in  these individuals, due only to
its translucency and vascularity.  In no other  respect, save as to
pigment anomaly, does the skin of the healthy albino indicate disease;
but the majority of persons thus deformed are far from vigorous.
   In albinismus the  defective condition  of the pigment is usually
unchanged  throughout  life.   The  causes  of  the  deformity are
unknown.  The few cases of inherited albinismus on record are not
sufficient to establish a  law  of inheritance in the face  of  many
instances M'here such transmissibility has not  occurred.  The union
of a male or female albino with an  individual  of normal color has
been repeatedly  followed  by  offspring  without  pigmentary  peculi-
arities.
   The condition is remediless ;  though it is probable that transfusion
with the blood of a vigorous  black-skinned African would  largely
modify the color characteristics of the pure albino. 
424
DISEASES  OF THE  SKIN.
                            Vitiligo.

                       Lat. vitium, a blemish.

Vitiligo is an acquired cutaneous achromia, exhibited  in single or multiple,
  variously shaped and sized patches, unaccompanied  by textural change in
  the skin, and usually bordered by tissues exhibiting  pigmentary excess.

  Symptoms.—The disorder is one  observed among the several races,
often in the negro, and not rarely among those of Aryan descent.   It
commonly occurs M'ithout the slightest appreciable disorder, subjective
or objective, save that betrayed to the eye in the discoloration of the
skin.   One or several roundish, or very irregularly shaped, smooth,
and well-defined, pale, or milky-white lines, streaks, or disks appear,
often bordered at the periphery by an integument which  assumes a
light or dark brown or chocolate shade, this  hue being by contrast
most noticeable immediately at the contour of  the patch, and imper-
ceptibly fading into  the normal  color of the outlying integument.
The hairs or lanugo filaments growing from the  affected area may or
may not be blanched.  Most commonly they are;  a condition  par-
ticularly conspicuous when, as is not rarely observed, a vitiliginous
disk extends from the back or side of the neck, well into the scalp, in
which case the outline of that portion of the scalp involved is clearly
defined by the whitened pilary growth.
  Lesser describes a condition termed by him " Poliosis Circumscripta
Acquisita," in which the hairs were thus blanched in a single area of
an unaffected scalp, an observation M'hich the author  has confirmed
in a single case.
  The surfaces thus blanched are otherwise unchanged.   In point of
subjective and objective sensation, secretion from the follicles, and the
condition of both epidermis and corium, aside from the dyschromia
there is  no departure from a  normal standard.  The disease  may
progress by the coalescence of  relatively small areas of involvement
till a large  portion  of the trunk, thighs, or buttocks is involved.
Hall1 reports the case of a dark mulatto who became  " perfectly
white" M'ith the exception of a patch  on the chin.   Levy2 reports
three instances  of  total disappearance of  pigment.   It is  then, as
Kaposi has well shown, that the eye of the observer is struck  no
longer  by the unusual whiteness of the involved  patches; but this
whiteness being generalized and apparently that proper to  the person,
by the intermediate peripheral belts of a deeper and  unusual color.
The greater portion of the surface of the  body may be finally thus
involved.  The most  common seats  of the disease are the face, the
neck, the backs of the hands,  and the extremities;  and in  these,
since the course of the disease is exceedingly slow, there may be
1 Louisville Med. News, 1880, x. p. 148.
2 Keceuil de Mem. de Med. de Chirurg et de Pharm. mil., 1865. 
VITILIGO.
425
Fig. 51.
for years no apparent extension of any involved area.  Upon the backs
of the hands the disfigurement is usually more conspicuous at some
seasons of the year than at others, a circumstance which probably ex-
plains the  reported  instances of  recurrence
and total disappearance of the disease in suc-
cessive years.   These changes are probably
due to the  influence  of  the sweat in washing
the pigment  to the  surface.   Such  an  effect
would, of course, render the hyper-pigmented
peripheral  zone  of  a vitiliginous disk  much
the more conspicuous.
   The health of the subjects of this disorder
is usuallv unimpaired.  A morbid mental
condition is often produced when the disfig-
urement involves the facial region, especially
in women  of middle life.
   As iu several of the other pigmentary dis-
orders of  the skin, the  patches  of vitiligo
may  be  symmetrical  in  distribution, M'ith
their outlines  limited  to  the areas  supplied
by certain  nerves.   Lesser,  however, attrib-
utes this peculiarity to  the symmetrical ana-
tomical relations of  the skin in symmetrical
regions of the body, an  explanation M'hich
will not suffice for all cases.
   The  course of the disorder is evidently
toward increase even where all the pigment
is not removed from the surface.   Generally
a term is reached beyond which  the atrophy
does  not progress.   In exceptional cases the
parts M'hich  have lost their pigment  again
acquire it.
   Patients of lymphatic temperament and
blonde complexion (often they are women in
early adult life) M'ill occasionally apply to  a
physician  for  relief of dark patches on  the
skin  of the  face.   Examination  of  these
faces often discloses faint lines, ribbons, or
streaks of pigment about one or both cheeks,
the temples, or the lips.  But a yet more careful  scrutiny recognizes
an undue whiteness  of  the skm, M'ith exceedingly faint and irregular
outline near or next to these pigmented portions of M'hich complaint
is made.   I  am  inclined to set all  these  cases down  as  instances of
vitiligo, even though thcv rarely exhibit the definite roundish contour
of the typical patch  of the disease.
   In some patients vitiligo is most conspicuous in summer; in others,
this  occurs in M'inter.   These peculiarities may depend upon  changes
either in the pigmented or unpigmented portions of the skin.
Vitiligo in a Negro boy.
   Piffard's case. 
426
DISEASES  OF  THE  SKIN.
  Etiology.—Vitiligo occurs in both sexes, aud in  individuals of all
complexions and ages; though it is commonly observed in  early or
middle life.   It is  at times  coincident with scleroderma, morphcea,
lepra, variola, and other diseases with similar cutaneous symptoms,
though  it occurs independently of all  such.   Its  etiology  must be
regarded as  obscure, unless the  strong  probabilities  in favor of its
occurrence under the influence of perturbed  innervation be^  accepted
as conclusive.   I am strongly inclined to believe that the disorder is
of more frequent  occurrence  than  dermatological  statistics tend to
show.   Many persons who are the  subjects  of vitiligo of an incon-
spicuous part of the body, do not consult a physician with regard to
the nature of the disease, as it occasions no physical distress.  Close
observation of the people with whom one comes in  contact in public
will often verify this  fact.
  Pathology.—The pathological anatomy of vitiligo may one day be
described in the changes which occur in the trophic nerves supplying
the skin.  At present, the cutaneous changes  alone are recognized;
and these are, probably,  as  regards the  pigment, neither  strictly
atrophic nor hypertrophic.  It is  true that  there is  an apparent
atrophy in one portion of the skin, and an apparent hypertrophy in
another;  but this may be  merely in cases falling  short of complete
pigment atrophy, a dystrophia or ataxia of the epidermis, a disturb-
ance of arrangement and distribution, as of the  blood  in the face, in
certain  cardiac diseases, when the skin is temporarily  streaked or
mottled by the irregularity in the distribution of the circulating fluid.
Under the microscope no change is recognized iu the skin beyond the
absence of pigment.
   Diagnosis.—Mr.  Hutchinson, of Loudon, has  devoted  an entire
chapter in his valuable  Lectures  on  Clinical Surgery^  to the impor-
tance of the diagnosis between leucoderma and white  leprosy; yet it
seems  incredible  that  the symptoms  characteristic  of a  systemic
disease could be confounded M'ith those described above, where there
is no cutaneous anaesthesia or structural change in the integument.
This latter is, in fact, the basis of discrimination betM'een all purely
pigmentary and all non-pigmentary changes in the skin-color, separ-
ating them widely from  parasitic diseases (tinea versicolor), morphcea,
lepra, and syphilis.   From the  chloasmata, which  are  ahvays accom-
panied by hyper-pigmentation, vitiligo  is readily differentiated.
   Treatment.—Much  chagrin will be  saved  both  physician  and
patient, by practically  regarding vitiligo as  not amenable  to  treat-
ment.   Patients  occasionally  recover  while  under  treatment; the
latter has, however, generally contributed but  very little to the result.
Arsenic and iron internally, recommended  highly by some  authors,
have repeatedly failed to accomplish any appreciable results as regards
dyschromia.    By  efforts directed  to the  removal  of the  hyper-
pigmentation in the border of the achromic patches, the disfigurement
may be somewhat lessened.   The method  of arriving at this end  is

                         1 Churchill, London, 1878.
f 
CANITIES.
427
described in connection M'ith the treatment of chloasma.   It is pos-
sible  that further  experimentation with hypodermatic injections of
pilocarpine, M'hich  have  in a limited number of cases been followed
by disappearance of the disease, may warrant a less unfavorable vieM'
of the results of treatment.
   Prognosis.—The health o1* the  subject of the malady is  not im-
paired.   The disease is practically incurable, progressing  usually till
it has obtained a  maximum of development; and then, as  a rule,
remaining unchanged throughout life.

                            Canities.
                          Lat. canus, white.
Canities is that condition of the hairs in which they become in various degrees
           decolorized as the result of atrophy of their pigment.
   Symptoms.—In Canities, or Poliosis, hairs appear in all shades of
whiteness, from dirty-gray to silvery-M'hite, and this either as a general
or partial, congenital  or acquired,  physiological  or pathological,
prematurely,  rapidly,  or gradually  acquired condition.   General
congenital whiteness  of the  hairs  is seen in albinismus,  where pig-
ment has never been supplied to  the filaments.   Partial  congenital
whiteness is occasionally seen, in  meshes limited  iu size, varying in
color from a pure white to a deeper hue,  M'hich from birth refuse to
receive  pigment in  due proportion, and thus contrast strangely with
the pigmented filaments by M'hich  they are surrounded.
   Physiological decoloration of the  hairs in  variable shades is the
well-known result  of advancing years.   When premature, it  may be
considered as resulting  from pathological causes, or due toother indi-
vidual  or  inherited  peculiarities.   It may  occur gradually or sud-
denly ;  in  the  former case, the hairs usually pass  through varying
shades of gray to M'hite, and this at any period after puberty  though
usually after middle life is reached.  Recurrence to the darker shades
is rarely noted.   Leonard, of Detroit,1  cites a  number of  curious
instances in which  changes of this sort  have occurred.   Generally,
however, canities of  advanced years is  progressive  and  permanent,
occurring earliest on the temples and the beard of man, then involving
the vertex  of the  head.  Finally, the hairs of  the  entire  surface
undergo a similar pigmentary loss.
   It should be remembered that the coloring of the hairs  of the head
is, to  a greater extent than is  commonly appreciated, subject  to vari-
ation  from the operation of external causes.   Thus washing the hair
with alkaline solutions has a bleaching effect, while profuse SM'eating,
inunction M'ith fats, subjection to smoke, aud the temperature changes
of the  summer, have the contrary influence, the last named being
possibly due to the  increased sweating iu the hot season.
   Cases of sudden blanching of the hairs, occurring, for  example, in
a single night, are sufficiently numerous aud well authenticated to be
i The Hair, etc., Detroit, 1880 
428
DISEASES OF THE  SKIN.
admitted  as  among  the  rare possibilities of a  clinical  experience.
Nervous disorders, both centric and  peripheral, such as long-con-
tinued  mental  depression,  melancholia,  paralysis,  neuralgia,  and
traumatism of nerves or of nervous centres, may be  followed by more
or less rapid, general or partial, and  permanent canities.   The same
result may follow Masting disorders, such as typhoid fever, in  which
cases, as distinguished from the others, properly pigmented hairs often
replace eventually those which were  white.   It  is  well knoMii that
the first hairs springing from a patch of alopecia areata M'here  repair
is in progress, are often white or M'hitish, and replaced later by those
of normal color.
  Landois has  shown  that many instances  of  suddenly occurring
canities depend solely upon the rapid appearance of air-bubbles in the
shaft, in excess of the average number.  Hairs whitened in alternate
patches,  rings, nodes, or   spots  have  been described  by  Landois,
Karsch, Richelot, Spiess, and others.
  Etiology.—Whitening of the hair may be senile in origin, in  which
case it is customary  to declare it to be physiological; or be due to
heredity; to  deficient nutrition or innervation of the hair-follicles;
to functional  or organic  nervous affections (fright, facial atrophy, etc.);
or to local chemical  action  upon the  hairs.   Premature canities in
young adults is often associated with the  occupations of life, being
much more common in  men who from necessity have the head  habit-
ually covered, and M'ho yet lead sedentary lives.
  Pathology.—The pigment substance of the hairs is both cellular and
intercellular in its distribution, and is supplied by the papilla.    De-
coloration of the hairs may be due  to  failure of supply or removal
of pigment;  to unevenuess of the hair surface (by which  the light is
refracted); or to air-bubbles between and  within the fibre-cells.   In
senile and presenile decolorations, there is commonly actual diminu-
tion of pigment, which has been ascribed  to failure of the papilla to
produce it.    Sudden canities is ascribed to the sudden appearance of
air-bubbles in quantity in  the shafts of the hairs.   Alternations of
color in the hairs  are ascribed to successive periods of activity  and
rest in the pigment-producing function of  the follicle.
   Treatment.—McCall  Anderson, M'hile admitting that the treatment
of canities is unsatisfactory, suggests, in cases of accidental  presenile
blanching, strict attention to  the general health, arsenic internally,
and local stimulation, as  in alopecia simplex.   But the chief  means
of remedying premature  canities is by the action of dyes, and these
are, in the  main, compounded of solutions  of  nitrate of  silver,
acetate of lead, and  the sulphate of iron.   The chief objections  to
their use are  the disagreeable coloring of the scalp which results from
incautious use of the dye, and the  consequent  liability to  irritation
of the surface.  When  applied to the hair alone, these substances are
not known to have a deleterious effect upon the health.  Kaposi gives
the following formulae  for hair dyes : 
ALOPECIA.
429
or,
  To obtain a black color—
        R. Argent, nitrat.            gr. xv;            1
           Ammon. carb.           grs. xxij;            1
           Unguent, adipis              Jj;           32      M.

        R. Argent, nit.                  5j;            4
           Plumb, acetas             gr. xv;            1
           Aq. Cologn.              gtt. xv;            1
           Aq. ros.                 ad fjiij;           96      M.

To obtain a broM'ii shade—

        R. Acid, pyrogall.            gr. xv;            1
           Aq. Cologn.                 3ss;            2J
           Aq. ros.                    |jss;           48j     M.

  Anderson first applies a lotion  of the  bichloride of mercury, two
grains to the ounce (0.133-32.), and  follows  this with a solution of
the hyposulphite of sodium, one  drachm to the ounce  (4.-32.), for
the production of a jet-black shade.
                         2.  Of Hair.

                            Alopecia.
                          Gr. akuiirj^, a fox.
Alopecia is a physiological or pathological, symmetrical  or asymmetrical,
                 partial or complete deficiency of hair.

   Alopecia, Calvities, Defluvium Capillorum, or Deficiency of Hair,
may be due to arrested pilary development at  birth,  or to any cause
interfering with the regular physiological process by  which hairs are
constantly shed and replaced by new filaments.

   Congenital Alopecia.—In rare cases, there is a partial or com-
plete absence of hairs at birth, in consequence of an arrested develop-
ment of the pilary system.   Generally, however,  these  appendages
of the  skin  are merely  of tardy appearance, their  eruption being
extraordinarily delayed, as  in cases of retarded dentition.
   When this condition persists to adult years, as  is very rarely the
case, neither hairs  nor  teeth  may be  formed, as  in Danz's observa-
tion.   The author has had a child  seven years of age presented at
his clinic,  with only a M'isp of white  hairs  upon the vertex of the
scalp.
   In localized congenital alopecia, hairs rarely develop after matu-
rity, aud here also  abnormalities of teeth may  be coincident features.
In  a  case examined by Schede, the  sebaceous  glands were found
opeuing on the free surface  of the skin.  In  the deeper part of the
cutis,  straight or  convoluted  hair-rudiments were  visible  iu  the
tubules, M'ithout  perceptible internal  cavity, which corresponded to
the external root-sheath. 
430
DISEASES  OF  THE  SKIN.
   Senile Alopecia.—The baldness of old age, whether occurring
 upon the vertex, so as to produce a tonsure like that of the priest, or
 whether limited to the frontal  region, or so extensive  as  to  involve
 nearly the entire calvarium, leaving a fringe of hairs at  the occiput
 aud temples merely, is always remarkable for its symmetry.   There
 is hence a certain degree  of dignity added  to the appearance of the
 head, M'hich an asymmetrical loss of hair could not produce.  It may
 occur at varying ages of advanced  life, and is quite frequently trace-
 able to an early seborrhcea sicca or alopecia furfuracea.   It  is much
 more common  in men than in women; and this largely because  of
 the difference in the manner of covering the head in the  two sexes,
 women usually wearing  an  exceedingly light dress for the head,
 while  men  encase  the  latter  with tight-fitting caps or  hats which
 interfere with proper aeration of the scalp.   Individuals  of the male
 sex, also, in consequence of their usually wearing  the  hair short,
 bestow far less time upon the care and dressing of it.  In uncivilized
 races, where these  differences are less  marked, and M'here men pay
 great attention to the ornamentation  of the scalp, senile  baldness is
 of less frequent occurrence.
   The bald surface is, as a rule, smooth and shining;  it is occasion-
 ally the seat of a seborrhcea oleosa.   The hair-follicles,  with their
 accessory sebaceous glands, and occasionally the skin  itself are often
 in a state of atrophy, though there may be dilatation of the sebaceous
 glands.  There is commonly some blanching of the hairs, which are
 gradually shed, as  also  of those which remain, though  this is not
 constant.    These conditions are  much less frequent upon the surface
 covered by the beard, and pubic and axillary hairs, where, according
 to Michelson, the hairs in advanced years are often  denser than  at
 other periods of life.

   Prematuee or  Presenile Alopecia,  or premature calvities, is
 that form of  acquired  baldness which occurs in individuals  M'ho
 have not attained advanced years.   It may be either  idiopathic or
 symptomatic.
   The idiopathic variety does not  originate in the  diseases of the
 scalp or of the general economy which are recognized as  effective in
 the  production of  other  forms of baldness.   It is, as  with senile
 alopecia, more common  in men than in women, and is,  in the former
 sex,  decidedly prevalent  among those leading sedentary lives.   The
 loss  of hair may be produced either rapidly, or, more  commonly,
 slowly, and at any period after the puberal epoch.    The pilary
 growtb may gradually and evenly recede from the forehead, or, what
 is more frequent, recede on either side of the median line, leaving a
 more vigorous crop extending centrally toward the root of the nose,
 or produce the  effect of the tonsure described above.   It is  always
 symmetrical, and usually remediless, partial calvities being the  per-
 manent result of the process.    In  many families, there is a predis-
position to this premature loss  of hair, which may be recognized in
the males of succeeding generations. 
ALOPECIA.
431
  Symptomatic premature alopecia is  the frequent result of a series
of local and general disorders M'hich vary in their gravity.   Sudden
and gradual symmetrical thinning of the hairs or complete baldness,
is sufficiently common as the result of  seborrhcea sicca, psoriasis, and
other cutaneous affections of the scalp; the asymmetrical forms being
more common  in asymmetrical scalp diseases, such  as those resulting
from the destructive action of the vegetable parasites.  Rarely, how-
ever, asymmetrical  seborrhoea, occurring in  patches upon the  side
of the head, may produce such disfigurement.   Among the systemic
disorders which have  this effect,  may be  named  almost  all severe
febrile processes,  including the exanthemata, profound  disorders pf
the nervous centres, lepra, and syphilis.  In the last-named disease it
may occur as a precocious or tardy symptom, the former being ahvays
symmetrical, variable as to the degree of loss, rarely so severe  as to
cause baldness, and, occurring as it does usually  in early adult years,
generally quite remediable.  The tardy form,  on  the  other hand,
is usually associated M'ith the  evolution or destructive  involution of
gummata of the scalp, and the  resulting baldness is often permanent.
   The forms  of alopecia described  above as encountered  upon  the
scalp, may involve  also  other  hairy portions of the  body, as of the
axillae and pubis;  and these also in variable degrees.
   Pathology.—In senile and premature alopecia, a fibrous endarteritis
is described  by Michelson as first  occurring to narrow the lumen of
the  vessels, which  starves the follicular and peri-follicular tissues till
au  atrophy  results.  The epidermis  becomes  thinned; the derma
contracts; the  hair-follicles shrink, M'hile their funnel-shaped  orifices,
occupied with  loose horny masses or  lanugo hairs, remain patulous.
 Convolutions  of pigmented, roundish nuclei, aborted results of hair-
 formation, may rarely be recognized at the base of the empty hair-sacs.
 The coil- and sebaceous glands and muscles are but slightly altered.
   Treatment.—The treatment  of  alopecia in general, is that M'hich
 stimulates the nutrition of the hair-follicle by producing in its peri-
 phery a species  of transitory and artificial hyperaemia.   This is
 usually  accomplished by friction of the scalp M'ith a brush, aided by
 the  local  employment  of one  or  more alcoholic,  oily, alkaline, and
 other stimulating applications described below.   The general health
 must in such  cases receive  special attention.   A  large  number of
 individuals suffering from premature baldness have a distaste for fat;
 and the ingestion of cod-liver and other nutritious oils, fat meat, or
 linseed  and linseed oils, as  recommended  by  Sherwell, is  for  such
 patients  advisable.  Iron, strychnia, tar,  phosphorus, and  arsenic,
 often meet the indications presented.
   A scanty  crop of short, soft, downy hairs may,  however, push for
 a time  to  the surface, but soon  yield  before  the inactivity of the
 follicles in M'hich they are implanted.   Inasmuch, however, as excep-
 tionally brilliant  results arc occasionally obtained  by treatment, the
 latter is ahvays deserving of a trial.   When the  alopecia is symp-
 tomatic of some local disease of the scalp, the latter of course is first
 to be relieved by the measures, appropriate for each, as, for example, 
432
DISEASES  OF THE  SKIN.
the use of parasiticides in those of parasitic origin.   The  total or
partial symmetrical losses of hair occurring in the course of systemic
disorders  have a much more hopeful  prognosis.   Exception, how-
ever, is to be made of  the  tardy syphilitic  alopecia associated  with
local scalp lesions or  profound cachexia.   In all forms of syphilitic
alopecia, local as well as constitutional  treatment is indicated.
  Local treatment may often be preceded by shampooing M'ith either
the Sarg  fluid soap, or combinations of glycerine, alcohol, and  sapo
viridis  to meet the requirements of individual cases.  The scalp,
after all such shampooings, should  be  anointed with lanoline, plain
or salicylated;  vaseline; the oil of benne; or scented castor oil.  In
obstinate cases the nail-brush may be vigorously used over insensitive
scalps at the time of the shampooing.   The salve used may be often
advantageously medicated with sulphur, chrysarobin, tar, cantharides,
or mercury.  Formulae for lotions and  salves to  be used in this way,
are appended:
R. Hydrarg. chlorid. corros.	grs. v;		33
Spts. vin. rectif.	3ij;	64	
Glycerin.	.?ss;	16	
Aq. ros.	3vj;	192	M.
For external use over the scalp.			
R. Picis liquid, [vel. ol. rusci] j 01. lavendul. j	aa£j ;	4	
			
01. pin. sylvestr.	§vj;	192	M.
		[Piffard.]	
R. Hydrarg. chlorid. mit.	9iv;	51	
Hydrarg. ammon. chlor.	9ij;	266	
Vase! in.	ad .lj ;	32| M. [Bronson.]	
R. 01. sabinse gtt.	v-xxx;	133-2.	
Spts. vin. rectif.	5r,	32] M. [Pincus.]	
R. Hydrarg. bichlorid.	gr. ss;	1032	
Cantharid. tinct.	f3j;	4	
Medull. bovis.	§ss;	iel	
01. rosar.	q. s.;	M. [Van Harlingen.]	
R. Acid, chrysophanic.	gr. x;		66
Glycerin.	rilxl;	2	66
Vaselin.	3vij ;	28	M.
		[Anderson.]	
R. Sulphur, prsecip.	3j;	4 16	
Ungt. aq. ros. | Vaselin. j	aa ^ss;		M.
  Andre is said to have induced an abundant growth of hair  in  an
obstinate case  of total baldness by hypodermatic  injections of the
muriate of pilocarpine, from one-eighth to one-fourth (0.008-0.016)
of a grain being injected on each occasion.
  The treatment of alopecia is that also of alopecia  furfuracea and
alopecia areata. 
ALOPECIA.
433
                        Alopecia Furfuracea,

 or  Pityriasis Capitis, or Alopecia Pityrodes Capillitii.   Under this
 title  is included that loss of hair,  varying greatlv  in  degree from
 moderate thinning of the growth to considerable symmetrical  bald-
 ness, usually of the vertex, which,  at  the onset, is  scarcely distin-
 guishable  from alopecia simplex, alopecia prematura or presenilis,
 and seborrhcea of the scalp in  some of its forms.  It is exceedingly
 common, especially  in men.
   The disorder, essentially chronic in  course,  is usually first mani-
 fested in early adult life, though persons of both sexes, from twelve
 to fifteen years of age, may at these ages display typical  forms of the
 disease.   After some months or years, the  subject of the affection
 discovers a  relatively large loss of hairs  from the scalp producing
 thinness of  the growth upon the vertex, near the brow or over the
 temples.   The hairs, when  examined  in situ upon  the scalp, are
 shortened  and  rebellious  to  the comb  and brush, projecting stiffly
 from the brushed surface, being also harsh, lustreless, and rarely M'ell
 anointed with  sebum.  Those shed from the scalp, especially of men,
 are  found to  be nearer in type to the  lanugo or doM'ny hairs than
 those M'hich  fall physiologically from a  vigorous growth of hair in a
 healthy subject; that is, they are short,  thin, pointed, and often with
 an indistinct medulla".
   At  the  same time the scalp is  in process of incessant desquama-
 tion, the scales being of  pityriasic type, and exceedingly abundant
 so long as the alopecia  is  not  complete, after  which, the epidermal
 catarrh promptly disappears.   The mealy, bran-like  scales are shed
 in a  fine shower  upon  the clothing of the patient, and, the  disease
 being more  common in  men  than  in women, its traces are often dis-
 tinct upon the collar of  the coat after the fingers have been passed
 through the  scalp.   The same  flour-like, whitish and grayish scales
 are distinct and plentiful  among the hairs to M'hich  they cling, and
 also can  be  recognized over the  scalp surface  when  the latter is
 inspected M'ith care.   Greasy  conditions  of this product  of secretion
 upon the scalp are  due to complications M'ith  a  seborrhoea  of this
 region, aud the reader is urged  to consult the chapter devoted  to that
 maladv in order to  study this  subject  from its several  pathological
 sides.   According to Pincus,  three-fifths by weight of the scales fur-
 nished by the  scalp in  this condition, are  inspissated products of
 sebaceous secretion.
  Often, however (aud it is this important feature which justifies the
 separate consideration of alopecia furfuracea and seborrhcea capitis),
 the scales  are  true  squamae; dry,  corneous,  and epithelial,  rather
 than  fatty and  seborrheic.   The  subjective  sensations   are  then
 usually marked; the scalp  is often scratched and  torn  by the nails,
and is, in some cases, reddened  and thickened.   There may be also
decided general  cachexia.  Among women  the patients are often
nervous  and sallow, with  a  long history of  distressing  headache,
                                28 
434
DISEASES OF  THE  SKIN.
uterine hemorrhage, or hepatic disorder.  These are simply states in
which there is malnutrition of the scalp.
   The scalp may or may not be the seat of perspiration.   Eczema,
of pustular type, occasionally complicates these cases.
   Etiology.—The disorder may be due to inheritance, to any systemic
affection impairing the bodily vigor, to long-continued neglect of the
hygiene of the scalp, or to such diseases of women as are accompanied
by menstrual  irregularities.   The confinement necessitated  by seden-
tary occupations of life;  those  trades and  professions M'hich permit
or require the constant covering of the head of men ; and the wearing
of heavy hats or bonnets interfering with  the  aeration of the scalp,
all furnish conditions  for the occurrence of the  disease.
   In 1882, Lassar and  Bishop produced alopecia by rubbing upon
the sound  surface of the skin of  animals the epidermic  detritus and
hairs furnished  by a patient affected with  the disease.  This  lends
color to the possibilities of contagion which should not be ignored.
   Pathology.—According to Pincus,  the  vessels of  the  scalp  are
unaltered,  but the corium beneath the affected  surface is thinned  in
proportion to  the severity of the disease.  Nothing characteristic can
be discovered in the hairs removed from an affected patch.
   Diagnosis.—The  disease is distinguished from seborrhea of  the
scalp by the epithelial character of a great part of the dry discharge
occurring  symmetrically from  the scalp surface,  coupled with  the
symmetrical and largely vertical alopecia.   The asymmetrical greasy
patches of pure seborrhcea capitis, pasting  the  hairs to  the scalp,
which may be limited  to the occipital or temporal  region of one side,
are strikingly different.   Michelson  and  Pincus place reliance  in
establishing a diagnosis, upon the  firmer attachment of the scalp and
the discovery  upon four successive days of a proportion of one-eighth
of pointed hairs to the entire pilary loss, with  an  average  length  of
thirteen centimetres.
   Treatment.—The general and local treatment of alopecia furfuracea
is practically that of alopecia simplex, alopecia areata, and seborrhoea
of the scalp.
   Pincus applies upou compresses the sodium bicarbonate in solution
sufficiently concentrated to stimulate  but not redden non-hairy por-
tions  of the skin.   Sulphur, tannin,  the oil of savin, the  bichloride
of mercury, tar, naphthol, resorcin, the peroxide of hydrogen (in two
volumes), and  ichthyol  have all  been successfully employed iu  the
management of these cases.  Each is best preceded by the shampoo-
ing described  iu  the   preceding  chapter.   Schmitz,  Schuller, and
Andre  have all reported excellent results  from hypodermatic injec-
tions  twice weekly of  one-twelfth  to one-sixth of a  grain  (0.005-
0.010) of the muriate of pilocarpine in distilled M'ater.
   No remedy has a  higher and more established value  in the local
management of these  cases, whether in an early or late stage, than
sulphur.  In the strength of from one-half to  one drachm (2.-4.) of
precipitated sulphur to  the ounce (32.) of vaseline  or lanoline  it
should be well rubbed  into the scalp after each shampooing.   When 
ALOPECIA  areata.
435
 there is marked  improvement of the  pityriasic  catarrh, one of the
 stimulating lotions may be used that are described in the pages devoted
 to the other varieties of alopecia.

                        Alopecia  Areata.
             Lat. area, a vacant space  {arere, to wither, Fox).
 Alopecia Areata is a disease of the pilary follicles characterized by the sudden
   occurrence of general and symmetrical, or partial  and asymmetrical  bald-
   ness, the latter  exhibited in  distinctly circumscribed, smooth, whitish
   patches, which are, in typical cases, completely destitute of hair.

   Symptoms.—This disorder, which is  more common than  is gener-
 ally believed by physicians, may be, at its outset, preceded or accom-
 panied by symptoms of ill-health, such as headache, malaise, inappe-
 tence, loss of flesh, or malnutrition.  In yet other cases, cephalalgia,
 paresthesia, pruritus, and formication of the skin  of the scalp and
 other regions indicate some disturbance of the nervous centres.
   Often, however, the patients of this  class are in sound  health, the
 disease then manifesting itself by the  sudden  and  complete loss of
 hair over a circumscribed  patch, usually upon one side of the scalp,
 so rapidly effected that they often  describe a first discovery of the
 fact at the toilet of the morning.  After a  variable  period  of time,
 other patches of baldness  may  occur, all of  the hairy portions of the
 body being liable  to the  affection, the  scalp first in order, next the
 beard, then the genitalia,  axillae, brows, eyelids, and the general sur-
 face of the body.   In early childhood cases  occur in M'hich the closest
 scrutiny with a glass fails to detect a single  filament of hair upon any
 portion of the skin.
   The patches may be roundish, ovalish, or irregularly shaped, aud
 may vary greatly iu size,  from that  of a small coin  upward.  They
 may be  so  numerous as  to  disfigure greatly the  entire scalp;  and
 though these touch  at  the borders  when  thus numerous, they can
 scarcely  be said to coalesce, as the  individual  elementary areas  are
 usually  recognizable.  Their surface is smooth,  whitish, and often
 perfectly destitute of hairs; it is rarely  tumid, aud slightly reddened.
 The hairs at the periphery are  usually of full length and fixed in situ,
 but are occasionally fragile, and readily M-ithdrawn from their follicles.
 Stumps of such friable hairs  may be at times seen at the  margin of
 the patch.   In point of abnormal subjective sensations, temperature,
 or disease of the surface from M'hich  the hairs have fallen, there is, as
 a rule, complete absence of symptoms.   The skin, when the evolution
 of the disease is complete,  is usually  normal  to the touch, and pliable.
 ()ccasioually it is anaemic,  thinned, and more movable over the corium
 than in the scalp M'hich is not the seat of the disease.
   In  incomplete evolution and  in periods of repair, downy  hairs may
appear upon the surface, at times considerably differing in color from
those  springing from unaltered  regions of the scalp.
  The loss of hair from  the  surface may be: rarely, gradual;  pre-
ceded  by mild  pruritus (Bcsnier  et  Doyou); or  followed  by auaes- 
436
DISEASES  OF  THE  SKIN.
 thesia (Neumann).  Its apogee once attained, the course of the disease
 is variable; it may persist for periods M'ithout  apparent change;  or
 new patches may form M'hile those of an older date either proceed to
 exhibit M'holly or in part the  pilary growth;  or, this latter accom-
 plished, suffer a fresh loss by relapse.  Shifting areas of the disease
 may, without question, in this manner  invade the entire surface  of
 the scalp, which yet at any one moment of time may exhibit a loss
 of but the half of its hirsute covering.
   There  is some reason for believing  that the disease has a relatively
 fixed period of evolution, though the  exact limits of the latter are not
 known.   Few individuals suffer  less than one year; the most are
 relieved  M'ithin  a period of  two years.  These remarks, however,
 apply to the asymmetrical forms of the disease in the relatively young.
 The symmetrical alopecia areata of the middle-aged is, in my experi-
 ence, a far more formidable affection.
   Few diseases are the source of greater  mental distress than those  of
 the class  now under consideration.   The prominent deformity  thus
 occasioned debars the subject  of the malady from social relations  of
 many kinds, and this  intensifies the morbid feeling which  every
 reflected  view  of the head  awakens.  This is particularly true  of
 women.   The successful management of  these cases calls often for the
 supporting assurances of the practitioner.
   Etiology.—The causes of the disease are obscure.   It is not trans-
 mitted  by heredity  nor by  contagion; and  it is  not due to  the
 presence of a parasite.   It occurs with equal proportion  in the  two
 sexes; and among  these, irrespective of social  condition.  Of the
 partial and asymmetrical forms, the larger number of  cases occur in
 young subjects,  from childhood  to  early adult  life.   The  severe
 and generalized  forms are more  often  encountered in middle-aged
 persons.    In the latter class especially, it is occasionally observed to
 follow the obscure disorders of the nervous centres due to sudden or
 prolonged undue  excitation.   In  young  subjects one may often  dis-
 cover a peculiar repugnance to the ingestion of fat and meat, a point
 to M'hich attention is called in considering alopecia simplex.
  The neurotic  explanation  of  this disorder   is  more generally
 accepted as facts  accumulate  bearing on  its etiology.  The nervous
 symptoms which often precede or  accompany the  appearance  of the
 bald patches are  strikingly suggestive, and led Aron Barensprung to
announce  his theory of "inherited innervation" as a cause  of the
 malady.   Further, the occurrence of  the disease after shock  of the
 nervous centres is significant.
  Collier1 cites  tMo cases  in which alopecia areata followed a blow
upon the temporal region, and Sir Dyce Duckworth reports the case of
a gentleman M'ho sustained an  injury to the head in a fall from a dog-
cart, who  suffered as a result from permauent loss of hair.  OveraP
has reported a similar instance; Joseph3 has produced the disease bv
section of nerves in a cat.

  1 Lancet, Amer. Ed., August, 1881, p. 130.           2 Alien, and Neurol., St. Louis, 1886
  3 Centralb. f. med. Wissenscliaft, 188(i, No. II. 
ALOPECIA  areata.
437
  On the other hand,  v. Sehlen,1 in 1885, exhibited in the Medical
Congress at Strasbourg, micrococci about the sheaths and roots of the
hairs, which he claimed to have demonstrated to be the cause  of the
disease.
  Pathology.—The anatomical lesions M'hich produce alopecia areata
have not been recognized.   The hairs fallen from the surface, when
examined with the microscrope, are seen to be atrophied in the bulb
and  shaft, though  Rindfleisch describes in certain cases a node-like
enlargement of  the  hair-shaft after its escape from the  follicle.
Fracture of the shaft  is iu some cases also noted, evidently an acci-
dent of the process.   No parasite can be discovered in uncomplicated
cases.   I  have in  one instance detected spores and  mycelia  of the
trichophyton in the hairs, a  coincidence of two disorders which  has
been observed by others.
  in default of all positive knoM'ledge on  the subject, the majority
of dermatologists have assumed the disease to be a trophoneurosis, a
view sustained by the etiological history of certain cases.
  Michelson,  however, regards the vasomotor nerves  as presiding
over the nutritive changes determining  the loss  of hairs.   Schultze
recognized some thinning of the scalp in sections examined by him.
Future investigation may establish some difference other than  that of
degree between the partial asymmetrical disease of the young and the
more general symmetrical affection of middle life, in which the entire
scalp,  lids, brows,  pubes, and axillae  are completely shorn of their
filaments.   It is, however, held to-day that all  forms of alopecia  are
parasitic in origin and are therefore all related.
  Diagnosis.—Alopecia areata is to be distinguished from  vitiligo of
the hairy portions  of  the surface by the preservation of the pilary
growth iu the disease last named, the filaments, moreover,  having
usually a blanched and whitened look, due to the absence of pigment.
  From ringworm and favus of the scalp the  disease in question is
readily differentiated,  by the  suddenness  of its onset;  the  absence of
all stumps of  hairs, scales, crusts, and evidences of irritation  in  the
involved area; the M'hiteuess, smoothness, and  complete baldness of
the latter; and, above all, by the  failure to detect M'ith  the  micro-
scope the  evidence of the presence  of a vegetable parasite.
  The asymmetrical patches of seborrhea of the scalp are recognized
by the presence of  the fatty plates  pasting the hairs to the  surface, as
Mell as by the slow and very gradual onset of the disorder.
  Other forms of baldness than those named above are all of gradual
and, in their early stages, of symmetrical development.    Those re-
sulting from traumatic injuries  of  the scalp, with cicatricial results,
are  easily determined as having such an origin.
  Treatment.—One must  necessarily view  M'ith  some  distrust all
treatment for  that  -disease M'hich in the  course of months or years
usually terminates iu spontaneous recovery,  and in  the  meantime
may bid defiance to each aud every therapeutic measure.   Neverthe-
1 Annal. de Derm, et de Syph., June, 1886. 
438
DISEASES OF THE SKIN.
less, persistent  and  hopeful  management of even the apparently
desperate- cases is occasionally rewarded  by  such brilliant  conse-
quences that, however slight may be the foundation for a  belief in
the value of the therapy employed, it deserves recognition and trial.
   The  hygienic  management of  every case is a  matter  of great
importance.   Tobacco should in every form  be denied to subjects
of the disease  addicted to its use.    Iron,  quinine, nux vomica, cod-
liver oil, phosphorus aud the hypophosphites, arseuic, and  strychnia
are often indicated, and used M'ith great benefit.
   The indication for local treatment is to  increase  the physiological
afflux of blood  to  the hair-follicles.   With this end in view,  the
affected parts are to be bathed  daily in Mater as hot  as  can  be  toler-
ated, then  dried,  and scrubbed with a stimulating lotion.    The
articles  usually employed are  alcohol, ether,  turpentine, ammonia,
camphor,  cantharides, carbolic acid, oil of mace, croton  oil, tincture
of nux  vomica, tincture of capsicum, tincture  of aconite, castor  oil,
tar, iodine, sulphur, and the mercurials.  All  frequently fail.  Several
of these in combination seem at times to be of  service.
   The  folloM'ing  is  a formula, the  ingredients of M'hich may be
varied to suit the indications in different cases :

        R.
M.
01. ricini	f^ss;	16
Acid, carbolic.	3j;	4
Cantharid. tinct.	Iss;	16
01. rosmarin.	gtt. xv;	1
Spts. vin. rectif.	ad f^iv;	128
Sig.  For external use over the scalp with friction.
  The formulae containing  chrysophanic acid and  the bichloride  of
mercury, given on a preceding page in connection with the treatment
of alopecia furfuracea, are well worth trying.
  Dr. Nevins,  of Liverpool,  mops  the entire  surface with strong
liquor ammoniae.   The speediest return of hair the author  has ever
observed in a patch of alopecia areata, followed a single application
of pure  creasote to  the  surface, resulting in  moderate vesication.
The spirit of turpentine has been similarly employed.
  Faradization of the scalp with a  stiff M'ire brush,  pushed to the
point of producing moderate hyperaemia, has been followed by excel-
lent results.
  Wilson recommends:
R. 01. amygd. dulc.
   Capsici tinct.
   Liq. ammon. fort.
   Spts. rosmarin.
   01. limon.
 f|j;
f3ij;
 f.lj;
f.lv;
Here is another stimulating application
M. 01
   terebinth.j
01. ricini    j
Origani tinct.
01. camphorat.
Liniment, volatil.
 aa. f^ss;
    f5y,
    f|j;
ad f^nj ;
 32
  8
 32
160
  4
16
 4
32
96
M.
Sig.  For external use with a brush till the scalp is irritated
M. 
ALOPECIA  areata.
439
  Repeated blisterings  of the  scalp  m ith cantharidal  collodion,  the
spirit of green soap, and petroleum have also been employed exter-
nally with success.  The ointment of chrysarobin has the disadvantage
of staining not only the remaining hairs, but often the face in conse-
quence  of the frequency of its  transmission to that locality by the
medium of the hands.   When  patients, however, consent to its use,
it is M'orthy of a trial,  as  its application has been speedily followed
by a vigorous growth of new pilary filaments.  Andre employed ten
hypodermatic injections of muriate of pilocarpine in one-eighth grain
(0.008) doses, which resulted, in the case  of a middle-aged woman
affected M'ith  total  symmetrical baldness, in an abundant growth of
hair.
   Lassar and Bishop'  operated by first vigorously shampooing  the
entire scalp daily  with  a strong solution of tar  soap for fifteen
minutes; rinsing next  with  an irrigator, by the aid of warm water,
followed by cold M'ater, and subsequently drying.  Then a corrosive
sublimate wash (1.:  300.  adde  spts.  cologniens.,  glycerin.,  aa
100.) Mas applied, and  the head again  dried;  then a  solution of
naphthol (naphthol, 0.5;  spts. dil.,  70.; aq.  dest,, 30.)  was rubbed
in.   Lastly,  carbolized oil,  1^ per cent., Mas poured sloM'ly over the
scalp, entering the  cleansed  and expanded orifices of  the  glands, so
that  seven drachms (28.)  could  be employed  at  a time.   This  was
pursued daily for eight weeks.
   Prognosis.—From what precedes, it will be justly inferred that, as
regards the relief of the baldness, the asymmetrical development of
the patches in youth is much  more favorable than  the  symmetrical
general  disease  of middle  life, the  latter being  often  remediless.
The  prognosis of the same affection of the beard is quite favorable.
In all' cases,  the practitioner  should actively persevere to the end.
In no case should any  encouragement be given as to complete relief
M'ithin the year, though such exceptionally short careers of the  dis-
ease are at times observed.
   The disease, when limited to the  regions of the beard in young
men, usually  concludes its stadium in the course  of about one year,
with a favorable termination.   Shaving should be regularly prac-
tised, as the deformity is  thus  rendered somewhat less conspicuous,
and the bald  surface should be  frequently stimulated with one or
several of the topical applications named above.  Alcoholic solutions
of the mercuric bichloride, half to one grain (0.033-0.066) to the
ounce (32.) are to be  well  rubbed  over  the patch or patches once
or twice daily.  The disease in this  locality may coexist with benig-
nant syphilis,  the latter  disease pursuing  a career considerably
shortened by vigorous treatment, while the  former,  none the less,
endures from twelve  to  fourteen months,  long  after the syphilitic
cachexia  has been relieved.  At the end of this time, recovery occurs
precisely as in those cases  M'hich have presented no  history  of in-
fection.
                               1 Loc cit. 
440
DISEASES  of  the  skin
   In all cases of implication of the head, where the scalp is involved
in either sex, and where the peculiar hypochondriasis of the disease
is developed, a Avig should be worn for the sake of its moral effect
upon the sufferer.   For such, however, its use should  be  limited to
social occasions, visits, etc., as  the  persistent wearing of a perruque
indoors seems to lengthen somewhat the course of the disease.

   Alopecia  Neurotica.—Under this title Michelson includes all
cases of loss of hair, (1) coincident with or following traumatism of
cerebral or peripheral  nerves; (2) those associated with  diseases of
the  nervous system due to internal  causes.  As to the first  class,
instances of alopecia are  given  above, where, as in the case reported
by Sir  Dyce  Duckworth, the loss followed a  fall upon  the  head.
Todd, Schultze, Fischer, and Michelson have also made observations
of this  character.   In the second category are the  local and general
losses of  hair reported  as associated  with melancholia, migraine,
neuralgias  of persistent type, and  facial and other paralyses.  In
some of them the  skin and  panniculus adiposus have wasted, the
hairs falling  in stripes  or ribbon-shaped  streaks, with  partial or
complete canities of those left in the follicles.

                 Atrophia Pilorum Propria.

   Atrophy  of the  hair  may be either symptomatic or  idiopathic.
Illustrations of the first  named condition  are observed in phthisis,
syphilis, seborrhea, ringworm of the scalp, and  almost all general
diseases interfering with  the nutrition of the pilary growth.  The
filaments then become  dry, lustreless, friable in both  longitudinal
and  transverse diameters, and diminished in each dimension.
   There are several  recognized forms of idiopathic atrophy of the
hair.  One  of these exists in those  long hairs which are seen to be
irregularly thinned  or flattened in  the shaft, and  split at the  point
into two or  more recurving  fibrillae, a  condition noted, for the  most
part, in few hairs  scattered  among those of full  development and
vigor.   This especially localized atrophy seems to  be peculiar to one
or more follicles merely; and is quite analogous to the condition in
which there appears among  the vigorous  pigmented  hairs of  early
life, a single blanched filament.
   Under the title " An Undescribed Form of Atrophy of the Hair of
the Beard/' Duhring1 gives the details of an exceedingly  interesting
case, in which either at the bulb or at a variable distance from it but
within  the  follicle, there was fission of the hair filament into from
two  to  four stalks with  coincident atrophy of the  bulb  itself and
consequent  irritation of  the surface.   The patient  exhibited  to  a
marked degree the species of hypochondriasis to which the subjects
of disease of the hair seem specially prone.  Through the kindness
of Dr. Duhring, the author had the opportunity of privately exam-
ining under the microscope some specimens  of these  hairs the
1 Amer. Journ. of the Med. Sci., July, 1878. 
ATROPHIA PILORUM  PROPRIA.            441
Fig. 52.
appearances of which are admirably portrayed in the woodcut M'hich
illustrates his paper.   This disorder is not induced by a  parasite.
  In the year 1887, a gen-
tleman applied to the author
for  advice who was in a fair
condition of general health,
but the hairs of whose beard,
when closely examined, both
with  the  naked  eye  and
the  microscope,  presented
a striking  resemblance  to
those described  and figured
by  Duhring.   Microphoto-
graphs of specimens of these
hairs show  clearly  that  in
every  case  the fission  of
the filament extended  com-
pletely to the  base of the
follicle  and produced  local
irritation there.   The  hairs
over several square inches of
surface were thus uniformly
affected,  normal  filaments
being in such areas absent.
The interfollicular spaces,
however, seemed  to be ab-
normally widened,as though
in these areas such normal
hairs might have fallen  in
consequence of  a species  of
alopecia.  The peculiar ap-
pearance of the  beard  to
the  naked eye was striking.
The disease  was much  more
strongly marked on the chin
than on the  cheeks or upper
lip.  The curling of some of
the  splinters M'as complete
and characteristic.
    Trichorexis Nodosa,

first  described  by  Wilks
and  Bcigel,  is a  condition
in M'hich the hairs display
nodose swellings along; the shaft at irregular distances, the beard aud
moustache being most often  affected, though  rarely there is involve-
ment also of the  hairs of the scalp.  Sherwell,1 in this country, has
Trichorexis nodosa.  (After Schwimmer.)
i Arch, of Derm., July, 1879. 
442                DISEASES  OF  THE SKIN
described one such case.   The hairs are brittle; and fracture usually
occurs through  the  node, leaving a broom-like  mass  of filaments
projecting there, M'hile the internodular portions of the shaft appear
normal  save for some enlargement of the medulla.  The fragility of
the hair at the centre of the node, seems to depend  upon the tension
and  consequent fissure of the cortical layer M'hich is greatest at that
point.   No parasite  has  been discovered in hairs thus affected, their
bulbs, moreover, being firmly adherent  in  their follicles.  Little  is
knoM'n  as regards appropriate treatment of the disease, M'hich is, it
must be said, persistent aud disfiguring.  Shaving has been followed
in some of  Kaposi's cases by good results; while Reser1 advocates
the local employment of dilute tincture  of cantharides.
   Smith,2 of Dublin, has also reported a curious  Case of Nodose
Swellings of the shafts of the hairs, differing somewhat from those
described above.  Through the kindness of Dr. Duhring, the author
has been enabled to  exhibit  some of these  hairs in Chicago, micro-
photographs of M'hich were, at his suggestion, taken by  Dr. Belfield,
of Chicago.  Here there M'as no fragility at the nodes, which  com-
mencing near the scalp were quite regularly displayed along the shaft,
the fracture being always internodular.   The spherical swellings along
the shaft M'ere also pigmented in  a brown hue, and  these contrasting
with the non-pigmented  color of  the unaffected portions of the shaft,
gave the hairs a singularly " checkered" appearance.  No parasite was
discernible in any of the specimens.
   Michelson,  under  the title " Expansions and  Fissures  of the
Hairs," discusses together these and other abnormalities  of the pilary
system  and concludes as to the  most of them,  that they are not
separate diseases but expressions of an abnormal dryness and  brittle-
ness of  the hair due to atrophy.   Cases of  broom-like Assuring and
division of the shaft into larger longitudinal splinters, he regards as
equivalent  processes both  beginning by a  cuticular loss and  often
merging into each other.
   This  view may be sound with regard to a number of these rare
affections;  but  even a superficial  examination of  the  longitudinal
splinters shown in Duhring's and my cases, reveals the fact that the
shaft represented by the sum of  all its splinters, is greater than that
of the average hair in diameter aud circumference.  Even the naked
eye can recognize this fact.   The epilating forceps seizing a single
hair in  the case of the author's patient, was distended as  in the grasp-
ing of as many sound filaments as are represented by splinters.
   The  therapy  of these cases is not  well  determined.  Michelson
believes shaving to be useless aud recommends systematic shampoo-
ing and oiling—the process pursued  in the  cases  treated  by the
author.   Arsenic internally is worth trying in all  cases M'here  it is
not contraindicated.

               1 Annal. de Derm, et de Syph , 1877-78, pp. 185, et seq.
               2 Brit. Med. Journ., May  1, 1880. 
ATROPHIA UNGUIS.                  443
                             Piedra,
is described as still another condition  of the  hairs  in M'hich dense
node-like masses are attached to or surround the hair shaft.   Morris
describes these as  containing  masses of spores.   In a single  case,
that of a young girl  sent to him by  Dr. Holmes,  of the Eye  and
Ear Infirmary,  the author  discovered there Mere  numerous,  jet-
black,  horny, and dense spherical masses attached to the hairs of the
eyelashes of each lid  of both  eyes.  The author was unfortunately
prevented from securing some of those hairs for microscopical exami-
nation.
                          3.  Of Nail.

                       Atrophia Unguis.
   Atrophy of the nails may be a congenital or acquired condition, in
 M'hich there is deficient or defective production of the nail substance.
 The congenital forms are usually observed when the digits are poorly
 developed, and there is  at  the  same time  a deficiency of the pilary
 growth.   The nails may be entirely absent in  these cases or merely
 tardy of evolution ; occasionally they are seen, especially upon  rudi-
 mentary or coalesced digits, in defective and distorted shapes.
   In acquired atrophy, the nail may be changed either in color, bulk,
 elasticity,  firmness, shape,  or position.    Thus the nail  may  be
 expanded and thin, narrow and acuminate, friable, furrowed, lami-
 nated, ridged, or  otherwise distorted.  It may  be  uniformly  or
 partially lustreless, or singularly striped, or even speckled irregularly.
   These changes  in various combinations  result  from  traumatism
 chiefly, such injuries, for example, as are common to the toes in  the
 boot or shoe, and to the  fingers when actively employed in the trades.
 Excessive  heat and cold,  and constant maceration  in chemicals (as
 among photographers, dyers, and druggists) often operate injuriously
 upon the nail  tissue.   All serious disturbances of systemic nutrition,
 such as are  incident to prolonged  fevers, surgical accidents, tubercu-
 losis, ataxic conditions, etc., interfere visibly with the nutrition and
 development  of  the nail.   The syphilitic changes in  the  nail  are
 commonly  due to gummatous involvement of the  matrix.   Severe
 ulceration  of  the  matrix  is often followed  by atrophic or  other
 distorted conditions of the nail-substance.
   The treatment of these conditions is largely that of the disorders
 upon M'hich they depend.   The nails may often M'ith  advantage be
 soaked in unguents, scraped  to a desired smoothness,  well trimmed,
and  then  protected  by Max, leather stalls, etc., from  injurious con-
tacts.  Arsenic internally is  said to be useful in some affections of
this  kind. 
444
DISEASES  OF THE  SKIN.
                         4.  Of Cutis.

                        Atrophia  Cutis.

                 Gr. a, privitive;  and rpo^fj, nutrition.
Atrophy of tbe skin is an idiopathic or symptomatic, diffuse or partial, dimin-
  ution of the mass of the integument, or its reduction in size after loss or
  degeneration of one or more of its histological elements.

  The skin and its appendages, in common with other organs of the
body, may suffer from atrophy, either idiopathic or  symptomatic in
character, and general or partial in extent.  It may result from either
quantitative  or qualitative,  retrogressive changes,  losing  thus its
normal  dimensions, either  from M'asting  of one or all of its normal
elements, or  from degenerative changes in the  latter, or from their
complete and final disappearance.  Naturally these changes may be
simultaneous.  They are usually effected  slowly, and the results are
persistent.  They are frequent concomitants of a  long  list of other
pathological  alterations.  Usually, however, they succeed the latter.
Under the general title of  atrophy of the skin,  several rare forms of
the disease have been considered.

                       Atrophia Senilis.

  This  is the frequently recognized  cutaneous degeneration peculiar
to old age.  The skin becomes colored  in various  shades of brown,
either uniformly  or in  tolerably distinct  maculatious over the  face,
dorsum of the  hands,  the genitalia and the anus, and the lower
extremities.  It is seamed with furrows and wrinkles, often in various
degrees  desquamates slightly, and, losing the cushion  of fat  upon
which it rested in earlier life, is either  readily raised from the  sub-
cutaneous structures, or depends from them iu loose folds.  Pea- to
finger-nail sized, verruciform, dirty-yellowish accumulations of epi-
dermis become  visible, often in numbers on  the face and elsewhere,
extending either as  far as the deeper  portions of the horny layer or
the rete.
  The  cutaneous atrophy in such  cases may be characterized by
unusual dryness, with failure of reproduction of the elements of the
skin after the loss by physiological waste.  The epidermis and derma,
by their shrivelling, lose largely their characteristic  interdigitations,
while the elements of M'hich they are composed  are impoverished in
protoplasm.  Vessels, relatively numerous before, disappear; pigment
multiplies;  the hairs are either produced as lanugo filaments, or fall
as the papillae  in the fundus of their sacs flatten ; the  root-sheaths
encroach upon  the follicle; while the sebaceous  and coil-glands  may
either disappear, or dilate and become  filled with an epidermic detritus.
  In other cases  the skin  elements  undergo  a  true metamorphosis
fatty, lardaceous, amyloid,  colloid, waxy,  or vitreous. 
ATROPHIA CUTIS.
445
               Atrophia Maculosa et Striata.
   Partial idiopathic atrophy of the skin occurs most  frequently in
linear  cicatriform  striae or  streaks, an  inch or  more  in length,
developed chiefly about the hips, buttocks, and upper portion of the
thighs in both sexes of adult years.   Less frequently they are observed
upon the neck, trunk, and extremities.  They are insidious of devel-
opment, indelibly persistent, and appear as sensibly thinned, glisten-
ing, and often depressed lines or furrows,  having a M'hitish hue, M'ith
an  occasional blending  of a very delicate purplish tint.   They are
usually  multiple, and  at times abundantly displayed, running in
various curves, for the most  part parallel with the  long  axis of the
body.   They occasion no subjective sensation and  their etiology is
unknown.
   Much more rarely the  atrophic  areas occur  in  macular patches.
The lesions are then fewer, more  isolated, and  are discovered more
frequently  upon  the extremities, but also on  the trunk,  varying in
size from  a coffee-bean to a chestnut.   This form  of atrophy often
succeeds either an  erythematous or  pigmented condition, M'hich very
slowly changes till  there is formed the dead white, round or oval, often
insensitive  patch,  resembling coarsely a  vaccine cicatrix.  Taylor,1
aud Atkinson,2 have described some very interesting features in  this
process; aud the author  has been able to verify the accuracy of their
observations in two typical cases of the affection he has had the oppor-
tunity of studying.  In  both, the lesions occurred about the ankles of
women with menstrual derangements, the largest spot of all attaining
the size of the transverse section of a hen's egg.  The patches Mere
in various  degrees insensitive, very slightly depressed, smooth, glis-
tening, and  scar-like, the  condition being the  sequel  of  broMn to
chocolate  tinted  pigmentations, limited to the spaces M'hich become
afterward  atrophic.   Cantani3  describes  similar atrophic maculae,
M'here  there had  been  a  bluish-red  color,  evidently  due to  the
development of minute vascular capillaries.   The  sensibility of the
skin Mas unaltered.   Under the  microscope both the  linear  and
macular lesions show separation  of the fibrous  fasciculi,  effacement of
the papillary layer of the corium, and diminution in the  number of
vessels and glandular appendages.  In Taylor's and the author's cases,
the maculae were quite  hairless; in Atkinson's, the  hairs were rela-
tively few in number.
   Fere and Quemonne4 have also described tM'o siugular cases observed
in  Charcot's clinic.  In one of these,  minute,  whitish,  elongated
cicatrices appeared, about M'hich there Mas  marked pigmentation of
the skin.   They Mere abundant.in  the  lumbar region.   In a second
case, brownish lines'appeared over the breast of an unmarried woman,
M'hich  gradually grew paler, M'hile others  appeared  over the skin of
the throat.   Those M'hich were  recent  had a brownish  or bluish-red
color;  others  M'ere of a  dead M'hite hue; some  appeared over  the
 1 Archives of Dermatology, vol. ii. No. 2,1867.      - Rich, and Lou. Med Journ., Nov. 16, 1877.
 » II Morgagni, May, 1881.                   4 Le Trogres Med., Oct. 29, 1881, p. 837. 
446
DISEASES  OF  THE  SKIN.
lumbar region and  the  upper part of the buttocks; but  there Mas
none  over the belly, groins,  aud  the  thighs.   In  both  cases  the
regions attacked were those in which there was no suspicion that the
vergetures resulted from overdistention of the skin.
  These lesions are to be distinguished from the sequelae of morphcea,
syphilis, and other  diseases  capable of leaving atrophic areas.   A
previous history of such pathological conditions M-ould usually be
needful; but in the cases M'here there is precedent  telangiectasis,
hyperaemia, or marked pigmentation of the spot, the diagnosis from
morphea will  be, as several authors suggest, attended with some
difficulty.
  Partial symptomatic atrophy  of the  skin,  in  its simplest form,
results from the traumatic action of tumors (ovarian, uterine, mesen-
teric,  etc.), by  M'hich it  is  distended.  The  well-known results  of
a first pregnancy conducted to full  term, are linear atrophies, at first
of a violet  tint, and later of a dead  whitish  hue, which are indis-
tinguishable, both clinically and pathologically, from the idiopathic
lesions of similar aspect,  Partial symptomatic atrophy, with degen-
eration of the cutaneous elements (fatty, lardaceous, waxy, etc.), is the
sequel common to a  long list of cutaneous affections.

  Blanching Atrophy of the  Skin.—Several instances of this
peculiar degeneration of the integument have  been observed.  It  is
characterized by an unnatural whiteness or pallor of the surface, M'ith
considerable  tension and  tenuity of the epidermis,  usually limited to
the extremities (the  arms and palmar faces, and the thighs aud legs
and plantar  faces);  moderate exfoliation occurs,  and  the  latter,  in
connection with the tension to which the  skin is subjected, is respon-
sible for more or less painful  subjective sensations.   The disorder is
chronic in its course, and may originate in infancy.
  This condition is  occasionally illustrated by patients affected M'ith
a sensori-motor paralysis of one limb, M'hen the muscles waste aud
the fat-cells persist, multiply, or wholly disappear.  The skin of such
limbs, wholly or in patches, becomes unnaturally soft and delicate, and
undergoes a loss of pigment and hairs at the same time that its bulk
actually diminishes.   The nails  may participate in the process.  In
yet other cases of trophic disturbance, the skin shrivels and  assumes
instead of a whitish, a yellowish, or yellowish-gray tinge.

  "Glossy  Fingers."—The  "glossy fingers"  described  by  Sir
James Paget, are probably of the same general character.   They are
"tapering, smooth, hairless, unwriukled, glossy, pink, and ruddy, or
blotched, as if with  permanent chilblains."  One  or several fingers
are affected.  The condition is associated with neuralgia or nervous
impairment.   The relations of this and several symmetrical disorders
of the hands and feet to the so-called " perforating ulcer of the foot,"
"asphyxia"  of the  extremities, "symmetrical gangrene"  of  the
extremities,  and so-called  "dying of the  fingers,"  all manifestly
trophoneurotic affections (see  the chapter on this  subject), have not
yet been satisfactorily established. 
KELOID.
447
                        CLASS YI.

                         NEW GROWTHS.

                1.   Of Connective Tissue.

                             Keloid.
                        Gr. xv'^v, a crab's claw.
 Keloid is a benign  cutaneous neoplasm, occurring as one or more elevated,
  whitish and reddish, firm and elastic nodules, plaques, ridges, or radiating
  stria'; or as several of such  forms in combination, resembling  an hyper-
  trophied cicatrix.

   The term Keloid, first  given to this disease by Alibert, should be
 restricted to it exclusively.  It has also been  termed Cheloid, Kelis,
 and Cancroid.   The so-called  Keloid of Addison, is known to-day
 more properly as  scleroderma.
   Authors have  described  two  varieties  of  this disease:  first, the
 "true," u spontaneous," idiopathic form; second, the "false," "spu-
 rious,"  or cicatricial.   In  these pages the first described condition is
 alone considered  as  entitled to  the name Keloid.   The  so-called
 spurious form  of  the affection  is described  in the pages devoted to
 Cicatrix.
   Symptoms.—The new-formation of this disease is always of spon-
 taneous origin, never resulting from attempts  at repair of ulcerative,
 traumatic, or other losses of tissue.   Dense, generally  elastic nodules
 are seen embedded in the corium, or projecting above the level of the
 skin  and  firmly  attached to  it.  They are usually  very slow of
 evolution,  and, having once obtained  their  full  development  and
 assumed one  of the several shapes M'hich they affect,  usually persist
 for a lifetime.   These  forms are globular or  semi-globular, M'hitish
 or  reddish nodules,  buttons, or plaques, M'ith  roundish or ovoid out-
 line;  linear elevated striae, bauds, ridges  resembling cords, ribbons,
 or tapes, in irregular outline and disposition;  or combinations of tM'o
 or more of these figures.  A common form over  the sternum, aud in
 other situations where the  development of the  growth in every direc-
 tion is impeded, is that of  a larger central mass with tM'o or more
diminishing and declining prolongations bearing a remote resemblance
to the body and claws of a crab.   The  lesions  vary  iu size from a
small pea to a  large saucer, the largest including  the outlying points
of the limbs or  radiating ridges.   Over it the  skin  is reddish or
whitish in  color, smooth, hairless, and occasionally hyper-sensitive to
pressure and heat.  The growth is also at times  the seat of sponta-
neous pain. 
448                DISEASES OF  THE SKIN.
  The most frequent site of the disease is the anterior surface of the
chest, but it is observed also upon the face, neck, ears, breast, hands,
between the scapulae, and on  the extremities.   It may be  encoun-
tered, indeed, upon any portion of the body.   I have seen  it upon
the penis of the negro.   It is far more common in the colored than
in the white races.   Though frequently multiple, there are rarely
more than a score of these groM'ths visible at one time upon the skin
of one person.
                             Fig. 53.
  Etiology.—The origin of the disease is exceedingly obscure.  Neither
age, sex, nor previous disorder of the skin seems to have any bearing
upon  its production.   It is seen in remarkably vigorous persons
(more often decidedly in the negro race), but also upon those who are
weakly.  The very young and very old are more rarely affected.
   Pathology.—No little confusion has  occurred in consequence of the
failure to distinguish  clearly between  keloid and cicatrix.   Epithe-
lioma,  sarcoma, fibroma, and other diseases have existed with  or
complicated keloid,  and the anatomical  features of the  last-named
disorder  been thus obscured.
   In true keloid, the papillary  layer  of the corium and the inter-
papillary projections of the  rete downward are intact.   The new
formation is strictly limited to the middle and lower portions of the
corium, where whitish, tendinous fibres of connective  tissue, dis-
persed, for the  most part parallel  to the  surface of the rete, are 
CICATRIX.
449
numerous.    Lymph-vessels,  with  proliferated  endothelium, com-
pressed  by longitudinal growth of the fibres, pass in both vertical
and horizontal planes, for the most part remaining patulous.  There
are few  spindle cells and nucleated cells.  Many of the blood-vascular
channels are choked or absent.
   Diagnosis.—The  clinical distinction between  keloid and cicatrix
rests mainly upon the history of the lesion M'hether, that is, it be of
spontaneous origin, or has resulted  from previous disease or traum-
atism.  The situation of the lesions of the former, often over the
sternum, the iufrequency of multiple tumors, its claw-like prolonga-
tions, and  yellowish-white, reddish, or grayish-white color, all point
to the nature  of the disease.
   Treatment.—Removal of keloid  by cauterization  and excision  is
not to be practised, as the growth does not  fail  to  reappear.  Vidal
has  successfully  employed multiple  linear scarifications.   Various
stimulating applications may also be made with a view  to  promote
resorption, such as the spirit  of green soap, iodated  glycerine, iodine
in ointment and tincture, and mercurial  and lead plasters.   Where
there is pain, anodyne unguents may be employed topically, such as
the freshly prepared belladonna  plaster, or  the ointments of bella-
donna,  stramonium, and opium.  By far the most elegant of these, and
one M'hich  also is capable of  producing an alterative effect, is the
oleate of mercury and morphia,  manufactured by Squibb, of Brooklyn.
   Internally, quinine, strychnine, arsenic, and the iodide of potas-
sium have been  exhibited  M'ith  varying success.   The author has
never happened  to see a case  where internal  medication  had been
followed by appreciable results in the diminution of  the growth.
   Prognosis.—As regards  the  general  condition of the patient, the
prognosis is favorable.  Very rarely there is spontaneous resorption
of the  nodule or  tumor.   Generally the latter may be  expected  to
persist, after full evolution is attained, for au indefinite period of time.

                             Cicatrix.
Cicatrix is  a dense, smooth, whitish or reddish new-formation of the skin,
   occurring where there has been  a loss of connective tissue following trau-
   matism or tissue degeneration.
   A cicatrix, as  has  already beeu  shown, is a new formation of the
skin, replacing connective tissue which has been lost by traumatism,
 by ulceration, or by some other pathological process.   The  most  of
cicatrices,  as, for example, those following the ulcerations of syphilis,
the operations of the surgeon, or the dermatitis produced by  a severe
 burn, are reparative in their  effect.
   They vary greatly in* shape, size, color, and other characteristics.
They mav be smooth, glossy, shining, scaling, dull-whitish iu  color,
or pinkish from  vascularization of the surface.   They may be linear,
 fan-shaped,  circular, corded, ridged, dotted, crateriform,  or tumor-
 like.   They may be raised  above the skin, on a level with it, or de-
 pressed beloM' it.    They may be  deeply attached  to  periosteum  or
                                 •29 
450
DISEASES  OF  THE SKIN.
bone, or be readily movable over the panniculus adiposus.    They
are of deeper color M'hen young, and  increase in M'hitencss with age.
They are unprovided, as a rule, with hairs, or coil- or sebaceous glands.
   The  most  insignificant cicatrices are  those  resulting from clean,
incised, and punctured M'ounds and lesions of similar grade.  Here the
wounded surface furnishes a connective  tissue that seals up the solu-
tion of continuity.  Healing is then said to be by "first intention," and
is at an end, so far as regards the gross  appearances, in one to two days.
   Healing by " second intention"  occurs  after  a longer period in
solutions of continuity of greater  extent, and  in  those of the same
extent in aseptic conditions.   Here  also  newly  formed  connective
tissue concludes the successive transformations  from epithelium and
leucocytes to embryonal vessels, pus, plasma, and cicatrix.
   Certain peculiarities of cicatrix are  seen in special disorders where
they are produced.  The circular,  oval,  reniform, horse-shoe-shaped,
S-shaped,  and  figure-of-eight-shaped scars,  thin  and flexible, are
characteristic  of  syphilis.    The  cicatrices  of  variola,   zona,  aud
ecthyma are slightly different each from the other, though  all  are of
small size  and  depressed.   Those of lupus,  scrofulosis, and  derma-
titis calorica  of severe grade are  exceedingly irregular  and  often
corded.  Hypertrophy of cicatrices is  the condition already described
as spurious or false keloid.   Here the resemblance  to true keloid is
produced by  a  tumor-like development of the cicatrix,  forming a
ridge,  button, knob, indurated  fold, or  puckered and irregularly
circumscribed whitish or reddish lesion.
   These have been described as following almost every traumatism
and destructive  process to which the integument is liable.
   A case of cicatrix  undergoing involution, has  been  described  by
Dyce DuckM'orth, in  a man aged fifty,  who suffered from  rheumatic
fever, on two occasions, ten years before the date of report.  He had
pericarditis, and Mas  blistered over  the  praecordia.   Nine months
afterward, lines  of cicatricial growth  began to form in the scar left
by the blister, and they extended  rapidly.  In two years' time they
were still enlarging.    In  seven years, some subsidence Mas noticed,
and, when  exhibited  ten years after their first formation,  involution
M'as  markedly progressing.   The case illustrates the frequent origin
of scar tissue, its common occurrence over the  sternum, and the fact
of the subsidence of the new growth in the course of time.1
   Chilton2 reports  a  case  of cicatrix  following erasion of a  lupous
patch, an issue which may be regarded as the most fortunate for any
case.
   Purdon3 announces the same result following a psoriasis treated with
green soap; and Taylor4 reports the same as a rare result of syphilis.
   Keloid-like cicatrix of the cheeks, is far from uncommon following
acne.  Its  lesion  is usually smoothed down  in the process of time,
after  the disappearance of the sebaceous gland disorder,  till the
deformity is greatly lessened, and often  scarcely noticeable.

   i Brit. Med. Journ., October 8, 1881, p. 597.               « Ibid., January 20, 1883.
   3 Journ. of Cutan. and Vencr. Dis., 1883, p. 203.           * Ibid., 1883, p. 308. 
CICATRIX.
451
  Etiology.—The formation of a  cicatrix is  ahvays preceded  by a
traumatism  or pathological  loss of tissue, the remote causes of M'hich
have  the M'idest  possible  variation.   Hypertrophied  cicatrix,  or
spurious keloid, is always  developed from a simple scar.   It affects
persons of  all  ages and sexes, but M'ith  decided  preference for the
negro race.   The traumatism  may occur from piercing  the ears for
ear-rings, the operations of surgery, leech-bites,  the deeper burns
from fire, and M'ounds iuflicted by accident.   It often follows cutting
the hands with glass; and has beeu caused  by the spur of a cock.
It is sufficiently common after the occurrence of acne indurata, but
the latter is of  all its  forms the  least persistent.   In  general, it may
be concluded, however, that it occurs chiefly in those whose skins
have a special tendency to such development.
  Pathology.—Kaposi has  demonstrated a difference, rather of dispo-
sition  than  of kind,  between  keloid,  hypertrophied cicatrix, and
"cicatricial  keloid."  In  the  first,  the  epidermis  is  described  as
intact, while the corium  at  one level  exhibits whitish, thickened, and
closely packed  bundles of fibrous elements, lying parallel to the long
axis of the  tumor and the  surface of the skin, traversed  here and
there  diagonally by  similar bundles, all probably derived  originally
from the  sheaths  of the  bloodvessels.  In the second, the  papillary
layer  of the corium has  been  destroyed by the process of which the
cicatrix is  a resultant, and the latter does not  surpass its original
limits by  invading the unaltered peripheral tissues.  The connective-
tissue  bundles are  here  also  much  less closely aggregated.  In the
third,  the tM'o forms described above can  be seen combined, the
papillary layer being destroyed, and  the peripheral parts invaded by
the connective-tissue new growth.-
   Diagnosis.—The  distinction betM'een  hypertrophied  cicatrix and
keloid is  based  upon  the fact,  chiefly clinical, that the last  named  is
a spontaneous affection and  the former is always the result of a  trau-
matic or pathological loss of tissue.
  In  any doubtful case  a distinction  between hypertrophied cicatrix
and keloid  M'ould be needless from a practical point of view.   Fol-
lowing the piercing  of the  lobule  of the ear for the insertion of ear-
rings, the lesion is distinguishable  by pinching the part between the
fingers, when a globular, pea- to cherry-sized mass will  be felt firmly
embedded in the  derma between  the  reflected  folds of the integu-
ment.   Upon the face, after the occurrence of acne, it can be usually
seen as a puckered ridge, often transverse in direction, occupying the
region of the cheek.
   Treatment,—The  resources of modern surgery are to  be trusted in
the production  of laudable  cicatrices when all antiseptic precautions
are observed.   The  treatment of pathological  conditions likely  to be
followed by cicatrices, is the treatment  largely of the special  disease
in M'hich such loss of  tissue occurs, c. g., the ulcer left by a degener-
ating  syphilitic gumma of the skin.
  The treatment  of hypertrophied  cicatrix, or false keloid, is the
treatment of keloid already given. 
452                DISEASES  OF  THE  SKIN.

                             Fibroma.
                           Lat. fibra, a fibre.
Fibromata are cutaneous or subcutaneous neoplastic tumors, projecting in dif-
  ferent degrees from the surface, single or multiple, of several grades of
  density, distinctly circumscribed, covered either by a sound and attached, or
  rarely by an ulcerated integument, and varying in size from a small pea to
  a foetal head.
   Symptoms.—Fibroma  is  a disease characterized  usually  by  the
occurrence of numerous roundish, sottish, semi-solid, or solid growths,
Fto. 54.                                  Fio. 55.
Multiple fibromata.  (Gross.)                  Large single fibroma. (From a photograph
                                           of one of the author's patients.)
varying in size from that of a small pea to tumors of several pounds
weight, though more rarely the neoplasm is single.  They are often 
FIBROMA.
453
called  molluscous fibromata, as  the disease Mas termed at  one time
molluscum  fibrosum.   When quite small they are seated M'ithin or
beneath the skin, where they can  be  distinguished as distinctly cir-
cumscribed  nodules, buttons, or  plaques often slightly projecting.
When more fully developed they become sessile, pedunculated, or
largely pendulous tumors, hanging from the part  to M'hich they are
attached so  as  to resemble in shape a cherry, a nipple, a pear, or a
sausage.   They are commonly  covered by an  integument M'hich is
natural in color and suppleness, though the latter may be  traversed
by bloodvessels;  sprinkled M'ith comedones or patent orifices of seba-
ceous gland ducts; thinned or thickened, or in  a state of ulceration;
the last named being usually the result of externally operating causes
in tumors of large size.   They  are productive of no subjective sensa-
tion beyond the more or less uncomfortable tension produced by the
weight of those attaining a great size.   When multiple, they may be
seen in  various  degrees of development, covering iu  hundreds the
entire body, especially the scalp, face, trunk, genitals, and extremities.
Upon  the lids, they may interfere with  vision  by tbe production of
ptosis.   To the touch they may be felt as sottish, somewhat elastic,
firm, or lobulated masses, though  at times nothing but a double fold
of skin can  be  perceived, or a cord-like contained body.
   They are often congenital.   When closely set  together  upon the
skin, and of small size  and pendulous,  the  features  of the disease
are characteristic.
   Schwimmer  distinguishes between these lesions, usually congenital
(termed  bv him, soft fibroma), and  the dense tumors of similar
anatomical  features  (termed by him,  firm or hard fibromas).  The
latter  arc circumscribed, deeply seated, very slow of development,
and apt to induce changes in the tissues M'hich surrouud them.  They
raav undergo fatty degeneration, or ossification,  or calcification.
   Dr.  R. W. Taylor, of New York,1 in an interesting paper on  the
mode of  development and  course of fibroma,  and its relations  to
acrochordon and  other cutaneous offshoots, describes the first appear-
ance of the disease as a roundish spot over M'hich the skin is uplifted.
It is of a light pinkish color.  The tumor is soft aud suggests to the
touch a thinning of the  derma  beneath it.  By firm pressure over
such lesions M'hen they have  in size attained about half au inch in
diahieter, they  may be slowly pushed  downward into the skin, and
the sensation  is  produced to the touch, of a foramen in the derma.
Fusion between  the new growth  and the skin over it, is of early
occurrence.  The  roundish or oval form of the tumor depends upon
the direction of the  bundles of  the subcutaneous  tissues of the part
invaded.   After  reaching full development, it  may be replaced by
wartv  growths, pouches, or nipples.   Involution  is more common
M-hen the patient  is under thirty years of age.   Dermatolysis is pro-
duced  by great activity of the  growth of one,  or  fusion of several
tumors, by which a flap of skin is  formed.
1 Jouru. of Cutau. and Ueuito-Urinary Dis., Feb 1887. 
454
DISEASES  OF  THE  SKIN.
  The large  tumors in the skin of the  patient carefully studied by-
Taylor, suggested, when handled, that  they contained  boiled vermi-
celli, or a  number of thread-Morms, and contrasted  thus with the
firm or semi-solid lesions of older patients  affected with  fibroma.
The soft  and gelatinous quality of the neoplasm in  earlier  life  is
believed to be proportioned to the  age of the subject, and this rapid
development and succulency of structure are the only conditions of a
perfect involution which are not to be looked for in  the firmer, more
slowly growing fibromata of later years.
  When involution occurs, after full maturity of the lesions has been
attained, the sottish contents of the tumors  are adherent to the cutis
above, and  the  cutaneous atrophy is  proportioned to the rapidity of
development of  the-growth and the firmness of its structure.  Then
comes a purse-like pedunculation of the tumor, produced by encroach-
ment of the  skin upon  its pedicle, rendering  its invagination, sup-
posably  possible before,  afterward difficult  or impossible.   Then
gradually the neoplasm loses  its  skin-connection.   Eventually, in
many cases only fibrous cords are left, evidently attached to  the con-
nective tissue beneath, the skin  color paling as  the vascular tension
correspondingly  diminishes.  Soon the  dermal  foramen closes, and
the involution process is at  an  end.   Then  empty  and wrinkled
pouches or  purses of integument are left, whose further shrinking
produces multiple Marty or nipple-like elevations of tissue (under the
microscope recognized as fibrous  structures  M'ith  epithelial envelope),
much in color like the virgin-nipple, or the  scrotum of a boy.   From
four months  to a year Mas requisite for the mature development of
the tumors, and  nearly as  long  a period for the completion of the
process of involution.   The dermatolytic flap was permanent.   Dr.
Taylor believes, as a  result of his interesting study, that there is the
closest possible relation between  fibroma, and the verrucous  growths
called acrochordon and ecphyma mollusciforme.
  Etiology.—The disease  is  peculiar to neither sex;  and, though
observed in  adults, is commonly first  developed in  childhood.   It
cannot be claimed as peculiar to any race, though in this country the
negroes have probably furnished the largest field for its observation.
Hebra called attention  to  the low standard of physical and  mental
development of the subjects of the disease seen by him, a fact well illus-
trated in a case recently presented at the author's clinic, the patient
being an  exceedingly myopic,  poorly nourished, M'hite, male dwarf,
M'hose  body  »vas  literally covered with  fibromata from  the  scalp to
the feet.  In view of this well established clinical fact, the heredita-
bility of the disease, M'hich is rendered probable by recorded observa-
tions, seems  capable  of explanation.    It  has  been  noted  in three
successive generations and in several children of one  family.  The
precise cause of the disease is unknown.   It is,  however, reasonable
to conclude that it is due to a vice of local development under the
influence of a constitutional predisposition.
  Pathology.—Fibromata originate in  gelatinous connective-tissue
elements, which  undergo metamorphosis  into bundles of fibres, the 
FIBROMA.
455
tumors ahvays exhibiting more of the formed  material  in the outer,
and the formative or protoplasmic material in the central parts of the
mass.   The fibrous  bundles pass downward, and unite with  those of
the derma or subcutaneous tissue, forming thus a firm attachment for
the pedicle of all pedunculated tumors.  There is some question as to
M'hether these growths originate in the deep interspaces of the corium,
or in  the connective tissue about the hair-follicles or fat  lobules.
   Heitzmann1 divides the fibrous tumors of the skin into two classes :
" a. Dense, fibrous,  connective-tissue bundles  M'ith  relatively  few
spindle-shaped  protoplasmic  bodies  or solid  nuclei  running in all
directions, apparently M'ithout any regularity, thus producing a hard
and dense felt-like tissue.  This  is an imitation  of the structure  of
aponeuroses  or  interarticular ligaments, if scantily supplied M'ith
bloodvessels ;  or of periosteum and perichondrium, if holding a larger
number of bloodvessels.   6. Dense, fibrous, connective-tissue bundles,
holding in their meshes a jelly-like basis substance, with a small
number of protoplasmic  bodies.  This variety  is an imitation of the
structure met  with in the valves of the heart mainly upon their inser-
tions.   The  supply  of  bloodvessels, as  a rule,  is  scanty.  Both
varieties are common tumors of the skin, in the shape of hard, sessile
nodules and nodes (hard fibroma);  or tumors of greatly varying size
but softer consistence (soft or  myxo-fibroma);  or shallow, as a  rule
pigmented, elevations  of the skin (naevi);  or scar-like, irregularly
branching, sometimes freely vascularized new formations (keloid)."
   A very large number of fibromata are of the so-called "mixed"
variety.  Some spring from the  nerve-sheaths, and actually contain
nervous filaments (neuro-fibroma);  others from muscular, vascular,
and glandular tissues, the compound tumor receiving in this M'ay a
part of its constituent elements; often Marty groM'ths  form M'ith  par-
ticipation  of epithelium in the connective tissue, constituting thus an
epithelioma (so-called " papilloma").   The large pendulous tumors of
naevus lipomatodes may be examples of mixed fibromata whose surface
is composed of pigmented and hairy skin.
  Diagnosis.—The tumors of molluscum  fibrosum are to be distin-
guished clinically from  multiple cutaneous sarcomata, by the viola-
ceous or reddish color of the latter, their absence of  pedunculation,
their  greater tendency to ulceration, and  their evidently malignant
character.  From the tubercles of lepra they are differentiated by the
entire absence of constitutional impairment and their general  develop-
ment in far greater multiplicity.  The tumors  of molluscum epithe-
liale differ in their contents, superficial location, and  in the  frequent
presence of the dark punctum at their summits.
  Neuroma is  usually painful; lipoma less frequently multiple  and
pedunculated, and more suggestive, when handled, of  the "pillowy"
sensation to the touch.  Warty growths are readily distinguished by
their vegetating summits; and the gummata of syphilis, by the con-
comitant or prior symptoms of the existence of lues.
i Archiv. of Dermat., October, 1880, p. 378 
456                DISEASES OF THE SKIN.
   Treatment.—The treatment of large single fibromata  is surgical;
 involving the employment  of knife, ligature, ecraseur,  or galvano-
 or thermo-cauterization.   Multiple lesions are often so numerous as
 to forbid such interference.  When there is a distinct vice of develop-
 ment or inherited tendency to the disease, little  can be accomplished
 in the M'ay of treatment.
   Prognosis.—Rarely, one  or more of these  lesions disappear  by
 spontaneous involution.   More  commonly  they persist  after their
 evolution is completed.   Marasmus, tuberculosis, and  a  fatal  result
 may occur.  One or several  of the tumors  may become sources of
 danger from the occurreuce iu  them of an active inflammation M'ith
 resulting degeneration  and  septicemic  consequences.  The  disease,
 however, does not, in many cases, shorten life.  In general, the prog-
 nosis of multiple fibromata may be  regarded  as  unfavorable.

                            Neuroma.
                          Gr. vevpov, nerve.
 Neuroma is a disease characterized by the occurrence of single or multiple,
   pin-head to small nut-sized, usually painful cutaneous papules or tubercles,
   constituted of a new growth of connective tissue and non-medullated nerves.
   Symptoms.—But few cases of this rare disease are recorded.   The
 description appended is  a summary of the symptoms detailed in  the
 reports of Duhring,1 of Rump,2 and of Kosinski.3
   The patients M'ere all  men of middle  life  or  advanced years, who
 exhibited  upon the  shoulders, arms, thighs,  or buttocks, numerous
 disseminated aud defined, pin-head  to hazel-nut sized, roundish  or
 oval nodules or tubercles.  They were either painful, or painless at
 the onset aud painful later.   Iu Rump's case, which was  a sample of
 the false  neuromata of VirchoM' (fibroid tumors of the nerve), there
 was no pain throughout the course of the disease.
   The nodules were not  arranged along the  tracts of nerves; M'ere
 immovable, dense, and elastic ; were fixed in the  corium, and extended
 below  it.  They were purplish to  pinkish in  color; and the skin
 between them was unaltered, or like that enveloping the lesions, dry,
 uneven, and  desquamative.   The tubercles  were both  tender and
 painful, the pain being excruciating, paroxysmal, usually lasting  in
 Duhring's patient for an  hour,  and  radiating.  It Mas aggravated by
 temperature changes, mental emotion, and movement.
   Sections of the growth in Duhring's case showed anatomically  a
 connective-tissue stroma, interwoven  M'ith fibres for the most part
 lying  parallel with  one another, each fibre  composed  of a finely
 granular  central  substance  surrounded  by a  sheath   containing
 numerous, elongated, oval,  somewhat granular nuclei.  There Mas
 also yellow elastic tissue, bloodvessels M'ith thickened and  nucleated

 i Case of Painful Neuroma of the Skin, Amer. Journ of the Med. Sciences, October, 1873 ; also Sup.
plenient to the same, with curs, Amer. Journ. of the Med. Sciences, October, 1881.
 *Arch. of Path. Anat., Bd. Ixxx., Hft. 1.
 a Centralblatt f. during., 1874,- No. 1C. 
NEUROMA.




   Fig.  56.
457
Neuroma of the skin ;  external appearance.  (Duhring.)




                   Fig.  57.
Microscopic structure of neuroma.  (Duhring ) 
458               DISEASES  OF  THE SKIN.

M'alls, and  about the latter  lymphoid, cell-like bodies.  There Mas
entire absence of unstriated muscular and fibrillar conuective tissue.
The  specimen M-as certainly unique, representing  the true amyelinic
neuromata  of VirchoM'.   In Kosinski's  case, non-medullated nerve
fibres and  connective tissue were also  discovered.  In both cases,
exsection of a portion of nerve (brachial plexus, of the one; and small
sciatic, of the other) was followed by considerable diminution of pain,
and  almost entire disappearance of the growths.   In  Rump's case,
which, as stated above, represented the fibromata and so-called fibro-
nucleated tumors of Yirchow, the nodules  were strung  upon  the
same nerve, " like beads upon a rosary," and were  similarly displayed
upon its branches.  Spinal, cerebral, and sympathetic fibres were all
involved.
   Duhring, in commenting upon these interesting cases,  calls attention
to the  distinction between these purely cutaneous lesions  and  the
generally solitary, movable, and " painful subcutaneous tubercle."

                           Xanthoma.

                         Gr. t-av66c, yellow.
Xanthoma is a cutaneous neoplasm, exhibited in one or several, isolated or
  grouped, occasionally symmetrical, flat or slightly  elevated, yellowish ma-
  cules, papules,  plaques, or tubercles, which are most commonly situated
  upon the eyelids.

   This affection, also termed Xanthelasma and Vitiligoidea, was first
described by  Rayer,1 and its clinical divisions established by Addison
and  Gull.
   Symptoms.—The macular symptoms  of  the  disease, are bean- to
finger-sized plaques, either quite flat or M'ith slightly elevated borders,
often constituted by an aggregation of millet-seed-sized lesions, and
covered with an apparently Jiormal integument.   In  color they vary
from light and chrome yellow to the " coffee  and  milk" shade;  and
in shape they may be punctiform, roundish, oval, elongated, or quite
irregularly grouped.  They  are  distinctly  circumscribed, and when
gathered between the thumb and  fiuger do  not  produce the sensation
of the  presence of a foreign material.   They are most often seen upon
the eyelids near the inner canthus, M'here they may be  symmetrically
disposed about the two orbits.   But they may  invade  also the peri-
orbicular region, as  also, rarely, the cheeks,  the  nose, the ears, and
the nucha.   They are rarely productive of subjective sensation, being
occasionally  the seat of slight pruritus.   This is  the commoner form
of the disease, and is termed Xanthoma Planum.
   The tubercular lesions of the same  affection, known  as Xan-
thoma Tuberculosum, may coexist M'ith the plane lesions described
above, and scarcely  differ from  the latter  save  in their  greater de-
velopment.   They are whitish  or yellowish  papules, plaques,  and
1 Traite prat, des maladies de la Peau.  Paris, 1830. 
Plate II.
    Xanthoma of the Hands, Elbows, and Knees
(Front a Photograph of one of'the author's patients.)
                   do  fat-e p.458.) 
 
XANTHOMA.
459
tubercles, circumscribed in  contour, covered M'ith an  unaltered epi-
dermis, and determinable  by palpation as having greater consistence
than the  flat macules.   They are less frequently seen upon the lids,
but occur upon  the scalp, cheeks, palmar and  plantar  surfaces, the
genital region, and about the joints of the digits.
  Other  exaggerated forms are described.   Thus sessile or  pedun-
culated tumors, cutaneous or subcutaneous in their  attachment, nut-
to hen's egg in size, and originating in one or another of the lesions
named above, are described by Gary1 and Ohambard.2   To these the
name  Xanthoma  Tuberosum  should  be  limited.   Xanthoma
Multiplex is  the form  in  M'hich the lesions, usuallv first mani-
fested in the sites of election aud in their simplest development, pro-
ceed to a gradual invasion of the trunk  and extremities.  Occasion-
ally the  mucous  surfaces  of the  mouth,  of  the respiratory  aud
gastro-intestinal tracts  are  involved,  as also of the surfaces of the
peritoneum, endocardium, aud larger  arteries.   The genital  region,
palate, oesophagus,  spleen, trachea, and cornea have all been recog-
nized as  seats of the disease.
   The conglomerate forms  upon the skin  constitute large  plaques
resembling tumors, compounded of lesions of xanthoma tuberosum.
They are distinctly circumscribed, deeply embedded in the  corium,
elevated  to the extent of one-fourth  to one-half  of an inch above the
general level of the integument, and  irregularly furrowed or tabu-
lated superficially.   An illustration of xanthoma occurring in  full
development and  in rare  situations, is  presented in Plate II., taken
from a photograph of one of the author's cases.
   In a proportion  of cases, the disease  is accompanied  by a gener-
alized  coloration of the skin  in a yelloM'ish shade, M'hich  has been
variously interpreted as a xanthomatous dyschromia, and  as a true
icterus.  The former is the more probable explanation of the fact, as
in such cases the urine aud viscera have been found normal.
   Korach' has described the interesting  case of  a M'oman twenty-five
years old suffering from  chronic  icterus produced by closure of the
ductus choledochus.   Beside  the typical  patches of xanthelasma on
the lids,  the skin surface Mas generally and similarly affected. Thus
the extensor faces  of the extremities, the palms  of the  hands, nates,
and other parts  were extensively covered with sago-grain to  pepper-
corn sized papules and tubercles of xanthoma, both  flat and elevated.
   Etiology.—The causes of the disease are unknown.  In many cases
the  lesions  are  first observed in early  childhood,  though they are
encountered also in  middle and later life.
   In some cases the disease would seem  to be inherited.   Hutchinson
aud Church have  reported  several instances M'here more  than one
member  of a single family suffered from the disease; and the mother
of the  patient exhibiting multiple lesions upon the elbows and knees
selected bv the author for illustration, presented plane lesions of xan-

               i Ann. de Derm, et de Syph., 1880, p. 75.
               - Archiv. de Phys. norm et path., Sept. and Dec, 1879.
               3 Deutsch. med. Mochenschrift, No. 20, 1881. 
460
diseases  of  the  skin.
thoma near the inner canthi of the eyes.   The association  of xan-
thoma with  disease of the liver,  diabetes, rheumatism, and other
disorders  cannot be denied for certain cases.   In the majority, no
such association can be recognized; and careful post-mortem examina-
tion of patients affected with  xanthoma, and dead  of intercurrent
disease, has either demonstrated a normal condition of the liver or a
disorder of it quite disconnected with  xanthoma, such as a stricture
of  the  bile-ducts  from  cicatricial  contraction.    In  Mr. Malcolm
Morris's cases, occurring in diabetic subjects,  three women  and  one
man,  the eyelids  were  unaffected, and the partially  xanthomatous
lesions transitory in duration.
  The author has reported a single case coming under his observa-
tion, M'here multiple plane lesions of the lid in a middle-aged woman
succeeded a dermatitis of that  region, induced by accidental contact
with a corrosive solution of mercury.
  Dr. Barlow1 reports one congenital case of the disease.
  Pathology.—Pathological studies of the  affection  have been made
by Cham bard, whose conclusions are briefly  these : u The three forms,
plane, tubercular,  and tuberose, are the results of two processes, irri-
tative and retrogressive;  the  first prevalent in the  tubercular and
tuberose forms, the last in  the plane variety.
  " In xanthoma planum,  the  irritative process is represented by an
albuminous tumefaction of the connective-tissue elements, with pro-
liferation  of their  nuclei;  the retrogressive process,  by a fatty  de-
generation of their protoplasm.   In the other  forms, the irritative
process is distinguished  by the new formation of connective  tissue;
the retrogressive by a fatty infiltration  of the  old and newly formed
connective-tissue elements.   In both forms, not only the connective
tissue of the  derma, but  also  the vascular, glandular,  and  nervous
organs,  within and about the  sclerosed  nodules, are  invaded.   The
sclerotic process involves also  the fibrous envelope of the sebaceous
and  sudoriparous  glands  (periadenitis); the  internal  and  external
sheaths  of the vessels (periarteritis, endarteritis obliterans); and the
lamellar sheath and intrafascicular connective tissue of  the  nerves
(perineuritis, endoneuritis).  The  nervous involvement is thought to
explain  not only  the pain, but also the tenderness peculiar  to  the
xanthelasmic tubercles."
  Balzer's conclusions as to the parasitic nature  of the disease have
not been verified by Hanot and Eichoff.2
  In  the careful  and exhaustive  paper by Dr.  Karl  Touton3 it is
clearly shown that the disease is due to an atypical new formation of
cells seated in the  corium.   These have a sharply defined membrane;
and a large,  roundish,  or ovalish nucleus.  All  parts are  thickly
studded with fat drops, and it is from these that the yellow coloring
of the xanthoma plaques is derived.  They originate in and near the
lymph spaces  and  conduits of the derma; and in the building up of

    1 Path. Soc. of London, 1884.               2 Deutsch. med. Woch., No. 4, 1884
    3 Viertljst. f. Derm  u. Syph., Hit. 1, 1885, p. 3. 
ADENOMA.
461
the lesions are associated chiefly with connective and  yellow elastic
tissue.  The sebaceous glands are not, as M*as once held by Hebra, Geber,
and  Simon, concerned in the process.  The epidermis superimposed
upon the lesions  may  be thinned, but  is otherwise pathologically
unaltered.
   Diagnosis.—Milia are occasionally associated upon the lids in the
form of oval plaques, but are distinguishable from xanthoma  by the
possibility of expressing their contents.
   The diagnosis from all other lesions  is readily made, when con-
sideration is had  of the peculiar  yellowish  or saffron-like hue  of
xanthoma, and  the common  situation, form, and general character-
istics of its plane or nodular lesions.
   Treatment.—Erasion  and excision are the usual methods of remov-
ing xanthomata.   Care should be taken in such operations to avoid a
consequent ectropion M'hen the operation is  performed  upon the skin
of the eyelids.   The Paquelin  knife, which  I  have  employed for
this purpose, is  objectionable on account of the radiation of the heat
to the  globe of  the eye.  ^Yith the tumor slipped through  an aper-
ture in a thin  sheet of asbestos paper, such  as is now found  in the
markets, this inconvenience might  be avoided.
   The more modern method, however, of electrolysis is far preferable
to others.  Caustics also have  been successfully employed.   Besnier
employs  phosphorus internally followed  by turpentine, by M'hich
course the disease is  said to  have been relieved.   Wilson, M'ith the
same end in view, employed nitro-muriatic acid, arsenic, bitters, and
blue pill.
   Prognosis.—The  lesions, M'hen  not  removed, are liable  to  persist
through  life.   Spontaneous  involution is said to occur very  rarely.
The French authors, M'ho have given considerable attention to this
subject, are disposed to  believe that some cases of xanthoma tubero-
sum, with permanent xanthochromia and involvement of the inner
coats of  the larger vessels, may prove serious.

                           Adenoma.
                         Gr. a6t)v,  a gland.
Adenoma is a new growth in which  there is proliferation of the glandular
   cells  and their investing connective tissue, which constitute normally a
   secreting organ of the skin.
   Authors  are  not generally  agreed  as  to M'hat growths shall and
what shall  not be considered exclusively as adenomata.   Geber
includes  under  this title adenoma sebaceum, adenoma sudoriferum,
and  epithelioma molluscum.   Anderson,  on the other hand, gives  no
consideration  to the  subject, aud other authors relegate it to a para-
graph.   This  is unquestionably due to the fact that, apart from the
lesions described in this work  as molluscum epitheliale, a number of
the growths assigned to  this class are epitheliomatous.
1 Doutsch. med. Wochensch. No. 23, 1S81.
2 Loc. cit. 
462
DISEASES  OF  THE SKIN.
  Yet there  is no  question that true adenomata of unmixed  type
originate from both sebaceous and coil-glands.
  Certain whitish or yellowish, pin-head-sized, rounded and isolated
lesions, with gelatinous contents, scattered over the faces  of persons
in middle life and advanced years, are occasionally  seen  either
flattened  or slightly elevated above the level of the integument.
They have been described under  the  title of " colloid degenerations
of the skin," but are probably instances of adenoma of small acini of
the sebaceous glands, the epithelium of M'hich has undergone colloid
degeneration.   According to Heitzmann, the distinguishing feature
of them  all is  a  wreath of cuboidal or short columnar  epithelium,
inclosing a  distinct  cavity.   Besnier,1 however,  concludes that  the
connective-tissue elements of the derma are primarily involved in the
colloid degeneration, and the glandular epithelia secondarily.
  In general, the features of adenoma are well defined, circumscribed
tumors, pin-bead  to small-egg sized  and larger, sessile or peduncu-
lated, softish or quite firm, and  always  occurring in regions where
there are either coil-glands  or sebaceous  glands.   For a  time, after
the formation of such a tumor, the gland or glands from which it is
proliferated may discharge the usual  function.   The course of the
tumor may be  stationary; it may atrophy; it may degenerate by an
ulcerative process;  cysts may form;  or the contracted cells undergo
hyaline, colloid, or fatty degeneration.
  Sections of simple adenomatous tumors always exhibit the epithe-
lium  of the glandular structure  from which the new growth was
derived, and the connective tissue framework  of tumors in general.
  The diagnosis is from epithelioma, molluscum epitheliale, steatoma,
and  lipoma, for the exact determination of  M'hich examinations of
sections with the microscope are needful.
  The treatment, when any is required, is surgical;  and the prog-
nosis, in uncomplicated adenoma,  favorable.
                2.  Of Muscular Tissue.

                           Myoma.
                         Gr. /zvuv, muscle.
Myoma is a tumor of the skin which is composed in great part of muscular
                              fibres.

  Tumors  of the skin  composed of smooth muscular fibres are
known  as  Myomata,  Leiomyomata,  or  Lyomyomata.   But
little  attention  had  been attracted  to these new growths up to a
recent date.  Jullien,2 however, in a review of the contribution to
the subject made by Messrs. Brigidi and Marcacci, of Florence, and

            1 Ann. de Derm, et de Svph , t. x., Nov. 5 and 6, 1879.
            2 Ibid., t. iii. 2me ser., Feb. 25, 1882. 
myoma.                         463
published by them in the Imparziale, in 1881, gives a full capitula-
tion of the bibliography of the subject,1
   From these reported cases, it  appears  that the tumors originate as
usually single, though  occasionally multiple, elevated, disseminated,
small  pin-head to orange-sized, macular or tubercular lesions,  the
skin covering which is  smooth, stretched, and glistening, with a rosy
or dark reddish tint,  paling or not under pressure.   The developed
lesions may be sessile or  peduuculated, and either intensely painful,
pruritic, or  remarkably sensitive to  cold.   Under the  influence of
muscular contractions, there may be, as in the cases of Challand aud
Axel-Key, sIom' vermicular motion and frequent changes of volume,
or other evidences of contractility.  They occur either as generalized
lesions, or limited to  the thorax, scrotum, mammae, labia majora, and
the hands and  feet, including the palmar and plantar surfaces.  The
ages of the patients  varied from the twenty-fifth to the sixty-fifth
year of life.   Of thirteen persons whose sex was given, five were
males  and eight females.
   Pathologically, these cases  were reported as either pure myomata,
or highly vascular types  of Myoma Telangiectodes and  Fibro-
myoma.   Verneuil's case resembled a neuroma, as it  contained  not
only smooth and striated muscular elements and  bloodvessels,  but
also nerves.   The case of Axel-Key is recorded as one of Lymph-
anoiectasic Fibro-myoma.
   The disease is a benign new growth, and is not  to  be confounded
with prurigo, lepra, syphilitic gumma, neuroma, sarcoma, or fibroma.
   Babes, more  lately, divides these growths  into (a) those derived
from the  smooth muscle-fibres of the vessel-Mall ; (6) those derived
from the cutaneous muscular  network.
   The first (angiomyomata) are combinations of new groMths of vessels
with muscle-fibres derived from the vascular parietes.   The second
(dartric myomata) arc seen especially about the scrotum, labia, aud
mamm;c. The deep muscular apparatus of the region named (dartos,
etc.) contributes in these cases the muscular elements  of the tumor.
In  still  other  cases  muscular tumors  occur  M'hen  no  such tissue
normally exists.   In  these cases a deep aponeurosis or subcutaneous
muscle furnishes the basis of the neoplasm.
   In a case treated by  the author, multiple  piu-head  to  large bean-
sized congenital tumors were  situated near  the  sterno-cleido-mastoid
muscle of a girl nineteen years old.   These were exquisitely sensitive
to pressure,  were capable  of slight vermiform motion M'hen irritated,
and examination of  the  largest, after  removal,  exhibited  smooth
muscular fibres, aud,  in small proportion, terminal  filaments  of
cutaneous nerves.
  The course  of the disease is slow, lasting as it  may for several

 1 1854, Virchow ; 1858, Forster, Verneuil; 18G4, Klob, two observations; 1871, Challand, two obser.
vations ; 1873, Marcano Sokoloff; 1878, Axel-Key, Santesson ; 1880, Besnier; 1881, Arnozan and  Vail-
lard; Brigidi and Marcacci. 
464
DISEASES  OF  THE  SKIN.
decades.   The etiology is unknown.   Treatment  is by  enucleation ;
or removal by ligature, electrolysis, or incision.    ,


                      3.  Of Vessels.

                           Angioma.
                         Gr. ayyelov, vessel.
Angioma is that pathological development which is constituted wholly or in
          part of dilated or new-formed blood- or lymph-vessels.

   The angiomata are naturally divided into those  composed of blood-
vessels and those formed of lymphatic vessels.   The former are much
more frequent and variable  in character.
   Blood-vascular  new-growths occur  in three  forms :  nsevus vascu-
losis, telangiectasis, and angioma cavernosum.

                        Nsevus Vasculosus.

   This term is limited to those vascular anomalies of the  skin which
are either visible at birth or become developed in a brief period there-
after.   They commonly  occur  as  irregularly outlined  or distinctly
circumscribed, smooth spots, patches, or maculations, varying in color
from light red to deep violet and port-wine, either flat or very slightly
elevated above the general level of the integument.  From this type
wide variations  are noted, from the development of pea-sized papules
or tubercles, to tumors eveu of large size ;  pulsating and  aneurismal
in character; spongy or relatively firm ; fading or  more  rarely per-
sistent under pressure; superficial or deeply seated ; venous or arterial
in their connections ; single or numerous; and  in either case limited
to a small area or involving a relatively large surface.   They are of
most common  occurrence  upon the head, but are seen also  on  the
trunk and extremities.   Often they are the sole  lesions of the skin
present in a single individual; in other rarer  cases they complicate
moles, warts, and lymphangiomata.
   The  surface of these lesions is usually smooth, though  it  may be
rugous.   They  are  always  compressible, losing their habitual color
when the blood is forcibly pressed  out from the loose mesh-work of
vessels  of which they are composed, and becoming turgid  and deeply
tinted M'hen the blood is forcibly "driven  into their tissue, as in the
act of sneezing.
   The  course of these lesions varies  with their essential character.
Of the simpler  varieties, the larger  number increase  somewhat in
extent and development till they have attained  a  maximum size,  and
then either persist  indefinitely or accomplish a species  of involution
after agglutination  of the  vascular M'alls,  leaving a whitish, cicatri-
form, occasionally  pigmented surface.  Others extend indefinitely,
involving the neighboring mucous surfaces, subcutaneous tissue, and
deeper  structures, forming  vast tumors, destructive not only by their 
ANGIOMA.
465
tendency to extension, but by their mechanical effects.   Fortunately,
these extreme developments  are rare.   Much  more  commonly they
are observed in the forms known as the "port-wine mark" or " claret-
stain,"  which awaken  no subjective  sensations, and are usually  of
clinical importance inconsequence of the marked disfigurement which
they occasion.
   Occasionally, especially in the case of infants  but a few days old,
phagedena or gangrene will  suddenly occur in these patches M'ithout
appreciable  cause  (probably in  consequence of the  occurrence  of
thrombus), and  the entire tumor M'ill be removed, the line of demar-
cation  of the destructive process being exactly limited to the outline
of the  angiomatous  tissue.   The scar  resulting is superficial, aud
becomes smoother  in course  of  time.   In this M'ay the author has
seen spontaneous cure of nsevi  of considerable  size existing on the
head aud genitalia of infants.

                          Telangiectasis.

   Telangiectases are  acquired blood-vascular new formations, which
appear at periods of  life other than at birth or  a few months later ;
and are, therefore, distinct from  the congenital forms of the disease.
They  are  commonly first observed in adult  life,  and occasionally
multiply with advancing years.   They occur in diffuse and localized
forms.
   Diffuse, generalized  telangiectasis is exceedingly rare.  Hillairet
and Vidal have each observed one such case in individuals of both
sexes ;  the condition  being apparently due to systemic disturbance.
   The localized  forms are  betrayed  by the occurrence  of  flat  or
slightly elevated,  pin-head  to  pea-sized  maculae;  diffuse patches;
linear ramifications of individual  vessels;  or contorted congeries of a
plexus of  the latter,  all exhibiting the variations  in color of nsevi
vasculosi,  but  usually  of pinkish  or violaceous  hue.   They  are
unaccompanied by subjective sensations, are evidently nou-inflamma-
torv in character, and  are seen  as single or multiple lesions chiefly
upou the face, but also upon the  neck, the  backs  of the  hands, the
thighs, and other parts of the body.  They are not rarely observed in
connection with other diseases.   Thus they occur  in the  vicinity of
the lesions of lupus erythematosus, morphcea, acue  rosacea, cicatrices,
and about the contour, or over the surface of many malignant tumors.
They may therefore have either an idiopathic or symptomatic character.
   The term Rosacea, as distinguished from acne rosacea, is employed
to designate that condition in M'hich the skin, of the face particularly,
exhibits a circumscribed or diffuse redness, due to dilatation  of the
capillaries, unassociated M'ith acne or other sebaceous gland disorder.

   The conditions here described  as nsevus vasculosis and  telangiect-
asis are displayed in forms M'hich, apart from the question of con-
genital  origin, offer the widest difference aud  the  most  bizarre
combinations.  The  so-called nsevus flammeus, nsevus aranseus (spider
                                 30 
466                DISEASES  OF  THE SKIN.
cancer), nsevus vinosus, "mulberry," "•strawberry," and  "mother's
marks" are all examples of these combinations.
   The lesions are often congenital.  There is not sufficient proof that
they are due to  ante-natal  maternal impressions.   The influence of
the nervous system in deciding the area of limitation of the congenital
forms is exceediugly distinct, as, for example, the limitation of a port
wine mark to the skin area supplied by one supraorbital nerve.
   Pathology.—Billroth  states  that  the new  formation has its origin
in the  vascular  network surrounding in basket-like forms  the fat
lobules, follicles,  and  glands  of the skin.   Embryonal, vascular
growths spring from these and  as  they multiply aud  develop  are
enforced by proliferation of fibrous, connective, and muscular tissue.
The color depends largely upon the preponderance of arterial or of
venous capillaries in the new formation.
   Diagnosis.—The ordinary lesions of angioma are readily  recognized
by their  color,  size,   shape,  and  obvious  vascular constituents.
Anderson calls attention to the importance of recognizing  eucephalo-
cele due to the failure of ossification of the ethmoid and froutal bones
at the root of the nose.   Operations upon such  tumors,  when sup-
posed to be angiomatous in character have resulted fatally.  Lobula-
tion, great distention (when a  child  is crying), a  superficial  rather
than deep and complete vascularization  of  the smooth and  glossy
skin of the tumor, and a double pulsation in it, all  point to frontal
encephalocele.
   Treatment.—The treatment of all  forms of angioma is described in
detail in the chapter on angioma cavernosum.  The  best  method is
decidedly  that by electrolysis when it is  practicable.  Then may be
named excision;  amputation;  injection of pure carbolic acid,  tannic
acid, or the perchloride  of iron ;  ligature  of vessels ; ligation  of
tumors  produciug  strangulation ; the actual cautery; the galvanic
ecraseur;  the use of the seton ; and the application of such caustics
as the  ethylate of sodium.   Squire's  method of multiple puncture
and scarification  has at times failed in the author's hands to accom-
plish the desired  end.

               Angioma Pigmentosum et Atrophicum.

   This disorder has been also termed Xeroderma Pigmentosum; Der-
matosis Kaposi;  Melanosis Lenticularis Progressiva ;  and  Liodermia
cum Melanosi et  Telangiectasia.
   But a few cases, less than forty all  told, have been recorded ; and
these by  Kaposi, Glax, Crocker, Vidal,  Pick, JSTeisser, and  Geber,
abroad; and, in  this country by Taylor, of  Xew York, iu an  inte-
resting series of  seven cases ; by Duhring, of Philadelpbia ; and  by
White, of Boston.  The disease results  ultimately in a diffuse  idio-
pathic cutaneous  atrophy, but this condition  is preceded  by a general
hypersemia with  vascular dilatation ;  the production of  numerous,
punctiform, bright red, pin's-head to pea-sized, flat, or raised telangi-
ectases ; and disseminated,  brownish, and yellowish-brown maculae, 
ANGIOMA.
467
varying  in  extent; betM'een which form  superficial, M'hitish,  and
glossy, atrophic  depressions, like  the  cicatrices  of variola.  The
melanosis is at times so uniform and diffuse as to suggest the dark
tints  of  the Spanish skin, as in Prof. White's  case, M'ith a dense
spattering  of a  still  darker  hue  and a  blackish scrotum.  The
atrophic or leucodermic condition of the skin may coexist M'ith the
melanoderma, and present large M-ell-defiued areas totally devoid  of
pigment where  the skin may have a pinkish tint.  The  ears may
thus come  to resemble tanned sheeprskin.   Prof. White iu the case
under his observation could  trace no transformation from a pigment
macule into a telangiectasic lesion.   The skin soon  becomes furrowed,
contracted, and  as dry as  parchment; and thus is readily developed
an  eczema  or  a  superficial  degeneration,  including ulceration.   A
species of  furfuraceous  desquamation also occurs iu patches.   The
faces of  most patients exhibit a peculiar checkered appearance, from
the  uniform dissemination over the skin of the  pigmented maculae.
Ectropion, with ulcerative keratitis, epitheliomatous, sarco-carciuoma-
tous and angio-myxomatous  growths complicated several of the cases
reported; and in  two, certainly,  were the immediate causes of a fatal
issue.  Often, however, the general health seems, for long periods of
time, to remain  unimpaired, the subjective sensations  being slight.
Observers of these cases differ someM'hat as to the  order in M'hich the
several lesions of the disease appear ; aud Duhring thinks it possible
that no definite order is observed in the evolution  of the symptoms.
Both  sexes  iu  early  life  seem  equally predisposed to this  disease
though the large number  of members of single families affected with
its symptoms indicates the importance of predisposition and heredity
in  point of etiology.   It  is usually first manifested before the third
year of life.
   It is  known that the  disease may endure for thirty years.  Its
etiology, pathology, and  appropriate treatment  are not as yet de-
termined.
                       Angioma Cavernosum.

   This  is also termed Tumor Cavernosus.   It is  distinguished from
the other angiomatous lesions described above by the peculiarities of
 its  formation.    It consists of a  dense framework of new-formed
connective  tissue, inclosing  loculi or chambers  of varying capacity,
containing  blood, and communicating not only with each  other, but
 with the larger vessels in  the vicinity.   Whether they originate in
the fibrous felt-work of the  derma,  M'hich later establishes a vascular
connection,  or  in the vessels themselves, or are constituted by a
 mechanical  dilatation  of  the latter,  in consequence of new-formed
connective  tissue in the adventitia, has not been  determined.   Ac-
cording to Virchow, thcv arise  generally from  coalescence and dila-
tation of vessels.   Other causes are explained by the earlier forma-
tion  of  a  contracted cicatricial  tissue by which  vascular distortion
occurs.  (Riudfleisch.)
   They arc said to be rarely congenital, developing soon after birth, 
468
DISEASES  OF  THE  SKIN.
and to be both superficial, deep, circumscribed, and  diffuse.   Some-
times  they originate  from  a  nsevus  or  superficial  telaugiectasis.
Often  when fully formed, they  are  distinctly  encapsulated.   The
diagnosis  is  between  cysts,  fibromata,  lipomata,  and  sarcomata.
Their rarity in dermatological  practice may" be explained by the sur-
gical features of many cases.   In five years, no  instance of angioma
caveruosum was  reported in the statistical tables of the American
Dermatological Association.

   Etiology  and Pathology.—The  causes  of the  several  forms  of
angioma, uamed above, are obscure.  The  symptomatic telangiectases
are undoubtedly to be  explained by obstruction  to the circulation
occasioned  by the tumor or other lesions to M'hich they are accessory.
The foundation  for the vulgar belief that maternal  impressions  are
responsible for the so-called  " mother's marks"  is very slight.   The
reputed resemblance of the latter to various flowers and fruits gener-
ally requires for its recognition a stretch of the imagination.
   Anatomically, these lesions are recognized as due to dilatation aud
formation  of venous and arterial capillaries in the superior portions
of the derma, the vessels of the newly formed plexus  freely com-
municating M'ith each other.   Generally there is a simultaneous new
formation  of connective tissue constituting  the framework of  the
growth,  which varies considerably in the different forms of the dis-
ease.   Lobules  constituted  of coils of capillary vessels are  often
separated by it into distinct masses.  According  to  Heitzmann, the
large  spaces of angioma cavernosum  imitate the structure of  the
corpora  cavernosa of the penis, and are  filled  with venous  blood,
being separated from each other by a scanty fibrous connective tissue.
   Treatment.—The treatment  of this  group of new growths is, in
general,  limited to a series of local  surgical procedures.   These all
have in vieM* either the destruction of  the new growth, or the arti-
ficial production of an inflammation, in order to  obliterate the lumen
of the capillaries of which it is composed, to an extent sufficient to
interfere with the  transmission of the blood-current.
   First  among these is electrolysis.  One or a set of several fine
cambric  needles, with their points  at the  same plane, are connected
with the negative pole of an ordinary zinc and carbon battery of ten
to twelve cells.   The points of the needles are quickly passed into
the tissues, and there  held for a  period of between  ten to thirty
seconds,  according to the effect  produced after completion of  the
circuit.  The new growth  is thus blanched in the vicinity  of the
needles, this effect disappearing iu the course of  a few moments.  In
about three weeks, the curative result of the operation  becomes  ap-
parent.  According to  Fox,1 of New York, the objections are that
the operation is sometimes painful and tedious, aud may occasionally
result in the production  of suppuration, superficial sloughs, minute,
keloid-like elevations, vascular nodules, depressed scars, or superficial
ulcers.   The author has operated in scores of cases M'ithout the pro-
1 New York Med. Rec, Feb. 18, 1882, p. 188. 
ANGIOMA.
469
 duction of any results  worse than the original disfigurement, often
 with complete success.
   The method of Sherwell1 is by multiple  puncture with a set of
 fine needles in a holder similar to that described above.   These are
 dipped in a twenty-five to  fifty  per  cent, solution  of chromic  acid,
 and then made to penetrate the part  to be attacked.   The bleeding
 is readily arrested by pressure, and  then the patch is to be covered
 with several  superimposed  layers of flexible collodion.   This  pro-
 cedure is of value in circumscribed  patches  of superficial character
 and relatively limited  area.   By it,  the author has succeeded in re-
 moving port-wine marks in three patients,  M'ith the result of  pro-
 ducing a  somewhat irregular cicatriform tissue much  less disfiguring
 than the  original blemish.    One of these  patients was repeatedly
 exhibited at the clinic during the progress of the case.
   Squire's operation is  done upon previously frozen  patches by the
 aid of an instrument which  destroys the vessels by making numerous
 crossed and closely spaced linear incisions, parallel to  each other and
 in a plane obliquely directed to that of the integument.   Here  also
 bleeding is arrested by pressure, exerted before the circulation is re-
 stored.    The operation has been, in  hands other than his own, at-
 tended at times M'ith unsatisfactory results.
   Sodium ethylate, a compound in M'hich the radical ethyl in ethylic
 alcohol is  united with sodium, is  a caustic recommended by Richard-
 son2 in the treatment of nsevus.   It  is applied by means of a glass
 rod.   A first application usually  results in the formation of a dense
 crust under which the nsevus contracts, and repeated applications are
 made at intervals of a  few days  till  the desired result is obtained.
 The sodium ethylate should be pure, and the crusts  should not be
 disturbed till they fall spontaneously.   In one case observed by the
 author, there  M'as a persistent redness of the  resulting scar which
 M'as decidedly open to objection.
   Other methods employed are the ligature when practicable; punc-
 ture with hot needles; the topical application  of caustics other than
 those named above,  such as hydrate of potassium, nitric and carbolic
 acids, and corrosive  sublimate; and  total  excision,  the latter being
 practicable in relatively small  growths.  The galvano-cautery  and
 the  thermo-cautery  are  both  valuable in the destruction  of  the
 capillaries, and have repeatedly proved successful in  my hands.   For
 telangiectases and nsevi  no  larger than a pea, the Paquelin knife is
 an efficient resort.  The  old method of multiple vaccination about
 and  upon  the involved area is frequently followed by the best of
 results,  and whether in consequence of the retraction of tissue under
 the influence  of the  inflammation excited, or  of the destructive re-
 sults of the suppuration induced,  or of an indefinite caustic effect, is
 not, as Kaposi suggests, quite clear.
  These results may  be  partly imitated  by the induction of superfi-
cial  pustulation  and  suppuration  through  the medium of tartar
emetic and croton  oil, methods which  certainly should  be considered
i Archives of Derm., Oct. 1879.
2 Lancet, November 9, 1878 
470
DISEASES OF THE SKIN.
 clumsy in the light of recent successes, obtained by more manageable
 expedients.
   Injections M'ith carbolic acid and the perchloride of iron, though in
 very few  cases folloMed by fatal  results, are often brilliantly suc-
 cessful.
   Coombs1 has lately modified someM'hat the method most in vogue,
 by passing fine silver wires through nsevous growths, and connecting
 the extremities with a Bunsen's battery.   When the wires are heated,
 the circuit is broken, and the ends of the wires disconnected from the
 battery and united to each other, being then left in situ  and covered
 with lint and plaster.  The current cau  then be passed repeatedly
 without reinsertion of the needles, and the latter need be withdrawn
 only when the cure is complete.
   The treatment of angioma cavernosum manifestly requires surgical
 interference.
   The prognosis in any case of angioma will evidently rest upon the
 method of treatment adopted for its removal.   In the larger number
 of cases, the lesions having attained a maximum development, persist
 without further pathological change, constituting a deformity rather
 than a disease.  Physiological alterations in the color of such lesions
 occur under the influence of changes in the circulation.

                       Lymphangioma.
 Lymphangioma of the skin is an ectasia or new growth of lymphatic vessels
  of the corium, spontaneous or traumatic in origin, producing usually cysts
  containing lymph.

   New growths of lymphatic vessels in the skin  have been noted as
 constituting a cutaneous disease proper, by Hebra and  Kaposi, Pos-
 peloM',2 Van Harlingen,3  and  a few other writers.  By the  authors
 first named, the disease is termed Lymphangioma Tuberosum Mul-
 tiplex.   The  lesions in these  several cases  were multiple, pea- to
 bean-sized, smooth, roundish, reddish, lilac-tinted or  bluish, firm or
 compressible tubercles, implanted in the skin, and occurring first in
 early life, about  the neck and trunk.   Some of these were  quite
 reducible under pressure, and transparent.  In Van Harlingen's case,
 the  lesions were  destitute  of fluid  contents,  and also  interspersed
 between  telangiectases.   Anatomically,  roundish or   oval  spaces
 appeared  in sections, recognizable as distended lymphatic vessels by
 the characteristic endothelium  with M'hich they were  lined.   Kaposi
 distinguishes these tubercles from all subcutaneous cavernous tumors
 constituted of new-formed dilated lymphatic vessels  reaching toward
 the skin,  by the limitation in the former of the neoplastic groM'th to
 the superior parts of the corium.
   In comparing these with the large number  of  cases of congenital

 1 London Lancet, 1881.
 2 Viertelj. f. Derm. u. Syph., Hft. 4, 1879.
 3 Paper read before the Amer. Dermat. Association, September, 1881. Phila. Med. Times, September
24, 1881. 
KHINOSCLEROMA.
471
and acquired dilatation of the lymph channels, collated  in  the valu-
able monographs on  these subjects by Dr. S. C. Busey,1 of Wash-
ington, 1). C, a further special  difference between the two becomes
apparent.   In  the  latter, when  the lymph-filled vesicle, papule, or
tubercle, M'hich appears  upon  the integument is ruptured, there at
once supervenes au  exhausting drain from the body, of pure, coagu-
lable lymph, a feature M'hich is not described by the  dermatological
authors named, as of occurrence in their cases.
   Most of the diffuse forms of lymphangioma, those of the class  last
described, constitute firm or lax tumors of such size as to be termed
Elephantiasis Lymphangiectatica or Pachydermia Lymphangiectatica.
These  contain often large lymph-filled sacs or lacunse, enveloped in
hypertrophied  muscular  and connective  tissue, and  an oedematous
integument.  Some of the elephantiasic deformities of this character
are fully as enormous as  the  extreme  distortions of  elephantiasis
proper.
   Lymphadenectasia  is a name given by  Virchow to  tumors usually
in the  axillary or inguinal regions where the lymphatic vessels in the
lymphatic glands dilate or multiply so as to form large tumors.  The
lymph-scrotum due to the presence of the filaria sanguinis homiuis is
else M'here described.
   Lymphangiomata  may be congenital or  appear soon  after birth.
Their  cause is unknown.  Anatomically the  lesions are found to
consist of greatly developed lymphatic vessels, lined with endothelium
and enveloped in small-celled connective-tissue stroma.   The treat-
ment,  of the larger  lesions only,  is surgical.


                                  4.

                         R hinoscleroma.
               Gr. pic, or piv, the nose; and  GKkrip6c, hard.
Rhinoscleroma is an infectious granuloma affecting the skin and mucous mem-
  branes of the nose and contiguous parts, characterized  by the formation of
  exceedingly dense, elastic,  and painful, flattened or elevated  plaques,
  nodules, or tubercles,  which may be isolated or confluent.
   Si/mptoms.—A  knowledge of  this rare disease,  first described by
Hebra and  Kaposi  in 18TO,2 has been  obtained solely from a study
of some fortv cases  chiefly observed by these authors.   The following
is a concise statement  of their description of the  malady :
   The disease commonly begins iu the septum or  a single ala  of the
nose M'ithout inflammatory symptoms.   The involved  parts slowly
enlarge, and become finally as dense as ivory. The individual lesions

  1 Congenital Occlusion and Dilatation of the Lymph Channels (Amer. Journal of Obstetrics, January,
1877, et neq.); Narrowing, Occlusion, and Dilatation of Lymph Channels, Acquired Forms (New Orleans
Medical and'Surgical Journal, No. 3, 1878, to No. 8, 1878, inclusive).  Si>e, e. g., history of Berkley
Hill's patient, p. 101; of Zambuco's,  p. 120 ; of Carter's, p. 103 ; of Cholmley's, p. 136 ; of Jackson's,
p. 173, and many others.
  2 Wien. med.'Woch., No 1, 1870. 
472
DISEASES  OF  THE  SKIN.
are flat patches, or elevated and circumscribed nodules, papules, and
tubercles, painful  upon  pressure, movable to a certain  extent over
underlying tissues, and covered either by a normal integument, or a
light  or  dark  red, shining, vascular epidermis.   Neither hairs nor
glands are discernible over the lesions.  As the disease progresses,
the alse become enlarged, flattened, and so indurated that they cannot
be pressed together,  M'hile  respiration may be impeded by stenosis of
the nares.   The process  may  extend  to  the  neighboring  parts,
involving thus the  upper  lip, gums, velum, epiglottis,  and larynx,
the teeth meanwhile  falling  from their sockets and the soft palate
becoming in some cases perforated.  Involution of the  process has
not been  observed, as the lesions do  not degenerate by ulceration.
Max  Zeissl,1 however, reports a single case in M'hich there had been
ulcerative destruction of the entire left nostril, as M'ell as the tip and
right  ala  of the nose.   Occasionally superficial excoriations have
occurred, but very rarely a diminution in the consistency of the mass.
The disease is  exceedingly chronic, requiring  years  for  its  develop-
ment ; and though the affected parts are painful on pressure, they are
otherwise not the seat of subjective sensation.
   Etiology and Pathology.—The  disease is  observed  between the
fifteenth  and fortieth years  in persons  of all social conditions and
individuals of  both  sexes,  free from  syphilitic, strumous, tubercular,
and other cachexise.
   Kaposi originally observed, as anatomical  lesions of the disease, a
dense infiltration of the corium, and its papillary layer, M'ith  small,
closely packed  elements, which he recognized as a true new-formation.
He considered  this as analogous to the small-celled sarcoma, inasmuch
as  Mikulicz, Geber, and Billroth have seen  some  of the elements of
the neoplasm transformed into osseous formations sufficiently common
in sarcomatous tumors.
   More  lately,  however, A. v.  Frisch,  after  examining  tissue
removed  from lesions of rhinoscleroma in twelve patients, found in
the cells and  between  them in  the interpapillary fissures of the
connective tissue, bacteria distinctly  rod-shaped, one and  one-half
times longer than they  were  broad.  These germs M'ere successfully
cultivated, but experimental  inoculations with culture fluids thus
obtained  were  negative  in results.   Neisser  in a single case found
no bacteria; nor did  Davis have better success in studying sections
removed  from his patient, the first reported as occurring in Egypt.2
   Dreschfeld,3 however, found in  sections  of tissue obtained from
Payne's  patient numerous bacilli  less slender and  smaller than those
occurring in tuberculosis with slightly thickened extremities.   These
were  unlike those exhibited by Paltaup, at the Berlin Congress, M'ho
regarded them as similar to if not identical  with Friedlauder's pneu-
mococcus.  Barduzzi, Pellizari, and others have added to the evidence
in favor of the parasitic nature of the disease.
i Wien. med. Woch., 1880, p. 621.
2 Brit. Med. Journ., May 29, 1886.           3 Brit. Med. Journ., October 24, 1885. 
LUPUS  ERYTHEMATOSUS.
473
  Diagnosis.—The disease  can hardly be  mistaken for another in
consequence of its situation, the disfigurement it occasions, the ivory-
like elasticity and induration of the affected parts, and  the rarity of
ulcerative degeneration.   As distinguished from syphilis, it is known
to be entirely unaffected by specific medication.  From the variety
of acne  rosacea  of the nose, known  as rhinophyma,  it is  readily
differentiated  by the softness and compressibility of the latter, aud
its evident vascular and glandular composition.
  The  ulcerations  of epithelioma have  a  more  circular outline, a
more elevated  edge, and occur in  persons of a  more  advanced age.
Keloid, if found  in the  situation of  rhinoscleroma, does not ulcerate.
   Treatment.—The method  of relief thus far employed  is a total or
partial  extirpation of the neoplasm.  Kaposi speaks of dilatation of
the nares by means of laminaria and compressed sponge, M'here there
is actual or threatened nasal occlusion.  Both excision by the knife and
destruction  by caustics  have, however, been found  to secure merely
temporary benefit, as the growth is reproduced M'ith some rapidity.
  Prognosis.—The future of the patient is grave.  The disease  not
only persists and recurs  after operative interference, but may endanger
life by  obstruction of the nostrils.   Zeissl's case1 proved  fatal in  ten
years after the disease first appeared.

                    Lupus Erythematosus.
                          Lat. lupus, a wolf.
Lupus Erythematosus is a cutaneous new growth, displayed to the view in
  well-defined, slightly raised, discoid  patches, often  with a depressed or
  atrophied centre, colored in various  shades of hyperaemia, covered with
  adherent, yellowish-gray scales, and terminating, after  a favorable involu-
  tion, by the production of a persistent scar.

  This  disease was first described by Biett under the  title Eryth&me     x
Centrifuge.   Hebra, in  1845, described  it among the seborrhceas as
Seborrhoea Congestiva.   Its present title was given by Cazenave in
1850.   It is also termed Lupus Erythematodes,  Lupus Sebaceus,
Lupus Superficialis, and " Scrofulous Ringworm."
  Symptoms.—The disease is first  exhibited in one  or several  rape-
seed to  bean-sized, reddish maculae, slightly elevated  from the  surface,
and covered with  a  peculiar  glistening epidermis, or  M'ith an adherent
scale.
  When  but a single patch is formed, the  primary lesion described
above enlarges its periphery, in the course  of months or years, by a
slowly  continuous  development.   Its  reddish   outer  rim   is  then
distinctly elevated, M'hile its  centre is  depressed, showing either
adherent, yellowish-gray scales, or  a  glistening  appearance of  the
unbroken epidermis.  It may thus attain the size  of a small  coin or
a large saucer, and occur in this form  symmetrically or asymmetri-
cally about  the cheeks, nose, eyelids, forehead, ears,  scalp,  mouth,
i Wien. med. Wocli., 1880, p. 621. 
474
DISEASES  OF  THE  SKIN.
hands, and feet.  The disks or  patches are very well defined in out-
line, and of a color varying with the complexion of the patient, from
a rosy-pinkish to a deep purplish hue.  The shape is usually circular,
oval, or in figures representing combinations of these outlines.   The
scales,  too, vary in color, being  at times of a clear  white or whitish-
yellow, and again, often from concurrence of comedones, of a leaden
or brownish tint.  The. latter are usually scanty and adherent, but are
also, rarely, abundant.  They can be occasionally seen firmly fastened
to the  orifice of the excretory duct of a sebaceous gland.   When such
a patch spreads  symmetrically  over the  brow and  cheeks, its figure
has  been  likeued by Hebra to  the open wings of a butterfly.   The
disease is  never accompanied by the occurrence  of other cutaneous

                             Fig. 58.
Hill      H
      Lupus erythematosus of the face (from a photograph of one of the author's patients).

lesions:  nor is it ever displayed in symptdms of moisture and dis-
charge.
  When the  maculse originate as multiple lesions, the evolution  of
the disease may be accomplished by increase in the number of the
former, rather than, as just described, by the  peripheral extension of
a single patch.  The  disease is then apt to be  manifested, not only
in the regions named  above,  but over  the  trunk and extremities,
where it is  likely to assume atypical forms, and be complicated by
accesses of a febrile or neuralgic character, and by various cutaneous
accidents, such as erysipelas, dermatitis, etc. 
LUPUS ERYTHEMATOSUS.
475
  The disease is remarkably chronic in its course, lasting in cases for
a quarter  of a century, and  throughout  not  interfering with  the
general health.  So-called " galloping" cases are described  by French
M'riters, M'here visceral complications were the causes of a fatal result.
The disease varies in the subjective sensations it produces;  being at
times accompanied by excessive itching, and often  by uo discomfort.
It is much more common in  women than iu men, and is a disease of
adult years.   Kaposi reports a single  case in  one child three years
of age.
  The  scars  left  by the affection  are  indelible and  characteristic.
They are generally uniform  and superficial; can be readily pinched
up  between the thumb  and  finger; are of a dull, M'hitish  tint, and
rendered punctate in a  peculiar manner, suggesting the  action of the
engraver's tool in what  is known as the "stippling" process.   They
are never  pigmented, puckered, radiate, stellate, corded,  or deeply
attached.
   According to some authors there are two varieties  of erythematous
lupus, the  first, the so-called discoid form, described above; second,
a disseminate form.   In the latter, graver in type, the disease begins
with numerous efflorescences of the character already described M'hich
multiply M'ithout  marked  enlargement of any single disk until very
extensive surfaces are involved including the trunk, extremities, and,
in generalized  forms, almost the entire  body.   There is often coinci-
dent fever or  erysipelatous  complication, and  the  result may be  a
typhoid condition with fatal result.   These cases are not knowu  in
America and  Great Britain.    Boeck has described  two cases of this
sort observed in Norway.
   Lupus erythematosus of the hands,  observed  rarely in France and
Germany,  more often decidedly in England  and America, occurs not
only in the generalized  forms referred to above wheu  large areas of
the body are involved, the hands included; but also when the lesions
are exclusively manual in situation.  These cases have been described
by  Hutchinson,  Sir Erasmus Wilson,  and others, including  the
author.1  The lesions are not to be mistaken  for chilblains  on  the
hands.   Very rarely they are  seated upon the glans penis.
  Etiology.—-The  causes  of  lupus erythematosus  are  unknown.
Much  has  been said  and written to prove that the disease  is of scro-
fulous origin,  but inasmuch  as an immense number of scrofulous
patients in all parts of the world never exhibit traces of the disease,
it is needless to say that the proof has  not been  obtained.   In by far
the larger number of patients actually displaying characteristic disks
of  erythematous   lupus,  the  usual concomitants  of scrofuloderma
(which  see)  are  actually wanting.   In many patients,  the most
careful investigation fails to discover any other evidence of ill health.
Yet inasmuch as many young women, after the puberal  epoch, suffer
from the chlorosis, ansemia, and  menstrual irregularities common bo
their sex and age,  these conditions may concur.   As for tuberculosis,
1 See his resume of these cases in the Journ. of Cutan. and Vener. Dis., Nov. 1884. 
476
DISEASES  OF  THE  SKIN.
adenopathy, and malnutrition, cases of erythematous  lupus occur in
subjects affected with such  symptoms  to  an extent which may pos-
sibly be the  result of  coincidence.   Considering  the remarkable
rarity of the disease, and the no less significant frequency of sebor-
rhcea, the wonder is not that they should occasionally concur, or be
transformed, the latter into the former, but that such phenomena are
not more conspicuously and frequently noted.
   The disease is more common in women than in men, usually ap-
pearing first in the third decade of life, in this particular presenting
a contrast with lupus vulgaris.
   It is reported to have followed acne, seborrhoea, variola, erysipelas,
vesication with cantharides, and the traumatism  of  leech-bites.  The
author has  seen  it  iu one  case appear when the curette  had been
employed in a patient with a characteristic patch elsewhere  on  the
face.
   Pathology.—The disease - process  originates  either in  the peri-
glandular tissues of the sebaceous or sudoriparous follicles and their
ducts, or in  some part  of the panniculus  adiposus;  in  other  words,
from any point in the superficial or deep strata  of the cutaneous  or
subcutaneous structure.   Under the microscope, the elements of both
the epithelia lining the glands and  of  the connective tissue without
are seen to be multiplied and largely commingled with the ordinary
products of an inflammatory process.
   Thin1 fouud enormous distention  of  the capillaries in the papillse,
their  loops  of venules  being choked  with  red  blood-disks, and  in
this  state almost completely  occupying the digitation.   The same
was  observed in the perifollicular plexuses, M'hile  yet  the rete and
glands were quite unaffected.   Such alterations would, without ques-
tion, ultimately follow as the result  of  the vascular trouble; but  the
observations are of interest as lending  color to the supposition that
the primary changes in  lupus erythematosus are chiefly vascular.
Similar vascular  dilatations, papillary  and perifollicular,  have been
noted by Kaposi and others as concurrent with  structual  alterations
iu other portions and appendages of the skin.
   Iu  consequeuce of the new growth thus  formed, there are moderate
elevation of the initial  macule  of  the  eruption  and a thickened rim
to its centrifugally developing  patches.   Central  resorption   or
atrophy of the same material  in the epidermis and corium  of  such a
patch explains the wasting  and depression so frequently observed  in
each.   By the destruction  of the glandular  and connective tissue
elements  in the course of a retrograde metamorphosis, a loss  is pro-
duced which is made good by the peculiarly punctate form  of  the
cicatrix which results.
   Veiel classes  the disease among the superficial inflammations of
the skin.
   Diagnosis.—The  facies of the  patient,  with lupus erythematosus
of that region, is usually so characteristic that  the  disease is there
1 Med. Clin. Trans., 1875. 
LUPUS  ERYTHEMATOSUS.
477
recognized M'ith ease.   When  the  hand  and other portions of the
body are involved, the diagnosis is somewhat less readily established.
In the former situation, the disease has a predilection for the dorsum,
and invades the palm  usually only by extension to it from behind.
  From lupus vulgaris  it  may be recognized,  by  its occurrence
originally at a  later period of life;  by its greater tendency to  sym-
metry;  aud by the absence of nodules,  ulceration, and extension to
the deeper portions of the skin or underlying structures.
  In  eczema,  there is usually some  history  of moisture; in ery-
thematous lupus, never.   In eczema, also, the itching is  a more per-
sistent and distressing symptom; but the acuteness of even chronic
eczema, as compared  with  lupus erythematosus, will suffice to dis-
tinguish the two diseases.   Psoriasis is rarely,  if ever,  limited to a
single patch  on the face;  it is also characterized by  more lustrous
and more readily  exfoliating scales.   Its patches are, furthermore,
uniformly well covered  with  scales, and of  equal  flatness in  all
parts, M'hile those of lupus erythematosus are irregularly squamous,
the scales  being often clustered  at  the orifices of the ducts of the
sebaceous glands,  while  the  rim of the  patch is  elevated and the
centre depressed.
   In  acne rosacea, there  are marked telangiectases and  papulo-pus-
tules  or nodules M'hich  are not  found  in erythematous  lupus.   In
tinea  circinata, there  may  be a clearing, but never a cicatriform
centre of the circular disk.    The  circular  serpiginous  syphiloder-
mata  of the face occur usually  with  other manifestations  of lues, are
characterized by a  much darker hue  of the dense infiltration, and
exhibit distinct signs of ulceration in  most cases.   Cicatrization
or atrophy of the skin without preceding ulceration, is the sign and
seal of typical  erythematous lupus.
   Treatment—The internal treatment of this affection is not highly
satisfactory.   Often none is indicated or required.  Anderson1 highly
recommends the trituration  of twenty-four grains (1.6)  of iodine
with a little  Mater, adding  to this  one ounce (32.)  of starch,  till a
uniform deep  blue, almost black color is obtained, after which the
iodide is  dried by gentle heat.   A  large  teaspoonful is given in a
little gruel three times daily.   The  administration of the  iodide of
potassium, arsenic,  aud  iodoform has also been folloM-ed  by  note-
worthy results.  In general, however, cod-liver oil and the chaly-
beates"  will  be found most serviceable,  in  connection M'ith  such
hygienic regimen and  diet as are in  each case specially indicated.
  * The  local treatment  of the patches of disease  is  of importance.
Inasmuch  as  the  affection  is  one M'hose  involution  is  occasionally
accomplished under the influence of mild topical applications, and is
succeeded very rarely  by grave sequelse, it is  evident that the simpler
measures should be first adopted.   Of  these, green  soap, applied as
a plaster, or in the form of the spiritus saponis viridis,  is  most ser-
viceable.   It not only cleanses the  patch  of  its scales, but stimulates
i Brit. Med. Journ., May, 1880. 
478
DISEASES OF THE  SKIN.
the surface, often to  the  extent of inducing  a  reparative  process.
The patch may be briskly rubbed, either with  the soap or the spirit,
in combination with hot M'ater, after which an  ointment may be ap-
plied, preferably sulphur, in the  strength of  tM'o drachms (8.) to the
ounce (32.) of petroleum ointment.   When a  decided  effect  is pro-
duced, the spirit may be discontinued, and the hot water and unguent
for a time employed alone.  A decided and  beneficial  effect  can be
noticed  at times after the topical  application of very hot Mater alone,
sopped  on the part for tM'enty minutes at a time with a small sponge
mounted  on a handle.
   The following is a gentle stimulant:

        M. Zinci sulphat.    |        - - _g.            2
           Potassii sulphuret. j
           Spts. vin. rectif.             f.^iij;          12
           Aq. rosar.                f^iijss;          112       M.
        To be diluted as required for external use.          [Duhring.]
   The following is a formula for a  stronger lotion :
        M. Chrysarobin.                3ijss;          10
           Acid.' salicylici  |          - - _   .            2
           Calaminis pulv. j                '
           JEtheris                     f3j;            4
           Collodii flex.                f3v;          20       M.
        Sig.  To be applied with a brush.
   For this  may be substituted  pyrogallol, in the strength of half a
drachm (2.) to the ounce (32.) of salve.
   Other  substances  for  local  applications  are: the  tars,  iodized
phenol, iodized glycerine, the iodide of sulphur, iodide  of potassium,
iodine in  fine powder and tincture, naphthol,  ichthyol, and chloracetic
acid.    Chrysarobin and pyrogallol  have a decidedly favorable effect,
subject, however, to the inconvenience of staining the skin, a promi-
nent objection in the majority of cases where the disease  is displayed
upon the face.   Upon tbe hands the author has employed chrysarobin
with  the  effect  of producing a  typical  cicatrix in  the  course of a
month  M'hen the disease had lasted  for two years.
   Erasion by the dermal curette, in accordance with the method pro-
posed by Dubini, of Milan, and popularized by Yolkmann, of Halle,
has been successfully practised  by many operators;  as  also the treat-
ment by multiple punctures.   These have  not  met with the favor
in lupus erythematosus M'hich has  been accorded them in lupus vul-
garis;  while multiple  incisions by  the  lancet,  or the  instrument
devised by Balmanno Squire1 have been rewarded with greater success.
The  instrument of the latter makes sixteen simultaneous superficial
incisions  in the patch previously frozen by the ether spray.   Vidal2
lays  stress upon  attacking in this way the peripheral  zone of the
lesions.
   In exceedingly obstinate cases, those especially where  the elevated
rim of the erythematous disk refuses to yield  to the simple measures

    1 British Medical Journal, May, 1880.        -          3 Le Praticien, Nov. 14 1881. 
LUPUS  VULGARIS.
479
described, a solution of caustic potassium  in distilled Mater, one part
to two or four, may be gently applied M'ith a camel's-hair brush, and
the alkali immediately neutralized by the  addition of dilute muriatic
acid, as soon as the desired .effect  is produced.  That effect, it must
be  remembered, is superficial cauterization only.   AVhen the  sero-
sanguiueous exudation and reactive effects disappear, the rim is seen
to be flattened and to have  lost in part its violaceous blush.  After
such severe application, M'hich should never  be trusted to the hand
of  one unskilled in its use, an anodyne cerate should be spread over
the part, containing morphia or  opium.
   Vesication  with  cantharides, recommended  by Andersou, has been
endorsed as valuable by several authors.  The same may be said of
the mercurial plaster,  of which Kaposi speaks highly; while he and
others agree  that  carbolic,  salicylic, nitric, chromic, and sulphuric
acids,  the chloride of zinc,  the. other mercurial preparations,  aud
arsenical pastes, are of less value.
   I have used electrolysis M'ith benefit in  a  few cases, passing  the
needle connected with the negative pole of the battery deeply  into
the involved tissue.   Among other useful applications may be named
pure creasote, white precipitate salve,  Unna's gutta-percha  plaster-
mull of pyrogallol, iodoform, and the zinc oxide pastes  (see p. 82).
   Prognosis.—A favorable opinion with respect  to the future of  the
disease can never be  safely given; though,  as  regards the  general
health and comfort of the patient, there can rarely  be question.   At
the same  time the affection  is  capricious in its course, and  may on
occasions, after long  periods of obstinate persistence,  very  rapidly
improve under the simplest treatment.  It is  liable to relapse, though
not to frequent recurrence.

                        Lupus Vulgaris.
                          Lat. lupus, a wolf.
Lupus Vulgaris is a neoplastic growth in the skin or contiguous mucous mem-
   brane, manifested in  the production  of slowly developing, reddish-brown
   nodules, whose involution, in certain cases,  is succeeded by ulceration and
   the production of  a cicatrix.
    This disorder has also been termed Lupus Exedens, Lupus Vorax,
 and Scrofulide Tuberculeuse.  Late discussion of the question of its
 extent, nature, and relations to  other  diseases,  has been prolific in
the production  of an enormous  mass of literature devoted to  the
 subject, of which there is uot space in a treatise of this scope for more
 than the briefest conclusions.
    Si/mptoms.—The disease is characterized at its outset and throughout
 its career, bv the development  of  numerous, softish,  isolated,  sub-
 epidermic nodules, varying  in size from a millet-seed to a hemp-seed,
 encompassed by the  derma, and betrayed  to view  in the epidermis
 bv punctiform maculations of a reddish-brown color, which fade under
 pressure with the finger.
    It is the subsequent evolution of these elements in each lupous 
480
DISEASES  of  the skin.
eruption, often, indeed, somewhat difficult to appreciate, which fur-
nishes  each variety of the disease.   Thus  they may be disseminated
irregularly as in segments of circles (Lupus Disseminatus, Lupus
Serpiginosus) ; or developed in bulk  to the size of  papules  or
tubercles  (Lupus Tuberculosus);  or  proceed  to involution  by
atrophy and desquamation (Lupus Exfoliativus) ; or by ulceration
(Lupus Vorax, Lupus  Exedens); or be the seat of proliferating
vegetation (Lupus Vegetans,  Lupus  Hypertrophicus);  or  of
corneous and papillomatous growths (Lupus Verrucosus).

                            Fig. 59.
       Lupus vulgaris of the face (from a photograph of one of the author's patients).

  Under the title of  Lupus Sclerosus (Lupus  Sclereux),  Vidal, in
1883, described a form having a cicatricial centre, a circulate outline,
and a firm elevated border, located often upon the hands.
  A number of other names are  employed to designate unessential
features of the disease, according  as its lesions appear in lines, with
well-defined margins, or  display  elephantiasic, acute, chronic,  and
other phenomena.
  The disease is quite rare in this country, aud  M'hen seen is usually
in papular or tubercular  phases.   The  lesions are  then commonly
agglomerated in patches;  and vary in  consistency, size, and depth of
involvement of  the derma and subcutaneous tissues, though often
distinctly circumscribed in outliue.  If involution occur, the papulo-
tubercles flatten by atrophy, and the shining, tense,  and imperfectly
formed epidermis with which they were covered, exfoliates, leaving a
cicatrix beneath.
  When ulceration of the patch occurs,  a suppurative, and often
painful inflammation precedes;  the ulcer, if the secretion it furnishes 
LUPUS vulgaris.
431
be permitted to dry upon its surface, very slowly spreading  beneath
the crust.   The  lupous  ulcer  has  a dirty, purplish-red, indolently
granulating or hsemorrhagic floor ; a generally circular outline ;  soft,
neither elevated nor  undermined edges; and a  discharge  M'hich is
sufficiently  abundant to drip freely from an  exposed surface, or to
dry in peculiar, broad, flat, rather uniformly homogeneous crusts.
   The nose is the most frequent seat of lupus, and this organ it may
reduce eventually to a mere atrophied miniature of its  former size,
or utterly destroy by extensive  ulcerative invasion of its  integument,
mucous membranes, and cartilages.   It occurs also upon the cheek,
chin, ears, lips, lids, scalp, neck, genitals, buttocks, and  extremities.
At times, two or more distant  regions are affected.   The author has
at present under his charge a young Englishman with a palm-sized
lupous  patch upon and  beneath the chin, and a large platter-sized
exulceration on  the  right buttock  and thigh, both  of  which have
tormented him from  his earliest childhood.
   One of the most conspicuous  features of lupus vulgaris is its essen-
tially  chronic  course.   Compared  with   other  chronic  infectious
diseases it requires far more time for its complete  evolution than
either syphilis or carcinoma;' and iu this point is best compared with
lepra.  For a quarter of a century, a lupous patch may be limited to
a  space no larger than  the  palm  of the  hand ; and exhibit some
evidence of activity during the greater part of that period of time.
   A  form  of  lupus  vulgaris,  not very  rarely  observed, produces
extensive changes in the skin (more particularly of the face)  M'ithout
ulcerative  effects.  Here a  large portion  of the skin  of the head
(cheeks, lips, nose, lids, chin, ears, brow, and  neck)  becomes altered
by the lupous  new growth.  The  resulting thickening produces a
marked and characteristic deformity reducing the openings of the
mouth and lids to narrow slits, interfering with vision, speech, and
mastication,  and  producing  a   marasmus  from  these causes alone
before there is ulceration at a single point.
   The ravages of  the  disease are at times frightful in severity; not
merely in consequence of the  destructive ulceration to which it tends,
but from the deformity left by its awkward attempts at repair.   The
entire head may be thus converted into a hideous travesty of humanity,
while vet its possessor is left with all his vital organs and functions
apparently unimpaired.
   Etiology.—Lupus vulgaris  is  generally first seen between the third
and  sixth  years  of life;  after  the  thirtieth year practically never,
unless there  have  been prior symptoms  of the disease.  It is not
congenital  in origin, nor  limited to either  sex, nor to individuals of
any social grade.   It occurs  in the ansemic and  the asthenic; in the
scrofulous, the  tuberculous, and  those free from such disorders.  It
is much rarer in this country than abroad, occurring here  with nearly
the frequency of lupus erythematosus.   It is in no way related to
either acquired  or hereditary syphilis.
  The author is in practical agreement M'ith Neisser, M'ho  believes
the disease to be a " partial manifestation of tuberculosis."   Though
                                31 
482                DISEASES  OF  THE  SKIN.
the actual  demonstration is yet wanting, the  proofs at  hand  point
conclusively to  the fact that lupus  vulgaris  should be classed with
the infectious granulomata.   The author has elsewhere called atten-
tion to the striking fact that the disease is commonly first manifested
at the early period of  life, when the habit is  not yet established of
keeping the soiled hands away  from the face.   Infection  of the skin
with  the  bacilli of lupus would thus produce, as is  the fact,  facial
lesions in the majority of all cases and lesions of other exposed  parts
of the body (bare legs of children) in the order of ease  with which
they might become the seat of infection.1

                               Fig. 60.
Section of a lupous nodule,  b, normal corium ; a, reticulum with lupous elements in groups;
                    c, d, giant cells.  (After Kaposi.)
  Pathology.—For a knowledge of the microscopic characters of lupus
vulgaris we are largely indebted to the Germans, M'hose opportunities
for  the study of the disease are unequalled.   Virchow, Auspitz, Bill-
roth,  Lang, Kaposi, Klebs, Stilling, and  Thin,  of England, have
amply contributed to the subject; and the result of their investiga-
tions  may be concisely stated as follows :
1 Relations of Lupus Vulgaris to Tuberculosis, Journ. of Cutan. and Vener. Dis., Nov. 1885. 
LUPUS  vulgaris.
483
  The more recent nodules when divided  exhibit at  different  depths
of the corium roundish  masses, comparable to a nidus or nest, above
M'hich spreads an unaltered epidermis.  These foci of the disease are
well defined in outline, and of a  reddish-yellowish tint.  Around
them is woven a network of connective-tissue bundles;  with larger

                              Fig 61.
Section of lupus of face. X 750 and reduced. (Delafifld and Prtjdden.)
and  smaller  interspaces containing vascular elements, and also cells
and nuclei, probably masses  of protoplasm originating in the rever-
sion  of  the   connective-tissue  elements  to the  embryonal  state.
Retrogression is marked  by a  diminished vascularity;  M'hile  the
elements disappear by resorption, or by  the  destructive process of
ulceration folloM'ed by the cicatrix.  Both Kaposi and Lang  agree
that the vascular and fibrous elements of the lupous mass are capable
of developing new connective-tissue M'hich later undergoes retraction.
This is curiously in  accord with the clinical result of Squire's  treat-
ment by multiple linear scarification, in M'hich  the lupous growth,
after replacing the normal elements of the derma, becomes itself the
source of the new material of repair.
   When the  disease is extending, the lupous growth, spreading  along
the vascular elements of the  derma, involves finally the rete and the 
484
DISEASES  OF  THE  SKIN.
panniculus adiposus.   The nest-like agglomerations disappear ;  there
is  in  their stead an  irregularly diffuse infiltration, producing subse-
quently hypertrophic, atrophic, desquamative, suppurative, or ulcera-
tive sequelse.   Finally, the glands of the skin may become involved,
the hairs  falling from  their  follicles,  the sebaceous glands either
becoming obliterated, or having  their  acini stuffed with  epidermal
masses which distend them in milium-like bodies grouped  about a
cicatricial pedicle.  When,  as  observed  by several authors,  there is
coincidence of lupus vulgaris and epithelioma, the latter is developed
from epithelial cones, described by Kaposi as penetrating doMnward
and in other directions from the coil-glands and the root-sheaths of
the hairs.
   The discovery of bacilli in lupous tissue, first made by Koch, has
been since verified by Doutrelepont, Weichselbaum, Meisels, Schuller,
Lustig, and others.   The striking resemblance first shown  by Vir-
chow between a caseous miliary tubercle and a  lupous nodule  had,
even before his discovery, pointed to an  identity of origin.
   The result of inoculation of culture fluids has given positive results.
Lenz,  Hiiter,  Schuller,  and others,  have  produced  tuberculosis in
rabbits,  by introducing within the  eye granulations taken  from
lupous patients.
   The bacteria of lupus are rod-shaped, and in length  from  one-
fourth to one-half the diameter of a red blood-corpuscle.  They are
usually found within the cells, and commonly but one is visible in a
single cell.   They are, however, also found free in the lupous tissue.
Some contain roundish  or  oval spaces.   They are more abundant in
recently formed lupous nodules exhibiting some pathological  activity.
   Diagnosis.—Epithelioma, though rarely resembling  lupus  vul-
garis, is  more often designated by that than by  any other false title.
Great  confusion  has  arisen  from the looseness  with which several
surgical  authors have furnished  illustrations of " lupus exedeus,"
which were  really pictures of cancer.   But the latter is  rarely a
disease  of early life,  and when of such  early occurrence  never per-
sists to adult years;  M'hile lupus is such exactly in the vast majority
of all cases.   The nodules of lupus are absent  in epithelioma,  and
the evolution  of the disease slower, less painful, and, in  its earlier
periods certainly, of deeper situation.   The ulcer of epithelioma is
more  often defined  and single;  its edges whitish,  indurated,  and
everted; its floor uneven and glazed; its secretion scanty and occa-
sionally fetid; its base a mass of indurated tissue.   Lupous ulcers
are often  ill-defined  and  multiple;  their edges, soft  and incon-
spicuous, neither everted nor  undermined; their floors  granulating
and flattened;  their secretion  relatively profuse  and  generally odor-
less ;  their bases soft and pliable, though occasionally indurated.
   Tubercular, serpiginous,  and ulcerative lesions of syphilis may at
times resemble certain forms of lupus.  In any doubtful case a history
of infection, of other  types of cutaneous disease, of mucous patches, of
adenopathy, of abortions in the female, etc., should aid in the recog- 
LUPUS  VULGARIS.
485
 nition  of  syphilis.   The  suspected lesions should be carefully  ex-
 amined for the purpose of distinguishing characteristic lupous nodules
 in the  patch itself or in the periphery of any exfoliating area.  In the
 case of an adult, a long  history of lupus can be often obtained; and
 it is M'orthy of note that syphilis M'ith  exceeding rarity displays  for
 long periods of time a single exanthematous lesion or aggregation of
 such lesions in one part of the body exclusively.  The lupous ulcers,
 often  multiple and  isolated,  insensitive, rarely of well  determined
 outline, never reuiform or  horse-shoe shaped, with supple, low edges
 and reddish, smooth, hsemorrhagic granulating floor, covered with
 erusts like soiled parchment of uniform  thickness, do not resemble
 those of syphilis.    The latter are often painful, single, circular, and
 clean-cut in contour, with  firm, raised, infiltrated margins, and with
 offensive greenish and  blackish crusts, resembling oyster shells. The
 cicatrices  of  syphilis are elegant,  smooth, delicate, superficial, cir-
 cular, and, after pigmentation has disappeared, dead-white in color.
 Those of lupus are irregular, indurated, deforming, yelloM'ish-white,
 and reddish-yellow.
   Acquired syphilis is  a disease  of adult  life; lupus  begins in
 childhood.
   The disks  of psoriasis  are  distinguished  from  flat exfoliating
 patches of lupus vulgaris  by the relatively  large  number of the
 former, the nacreous lustre of the scales, the reddish hsemorrhagic
 surface beneath, and the sites of election of the disks, usually on the
 extensor faces of the limbs.
   Lupus  erythematosus is even more readily distinguished  by  its
 characteristics; including the  absence of  nodules, ulcers, and crusts,
 the superficial  character of the  disease  process, the scaliness, and
 occasional symmetry of the patch.   Cases are described of interme-
 diate forms between  lupus  erythematosus and  lupus vulgaris, but I
 have never been able to persuade myself that these really occur. The
 two diseases,  unfortunately somewhat similar in name, are  unques- '
 tionably  distinct in character.   The  so-called  intermediate  forms
 sIiomu  to  me have  been iu every instance  cases of flat and  scaling
 epitheliomatous infiltrations going on to ulceration.
   In acne and rosacea with a bulbous condition of the tip of the
 nose, the redness is vivid;  and the  telangiectasic complications with
 the seborrhoeic flux, are conspicuous points of difference from lupus
 vulgaris.   There is further no ulceration nor scarring, and the patients
 have usuallv suffered from the disease only after arriving at maturity
 of life.   The mucous surfaces  are also spared.

   Lupus of the Face.—Here the first  manifestations are the so-
 called primary efflorescences, exhibited on one or both cheeks, nose,
 or cheek and  nose, as a dull-colored maculation, or minute  nodule,
 often  long unnoticed, or a finger-nail sized, purplish thickening of
 the skin.   Extension may then occur by multiplication of lesions, or
 by spreading of the single  patch, the central  parts wasting or cica-
trizing.    The  contracture  of  the irregular scars thus resulting may 
486
DISEASES  OF  THE  SKIN.
produce an ectropion  of  the  lid or lip,  and M'ith this is often seen
the "bouffissure" of the features already described.  Crusting  and
ulceration may be conspicuous or well  nigh absent features.  Gradu-
ally the subcutaneous tissue becomes involved.
   The  nose, as already stated, may, after absorption  of the  lupous
tissue, become shrunken and retracted to a miniature of its  former
dimensions, its tip being  noticeably reduced to a sharp  point.   Iu
other cases  (one such  is now under  the author's  care), the point
becomes bulbous, flattened, livid,  and knobbed, with  a thickened
septum and distorted alse, an isolated patch or two of  lupus infiltra-
tion showing in the neighborhood  of the cheek on one or both sides.
The last described condition may lead by degenerative  processes to
the first, but  is more  commonly noticed  as a less severe and more
localized involvement of the face which  may terminate, in favorable
cases, without the severe mutilation first described.
   The  upper  lip, when involved, becomes  first swollen, fissured,
hsemorrhagic,  and crusted, aud a granulating surface indicates exten-
sion of the  disease to  the adjacent mucous  surface.   Later, if the
ulcer heal,  the mouth, by coutracture, is reduced  to  a repulsive
looking slit or chasm  in  the  face, permanently retracted, and either
open or closed.  The gums, lining membrane of the lips, velum, and
hard palate  may be also  granulating,  eroded, or M'hitish, when the
exfoliated epithelium  is in  situ.   Ulceration  and cicatrization  here
also produce deformities interfering with  the functiou  of the  parts,
aphonia, for example, resulting from the operation of these causes in
the larynx.

   Lupus Vulgaris of the Ears may be symmetrical  in develop-
ment, or affect but one auricle.   As in  eczema, a favorite point of
election is  the lobule,  which, M'ith or M'ithout  tumefaction  of the
whole  organ,  becomes a  pyriform,  purplish,  dependent  tumor,
agglutinated speedily to the cheek.  Later, when ulceration  occurs,
the auricle may disappear, or  be reduced  to  a shrunken shell  of its
former state, the external auditory meatus  being, by the same process,
occluded.

   Lupus of  the Trunk  is, as a rule, more  extensive and  less
destructive than lupus  of  other parts.   Giant areas over the loins,
hips, and belly may be involved in superficial serpiginous ulceration,
the centre healing as the peripheral ring spreads.   In these cases, it
is  even more difficult than in others to insure cicatrization.

   Lupus of the Genital Region may occur in  both sexes; and
then, as a rule, has extended  thither from affected areas of the adjacent
integument.   "Lupus  of the  genital region"  in women, so  called,
beginning in adult years, and  strictly limited to incoercible ulceration
of the mucous surfaces M'ithout marked involvement of the  groins
pubic region, or cutaneous  surface of the labia, is usually syphilitic
in  origin. 
lupus vulgaris.
487
   Lupus of the Extremities is remarkable for its  interference
with the mobility of the smaller bones of the hands and feet, as a result
of rigid cicatrices;  and also for the production of caries  and osseous
necrosis.  Mutilating effects are thus produced by loss  of phalanges,
and also by shortening of the hand or foot after destruction of cen-
trally situated bone.  Elephautiasic enlargements of such organs as
the hands aud feet thus correspond to  the livid tumefaction seen occa-
sionally  in  the face.   Thickenings,  ridges,  knobs,  nodules,  warty
excrescences, ulcers, crusts, and callosities are often commingled, and
in patients of mature years strongly resemble some  forms of vege-
tating and ulcerating epithelioma.

   Lupus of  the  Mucous Membranes means, for the most part,
extension of the disease from an  affected adjacent integument.  The
lupous nodule, in consequence of warmth and moisture, is  here trans-
formed  into a moist papillary outgrowth, or externally granulating
patch which may ulcerate and cicatrize.   The borders of  such  an
affected area are well defined, and its surface is of a dirty  grayish-
white color, where the  investing epithelium  is loosened but not  yet
detached.

   Treatment.—The internal treatment of lupus vulgaris is  practically
that indicated by the condition of the  patient; inasmuch as no medi-
cament is known to be capable, after ingestion, of relieving the victim
of his local ailment.  Of the  articles in this category none will be
more often  indicated  than cod-liver oil, the chalybeates, the bitters,
the preparations of iodine, and  possibly phosphorus.  Arsenic  and
mercury are powerless to prevent the extension of the disease.  With
these, it is needless to add, a diet of the most  generous character is to
be supplied, and the rules of hygiene enforced.
   Iodoform and the iodide of  potassium  have been  recently freshly
recommended by Neisser, who employs the former in pills each con-
taining half a grain (0.033).   The hypophosphites are useful  iu many
cases.
   The local treatment of lupus vulgaris by the aid of parasiticides is
based upon the infectious character of the disease ; and  in many cases
is brilliantly successful.   Dr.  White,  of Boston,1 M'ith  a view to  its
parasitic action, applies to the lupous patches rags soaked in solutions
of the bichloride of mercury,  one to two grains to the ounce (0.066-
0.133 to 32.), and also applies ointments containing the  same quantity
of metal  in the ounce of salve-basis.   The favorable results obtained
by him have been  again and again  verified by the author, who is in
the habit of freely painting lupous ulcers with a solution of corrosive
sublimate in the tincture of benzoin of the strength named. Salicylic
acid two  to four per cent,  solution in castor oil and in ointments, half
to oue drachm to the ounce (2.-4. to  32.); sulphurous  acid  (Hutch-
inson) ;  pyrogallol (Xeisser)  in ten per  cent, ointments, spread  on
1 Boston Med. and Sugical Journ., October 29, 1885 
488
DISEASES  of  the  skin.
linen rags and covered with impermeable tissue; and iodoform, have
all been successfully employed with the same object in view,   ^'p!"
  A modification of the Dubini-Volkmann method (that namely by
multiple linear scarification) deserves mention here, as  it  is claimed
with some justice to have changed the prognosis of the  disease.   It is
somewhat doubtful whether anything is to be gained by either a pre-
liminary freezing of the part, or the use of the cutting instrument of
many blades devised by Squire, of which mention is  made iu the
preceding article.   The incisions  are best produced with  a delicate
bistoury held in the fingers like a  pen.   They should  be in parallel
lines, closely set  together, and  crossed;  should extend completely
through the depth of the lupous growth; and this is  determinable
after some practice by the cessation of the creaking resistance which
the blade fails  to discover in  normal tissue.   Further, they should
extend laterally beyond the borders of  the lupous. patch into the
sound peripheral zoue.  The bleeding is trifling, and readily arrested
by firmly pressing  small  pieces of fine  sponge, lint,  or  absorbent
cotton over the part.  The edges of the incision unite either by granu-
lation or first intention ; and in  both cases seem to  serve as starting-
points of the reparative  process, the material for  which, as already
pointed out, seems to be supplied from the lupous  nests themselves.
Subsequent operations, when needed, require  a previous freezing of
the affected  surface.
  Less efficacious, more painful, and much  more  disfiguring in its
results, is the method of erasion by the dermal curette.   This instru-
ment is a sharp-edged spoon with a fenestra m in the bowl to permit
escape of the debris.   With  it, the  frozen  lupous growth may be
completely scraped  away, and, if necessary,  caustics  subsequently
applied.  The method of treatment by multiple punctures  instead of
incisions is efficacious, though less satisfactory.   Schiff,1 and Auspitz,
have combined puncture with  the introduction of  iodized  glycerine
(one part of the former  to twenty of the  latter), the first named
operator  using a tubular needle filled from a rubber pipette.
  The author has on several occasions, both in public  aud  private,
employed the Paquelin knife without ansesthesia and with good results.
The finer blades, especially manufactured for the purpose, are thrust
at a red  heat again  and again through the lupous tissue  until  it is
destroyed in its depth.  Over  the M'hole, the  lower blade  is firmly
passed and pressed, the blackish coal  resulting being the best subse-
quent  dressing  after  the  serous exudation  ceases.  Americans are
generally credited, abroad, with a preference for erasion followed by
the galvano- or thermo-cautery.
  Treatment by chemical cauterization  alone is now somewhat obso-
lete.  The various acids and alkalies, Cosme's  paste, nitrate of silver
arsenical, mercurial,  and zinc compounds, have all been  thus em-
ployed,  and each, in suitably  selected  cases, may be productive of
fairly satisfactory results.
  For the cases which do not require  surgical or other  operative
Vierteljhsft. f. Derm. u. Syph., Xos. 2 and 3, 1880. 
SCROFULODERMA.
489
interference, simple local applications may be made, such as oily and
fatty substances for the softening of crusts ;  stimulating dressings  of
tar, iodated glycerine, thymol, ichthyol, carbolized glycerine, iodized
phenol, naphthol, chrysarobin, and iodoform; as also' the carbolated
unguents appropriate for the reparative phases of the ulcer left after
the destruction of the lupous growth.
   The author's dernier ressort in the local  management of ulcerative
and rebellious forms of lupus vulgaris is creasote.  It is applied with
a brush  in  a pure state; is exceedingly painful, and  often followed
by uncomfortable reactive  effects.  It should be applied  only by the
practitioner.   Cicatrization  of  exceedingly  indolent  and  obstinate
ulcers has followed this application.
   Bartarelli applies, in similar cases, equal parts of resorcin and vase-
line.  Gerhardt,1 of Berlin, claims to have had good  results in the
local  management  of lupus by the use of ice-bags.   Gartner and
Lustgarten2 claim to have better results in the employment of electro-
lysis in lupus, by using as  an electrode a flat silver plate attached  to
the negative pole of the battery, the plate being set in a hard rubber
ring.   They employ a current of from five to eight millamperes.'
   Prognosis.—The future of most lupous patients treated with skill
and in this  country is quite satisfactory.   Generalized tuberculosis  or
cachexia  may complicate  a small proportion  of cases.   The local
process  may result  in grave deformity or  disfigurement.  But even
in cases where this last issue seems of severest  grade, if there be no
recurrence of lupous nodules in  the cicatrix, the  latter, in course  of
time, becomes less  and less conspicuous.  One of the author's patients
affected with disfiguring ectropion M'hich several distinguished oculists
failed to  relieve by operative interference, completely disguised his
deformity by the aid of a  flesh-tinted silver plate covering  the lid,
and fastened  by the aid of a slender arm  to the  bridge of a pair  of
spectacles.
                         Scrofuloderma.

                          Lat. scvofa, a sow.
Scrofuloderma is an  affection  characterized by indolent hyperaemic, granu-
  lating, and degenerative changes in the skin and subcutaneous tissue, asso-
  ciated with adenopathy of the contiguous lymphatic ganglia, and otfen with
  other evidences of a systemic vice of nutrition.
   Symptoms.—The term Scrofula, or Struma, has  been long  and
loosely applied iu general medicine, for the purpose of designating a
number of diseases whose real significance Mas  unknown, aud whose
points  of resemblance to  each  other were greatly outnumbered by
their  specific differences.   The  researches of the last twenty years
have been steadily and  continuously restricting this  list, in almost
every department of medicine.   Many of the disorders once supposed
to be  scrofulous are now  known to be  syphilitic.    Rickets, for

                 1 Medical Times, November 7, 1885.
                  ■ Wkn. med. Wochenschrift, Nus. 27 and 28, 188fi. 
490
DISEASES  OF  THE  SKIN.
example, is properly recognized to-day as a manifestation of hereditary
lues.   In  orthopaedic  surgery, a  number  of joint  affections  once
believed to  be incontestably  of  strumous  origin, are  known to be
producible by traumatism exclusively.   Aud in dermatology, no less,
a broad advance has been made since the day M'hen eczema, psoriasis,
and acne were  described as evidences of scrofula.
   It  should, however, not be  forgotten that there are few fast and
hard lines in the economy of nature.   The  requirements  of  a  scien-
tific classification of diseases are often too rigid  for the  phenomena
both of good and ill health.  It cannot be questioned that the scrofu-
lous  may become both  eczematous and psoriasic; that, in short,
struma may coexist with  other diseases.
   The coexistence of cutaneous with other diseases proves nothing as
to the essential character  of either, or  the  relation of the  one to the
other.  The author has at this moment in  his charge two  patients
M'ho have been psoriasic for years, each of whom has lately contracted
syphilis, one M'ith the addition of a blennorrhagia.  The distinction
between  these disorders is admitted beyond a peradventure;  and yet
when the strumous patient gets eczema, acne, or  lupus, it is  difficult
and often impossible to establish in the mind of  some observers the
conviction that there is no essential  connection or  relation   between
these disorders.
   It  is only by comparing such cases with the multitude of others
where no such  concomitance  can be recognized, that a just  estimate
of the truth can be made.
   This much premised, it may be added that the  term, scrofuloderm,
is here strictly limited to those  cutaneous changes which occur in
distinctly scrofulous subjects, and M'hich are themselves stamped by
the peculiar imprint of  the disease.   Billroth's description of the
scrofulous diathesis may here be recalled.   By this term he recognized
that condition in which there occurs at  any point  in the body where
irritation has been induced, an  indolent inflammation which  persists
after such irritation has ceased, M'hich  frequently terminates  in  sup-
puration and caseification, and  M'hich subsequently rarely  pursues an
hyperplastic  career.  If  with  this  be conjoined inflammation and
caseous infiltration of the lymphatic ganglia or of the subcutaneous
connective tissue;  amyloid degeneration  of one or  several  of the
viscera;  tumefaction of the  belly;   chronic  keratitis, ophthalmia,
otorrhoea, or coryza; a chrouic arthritis (white  swelling);  a pasty,
dirty-colored and thick, or delicate  and transparent skin  exhibiting
cicatrices of old abscesses  or ulcers, the general  picture of  the scrofu-
lous patient may be considered complete.
   The recognition  by Robert Koch of the etiological  importance of
the bacillus tuberculosis iu tuberculous disease, and the demonstration
of the presence of these microorganisms in  a number of lesions hereto-
fore regarded as " scrofulous,"  has produced no little  uncertainty as
to the dividing line between struma aud tuberculosis.   Neisser, in the
list of ten disorders described by him as both chrouic and infectious
names tuberculosis as first, and under this  as a generic title, places 
SCROFULODERMA.
491
miliary tuberculosis of the skin, scrofuloderma, and  lupus vulgaris.
Doutrelepont, Robinson, and a number of other authors regard these
as  related if not  identical processes.   The  position assumed with
regard  to this  question by Volkmann1 agrees both with  the  strict
requirements of pathological demonstration and with clinical  experi-
ence.  These disorders  are identical  as regards  the  bacillus, but
different clinically.
   The  scrofulodermata  are all characterized  by the occurrence  of
pathological  processes in the  skin  which  betray the evidence of the
scrofulous process.  They usually  begiu as  subcutaneous nodules
similar in type to the syphilitic gumma, M'hich  gradually  become
attached  to  the  skin, subsequently degenerate, exhibit  characteristic
ulcers, and usually terminate by no less characteristic cicatrices.
   The typical scrofuloderm is encountered about the face and  neck,
M'here tbe lymphatic glands have  long been tumid, and  either  dense
or  doughy  to  the touch.  This  condition is usually  reached  very
slowly; often months and years are required for its production.  The
glands may  be  as  small  as almonds' or as  large  as  the closed fist.
Gradually a  scrofulous dermatitis ensues in the skin which is super-
imposed.   It becomes purplish and thinned, and finally yields, giving
exit to a sero-purulent fluid mingled with caseous matter and blood.
The pus-corpuscles of this fluid, examined under the microscope, are
seen to be poor  in protoplasm.   Fistulous tracts and sinuses result,
which undermine and perforate the skin, resulting  iu  the formation
of a chronic  discharge and characteristic ulcers.
   The  latter are far  more remarkable for  their  borders and  bases
than for their floors.  They are usually linear, occasionally elongated
and oval, almost never circular.  As a result, their uneven floors,
covered with pallid granulations and a M'atery pus, are often  hidden
beneath  their inverted,  tumid, and  uncolored edges:  or the  latter
may be thinned, stretched over a  fistulous pocket, and reddish  or
purplish  in  color.  Their bases are usually deeply attached to the
subcutaneous tissues, and  are  firm  or soft, never densely indurated.
The  resulting crusts  are thin, tenacious, reddish or brownish, and,
like the ulcer, often linear, rarely bulky, never rupioid.   The result-
ing  cicatrices are corded, depressed  in irregular  lines or bands, and
often alternate with equally irregular nodules (scrofulous gummata),
where the degenerative process has been either arrested  or is still  in
progress.
  Rarely, enormous ulcers originate in the manner described above,
which dissect out vast areas of subcutaneous and intramuscular tissues
in the neck  or over the extremities, in the course of which cartilage,
bone, and  periosteum are melted away.   Usually but a  few of  these
points of  degeneration, from two to six, are exhibited in one patient.

         The Papular Scrofuloderm (Lichen Scrofulosorum).

  This  eruption, first described  by  Hebra,  is characterized  by its
chronicity, and  the occurrence chiefly  upon  the trunk,  back, and
1 See his remarks before the German Surgical Society, Fourteenth Congress. 
492
DISEASES  OF  THE  SKIN.
belly, of millet-seed to pin-head  sized, firm, flat, light to  livid red,
and  grouped  papules.   These  are  occasionally surmounted  at  the
apex  by a minute  scale, rarely by an  equally small pustule.  The
lesions are at the onset isolated ; later, they tend to arrange them-
selves in coin-sized patches; when  evolution  is accomplished  they
are closely set together, the surface of the skiu  being then of a dirty
reddish-brown color, and  covered by  thin  scales M'hich are readily
detached.  Often a crescentic outline can be determined in a group
of aggregated  lesions.
   The course  of the eruption is slow; often the cutaneous symptoms
persist for mouths without apparent change, awaking  little or no
pruritus, and followed  by involution, accompanied by slight desquam-
ation and no cicatrices.
   In ninety-nine per cent, of all cases observed in Austria, there was
concomitance of the general symptoms of struma named above (sub-
maxillary, cervical,  and axillary adenopathy,  periostitis, ulcerative
dermatitis, etc.), with frequent  complications, such  as eczema of the
scrotum  and acne cachecticorum.  The  disease M'as encountered  in
young strumous patients between the periods of infancy and puberty,
never after the twentieth year.
   According to Kaposi, the disease consists in  an exudative infiltra-
tion  of the pilo-sebaceous follicles and the perifollicular tissue.   Each
papule represents, therefore, the orifice of a follicle, with an infiltrated
perifollicular  annex ;  and its  apicial  scale or pustule,  a mass  of
epithelial debris,  or the inflammatory exudate
   The disease is readily  differentiated, by the absence of itching,
from papular eczema.   From the  miliary papular  syphiloderm it
differs in that the  lesions of the latter, even though grouped, are
always individually distinct.   The general symptoms, however, are
strikingly different in the two diseases.   Lichen  scrofulosorum can-
not be confounded with lichen planus or lichen ruber.  Lichen pilaris,
however, in a young and lymphatic  patient, might readily be  mis-
taken for the disease in question.
   This scrofuloderm is rare in France, and has not yet been recog-
nized in  this country.

                 The Small Pustular Scrofuloderm.

   This  eruption  has   been described  by  Duhring1 only.   In the
three patients whose cases  are reported, there were  disseminated pin-
head  and small split-pea sized, yellowish pustules, having a firm base
and purulent  contents visible on  the extremities, especially over the
hands and forearms.   Their course M'as indolent.   Corneous, yel-
lowish, or gray-tinted crusts succeeded, leaving a marked " puuched-
out" scar.   Relapses  occurred, the entire process lasting for months
and years.  The general  symptoms of struma were present in each
case.   The disease  is to  be distinguished  from  the small pustular
syphiloderm, acne cachecticorum, and follicular lupus/   Microscopic
Trans. Am. Derm. Assoc , Fourth Annual Meeting, Chicago, 1881, p. 29. 
SCROFULODERMA.
493
examinations  of the lesions exhibited unmistakably a non-follicular
origin of the disease.

                 The Large Pustular Scrofuloderm

is described by the same author as a rare eruption,  constituted of
large, roundish, flat pustules, M'ith  a deep red or violaceous  areola.
A thin, flat,  brownish, and adherent  crust partially or  completely
covers each lesion, after the desiccation of its yellowish contents, and
beneath is  found a shallow ulcer of the scrofulous type.   One, two,
or more  lesions may exist, often over the sternum, where they leave
superficial  cicatrices.  There is concomitance of the general symptoms
of struma.

   Etiology.—Scrofula is a disease of both sexes and all races, usually
developed  in early  life, and pathologically due to the presence of the
bacillus tuberculosis, though its clinical phenomena differ from those
exhibited both in tuberculosis of the skin and lupus vulgaris.
   All causes which tend to  impair the nutrition and  vigor  of the
body are, to  an extent  at least, efficient in its development, including
privation  from  sunlight,  fresh air,  wholesome  food, exercise, and
hygienic  influences in  general.   It  is common among  prisoners,
exiles, and,  in this country, among negroes and  those of mixed
blood.   Consanguiueous  marriages  are said  to result  often  in
strumous offspring.    Syphilis, in the third and fourth generation, is
known to be  pathologically distinct from  all of its manifestations.
The question of the possibility of its  production by inoculation and
its transmission in a feeble degree by contagion is still unsolved, with
the probabilities strongly in the affirmative.   In many cases, it is
the sequence of other depressing medical diseases and  surgical acci-
dents.  In other cases, especially where it is limited to the neck, and
accompanied  merely by cervical or  submaxillary adenopathy, it is
consistent  with full vigor  and nutrition  of the  body and all other
evidences  of sound  health.
   Diagnosis.—The  disease is  to  be distinguished  by  its general
physiognomy from  syphilis,  lupus,  cancer, purpura  scorbutica, and
other  diseases  exhibiting  cachectic symptoms.   The  early  age at
which it is commonly developed is usually significant.   The  site of
the lesions, M'ith their characteristic ulcerations, crusts, and cicatrices,
are also  distinguishing features.
   Treatment.—The general treatment of struma demands a generous
supply of fresh air (especially that of the seashores abounding in
kelp); a liberal animal  diet, including an  abundance of pure  milk
and cream; and the employment of cod-liver oil, iron, iodine,  lime,
phosphorus,  aud similar substances internally.    The local treatment
of the disease  requires the employment of poultices, lotions, stimu-
lating unguents, aud disinfecting washes,  M'ith such surgical inter-
ference as  is  demanded by the existence of pus-filled pockets, sinuses,
and fistulous tracts. 
494
DISEASES OF THE SKIN.
   Prognosis.—The disease, when skilfully managed, is  amenable to
treatment.  The strumous patient M'ho survives puberty will, if sur-
rounded by favorable circumstances, usually show fair health  after-
ward.   The course of the malady is, however, ahvays tedious.   The
prognosis may be said iu general to be based upou the severity of the
symptoms in early life.

                     Tuberculosis of the Skin.

   This exceedingly rare manifestation of tuberculosis is usually first
disclosed in indolent, circular, or oval superficial losses of substance
in the  skin, covered with crusts.  The floor of each is a granulating,
hsemorrhagic,  pale,  reddish surface;  its base is  infiltrated, but
supple; its edges are irregularly notched from the occurrence of suc-
ceeding purulent foci about the  original sore.    They  spread very
slowly, and, though small, may coalesce.   They usually occur about
the mucous outlets.
   Tuberculosis of the skin, associated with or secondary to  tubercu-
lous foci iu underlying tissues, is  occasionally  encountered.   In this
way, for example, in tubercular  disease of the testis, the  skin will
become painful, tender, and of a  livid  hue, will become attached  to
the subcutaneous tissues,  and  finally yield,  giving exit to a soft,
caseous matter, mingled  with  pus.   Wagner,1  Weber, Vidal, and
other authors  have described similar changes.    True tuberculosis of
the  skin  proper  is  of  exceedingly rare occurrence.   Chiari  and
Jarisch have,  however,  reported such  cases, oue in a man  forty-
two years old, who had  behind the  left ear  a reddish-yellow, cres-
centic,  granulating ulcer, with  infiltrated borders  and a number  of
degenerating  miliary granulations  upon the velum  of the palate.
Post-mortem, isolated aud grouped, roundish nodules M'ere discovered
undergoing caseous degeneration.    Spillman2 gives several instances
of tuberculization of the skin associated with pulmonary phthisis.
   Two cases of  tuberculosis of  the skin  have  been  observed  at
Kaposi's clinic.3
   The patients were aged respectively fifty-three and thirty-six years.
In one, there Mere  buccal, laryngeal,  and  tracheal  ulcerations  of
tuberculous character, with an  ulcer of  the  upper lip, occupying the
entire space between the nose and the lip.  The other  patient  pre-
sented  a coin-sized ulcer near the  left ala nasi, and others on the lip
and adjacent  gum.   In one of these patients, the  lungs were intact,
aud the tuberculosis  of the skin was primary.   The other died  of
pulmonary phthisis; but  in both there was  intestinal tuberculosis.
Microscopical examination of the cutaneous lesions disclosed nume-
rous tubercles in the  corium which  had  undergone caseous degenera-
tion.    In the  centre  of the  mass,  disseminated miliary  nodules,
transparent  or light-yellow in  color,  were visible in the parts M'hich
had not undergone characteristic granulation.

           i Diseases of the Testis, T B.  Curling, F.R.S., London, 1878, p. 389.
           2 De la Tuberculation du Tube Digestif,-These de Paris, 1878.
           3 Deuts. Med.  Zeit., Jan. 1882. 
SCROFULODERMA.
495
  There are several disorders of the skin, M'hich may be very briefly
considered in this  conuection, whose  nature is obscure, and with re-
gard to whose identity there may be some doubt.

  Ainhum.—This disease was first described  by  Dr. J. F. Da Silva
Lima,1 of Bahia, in Brazil.   In a paper by this observer, which Mas
read by me before the American Dermatological Association, in 1880,2
the disease was  described as  affecting  usually the  little toe  of the
negroes  resident both  in Africa and Brazil.   An  indurated ring
encircled  the root of the digit, which produced,  finally, a  deep,
uarroM',  circular depression,  the latter  deepening till the toe was
strangulated, and finally, in  the course of from  five to ten years,
completely detached.   Meantime, the volume of the digit M'as greatly
increased by development of  fatty tissue at the expense of the ten-
dons, vascular elements, bones, and cartilages.
  This paper was accompanied by the presentation of a toe affected
with ainhum; and the specimen  Mas  referred to a  committee, M'ho
examined it with care, and reported the result  of the examiuatiou by
the succeeding year.   The report, presented by Dr.  Heitzmann,  of
New York, after giving a full description of the  anatomical appear-
ance of the specimen, suggested the probability that the constricting
ring was produced  artificially by tying a thin ligature around the toe,
M'hich, if not continuously encircling  it, Mas worn  at least  for long
periods of time.
  Duhring3 also has  published the report of a case of ainhum M'here
microscopical examination of  a toe M'hich Mas cast  off from the foot
of a negro in  West  Virginia M'as made by Dr. Wile.   The  latter
came to the conclusion  in this case also that the disease was essen-
tially an inflammatory oedema produced by ligating the toe.

  Podelcoma.—This  disease, known as Madura  Foot, Mycetoma,
or the Fungous Foot of India, attacks generally the foot, though the
hand also may  be affected.   Its beginning is insidious.  The part
becomes swollen, painless, and  covered with pea-sized  vesicles, bou-
tons, or elevations, over which arc dispersed minute blackish granules.
Each  tubercle  surmounts a  sinus,  from M'hich,  after bursting,  is
discharged  a thin, sero-purulcnt fluid, containing granules, separate
or  aggregated  in  yellowish-brown  mulberry-like  masses.   The
swelling  gradually increases, till the  foot  is a misshapen  organ,
riddled xv ith sinuses  M'hich perforate  periosteum  and bone.   Then
fistulous tracts discharge from time to  time granules like poppy-seeds,
caseous matters, or substances likened  to blackish  fish-roe.
  According to  Carter, the disease depends upon the existence in the
parts of a specific fungus, Cbionyphe Carteri.  The spread of this
mycelium in the skin, subcutaneous tissue, and deeper parts produces
the tubercular buttons M'hich  break down and  ultimately lead to the

                1 In the Gazeta Medica du Bahia, Nov. 13 and 15  1867.
                2 Arch, of  Derm., October, 1880.
                3 Anier. Journ. of the Med. Sci., Jan. 18J-4. 
496
DISEASES  OF THE  SKIN.
sinuses described above.  Some authors are incredu lus, however, as
to the mycotic uature of this affection.   The disorder has been studied
by Vandyke Carter, Minas, Moore, Christie, and other  surgeons of
India, a country where the disease has been prevalent.   Tilbury Fox
presented,  at  different  times,  two specimens of the disease  to the
London Pathological Society;  and it is worthy of note that in Eng-
land the black masses were not  in every case discovered.  Kemper1
has reported a similar case in this country.
   Prof. Chas. T. Parkes, of Chicago, has recently had under obser-
vation a similar case, occurring  in the person of a gentleman who
had long been a resident of India.  From the notes  kindly furnished
the author, it  appears that, after the  occurrence  of characteristic
tubercles, an ulcer attacked the skin over the inner  malleolus  of the
right ankle, and steadily increased in size and depth for a period of
five years,  in spite of all  treatment.  Sinuses extended deeply to the
tissues beneath.   The entire surface was covered by a peculiar, softish,
light  colored, fluffy material,  corresponding  to  that  described by
several of  the Indian  observers.  The general appearance  of  the
disease was unlike any previously observed here.  The entire surface
Mas  thoroughly scraped with  a Simon's spoon, and dressed with a
saturated solution of boric acid, after which  repair ensued.

   Synovial  Lesions  of the Skin.—Under  this title should be
described certain strictly cutaneous lesions which possess some impor-
tance from a diagnostic point of  view.   I have had  the opportunity
of observing these in several  individuals, where the exact nature of
the disorder had not been understood.   They occur in  the form of
wart-like   projections from the  skin,  pseudo-vesicles,  and   bullse,
always over the site of bursse connected with tendons, traversing the
small  articulations of the hand  and foot.   They are seen over the
metatarso-phalangeal articulations; and in the hand  most frequently
over the dorsal  face of the articulation between  the distal  and adja-
cent phalanges of the index and  thumb.  The first form is that of a
roundish, corneous, pea-sized wart with a yellowish centre, of  long
duration, usually insensitive unless roughly handled.  When punc-
tured,  a syrupy,  yellowish, or  grumous fluid  exudes, and continues
to form after repeated puncture.   Split-pea sized vesicles, and bullse
as large as  a silver fifty-cent piece, often exceedingly painful, are also
seen, especially upon the feet,  with simply an epidermic roof-wall.
Each contains the same thickened, yellowish, or whitish fluid, occa-
sionally mingled with masses  like sago grains.   In every case  the
contents of the lesion  are supplied by a synovial bursa beneath the
skin, with M'hich the lesion is either directly connected, or in communi-
cation  by a short sinus.   The treatment requires the complete excision
or destruction of the secreting  cyst-wall.
   Mr. Sidney Jones, and Mr. Makins, of St. Thomas's Hospital, have
recently exhibited several lesions of this character  to  the London
Pathological Society.
1 Amer Practitioner, Sept. 1876. 
SYPHILODERMA.
497
  The Sartian Disease (Taschkent-geschmtur) is an infectious
granuloma, described by Heiman,1 and examined microscopically by
Rudniew.
  It occurs  in Taschkent, affecting the  face, upper extremities,  and
trunk, avoiding always  the  palmar and plantar regions.  Reddish
maculse  develop here   into  nodules,  M'hich  desquamate,  coalesce,
degenerate, and leave crusted ulcers, M'hich may cicatrize.


                         Syphiloderma.

Syphilis is a chronic infectious disease, transmitted sby heredity, or by the
  medium of intoxicated blood  or morbid secretions, capable of involving in
  its course any one of the organs and tissues of the body, whose manifesta-
  tions in the skin are termed syphilodermata.

   Syphilis is a disease not yet actually demonstrated to be produced
by microorganisms, but whose position among the infectious granulo-
mata is now almost established.   It is true that Lustgarten,  Doutre-
lepout,  and  others,  have   demonstrated  the  presence  of bacilli
resembling those found in tubercle, in  papules, nodes, chancres,  and
secretions  from  syphilitic  lesion; but the  strict  requirements of
science as to the proofs of etiological value in these particular germs
have  not  yet been  fully  satisfied  with respect  to  this  disease.
Whether these microbrganisms or others be  finally demonstrated to
be  the potent agency in producing syphilis when it is transmitted by
the medium of a virus, it is  at least certain that the revelations made
by late investigations into the nature of lepra, mycosis fungoides,  and
tuberculosis  leud the very strongest support  to the doctrine  that the
contagium of syphilis is due to the  presence  in its secretions of a
species of bacterium.
   Syphilis has beeu described by one M'riter as an " imitator of other
diseases."   Whatever exception it is  proper  to take to  the  doctrine
implied by such a term, it  is  necessary to understand clearly of the
manifestations of the disease that they are protean in character,  and
may occur in every organ and tissue of the body.   These manifesta-
tions are both like and unlike the symptoms  of non-syphilitic disease
of such organs aud tissues.  It Mould be, therefore, more in accord-
ance M'ith  facts to describe syphilis  as a special mode of disease.   Its
phenomena differ from other pathological phenomena, chiefly in the
syphilitic modality with M'hich they are impressed.   After  infection
there is a different behavior of the living matter  or  protoplasm of
which  the body is constituted.   Its  mode is thenceforward tempo-
rarily  changed,  as  regards the processes  of disease.   Hence the
importance of recognizing this modality in relation to disease of the
skin, and of ascertaining the limits within which this influence is both
originated and exhausted.
   The skin  manifestations  of syphilis are  of common occurrence;

                      i Deutsch. med. Woch., No. 3, 1883.
                                 32 
498                diseases  of  the skin.
numerous as to their forms, and of  the greatest importance from the
diagnostic standpoint.
   As  in syphilis  of other  organs, that of the  skin is betrayed in
symptoms like and uulike those of non-syphilitic  affections.  The
study of these differences is here also a study of the syphilitic mode
of disease.   In a treatise of this scope and M'ithin these  limits, it will
be proper to describe only those evidences of the syphilitic process to
be recognized in the integument.  The initial lesion of the  malady
occurring either on the mucous membrane or integument, requires
brief consideration :

   Chancre.—A chancre is that modification of the sound or patho-
logically altered skin  or mucous  membrane, preceded by a period of
incubation, characterized by sclerosis, and accompanied by adenopathy,
which constitutes the initial lesion of inevitable syphilis.
   Chancres usually appear upon or  about the genital organs simply
because those organs are most often  exposed to the disease.   They
may, however, occur upon any portion of the surface of the body.
   They  appear after  a period of  incubation,  an  interval  of time
between  the date of exposure to the disease and the manifestation  of
its first symptom.   This period averages  in length  twenty-one days,
and  may extend from ten days to two months and even  more.
   The chancrous  modification  may,  as  stated  above,  involve the
normal or pathologically altered skin or  mucous  membrane.   Upon
previously sound surfaces chancres may appear, after the incubative
period, as maculse,  papules, tubercles, erosions, fissures, or ulcers, each
of which, at some future  period of  its history, is characterized by a
peculiar  hardness of the tissues about and "beneath the lesion, this
condition being known as the initial sclerosis.   These symptoms vary
according to the location of the  lesion, and the friction or  other
external  treatment to M'hich it has been accidentally subjected.   Gen-
erally it  may be said that they all tend to the  papular type, the
macule developing  into that lesion, the tubercle being evolved from
its exceptional enlargement, the ulcer from its degeneration, and the
erosions  or fissures  from the accidents of its less pronounced features.
Occurring upon mucous or quasi-mucous surfaces, these  lesions are
influenced by heat,  moisture, and friction  (labia, prepuce, etc.).   Here
the  superficial erosions  are  usually circular in  outline, are very
slightly depressed, and rest upon delicate  beds of sclerosed tissue, the
so-called parchment induration.  The papule is often represented by
a macular  discoloration  of  the membrane, tolerably  well  circum-
scribed, where coarse examination would  scarcely suggest elevation of
the surface, with  a sclerosis  of no  greater extent than that  of the
erosion M'ith  M'hich  it probably sustains a close relation.   As a result
of heat, moisture, and friction, however, the typically dry and scaling
papule constituting the  chancre of the  integument, is here  rarely
encountered.   More often, the lesion is a circumscribed ulcer with
clean-cut walls, penetrating deeply to the derma or even beloM'  it,
with a scanty secretion  and  reddish  floor, resting  upon a split-pea
sized mass of sclerosed tissue.  Other usual  forms are superficial 
SYPHILODERMA.
499
erosions, in  themselves of  insignificant aspect,  surmounting large
nodules, tubercles, or even  long linear ridges of  densely sclerosed
tissue, undergoing repair or  degenerating according to the condition
of the patient  and the  treatment to which he  has been  subjected.
These erosions are  usually out of all  proportion  to the size  of the
indurated mass upon M'hich they rest.  Such voluminous indurations
are occasionally perforated by deep conical or funnel-shaped  ulcera-
tions of formidable aspect, to M'hich the name "Hunterian chancre"
was once applied.
   Occurring upon cutaneous or mucous surfaces where there has been
a previous pathological  condition, the syphilitic  mode is impressed
upon the symptoms significant of such previous disease.  This acci-
dent is sufficiently  common,  and the resulting lesions as different as
those of different diseases.  Thus a man or woman may be infected
M'ith syphilis at the site of an herpetic vesicle upon the lip or genitals,
such vesicle being unbroken  and recent, or several days ruptured ; or
at the site of a balanitis; or of a vegetation ;  or of the soft conta-
gious sore of the genital region best recognized in America under the
term " chancroid."   Or the inoculation  may occur at  the site of a
traumatism,  as for example where the frenum  is slightly  torn in
coitus, or where the bruised  knuckle of the accoucheur is exposed
during the practice of his art.
   The induration of chancres may precede, accompany, or follow the
lesion with M'hich they are associated.   The sclerosis may be short-
lived, persisteut,  or  recurrent;  and in  this respect  resemble the
chancre itself,  M'hich may endure for but a few days, or be in course
of full evolution at the date  of the appearance of  the so-called
secondary symptoms.
   AVith very rare  exceptions, the ganglia in  anatomical connection
with the chancre become, as a consequence, enlarged and  specifically
indurated.   With  genital chancres there is usually double inguinal
adenopathy; with  labial chancres, submaxillary  adenopathy; with
chancres of the lid, pre-auricular adenopathy, etc.  The glands  usually
enlarge M'ithin a few days after  the appearance of the chancre, and
remain in  that condition for  several months afterward.  They are
indurated, on one or both sides of the body; are freely  movable; are
unattached  to surrounding  tissues; are neither  painful, tender, nor
inflammatory;  and hence  neither terminate  by suppuration nor
ulceration.
   It Mill thus be evident that the M'ord "chancre " is applicable only
to certain features assumed by other lesions ; and is not itself descrip-
tive of a lesion  differing absolutely from  all others.   It is  indeed
clear that there can be no particular chancre lesion, since in turn the
macule, vesicle, pustule, papule,  tubercle,  erosion, vegetation,  ulcer,
and fissure  may  each become a chancre.  Every other elementary
lesion of the skin, therefore, may assume the chancrous  features,  in
other words, display iu  its  disease-process the modality of syphilis.
These chancrous features are : infection ; sclerosis after an  ncubative
period ; coincident or consequent adenopathy (sclerosis of neighboring 
500               DISEASES OF THE  SKIN.
 ganglia); and, after a second incubative period, the occurrence of the
 symptoms of general syphilis.   The  last named is of  course  an
 historical feature, not  recognizable during the greater part of the life
 of most chancres.
   Their minor features are less constant and trustworthy.   Chancres
 of the skin are  often deeply pigmented.   Some are painful from the
 occurrence  of inflammation.   Some  are injured by traumatism
 (chancres of nipple in nursing women);  some, by irritants (caustic
 improperly applied);  some  finally are so insignificant in  feature
 (chancre of the vagina) that even the expert is  readily deceived in
 their recognition.
   With or without involution and  complete disappearance  of the
 chancre, the symptoms of general syphilis occur only after a second
 period of incubation.   This extends usually from between the end of
 the first to the end of  the second  month after the appearance of the
 chancre, the average being between the fortieth aud forty-fifth days.
 During this period the general condition of the patient is one which,
 by subjective  and objective phenomena, displays  signals of the ap-
 proaching  distress of the economy.   There is ansemia  and even in
 cases, chloro-ansemia, wandering pains, substernal or about the articu-
 lations, a cachectic look, engorgement  of the superficial and deep gan-
 glia, occasionally a well-marked febrile process, the so-called syphilitic
 fever, and, as Bumstead has  shown, a special  irritability of the skin
 aud mucous membranes.
   At this  moment, the  second period  of incubation  of the disease
 being completed, the patient is ready for au "explosion" of general
 syphilis.  Insidiously  or suddenly, first noticed upon the skin beneath
 the clothing, with rapid efflorescence over the entire surface after  a
 hot bath, the stimulus of liquor, or the excitement of the dance,
 appear  the  syphilodermata,  or syphilides, the skin  symptoms  of
 syphilis.
                         Syphilodermata.

   Lesions of the skin  appear in syphilitic  individuals of both sexes,
 in all  periods of life, and in all  stages of the disease.  They are,
 however, much more  frequent during the  first two years after infec-
 tion, subsequent to which  period  the symptoms of the disease are
 more  commonly  betrayed  in subcutaneous lesions, or those which
 affect the viscera, the  osseous,  nervous, muscular, and vascular sys-
 tems.

   General Characteristics of the  Syphilodermata.__The
 syphilodermata, like chancres, are, properly speaking, modalities  of
 such symptoms  as occur in  diseases not syphilitic.  The distinctive
 difference between  the papules, ulcers, and other lesions of syphilis
 and lupus for example, is a difference  chiefly in their mode of evolu-
tion and involution.   It is the syphilitic  behavior, rather than the
syphilitic lesion,  which guides the diagnostician to his end.   The
syphilides, in short, resemble in  their lesions most of the other diseases 
SYPHILODERMA.
501
of the skin, and differ also  iu various degrees  from each one of the
latter.   Hence is seen the importance of a clear recognition of their
general characteristics:
   Absence of subjective  sensation. — The eruptions  produced  by
syphilis are rarely attended by  itching, burning, or painful sensa-
tions of any sort.  This is frequently a positive aid in establishing a
diagnosis, and, as a rule, is the more  valuable the graver the  lesion.
Great  difference, however,  will be  noted in this  respect  between
different individuals.   Occasionally considerable itching will be per-
ceived, and syphilitic ulcers, especially of the leg, M'ill be productive
of severe pain.   At the same time, it is a common experience  to find
a  patient  quite tranquil  as  regards all subjective  symptoms, covered
from  head to  foot with a brilliant macular syphiloderm, or exhibiting,
M'ith  the  utmost composure, an enormrms number  of serpiginous
ulcerations on his scalp and  extremities.
   Polymorphism, multiformity  of lesions, a term used to designate
the coincident appearance of lesions of various types  upon one indi-
vidual, is  true  of syphilis as of other diseases such as lepra  and
scabies.   Viewing  the cutaneous and other lesions of syphilis  as a
whole, this feature is  strikingly significant, as it is possible to observe
at one and the same  time upon the person of a single infected indi-
vidual, symptoms  indicative of pathological  changes  in  the skin,
mucous membranes, hair, nails,  lymphatic glands, and periosteum.
   To a less marked degree, this is  true of the syphilodermata.  The
type  of the syphilitic skin  lesion is generally papular; and such
lesions may originate  from macules, enlarge into tubercles, or  degen-
erate into  ulcers.  The simultaneous  coexistence  of  several of these
forms  is  often due, as  Bumstead aud Taylor  have  well shown, to
their chronicity, their tendency to recurrence,  aud the changes which
they undergo.
   (hreer.—The  historical course of the syphilides suggests  certain
common features.  They are rarely accompanied by local inflamma-
tion,  and   M'ith the  exception of  the syphilitic  fever,  are usually
unattended M'ith  pyrexia or  malaise.   The tolerance by the general
economy of an extensively developed syphiloderm, is highly significant
of  the  disease.  Again, syphilis,  though  generally  described as  a
chronic disease, is, judged from the standpoint of time merely, much
more  acute than several  others.  The syphilides  have a distinct
career, pursuing, even when untreated, a natural process of evolution
and involution.  Few, save those upon the lower extremities where
the force  of gravity  is an  important element  in the fixation of all
local disease, persist iu unvarying  type for any lengthened period of
time.   One lesion  is apt  to  succeed another by  development or
degeneration;  and many of the untreated syphilides disappear without
leaving relics  of their existence  upon the surface of the skin.   In
these  last  named particulars, syphilitic cutaneous manifestations are
singularly different from lupus  and  carcinoma, for  example, where
the lesion  is  usually of one type, and  persists in one location for a
long period of time, during which the syphilide M'hich it resembles 
502
DISEASES  OF  THE  SKIN.
 would  have progressed either to much  more extensive damage  or
 permanent repair.
   Color.—There  is no color peculiar  to  the  syphilodermata,  M'hich
 may uot  be seen in other diseases of  the skin.   It is important  to
 recognize  the  fact clearly, as there are those M'ho claim to diagnosti-
 cate the syphilides  by their hue alone.  The color, liOM-ever, consid-
 ered in connectiou M'ith the other features of the syphilides, is highly
 characteristic, and often sufficient to enable one at a glance to identify
 the  nature of  the disease.  These color shades  are usually less bril-
 liant than those seen  in  other cutaneous diseases, and possess less  of
 the  scarlet and crimson quality.   They are admixtures of red, yellow,
 and brown, in various proportions, with a frequent slight preponder-
. ance of the brown.  They have been compared to the color of raw
 ham and  copper, terms which have  been  unfortunately so associated
 M'ith the  hue of the syphilides,  that the non-recognition of such
 peculiarity has led  to many errors in diagnosis.   Pigmentations,  in
 various shades of chocolate, coffee, and black, are recognized among
 the  syphilides both during their evolution and  after completion  of
 their involution.  The process, as in  cases where there has been no
 luetic affection, is here also due to increase of the pigment in the
 part, both with  and M'ithout the extravasation  of blood.   Recent
 syphilitic scars are usually pigmented both in centre and periphery.
 Here also it is not so much the color, as the scar with the  color M'hich
 gives special significance to such lesion-relics.
   Contour.—The contour of single  elementary cutaneous lesions  in
 syphilis as also of a group of aggregated lesions, is usually either
 circular, or has  a distinct tendency  to assume such a configuration.
 Thus it  is common  to  find  outlines  of patches, ulcers, and  scars
 observing the curve of a segment  of a  circle;  and coalescence  of
 several such tends  to produce the serpiginous aspect.   The earlier
 exanthems of syphilis are usually symmetrical;  the later,  asym-
 metrical.   Even the symmetrically distributed eruptions will at times
 occur in annular patches, made up of maculo-papular lesions arranged
 in a circular  or crescentic line.  Patches of syphilitic eruption will
 often clear up  at  the centre and develop or spread at the circumfer-
 ence of a  circle.
   Site.—No portion of the integument is  free from the possibility
 of invasion by syphilis.   It may involve at  once almost the entire
 integument, or spread rapidly from point  to point, having covered
 finally  a large  area, or appear conspicuously at distant and isolated
 points of  limited extent, or, finally, be exclusively manifested in an
 insignificant lesion  or group of lesions,  ephemeral in  course,  and
 limited to one  portion of  the body.
   The  site of  a  syphilitic eruption  may be  determined apparently
 by the  capriciousness of  the disease, and  yet result from  local irrita-
 tion  of the  skin of  infected individuals.    The  accumulations on
 the  napkin of women invite  the occurrence of labial  condylomata;
 the  lips of the infant, after contact  with the nipple of the mother,
 become the seat of rhagades  and fissures; while the tongue  of the 
SYPHILODERMA.                    503
tobacco-chewer  and the fauces of  the tobacco-smoker  acknowledge
similar sources of mischief.
  There  are some sites  of  preference  for  special lesions, as, for
example,  the squamous syphiloderm of the palms and soles, and the
papules of the forehead, constituting the so-called "corona veneris."
  Amenability to treatment.—Mercury possesses  a singular influence
upon the syphilodermata, which  is  promptly  perceived when  the
drug is administered  internally.   This  singularity rests upou  the
broad fact that the lesions of  most other cutaneous diseases  not only
refuse to  acknowledge the benefit of such medication, but in  many
cases are aggravated by it.  The importance of clearly recognizing the
character  of each cutaneous disorder  submitted to  treatment is thus
M'ell illustrated.

                              Fig. 62.
   Facial cicatrices of tubercular syphilodermata after twenty-five years of infection.  (From a
                   photograph of one of the author's patients.)

   f 'haracters of certain particular lesions.—Certain families of lesions
in syphilis exhibit characteristic features.  Thus some papular lesions
are surrounded at the base  by a peculiar fraying  of the epidermis,
in consequence  of which  they are encircled by a  little  fringe of
scales  resembling a  collar.    The  scales of syphilis are  usually
not abundant, but fine, dirty-whitish in  color, or occasionally brown-
ish.  The crusts of syphilis  are  apt to be bulky, greenish-black in
hue, and to  surmount  secreting  ulcers of various  depths.    Such
ulcers  arc generally circular,  or  exhibit  in  contour  a tendency to 
504
DISEASES  OF  THE  SKIN.
assume the circular line, M'hile the cicatrices by which they are suc-
ceeded have a similar configuration.   The scars  of syphilis  are fre-
quently smooth, delicate, very slightly depressed, unattached to sub-
jacent tissues, and pigmented.  Lastly, from several of the secreting
lesions of syphilis, especially  those upon and about the  auo-genital
region, proceeds a discharge having an offensive odor, and capable of
communicating the disease to a sound individual  by inoculation.


                    Syphiloderma Maculosum.

   The  cutaneous lesions of  syphilis,  limited to color changes  in
more or less  circumscribed areas  of  the  skin, are exhibited in two
distinct forms, due respectively to anomalies in  blood  and pigment
distribution.

   (a.)  The  Macular  Syphiloderm due  to Hyperemia is
termed by several  authors the  Erythematous  Syphilide,  or
Syphilitic Roseola.   It is the earliest expression  of cutaneous
syphilis, and is more or less constant  in  occurrence, differing in this
respect from several of the  other syphilides.  It is often unnoticed
by the patient, whose attention  may be first called to  it after  its
recognition by the skilled eye of another.   It occurs  in  coffee-beau
to filbert-sized maculse, roundish, oval-shaped, or of irregular contour,
varying in color from  a light rosy to  a dull mulberry hue.  In some
cases, these markings of the surface are very indistinct, requiring for
their recognition the closest scrutiny in a clear light, and occasionally
even then  leaving uncertainty in the mind of the expert.   At  times,
they constitute an irregular " marbling"  of the surface, of a kind
which renders it difficult to define with the eye the individual lesions
of which the eruption is  composed, while the general visual effect of
the exanthem is exceedingly distinct.   They are not elevated above
the general  level of  the integument,  but may change  in type, a
papular lesion developing later in the same site.
   Like all maculse of the skin due to vascular changes, they vary in
color with the complexion  of the individual,  with the time  which
elapses after their first appearance, and M'ith vascular changes in the
superficial  plexus of bloodvessels.   Thus the deeper  shades are
usually observed in thick and muddy-tinted skins; the more delicate
upon  the  breast, for example,  of blonde women.   The  eruption
usually appears between the sixth and eighth week after the appear-
ance of the initial  sclerosis, and, when untreated, develops for about
one week more.  It persists for a variable period of time, depending
upon the severity of the constitutional  disorder and the treatment to
which the patient is subjected.   During  the early part of this time,
the hue of the lesions is lighter, and  they may be made to disappear
under pressure; later, they are more deeply stained, and, exudation
having occurred, the color of the spot does not disappear under  the
finger.   When involution  is in progress, there is slow disappearance
of all symptoms of the  eruption, which  fades gradually from view. 
SYPHILODERMA.
505
The vascular changes in the capillaries, occasioned by cold, heat, and
rapid cardiac  contractions, all  influence the eruption to a marked
degree.   A hot  bath, a dance, a glass  of spirits, a fit of excessive
coughing, laughter, etc., may all bring the lesions iuto prominence.
  The eruption may be limited to the skin of the belly, extending
also sparsely over the chest,  loins, ano-genital region, and thighs, the
palms, soles, forearms,  and  legs, or, in exceptional cases, profusely
cover the entire surface of the body, face, ears, dorsal surfaces of the
hands and  feet, and skin of the penis with the progenital region.  In
the milder forms, it is evidently susceptible  to external irritation of
the skiu, as it is common at  the wrists where a starched cuff is M'orn,
over the brow in the line covered by the hat-band, and particularly
well  developed  in men where the  trousers are " reinforced" (peri-
neum and  inner faces of the thighs).
  At times, as in the exanthematous fevers, the eruption is preceded
by  a febrile state with marked  amelioration of symptoms  M'hen the
rash  is fully developed; while  again it is throughout accompanied
by  slight  rise  in the  temperature,  the  patient having the so-called
" bilious"  appearance,  muddy complexion, coated  tongue,  icteroid
hue of  conjunctivse, and offensive condition of the breath.   Wan-
dering pains in the extremities, and especially beneath the sternum,
are frequently experienced.  The last mentioned is highly significant,
and the whole is probably due  to the effect upon the nervous system
of  the circulation of the recently intoxicated blood.  These pains are
not those produced later in periosteal and  other complications of the
disease, and are the more significant as the eruption itself is  produc-
tive of a scarcely appreciable  subjective sensation.   The superficial
ganglia  of the body  are usually engorged  at  the same  time; the
fauces congested ; the  hairs of the  scalp slightly  loosened in  their
follicles, and, in  the latter region, in severe cases, papules and pus-
tules may  form.   Inasmuch as the order  of sequence  of phenomena
in syphilis is subject to a singular inversion, it  occasionally happens
that there  is concomitance of later signs of the disease, such as iritis,
affection of the nails and bones, or even, in places, pustular, papular,
and squamous syphilodermata.
   Much less rare is the survival of  the initial sclerosis to the date of
this efflorescence.   This is a point of considerable importance.  The
physician  should  never conclude the examination of a patient  com-
plaining of suspicious genital  lesions without carefully exploring the
surface of the trunk, and also never pronounce upon an exanthem of
this sort M'ithout  minute inspection and palpation of the part M'here
an  initial sclerosis may exist.   In a diagnostic and therapeutic sense,
the information thus gained may be precious, and in a large  propor-
tion of all cases  is of a kind quite hidden from the knoM'ledge of the
patient.
   Relapses occur in certain cases with limitation of the disease to
parts previously affected or unaffected.  At the end of the first twelve-
month, recrudescence of larger maculse in  annular groups may occur.
Exceptional forms  are  noted where darker puncta appear in  the 
506                DISEASES  OF  THE SKIN.
 macular lesion, occasionally traversed by a hair.   These are localiza-
 tions of a more intensely  hyperaemic or exudative condition about
 the orifices of the ducts of the follicles.
    The diagnosis of this syphiloderm is readily established, in view
 of its essentially symptomatic character.   From  scarlatina, measles,
 and  rotheln, it differs in the indolence of the rash, the absence of
 decided elevation of temperature, and  the order of its appearance in
 different portions of the body, as it rarely occurs first upon the face.
 Urticaria  and the rashes induced by the ingestion  of  copaiba and
 other medicaments, are distinguished by the marked itching of the
 surface and their very general diffusion over the entire body rarely
 observed  in the syphiloderm.  Tinea versicolor, usually limited to
 the anterior  surface  of the  trunk,  is  characterized  by a  faM'n  to
 chocolate  tinted color,  by the existence  of the readily recognized
 vegetable parasite beneath the scales scraped from the surface, aud by
 the furfuraceous desquamation which the patient usually describes as
 most noticeable after a hot bath.   It is, moreover, of much longer
 duration.   Ringworm of the skin of the body is not symmetrical,
 and is also a parasitic  disease.
   All these distinctions,  however, are not  to be compared  for a
 moment in their diagnostic value, with the concomitant symptoms of
 syphilis, M'hich are very generally present, such as adenopathy, per-
 sistence of the initial sclerosis, and evident involvement of other than
 cutaneous tissues.
   Such concomitant  symptoms will  be found  occasionally with a
 non-syphilitic eruption due to drugs ingested for relief  of the infec-
 tious disease.  The most common of these  is the iodide of potas-
 sium ; and the eruptions it produces are frequently found both com-
 mingled with the macular syphiloderm and occurring on  the eve of
 the  appearance of the latter.  The existence  of acneiform lesions
 upon the  face, neck,  and  posterior  surface  of the  trunk, a vivid
 erythema   of  the forearms  including  the  hands, and purpuradike
 maculations of the face,  legs, and feet, should never  mislead the
 physician  as to the character of the. disorder with which he  is  con-
 fronted.   It is undeveloped syphilis with a dermatitis medicamentosa
 of the surface.   Suspension of the iodide, which  fortunately is not
 required in the immense  majority of all  such  cases ; the use of a
 properly selected mercurial, or even  (and this  is often wise) absten-
 tion from all  medication, will be succeeded by disappearance of the
 cutaneous  lesions, which  may be  followed  later by a mild macular
 syphiloderm, altogether insignificant in comparison with  the eruption
 artificially  induced.

  (b.)  The second  form  of  Syphiloderma  Maculosum  is  that
 due  to Anomalous  Distribution  of  Pigment, described  by
authors under the title of the Pigmentary Sfphilide.   The erup-
tion, if such it may be called, is occasioned by the appearance upon
the surface, of irregularly circular,  usually poorly  defined,  dirty
brown and chocolate  tinted  maculse M'hich, as  they are  entirely 
SYPHILODERMA.
507
unconnected M'ith vascular changes, do not disappear under pressure.
The lesions occur as sparse and M'ell isolated discolorations or, more
commonly, as forming by a species of confluence an irregular rete or
network, with relatively large interspaces characterized by an absence
of such color.   The eruption is most common upon the sides  of the
neck especially in blonde women, though it may more rarely involve
the surface of the  trunk and  the extremities.  It is also  most fre-
quent  during the first year after infection, though it may develop
later.
   According  to Fox, of New  York, the color changes observed in
the skin are explained by the occurrence: first, of pigmentary deposit
chiefly at the  centre of the ordinary macular or papular syphiloderm;
second, of peripheral absorption of such pigment with possible per-
sistence at the centre of the lesion for a variable time; third, of total
absorption of all pigment  from the original  lesion;  and lastly, of
peripheral hyperpiginentatiou of the spaces intermediate between the
original maculae.
   The eruption is  regarded by some observers as an epiphenomenon
of the syphilitic process, being not amenable to the treatment under
which other  macular syphilodermata speedily disappear.  It is of
rare occurrence; and in the cases where I have had the opportunity
of studying its features, seemed to be an expression rather of general
deterioratiou of the health of the skin than of specific disease.1
   It  is  liable to be mistaken for  that  condition in which there  is
simply an accumulation  upon  a somewhat  greasy skin, of secretions
aud dust, to be seeu upon the integument long unwashed.   Tinea
versicolor  has a more yellowish  or fawn-colored tint, and is more
abundantly developed  upon the  front  of the chest  than  the neck.
Neither chloasma,  vitiligo,  nor  leucoderma are  symmetrically dis-
posed, as is usually the pigmentary macular syphiloderm.


                     Syphiloderma Papulosum.

   The  tvpe of all  cutaneous lesions produced by syphilis, is to be
recognized in the  papule.   Most of the others  are either developed
from it, transformed to it, or by reversion or admixture, confess that
the neoplasm  of syphilis iu  the skin  is essentially a more or less solid
circumscribed cutaneous lesion, varying as to size aud  history.
   Papules, occurring in  syphilis, may appear as  the first cutaneous
evidence  of infection,  or may be developed from earlier maculse.
They may be  small, acuminate, flat,  large, disseminated, or in groups.

   Small Acuminate Papular Syphiloderm.—In this eruption
the lesions are recognized as millet- to hemp-seed sized, circumscribed,
globular,  acuminate, reddish, and  salmon-reddish, firm elevations of
the surface, or minute nodules upon the skin, generally symmetrically

 1 The author has  seen this eruption most  perfectly developed upon the skin of Chinese patients
affected with syphilis. 
508
DISEASES OF THE SKIN.
developed, often over  the entire body, closely set together, and occa-
sionally grouped in crescentic  figures.   When viewed  with care, a
minute vesicle, pustule, or  scale may be often detected at the conical
apex  of each lesion, which rarely develops to such an  extent  as to
become a  characteristic feature of the eruption.  The color is at first,
especially in blonde skins, a species of salmon and  red, mixed;  later,
the darker aud browner shades appear.  When generalized, the  erup-
tion is well developed, especially over the posterior face of the body,
the occipito-cervical and scapular regious, the  buttocks and calves  of

                              Fig. 63.
Syphiloderma papulosum.  (After Jullien.)
the legs,  though  it  is often distinct about  the  anus and genitalia.
Like  several other of the syphilodermata, its earlier are more sym-
metrical than  its later  manifestations, whether these be tardy, or
relapsing, or both.  The involution occurs by resorption of the plastic
exudate, minute and usually scanty, dirty-whitish,  colored  scales
encircling  the  base of each lesion.  When the eruption has proved
especially  persistent, marked  pigmentation follows in the  form of
brownish-red blotches, the centre of  each of which displays a cicatri-
form  relic  in the form of a punctum.
   The eruption is often first noticed  about the forehead, nose, mouth,
and neck, localities  commonly  subject to topical irritation.   Thus
about the  forehead in men, the papules M'ill be frequently arranged
along the  band  pressed  by the lining of the hat;  and the frequent
fingering of the face, shaving, and irritation by the edge of the collar 
SYPHILODERMA.
509
of the shirt, may determine a more speedy efflorescence in the sites of
contact.  About the  mouth, tobacco plays  the part of an excitant;
and about the nose, a localized seborrhoea may be added to the syphi-
litic phenomena, iu which case the lesions may be covered M'ith thin
greasy crusts.  The eruption is common during the first six months
after infection,  and is usully fully developed after a fortnight M'hen
no treatment has influenced its evolution.   When the lesions are per-
forated by hairs,  they suggest, on superficial examination, a  resem-
blance to lichen pilaris, and when aggregated in patches of distinct
contour, they might be confounded with psoriasis or squamous eczema.
But in every case the physiognomy  of the disease in general may
well be trusted for the establishment of a diagnosis, having in mind
the color, the absence of intense pruritus and serous exudation, the
disposition over the body as a whole, or in portions widely separated,
and the rarely  failing concomitant evidence of syphilitic infection.

   Laroe  Acuminate Papular  Syphiloderm.—Lesions of the
character just  described occasionally develop to ,an  unusual  degree,
attaining the size of a coffee-bean  in localities where the apex of
each is free to  push forward without coming into contact with adja-
cent planes of the integument.  Thus about the dorsum of the body,
the gluteal  regions, the calves of the legs,  and the  extensor surfaces
of the forearms, they  may be seen as  fully developed,  slightly scale-
capped or scale-encircled, and  grouped papules, often commingled
with pustules and superficial ulcers, the polymorphic patch haviug a
figure of eight or S-shaped outline.   These are apt to be distinguished
in patients  under treatment, the influence of M'hich  has interfered
M'ith the full evolution of the disease.

   The  Small Flat Papular Syphiloderm.—The lesions recog-
nized  under this title differ from those just  described in that they are
not acuminate, but distiuctly flattened at the  apex, this flattening being
at times so pronounced that the lesion resembles a small button or plaque.
The contour is roundish  or oval-shaped.   They are  frequently en-
countered on the face, especially near the mucous outlets, over the ante-
rior and posterior surfaces of the trunk, and on the flexor aspects of
the extremities.  The palms of the hands are often affected.  In color
they exhibit the variation usual in individuals of different complexions,
and in the same individual according to the condition  of the circula-
tion.  Thus, on the face, a scarcely distinguished pink will become a
deep,  lurid,  reddish-brown from an attack of sneezing, a paroxysm of
laughter or rage, and violent  exercise.   The seborrheic condition
noted  on the face  in the acuminate  lesions  is also  occasionally seen
about the plaques.  The same is true of the scaling described above.
The  eruption  is  much less copious,  as a  rule, than M'ith the other
 forms of syphilitic papules, due doubtless to the fact of its frequent
occurrence in those subjected to some treatment.  It differs from the
lesion about to be described M'ith  respect  to its  size, being rarely
laro-er than the smaller buttons employed as "shirt  studs;" M'hile the 
510
DISEASES  OF  THE  SKIN.
largest papules of the same variety may attain the size of the largest
overcoat button.  The diagnosis is in general that already given.

  The Large Flat Papular Syphiloderm.—Here the resem-
blance to a button is even more distinct, the lesions occurring with a
well-defined, firm, raised  border,  and  a  shallow depression in the
centre, though at times, especially in moist situations, the superficies
of the plaques is a smooth, flat  plane.   They commonly begin as
macular  lesions and rapidly  develop at the periphery, this  develop-
ment often corresponding to centric involution by which the shallow
depression described above is reduced to the level of the adjacent skin
and  the  lesion transformed to a  ring.   In  shape  they are circular
and oval; aud, in size, vary  from a  finger-nail to the section of a
pigeon's  egg.   They have the usual variation in color, and may scale
at the edge, or  over the flat top, or the depressed centre.   In moist
situations they  frequently secrete a muco-purulent fluid which smears
the papules aud adjacent integument; and in the vicinity of the anus
or genitals  exhales an offensive odor.    It is  especially iu  such situa-
tions  that they  occasionally degenerate by fissure or circular  ulcera-
tion.   Condylomata Lata are such lesions, flat and secreting papules
of the region named, somewhat transformed by the influence of heat,
moisture, and  either friction or  apposition  of contiguous integu-
mentary folds.
  The eruption may become  generalized, or be limited to certain sites
of preference, as the face, neck, flexor surfaces of the extremities, and
the ano-geuital region.   It is either  an  early, late, or intermediate
symptom of syphilis, in my experience  occurring most abundantly in
young and  delicate skins, where  the disease  has been ignored, and
therefore untreated;  and most scantily  in the thicker  integument of
middle life, where prompt resort  has  been had to appropriate medi-
cation.
  Syphilitic papules  undergo a  series of modifications, under the
influence of various causes, M'hich  may be enumerated as follows:
  (a) There  is considerable  hyperplasia  of the cutaneous elements
(papillary layer of  the corium, rete, and  bloodvessels), by M'hich the
papule becomes largely raised from the surface, so as to resemble a
papilloma or wart, or the lesious characteristic of frambcesia.   In this
way,  rarely, a portion, or the entire surface, of the body may be
covered  with light-red or violaceous red, non-ulcerative, vegetating
growths.   They secrete freely, and the  discharge is liable to concrete
into  crusts,  and to  exhale  an  offensive odor.  De Amicis1 has
described a  marked instance of this lesion occurring upon the scalp,
under the  title of the " frambcesioid coudylomatous  syphiloderm."
A translation  of his paper  by myself appeared in  the Archives  of
Dermatology for October, 1879, p. 39.
  (b) There is considerable  hyperplasia  of  the elements, in  conse-
quence of which the lesion spreads laterally, while  its elevation from
Annal. Clin, de Osped. Incurab. 
SYPHILODERMA.
511
the surface is  prevented by contact with apposed surfaces.  Thus is
formed the broad, flat, moist papule, known as the vegetating mucous
patch, condyloma,  plaque muqueuse, etc.   The lesions, when  unal-
tered and fully developed, are of a decidedly  whitish color, from the
puriform  mucus M'hich covers them  and which, as with so many of
the  syphilodermata  in   moist  situations, is  liable  to exhale  an
extremely offensive odor.   When the  secretion is removed, the lesions
are seen to be pinkish, or light or dark red in color, and to be  either
firm  or  soft,  scarcely raised, and indefinite in contour, or distinctly
elevated  and  very  well defined.   They are  chiefly found in  moist
situations, where regions  of the skin  are apposed, as about the  peri-
neum, groins, axillse, mammae, nates, anus, genitals, and inner faces
of the thighs.   They may coalesce so as to form  palm-sized patches,
and frequently are associated with  hyperidrosis, seborrhcea oleosa,
aud the dried products  of secretion from the  mucous outlets adjacent.

                              Fig. 64.
Vegetating condylomata of the vulva.  (After Jullien.)
   (c) In consequence of changes in the superficial  layers of the epi-
dermis, the papules  may become covered with scales, either at the
base  or  apex, more commonly the  latter, forming thus the  papulo-
squamous syphiloderm.   The  scales are of a dirty grayish hue, often
desiccated, generally attached, rarely freely  exfoliating.  They are
relatively few,  occurring M'here the lesions  are closely set together.
The desquamation may be the  most suggestive  feature of the patch.
Beneath them,  show distinctly elevated brownish-red papules  or
merely   slightly elevated,  dull-red  or purplish-reel  maculatious.
When the  scales accumulate at the base  of the  papule, they tend to
surround it  M'ith  a circlet or collarette  of  exfoliated shreds  of
epidermis. 
512
DISEASES  OF  THE  SKIN.
  In consequence of the thickness of the epidermis in the  palms and
soles, the papular or papulo-squamous  syphiloderm  of these  regions
is presented under somewhat atypical  forms.   These  are  recognized
as the Palmar and Plantar Syphilides.   The dense stratum
corneum of the epidermis in these situations is not readily raised from
its underlying tissue into papular forms.  Its pathological manifesta-
tions in this disease are rather displayed in thickeniugs, separations,
stainings, aud frayings.
                              Fig. 65.
Palmar syphiloderm. (After Ketes.)
  Here, therefore, are seen dull-red maculations, covered throughout,
or at the edge merely, by scales or epidermal  shreds;  minute, firm,
corneous thickenings, few or many, often without color in consequence
of the depth of the vessels beneath the opaque horny layer; and dis-
tinctly elevated (not flattened) aud circumscribed papules, of the usual
livid-red color, coffee-bean to small-nut in  size, often aggregated in
patches having a tendency to assume the circinate outline.   These
are covered  with dirty-M'hitish, tenacious,  half-loosened, epidermic
flakes, which are quite characteristic.  In yet other cases, usually in
consequence of the motions of the hand or foot or the exigencies of
toil, irregularly  angular losses of epidermis are  visible, resembling
the fracture of a pane of glass, M'hich project, at the edges only, over
deep fissures, broad  exulcerations, or  a ham-red, tender, and  newly
formed epidermic stratum.
  The eruption is frequently seen in the centre  of both  palms and
soles symmetrically,  rarely upon the dorsum of the hands and  feet,
and then  never  typical, but  always  by extension from  the  former
regions;  also on  the lateral  surfaces of the hands, feet, fingers, and
toes.   It is a persistent,  rebellious, and usually late cutaneous symp-
tom of syphilis, occurring often six,  eight, aud  more years after infec-
tion.   Rarely it  is seen M'ithin a few months  after the existence of
chancre,  and is then  usually manifested in its simpler forms.
   The papulo-squamous syphiloderm bears  in  many  instances  a
strong resemblance  to  the patches of psoriasis, but can usually be 
SYPHILODERMA.
513
 readily  distinguished  from  the latter  by  a consideration of  the
 folloM'ing points :
   The syphilide is, as a rule, not generally diffused; displays sym-
 metry only when it involves the palms and soles; is  elevated at the
 border of the patch ; and observes the contour of the segment of a
 circle.   Psoriasis is more widely diffuse;  generally symmetrical;  not
 specially elevated  at the border of the  patches; and the latter  are
 rather more completely  thau partially circular in  outline.   In  the
 former there is generally a history of infection, of other cutaneous or
 mucous  symptoms  of  the  disease, and  in the  married woman, of
 abortions, miscarriages, or  birth of diseased children.  All this is
 wanting in psoriasis.  In the latter there  is a decided predisposition
 to the development of the disease about the extensor surfaces of  the
 joints and the  posterior aspect of the trunk ; the syphiloderm, though
 it may occupy these situations, can rarely be found thus displayed
 wheu the other surfaces are  neglected.   The scales in psoriasis  are
 more lustrous;  more freely  produced and shed;  and exist signifi-
 cantly at an earlier period of the exanthem.   It may be safely said,
 that with only such exceptions  as  prove  the rule, psoriasis  is never
 strictly limited to  the regions  of  the palms  and soles.  A scaling,
 palmar or plantar disease of the skin in childhood is more apt to be
 psoriasic, though both  diseases are  seen  in the  early  periods  of
 puberty.
   Eczema is  yet more readily recognized by its severe itching, its
 history  of discharge and moisture,  and  its characteristic crusts.
 Ancient patches  of squamous eczema are often very indeterminate in
 outline,  do not ulcerate, and  exhibit the  scales on  the  surface of a
 much more deeply infiltrated area.   Eczema of the palms  and soles,'
 when chronic, usually  involves the dorsum of the hands  and feet,
 whence it has extended to the former situations.   When this  is  not
 the case, the eczematous infiltration if of  long duration, will, in  the
 vast  majority of  all cases, be  found to involve uniformly and evenly
 the entire palm or sole, including the palmar or plautar  faces of the
 digits.   Eczema  is, finally,  much more frequently encountered either
 solely upon the right hand in right-handed patients, or  to a  greater
 extent in that organ by reason of its preference in the performance of
 function.  This  is less  common  in syphilis.


                     Syphiloderma Vesiculosum.

  The vesicular are either the rarest of all  cutaneous symptoms of
 syphilis, or do not actually exist.   Certain French authors  describe
 pin-head  to  pea-sized,  conical,  globoid  or umbilicated,  isolated or
 grouped,  and  crusting elevations  of the  epidermis,  M'ith  lucid  or
 cloudy contents, seated  upon the face and genitalia.   The eruption is
 described as an early syphiloderm, often exhibiting a halo of charac-
teristic tint, the resulting crusts being granular and  somewhat lighter
                                 33 
514
DISEASES  OF  THE  SKIN.
in color than  those M'hich are commonly seen in the disease.   Both
small and large vesicles have been thus assigned  to the  disease.
   But the  larger number of such  lesions  are,  M'ithout question,
either immature pustules, eczematous lesions in syphilitic subjects, or
pure accidents of the syphilitic process.   With regard to the first, it
may be said that the pustular syphiloderm  not rarely begins as a
vesicular lesion; with regard  to the  second, that coincidences  of so
common  a disease as  syphilis with  other  cutaneous disorders is a
matter of frequent   observation;  and  with regard  to  the  third,
bearing in mind the  large quantity of iodide of potassium swallowed
for the relief of  the disease, and its capability of exciting a vesicular
eruption, it  can  be reasonably concluded that some, at least, of  the
cases of so-called vesicular syphilis have been imperfectly studied.

                     Syphiloderma Pustulosum.

   Pustular  lesions in syphilis present a wide range of differences.
They vary in size from a  pin-head  to a  finger nail;  may be acu-
minate, flat, hemispherical, or irregular in shape;  may  be few or
very numerous ; distinctly localized or generally  dispersed ;  grouped
or  disseminated, and may occur from the first as minute vesico-
pustules, or as pustular  transformations of variously sized  papules.
They may be surrounded by inflammatory areolae, or spring from an
unaltered integument, or be sub-epidermic  in situation, and scarcely
project from the surface.   They  may be seated  upon  superficial or
deep, sharply cut, secretory  ulcers,  and  are usually  followed  by
crusts differing in bulk  and consistency, forming thus the  pustulo-
crustaceous  syphilide.   According to the depth  of the ulceration at
the base  are  they folloM'ed by cicatrices.   Pigmentation is a  fre-
quent  result.    The  crusts which  form by the  desiecation of their
contents are  usually  reddish-broMn to greenish-black  in  hue,  occur
in  strata or laminae  by accretions  from  beneath, and, even  M'hen
superimposed upon a moist aud secreting ulcer, are quite adherent at
the edges.   They may occur early or late in the disease, and at either
epoch constitute trifling or grave cutaneous lesions.   They have a
marked predisposition for  involvement of the sebaceous and pilary
follicles,  and are frequently disposed  about the mucous outlets of the
body.

   Small Acuminate Pustular Syphiloderm.—This exanthem
is usuallv largely diffused over an extensive surface,  and probably
represents, as Jullien has suggested,  a  transformation  from papular
lesions due to either a pyogenic tendency of the infected  subject, or
to uucleanlincss and external  irritation of the skin.   It is certainly
rare in  patients of  the better class who are  seen  in the private
clientele of  the physician.   The  pustules  are  geuerally  recognized
about the pilo-sebaceous orifices,  and upon minute  papular lesions,
M'hich, as undisguised elements of the  eruption, may be interspersed 
SYPHILODERMA.
515
among the latter.   They are acuminate and contain but a droplet of
cloudy serum or pus, M'hose  desiccation furnishes a thin yelloM'ish or
reddish-brown crust.   The  fall of  the  latter exposes the gravish
epidermal fringe of the base occasionally seen in papules of similar
size.
   The lesions may be discrete, confluent, disseminated, or in groups
affecting the curve of a circle.  The extremities and trunk are chiefly
involved, though the disease may  be well nigh universal.   Under
the influence of treatment, minute, punctiform, and pigmented cica-
tricial atrophic depressions  form,  which  are not persistent.   The
eruption may be an early or  late secondary symptom,  but is usually
first seen M'ithin a feM' months after infection.   Relapses occur when
treatment  has been  irregularly pursued.   Their concomitants are
those symptoms of syphilis proper  to  the period  in which  they
appear.

   Large Acuminate Pustular Syphiloderm.—The  lesions are
here  usually coffee-bean sized  pustules,  M'hich  may  spring  from
macular or  smaller pustular lesions, very rarely from  an indurated
or papular  base.   They have a thin roof-wall, occurring by prefer-
ence M'here the epidermis is delicate,  and  are often surrounded  by a
halo.   They are  usually  acuminate, but  may, after  full evolution,
slightly flatten at the apex in consequence of partial  collapse.  The
crusts are bulkier  and darker in color than those of the lesions just
described ; their bases are superficially ulcerated.  They occur slowly
or M'ith rapidity,  in disseminated  or grouped forms, usually at  an
early period  of the disease,  though commonly after the appearance
of some syphilide of another type.

   Small Flat  Pustular Syphiloderm.—This  is a relatively
frequent manifestation  of syphilis, occurring  upon the face,  scalp,
trunk, and  the flexor  surfaces of the extremities.   It  exhibits a
decided tendency to characteristic  and circular grouping about the
mucous outlets of  the body.   Such groups  are  composed of small,
flat pustules, originating as  reddish,  macular lesions  which tend to
dry in flatfish, irregular, adherent  crusts;  and the latter either sur-
pass the limits of the diseased surface beneath, or are conspicuous
upon a  dull brownish-red  area  of inflamed, and   even at times
ulcerated, aspect.   Often the pustules are so closely set  as to become
confluent, and in  such  case  a  single convex crust, like a carapace,
M'ill often completely cover the involved area.   Frequent sites of the
exanthem are the regions about the nose  and the lips, as  also the
chin,  beard, and the anterior faces of the  elbow and M'rist-joiuts.
  The  eruption  is of the  pustulo-crustaceous  type, and  may  be
evolved from either papular or macular lesions.  In this country, it
is rarely long untreated, and  M'hen  in full evolution is, therefore, not
often  presented for observation.   It is usually amenable to judicious
treatment, and, when followed by  severe ulceration, destroying one
ala of the nose or  a part of the lip, the patient has usually suffered 
516
DISEASES  OF  THE
SKIN.
from either  cachexia  or  neglect.    In these same  cases,  less severe
phenomena are presented in the superficial  serpiginous syphilide, the
lesions  extending iu circinate or annular gyrations about a sound or
previously involved  and  healed  centre.   Thus a circlet of crusts,
M'ith underspreading superficial ulceration, perhaps alternating with
pustules of various  ages  and reniform  cicatrices, M'ill surround the
elbow or traverse the scalp.    The resemblance to pustular eczema
is at times suggestive;  but the ulceration  and outline  M'ill aid in
their discrimination.   The lesions are usually late among the earlier
symptoms of the  disease, but may be delayed  for  six months  after
infection.  They indicate, as a rule, either severity of the disease, or,
much more commonly, constitutional impairment.

   Large Flat  Pustular  Syphiloderm.—The  lesions  here  are,
naturally, fully developed forms of those described above.   Like the
latter, they originate as usually numerous, maculo-papular symptoms,
M'hich gradually  deepen  into  pea-sized and  even larger flat pustules,
whose further history is  one of enlarging, blood-mixed, reddish- and
greenish-brown, also flatfish crusts with underspreading  pus-bathed
ulceration of varying extent.  The superficial variety of this syphilo-
derm is distinguished from the  deep,  chiefly by  the extent  of its
ulcer, the size of its superimposed crust, and  the  slighter, dull-red
areola which encircles it.
   The  deep  variety, like the superficial, may be limited to the scalp,
face, neck, and flexor aspects  of the  extremities, or it may be much
more M'idely diffused.   I have seen the entire surface  of the body
covered with discrete lesions of this type in cases of unusual neglect
or profound  cachexia.   It is usually of late  occurrence, but in the
so-called "galloping syphilis" of the French, it may be precocious in
development,   The lesions are at  the onset  nodules or tubercles,
which  become transformed into pus, and which have a deep infil-
trated base M'ith  a dark brown halo.  Incrustation follows, with the
formation of a conical, roundish, or oval-shaped, blackish-broM'n crust,
beneath which lies  a clean-cut ulcer, its sharp edges usually exactly
roofed  by the incrustation.   The  crust thickens by concretions from
the  foul and  purulent ulcer beneath, and  spreads  at  the periphery
M'hile it thickens in the centre.   In this  May, the  stratified crust
comes to resemble an oyster-shell, the  condition described by some
authors as Rupia, a term once employed as the name of a disease.
The ulcer M'hich is exposed after removal of the crust is  of charac-
teristic syphilitic type, in its deep base, foul floor, clean-cut edges, and
sanguineo-purulent secretion, attaining at times a diameter of several
inches, and having a circular, reniform, or horseshoe-shaped contour.
The degree  of destruction it  may occasion is  proportioned to the
constitutional vigor of the subject and the treatment pursued.   It is
usually a grave  but may be a malignant exanthem,  though  under
favorable circumstances it is easily managed.   It may be an early,
though is usually a late  symptom of the disease.  The  pigmented
' scars left are characteristic and indelible. 
SYPHILODERMA.
517
                       Syphiloderma Bullosnm.

   Bullse  in  acquired syphilis  are late and  relatively rare lesions.
 They are  pea- to large nut-sized elevations of the epidermis, filled at
 first with  a cloudy  serum, which is soon transformed into  pus, and
 often mingled with blood.   They have usually a characteristic halo
 about the periphery;  are roundish or oval in contour; are usually
 discrete, rarely disseminated, and, after development, produce char-
 acteristic  crusts with  underlying ulcers, identical  in features with
 the rupioid  sequelae of large syphilitic pustules.   The eruption is
 localized by preference upon the extremities,  more particularly  the
 lower extremities, and is indolent in its course.   It is always signifi-
 cant of a cachectic  condition in the subject of the disease.   Its more
 frequent occurrence in congenital syphilis will be described later.  It
 is to be distinguished  from pemphigus vulgaris  by its characteristic
 crusts and ulcers, considered in  connection  with  the  history  aud
 associated  symptoms of lues.


                    Syphiloderma Tuberculosum.

   In this eruption, the  lesions are usually multiple, flat, roundish,
 circumscribed,  firm, light to dull crimsou-red  nodules, beginning
 commonly as  maculse of a  lurid hue.  They vary in  size from a
 coffee-bean to small nut and  involve the entire thickness of the skin,
 often also of the subcutaneous tissue.  Their  surface  is  smooth,
 glazed, or  desquamating; and  their evolution peculiar  in this, that
 they rarely exhibit apicial pustulation or ulcerative degeneration.
   The eruption is, with  few exceptions, usuallv limited  to one or
 more regions of the  body, such  as the forehead, the chin, the nucha,
 the  buttocks, and the outer surface of  the thighs.   It is less often
 disseminated  than  grouped.   Occasionally  but  a  single tubercular
 lesion may be displayed upon the surface of the body, the recognition
 of whose character usually demands some skill ou  the  part of the
 diagnostician.   When  occurring in  groups,  the  typical  circiuate
 appearance of the syphilodermata  in  general  may be wanting,  the
 patches having  an  irregular boundary; but at  times the  circular,
 reniform, or  horseshoe-shaped   outline is quite distinct, with   an
 inclosed area of integument, unaltered or the seat of atrophic changes.
 At other times the lesions assume a serpiginous character and distri-
 bution, a condition to which the term


             Syphiloderma Tuberculosum  Serpiginosum

 has  beeu applied.  Bumstead and Taylor, however (wisely it seems
to me), prefer  to reserve that title for the description of the serpigi-
nous syphiloderm of ulcerative type.
  In exceptional cases, the  lesions thus  described  are  marked   by
secondary changes.   They may  become  covered on the surface M'ith" 
518
DISEASES OF THE  SKIN.
a thin yellowish  crust; may  lose their firmness and become  soft
and  rather more lurid-red in  hue  from  colloid,  or even rarely
suppurative, degeneration;  may vegetate luxuriantly and become
the seat, especially on  the  scalp, of warty growths, smeared with a
semi-purulent secretion  of  disgusting  odor (syphilis  papillomatosa,
syphiloderma framboesioides);  or may finally  ulcerate,  the super-
imposed  crust thickening  in bulk,  deepening  into blackish  and
greenish shades,  and covering typical  syphilitic exulcerations, M'ith
characteristic edges, floor, base, and secretion.  The degeneration in
the latter case may be rapid, and the destruction extensive.   This is,
however, of rare occurrence.

                              Fig. 66.
Ulcerative tubercular syphiloderm.  (After Keyes.)
  The course of the eruption is indolent,  months  usually elapsing
before its full evolution is accomplished.   In untreated cases there is
unquestionably produced a generalized and symmetrical syphiloderm.
It is rare, however, even in hospital and  dispensary  cases, to observe
such generalized development; the more superficial,  generalized, and
symmetrical the lesions, the briefer, as a rule, is the  interval between
such an eruption and the date of infection.   The later the lesions,
the more apt are they to be asymmetrical, localized,  and profound in
their  involvement  of the  deep tissues.  This syphiloderm rarely
appears in the second, more often in the  third  or fourth, still  more
rarely in the fifth, tenth, or fifteenth year of the disease.
  Resolution occurs by resorption leaving in the site of the tubercles,
according to their age, size, and contents, livid  and pigmented macu-
lations,  or  peculiar, pigmented, atrophic,  cicatriform areas.   Scars
following the ulcerative lesions are typical in color, shape, and career, 
SYPHILODERMA.
519
the pigmentation of both cicatrix and areola blanching from centre to
periphery, and  leaving a delicate, dull-M'hitish, glazed, or slightly
desquamating membranous new growth, ancient relics of this process
resembling  in appearance thin, small  coin- and larger-sized, circular
sheets of mica.
   The diagnosis is betM'een  lupus vulgaris, lepra, epithelioma, and
psoriasis.   In lupus, the age of the subject, the character of any scars
left upon the surface, the chronicity of the disease, and the absence
of a history of polymorphism, will usually point to the nature  of the
disease.   The tubercles of lepra  are very much more indolent than
those of syphilis, and have a characteristic oiled or varnished look,
never the livid or dull  crimson color of those last named.  Set upon
the forehead, the tubercles of syphilis, nearer  the  line  of the  hairs,
never give the leonine aspect  of those at the lower border of the fore-
head  and over the eyebrows of the leper.  In epithelioma, the age of
the subject and the  history of the disease are always significant.  In
the early stage of  epithelioma, the patient  is  often in a condition of
excellent  general health, M'hile the imprint  of  cachexia is distinct in
tubercular syphilis of the skin.   In the later  stages of epithelioma,
the ulcer M'ith everted  edges  and eroded, hsemorrhagic floor, " var-
nished "  by its translucent secretiou,  is totally different from  the
"punched out," syphilitic ulcer with  its puriform secretion and dis-
colored crusts.   The  deep  infiltration  of even the desquamating
tubercular syphiloderm will  distinguish it from the circular patches
of psoriasis.

                    Syphiloderma Gummatosum.

   The gumma is a lesion peculiar to  syphilis; no other disease ex-
hibiting an exactly similar feature.  It is usually a late or so-called
tertiary manifestation of the  disease; and  is commonly observed in
the form of one or relatively few, subcutaneous,  strictly circumscribed,
firm,  well rounded, painless and  indolent tumors  or nodules which,
when first observed, are  scarcely  larger than a pea.  They are then
covered by an unaltered integument aud are quite movable.
   Verv slowlv they may, M'hen untreated, increase in size till they
have  the dimensions of a marble, au egg, or even bodies of a consid-
erably larger size.   Sooner or later, M'hen not  resolved by treatment,
they usually become attached and the overlying skin becomes involved,
showing by its livid,  reddish, or purplish hue, and its hyperaemic
areola, that it threatens  to yield.  Finally, at one or several points, the
skin is so thinned as to be incapable of further  resistance, and a thick
sanious secretion is exuded,  M'hose gummy character has  given  the
lesion its  name.   When  the inflammation has  been active, its secre-
tion  may be wholly or  partly purulent, and  in  that case be fur-
nished, either by the contents of  the tumor, or the peripheral tissue
M'hich participates in the process.   Ulcers ahvays result, occasionally
fistulous in  type, roundish or oval in  contour; with edges clean cut,
and floor purulent  and  extending to the subcutaneous tis-ue, tendons, 
520
DISEASES  OF  THE  SKIN.
aponeuroses, cartilage, or bone.  Thin and yielding bands or bridges
of undermined skin often extend between several such  solutions of
continuity, and usually melt down in  the presence of the destructive
process.  Wheu repair is  progressing, which is decidedly the rule as
regards the ultimate result, granulations spring from  the  floor,  the
                                  edges contract, and the gummatous
            FlG  67                eventually  exhibits  the  appear-
                                  ance  of a simple  ulcer,  save in
                                  the thinned, purplish, pigmented
                 Pllp'             appearance  of the  outlying  in-
                 |frv             tegument.  The scars are typical,
          »^r                   bleaching;  from  the centre, and
                           :W;::-..   may be attached to periosteum or
                           ij     bone, though this is exceedingly
     ^f||fcgg|i^^   ^^%?   Hlf   rare.   Considering the depth of
                                  the process, the gumma of  the
                       Ist^lll^    skin  is certainly  as  a rule suc-
                                  ceeded by less evidence of  de-
                 ^^^           st ruction  than is  threatened  at
                                  the height of the process.  About
                                  the neck, the cicatrices  may  be
                                  linear in shape and slightly puck-
                                  ered.  Upon the lower extremities
                                  and trunk,  they  are usually  cir-
                                  cular or oval.
                                    But one  gumma  may appear
                                  upon the person of a single indi-
                                  vidual and, when this is the case,
         ^||p'-"                    it M'ill usually be found upon the
                                  leg.   Half a dozen or  more may
    Syphilitic gummata of head and face.        ~  .     .              T     J
           (After juluen.)             at other  times coexist.  In  one
                                  instance, I counted more than one
hundred upon the person of a male  patient who Mas the father of
two syphilitic  children, and who at the  time had also symptoms of
visceral syphilis.  This number is greatly in excess of any previously
observed  by me  in a single case.   Gummata may develop upon  any
part  of  the  body, and  when situated over the  trunk of  a nerve
become the seat of  severe  neuralgic pain.  They are particularly
amenable to treatment;  and may undergo resorption, leaving little
or no trace of their former existence.
   Gummata are to be distinguished from fibrous, carcinomatous, and
lipomatous tumors, as also from indurated and enlarged  lymphatic
ganglia.   As  they occur  in  very marked preponderance  below the
level of the knees, and are for the most part single  or relatively few
in  such  situation, they  can  by their position alone be  frequently
differentiated  from each  of the new  growths  mentioned,  no one  of
M'hich occurs by preference upon the  lower extremities.  As they are,
moreover,  relatively late  lesions of syphilis,  a history of preexisting
symptoms of that disease  can usually  be obtained.
 
SYPHILODERMA.                   521
                    Erythanthema Syphiliticum.

   Under this  title, Dr.  E. B. Bronson, of New  York,1 describes a
condition ol (served by himself in syphilitic patients.  Upon  a well
defined,  crimson  or livid, erythematous  surface (face, palms, soles)
appeared an abundant crop of pea-sized vesico-pustules,  M'hich  Mere
converted later  into  an exuding, M'hitish, elevated, and  diphtheroid
patch.  The multiformity of  the exanthem Mas characteristic.  In
parts it suggested the hydroa bulleux of Bazin; elsewhere, the derma-
titis herpetiformis of Duhring.  The fluid exudation that affected the
face Mas not characteristic of the evolution of the palmar and plantar
lesions.
   Later, warty, papilliform lesions appeared over the face and neck,
somewhat  resembling  secreting condylomata, and  surmounting, for
the most part, a dusky-red or erythematous surface.
   The  author  regarded  the  exanthem  as  primarily  a  syphilitic
product, but not pathologically or etiological!)' a true syphiloderm.
Its origin Mas  possibly similar to that of the  angioneurotic, tropho-
neurotic, or reflex phenomena of skin disorders iu general.     >

        Syphiloderma Infantile, Acquisitum et  Haereditarium.

   Syphilis may be acquired by the infant and  child  at  any period
after birth, as,  for example,  by immediate contagion  from the nipple
of the nurse, or mediately, as  by  the use of utensils smeared with  a
secretion capable of transmitting the disease.  Such acquired infantile
disease displays for the most  part the  symptoms  observed in adult
years, except that the delicate and tender skin  at this early period of
life is apt to exhibit the moist and secreting lesions of syphilis.  The
mucous patch, the pustule, and the condyloma, are here more common
than the papulo-squamous symptoms of the adult.   Some influence
is also exerted upon the disease by the dress, habits of life, and mode
of obtaining nutriment, M'hich are conditioned  upon the  helplessness
of the young  child.  In this  way the soiled  napkin  over  the ano-
genital  region, the warm covering of, and free diaphoresis from, the
general  surface of the skin, and the frequent contacts of the lips M'ith
the nipple, suffice to determine in special  regions, particular local
expressions of the constitutional vice.   It is much less grave in char-
acter and portent than the inherited form of the disease.
  Hereditary syphilis may be first displayed in infancy or early adult
years, and  is ahvays strictly transmitted by inheritance  from one or
both parents.   The consideration  of the disease being in these  pages
limited to its cutaneous manifestations, it is first to be noted that the
infected fetus maybe prematurely expelled with cutaneous symptoms
displayed  upon its surface.   This generally argues  in favor, either of
intense  syphilis in one or both progenitors, or, more  commonly, of
relatively recent infection of the latter.  Under these circumstances,

                   i Medical Becord, September 4, 188'". p. 253. 
522                DISEASES  OF  THE SKIN.
there are usually evidences of the death of the foetus  at some date
prior to  its expulsion, the skin  being macerated and the epidermis
raised from the corium in few or many bullous lesions, beneath which
the derma exhibits a livid reddish or purplish  hue.
   When the infant  is born with  a clean skin, it  may be shrivelled
and emaciated, or fat and presenting the appearance of sound health.
Soon after, however, cutaneous  manifestations  appear, usually not
before the conclusion of  the first month, more  commonly during the
second, very rarely after the third and fourth.   The earlier  the date
of such explosion, the more intense as  a rule is the evidence of the
disorder.   The first symptoms displayed are  significant of visceral
involvement, and are, in brief, those of marasmus.   Emaciation pro-
gresses rapidly ; the skin seems stretched unnaturally over the facial
bones; the expression is that of physical distress ; tbe cry becomes a
fretful moan; the  integument  loses entirely the  rosy hue  of the
healthy  infant, and  acquires  instead a  sallow or  muddy tint; and
very  peculiar wrinkles or puckered lines radiate from the angles of
the lips.   FeM' observers have failed to  notice the resemblance which
then exists between the faces of these emaciated little creatures and
those of the aged of both sexes.
   In all this, however, there  is absolutely  nothing characteristic of
syphilis,  as  distinguished from  other wasting diseases  of  infancy.
Chronic  tubercular meningitis and the gastro-intestinal disorders of
infancy in their extreme expression furnish a precisely similar picture.
This  is natural enough,  since  all depend alike upon a similar cause,
failure of proper performance of function on  the part of the viscera
in consequence of pathological alterations.
   The coryza of tbe syphilitic infant is, however, soon declared, and
speedily gives a clew  to the  nature of  the  morbid  process.  The
discharge from the  nares, at  first serous, later  purulent, desiccates
sufficiently to obstruct the nasal  passages, or, in consequence of the
tumid condition  of the membrane  lining the  latter,  is prevented
from escaping.  Often it is furnished by mucous patches forming on
the Schneideriau membrane.   At times, crusts form so as to accumu-
late  externally about  the nasal  orifices, aud then  are seen to be
similar to those M'hich are apt to form also at the angles of the mouth.
In this way the characteristic " snuffles " of the syphilitic infant  is
induced, in  consequence  of which it is obliged when nursing to release
the nipple  from  its mouth, in  order to respire, an act  often accom-
panied by a hoarse cry.   The breathing of such an infant, eveu when
asleep, or awake  and  undisturbed, is always  sufficient to arouse a
suspicion as to the nature of  the disease from M'hich it is  suffering.
The mouth, larynx, vulva, and  anus are often the seat of similar
lesions, whose development into an obstructive tumefaction secreting
more or  less profusely, or into moist condylomata, will depend largely
upon the seat and surroundings of the lesion.
   The cutaneous symptoms of the disorder, presented  usually at  or
about this time, are macular, papular, pustular, bullous, or furuncular
two or more of them being at times commingled, attesting thus the 
SYPHILODERMA.
523
identity  of the disease with the  polymorphic  acquired  forms  of
maturer  years.  Maculse  are early to appear  upon the  trunk, face,
and  extremities, usually  of a livid reddish hue, commingled with
papules,  and indeed often occurring as the first manifestation  of  the
latter.   They are irregular as to  shape, and though occasionally
pinkish,  discrete, circinate, and coffee-bean  sized, often constitute a
diffuse, coppery-red, or violaceous, glazed,  or moist  and secreting
surface, affecting an entire region, as the neck, the trunk, or  thighs
and genitalia.  Deep excoriations and even fissures occasionally form
in these  extensive patches, and the secretions  may incrust them irregu-
larly, the general aspect of the patch somewhat suggesting an ecze-
matous condition, yet remarkably differing from the latter in color.
   In hereditary as  iu acquired syphilis, the type  of all the eruptive
symptoms is to be sought in the papules M'hich may spring from  the
maculse described above, and develop into pustules, bullse, or condylo-
mata ; and, in the  former  case, dull red or  violaceous  papules of
lenticular size, occur either in asymmetrical  or  symmetrical arrange-
ment, discrete or agglomerated in patches of infiltration.   They may,
upon the buttocks especially, scale at the apex ; or, particularly, upon
the palms and soles, constitute, by fusion  a thickened desquamating
epidermal patch; or,  commonly  about the ano-geuital region,  the
intcrdigital spaces,  the  axillae aud  face, become moist, and secrete a
puriform mucus.   By vegetation  or hypertrophy, they develop  into
flat or fissured condylomata, smeared M'ith an offensive, yelloM'ish, or
yellowish-white discharge, and vary in size from a coin to a lesion an
inch or more in diameter, M'ith corresponding variation in the degree
of their  elevation from the surface.   The latter may be few or very
numerous.  Sometimes a child will appear to  be well nigh covered with
large, moist, secreting papules.   The author has  seen an infant with
snuffles and  macuhe of the trunk,  having but a single  condyloma of
the anal region.  Again, the papulo-condyloma may ulcerate deeply
and  crust.  It should  be remembered, in  studying these symptoms
from a verbal description, that  they are those  of a  cachectic infant
affected  with a grave disease.  Death often interrupts the sequence of
the manifestations here described.   This event is usually preceded by
the signs of apparent amelioration, shrinkage of hypertrophic growths,
and  decolorization of hyperaemic lesions and patches.   Of the other
cutaueous symptoms of hereditary syphilis, vesicles are  the rarest, the
smaller being occasionally seen, having a  couical  apex,  with  serous
contents, closely set together about the lips, and  springing  from a
violaceous infiltrated  patch.   The resulting crusts  never have  the
reddish-yellow tint of those observed  in eczema, nor,  after rupture,
are they* folio Med by serous oozing from a wounded epidermis.   The
larger lesions  of this  sort  are  usually transformations of papules
which rapidly assume a pustular phase.
   Pustular eruptions,  in this form of syphilis, may  be  discrete or
confluent,  localized  or generalized.   They  are particularly apt  to
occur  in groups about  the  mucous  outlets,  with maculo-papular
lesions developed elsewhere, aud may result in ulceration, often after 
524
DISEASES  OF  THE  SKIN.
development into bullse  M'ith pustular  or  sanious coutents.   The
resulting crusts are bulky and dark colored, and, especially upon the
face, disfiguriug.   The subjective sensations are probably insignifi-
cant, since the child does not attempt to tear the surface, as iu pustular
eczema.  The cachectic condition  of the little  patient,  M'hen  these
lesions are  large  and  numerous, is  usually pronounced.   They may
be seen in typical development  by the side of the  nail, occasionally
involving the  matrix,  and  productive, in  this situation, of con-
siderable swelling of the digit, with an ulcerative sequel,  which com-
monly results in  distortion, and  ultimate loss, of the nail-substance.
Onychia, however, may result from perverted nutrition of the part,
with increase in  its friability, loss  of  lustre, assumption  of a  dirty
grayish hue, aud  phalangeal  oedema.   These changes  are analogous
to those  resulting in  loss of the hair  where the follicles have  been
imperfectly  nourished.
   The furuncles which form in  other cases are exaggerated manifes-
tations of the same pyogenic tendency in the skin of the infant, a
complication common  to syphilitic and other cachectic conditions in
young children.   They may be few or numerous,  and  are chiefly
characterized by their indolence,  the absence of laudable pus in their
contents, the ulcerative condition left after their evacuation, and  the
bluish or purplish condition of the  integument  which  surrounds
their edges.
   Bullse in  hereditary syphilis are early or late manifestations of the
disease, aud  may be represented by a  single lesion  on the palm or
soles  (the site of their  predilection),  or constitute a symmetrical
generalized  efflorescence.   They  should be regarded as evidences of
a  grave  form of the  disease, being often the precursors of a  fatal
issue, as indicating a feeble resistance on the part of the epidermis to
the fluid exudate furnished  from the  corium  beneath.   In severe
cases, the bullse are ill developed, and  the  integument will be seen
to be marked here and there by small  coin sized  aud larger disks or
plaques of macerated epidermis,  separated from  the derma by a thin
film of serous, sanious, or purulent fluid, in quantity insufficient to
raise the roof above the general level of the integument.   When fully
developed, there may be conical, rounded, flat, or quite flaccid, and sur-
rounded  by an infiltrated border of dark reddish or violaceous hue.
Their color  varies M'ith the color of their contents.   Their subsequent
career  is concluded by shallow or deep ulceration, the base secreting
a  sanious discharge.   Crusts may  form  if the  patient survive.   A
fatal termination  of the disease  is usually announced by their flat-
tening or collapse.  They may be commingled with pustules  and
maculo-papules, condylomata, mucous  patches of  the anus, mouth,
and nares, but are somewhat different from the other lesions described
in  this, that they may  constitute  a uniform efflorescence, no  other
cutaneous symptoms being manifested.   This is explained by the fact
to M'hich attention  has been directed, that they represent  the state of
feeblest resistance in the epidermis, the fluid exudate of exceedingly
low grade mechanically separating the rete from the tissues beneath. 
SYPHILODERMA.
525
   Tubercles and subcutaneous  gummata  may develop  in  hereditary
syphilis, but are  usually  late manifestations of the disease,  one or
more years  elapsing  before  their  appearance.   Their behavior  is
scarcely different  from that of those observed in the  acquired forms,
although  the destruction M'rought by their degeneration in verv late
mauifestatious  may be of the most  intractable type.  Usually'there
is a preceding history of parental or inherited disease, and coincident
symptoms or sequelae of such, in the  altered  teeth,  described  by
Hutchinson, of London, in an ancient keratitis, or iu a hopeless form
of surdity.
   Mucous patches  are very  constant symptoms of the disease, and
represent  papules of the mucous membrane,  M'hich differ from those
seen  in the skin only  because they are moistened, macerated, and
flattened  by juxtaposition of  neighboring tissues.  They are sur-
rounded u.sually by a  lurid halo, and may have the pearly whiteness
always  seen M'hen the epidermis  of  mucous  membranes is detached
wholly or partly from the corium ; or may lose this protecting disk
in  shreds  or patches, and show, beneath, an engorged,  or  ulcerated
and secreting tissue.  They  may  be isolated or broadly  confluent;
aud oval, circular,  or decidedly linear  in  shape; the last  named
appearance being characteristic of those existing at the  angles of the
mouth.
   They are to be recognized  as distinct from both the  parasitic and
non-parasitic forms  of simple stomatitis or thrush, the  former being
due to  the presence of the  o'idium  albicans.  In  both of the  non-
syphilitic disorders, the  mouth of the child will be seen to be very
generally, uniformly,  and symmetrically  involved, the circumscribed
patches being distinctly discrete and  resembling iu color, soft M'hitish
or yellowish flocculi of  curdled milk.   The  diagnosis  is ahvays
greatly aided by noticing the  well-nigh constant occurrence of patches
just at  the angles of  the syphilitic mouth, M'hich latter has also the
seamed and puckered appearauce described above.  Snuffles, syphilo-
dermata,  and marked cachexia, when established,  will leave  little
doubt as to the  nature of the malady.
   The  future of the  infant  affected M'ith hereditary syphilis is not
ahvays  as dark  as might be gathered from what  has preceded.   In
this, as in the  acquired form of the disease, beniguancy  may  be a
conspicuous  feature of the entire  process.  The  evolution of the
disease  may be tardy;  its symptoms few and unimportant; its amena-
bility to judicious treatment  speedily demonstrated. Still, the fact
remains,  that the disease M'hen inherited is far graver than  M'hen
acquired,  the victim entering the world  with its  viscera and  bones
liable to profound pathological alterations.

   Etiology.—Syphilis, in the course  of  M'hich  appear  the syphilo-
dermata,  is produced  invariably either  by  infectiou,  accidental  or
intentional, or by the obscure influences  of heredity.  The methods
of transmission  may be immediate as in sexual congress, kissing, and
nursing at the nipple, by which act the child may infect  the  nurse 
526
DISEASES OF THE  SKIN.
with the secretion of the mucous patches in its mouth, or may, instead,
receive  the disease from the excoriations on the breast of the lattre.
Or the disorder may result  from the medium of utensils charged
with an  infectious secretion, such as the needles of the tattooer wet
with  saliva commingled  with diseased mucus, or  the lancet  of the
vaccinator covered with an  intoxicated blood.   Generally it may be
said that all the discharging and moist syphilodermata are sources of
danger  to  a  sound individual, both in the acquired and  inherited
forms of the disease.   By these and other  similar methods, persons
of both sexes, and of all ages, may become infected.
   However begotten, the syphilodermata are yet not excluded from
subjection  to  the long list of external irritants which  may in turn
annoy the skin.   The influence of a hot bath,  or the excitement and
perspiration of the dance, will often invite to  the surface a macular
syphilide which  might otherwise be  less fully developed;  and fric-
tion, as by the hat-band over  the forehead,  the cuff' at the wrist, and
the shoe over the foot, demonstrates its influence by daily examples
of determination of the morbid process to special localities.  The same
may be said of filth, such as the feces on the napkin of the infant which
frequently provoke in this region the vegetation of condylomata.  It
is a mistake to suppose that syphilis, and syphilis only, is responsible
for the exanthemata of that disease in all shades, grades, aud situa-
tions.   Soap and water are  as efficient in preserving the skin  of the
syphilitic as  of the  sound; and the  infected tobacco-chewer  pays a
price for his nauseous habit.  Poverty, misery, aud wilful neglect or
ignorance of the laM.s  of hygiene,  are  responsible for a  long and
lengthening list  of the complications of the disease.
   Pathology.—The pathological anatomy of syphilis and the syphilo-
dermata has been carefully  studied by a large number of observers,
including VirchoM', AVagner, Cornil and Ranvier, Neumann, Auspitz,
and Biesiadecki.  It must  be admitted that the result, even though
it present a fair  picture of the pathological appearances exhibited  by
the several lesions subjected  to examination, is yet far from furnishing
an explanation of the nature and peculiarly capricious career  of the
disease.  Without  stopping  to consider,  much  less  discuss, the
numerous  conflicting  theories  respecting  the nature  of syphilis,
which the investigations of  the eminent authors named  have not yet
succeeded  in  either disproving or  establishing,  it  can  be  merely
asserted  to-day that  the solution of  this important question has not
yet been  reached.  Under  the microscope, it  can be clearly deter-
mined merely, that the recognized  processes of hyperaemia, exudation,
hypertrophy, new growth, and degeneration (caseous,  fatty, amyloid,
atrophic, and  necrotic) occur  in syphilis  as in some other disorders
with cutaneous  lesions; that  the  specific character of the disease is
not betrayed by any specificity of  elements or of their arrangement;
and yet that every pathological process of syphilis  bears the imprint
of the malady whose influence it  acknowledges.   Here is a  lesson
certainly confirmed by clinical facts.   With the possible exception of 
SYPHILODERMA.
527
the gumma, there are no  cutaneous  lesions of syphilis  M'hich are
peculiar to itself, aud  yet there are certain  modes  of  behavior by
which each, M'hen carefully studied, betrays its identity.  It is then
by the modality rather than by any essential character of the syphi-
litic process, that it is to be  differentiated from all others.
  The papule, the  tubercle,  and  the  gumma may  be  regarded as
typical  pathological developments of the disease, as they certainly
constitute the basis of its common and  important cutaueous manifes-
tations.  One of them indeed, the gumma, may develop  in any organ
of the body other than the skin.   Under the microscope, these lesions
are seen to be  made  up of  a  new growth M'hose numerous, small,
rounded, or spindle-shaped elements, whether derived from connective
tissue or outwandered  leucocytes or both, and M'hether found, as they
may  be, in the rete,  the corium, or  the subcutaneous tissue, very
probably represent transformation of protoplasm previously existing,
or  resulting  from  embryonal  metamorphosis of such  preexisting
elements.  Kaposi well  summarizes the  chief peculiarities  of this
new  growth,  by remarking:   First, that  its elements are distinctly
circumscribed and homogeneous, differing, the minutest papule from
the largest tubercle, only in respect to volume; second,  that they are
inapt for permanent organization, but retrograde and disappear either
by resorption or by suppuration ; third, that they are remarkable for
their tendency to coincident  evolution  and involution, usually in  a
centrifugal direction, the younger  peripheral portions presenting the
characters of recent infiltration, M'hile  the  more aucieut  situated at
the pathological centre, are earliest to disappear.
   This new growth naturally plays a more important  part  in some
lesions than in others.   Scarcely discernible in the hyperaemia of the
 macular lesions, and well defined  in the papule and  its  modifications
(the  tubercle, the condyloma, and  the forming gumma), it is repre-
sented  in  the vesicle, pustule,  bulla,  and degenerating gumma by
either a fluid exudate composed of granular, cloudy, aud nucleated
elements, or by a soft, succulent, grayish, or grayish-red  homogeneous
mass, yielding a scanty juice, and  not yet completely transformed by
degeneration to the fluid condition.  Beneath and about any  of these
 last-named lesions, the circumscribed  new growth may lay a  founda-
tion  or erect a Mall, M'hich  unmistakably asserts the  unity of all such
 processes.
   Viewed  comprehensively, the multiform developments   of  the
syphilitic  new growth  are seen to be incontestable more  rapid of
evolution  and involution  than, in their  average  career, are all the
 neoplasmata.   Sarcoma alone competes with it in this regard.   Lepra,
 lupus erythematosus,  lupus vulgaris, keloid, xanthoma, and the large
 majority of all forms of epithelioma outlive, as a rule, generations of
syphilodermata.   This relative rapidity of career has entailed upon
the disease its possibilities  in the direction  both  of benignancy aud
 malignancy.  Whether, as it may, it destroy life, or, as may also be
the case, it so slightly  interfere M'ith health as M'ell  nigh  to pass 
528
DISEASES  OF  THE  SKIN.
unnoticed, in either event the total period  of its activity is relatively
brief.
   The demonstration  of the bacillary origin of syphilis, as already
stated is uot  yet complete.   Every fact in its history, however, and
the recent advances in the  discovery of the part played  by micro-
organisms in the  production of other diseases, point unmistakably to
a parasitic origin of syphilis.   There is reasonable ground for believ-
ing to-day that the disease belongs to the class of infectious granulo-
mata, even if the conclusions of Lustgarteu and Doutrelepont be not
confirmed by further experiment, the crucial test' being a  series  of
productions of syphilis in unmistakably sound  individuals, by infec-
tion with a product of bacilli obtained by cultivation.
   Lustgarten first hardened  sections  of  syphilitic  lesions  (initial
chancres, papules,  and gummata) in  absolute  alcohol and colored
them in  a solution  of  gentian-violet for twelve  to twenty-four hours
at the ordinary temperature aud then for two hours at 104° F.  The
sections were  decolorized by repeated washings  in absolute alcohol, a
one and  one-half  per cent, aqueous solution of  the  permanganate of
potassium, and chemically pure sulphurous acid.
   It is claimed that by the  special method employed, the character-
istic organisms were always recognized in syphilitic and  never  in
non-syphilitic  lesions.   The  bacilli  were  never free  but  always
enclosed in cells of amoeboid movement, resembling lymphoid cells.
These bodies were straight,  curved, or irregularly bent in  rod-like
forms, averaging three and  one-half to four and three-tenths of a
micromillimetre in thickness.   Under  objectives of low power they
presented a  uniform smoothness with  occasional terminal  bulbous
expansions.  The surface, however, vieM'ed under  a  homogeneous
immersion lens, appeared irregularly undulating and slightly notched,
the  bacillus or rod-like appearance,  however, remaining  distinct.
Within each bacillus,  separated from each  other by  spaces of equal
length, were from two to four bright and colorless spores.
   More recently, hoM'ever, microorganisms, similar to those believed
to be the sources of syphilis, have been  discovered  in the  smegma
preputii and  other secretions obtained from the genital organs of
non-infected persons of both sexes, thus confirming the belief that the
specific bacterium of the.disease has uot been recognized.
   Diagnosis.—The syphilodermata are to be distinguished  from  all
other cutaueous eruptions by their general characteristics, and by the
features  peculiar to each lesion.   It must  not be forgotten, however,
that these lesions are not essentially different  in character from all
others, but  are to  be  recognized with  ease or difficulty, according as
they do  or do not betray the syphilitic expression.  No one, however
expert in diagnosis, can always trust himself to  recognize these special
features  by  a study of the eruption only, at a given moment of time.
Neither  iu respect to color, form, size, situation, disposition, or other
peculiarity, do  the syphilodermata  exhibit an absolute difference
from the non-syphilitic affections of the skin.   It is  therefore requi-
site in every case, to investigate in the fullest manner, the history of 
SYPHILODERMA.                    529
the disease, of all prior skin lesions, of a primary sclerosis (when
this  can be obtained), of adenopathy,  miscarriages, abortions, and
disorders  affecting other organs  of the body,  such as the  bones,
viscera, organs of sense, and the mucous surfaces.   Often a single
extra-cutaneous fact M'ill be a valuable aid in establishing the diagnosis
of syphilis.  An  "eczematous" infant, with  snuffles and a  hoarse
cry,  has been treated in vain by many a physician, otherwise capable
of making a  diagnosis, M'ho might have been given, a  clew to the
nature of the disease from which  the child was  suffering, if he had
taken the pains to inspect the anus and question the father in private.
   It is very necessary in this connection to lay stress upon the well-
known fact that every syphilitic patient  M'ith a disease  of the  skin
does not necessarily exhibit syphilodermata.   The course of the dis-
ease  is in many cases so protracted that  patients have ample  oppor-
tunities to contract other disorders, and their number is  larger than
is commonly supposed to be the case.   They suffer most often from
the medicamentous eruptions, especially those induced bv  the inges-
tion  of iodide of potassium (q. v.); are, like other  men and M'omen,
bitten  by bugs and lice; and suffer from  eczema, acne, psoriasis, and
other non-venereal disorders.  This is less true possibly of the inno-
cent victims of the disease than of those  guilty of sexual excesses  iu
and  out of the married state, many of the latter leading the most
disordered lives, and  exposing themselves  to the ordinary causes  of
disease to a degree not noted in other cases.
   It is ahvays necessary, therefore, in making a diagnosis in a case
supposed  to  be  syphilitic, first, to determine ah origine the  fact  of
syphilis, aud,  if that fact cannot be  indubitably determined, to  be
careful that the statements of the patient be not  allowed to bias the
judgment in pronouncing upon any eruption present;  second,  sup-
posing  that  such a  fact is established  by  clinical  proofs M'ithout
reserve, to determine whether the eruption present is produced by
the existing syphilis or some other externally or internally operating
cause; and if this last be determined, to be careful iu eliminating the
syphilitic influence from its operation.
   Ignored syphilis is usually severe; but it is  M'ithont  avail that
disorders of a different character are  treated by the  methods useful
in the former.   Thousands are annually so mistreated who might  be
spared  such a course.   The  frequent occurrence,  after a  suspicious
exposure, of a balanitis, an  attack of progenital  herpes,  uninfected
excoriations,  blennorrhagic  discharges, and even the appearance  of
molluscous tumors, Marts, and parasitic cutaneous disorders upon the
genital  region, is a source of alarm and of  fruitful error to the many
rather than to the few.
   On the other hand,  the diagnostician must be  ever on  the  alert  to
recognize the  symptoms of  the disease  in  those M'ho least suspect it.
Thus,  married women complaining of a " humor of the blood," men
M'ho have been  " over-heated, and broken  out M'ith  a rash," and a
long list of patients exhibiting upon their  persons  the symptoms  of
"salt  rheum," "tetter," "scrofulous ulcers," and  "erysipelas" are
                                 34 
530
DISEASES OF THE  SKIN.
 those whose speedy relief will depend upon the skill of the practi-
 tioner in recognizing exactly the precise nature of the malady.
   The diagnosis of the syphilitic lesions of the skin is a matter of
 the very greatest importance, inasmuch as the health, comfort, mental
 happiness, and domestic relations of thousands of  men  and  women
 annually depend  upon  it alone.   An error  in  either direction may
 involve the most serious consequences to both physician and patient.
 He is  but  poorly qualified  to  discharge the important duties of a
 general practitioner  of  medicine who has not carefully trained him-
 self to establish the  truth in these cases, irrespective of the diagnosis
 of the  patient, and of all others M'ho may have been consulted.
   Treatment.—The syphilodermata are to be treated by topical appli-
 cations intended to hasten  their disappearance or involution, but  as
 local manifestations of a constitutional disease, their management  is
 largely that which looks to the  relief of  the latter.
   The  treatment  of syphilis M'ill,   in the  pages  M'hich follow,  be
 described iu outline, so  far as it relates to the relief  of the cutaneous
 lesions  aud of the systemic condition.   The important modifications
 of therapy  which are required in the management of syphilis of the
 osseous aud nervous  system, of the respiratory, gastro-intestinal, and
 other organs, it  is scarcely necessary to remark, are fully described
 in the standard  treatises specially devoted to this subject.   Among
 them may be named, as of American authorship, the sterling works
 of Bumstead and Taylor j1 of Van Buren aud Keyes,2 aud of E.  L.
 Keyes.3  Of those more or  less recently published abroad may be
named the standard treatises of  Lancereaux f of Jullien  f of Four-
 nier ;6  of Diday and Doyon ;7 of Zeissl ;8  and of Mauriac.6
   The  first and  often the  most important consideration for the prac-
 titioner  who is in face of a syphilitic  patient  is  the  care of that
 patient's general  health.   Simple and  natural as  it may be to set
 dowu such an injunction in this connection, its importance rests upon
 the fact that  it is too  often neglected.    Patient and physician are
often respectively hurried into the precipitate ordering and swallowing
 of specific drugs, without regard to other as important details.
   The author is in the habit of hauding to the patient,  at the outset
of all treatment for syphilis, a slip of paper on which are printed in
concise and simple terms  a set of rules  which  should  be  observed
during  its continuance.  For physicians who do not take  similar pre-
cautions, it  is advisable  to  enter rather fully into the explanation of
certain  details which the patient should be made to understand.
   He  or she, if an adult,  should,  as a rule, be  informed of the
nature of the disease recognized, since every infected patient  has  an
interest in knowing such fact, and it has  an important bearing upon

 1 The Pathology and Treatment of Venereal Diseases, Philadelphia, 1883.
 2 A Practical Treatise on the Surgical Diseases of the Geiiito-urinary Organs, including Svnhilis.
New York, 1874.                                                         '
 3 The Venereal Diseases, etc., New York, 1880.
 1 Traite Uistorique et Pratique sur la Syphilis, Paris, 1874.
 6 Traite Pratique des Maladies Venerienues, Paris, 1886.
 6 Lecotis sur la Syphilis, etc., Paris, 187:1.  La Syph.  Hered. tard., 1886.
 7 Tlierapentique des Maladies Venerienues. Palis, 1876
 9 Lehrbuch der Syphilis, etc., Stuttgart, 1875.    9 Lecons sur les Malad. Vener., Paris, 1883. 
SYPHILODERMA.
531
his or her relations to the uninfected.   To  every such  person, with
the assurance that the  disease is often benign, and productive  of
little discomfort, and in any case curable, it should be stated that the
affection is contagious, and  capable of transmission to sound persons
by physical contacts of various characters.   The patient should  be
instructed as to the nutritious  character of the diet he should select,
and  should be informed that  an increase in weight, M'hile subjected
to treatment, is decidedly favorable in the matter of prognosis;  that
the starving and sweating  processes so  highly esteemed by the char-
latan and the advocate of the virtues of the Maters of certain resorts
are relics of antiquity, as useless  in fact as they are  frequent sources
of peril.
   The bathing of the body is  a matter of importance.  Hot Turkish
and  Russian baths  are, as a rule, to be interdicted, inasmuch as they
tend to invite cutaueous hyperaemia, and thus to favor the occurrence
of eruptions.  Cool or tepid baths are to be employed sufficiently
often for the purposes of cleanliness, and by the sponge rather than
by immersion.   Dry friction  of  the surface of the  body daily may
be ordered M'ith advantage  M'here the skin is still sound.   The teeth,
mouth, and gums require constant care.   The use of the tooth-brush
with cool M'ater twice daily is a matter of importance, to be preceded
for a time, M'hen the gums  at  the outset are in a tender, fungous, or
hsemorrhagic state, by gentle  friction M'ith  the  finger, covered  by a
handkerchief dipped in a weak spirit-and-water  lotion, to which the
tincture of cinchona and of myrrh may be added in any desired pro-
portion.   Tobacco in every form is, without any question, decidedly
injurious.   Often  the patient should  be sent early to a competent
dentist for the extraction or filling of carious teeth, and the removal
by the file or dental engine of all sharp projecting edges.
   Malt  liquors. Mines, and spirits should be employed solely under
the explicit direction of the physician.   They are exceedingly useful
in debilitated subjects of a certain class,  and need  not  be  unneces-
sarily  prohibited in toto to those long habituated to their  use.   At
the same time, an  improper  use  of such stimulants  is, it  need not
be  said, in the highest  degree harmful.   When employed at all,
they should be rigidly restricted to the dining-table aud  the hours of
meals.
   A compliance M'ith the laM'S of hygiene is even more  requisite  for
the syphilitic than  the non-infected.   Fresh  air, social  amusements,
exercise,  the regular routine of business  life,  or, M'hen  this  has
proved exhausting, the  recreation of travel—the claims of all these
need at times to be urged  by the physician.   With this the patient
should  be encouraged to free  his  or  her mind from needless anxiety,
and to avoid  particularly  the company  and conversation of those
similarly infected, whose opinions are based too often upon ignorance,
or a knoM'ledge of half truths.   The  literature  of syphilis is,  for a
similar reason, to be eschewed, as the mass of patients, too many of
whom purchase treatises on the subject,  are able only to glean imper-
fectly the meaning of the authors consulted. 
532
DISEASES  OF  THE  SKIN.
  It should be a rule to urge married  patients frankly to inform the
partner, of the fact  of infection, for the  sake of both.   When this
advice is followed, much trouble is avoided for the future, and  one
of the obstacles to a completely favorable issue is at once set aside.
In the author's professional experience, many instances have occurred
in which the disruption of the conjugal bond resulted from infection
of one, but usually of both parties; but it is a striking argument in
favor of  the  policy here urged, that in this entire experience there
has been no single instance in which a frank and honorable  confes-
sion has been folloMed  by such a  consequence.   It should be added
that in no one of the " confessed" cases  has there beeu  subsequent
infection of the innocent,    It need scarcely be said  that the larger
number of these patients  have  been  husbands.   Recently infected
young adults M'ho have contracted a marriage engagement should
invariably claim release  from such a tie for  the sake  of all con-
cerned.   The syphilitic nurse must be taken at once  from the sound
nursling, and the child with hereditary syphilis be suckled only by
its  own  mother.   The  latter, according to  the law of Colics  the
exceptions to which  arc so few  as to  prove the rule, ahvays enjoys
immunity against the diseased mouth of her own child.
  Turning  to  the  consideration  of the  medicaments  employed in
syphilis,  it is to be remarked at the outset  that there is  no  routine
plan  of  treatment  M'hich  in  every  case  can be  advantageously
employed.   In  no respect  do physicians  so differ from  each other,
judged by the standard of  professional skill,  as in their ability to use
a single remedy M'ith success.   He who  has the largest armament-
arium is  not  ahvays  either  the best equipped or the most  successful.
Mercury, iodide of potassium, iron, and quiuine are the great reme-
dial agents in syphilis, but they  may also  be used vainly by one man
in the long effort to  accomplish that M'hich another achieves speedily
aud brilliantly by use of the same remedies, employed with greater
skill.
  Of the other substances  vaunted as either advantageous or specific
in the treatment of the disease, no one possesses any  claim m hatever
to the confidence  of physicians.   Sarsaparilla, dulcamara, stillingia,
guiacum, tayuya, mezereou, and the long list of other vegetable pre-
parations whose virtues have thus  beeu extolled, are all  as harmless
in themselves as they are ineffectual for the relief of the malady.
  Before  proceeding, however,  to  assume  the responsibility of
directing a course of treatment for syphilis with remedies of acknoM'l-
edged  value, the physician M'ill  do M'ell  to  remember that  no  tMO
cases of the disease are precisely similar, and that there is the widest
range  betM'een  the  most  benignant  forms  encountered  in  private
practice  and the malignant cases that are  seen in  hospital Mards.
Some forms of the malady are so absolutely mild as to constitute an
inconvenience merely; others so severe as  to destroy life.   It is an
axiom in venereal disease,  that more patients  perish annually from
blennorrhagia and its results, than from  syphilis.  There could be 
SYPHILODERMA.
533
 no greater error than to treat any disease exhibiting so wide a vari-
 ation in severity, by a uniform method.
   Mercury, after  the  assaults upon it of generations of  men  of
 admitted wisdom and candor, stands to-day unrivalled as a  remedy
 for the relief particularly of those stages of syphilis in which the skin
 is involved.   Administered M'ith skill, it can be giveu for years at a
 time with immense advantage  to  the syphilitic, who, during a well-
 regulated mercurial course, should gain  in weight, improve in vigor,
 and exhibit a healthier color of the skin.   No competent physician
 of to-day employs it in such a manner as to induce salivation or any
 other of its toxic  effects.  During  the  last twenty years the author
 has had the opportunity not merely of making large use of this drug
 in  his  own practice, but  of seeing  many patients  treated by other
 physicians in  a similar way.  Iu about a dozen cases  there Mere
 excessive toxic effects of the remedy, and in each the carelessness or
 ignorance of the prescriber Mas responsible for the result.  It should
 be remembered that in  every discussion  of the merits of  mercury in
 syphilis, both physicians and patients have been  guilty of the ignor-
 ance or folly of ascribing  to the remedy the disastrous  effects of the
 disease.
   Mercury may be given by the  mouth, by inunction, by subcu-
 taneous injection, or externally by the aid of the vapor bath.   Decid-
 edly the most popular method, and that productive  of least inconve-
 nience to all concerned, is the method by ingestion.
   In the treatment of syphilis, the mild chloride, corrosive sublimate,
 and bicyauide of mercury, together with blue mass, may be effectively
 employed.  These preparations are, however, rather less adapted than
 others for continued employment during long periods of time, aud
 are open to the objection of either readily undergoing rearrangement
 into more stable compounds  of the metal, or of producing undesirable
 irritative effects.   With the protiodide and biniodide of mercury, an
 impression can be produced upon the system  M'hich can  be readily
 proportioned to the  exigencies arising  in  every case, which  can  be
 sustained during that "chronic medication" which Founder declares
 to be  requisite in every chronic disease, and which can be  exerted
 without fear of immediate  or remote deleterious consequences.
   Treatment of syphilis by the mercurial selected for use should, as
 a rule, be begun only at the  moment of evolution  of constitutional
 symptoms.  The initial sclerosis of  the disease is, to a  remarkable
 extent, amenable to the action of the  metal, but in the  large propor-
 tion of cases  will cicatrize,  when in  au  ulcerative stage, without
 having recourse  to  general medication.   The latter  may  be well
 reserved, as suggested  by Bumstead  and Taylor, for such primary
 lesions as are threatening in  symptoms, and for  such individuals as
 require or demand  speedy  cicatrization  of their  chancres, as, for
example, those about to travel beyond the reach of medical assistance.
 Personal experience fully confirms the M'isdom  of the teaching M'hich
reserves specific medication till the second  period of incubation has
 passed.   No local or general treatment can avert either a  mild or 
534
DISEASES OF THE SKIN.
severe explosion of symptoms after that period is completed.  In the
experiments made by the  author, in order to  determine this point,
there M'as either the production of strikingly  irritative effects, such as
very marked relapse, or unusual increase in the volume of the initial
sclerosis immediately before the evolution of the first syphilodermata,
or a distinct obstinacy in the latter  to the action of the medicament
employed.
   In the early stages of syphilis in adults, the protiodide of mercury
may be named as one of  the most trustworthy of preparations.   Of
all classes  of  adult  patients,  including strong males  and  delicate
females, there are  scarcely tMO per  cent, who  cannot  take  it, if the
dose be proportioned to the  individual susceptibility.   It  is  usually
administered iu pill form,  in  doses  of one-fifth (0.01), one-fourth
(0.016), or  one-third (0.022) of a grain, three  times daily,  combined
with the extract of gentian.   The  dose maybe gradually  increased,
according to the necessities of the case, from one-half (0.032)  to three
(0.266), and even  four  (0.332) grains  in the  twenty-four hours.
Many of the gelatine-coated pills found in the market contain accu-
rately divided doses of the salt.  The sugar-coated  pills of  Messrs.
Gamier and Lamoureux, containing  each  one centigramme of the
protiodide,  are efficient, and largely employed.
   Commencing with a minimum dose, the  remedy is to be steadily
exhibited, and  the daily quantity consumed very gradually  increased,
till the degree of tolerance of which the patient is  capable  has  been
ascertained.  Should the stools become frequent, pain be excited, or a
slight effect be produced upon  the mouth, such as is indicated by a
metallic taste,  moderate  increase in the quantity  of saliva, or  any
noticeable degree of tenderness  of the gums, the dosage is to be grad-
ually  diminished  till these symptoms disappear.   Often  the with-
drawal of a fifth (0.01) or a half (0.032) of a grain daily, will suffice
to enable the patient  to tolerate the quantity thus diminished.   The
medication  is  to be  faithfully continued till  the  object in  view is
obtained, viz.,  relief of all symptoms of the disease.
   Keyes's  mell-known,  so-called "tonic treatment of syphilis" is
based  largely upon the plan M'hose outline is merely sketched above.
By the method which this author  has certainly  popularized,  the
dosage is increased only  on  each third or fourth day, till  irritative
effects are produced, when, after an  interval of two days, the quantity
taken  at the time of the production  of such effects is reduced one-half
to one-third.  This reduced quantity is termed the "tonic dose," and
is thereafter continued throughout the treatment in "nearly all condi-
tions of health  or disease."1
   This method of treatment is  in many cases admirably effective and
is eminently safe.   Still,  viewing the  subject with the conservatism
M'hich its importance  justifies  and M'hich a  mass  of clinical facts
demands, it may be well doubted  whether  it is ahvays   proper to
administer a mercurial  for weeks at a time  to a man iu apparently

  1 Consult the interesting paper of the author in the American Journal of  the Med.  Sci., January,
1876; also his latest exposition of his views in the Philada. Med. Times, November 2b, 1882, p. 3_)7. 
SYPHILODERMA.
535
good health.   With the active measures at immediate control  in  the
mercurial vapor bath, it'is usually safe and not unwise to suspend tem-
porarily specific medication of the patient mIio exhibits such ameliora-
tion of symptoms as to be free from  external  manifestations of  the
disease.  Every syphilis has its periods of activity aud  repose.   Such
an  hour of repose will be well employed in the administration of iron,
which, as tending to relieve the distinct chloro-ansemiaof the disease,
has its claims to recognition in  the  list of " specific" remedies.   No
case of syphilis  can be  said to have been  properly treated, in  M'hich
this remedy has not been given for at  least a part of the time during
which the patient M'as under  observation.   The citrate of iron and
quinia is an excellent preparation  for  this purpose, administered at
the meal hours, in  a small  quantity of sound sherry wine;  or  the
iodide of iron may be employed in syrup, or in the pills made by the
formula of  Blancard, or  in Vallet's mass.  In  other  cases,  the
muriated tincture may be employed, but the physician M'ill always be
cautious about ordering an acid preparation of  any kind during  the
intervals of a mercurial course.  There is no form of anaemia  which
responds more promptly to the chalybeates than does that produced
by  the syphilitic virus.
  The biniodide may  be substituted for the protiodide  M'hen, for any
reason, it may  be  thought desirable, commencing M'ith a  minimum
dose  of one sixty-fourth of  a grain   (0.001),  and  increasing this
gradually to one-fortieth (0.0016) or rarely to one-twentieth (0.0033),
either in pill or solution.   The average dose of one-fortieth (0.0016)
of  a  grain  in pill form, administered three  times daily, soon after
eating, is tolerated by  the  majority   of all  patients  of  both sexes
M'ithout consciousness of  unpleasant effects.
  For those who prefer to use the rather more active and correspond-
ingly dangerous salts of  the  metal, calomel may be  administered in
one or two  grain doses (0.066-0.133) three times daily, in combina-
tion with an opiate to prevent its action on the bowels, or, as recom-
mended  by  Peters, in  one-tenth (0.0066) of a grain dose every hour.
Small doses of blue  mass or gray powder may also  be employed.
According  to the  traditions  of the profession, the  gray powder is
most   suitable  for children  and  infants, but since  the  frequent
discovery in the latter of the  corrosive chloride, either as  of early or
late chemical production, it is less esteemed.   The homoeopathic first
decimal  trituration  of calomel with  sugar of  milk, is  a far more
suitable  compound.   Corrosive sublimate in  doses  of  from one-
twentieth (0.0033) to  one-twelfth (0.005)  of a  grain is exhibited in
pill form or in solution; and is probably more generally employed in
the treatment of syphilis than any other mercurial salt.   The objec-
tions  to  its  use  are suggested above.   Though constantly employed
in  the public charities, M'here it is  furnished as  a cheap  and  a con-
venient  substitute  for the more elegant preparations in the market,
it is  much  less  frequently ordered for syphilitic  patients  in private
practice.  When given iu solution,  it produces a disagreeable metallic 
536
DISEASES  OF  THE  SKIN.
taste iii the mouth, which some patients can perceive after the lapse of
six hours.
   With many authors of M'ide experience, it is customary to employ
opium, either alone or in connection with the use of mercury, for the
relief of  ulcerative or other lesions  of syphilis.  Sometimes  it is
employed for the purpose of relieving pain, sometimes to prevent the
cathartic action of  the metal upon the bowels, and again because it is
supposed to possess some power of arrest over  the destructive action
of  the  disease.   It  should not,  as  a rule,  be  exhibited  M'hen by
reducing the mercurial or exchanging the latter for a ferruginous dose,
the same result can be reached.  Few syphilitic patients are in the end
brought to the desired termination of the disorder, by the  use  of a
remedy which interferes with assimilation and digestion;  and such a
remedy is opium  in all its  forms.   Temporary achantage is often
gained  by its employment, but tins may be more than counteracted
by  its ultimate effect  upon the gastro-intestinal tract.
  Mercury is also  satisfactorily introduced by the method of inunc-
tion.   The metal,  M'hen thus employed, is readily absorbed by  the
system, and its  therapeutic  value  is  no  less   evident.   Inunction
should be employed in every case which  admits of it, since the gastro-
intestinal tract is  thus left  undisturbed, and, further, the dose of any
needed chalybeate or  the iodide of potassium per os, can be regulated
without  increasing or diminishing the quantity of mercury in  daily
use.  Mercurial ointment  is commonly used  for this purpose, but a
much more  cleanly  substitute for it, is provided in  the oleate of
mercury in the strength of ten, fifteen, or twenty per cent.   There is
but  little  question that the  oleate also is  somewhat  more readily
absorbed  from the surface of the  skin.  Tbe ten per cent,  oleate is
in general to be  preferred to the stronger preparation, as  less liable
to irritate the surface of the skin.   From half a drachm to a drachm
(2.-4.) of either the ointment or  the  oleate can be rubbed  into the
skin at  night  before retiring, and the part selected  for inunction
cleansed by Mashing in the morning.  Both, if continuously applied
to a single portion of the skin, are liable  to produce a  mild  local
dermatitis or eczema, and hence it  is  wise to select  on successive
evenings  a fresh portion  of integument  for the local application,
preferably that where the epidermis is relatively thin, as, for example,
the flexor aspects  of the joints.  The  patient  can thus upon one
evening anoint the internal  faces of the thighs; upon  the next, the
sides of the  chest;  upon another, the  loins,   etc.,  taking  care to
avoid surfaces where  an induced eczema is likely to prove especially
annoying,  such as  the scrotum, the axillae,  aud  the  groins.   The
oleate  may in some cases  be well rubbed  into  the soles of the feet
previously soaked in  warm water, after which the socks or stockings
may be drawn over the feet for the night.  In the case of infants, the
inunction is well  performed by the natural movements of the child,
if a flannel  swathing-band  previously  smeared with  the oleate be
wrapped about its belly, so that the mercurial comes in contact M'ith
the  skin.   Should local  irritative effects be produced, these subside 
SYPHILODERMA.
537
rapidly, as a  rule, after a warm alkaline ablution  followed M'ith a
bland dusting powder.  Subsequently or  even before such accideut
in the case of infants or patients having unusually sensitive skins, the
oleate  may be mixed M'ith equal  parts of  vaseline, lard, or olive oil.
As some patients become disgusted with this routine, it is  well at the
onset to flavor  the substance  selected for inunction  with lavender,
rosemary, or bergamot.
   In this country too little attention  has been attracted to the treat-
ment of syphilis by mercurial inunction.   With this in view the pre-
ceding  paragraphs which describe the use of mercury by  the  mouth
arc to be understood as related in all cases to the employment of the
metal by the skin.  It is well to order inunction  in all  practicable
cases;  to save the stomach as much  as possible; to continue M'ith the
oleate  nightly, Meekly, or less frequently so long  as  there is danger
of  relapse; and to adjust  carefully  tbe  quantity  employed  to the
exigencies of every case.  In  this manner patients may be relieved
of  all  symptoms of the disease M'ho have not during  their treatment
sMallowed a  single dose of mercury,  and the permanency of M'hose
relief may be tested during years of subsequent observation.
   One  of the most  effective methods of administering the metal is
by fumigation, in the mercurial vapor  bath.  It is employed by many
svphilologists as the sole means of exhibiting the mercurial selected
for use, but is, for the average of American patients, too inconvenient
for continuous employment.   It should be regularly  employed  first,
in all cases where the earliest syphilodermata are intense, generalized,
and particularly conspicuous  upon  the face;  second, in  all obstinate
cases where  the patients  are  not  women nor cachectic  subjects  of
either sex ; third, at the outset of many  "ignored" cases, where the
syphilodermata, either more or less generalized, have proceeded to unin-
terrupted evolution; fourth, in  the severe cases  of patients coming
from the country  to  the city, and  able to remain  but  a  brief time
within  reach of the  advantages  offered in the metropolitan  centres.
From half a drachm to a drachm (2.-4.) of calomel,  metallic mercury,
the bisulphuret, the black oxide, or the  hydrargyrum cum creta may
be employed  for  each  bath.   It is common  to order from a scruple
to  a drachm each (1.-4.) of calomel  and cinnabar.  The patient is
stripped of his  clothing and seated in a chair, the patient and chair
being  completely enveloped in  blankets, which are closely fasteued
at the neck of the bather.   Beneath the chair is an alcohol lamp, sur-
mounted by  a tin vessel containing  M'ater in ebullition, the hot vapor
of M'hich in a few moments induces  copious perspiration.   When this
result is obtained, the lamp is brought  beneath a metal plate containing
the substance to be volatilized.   The  patient remains exposed to the
vapor about ten minutes after this process of sublimation  is finished,
and retires at once to bed  M'ithout cleansing the skin, the  fumigation
being preferably conducted before the hour of sleep.   Iu the morning,
a bath may be taken for the purpose of cleanliness.   It is more con-
venient in the  generation of the vapor in this May,  to make use of
Mr. Henry Lea's safety fumigating lamp, but the materials requisite 
533
DISEASES  OF  THE SKIN.
for the production of all desired effects, with the exception of the
alcohol lamp, cau be procured  of any good tinsmith.   In the city,
male  patients are often  sent to the bath-houses, M'here the fumiga-
tion is conducted in  the daytime; and  rarely experience as  a con-
sequence unpleasant effects, such  as  are popularly associated  with
"taking cold" after exposure to the action of mercury.   In the most
of these  establishments,  provision is made so  that tbe head also can
be  exposed  to  the  mercurial   fumes,  respiration being  conducted
through a tube in connection with pure air, a provision useful in cer-
tain cases  of emergency; and  only " emergeucy cases"  should  be
required to resort to such measures.

                             Fig. (58.
Lea's lamp for fumigation.
  The happy effect of the mercurial  vapor bath is often marvellously
rapid.   A generalized syphiloderm  may  become well-nigh indistin-
guishable upon the surface after four baths at intervals of two  days
each.  With this potent agency at hand,  it can  be well  understood
how the skilled physician can afford to watch his  syphilitic patieut
from week to week, taking a dose of iron internally and employing
inunction externally, the few lesions  fading slowly  from the surface,
all fears quieted, and  the nutrition  sustained at a  high grade.   In
comparison with this combined method, the swallowing of blue mass,
or calomel and  opium, should  be regarded as a more  clumsy  and
dangerous procedure.
  The hypodermatic injection  of mercury, largely popularized  by
99941 
SYPHILODERMA.
539
Lewin,1 though very frequently employed in Europe in the treatment
of syphilis, is open to the serious objection of requiring the aid of the
physician  for  the administration  of each dose.   It is an efficient,
speed)-, and safe method, but will probably ahvays find largest favor
in the treatment  of patients in hospital, M'ho  are  there completely
subject to the orders of their medical  attendant.  At the site of the
injections, too, not rarely abscesses have formed.  One-twelfth (0.005)
or one-eighth of a grain (0.008) of corrosive  sublimate, dissolved in
ten or fifteen  minims of distilled Avater may be injected at a time, the
operation being repeated upon about twenty occasions.  Bamberger,
of Vienna, has reported  favorable results after  the injection of an
albuminate or a  peptone of mercury, thus attempting  to avoid the
danger of localized abscesses, and  insuring speedy absorption of the
metal.   All formulae, however, proposed for preparation of solutions
of this character have hitherto proved imperfect, both in consequence
of failure to obtain a pure mercuric albuminate, and also from failure
of permanency in the solution.   Staub's formula, the result of experi-
ments made by Hepp,2 may be taken as a sample of the rest :

            Hydrarg. chlorid. corros.  gr. xviij;            1125
            Ammon. chlorid.         gr. xviij;            l|2o
            Sod. chlorid.                 3j ;            4
            Aq. dest.                   f-iv;         128|      M.
         Dissolve, filter, and add the white of one egg in distilled water suf-
          ficient to make (128.) £iv;  fifteen minims of the solution contain
          about one-twelfth of a grain (0.005) of the sublimate.

   Ptyalism, stomatitis, fetor of the breath, or a fungous condition of
the gums with inappetence and other characteristic  symptoms of the
ill effects of mercury, including all  grades of gastro-intestinal disturb-
ance, arc rarely seen  in modern  practice, and  should  never be  per-
mitted to occur in a properly regulated mercurial  course.  When  they
are produced, the tongue projected  from the mouth is usually tumid,
and  exhibits at its lateral borders the imprints  of the  inner faces of
the molar teeth.   Its surface is also covered in various degrees  M'ith
a thin, dirty-grayish coat; and the  odor of the breath is  peculiarly
offensive, being  often  noticeable at a  distance of several feet from
the patient,   hi such cases, the food should be liquid and nutritious;
hot and cold drinks alike should  be scrupulously avoided;  and the
mouth frequently cleansed M'ith washes containing dilute liquor sodse
chlorinatae, or the chlorate of potassium, or very M-eak carbolic  acid
in solution.   Internally, the citrate of iron and quinia  may be often
used with  advantage;  and,  in  particularly severe cases, the  chlorate
of potassium to the extent of a drachm (4.) daily.  The compressed
tablets of this salt, each containing  five grains (0.33), are available
for this purpose, being slowly dissolved in the  mouth, the medicated
saliva  and  mucus being then well diffused  over the  inflamed buccal
membraue,  tongue, aud fauces.  The mercurial is to be suspended in

 ' Die Behanrllung dor Syphilis mit Subcutaner Sublimat-injection, Berlin, 1869 ; also translated by
PiusrliT and Gale, Phila., 1S72                        ,           .
 "- Tiaitement de la Syph. par les Inject. Hvpoderm. de Sublime.  These de Pans, 1872. 
540
DISEASES  OF  THE  SKIN.
all cases, and iced water to be interdicted, gangrene having followed
its use in a few cases.  In milder forms, the tincture  of myrrh and
of cinchona, diluted M'ith  sweetened water, or honey and water, will
be sufficient for local medication of the mouth.
  Iodine is chiefly employed in syphilis in the form of the iodide of
potassium.   It possesses  some value, without any question, in every
stage of syphilis, and is thus indiscriminately used  by many practi-
tioners.  Its value, however, in late secondary and tertiary, is incon-
testably greater than in the earlier lesions of the disease, and  its use
should be largely restricted to the particular periods in M'hich  these
manifestations appear.   Every  prudent physician will hesitate before
ordering, for a disease exhibiting  cutaneous lesions, a  remedy M'hich
will  positively produce  cutaneous  lesions in  the  majority of all
patients ingesting it.  In  this connection the reader will do well to
consult the  chapter  on  dermatitis  medicamentosa,  in  M'hich the
various eruptions produced by  this drug  are  recorded.  Thoughtful
men  are beginning, in the light of the present knoM'ledge upon this
subject, to ask, to what extent the syphilodermata have been in the
past  aggravated or obscured  by this  remedy.  He would be indeed
bold who would attempt to prove that the medicamentous  eruptions
thus excited have not, in the  past, figured  largely in the catalogue of
the syphilodermata.
  On the other hand, the value of the  remedy, properly adjusted to
the age and  other conditions of the disease, is more than incontestable,
it is  peerless  in its special field.   Whether giveu alone ; or  by the
so-called "mixed" treatment in combination with mercury; or admin-
istered internally while a  mercurial  is introduced by the skin ; or
exhibited, lastly, by alternation with  the metal, in each  it finds a
special value, aud may be simply indispensable.  It may be given in
doses of  from five grains (0.33) to a drachm (4.) three  or four  times
daily after eating, well diluted M'ith  M'ater.   The larger doses should
be invariably reached gradually ; should never be employed except
by special order of the physician, and when the patient is M'ithin easy
reach of the latter;  and should always be ordered with  the under-
standing that  the patient should diminish  or suspend treatment in
case  of unpleasant results.  The symptoms of iodism, other than the
production of cutaneous lesions, such as coryza, oedema of the  lids,
and  faucial irritation, are  apt to be the  result of the first  few  doses
ingested, and often bear no relation  to  the size of  the latter.   One
or two grains (0.66-0.133)  will, in  certain cases, be  sufficient to
produce  the most  disagreeable  effects which, if they  are observed
before  the remedy be suspended, may not return with even the largest
doses.  In a few cases, the iodide of potassium produces violent toxic
effects  in any dose, owing to  exceptional  idiosyncrasy.  The author
has  met with several such  cases, and has  had one  patient in  his
charge suffering from  an  ulcerative  tubercular syphiloderm of the
nose, who was quite unable to tolerate  the drug in any form.   Both
the chloride of ammonium and carbonate of ammonium  are recom-
mended  for  use  iu combination with  the  iodide  of potassium as 
SYPHILODERMA.
541
increasing  its efficiency.   The iodides of  sodium, ammonium, and
lithium possess also, M'ithout question, some influence over the disease,
but are for most cases less efficacious than the potassium salt.  Of the
three named above, the iodide of lithium is  apparently most prompt
in its effects.
   There is no combination  of mercury with the iodide of potassium
which  is employed more frequently than the well-known "sirop de
(Jibert," which though first popularized in the St. Louis Hospital, of
Paris,  has been since extensively employed in this country.  It has
been slightly modified to suit the varying  tastes of  many surgeons.
It is often ordered in the following: formula:
B. Hydrargyri biniodid.     gr. ss-ij ;
   Potass, iodid.           3'j-viij;        8-32
   Gentian, syrup, (vel  ]
     syrup, glycyrrhiz.)  >   aa 15ij;          64
   Aq. dest.            j
Dose.  A teaspoonful in water after eating.
033-.13
M.
   The syrup of liquorice disguises the taste of this combination better
than most of the other syrups used.  With the dosage carefully regu-
lated, a few drops (ten to fifteen) may be administered M'ith advantage
to children.
   The following are indications for the  use of the iodide of potassium
either alone or by the so-called "mixed" method in the treatment of
syphilodermata : The occurrence (1) of late, tubercular, gummatous,
or ulcerative lesions; (2) of formidable symptoms in other portions
of the  body concurrent m ith  early or late, mild or  severe  syphilo-
dermata, as, for  example,  grave ulcerations  of  the velum  or fauces
with a symmetrical  macular eruption, or coincidence of a generalized
pustular or papular syphiloderm  with hemiplegic, aphasic, ocular, or
renal complications; (3) of early  or late manifestations which either
assume the so-called "galloping" type, being rapidly  succeeded by
more and more formidable symptoms, or which exhibit the capricious-
ness of the disease in a reversal of the usual sequence of evolution, as,
for example, when  symptoms  usually  counted  as late phenomena,
occur M'ithin a few weeks after infection and are  folloMed by the early
symmetrical  rashes; (4) of early  or  late  symptoms  occurring in
cachectic, strumous,  or  otherwise  debilitated  patients.   The author
lias treated  eleven tuberculous patients infected with syphilis;  and
this experience has led to  the belief that in all such cases it is imper-
ative  to dispense M'ith  every  mercurial dose possible.  Mercury  is
assuredly not a tonic in tuberculosis commingled M'ith syphilis.
   The local treatment of the initial sclerosis of  syphilis by complete
excision, lately revived  by Auspitz, has been practised since the  date
of his  paper  in 1879,  by  Kolliker,  Zeissl,  Leloir, Chadzynski,
Mauriac,  and others ;T aud  the result  has proved conclusively  that
such operative  interference furnishes no bar  to  constitutional infec-
tion.   Chancres  should not  be destroyed by caustic agents of  any

               1 See Reyes's later communication  on this subject, 1. c. 
542
DISEASES  OF  THE  SKIN
character, as the latter are liable to induce either irritative or inflam-
matory effects M'hich  may be followed by denser induration.  Oint-
ments, as a rule, are also objectionable, exception being  made iu the
case of hsemorrhagic lesions when the removal of an adherent dressing
is followed by unpleasant consequences.   Cleanliness with soap and
water is of chief importance.   After each local  bath the parts may
be dusted with a  dry powder such  as iodoform, iodol, calomel, zinc
oxide,  hydronaphthol, or starch ;  or dressed with a soft piece of lint
saturated in the lotio nigra, or eveu better a spirit lotion containing
tanuin and carbolic or boric acid.  Opiated M'ashes may be  requisite
in all painful and  ulcerative lesions.  When a phagedaenic tendency
is displayed, deep  cauterization may be required; aud the subsequent
local employment  of solutions of the potassic permanganate, two to
ten  grains (0.133-0.666) to the ounce (32.) of water.
  When a primary venereal sore of any character (the initial  sclerosis
of syphilis or the  chancroid) actually falls into gangrene or  becomes
phagedasnic or, eveu iu the absence of both of these calamities, extends
rapidly in depth  or in superficial  area, cauterization  should not be
longer tried.   The most effectual treatment of these complications in
the  genital region, is by the employment of the continuous hot water
bath, aided  by antisepsis.  The patient  remains seated  in the bath
(the water being of the temperature most grateful to the surface and
with great care maintained at that degree  of  heat) throughout the
day, or, in formidable emergencies, if carefully  Matched, by  day and
night.   The bath  is left by  the  patient only  for  the purpose of
evacuating the  bladder or rectum.  Granulation  and repair  speedily
set in.   The parts are well dusted with iodoform or iodol, whenever
the  patient  leaves the M'ater.   By this invaluable means, the author,
in both  hospital  and private practice,  has  succeeded in obtaining
cicatrization of extensive ulcers which  had  reached over the peuis
halfway to  the pubic region.
  Local  treatment of tbe syphilodermata may be demanded, either
by reason of their  appearance on exposed surface, such as the face and
hands, or by reason of their obstinacy or threatening character, as
when they are ulcerating rapidly.   Macular and papular lesions of
the  face  may be treated by local applications of  the five per cent.
oleate ; mercurial  ointment, one to two  drachms (4.-8.) to the ounce
(32.) of cold cream or vaseline; the red  oxide, two to four grains
(U.133-0.266) to the ounce  (32.);  or the ammonio-chloride, half to
one scruple (0.666-1.33) to the ounce (32.) of ointment.  Lotions of
the  bichloride, oue to two grains (0.066-0.133) to  the ounce (32.) of
cologne, are also efficient.  These  preparations will  be found much
more valuable if used at night before retiring, and  left upon the face
during the hours of sleep.  Each is well preceded by hot  bathing of
the  face for several minutes, as  in  the  preparatory treatment of the
same region  in acne papulosa, and indeed the sulphur  preparations
employed for the relief of that disease, will at.times be found useful
also in the local treatment of the syphilodermata.
  The hot  ablution  is particularly useful in the treatment  of the 
SYPHILODERMA.
543
scaling and  frequently fissured  lesions of the palms and  soles, the
pain of M'hich  in severe cases, is greatly alleviated  by this treatment,
After the epidermis in these parts has been well macerated, the hands
or feet should be thoroughly dried, and the mercurial, tarry, or other
salve well rubbed  in.   The glove or stocking should be then drawn
over the part.
   Secreting  condylomata, flat papules, vegetations, etc., also require
bathing in soap and Mater, especially when situated at the mucous
outlets of the  body or on the scalp.  When the secretion is offensive
carbolic acid, thymol, or chlorinated  soda should be  added to the
lotion.   Cleanliness is indeed  more essential to the syphilitic patient,
man or woman, than to the  healthy.   After such  cleansing or disin-
fecting ablution, the  parts should  be  dressed with a powder, such as
dry calomel, iodoform, iodol, hydronaphthol, bismuth, the zinc  oxide,
salicylate of soda, or starch.   Vegetating lesions of these regions may
require also  pencilling M'ith a crayon of  the nitrate of silver.  Oint-
ments, as containing grease, are decidedly objectionable for this purpose.
   Crusted and  ulcerative lesions, large or small, are  to be treated in
accordance with  general   principles.   Crusts should always  be
removed, either  by the oil and soap  and water treatment, or by the
dermal curette, after M'hich the underlying ulcers should be thoroughly
cleansed, pencilled with nitrate of silver, filled M'ith  powdered iodo-
form,  iodol, or calomel, or  touched with a five to twenty per cent.
solution  of carbolic acid, and  then  dressed »vith a dilute ointment of
the nitrate of mercury, one to two drachms (4.-8.)  to  the ounce (32.).
Large syphilitic ulcers are often encountered  on the surface of the
lower  extremities,  especially the legs, and in this situation elastic
compression  by the rubber bandage will  greatly accelerate their cica-
trization.
   The syphilodermata are  in general particularly amenable to the
action of the mercurial vapor bath, which may be  regarded as  exert-
ing upon  them  both  a  local agd constitutional   influence.  Those
existing  upon the face are thus benefited  by exposure to the metallic
vapor  in  the  " head-piece" arrangement already described.   The
patient may also less  comfortably  avail  himself  of  the same  local
treatment, by holding the breath and  exposing  the  head and face for
a few minutes  at a time to the fumes of the mercury beneath the
blanket,  in the plan described as practicable at the bedside.
   It is M'ithin reasonable bounds to say, that the  syphilodermata, if
treated locally by the measures described  as useful iu non-syphilitic
cutaneous  affections of similar type,  will  ahvays proceed  to a satis-
factory involution,  if the general treatment of the patient is at the
same time skilfully ordered.
  Prognosis.—The prognosis of syphilis  may be said to be in general
favorable, the popular opinion on the subject being at variance M'ith
fact.  Benignant syphilis may even disappear M'ithout treatment.
  Malignant forms of the  disease may,  but rarely do, destroy life.
The element of treatment, both as to  the character of the  latter and
the period of its continuance, enters  more largely into  the estimate 
544
DISEASES  OF  THE  SKIN.
upon M'hich a prognosis rests, than in most other disorders exhibiting
cutaneous  symptoms.   The  syphilis M'hich  is  untreated,  whether
because of a failure to recognize its real character, or of ignorance,
poverty, neglect,  or  extravagance  in dissipation,  is  usually  grave.
The same may be said of syphilis occurring in strumous, tuberculous,
and cachectic subjects, those  enfeebled  by age, by other  diseases, by
chronic alcoholism, or by sexual excesses.   Hereditary syphilis is by
far the gravest form of  the malady, not merely because of the  tender
age of its victims, but also because the latter, at  the earliest period of
their lives, find themselves burdened by  a disease which may first
attack organs essential to life.
   The majority of adult American patients sooner or later get rid of
all active manifestations of the acquired disease,  marry, and  beget ill
the end sound children.

                            Chancroid.

   This  term has been very generally adopted in this country for the
purpose  of designating  the virulent, local, contagious ulcer  of the
genitals, designated also as the  " simple," " soft,"  " non-infecting"
chancre, the  chancrelle  of French authors.  It has  no  relation to
syphilis, nor  to the  neoplasmata with M'hich syphilis  is  commonly
classified.  As it is, however,  a disease with M'hich the initial sclerosis
of  syphilis may be confounded, and is  also, not merely a  venereal
lesion, but one M'hich  may be encountered  upon  the skin as well as
the mucous surfaces, it is briefly  described in this connection.
   Chancroids present as distinct a uniformity of  feature as the lesions
of vaccinia or of herpes zoster.   They are  thus stamped with special
and readily recognized characteristics, differing  iu  this respect from
the various modes in which  the first lesion of  syphilis may declare
its  nature.   The virus  of  the disease, for such it  must  be termed,
is  one sui generis, and  derived exclusively from  lesions  of  like
character.   That virus  is  contained in  a  purulent  secretion, and is
capable of  transmission  by inoculation and auto-inoculation.  After
such  successful inoculation, there  is no  period  of  incubation.   The
results of experimental  generation  of the  virus iu  human  subjects,
indicate  that the  pathological  process  which  it  awakens can be
determined  within twenty-four hours after its introduction within
the skin.   At times, after  accidental inoculation, eight aud  ten days
elapse before the lesion of the disease is manifested, cases where pre-
sumably the virulent secretion has remained pocketed  in  the  orifice
of a follicle or a fold  of mucous membrane, M'here its irritant effects
have finally opened an avenue for its deeper ingress.   When typically
developed,  the chancroid is seen to  be a pustular  lesion, frequently
multiple, of  roundish  outline, beginning as a pin-head sized, turbid,
vesico-pustule,  rapidly  enlarging  to a  pea-  or   bean-sized,  well
developed,  projecting,  yellowish,  globoid, elevation  of the epidermis,
filled with  greenish-yellow pus.  When located in furrows or depres-
sions of the surface, it may have a  linear,  oval, or  even a dumb-bell 
CHANCROID.
545
shape, the latter in consequence of its extension from a sulcus to over-
lying folds.
  Clinically, the roof-Mall of this pustule is not frequently encount-
ered,  the lesions from the first exhibiting the ulcers from M'hich the
pustules described above invariably rise.   These ulcers varv  M'ith
the shape  of the superimposed pustules, being  round, ovalish,  or
linear, occasionally irregular iu outline, with  sharply defined  or cut
edges;  uneven,  pus-bathed floor; faint pinkish areola; supple, non-
indurated base;  abundant puriform secretion ; and  are accompanied
by pain or not,  according to the degree of inflammation present.   In
consequence  of the auto-inoculability of the discharge, the  ulcers
frequently  give  rise to others in the vicinity, as when the prepuce lies
in contact M'ith  chancroids of the glans.
  The ulcers thus  presented usually attain an average  size of a pea
or bean in  the course of from ten to fourteen days; then remain in
an indolent and  suppurative condition, shoM'ing no tendency to heal
for a  fortnight or three  weeks ; and finally granulate, exhibiting the
ordinary phases of repair;  the resulting  cicatrix being transitory
or,  more often,  indelible.   In  exceptional  cases the ulcer spreads
M'idely.  In the groin,  it may attain  a  diameter  of several inches;
its floor secreting scantily; its edges, lurid, undermined, purplish, or
ragged; its color, reddish, bluish, purplish, or leaden; fistulous tracts
and sinuses filled with an ichorous sero-pus, radiating  in dependent
situations; its base, densely indurated;  its career, prolonged  for years,
and inducing finally  a systemic cachexia not different from  those
observed in  all  chronic  ulcerations of severe grade.   Iu  yet other
cases, the occurrence of gangrene, or phagedena, changes the features of
the lesion to those of other ulcers undergoing similar metamorphosis.
  Chancroids occur upon all exposed mucous surfaces  of  the geni-
talia of both sexes, upon the integument of the penis, scrotum, labia,
thighs, fingers, perineum, peri-anal region,  aud, very rarely  indeed,
upon the face.   In consequence of their tendency to relapse, abundant
contagious secretion, and auto-inoculability,  they are more frequently
encountered than the  primary  syphilitic lesion,  among the filthy,
the poor, and the classes that frequent hospitals and dispensaries.
Among the wealthy,  the M'ell-to-do,  and the cleanly, this order of
frequency is reversed.
  The chancroid ulcer is also  much more frequently complicated by
surgical accidents than  is  the  infecting lesion of syphilis.  This is
partly due  to the prevalence of an ulcerative type in  all its manifesta-
tions, and  in part  to its situation.  Thus it  is often accompanied by
severe inflammatory  symptoms, M'hich may be aggravated both by
phimosis aud  paraphimosis, occurring  with  stenosis of the preputial
aperture, or M'ith a long, lax, and redundant foreskin.  Phagedena is
also a formidable complication, M'hether of sloughing or serpiginous
tendency, the lesion in each case losing its chancrous characteristics.
It is evident also that the disease may coexist  with others of a different
character.   Thus a single point may be simultaneously iuoculated M'ith
chancroidal aud syphilitic  virus; the former, M'ithout au  incubative
                                 35 
546
DISEASES  OF  THE  SKIN.
 period, followed rapidly by a pustular or ulcerative lesion; the latter,
 after its incubation is complete, producing the characteristic symptoms
 of an initial sclerosis.   Chancroids may also be found coexisting M'ith
 secondary and tertiary syphilitic lesions of the genitals, with vegeta-
 tions, with  blennorrhagic  discharges and balanitis, M'ith pediculi of
 the pubes, and with herpes progenitalis.  Patients of the class exhib-
 iting these lesions, not  infrequently present themselves at public dis-
 pensaries with three or more of these concurrent disorders.
   One of  the most serious complications  of the chancroid is  its
 association M'ith a specific lymphangitis, peri-adenitis, or adenopathy.
 In such case,  the lymphatic trunks  connected  M'ith  the lesion become
 inflamed, indurated, and irregularly  corded,  with the  overlying
 integument often oedematous, reddened, and painful.  The chancrous
 process in these vessels rarely terminates by suppuration.   The bubo
 of chancroid  is  more  common, and may be either a  sympathetic
 adenopathy, resulting from the severity of  the process at the  site of
 the  lesion, or virulent and due to  the  transmission of an inoculable
 pus to one or more of the glands in near connection M'ith the source
 of the trouble.  These gland complications may coexist in one person,
 in men more  often than in women,  and  in about one of each four or
 five  cases presented  to  observation.   When inoculable  pus has  been
 formed in a  neighboring  gland, the latter is  at once converted into
 the seat of an abscess, the pus of M'hich, whether evacuated sponta-
 neously or by the knife of the surgeon, speedily inoculates the lips
 of the wound through  M'hich exit  has  been obtained.   The Mound
 and  contiguous  abscess cavity then form a large chancroidal ulcer,
 usually  inguinal  in  situation, as   the  glands  in  this  locality are
 nearest the  most frequent seat of the lesion.   Such an inguinal ulcer
 discharges a greenish-yellow pus, often  commingled with blood;  its
 borders  are undermined,  thin, livid or purplish, aud ragged;  its
 floor is irregular, sloughy, and often covered by nodules representing
 the debris of  glandular  structure;  from  it depart sinuses traversing
 the tissues in  the vicinity, often downward to  the thigh,  occasionally
 upward over  the belly.   When occurring in strumous and cachectic
 subjects, or  when  long  neglected  or mismanaged, the resulting dis-
 order is one of the most serious character, and may surpass in dura-
 tion  and  severity certain of the varieties of lupus  aud epithelioma.
 The  author has had under his charge a man, the skin of whose right
 thigh, from the groin to the knee, M'as completely riddled by sinuses
 resulting from a chancroidal  bubo which had  occurred  several years
 before.   A few years ago, the author M'as called in consultation to visit
 a woman in wretched health with an indolent ulcerative lesion of this
 sort  in the  right groin, M'hich had lasted for five years.   Despairing
 of relief, and  before a change  of treatment  could be instituted, she
 hanged herself by the neck till she  M'as dead.
   Facts of this sort have an important bearing.   It is true  that
 syphilis is a constitutional  disease, and  usually occurs  but once  in a
 lifetime.  It is equally true that the chancroid  is the evidence of a
local and non-systemic disorder, producing constitutional  effects  only 
CHANCROID.
547
 as may all other local affections of chronic course aud  severe  grade.
 But it is a grievous blunder to suppose  for  these reasons, that the
 latter is the milder of the two maladies.   Many of its consequences
 are very much more severe, aud some of them even more malignant,
 than the average  of syphilitic explosions, and even, as  indicated
 above, worse than some  forms of other diseases usually counted as
 malignant.  Greater attention  should  be generally  directed to the
 truth respecting the comparative gravity of the two diseases, as there
 is widespread ignorance of the  real fact.
   Chancroid is to  be distinguished from syphilitic  chancre, but no
 skill, however  great, and no experience, however  wide, will enable
 the  diagnostician, even when  typical chancroid is present, to assert
 that  syphilis will not follow, until the longest incubative  period of
 the  initial  sclerosis  of the last-named disease has elapsed without
 production of suspicious symptoms.   The rule M'hich necessarily fol-
 lows is imperative, and,  being too frequently  ignored, a great deal of
 bitter disappointment on the part of the infected individual, and of
 keen mortification on the part of the physician, has naturally resulted.
 XO   PATIENT  SUFFERING  FROM  A  CHANCROID  CAN  BE SAFELY
 PROMISED  IMMUNITY  AGAINST SYPHILIS,  TILL TWO  MONTHS AND
 A HALF HAVE ELAPSED SINCE  THE  DATE  OF  LAST EXPOSURE.
 Subject to this essential reserve, the diagnosis rests upon the pustular,
 ulcerative, and  discharging  features of the chancroid,  its  failure to
 indurate  at the base,  its auto-inoculability, its  appearance without
 previous  incubation,  its  more formidable localized expression  of
 disease,  and  the  characteristics of the accompanying adenopathy.
 The  short-lived,  superficial vesicles of  herpes progeuitalis, often
 accompanied by tingling and painful  sensations, with sequelae in the
 form of equally superficial, epidermal excoriations, are not to be con-
 founded with chancroids; and yet it must be  remembered that these
 lesions may also precede or accompany any form of venereal disorder.
 Chancroids are also to be distinguished from secondary and tertiary
 lesions  of  the  genitals, aud   from uon-syphilitic  vegetations and
 molluscum epitheliale of the same region.
   The pathology of the chancroid, though illustrated by the researches
 of Biesiadecki, Auspitz, aud Unna, is yet not understood to an extent
 that will explain its specific character.  Anatomically, there is disclosed
 by the  microscope a  uniform,  dense  infiltration of the corium with
 elements which  undoubtedly represent inflammatory  metamorphosis
 of the connective tissue  of  the derma;  degenerative  chauges M'here
 the ulceration  has proceeded superficially; enlargement  of  vessels
 from thickening of their Malls, often M'ith  diminished lumen ; and
 relatively intact rete and corium at the lateral borders  of  the ulcer.
 This  fully confirms the  inferences suggested  by a clinical  study of
 the  disease.  Many  roundish,  circumscribed, cleau-cut ulcers with
 purulent floors occur  upon  the skin, M'hich bear no  relation to the
chancroid disease.   It is the history and career of  the  latter, which
stamp it  M'ith an individuality of its own.  It  is not the form and 
518
DISEASES  OF  THE  SKIN.
appearance of its pus elements, but their power  and potency, M'hich
make them singular.
  The routine treatment of chancroids is by destructive cauterization
with nitric or sulphuric acid.   Keyes  recommends a previous appli-
cation of pure carbolic acid, in order to benumb the part aud render
the subsequent application less painful.   If employed at all, the  latter
should be carefully M'iped from the sore  before the subsequent cauter-
ization,  as  the two acids M'ill explode  if suddenly united.   As  the
slough  separates, the ulcer may be dressed in accordance M'ith  the
general  principles  governing  the treatment of simple granulating
wounds.  Vinous,  carbolated, and opiated lotions, soothing powders
of iodoform, iodol,  calomel, bismuth and starch, simple unguents, and
the interposition of a pledget of borated cotton  betM'een all  affected
and sound tissues, these in most cases suffice to insure relief.  Pencil-
lings  with the nitrate of silver, though ineffective for the purposes of
cauterization, often answer a good purpose in hastening repair.  The
prepuce may require division  or circumcision.
  For the grave and extensive ulcerations, accompanied or not by
phagedena or gangrene, there is no treatment at all  comparable in
value M'ith the hot-water  bath of an average temperature of 98°  F.
For the details of this method, the reader is referred to the paragraph
devoted to the treatment of syphilitic chancre.
  Phimosis and paraphimosis, M'hen complicating chancroids, require
the surgical treatment appropriate for the relief of those  conditions.
For the accompanying adenopathy in  chancroid  disease, before sup-
puration has occurred, rest is  essential, with  laxatives internally and
gentle local compression.   When there is great  heat and  tenderness,
a few leeches  may be applied.  After  pus has formed, it may  be
evacuated with the aspirator-needle, or by a  free  incision in the long
axis of the swelling.  The resulting ulcer is  to be dressed aud treated
as a large chancroid.   Constitutional treatment by iron, quinine, cod-
liver  oil, and the employment of a generous diet M'ith  milk, malt
liquors, or wines, is often required  in broken-down and debilitated
patients.
  The prognosis, in uncomplicated cases, is generally favorable.   The
scar left by a suppurating gland in the groin is indelible, but becomes
less and less conspicuous with years.   Sloughing  and gangrenous
sores  usually leave  deforming cicatrices,  especially when occurring at
the apex of the  glans, to which they are  apt  to give a peculiarly
truncated shape.   A just  reserve should  be made in all  cases compli-
cated  with syphilis  or  extensive  fistulous sinuses;  the  latter, as
described above, often persisting for years. 
LEPRA.
549
                              Lepra.

                            Gr. Xenpbg-, scaly.

Lepra is an infectious, parasitic disease, of exceedingly chronic course, capa-
  ble of involving all of the organs and tissues of the body, characterized by
  cutaneous pigment alterations, disordered or abolished sensation, tubercles,
  or  other circumscribed  or diffuse infiltrations,  bulla?, ulcers,  cicatrices,
  atrophies, destruction of deep tissues, loss of the appendages of the skin,
  and the ultimate production of a cachexia which usually terminates fatally.

  Symptoms.—Leprosy has also been termed Elephantiasis Gr.e-
corum, Leontiasis, and  Lepra Arabum.   In whatever form  it
may be ultimately manifested, its appearance is usually preceded by
the prodromic symptoms generally recognized  as the  precursors of
severe constitutional  disease.    These are: anorexia;  chills, alter-
nating with mild  or severe febrile attacks ;  depressiou ;  gastro-intes-
tinal  disturbance; and  insomnia.   Their  duration  is exceedingly
variable; in some cases, patients will remember that these or similar
symptoms preceded  for years the earliest outbreak of the disease.  Iu
yet others, but a  few weeks' interval occurs between the prodromic
and successive stages of the disease.  It is worthy of note that the
character of the former furnishes no clew to the severity and type of
the latter.
  The earlier cutaneous lesions of leprosy are tubercular, macular, or
bullous.  These may be coincident or successive, or one or two of these
types may so far  predominate that another may be either altogether
wanting, or possess, in the general pathological history, but a trifling
significance.   It has thus been  customary to make  au  entirely arti-
ficial  distinction between cases of leprosy, by assigning them to  three
varieties, tubercular, macular,  and anaesthetic.  It will be understood,
then, in separately considering these three forms, that the distinction
between them is useful simply for the purposes of classification;  that
mixed cases of the disease occur which it would be difficult to assign
to either variety exclusively;  and that each merely represents a pre-
dominance of certain lesions at one pathological epoch.   It should be
noted also that the symptoms  of leprosy are particularly remarkable
for their polymorphism; a M-ide variation often  existing between the
character of two  or more lesions which at any given moment are
apparent.  This is largely owing to the fact that leprosy is a general
and constitutional disorder,  the cutaueous  symptoms  of  which  are
simply its surface markings.

                      [A.]   Lepra  Tuberosa.

  Tubercular leprosy commonly begins in the skin  with macular
lesions.   These  are beau-  to  tomato-sized,  reddish,  brownish,  or
brouze-hued patches; roundish,  oval, or irregular in contour; aud
occurring upon the face, trunk, or extremities.  The  skin  covering 
550
DISEASES  OF  THE  SRIN.
these is either smooth and  shining  as  if  oiled, or  moderately infil-
trated and elevated.
   After a period ranging in duration from weeks to years, tubercles
rise from  these maculatious, varying  in size  from  a pea  to a  nut,
though  they may be as large as a tomato.  They are yellowish, red-
dish-brown, or bronzed in color, often shining  as if varnished or
oiled, covered with a soft, natural, or slightly desquamating epidermis,
roundish,  or quite irregular in contour, and either isolated or grouped.
Numbers  of very  small and ill-determined  nodules may often be
recognized by careful examination of the skin in the vicinity of those
fully developed.   They may be either cutaneous or subcutaneous in
situation, aud softish or quite firm to the touch.

                             Fig. 60.
Lepra tuberculosa. (After Danielssen and Boeok.)
   The site of predilection of leprous tubercles is the face ; and their
massing in great numbers upon this region produces the characteristic
deformity of the countenance M'hich has  given to the disease one of
its names, Leontiasis (face of a lion).   In such faces the tubercles
are ranged in parallel series above the brows, down the nose, over
the cheeks, the lips, and the chin.  In  consequence of the infiltration
and development of the lesions, the brows deeply overhang the globes
of the eyes, the lids become affected with a partial ptosis, the lips
pout, and the ears are so studded M'ith tubercular masses as to project
from  the side of the head.   The trunk and extremities, including the
palmar and  plantar surfaces, are then usually  to a  less  degree
involved.    Occasionally,  indeed,  with  extensive  development  of
tubercles upou the face and ears,  there may not be more than from
five to  fifty  upon  the rest  of  the body, aud these either  widely 
LEPRA.
551
dispersed and isolated, or agglomerated in a single, hard, flat, elevated
plaque of infiltration upon  the elboM' or thigh.
   With  these cutaneous lesions there is often involvement of the
mucous  surfaces, especially the  velum palati  and larynx.   In the
case of a leper affected with the tubercular form of the disease whom
the author exhibited  at the clinic  in 1879,1 there M'as very marked
gruffness and hoarseness of the voice, and the larynx and velum were
studded  with pin-head  to  pea-sized,  ashen-hued tubercles.   Others
may form upon the conjunctiva and the Sclmeiderian membrane.

                              Fig. 70.
Tubercular leprosy (from a photograph of a leper in the Sandwich Islands).
  These tubercles may degenerate into ulcers;  or undergo resorption
and disappear, leaving in their place pigmented atrophic depressions;
or lose their shape in consequence of partial resorption.   I have thus
seen  a large plaque flatten centrally till an  annular disk was left to
indicate its former site.
  It should be borne in mind, however, that the course  of the disease
is  exceedingly slow, and that years may elapse  before  these  several

 1 Chicago Med. Journ. and Exam., December, 1879, with cut showing laryngoscopy appearance of
larynx. 
552
DISEASES  OF THE  SKIN.
 changes are accomplished.  The disease, indeed, often  appears to be
 quiescent for months at a time, after M'hich with the  occurrence of
 fever acute  or subacute manifestations appear, aud a  relatively rapid
 progress is made toward its fatal conclusion.  Long before the latter
 is reached there are usually, in tubercular leprosy, intermingled symp-
 toms of anaesthetic type, such as the occurrence of bullae or of anaes-
 thetic patches with and without pigmentation.  Toward the last, the
 mutilations effected by the disease may result (Lepra Mutilans).
 Phalanges of the fingers or toes, whole digits, au entire hand or foot
 may then become partially or wholly detached by ulcerative, atrophic,
 or other degenerations of skin, bones, and ligaments,  hastened  or not
 by intercurrent  attacks of lymphangitis, erysipelas, septicaemia, and
 irritative fever.
   The  stadium of  this type of  the disease  may extend through ten
 or even  more  years.  After  its full development,  the  peculiarly
 dejected countenance of the leper with his leonine facies and general
 appearance of cachexia, are highly characteristic.

                      [B,]  Lepra Maculosa.

   This form of the disease is chiefly distinguished, as its name implies,
 by its  macular lesions.   These  have the general character of those
 described as preceding the appearance of the  leprous tubercles.   They
 are diffused or circumscribed, roundish or irregularly shaped, and in
 color yellowish, broM'nish or bronzed, often shining or glazed.   They
 may be infiltrated or not;  and in the former case, be slightly raised
 from, or on a level M'ith, the adjacent tissues.  At times, they appear
 as lardaceous deposits  in the skin, M'hitish, reddish, or even blackish
 in color, with a telangiectasic border.  These patches are usually at
 first hyperaesthetic, but finally  become quite insensitive, so  that  a
 lancet can be thrust deeply into them without  producing the slighest
 sensation.
   The pigment variations in macular lepra are noticeable.   At times,
 a distinctly anaesthetic patch may be  readily  limited both by its lack
 of sensation  and of normal color;  at others, either symptom may
 fail to correspond with the area of involvement defined'by the other.
 Thus a palm to platter-sized, texturally unaltered area over the thigh
 or belly, may suggest a vitiligo by its relatively slight  pigmentation
 and  its distinct  contour, beyond  which  are  sepia- to deep-chocolate
 tints, gradually  fading toward some  adjacent and similarly involved
 patch.  Yet this area will  often differ materially from that of vitiligo
 in other respects.  Every inch of the former may be totally insensi-
 tive  to  the  prick of the lancet, aud  be moreover of a dull, tawny,
 yelloM'ish, or parchment-like hue, never having the peculiar  milky-
 white tinge  of vitiligo.  Again,  this anaesthesia may extend  widely
 beyond  the line traced by the pigment anomaly, or even M'ithin the
 latter vary, islets of skin  capable of perceiving sensation, beino- in
cases here and there discernible. 
lepra.
553
                     f C]   Lepra Anaesthetica.

  This variety  may be, as has been  described, commingled in its
symptoms with  each of the others.   With aud without  these, how-
ever, there is commonly uoted first an eruption of bullae, bean- to large
nut-sized, with a roof-wall  constituted  of the entire thickness of the
epidermis, filled M'ith a clear tinted or blood-mixed serum, occurring
usually upon the extremities.  The cicatrices which follow these are
atrophic patches,  often  far greater in  extent than the  base  of the
original  bulla;  M'hitish,  shining, glazed, or  better described as  of a
tint suggesting the hue of mica; circular in outline, forming also the
dumb-bell figure by coalescence  or juxtaposition.   These are ahvays
anaesthetic;  and  may coexist  with macular  aud  anaesthetic  patches
upon the trunk or other portions of the body.  Neither those of the
one class nor of the other, are, however, disposed  over the surface of
the body in lines, bands, or curves corresponding to  the  distribution

                              Fig. 71.
Anaesthetic leprosy with mutilating results (from a photograph taken of a leper in the
                      Sandwich Islands).
of the cutaueous  nerves.  The  greatest irregularity  is displayed;
asymmetry  is the rule.   Occasionally, however, the ulnar and other
nerves accessible to the  touch, are recognized  to  be  tumid, tender,
insensitive, or as rigid as indurated  cords.   General  atrophic cuta-
neous symptoms follow these; the skin becomes  dry and harsh; there
is manifestly little or no sebaceous product;  the sweat is scanty;  the 
554
DISEASES  OF  THE  SKIN.
 muscles atrophy; the hairs fall; the lymphatic ganglia  enlarge;  the
 skin of the face seems tightly stretched over the bones.   As a result
 of deforming atrophy of the lids, epiphora and consequent orbicular
 changes ensue, and  the parted  lips permit constant escape of saliva.
 The fingers are half drawn into the palm of the hand; the nails  are
 distorted, aud, later, ulceration occurs.   The ulcers are irregular, oval,
 roundish,  linear; covered  with thin,  blackish,  flattened, tenacious,
 never rupioid, crusts;  their bases are soft, their floors covered with a
 pultaceous debris often mixed with  blood; the whole often insensitive
 to  every foreign body and external application.  Lastly the symp-
 toms of lepra mutilans often occur, digits, or portions of the carpus,
 metacarpus, or  corresponding parts of the foot being detached from
 the body.
   Death may ensue at any time during the course of the disease from
 septicaemia, exhaustion, or any of the intercurrent affections to which
 a  patient in such condition  is particularly disposed.   Thus a  leper
 M'as lately accidentally choked to death  in San Francisco  by  some
 perversion of the function  of deglutition.  The disease, however, in
 this form  is said to last from eighteen to twenty years, and is thus
 less rapidly fatal than the tubercular variety.

   Etiology.—Leprosy is a contagious and  infectious parasitic disorder
 produced by the bacillus leprae.  Secretions of  a leprous patient con-
                          taining these  bacilli or their  spores,  are
         FlQ- 72-           the usual vehicles by M'hich the disease is
                          transmitted from man to man.   The ques-
                          tion of the  inheritance of leprosy may be
                          regarded to-day as in much the same posi-
                          tion as  that relating to the inheritance of
                          tuberculosis, an admitted fact as yet not
                          fully explained.   Men  are more often
                          affected with the disease than women. The
                          disease is more common  after the second
                          decade, though children  are occasionally
 Larynx of patient affected with   j?    ]        •,   •  .•                 J
lepra tuberculosa.  (The author's   f°U™ amODg ltS. Victims.
case.)                         The geographical distribution of leprosy
                          is widely extended.   In  countries where
it has previously existed,  its appearance is invariably due to the con-
tagion of sound individuals by lepers infected in a country where the
disease is prevalent.   Neisser formulates the law of its prevalence by
stating that the number of lepers iu any country bears an inverse ratio
to  the laws executed for the care and isolation of infected persons.
  The disease exists in the interior and throughout the seaboard regions
of Africa, including Egypt; in Arabia, Syria, Persia, China, Japan,
and India; in  the  Islands  of  the  Mediterranean,  Black, Caspian,
and China  Seas, of  the Indian Ocean, and of the Australian Archi-
pelago; in  Norway and Sweden, Iceland,  Russia, Turkey in Europe,
Spain, France,  Portugal, Greece, Italy,  and sporadically in Germany,
England, and  the smaller  Europeaii  States; in  Northern, Central,
 
LEPRA.
555
and  South  America,  and  the West India Islands.    In our  own
country, special  attention  has been  directed to the  subject by the
existence of the disease in an epidemic form  in the Sandwich Islands,
M'ith which the Pacific States sustain close  commercial relations; by
Fig. 73.
Fig. 74.
1  * I
                                                   :[iiim:»i(JJillJift;'-
           Larynges of lepers affected with lepra tuberculosa. (Elsberg's cases.)

 its occurrence among  the Chinese immigrants  in San Francisco and
 other  portions  of California;  by cases  reported  from  New Orleans
 by Burns,1 Bemiss,2 Jones,3 and Solomon,4 and  by various reports of
 sporadic cases observed in Minnesota, Maryland, Illinois, Nebraska,
 New York,  aud other States  of the Union, by Gronvold, Hoegh,
 Bendeke,  Rohe, Piffard, Elsberg, Atkinson, the  author,  and others,
 collected  by the Committee on Statistics of the American Dermato-
 logical Association, and presented to that and other bodies in special
 papers.  Drs. White and Graham, of the same committee, have also
 contributed  to  the history  of  the colony of lepers  which  has long
 existed in  Tracadie, in the province of New Brunswick.
   With this M-ide geographical distribution, it  is yet clear that the
 disease exists endemically in  certain  countries, aud  also in  certain
 regions of the same country, with greater frequency than in  others.
 All  attempts, however,  to  connect its  origin with  malaria, with  a
 residence  near  inundated sea  marshes, with the ingestion of a diet
 consisting  largely of fish, or  of  a diet  from  which  salt' has  been
 largely excluded, have failed of any recognized success.  It is true
 that probably the  larger number of all  living  lepers are those who
 have been  poorly fed, and otherwise subjected to the most insalubrious
 of influences, but  the  disease  also attacks,  though far more rarely,
 persons M'hose social  position and  hygienic  surroundings are of the
 best.   It occurs in both sexes aud at all  ages; and, despite all efforts
 to show the contrary, bears  uo  relation to syphilis.   Lepers become,
 however, syphilitic if infected with the disease, precisely as they may
 and  do acquire variola, varicella, morbilli, erysipelas, and  phthisis.
 The Hebrew Scriptures, are often interpreted  as showing  that the
disease among the JeMS  in  Palestine  M'as regarded by them as con-
tagious and so treated.   The modern  student of these writings will,
however,  be  convinced that this  interpretation is  erroneous.   The
1 Arch, of Med., December, 1881.
8 Ibid., March, 1878.
2 N. 0. Med. and Surg Journ , April, 1880.
4 Trans. Louis. State Med. Assoc, 1879. 
556                DISEASES  OF  THE  SKIN.
leprosy of the book of Leviticus not only includes lepra, as that term
is understood  to-day, but also psoriasis, scabies, and other cutaneous
affections.   The leper in the eye of the Mosaic law, was ceremonially
unclean, and capable of communicating  only a ceremonial unclean-
ness.   Several of the narratives contained in these books bear witness
to the fact that the Oriental leper M'as occasionally seen doing service
in the court of kings, and even iu personal communication and con-
tact with officers of high rank.
  Pathology.—The histological element of leprosy is represented by
a new growth of round, oval, uni- or bipolar or otherwise  irregularly
contoured bodies.   These  originate either in the connective tissue of
the  skiu,  mucous membranes,  adventitia of the  vessels, or  nerve-
sheaths, or are derived, as  Schmidt has shown, from the epithelium,
endothelium, and even the fat elements of the affected tissue.   These
are  single, or grouped  in  a collection of two, a dozen, or even more
individuals; such groups being arranged in elongated, oval, pyram-
idal, or ellipsoidal forms.   Making its earliest  appearance in the
Fig. 75.
   Bacilli of leprosy,  a, epithelial scale About X 1200. (From one of the author's patients.)

reticular portions of the corium, the  growth  may progress thence
externally toward the papillary layer  and epidermis, or doM'nward
to the subcutaneous  tissue, or  develop in both  directions simulta-
neously.  Gradually there is invasion of the  pilary and sebaceous
follicles, the coil-glands  being apparently less frequently involved.
In the same way, the fat and vascular elements  undergo a transfor-
mation  into the  newly formed  elements.   The  viscera are  also
changed by the pathological process, particularly the liver, kidneys,
and spleen.   By degeneration of these elements, atrophy, ulceration,
and eventually the mutilating deformities of the advanced stages of
the disease are  induced.
  The  result of the researches of Schmidt  are  in accord M'ith the
observations of Virchow,  relative  to the peculiar  changes in the 
LEPRA.
557
nerves.  Explaining thus the hyperaesthetic, anaesthetic, and possibly
also the pigment alterations so characteristic of the malady, prolifer-
ating elements are recognized by this author in the ependyma of the
central canal of the spinal medulla, in the posterior commissure, aud
about  the  fourth  ventricle.   The  nerve-fibres  in  the posterior and
other  white columns,  undergo  degeneration,  as  also  those  of the
medulla oblongata, the corpus striatum, and the Gasserian ganglion,
the  latter   being  in one case small, indurated,  and its connective
tissue sheath thickened and adherent to the dura mater.   The sheaths
of the larger nervous trunks have been also seen to be involved, and
the peri- and endo-neurium atrophied as a result of previous infiltra-
tion, the axis-cylinders often, however, persistent.
   The relatively  sIom- progress  of the  disease is explained by  the
exceedingly slow development of the new formed material;  its inapti-
tude, for long periods of time, to undergo retrogressive metamorphosis;
and its tendency,  for similar periods, to invade the skin exclusively,
thus spariug for years the viscera M'hose ultimate involvement neces-
sitates cachexia and a fatal issue.
   In  leprosy, as in scrofuloderma  and syphilis,  the  aggregation of
the cellular elements in the new growth tends to form cutaneous and
subcutaneous nodes.  Similar nodules are found in cornea, cartilage,
testicle, spleen, liver, bone, and other affected organs.  The body of
each cell sometimes grows till it  has four aud  five times the dimen-
sions it  originally possessed ; being surrounded in its full maturity
by an abundant vascular plexus.
   The specific  parasite of leprosy, the  bacillus leprae, is discovered
in  no other  disease affecting man.  It is  visible M'ithin  all  cells
actively concerned  in the leprous new formation.  They are delicate
rods, M'ith  tapering extremities, one-half to three-fourths the diameter
of a red blood-corpuscle, and have a breadth about one-fourth of their
length, as distinguished from the bacillus of tuberculosis.  Granular
particles are occasionally recognized sprinkled through the protoplasm
of a single cell M'hich Neisser supposes to be either products of degen-
eration or  spore  formations.  These various microorganisms have
been chiefly studied  and described  by Hansen (1870,  1874,  1880),
Carter (1875), Neisser  (1879), Cornil (1881), Hillairet and Gauche
(1881), and  in  our country by Bermann, of Baltimore.  These  ob-
servers not only recognized  parasitic organisms in various tissues of
the bodies  of patients living and  dead of leprosy ; but  have shown
that the bacteria thus discovered, were the causes of the disease.
   It is true that no human  being has ever been infected with leprosy
by the medium  of culture-fluids originally derived from an infected
person ; but the demonstration to that  point is satisfactorily conclu-
sive.   The appended illustration represents the bacillus leprae recog-
nized  in the nodules taken from the arm of a  patient affected with
tubercular  leprosy, exhibited at the  author's clinic in 1886.
  These organisms have since been recognized in mucous membranes,
perichondrium,  cartilage, testicle,  liver, spleen,  kidney, lymphatic
glands, and in the large cells between the peripheral nerve-fibres and 
558
DISEASES  OF THE  SKIN.
fasciculi.  Neisser has failed  to  recognize them in the spinal cord,
muscles, pemphigoid  lesions (bullae), and rete mucosum.   The older
and  larger the cells, the more numerous and more closely packed are
the rods of bacteria contained M'ithin them.
  Diagnosis.—In well-marked cases the recognition of  leprosy is
simple.   In its prodromic periods, no suspicion of its existence Mould
be awakened in couutries where the disease was not endemic.
  From syphilis, which is also a disease M'hose lesions are polymor-
phic in character, lepra can  be distinguished by its much greater
chronicity ; its larger  and brownish-yelloM', glazed tubercles ; its
frequent hyperaesthetic and anaesthetic symptoms ;  its bullous lesions,
rare in acquired syphilis ; the far more extended areas of its erythem-
atous macules;  its blackish  crusts, lacking  the  rupioid aspect of
those in syphilis; its  leathery, mica-tinted cicatrices ;  and the charac-
teristic leonine facies  of its tubercular forms.
  Morphcea and vitiligo are both unattended by constitutional changes,
and  more particularly by hyperaesthetic or anaesthetic symptoms in
the affected  patches.  The atrophic and often deeply pigmented con-
dition  of the skin in the final stages of pityriasis rubra, associated
with the emaciation and febrile condition of the patient, might mis-
lead  for a time the observer who had not a full history of the case.
Multiple sarcomata, especially upou  the face,  are followed by much
more rapid degeneration and a fatal result.
  Finally, we are now in position  to assert  boldly that,  certainly in
America, the diagnosis of leprosy requires not only clinical  symptoms
but a definite contagion.  Whether the history of such transmission
from one individual  to another be or be not obtainable, it is certain
that  no person ever  manifests leprous symptoms who has not beeu
infected by some other individual who is the victim of the disease.
   Treatment.—One of the most important considerations relative to the
therapy of leprosy is  that requiring the segregation and  isolation of
all lepers  from contact M'ith the uninfected.  In some countries, those
particularly where leprosy prevails, M'holesome laws  enforce   this
separation of the infected, and charitably provide also for the care of
the wretched victims  of the disease.  In this couutry, where leprosy,
in consequence of its  great rarity, has not yet awakened the attention
of legislators  beyond the point of  forbidding the  importation of
infected persons, the proper care of lepers in a community only too
ready to take  alarm   even  at  the name of the disease is a serious
matter.   Many of our public hospitals  for the care of the sick poor
refuse to receive them.   The author has had experience  in several
States  of the Northwest, where the officers of health-boards  Mere
powerless to make proper provision for the care of a leper whose  case
was brought to their  attention.
  No remedies are known to have a directly curative effect in leprosy.
As a consequence, the treatment of the disease is that suggested to the
intelligent practitioner by the  indications in  each  case.    The most
important of the latter is, when the  patient happens to  reside in a 
LEPRA.
559
 district M'here the disease prevails, au immediate change of residence
 and climate ; the adoption of a highly nutritious diet;  and the exhib-
 ition of roborant remedies, including steel, quinine, cod-liver oil, and
 often the moderate use of M'ines and malt liquors.  Mercury, arsenic,
 the iodine compounds, Hoang-Nan  in pills of three grains (0.266);
 creasote, in  half-drop  doses (0.033); the oil  of cashew nut, gurjuu
 balsam, ichthyol, and chaulmoogra oil, internally and externally, have
 all been employed with varying success by different practitioners, but
 an unprejudiced review of the maximum of results thus obtained, will
 establish the conviction that no one  of  the  remedies named may be
 regarded as in any sense possessing  a controlling  influence over the
 disease.   Most of them  have been  employed  by skilful  physicians,
 sufficiently wise to  enforce simultaneously the most  generous  tonic
 regimen, thus clouding M'ith some doubt a belief in  the part  played
 by the medicament in the production of the result.   In the case of a
 leper and  his little  daughter in the State of Nebraska, who  Mere
 treated by the  author for some time with  chaulmoogra oil, verv
 marked benefit was noticeable in the course of a few months, a result
 lie is quite Milling to credit, in  this instance, to the salubrious  sur-
 roundings of a farm  in the country.
   Every secreting ulcer and open  surface  in  the  person  of a leper
 requires prompt aud  absolute disinfection with a solution of bichloride
 of mercury, in order to destroy the  bacilli  that are commonly con-
 tained in it.
   Baths aj'e of great value in all these  cases, and may be  medicated
 with any desirable substance.   It should not be forgotten in the local
 treatment of leprous  tubercles, ulcers, and other lesions, that hoMever
 foreign the disease may be to this climate and this country, the simple
 principles, dermatological and surgical,  by which one is governed in
 ordinary cases, are here not to be forgotten.  Disinfectants, carbolic
 acid, bland unguents, inunctions, and local stimulants of the skin, are
 as useful, when properly  applied to the  leper, as to the syphilitic, the
 cancerous,  and the scorbutic.
   Prognosis.—The future of the leper is  indeed dark. The  disease
 is malignant in character, and, however protracted, a  fatal result is
 usually inevitable.  Still, with a change  of climate  and  improved
 hygienic conditions,  much can  be accomplished.  There  can be no
 question that the Scandinavian  lepers  who  have removed to this
 country have  beeu greatly  benefited by the change.  Such, indeed,
 was the opinion of the  late eminent Professor  Bceck, M'ho,  during
 his useful career, visited Minnesota, and there studied  the history of
 eighteen leprous  immigrants who had come from  his  own country.
 He believed,  in  fact, that  the change  in some cases  M'ould work a
complete arrest  of the disease.   A  careful stud)' of  the history of
 leprosy in America will induce the belief that such a favorable result
can be anticipated after residence in the  Northwestern  States, as M-ell
as in other portions of this country. 
560
DISEASES  OF  THE  SKIN.
                           Pellagra.
                  Lat. pellis, the skin ; azger, diseased.
  This disease  has attracted attention  by its extensive ravages  in
Lombardy and the  contiguous  provinces, including a  portion  of
Southern France and Spain.  It is also termed Risipola Lombarda
(Lombardy erysipelas), Lombardy Leprosy, and among the common
people, La Rosa.  It is a  constitutional endemic disorder, accom-
panied by an exanthem, which justifies its brief consideration iu this
connection.
  The first symptoms of the disease are prodromic, and characterized
by marked fatigue, malaise, and  occasionally by febrile  symptoms.
Soon  the  face,  neck, chest,  and  backs  of the hands and  forearms
(M'hen exposed  to  the sun) are  affected M'ith  an erythema of a dull,
lurid  hue, which may be accompanied by desquamation, occurring in
successive years, chiefly in the summer season, often fading, at times
with desquamation, in the autumn.  After frequent relapses, the skin
becomes of a dark olive-brown, bluish-red, or deeply  pigmented  and
bronzed hue, and general exfoliation of the epidermis  follows in large
flakes.  Simultaneously,  an extraordinary degree of muscular feeble-
ness is noticed ; the skin becomes pruritic or hyperaesthetic; and  a
sensation of chilliness is induced, similar to that observed in general
exfoliative dermatitis.  As in that disease also, the fingers gradually
become semi-flexed into the  palm, aud gastro-intestinal derangements
supervene, accompanied  by a  furred tongue,  inappetence, colicky
pains, and diarrhoea.   Disorders  of the nervous system are betrayed
by melancholia, disturbed vision, idiocy, convulsions, and symptoms
of meningitis.    Post-mortem,  pachy-meningitis,  with induration,
atrophy, and other secondary changes of the brain  and cord, have
been observed.
  Pellagra has been very generally believed  to originate  in  the use,
as an article of diet, of maize which Mas either invaded by the fungus
of ergot, or had developed other deleterious substance after its reduc-
tion to a coarse poM'der.  While  this cannot be  said to have been
fully  disproved, it is certain that  individuals have suffered from  the
disease who have never partaken  of maize, and also those who have
not been specially exposed to the action  of the  sun,  M'hich in some
cases  seems to have served as the exciting cause of the disease.   The
exact etiology of the malady should rather be traced by the statesman
and politico-economist.   The wretchedness, poverty,  poor food, and
hopeless moral and social condition of the inhabitants of the pella-
grous districts, many  of them  toiling  under a burning  sun, half-
starved, emaciated, and despairing, should  explain  largely the symp-
toms  of the scourge which afflicts them.   Certainly there is here  to
be  found  a very satisfactory explanation  of the failure of several
writers on the subject to describe a disease of such typical aspect  and
career as to command recognition of its distinct and  special identity.
Subjected  to  the  influences  named  above, a large population  could 
CARCINOMA.
561
scarcely fail to exhibit a wide range of differences in the  symptoms
by  which M'as expressed  their physical protest against the severe
ordeal to which they were alike exposed.
  The treatment is  that manifestly indicated  in the facts  set forth
above.
                  Actinomy co sis.  [Kay-F ungus. ]

  This is a disease originally recognized in the jaws of horned cattle
by  Bollinger;  aud shown by  Israel, Ponfick, Johne, and  others to
be  occasionally transmitted  to  man.   The  disease  is said, iu such
cases, to gain access  to the jaM' by the avenue of the cavities in carious
teeth, where the fungus  lodges  and fructifies.   One  or several  small
or  large tumors form in the jaw and submaxillary region, after the
fungus has fully developed, in consequence of the formation of granu-
lation tissue.   By a process of  ulceration and  sloughing, the tongue,
pharynx, larynx, and other parts may be invaded; and in cases even
the intestinal canal,  lungs, and spleen.   The nodules M'hich  form and
which once were believed to be sarcomatous, contain a fungus seen in
the form of millet-seed sized and smaller yellow masses mingled with
the new-formed granulation tissue.  The fungus by its growth only
seems to excite the chronic inflammatory process in the tissue M'ithout
directly influencing  the  cells of M'hich it  is  built  up.  Its title of
ray-fungus  is  derived from a characteristic radiation of the grouped
filaments of the vegetation.  As degeneration progresses in the deeper
parts attacked  by the fungus (bone, periosteum, etc.), fistulous  tracts
communicate with the skin and furnish a secretion iu which  the para-
site may be recognized.
  The diagnosis rests upon the discovery of the small, yellow granules
in M'hich  the  fungus may  be detected.   The disease  is not  to be con-
founded with  extra-periosteal abscess of the soft tissue about the jaw
due to carious  teeth.
  The treatment, after thorough employment of antiseptics and para-
siticides, is largely surgical.

                          Carcinoma.

                         Gr. napnivoc,  cancer.
Carcinoma of the skin, is a term employed in the designation of the several
  forms of malignant tumors which are in part constituted of epithelial new
  growth, either occurring primarily in the cutaneous tissues, or appearing
  there after the involvement of other  organs.

  The term Cancer  has been both  loosely and definitely employed in
the designation of malignant cutaueous tumors.  Every cancer of the
skin is, according to  Heitzmann, necessarily both alveolar and epithe-
liomatous in structure;  M'hile  Kaposi  distinctly recognizes forms of
cancer  M'hich  are not epithelial.   In these pages,  for  the sake  of
retaining  a  convenient clinical distinction,  the term  carcinoma,  or
cancer  is used generically to include epithelial, fibrous, and melanotic
                                36 
562
DISEASES  OF  THE  SKIN.
neoplasms.  It will be understood, however, that in the structure of
all  of these new-formed groups epithelium  plays an important part.

                Epithelioma.  (Epithelial Cancer.)

  Three varieties  of epithelioma  are recognized—the superficial, the
deep, and the papillary.

  Superficial Epithelioma is usually first  displayed  upon  the
sound skin in the  form of one or several, pin-head sized papules,  flat
infiltrations, or nodosities of a dull-yelloM'ish,  reddish, grayish, or
dirty wax-like  hue.  The growth may also have its origin in pre-
viously existing lesions  of the  skin, M'hich are  both numerous and
different from each other.  Among the latter may be named fissures
and excoriations (especially those long teased by caustic applications),
Marts, naevi, acneiform and molluscoid  lesions ;  and  the dry  or
greasy epidermal  scales  often seen  at  the  orifices of  the  sebaceous
glands in the faces of the aged.   The outline of the newly developed
growth  as a consequence varies, being  roundish,  linear, or irregular,
As  a result  of accident or traumatism (especially scratching and
picking, which  the history of a large proportion of all cases includes),
a superficial  excoriation forms, which  may  be  covered with a sero-
sanguineous crust,  after the desiccation of its scanty and ichorous secre-
tion.   In the progress of its development, it is often noticed that new
foci of disease  appear in the immediate vicinity of the first, repre-
sented by sub-epidermic, indurated  nodules, or superficial  "pearls"
resembling milia,  whitish and  lustrous, with  marked tendency  to
vascularization, exfoliation, and superficial ulceration.
  The  result  is the  ultimate formation  of an ulcer, called also the
Rodent  Ulcer,  M'hose characteristics are  marked.   These  are a
roundish, fissured, or slightly  angular contour; and  a reddish  or
reddish-brown, irregular, granulating, and mamillated  floor, covered
with  a  thin, translucent, viscid serum, which,  in  drying,  suggests
the effect of a varnish over the part.   The edges of the  ulcer are
clean-cut, indurated,  usually M'ell  attached ;  and, seen  in horizontal
profile, irregularly indented.  The symptoms are slight at first;  the
lymphatic ganglia and general health being unimpaired.  Its site of
election is the face, particularly the eyelids, nose, temples, and lips,
though  the  genitalia, hands, and  feet may  be affected.   Of two
hundred and fifty cases  collated by Heurtaux, iu oue hundred and
ninety the face  Mas attacked.
  The subsequent course of the  lesion  varies,  its evolution  being
generally sIom'  and  accomplished  in  years.   Sometimes  having
attained  a maximum  of size, an  ulcer, if unmolested,  long persists
without appreciable change.   In other  cases, the  base  cicatrizes and
the epithelioma completely  exfoliates,  leaving  an outlying linear
ulceration which may persist or spread.  In yet other  cases, after a
persistence of ten  to  tMenty years, the ulcer may  spontaneously close
and the  disease be at an end.  Finally, any one of the destructive 
CARCINOMA.
563
and  malignant cancerous processes  may be awakened, and the epi-
thelioma be thus transformed from the type of the superficial to that
of the deep  variety of the disease.

   Deep or Tubercular Epithelioma.—This variety may origi-
nate in  the manner already described, or  may be  from the first
characterized  by its specific  features.   It  commonly  begins by the
formation  of roundish, very  firm  pea-sized  nodosities closely set
together, deeply in the skin and  subcutaneous connective  tissue, or
thus situated  and  well  projected from the surface.  In the course of
months and years these develop to  form a  nut- or  even small egg-
sized tumor, roundish,  dark  reddish in color, and delicately vascular
on its surface.  This may be a deep flattish or  globoid  development
M'ithin the skin ;  or a well-defined tumor attached to it; or (and this
is a  common form) a dense, thick, flattened plaque,  one inch or more
in diameter;  its walls steeply descending to the sound skin on either
hand or  moderately everted;  its centre depressed by atrophic changes;
its surface shining, waxy, pinkish or red, with ramifying capillaries.
"Satellites" may form in its vicinity.
   Degeneration of  these forms produces in  the course of time  an
ulcer either quite  like that described above, or one M'hich deeply and
destructively  encroaches upon the tissues beneath.  In advanced cases,
the  latter is irregular in contour, with a clean-cut, everted, indurated
lip ; eroded and " gouged," haemorrhagic and granulating floor; thin,
viscid secretion which is purulent at times when the resulting destruc-
tion is rapidly accomplished ;  and a deep attached base which may
 be perforated by a crateriform  excoriation  extending down to or
through muscles,  fasciae, cartilage, and bone.  The lymphatic ganglia
become  simultaneously involved, and  a general cachectic condition
 fully established.   Death may ensue from  marasmus, exhaustiou, or
 haemorrhage, in the course  of several  months  or from  one to three
 years.

   Papillary Epithelioma.—The cancer in this variety assumes
 the  form of a malignant papilloma.  In these cases,  a  pedunculated
 or sessile,  narrow  or  broad based, smooth-capped,  or spongy and
 verrucous vegetation is attached to the skin  upon which it  forms.
 It may be originally as small as a pea, but usually increases consider-
 ably in volume,  being not rarely  pigeon's  and turkey's  egg-sized.
 The surface  is either  dry, reddish-yellow, smooth, aud lustrous;
 exfoliating, and  secreting   an offensively  smelling  sanguineous  or
 translucent fluid ; or moist, granulating, filamentous, and intermingled
 with hairs, as when it occurs upon the bearded  cheek.   Degeneration
 occurs  later, fissures forming  first; subsequently appear superficial,
 and finally deep,  ulcers M'hich  ultimately assume all the features of
 those described above.
   Singular varieties of papillary epithelioma are  occasionally seen
 upon the face.  Iu a case lately observed  by the author, the entire
 face of an elderly man M'as covered with rings  having a diameter of 
564
DISEASES  OF  THE  SKIN.
 an inch or more, of which the centre was largely composed of densely
 indurated, cicatricial tissue.   The  borders  of these rings were built
 up of a reddish-brown, warty, cancerous  growth, secreting slightly,
 here and  there commingled M'ith  the  hairs  of the face (beard, eye-
 lashes, brows), and elevated one-fourth  of an inch aud  more above
 the general level of the integument.   Growths of this sort are  not
 rarely seen upon the back of the hand, over the  forearm, and  on the
 leg.  Distinctly  circinate forms  are produced, the  vegetation here
 having a dryish appearance, a brownish-red crust, neither bulky  nor
 uniform, a cicatriform or infiltrated central area, and  an exceedingly
 slow course.  In some cases the epithelioma forms a soft, hemispherical,
 small-nut to  egg-sized  tumor, which, upon pressure,  discharges
 numerous convoluted plugs, composed  of epithelium, fatty masses,
 and a purulent secretion.  The bases of these soft masses are remark-
 able for the ease with which they can be curetted, and thus  radically
 removed.

   These varieties  or types of epithelioma may coexist  in  different
 portions of the same integument;  or the one may develop from  the
 other, a malignant papillary growth  springing from a superficial or
 deep cancerous infiltration.   Familiar examples of the disease  are
 seen  upon the lids and contiguous portions of the nose; the cheek and
 the lower  lid, the latter being often drawn  into ectropion by a cicatri-
 form bridle or band; the nose or lip and adjacent mucous or osseous
 tissue ;  and the glans and prepuce where the vegetating forms are of
 more frequent  occurrence.  The vast destruction  wrought by  the
 M'idest development and  consequent degeneration  of  epithelioma is
 sufficiently recorded  in  the  annals of both  medicine and  surgery.
 The author M'as lately consulted  iu the case  of a woman sixty-four
 years of age, in the centre of M'hose face an ulcerating epithelioma had
 left a wide chasm, after destroying three-fourths of the nose and upper
 lip,  and the hard  palate with all  the upper teeth and  the  antrum.
 The bones at the base of the skull were  exposed.  The case illustrated
 well the occasional remarkable tolerance by the  system of  the pro-
 foundest encroachments of epithelioma.   She  was then digesting and
 assimilating food M'ith fair profit, and suffered  chiefly from pain. She
 did not die till several months had elapsed, and then only as the result
 of hemorrhage from an ulcerative opening into one of the large arteries.

   Cancer of the Head.—In this region of the body nearly three-
 fourths  of all cancers of the skin  are  recognized.   Upon the brow,
 alae  of  the nose,  temples,  cheeks, chin,  scalp,  or other part,  the
 disease may begiu  either upon or beneath entirely normal skin, or in
 that which has been pathologically changed.  The  origin  of the
 disease  is  usually  ascribed to the picking,  scratching,  or  shaving of
 a sebaceous wart in the  old man ; or in  similar traumatisms of acnei-
 form, seborrhceic, or furuncular lesions  in either sex.   In other cases,
 the dermatologist,  cousulted M'ith reference to some other ailment of
 the skin, can recognize, in persons of the age most liable to such acci-
dents, one or several  pin-head-sized, or larger milium-like  uodules, 
CARCINOMA.                      565
clustered about the temples or nose, M'hich indicate  the  site of the
awakened  epitheliomatous  change.    The  disease progresses very
sJoM'ly, spreading superficially, along the alae of the nose iu irregular
lines, in more complete centrifugal outline over the temple and brow;
almost symmetrically over the tip of the nose, and with odd indenta-
tions of contour iu the dense integument immediately in front of  the
tragus of the ear.  The vegetating forms  are more common  on  the
brow, scalp, and chin; the "rodent ulcer" type, over the temples
and  cheeks.  The more superficial varieties  in any part of the face
may be slowly converted into the deeper.  The flattened, egg-sized
disks of infiltration are more common on the cheeks and chin.
   The devastation produced by malignant  cancer is nowhere more
conspicuous than  in the face.   Cartilage, bone, muscle,  and entire
organs melt before its ravages with  astounding  readiness.   During
the last two years, the author has seen  a circumscribed flat epitheli-
omatous infiltration, limited for years to one cheek, spread  to  the
point of destroying the ear, eye, and  inferior  maxilla of oue side of
the face, opening into the larynx and oesophagus, and not producing
fatal results till the jugular vein of the same side had been opened by
ulceration.

   Cancer  of the Lower Lip, far more common in men  than in
women on account of the  tobacco  habits of the former, may arise
either as a minute nodule, or circumscribed thickening on  or near the
vermilion border,  usually of oue side, or as a  linear, narrow, and
shallow excoriation,  often protected  by a thin  crust, extending well
along the  mucous edge of the lower  lip that  is in contact with  the
other when the two are lightly  approximated.   Later, the  lip may be
the seat of a defined  tumor, small-nut to egg-sized, which may deeply
involve the  entire thickness of the lip, encroach upou the chin, loosen
the  teeth, destroy the  gums, larynx,  pharynx, tongue, and maxilla;
and  eventually produce one of  the most formidable and  remediless
chasms of the lower  part of the face already  described.

   Cancer  of the  Genital  Organs is submitted to the surgeon
far more frequently than to the dermatologist.  The glans penis and
prepuce are occasionally the scat  of  the  warty variety;  but  the
scrotum, labia, thighs, mous veneris, and abdominal walls, as well as
the parts first named, may be involved in the superficial or deep form
of cancer.   In persons of  cleanly habits, the  superficial  variety of
epithelioma  may remain in this region as indolent and innocuous as
upon the face.  But  M'here filth is permitted to accumulate about the
part  (lochial,  menstrual, catarrhal secretions, pus, urine,  feces, etc.)
the spread may be relatively rapid.   In such cases the ulcer is deep,
seated upon  an indurated aud very tender base,  and  has  the steep,
punched edge and haemorrhagic floor of the rodent ulcer. Ulceration
may, later,  open the  rectum, vagina, corpora  cavernosa, perineum,
and deep perineal fascia, resulting in vast destruction that proves fatal
by exhaustion of the forces of the aged patient. 
566
DISEASES  of the  skin.
  Cancer of the Extremities, particularly of the back  of the
hand, is at first usuallv of the papillomatous, or flat, superficial form.
It may first appear upon the left hand of right-handed patients.  Its
progress is indolent, and M'hen properly treated is much less liable to
grave ulceration, than  epitheliomata in different situations.   In other
cases, especially on the lower  extremity M'here the force  of gravity
generally aggravates any ulcerative process, caries, necrosis, fistulae,
loss of phlanges, etc.,  may result.

  Paget's Disease of the Nipple, first described by that  author
in 1874/ is a disease  of women  from  forty to sixty years of age,
affecting the nipple and areola.   An intensely red, raw, granulating
surface begins by exuding a copious, clear, viscid secretion,  accom-
panied by sensations of intense pruritus, heat, and burning.   This is
followed by unmistakable signs  of epithelioma in one or another of
the forms described above.   Thin believes that the cancerous  change
involves the mouths of the lactiferous ducts, which spreads thence to
the nipple, skin, and deep mammary structure.  Munro, Anderson,
Sherwell,  Duhring, and  others  have  reported cases  of  this kind,
which Schwimmer concludes present no peculiarities  entitling them
to separate classification.

  Etiology.—The essential causes of cancer are unknown, though
there can be no questiou  that mechanical, chemical, and other local
irritations  are  often  the  immediate excitants  of its pathological
processes  iu  the predisposed skiu.   In this way the excoriations,
warts, naevi, and other lesions named  above, though  not  in  them-
selves cancerous, may become the original sites of the disease.  In this
way, too, the  irritation produced upon  the lip of the smoker  by his
pipe or tobacco; the local disorder about the  inner canthus  of the
eye resulting  from occlusion of the lachrymal ducts; the frequent
teasing by caustic or other substances, of the wart on an old man's
hand; and other agencies disturbing the balance  between waste and
repair, aided at  times  by senile atrophic changes,  may result  in  the
development of an epithelioma.  The possibility of the transmission
of cancer by  heredity has almost ceased to obtain credence  in  the
light  of modern pathology,  yet  Broca  reports sixteen deaths from
cancer in one family, aud Friederich, a congenital epithelioma in  the
child of  a cancerous woman.
  The disease is eminently one  of advanced years, being most fre-
quent  after the fortieth year, and a  pathological curiosity in  child-
hood.  Kaposi reports one case at the tenth year.   Only about thirty
per cent, of all  cases  occur  in women,  a fact possibly explained by
the relative iufrequency of the action of local  irritants in those who
are not subjected to the exposure incidental to the trades  and severe
occupations of life.
  These figures, however, relate only  to  cancer  of the skin, since,

 1 St. Bartholomew's Hospital Reports, p. 87, 1874.  See also the paragraph devoted to this subject
under the title of Eczema, p. 307. 
carcinoma.
567
M'hen cases of cancer of the breast and uterus are included, the pro-
portion of the sexes affected is almost exactly reversed.
  In favor of the local origin of all epitheliomata, is the clinical fact
of the excellent general health of most patients in  the  earliest stage
of the malady; M'hile  those affected with syphilis and tuberculosis
are usually exempt.
  Pathology.—The histological forms of epithelioma are well classified
by Vidal,1 as  follows: 1.  The  interpapillary form, in  which  cylin-
drical or peg-like epidermal prolongations flattened at the periphery,
penetrate doM'nward from the rete, often in parallel columns, between
the papillae of the corium, and  are  occasionally connected  below by
a species  of  anastomosis.   Here,  at times,  onion-like  "globes,"
" nests," or clusters of concentrically arranged epithelial masses are
  Epithelioma, vertical section,  a, d, cones of the rete projecting downward ; between these are
seen atrophied papillae 6; at e, d, and other points, are "nests" of epithelium ; c, atrophied stratum
corneum.  (After Kaposi.)
to be recognized, the centre, as Heitzmann remarks, beiug too  often
occupied  by epithelium  in a  state of fatty  degeneration.  In  this
M'av the derma and subcutaneous tissue may be, after previous vascu-
larization, completely invaded.  2. The lobulate  form, in  which the
epidermic globes are in pronounced excess, forming distinctly defined
masses  invading  the connective tissue.  Here multiplication of the
elements  is  abundant, thus diminishing or occluding the lumen of
the vascular elements, and leading to necrobiosis  aud  ulceration.  3.
The tubular form, cylindroma of Billroth, the adenome sudoripare,
of Verneuil.   In this, tubes like sweat ducts with a calibre, penetrate
the meshes of the connective tissue, often intermingled M'ith epidermic
globes.   It  is largely this form of the  disease  M'hich Tilbury Fox
and T.  Colcott Fox2 have recognized as originating from the  external
root sheath  of the  hair-follicle.   4. The pearly form, which Heitz-
mann  has  demonstrated to result  from fatty degeneration of the
epithelium in the centre  of a  "globe" or "nest."
  With regard to the secondary structural metamorphoses of epithe-

                  i Gazette des Hopitanx, Nos. 113 and 114, 1879.
                  2 Trans, of ihn London Path. Soc, 1879. 
568
DISEASES  OF  THE SKIN.
lioma, these are described by Heitzmann as due to fatty degeneration
of the epithelium, M'hich process may  result in  its calcification.
Waxy degeneration of both epithelium and  connective  tissue pro-
duces  the  appearance of shining homogeneous masses  M'ithin the
tumor, which  are characterized by a  noteworthy indifference to the
action of chemical reagents.   Colloid  and adenoid  metamorphoses
follow the breaking apart of already  formed cancer  epithelium, into
medullary  elements from M'hich  myxomatous tissue arises.  Cystic
cancer is a  higher development of the colloid form, M'here the myxo-
matous tissue  in  the alveoli  liquefies.   The papillary forms are
exuberant  groM'ths of circumscribed  portions of the tumor toward
and beyond the surface.
  Briefly, every column, "nest," "globe," or tubular prolongation
M'ithin the  skin, containing M'ithin itself an  irregular admixture of
epithelium  and connective  tissue, is  a caucer, or epithelioma, whose
gravity seems to be proportioned to the relative development of the
contained epithelium.   As  to the origin of the latter, Heitzmann is
in accord M'ith Virchow in affirming  the fact of its production from
connective  tissue.   The medullary elements  into M'hich connective
tissue  is transformed as  the result of an inflammatory  infiltration,
have been traced in the process of metamorphosis into cancer epithe-
lium.  Once fully developed, the neighboring lymphatics are invaded,
and secondary involvement of the viscera may follow.  These minute
epithelial particles of the neoplasm are SMept into the lymph ganglia,
thence through the lymph to the bloodvessels; where finally, lodged
in capillaries M'ith  a narrow lumen, they produce embolism.
  The malignant  forms of cancer may undergo changes by which
they are  transformed  into sarcoma.   In these, the epithelia become
gradually indistinguishable  as  such, in consequence of a species  of
liquefaction by which they are converted into medullary elements.
  Geber explains the pathological changes as follows: 1. Enlargement
of cones of the rete, the  peripheral epithelium  becoming cylindrical;
the  central, showing cubic aud  rhombic,  or flat, compressed, poly-
gonal, dentated, and spinous elements.   There are  multiple uuclei,
nucleoli, and vacuoles.   2.  The  sprouts of epithelium passing into
the  connective tissue become  so  long,  flat, and  abundant, that the
products of secondary inflammation  choke  them  at one  point or
another, so that separation occurs, and the isolated  part becomes  a
brood-nest  for one or several cancer colonies.  3. The cylindrical form
of the cells is either then  not visible or  rudimentary in character,
the cells and nuclei dividing.  4. There  is dichotomous  division of
the smaller and  infiltrated papillae,  projected beyond  the general
surface of  the  skin, producing thus  the papillary  form  of cancer.
Or, the irritation  progressing pari passu  with the  proliferation of
epithelium, the corium  is uniformly infiltrated with round  cells, the
connective  tissue corpuscles multiply,  the vessels dilate, and the cells,
constituting their parietes, proceed to further development.
  When the epithelioma originates in the deeper structure of the
corium, a round-celled proliferation affects all the epithelial structures 
CARCINOMA.
569
 in the cutaneous glands and hair-follicles, as M'ell as in  the  deeper
 portions of the rete mucosum.   The epithelial cones are large and
 increase out of proportion to the stroma of the cancer-tumor, M'hich
 is, therefore, softer and more juicy.   The bloodvessels aud  lymphatics
 multiply, especially in the rapidly growing nodules.   As the disease
 advances, nervous, muscular, cartilaginous, osseous, and other tissues
 may undergo a cancerous transformation, or be simply eroded before
 the  inflammatory and pressure effects of  the groM'ing  neoplasm.
 Occasional terminations of the disease are  by exfoliation, ossification,
 calcification, fatty metamorphosis, and sloughing en masse.
   Diagnosis.—Epithelioma is to be distinguished from lupus vulgaris
 approximately, by the  age  of the  patient, the latter disease  rarely
 appearing after the thirty-fifth  year where there is not a scar  or
 history of its earlier existence.   Lupus is, at an earlier period of  its
 career, more diffuse  than  epithelioma;  its elementary  lesions  are
 more  distinctly groups of individuals than a homogeneous aggrega-
 tion ;  its ulcers are more  often  bordered by outlyiug non-ulcerative
 papules, furnish a more puriform discharge, and, most distinctive of
 all,  are never walled  about by the firm, densely indurated,  often
 everted lip of the epitheliomatous ulcer, opening out often to a sound
 peripheral integument.  The peculiar and often  characteristic odor
 of the cancer discharge, is absent in  lupus.
   From syphilis,  epithelioma  is to be distinguished : first, by  the
 age  of the patient, syphilis  being decidedly a  disease  of early and
 middle life;  second, by the  far greater relative rapidity of the syphi-
 litic process, exception being always made of fertiary gummatous
 ulcers upon  the lower  extremities persisting for years M'hen there is
 both lack of internal  treatment and local support;  third, by the
 history of the disease  in each  particular case  ; and fourth, by the
 characteristic syphilitic features always present in infected individuals,
 including multiplicity  of  lesions, typical cicatrices, contour of ulcers
 (that of epithelioma is  rarely either  reniform, horse-shoe  shaped,  or
 crescentic), character of discharge, and general  absence  of pain.   A
 very important point  to  note  is  a  marked tendency  to reparative
 cicatrization  in  old  syphilitic ulcers, partly due to the exhaustion of
 the infective poison, partly to the influence of the insufficient but yet
 modifying treatment so common in this country.  This is exceedingly
 rare in  epithelioma,  the  latter  being  often,  the  former rarely, a
 malignant disease.
  Epithelioma of the genitals is not to  be confounded with chancre,
 or syphilitic  tubercles of that region.  The peculiarities of the con-
 sequent adenopathy in each case ;  the lancinating pains of the cancer;
 its much more prolonged  duration ;  and occurrence in an aged sub-
ject, M'ith the general  history of the case, will  usually point to the
 truth.
  Sarcoma is characterized by :  its far more rapid  evolution, tumors
 often attaining their maximum of development in the course of a few
 months ; its occurrence  by predilection in earlier life ; its inaptitude 
570                DISEASES  OF  THE  SKIN.
for ulcerative degeneration ; and its marked tendency to multiplication
in contiguous or distant portions of the body.
   The warts,  naevi, excoriations, aud seborrhceic lesions, from which
epitheliomata  often take their origin, cannot be determined as having
such  a  tendency before the cancer has attained some  development.
Every such persistent  and  long  irritated  lesion on the person of a
male  subject of advanced years, should  be regarded M'ith a degree of
suspicion.
   Treatment.—No internal  treatment of cancer of the skin is known
to exert the slightest influence upon the growth.
   The treatment of epithelioma is by excision, erasion, or destruction
of the growth.  The first is performed by surgical ablation with the
bistoury, after M'hich one of the  plastic  operations may be required
for either the  complete  covering  of the M'ound, or  the relief of the
resulting deformity.  The second is applicable only to  the less formid-
able growths,  and is performed by the aid of the dermal curette.
   Destruction of cancerous tumors  of the  skin is  usually  performed
by the aid of caustics,  of which  caustic  potash, in stick or solution,
is, perhaps, the most valuable, as  its destructive action may be con-
trolled by the topical employment of acids, and is followed by  less
pain  than some  other  chemical  agents.   Other caustic  substances
employed  for a similar  purpose are, chloride of zinc, Vienna paste,
nitrate of silver, arsenical paste, and pyrogallol.  The latter is recom-
mended highly by Kaposi, not only because  its  application is  un-
productive of pain, but also because it does not attack sound tissue.
It is used  iu au ointment of ten per cent, strength.   All  such pastes
and ointments should be spread  upon cloths, and  applied for from
three  to six days.   Opiates  may be required, in the  case of several of
these  agents, to relieve  the consequent pain.
   Among  the formulae  used for caustic purposes are the following:
        R. Creasoti                    ^ss;           16
            Acid, arsenios.            gr. iv;             266
            Opii pulv.                 gr. ij;             133   M.
        For employment upon circumscribed surfaces.        [Kaposi.]

   Marsden's paste, also employed as a caustic,  is made by combining
equal parts of gum Arabic and arsenious acid with water sufficient to
make a softish paste.    It is preferred by Robinson to others, and is
applied on rubber plaster.
   Cosme's paste, as modified  by Hebra, is prepared as folloM'S :
        R. Acid, arsenios.            gr. vj ;            140
            Hydrarg. sulphuret. rub.     £ss;            2,
            Unguent, aq. ros.           i$ss;           16      M.
        Sig.  Arsenical  paste.

   The method of its application is as follows :  The paste is spread
over a thin sheet of lint to the  thickness  of a knife-blade, aud  the
lint then cut to a shape  and  size corresponding with that of the tumor
or ulcer to be  destroyed.  After its close apposition with the surface
to be attacked, it should  be covered with gutta-percha, or other 
CARCINOMA.
571
impermeable tissue, and a compress laid over the M'hole.  The dress-
ing is removed, the parts washed clean, aud the same application
renewed  in  twenty-four  hours.   By the third  or fourth day, the
destruction  of the cancerous growth is usually  complete,  and the
parts are ready for an emollient  poultice, which  should be applied
for the three or four days  during  which  the  separation  of the
sloughs occurs.   The simple ulcer  left, is to be  treated on general
principles.   The danger of arsenical  poisoning is here reduced to a
minimum;  the treatment being very effectual where patients consent
to the delay as to time and  to the very severe pain which it occasions.
It  has  been  used by  me  M'ith  satisfactory results, and is highly
praised  by  Atkinson1 in an admirable lecture on epithelioma, deliv-
ered by him in the University of Maryland.
   The thermo- and galvano-cautery also may be often advantageously
used for the destruction of the growths.  I  have used  the former by
preference in many cases, occasionally M'ithout, often with, return of
the neoplasm.  Its advantages are:  the transitory character of the
induced paiu; the coal-like dressing left upon the attacked  surface;
and the elegance of the  resulting scar.  Both  measures find  their
highest value M'hen employed after effectual excision or erasion.
   Whatever method be employed, thoroughness is essential in attack-
ing all portions of the new growth ;  and it is well to encroach some-
wbat upon  the unaffected contiguous  structure.   The subsequent
dressings  should  be  made with simple or  carbolated unguents, to
M'hich one of the salts of morphia may be added in case of continuous
pain.  The  eschar usuallv separates  in the course of a few days,
leaving a  simple granulating Mound M'hich may cicatrize  soundly,
and the epithelioma be thus radically relieved.   In other cases, the
disease  reappears in the ulcer or cicatrix;  or by recurrence of can-
cerous nodules  in the previously sound integument.  Even after
these recurrences, prompt  destruction  of the new  growth may be
finally successful.
   But little confidence is placed  upon any external treatment which
does not effect the complete destruction  of the neoplasm.  Yet there
are those  who highly esteem  some of the procedures M'hich are less
radical in their aim.   It is proper to mention these.
   There  can be  no doubt whatever  that  some circumscribed  and
relatively small  growths disappear under the  hot-water treatment.
The sole question which then arises concerns the possibility of spon-
taneous recovery iu such cases irrespective of the treatment  pursued,
since such spontaneous involution is a clinical fact, rare of occurrence
though  it be.   By this method, the  neoplasm is sponged with hot
Mater for from  fifteen  to  twenty minutes every three hours  of the
day,  and  oftener if possible, for three weeks  in  succession.  The
M'ater is as hot as can be tolerated, and applied by the aid of a bit of
sponge mounted on a probang.  During the course of the application,
Mater in a state  of ebullition, is added in small  quantities to that in

  i Reprint, in Chicago Med Journ  and Exam., Aug. 1880,  p. 188, from the Virginia Medical
Monthly. 
572
DISEASES  OF THE  SKIN.
which the sponge is dipped from minute to minute, thus keeping the
temperature at the highest tolerated point.   Immediately after each
application, the part is thoroughly dried, and then  either anoiuted
M'ith a bland unguent or completely covered with iodoform in powder.
When such applications are of service, the good effect M-ill  usually be
noted  in a week.   The ulcer changes its aspect  in color, edges, and
floor;  and the pain, if any have existed, is greatly relieved.  Granu-
lations of a healthy type appear, and  the  lips of the sore contract.
Non-ulcerated lesions shrink  in  volume, and otherwise  change in
feature.   This system of "parboiling" has the advantage of not pre-
cluding the ultimate employment of radical  measures.   The largest
epithelioma completely relieved by this method,  was of the type of
the " rodent ulcer," on  the temple of a male patient  seventy-two
years of age.   It had the size of a section of a small hen's egg.  The
resulting  cicatrization was satisfactory in  all  respects.   There has
been no return in two years.   Needless to say, the method M'ill often
fail.
   Leveque,1 Vidal,2 Bergeron,3 Euthyboule,4 and others claim large
success in the treatment of  epithelioma  by chlorate  of  potash.
Locally, the part is  frequently touched with  a saturated  solution of
the salt in glycerine and warm M'ater, after which a simple ointment
dressing is applied.  Vidal administers also the same drug internally,
in  doses  of a drachm  and  a half (6.) in syrup and  water before
meals.  It is  possible that any remedial effect obtained from  such
measures should be attributed to the fomentations employed.
   Latterly, benzole has been reported as a valuable topical  applica-
tion to small-sized  epitheliomata.   The author  has employed  it in
several cases with no very marked  results.
   Injections of solutions containing copper-sulphate,  iodine,  alcohol,
acetic acid, nitrate of silver, chloride of sodium, and hydrochloric acid
have been  practised, it  is  claimed, M'ith some success ;  certainly at
times M'ith fatal results.   The  method is unquestionably inferior to
others described above.
   Prognosis.—In general, it  is scarcely necessary to say that the
prognosis of cutaneous cancer  is  grave.   The relative  degree of
gravity will, of course be  largely proportioned to the variety, form,
size, career, and complications  of the  growth in  each  case.  The
variety in M'hich " pearls " only form in the skin is the most benign
of all,  as the lesions are usually isolated, and  often, when unirritated,
undergo spontaneous  exfoliation.   In  other  cases, the  disorder for
from fifteen to twenty years seems  to make no progress of any  sort.
The malignity of  a cancerous growth  is ahvays proportioned to the
quantity of epithelium contained in its alveoli as compared with the
connective tissue present;  the  more abundant the latter, the more
favorable  the prognosis.   Naturally, also, the deeper and the more
destructive the groM'th, the fewer are the chances of ultimate recovery.
Excessive pain and adenopathy are unfavorable symptoms  in any
1 Glasgow Medical Journal, 1881.               * Loc. cit.
8 Acad, de Med., Paris, 1873.                  * These de Paris, 1877. 
CARCINOMA.
573
case.   Koch1 gives some interesting statistics of the results of opera-
tions, at the  Erlangen Clinic, for removal of epithelioma of the lower
lip, in one hundred and thirty-one patients exhibiting primary lesions.
One hundred and fifteen M'ere for the time " cured ;" four had speedy
relapse ; and three M'ere, at the date of writing, living  and suffering
from recurrence of the disease.  The prognosis M'as thus absolutely
favorable in  but twenty-eight cases.

                 Cancer of the Connective Tissue.

   This  is rare as a primary cutaneous manifestation, but appears
generally as  secondary to a cancerous involvement of other organs,
as of tbe female breast.   It is  termed also  Scirrhous, Hard,
Fibrous, or Lenticular Cancer.   It occurs either  upon the skin
covering a breast M'hich has beeu previously transformed  into a can-
cerous mass, or as a cutaneous relapsing  lesion  after the  extirpation
of the  latter.   Its  symptoms are pea-  to  bean-sized, densely firm,
shining nodules, varying in color ; or a more or less diffuse infiltra-
tion of  the skin of similar characteristic hardness, associated often
M'ith hyperaemia of a purplish-red shade.
   A very interesting case of widely disseminated lenticular cancer of
the skin, illustrated by  au  excellent  portrait,  is described by Dr. P.
A. Morrow,2 occurring in a healthy-looking woman  as a secondary
phenomenon after  removal of primary cancer of the breast.   The
lesions Mere  closely set,  small, shining, firm, red papules ; erythema-
tous redness ;  miliary and  pigmented  deposits, tubercles  varying in
size ;  subcutaneous nodules ; ulcers, crusts, and cicatrices.
F'i When the cancerous  infiltration  is M'idely diffused and indurated,
involving at once a large portion of the integument of the  thorax, the
condition  is  produced  which  is termed by  the  French cancer  en
euirasse.  This infiltration  also is usually secondary to involvement
of other organs;  but, according to Cornil and Besnier,3 it may first
develop  in the skin.   Pathologically, the  form of carcinoma here
described is  also  epitheliomatous, since its   fibrous  stroma  always
contains, in the centre of narrow alveoli,  a relatively small number of
epithelial bodies.  It is  usually slow of development, but in the end
accompanied, as  are  other  cancerous tumors, by adenopathy, pain,
and ulcerative changes,  M'hich induce an inevitable cachexia.  Like
the other varieties also, relapse after  extirpation is common, and the
prognosis is proportionately grave.

                       Tuberose Carcinoma

is a rare manifestation of the disease, occurring in the  form of mul-
tiple, firm, peanut- or egg-sized, roundish nodules, M'hich break down
bv ulcerative processes  into deep losses of tissue.  It is  frequently
accompanied  or followed by cancerous involvement of  other organs.

              l Centralblatt f. Chirurg., 1881, Xo. 40.
              - Journal of Cutan. and Vener Diseases, June, 1881, p. 1.
              s Bulletin de la Sue. Med. des Hop., 1878, p 158. 
574
DISEASES  OF  THE  SKIN.
it occurs chiefly upon the face, hands, arms, and  chest, though also
upon other portions of the skin of persons of advanced years, either
as a primary or secondary cancerous manifestation.   Guinard1  reports
the case of a cancer of this variety, remarkable  for the small  size of
the existing nodules, which varied from that of a hempseed to a pea.
They covered the entire thorax, back, and  right arm, and  had here
and there broken down into ulcers.  One of the latter was as large as
the hand.

               Melanotic or Pigmented Carcinoma

is that form in  which both  the epithelium and  connective tissue
framework of the cancer are richly supplied with bloodvessels, and
probably, as a consequence of transudations  from the  latter, an abun-
dant  supply of pigment granules in groups and  clusters.   These
growths usually begin as hempseed- to pea-sized, single or numerous,
soft or dense nodules, which may develop in time  to  tumors of con-
siderable size, and are stained in various shades from a grayish-brown
or a  slate-color to a dead black, the pigment being occasionally dis-
played irregularly in streaks or bands over the surface of the growth.
They occur over any portion of the surface,  oftener upon the extrem-
ities  and genitals, starting frequently from benign pigmentary  lesions,
such as naevi and moles.   Anatomically the  pigment is found to  be
deposited both between the cells and in the protoplasm of the cells
themselves.
   The author has, in a few instances, seen the disease limited to single
melanotic growths of this character.  The cancer is apt to develop in
the papillary form, furnishing thus fungoid  vegetations which have a
noteworthy tendency to degenerate into ulcers.  Often such verrucous
masses are seen  surrounded by grayish or blackish papules, or by a
diffuse cancerous infiltration of the integument, exhibiting irregular
pigmentation of the  surface.  The disease  is apt  to appear  in the
viscera, in  the form of disseminated cancerous nodules, each  highly
vascular, and  exhibiting in varying quantity granules of pigment.
The growth has  usually  a  relatively  rapid course  and  malignant
career.   Relapses  are frequent,  the  amount  of pigment  usually
increasing with  each  relapse.   A nut-sized melanotic  cancer of the
skin, removed  from the  hand of a patient  in Chicago  by one of the
author's colleagues, Mas  not  followed by other manifestations of the
disease during the ensuing year.  At the end of that  time the patient
passed from observation.
1 Union MOd., February 5, 1881. 
SARCOMA.
Ol o
                            Sarcoma
                           Gr. oiip~, flesb.
Sarcoma of the skin is characterized by the occurrence, either as primary or
  secondary developments, of single or multiple, pea-to egg-sized and larger,
  pigmented and  non-pigmented, cutaneous and  subcutaneous neoplasms
  having a marked inaptitude for ulceration but malignant  in character,
  recurring after extirpation, and usually terminating fatally with  involve-
  ment of the viscera.

  The  term Sarcoma,  meaning  a fleshy tumor, M'as originally em-
ployed by Virchow iu the designation of this disease. Its anatomical
features have been carefully studied since by Rindfleisch, Cornil and
Ranvier,  Babes, Heitzmann, and others.
  Symptoms.—The disease, when affecting  the skin, is characterized
by the appearance of one or several, usually at first isolated, pea- to
nut-sized and   larger,   smooth,  spherical, irregular,  or lobulated,
cutaneous or subcutaneous tumors.  They may or may not be at first
attached to the epidermis above and the deeper structure beneath, but
eventually contract such adhesions.  BetM'een  them the skiu may not
be involved.  Iu  uncomplicated cases at this period, the  conspicuous
features  of these lesions are  (a) their  M'hitish color, due to their
envelopment in an unaltered  epidermis ; (b)  the history of a rela-
tively rapid development, as distinguished  from fibromata, epithelio-
mata, gummata, and lupous tubercles; (c)the speedily declared sys-
temic results of the growth.
  Later, the skin  betM'een the lesions  becomes  swollen, infiltrated,
painful; and, even before the  tubercles desquamate, enormous tume-
faction  and redness of an erysipelatous type may  affect the  inter-
nodular  tissue.   In this way an  entire limb, only one  portion  of
which is the seat of the tubercular growth, may attain an elephanti-
asic size, ulcerate at one or  more points, and   pour  out an offensive
secretion as a consequence of ulceration of the  inflamed integument.
  In the course of time, weeks not years, the  nodules  or tumors  of
sarcoma coalesce,  degenerate  by  ulceration,  and participate  in the
process  of secretion going on in the inflamed  and excoriated surface
of the skin M'here they  are implanted.  Death speedily results, either
from  exhaustion,  intercurrent  fever, or  sarcomatous involvement  of
one or several viscera.   By the same process the skin lesions  may  be
the product of metastasis from the lymphatic glands or viscera.
  The disease  occurs in this form over the  chest, extremities, and
genitalia, though  all parts of the skin have been invaded.   The
patient  from whom the tumors  M'ere removed, M'hose microscopical
features  are  represented  in the  accompanying  illustration,  was a
woman  in middle life.
  The disease is both rapid iu course aud malignant in type.   In a
total of more than fifty  thousand cases of disease of the skin reported
to the American Dermatological Association up to 1882, only sixteen
Mere sarcomatous, the actual percentage being  0.027. 
576
DISEASES OF THE  SKIN.
   The Etiology of the disease is unkuowu.
   According to Babes, sarcomata are  frequently congenital, and  not
rarely formed in early youth on the lids, extremities, and genitalia.
   Pathologically,  according  to   the*  same   author,  sarcomata  are
                                   new-formations  of  embryonal
                                   tissue  M'ith abundant prolifera-
                                   tion of  vascular  elements and
                                   vessels,  As to the former, nume-
                                   rous rudiments of vessels mul-
                                   tiply without  developing  into
                                   complete  vascular   channels,
                                   often making eventual connec-
                                   tion with preexisting  vessels.
                                   In  these there may be a  com-
                                   plete or incomplete development
                                   of  blood.   In other cases, the
                                   parietal portions of young blood-
                                   aud  lymph-vessels  proliferate
                                   abundantly  in  an  embryonal
                                   formation  of fasciculi and alve-
                                   oli, either  choking the lumen of
                                   the original vessel, or transform-
                                   ing it into vacuoles, cups, aud
                                   spaces.
                                      All tumors of  this character
are abundantly supplied with cells, the  proportion  of M'hich  to  the
stroma is markedly in excess.  They never resemble embryonal and
granulation tissues.   The cells  may  be spindle-shaped, spheroidal,
branched, with one or many nuclei, and either  large or small.   The
fibrillar  basement-substance,  according  to  Delafield and Prudden,1
may be present in such small quantity as entirely to escape superficial
observation ;  or  so  abundant as  to  suggest the appearance  of  a
fibroma.   It may be closely inwoven witb the cells in  such bundles,
or exhibit M'ide and open meshes presenting the appearance of alveoli.
The cells are  in  intimate relation, and  often  continuous with  the
basement-substance.   Both cells aud substance  are in  the.same close
relation  with  the vascular elements  described above, upon  M'hich
Babes relies so largely for identification of  the nature of the growth.
   Virchow described  originally  five  varieties of sarcoma : round-
celled, spindle-celled,  net-celled,  giant-celled,  and  melanotic.   In
spindle-celled  sarcoma the cells may be  large or  small, and  vary so
greatly in proportion to the stroma as to furnish the  subvariety of
fibro-sarcoma, in  M'hich the fibrous tissue abounds between the cells.
These may be encapsulated or infiltrating.  The mass of the tumor
is then  constituted  of a  decussating  felt-work  of spindle-shaped,
nucleated, protoplasmic bodies.
   Round-celled sarcoma is constituted of globular, protoplasmic  ele-

Fig. 77.
  Sarcoma.  Spindle-cells visible in sections of a
cutaneous nodule removed from one of the author's
patients.  (About X 300.)
1 Handbook of Pathological Anatomy and Histology, New York, 1885 
SARCOMA.
577
ments closely packed together, and separated by a very narrow layer
of cement-substance, traversed by delicate prolongations of the living
matter which uninterruptedly connect the  elements.  The  vascular
supply is scanty.  There are two forms of this growth found  in the
skin: (a) Those with relatively large protoplasmic bodies and large
nuclei—large round-celled sarcoma.  (6) Those with relatively small
homogeneous lumps of living matter—small round-celled sarcoma or
" lympho-sarcoma."  The  last-named  varieties  are,  as  a  rule, more
rapid in  growth aud more malignant in career than the former.
   In the "alveolar sarcoma" of Billroth there is a delicate connective
tissue framework, containing attached  globular  or pyriform bodies.
Heitzmann has recognized this form once, in the skin of the left groin.
   The compound varieties of the disease, myxo- aud fibro-sarcoma,
are  occasionally seen  in the  skin.  The  formation  of  secondary
tumors is explained, according to Heitzmann, by the transmission of
minute  particles of the neoplasm to capillaries of a fine lumen, pre-
sumably through the  bloodvessels, as the  lymph ganglia are rarely
involved.
   The diagnosis rests  upon microscopical  examination of the new
growth   in every case.  Sarcoma should  not  be confounded with
fibroma,  epithelioma, gummata, or lupous nodules.
   The treatment is  highly unsatisfactory.   The surgical ablation of
these tumors is apt  to be followed by their speedy return.
   The prognosis is exceedingly unfavorable, a fatal issue occurring
in most cases.

   Melanotic Sarcoma, or Melasto-sarcoma of the skin may be
of primary occurrence or develop from a naevus  pigmentosus.  The
lesions are bean- to egg-sized, single or  multiple, firm or  doughy,
sessile  or pedunculated, spheroid or tabulated; aud vary  in  color
from grayish-brown to  deep black.   The  epidermis  which  covers
them may be discolored, thinned, and intact  or ulcerated.   The secre-
tion  maybe of any shade to an inky blackness.  The nodules are often
surrounded by blackish puncta which eventually develop into tubercles.
   In a case lately observed by the author, the left lower extremity of
a  middle-aged  woman Mas studded with split pea-sized to  marble-
sized, ink-black masses from the ankle to the middle of  the  thigh.
The  larger M'ere always centres of groups  of similar pin-head sized
black masses.   The skin of the region affected M'as swollen,  inexten-
sible, inelastic, and as firm as sole-leather.   The disease had rapidly
extended from the aukle upward in the course of a few months.
   Pathologically, tumors of this  kind  are fouud to  exhibit  the ana-
tomical  features of  sarcomata in general, M'ith  pigment distributed
both M'ithin  and between the cellular elements  of the tumor, and
between  the fasciculi of connective  tissue in the framework.   It is
one of the  most malignant and rapidly  fatal  of all  neoplasms.
Therapy  is unavailing; and the prognosis is grave indeed.
                                37 
578
DISEASES  of  the  skin.
                     Mycosis  Fungoides.
                       Gr. iivkt)c,  a mushroom.
Mycosis Fungoides is an infective disease, characterized by various cutaneous
  phenomena which result finally in the production of one or several well-
  defined, firm, reddish tumors, probably due to the presence of specific micro-
  organisms.
  This disease, first named by Alibert, has also been termed, Granu-
loma  Fungoides, Granuloma Sarcomatodes,  Lymphadenie Cutanee,
Inflammatory Fungoid Neoplasm, and Eczema Tuberculatum.
  Symptoms.—The disease  is  often preceded  by the occurrence  of
inflammatory changes  in the  skin,  erythematous, eczematous, psori-
asiform, urticarial, or lichenoid, which may be transient  and recur,
or persist.  Eventually the skin becomes infiltrated, thickened, and
decidedly pruritic.  In either case,  the characteristic lesions of the
disease develop upon a sound integument.

                             Fig. 78.
                           Mycosis Fungoides.
      (Drawn from an oil painting tak*n at the bedside of one of the author's patients.)

  In a variable period of time, the characteristic tumors of the disease
appear  upon the face, scalp,  chest,  or other portions  of the body.
They are  bean-to  palm-sized;  M'hitish, pinkish,  or  pale reddish  in
hue;  firm, M'ell rounded, and distinctly circumscribed.   Often they
are like flat buttons,  movable M'ithin the skin.  They may then dis-
appear by absorption M'hile others appear;  may degenerate by erosion
leading to superficial  ulceration ; or may melt doM'n  into deep losses
of tissue  by ulceration.   Coincidently the lymphatic  glands may 
MYCOSIS  FUNGOIDES.
579
enlarge and  this adenopathy, as in case of the tumors, subside to be
replaced later by similar involvement of the same or other glands.
   \Y hen  the tumors  have attained  maturity aud  before involution
has begun, their appearance, especially upou the face, is characteristic.
They  are smooth,  moderately  firm,  sausage-like iu  shape, often
tabulated, of a peculiarly reddish  hue, and produce M'hen numerous
a  lepra-like  deformity, closing the eyes by their size or Mcight, pro-
ducing the leonine brow and  the  elephantiasic ear.  In theauthor's
case illustrated in  the cut1 the body of the  patient Mas  extensively
covered M'ith tumors of all sizes, resembling those seen upou the face.
   The  general  condition  of the patient  at  first   seems unaltered;
later, M'hen   the tumors ulcerate, exhaustion  occurs and the victim
usually dies, as  in other cutaneous disorders  of similar gravity, as a
result  of febrile processes,  or of an intercurrent diarrhoea, or of
cachexia.  When the tumors  are many and the ulceration extensive,
the appearance of the  patient is repulsive in the extreme, the exhala-
tions  from the  body  in  the highest degree  fetid, aud  the difficulty
of securing  antisepsis, hygienic care, and comfort  for  the wretched
sufferer well nigh insurmountable.
   The  fully developed tumors occur upon  all parts  of the body,
more particularly upon the palmar and  plantar  surfaces, the  fore-
arms, the legs, the face, aud the back.  Often  they are in  various
degrees pigmented, showing then  purplish, brownish, or even black
colors.   They are usually painful, and  may or  may not be  tender.
They  sometimes, after  disappearing, leave  atrophic or pigmented
depressions   as relics  of their career.   They  are  said  to  ulcerate
rarely.    In the author's  patient, ulceration attacked some of the
tumors, leaving crateriform excavations in their centres, but this Mas
an exception to the rule, the larger number present preserving their
shape  in death,  in a few, vegetations appeared upon  the summit,
smeared M'ith a thin and very offensive secretion.
   AVhen  the tumor is single, and apparently uncomplicated  by in-
volvement of deeper organs, extirpation is usually followed by recur-
rence, either in the scar or vicinity, M'ith added malignancy.
   On the backs of the hands the lesions may be no larger than small
marbles, M'ith infiltration  of the skin  lying  betM'een  the latter, pro-
ducing thus  the appearance of a small, well-rounded, cushion.  The
epidermis of such an  oedematous  hand  usually exfoliates in  silvery-
M'hite  or grayish scales, more or less adherent.   The  feet and legs
may exhibit a similar appearance.
   The  disease has  been studied  abroad by  Hebra,  Kaposi, Geber,
Alibert,  Fox,  Kbbner, Auspitz,  and others; in  this  country  by
Duhring, Piffard, WigglesM'orth, Tilden,2 and the author.
   Etiology.—The disease  is  fortunately rare.  Dr. Tilden collected
the records   of thirty  cases of the  disease  and of  sixteen  deaths.
Twenty-three patients were males,  aud seven  females; more than
half the whole number were over forty years of  age;  in only  one

 1 Edinburgh Med. Journ., 1SS3-1884, xxix. p. 592.
 2 Consult Dr. Tilden's admirable monograph on the subject, in  the Toston Med. and Surg. Journ.
of Oct. Tl, K«8.'>. 
580
DISEASES OF THE SKIN.
fourth of the number had the disease developed before the twentieth
year of life.   There can be  little question to-day as to its infectious
character.   It is probably produced by a specific microorganism.
  Pathology.—Under the microscope, sections of tumors removed from
patients  affected with the  disease, exhibit infiltration of the  corium
and  subcutaneous tissue with small round cells  arranged in circular
or irregular groups, enclosed in  a narroM' stroma of fine connective
tissue  fibres, with often a centrally situated bloodvessel.   The epi-
dermis, at first spared, is afterward involved by ulceration.  According
to Gannett, M'ho examined sections  in Tilden's case, the cells corre-
sponded, morphologically, to lymph-corpuscles.
  The microorganisms of mycosis  fungoides have been recognized
by Rindfleisch,  Auspitz,1  and others.   An  exhaustive  report on the
subject has been made more  lately by  Auspitz's collaborators, Messrs.
Hochsinger and Schiff;2 and Professor Firket,3 of the University of
Liege, reports yet another case, illustrated by a photograph, in M'hich
micrococci were  recognized.   These are diplococci or streptococci, 0.9
to 1.2  mm. in diameter, and found clustered together both in  tumors
aud in bloodvessels.   They were found not only in the protoplasm of
the cells, from ten  to twenty in  each, but  also thickly spread along
the connective tissue fibres  in the neoplasm.  These were cultivated
successfully for  a series of generations in gelatine and  blood-serum.
Post-mortem examination has rarely shown visceral involvement.
  The diagnosis of mycosis  fungoides cannot be made M'ith certainty
before the characteristic  tumors have been developed.  After that,
the peculiar shape, reddish  color, situation, and  relative rapidity of
the growth point to the nature of the disease.
  From lupus vulgaris, with M'hich  it may be confounded in vieM' of
the age of the patient,  it  may be  recognized  by its relative rapidity
of evolution, its failure to ulcerate at an early stage, and the absence
of cicatrices in cases where there has been  no operative  interference.
  Syphilis is to be distinguished  by its history,  its multiformity, its
ulcerative  type,  and its  amenability to specific treatment.   Lepra
does indeed, when occurring in  its  rare and acute forms, suggest
mycosis fungoides of the face.  But the presence or history of hyper-
resthetic or anaesthetic symptoms, of  bullous or  macular lesions, and
the  absence  of  deforming  mutilations in advanced  periods, will
usually poiut to the nature  of the disease.  The tubercles of lepra
are smaller than the tumors  of mycosis fungoides; more bronzed and
less fleshy in color, and of far less general distribution than in several
cases on record of the last mentioned  disease.
  The  treatment is unsatisfactory.    With the knoM'ledge now pos-
sessed as to the nature of the disorder, the  bichloride of mercury
would certainly  be indicated in the local management of the disease.
  The  comfort  of the patient is to be secured  by all measures, in-
cluding anodynes in an advanced stage of the disease, and his strength
should be supported  by a generous diet and tonic  regimen.   AVhen
the disease is generalized, tepid baths are productive of great comfort
1 Viertl. f. Derm. u. Syph., 1885.
3 Ann. de. la Soc. Med. Chir. de Liege, 1886.
2 Ibid., 1886. 
PRURITUS.
581
and  the use of carbolic acid, or some similar agent,  is indicated by
the fetor arising  from  the  person.  The body should be  anointed
with a bland unguent after each bath.   When  the lesions are single
or few, it is doubtful whether extirpation should be practised.
  The prognosis is  unfavorable.   The  patient may survive from a
few mouths only to  a maximum of twelve years, the average being
two to four years.
                       CLASS   VII.

                           NEUROSES.

                         Hyperesthesia.
                  Gr. vwep, above; aladijaic, sensibility.
   This is a condition characterized by exaggerated  sensibility unat-
tended by structural changes  in the skin.  It may be idiopathic or
symptomatic, general or partial, unilateral or bilateral, and  may also
vary greatly iu the degree of abnormal subjective sensation by which
alone it  is declared.  In mild  cases, there is unusual sensitiveness
to contact M'ith foreign  bodies,  such as the clothing; in others, the
distress occasioned by even the passage of a feather  over the surface
is almost intolerable.  The  symptomatic  variety of the malady is
most common, occurring as one  of the  several manifestations of
hysteria, tetanus, and other nervous disorders, including certain forms
of  motor paralysis M'here seusatiou  has beeu retained, though  in  a
perverted  condition.   The disease   is  properly  classed  with  the
neuroses of the skin, with respect to whose  etiology and  pathology
much remains to  be  investigated.   Its chief manifestations are the
production of itching and pain.
   The former is in the skin much  more  frequently experienced  than
the latter; and is an  almost  constant symptom  of active cutaneous
hyperaemia and exudation.   The parsesthesioe (in which sensations of
heat, formication, tickling, dripping  or pouring  of liquids of various
temperatures are experienced) are more often  associated with extra-
cutaneous affections.
   Pain, solely and simply limited to the skin, is, in fact a neuralgia
of a nerve  having a cutaneous distribution.

                         [A.]  Pruritus.
                         Lat. prurire, to itch.
Pruritus is a functional disorder of the skin, characterized by the sensation of
  itching in a part or a whole of the body, and  unaccompanied by objective
  symptoms of disease.
  Symptoms.—Pruritus  is to  be distinguished not only from prurigo,
a rare disease of the skiu already described, but also  from the symp-
tomatic sensation  of  itching which is  occasioned by a number of 
582
DISEASES  OF  THE  SKIN.
cutaneous disorders, such as  eczema, scabies, and  those produced by
pediculi.   Hebra was first to recognize the  indepeudent character  of
the disease here considered ;  and it is perhaps to be regretted that he
did not give to it a name distinct from that which is also applied  to
a symptom common to several  maladies of the skin.
   Pruritus is  characterized  by a sensation  of itching  not produced
originally by  cutaneous lesions.  It may be general  or partial.  In
either form, it  begins usually by a tickling, pricking, crawling, or
itching sensation in the skin, M'hich solicits the sufferer to rub, press,
scratch, or  otherwise irritate the affected  integument.    It usually
occurs by accesses in the day or night, much  more ofteu the latter,
occasionally both;  and  these  accesses manifestly occur under the
immediate stimulus of some internal or external cause.   Thus moral
emotions, a cool draught of air, the warmth of the bed, the pressure
of clothing, and often the substances  applied externally  with a view
to the relief of  the pruritus, suffice to determine  a crisis.  Hcnvever
firmly the sufferer may determine to  avoid injury to the person, in
well-marked cases  the impulse to scratch becomes well nigh  irresis-
tible, and, in the highest degree, tormenting.   From the milder, the
patient will thus be  frequently teased to inflict the severer injuries
upon the skin.  Brushes, combs, coarse cloths, and even metal instru-
ments, will be  employed in exaggerated cases, for  the purpose of
assuaging temporarily the local distress.
   The objective cutaneous symptoms which may be presented are all
secondary, and invariably result from  self-inflicted injury.  In some
cases they do not appear, the statements of the patient being the sole
basis for a recognition of his disease.    This may  be the  consequence
of unwonted self-control, or of the mildness of the malady, or of the
transitory character of the lesions produced.   Thus the skin may be
reddened during a nocturnal paroxysm under the  manipulation of
the sufferer, and the transitory hyperaemia disappear in  the daytime
M'hen the skin is submitted for inspection.  Not rarely, however, the
integument resents the  treatment  to  which  it is subjected,  by dis-
playing wheals, hyperaemic blotches, reddeued papules, excoriations,
characteristic  "scratch  lines," and  the  minute blood-crusts  which
indicate that the papillary layer of the derma  has been reached and
slightly torn.  As these causes are among those recognized for eczema
and dermatitis, it is not surprising to note that such disorders of the
skin may be in this way originated, and still  further add to the sub-
jective distress.   Skins M'hich have been  for years the seat of a per-
sistent pruritus  leading  to traumatisms of the epidermis, are  always
deeply pigmented.
   The localized  forms of pruritus, albeit the abnormal sensation is in
them limited  to certain  regions of the body, may occasion fully  as
much distress  as those in which a larger  part of  the integument is
affected.   They  are of more  frequent occurrence than the generalized
forms.  Pruritus of the  anus,  of the  scrotum, of the  vulva,  of the
vagina, of the scalp, of the nose, of the mouth, of  the axillae,  are  all
localized forms of the disease, two or more of which  may coexist or
develop in succession. 
PRURITUS.
583
   Pruritus Narium  is  a frequent symptom of irritation  of the
 Schneiderian membrane.   It is thus' a  common  precursory or
 attendant phenomenon  of rose-  or hay-asthma;  and in some indi-
 viduals announces the systemic effect of opium and its alkaloids after
 ingestion. ^ It may result also from the irritation awakened by intes-
 tinal parasites.

   Pruritus Genitalium is  often  an exceedingly severe and  dis-
 tressing affection.   As the parts in question are apt to be rubbed and
 scratched in the efforts to secure relief of the itching sensation, orgastic
 effects and pollutions are often produced in early youth and  extreme
 age, M'hose moral effects are degrading.  The scrotum, labia majora
 and  minora, penis,  clitoris,  and adjacent  cutaneous and  mucous
 surfaces may be the seat of the pruritus.   Search  should always be
 made, in such  cases, for  ascaridcs of rectum  or  vagina, saccharine
 urine, and uterine or ovarian affections.  A perverted sexual hygiene
 may lie at the root of these disorders.   In the severe cases the violence
 M'ith which the parts are attacked suggests frenzy on the part of the
 patient, M'ho at times is never content  till  the scrotum or other parts
 are  bathed in blood.  The thickening, erosions, and  excoriations of
 the regions attacked are conspicuous features of the disease.

   Pruritus Ant.—This is a disorder of adults  of  both sexes, and
 may coexist with pruritus  of the genital  region.   There is usually
 nocturnal exacerbation.   The anus may become iiifundibuliform from
 induration;  its  mucous surface  excoriated;  its  cutaneous borders
 seamed, puckered, eroded, aud fissured.   It is often complicated M'ith,
 because the origin of, an eczema M'hose lesions reach upward over the
 coccyx or forward to the genital region over the perineum.  Haemor-
 rhoids,  ascarides,  chronic  prostatitis, rectal  impaction,  proctitis,
 unnatural vices, and diabetes may be all responsible for its occurrence.
 In all  exaggerated  forms of pruritus cutaneus, the general health
 perceptibly fails.   Whether from prolonged insomnia arising from
 the  nocturnal  exacerbations to M'hich there are but few exceptions;
 or from the perversion of nutrition incident to  the continuous teasing
 of the  nervous system ;  or yet from  the hypochondriacal state into
 which some patients are plunged  by their sufferings, such an issue is
 often to  be expected.  It is in fact a complication M'hich  may merit,
 as much as the disease itself, the attention of the physician.

   Etiology.—The causes of pruritus are numerous, and the necessity
 for the discovery of the particular cause in each patient, often makes
 the largest demands  upon the practitioner.  The disease may occur
 at all periods of life and in both  sexes, but its  exaggerated forms are
 peculiar to middle life and advanced years  (Pruritus Senilis).   It
 is frequently a reflex symptom of one of  several internal disorders.
 Among the  latter may be  named, malarial  affections, tuberculosis,
 carcinoma of the viscera, disorders of the liver or  kidneys (especially
jaundice, Plight's disease,  and  diabetes),  and  disturbauces  of the
 alimentary canal, including those due to intestinal Avorms, hsemor- 
584
DISEASES  OF  THE  SKIN.
 rhoids, and dietetic or medicinal ingesta.   It may be associated M'ith
 almost every one of the functional, and not a feM' of the organic, dis-
 orders  of the uterus and  ovaries.  The  same may be  said  of its
 dependence upou the genito-urinary diseases of the male sex, includ-
 ing stone in the bladder, stricture of the urethra,  disorders of the
 testis and epididymis, and perverted sexual hygiene.
   Lastly, the moral  emotions of a depressing  character play an im-
 portant part in the etiology of pruritus.   Mental distress, occasioned
 by bereavement, separation  from  relatives, misfortune of all  sorts,
 and anxieties as to the future, often find physical expression in the
 disease.
   Pathology.—The disease is essentially a functional disorder of the
 nerves  of sensation applied to the skin, and is of itself incapable of
 producing  objective symptoms.  This fact can,  in  some cases, be
 clinically demonstrated,  as  the seat of the  pruritus,  even  though
 exhibiting artificially produced  lesions, will, when protected from all
 external  injury, speedily regain  its normal appearance, the pruritus
 no less continuing.   It is  probable,  though  not certain,  that the
 nerves  also in this  disease undergo no  structural  change,  but merely
 convey to the periphery a perverted sensation which  is often reflected
 from some centric point of disturbance.
   Diagnosis.—The  recognition  of general pruritus is usually not
 difficult, as the secoudary results of the  disease are apt to  be  less
 marked than in its other forms.  The complaint  of the patient, the
 absence of cutaneous disease sufficient  to explain his symptoms, and
 especially the discovery of such a sufficient  cause in some  visceral
 or systemic disorder, are all significant.
   One  of the most constant features  of general pruritus is visible
 only when the clothing  of the  patient is entirely removed.   It then
 becomes evident to the eye that the affected regions  are, in order of
 frequency, those  most  accessible to  the hands.   The posterior are
 much  less involved than the anterior surfaces.   The  small of the
 back  and interscapular regions are usually untouched.  The tibial
 regions of the legs and the forearms, suffer more than the calves and
 the upper arms.  The lower  belly and inner feces of the thighs are
 punished more severely than the breast and outer faces of the thighs
 and the hips.   The  clavicular regions are more  excoriated than the
 back of the neck.  There is no more precise evidence than this as to
 the pruritic character of any cutaneous affectiou, and it  is  one too
 often ignored by the practitioner who prescribes under those  circum-
 stances  for a "disease of the blood."
   It must be admitted, however, that M'hen the disease is localized,
 and complicated, as  it  frequently is,  by an eczema or  dermatitis,
 obscurity often arises.   Attention should" then be paid to the historv
 of the disorder, M'hich may reveal the fact that  the pruritus preceded
 for some time the cutaneous symptoms, and may reveal even more.
 Intelligent patients will often assure  the physician of the real nature
 of their malady, by voluntarily remarking that the skin symptoms
disappear upon the region which is not scratched, though the pruritus 
PRURITUS.
585
continues.   In all cases the operation of exterior agencies should be
carefully eliminated.
  Prurigo,  with its infiltrated  skin,  its primary papules, and its
severe itching, beginning  in early infancy and  commonly persisting
through life, can scarcely be confounded with pruritus cutaneus.
   Treatment.—The degree of success to be obtained in the treatment
of pruritus  cutaneus, is  largely proportioned  to the skill with which
the cause of the disease is recognized  and remedied.   Taking into
consideration the number  of systemic  and visceral disorders M'hich
may be, in  different cases, responsible  for the  skin symptoms, it is
clear that an exhaustive study of the mental  and physical history of
each  patient will  be essential at the onset of treatment.   The cause
once recognized, the treatment should  be directed to the special dis-
order discovered; and this largely requires  the skill  of the  general
practitioner.  The gastro-intestinal tract, the kidneys, the  liver, the
bladder, the uterus, the prostate  gland, the  rectum, and indeed any
one  of the  viscera, may require therapeutic  management.   For the
frequent gastric disorders, the alkalies  and alkaline  waters, with
occasional cathartics and strict regulation of the diet, are often useful.
Attention should be particularly directed to any medication to M'hich
the patient may have  beeu  subjected with  a view to  a therapeutic
effect, and which may have aggravated the complaint.   The mineral
acids, chalybeates, pepsin, lactopeptin, quinine, strychuine, phosphorus,
arsenic, or atropine  may be indicated in individual cases and produc-
tive of favorable results.
   The  substances which have  been  topically employed  for the relief
of puritus  cutaneus are almost without number, a fact warranting
the conclusion that each occasionally fails to afford the desired relief.
This is corroborated with  every wide clinical experience; that prepa-
ration,  moreover, M'hich is at one time of the highest value, will dis-
appoint at  another  period in the history  of a single case.   Attempts
to  secure  relief by such  topical  applications  should,  however, be
ahvavs made and will often be followed by gratifying results.
   First in  order of value are baths and lotions of M'ater, hot, M-arm,
or cold, or alternately hot and cold, and medicated by the addition
of the  sodic bicarbonate  or biborate, the potassic  carbonate or sul-
phuret, varying in  strength from one ounce (32.) of the last-named
to six ounces (192.) of the first-named substance, in thirty gallons of
M-ater.   Gelatine or bran  may  often M'ith   advantage be added to
these, as suggested in the chapter on general therapeutics.  Alcoholic,
ethereal, camphorated, and carbolated lotions are to be regarded as of
equal value.   Duhring specially recommends  solutions of carbolic
acid, in the strength of from five to twenty grains (0.33-1.33) to the
ounce (32.) of  water, to which a half drachm (2.) of glycerine has
been  added.  Rohe similarly  employs  boric acid,  one drachm  (4.)
to the pint  (~>12.).
   Van Harlingen adds the anti-pruritic  effect of potash as folloM'S :

        R. Acid, carbolici                3j;            ■*
            Potassse  fus.                 ."ss;
            Aq. dest.                   Oss;          256|        M. 
586
DISEASES OF THE SKIN.
  Baths and lotions of this character usually procure merely tempo-
rary relief;  and the  treatment in the interval of their application
demands the  wearing  of soft linen,  or  other  unirritating  material
next the skin, and the free use of a dusting-powder.   Those of pure
starch are here less useful than those  compounded with oxide of zinc
and  bismuth, as in the "Anderson powder."  Gorecki1 mingles the
starch with  perfectly pure boric acid.
  Dr. R.  W. Taylor, of New York,  in a valuable paper,2 gives the
following formulae:
        R.  Potass, sulphuret.            3iij ;           12
            Camphor, spts.              f^ss;          16
            Glycerin.                   f'^j;          32
            Aq. font.            q. s. ad fgvj,          192       M.
        Sig.  For external use as a lotion, and to be applied by the medium
               of a saturated strip of lint.
        R.  Spts. camphor.              f^ss;          16
            Boracis                     3ij;           8
            Glycerin.                   f^ij;          64
            Aq. fluv.                   gvj;          192      M.
        Sig.  To be well shaken and applied externally.
  Morphia, in the strength of one grain (0.066) to the ounce (32.),
may be added to this aud other lotions.
  Chloral-camphor, a pungent, syrupy liquid obtained,  as suggested
by Bulkley, of New York, after  triturating au equal amount of the
two substances iu fine powder, is  an antipruritic remedy of value  in
certain  cases applied  in a  salve  containing  one drachm  (4.)  to the
ounce (32.)  of salve, and is comparable in its  action to phenol-cam-
phor, described in the chapter ou  general  therapeutics.
  Other lotions  may be made to contain corrosive sublimate, one-
quarter of a  grain  (0.016)  to the ounce (32.); dilute  hydrocyanic
acid,  a drachm (4.)  to  the  half  pint (256.); Goulard's extract, a
drachm (4.) to the pint (512.); chloroform, sulphur, alum, oil of pep-
permint, dilute nitric, acetic, or  salicylic acids, tannin, or  the  zinc
sulphate in  due proportions.
  Often the aqua calcis, medicated M'ith calomel, zinc oxide, bismuth,
or calamine, answers M'ell, and,  if tolerated at  all, the addition  of
linseed  oil, four  ounces (128.) to  the pint (512.), with a drachm (4.)
of one  of the  inert substances named,  flavored  with  rosemary  or
bergamot, will aid in relieving the local distress.
  Ointments  and fatty substances in general are usually  not  well
tolerated in cutaueous pruritus.   Occasionally, however,  they are of
more value than lotions, and  may be  made to contain one or more of
the substances named above, such as carbolic  acid, five grains to fif-
teen (0.33-1.) to the  ounce  (32.); subnitrate  of bismuth, a scruple
(1.33) to the ounce (32.), chloral  camphor, five minims  (0.33) to the
ounce (32.), and calomel, five  to ten  grains (0.33-0.66)  to the ounce
(32.) of cold cream, petroleum ointment, or lard.

   1 Le Praticien. Oct. 3, 1881, \>. 473.
   2 On the Various Forms of Pruritus Cutaneus, and their Treatment, Arch, of Clin. Sure. Eutledee
& Co., 1877. 
PRURITUS.
587
  Tarry substances are usually not well tolerated in the disease, and
are, as a rule, M'hen the skin is sound, objectionable as liable to irritate.
Duhring, however, speaks  M-ell  of the liquor carbouis detergens, iu
the strength of a  drachm (4.) to two ounces (64.) of water.   This
alcoholic solution of coal tar has been for some time in the market of
our large cities.  The  liquor picis  alkalinus  may be similarly em-
ployed.   Special attention  has been directed by many writers  to the
treatment of the  local  forms of pruritus,  the  principles of  which
have beeu in the main described above.
   For pruritus of the vulva, Wiltshire1 recommends decoctions  of
almond meal, marshmallow,  slippery  elm, and  rice; and in case of
failure of the  latter, an infusion  of tobacco  two ounces (64.) to the
pint (512.).  Vaginal  injections of hot water and tampons or cocoa-
butter suppositories medicated M'ith  opium,  belladonna, or carbolic
acid are also available.
   Many of the medicaments named above are also useful in pruritus
of the ano-genital  region.  The application of very hot M'ater is of
decided  service.  Exception  should  be made here to the rule with
regard to the exclusion  of tars generally from the treatment of pru-
ritus; as in the  distressing itching  of the scrotum aud anus especially,
they  are often essential.  The tincture of tar, oil of cade, and oil of
M'hite birch will  here often be  needed.   Pencilling  any existing
fissures with the compound  tincture  of benzoin or nitrate of silver,
is serviceable.   The scrotum when attacked, usually requires the use
of a  suspender or suspensory bag, lined  M'ith soft lint or borated
cotton, which may also be incorporated with a dusting powder, wetted
with  a lotion, or smeared M'ith an  unguent.
   Simon has successfully employed pilocarpine in cutaneous pruritus,
both  internally and by hypodermatic injection.   For the latter, the
muriate  of  pilocarpine  is used in  doses  of  one-sixth  of a  grain
(0.011).   The  same author  has  administered  with good results  a
syrup of jaboraudi, made  in the proportion  of three  parts  of the
leaves of the plant to fifteen of water, and  eighteen  of dissolved
white sugar, of which  tMO tablespoonfuls are taken at a dose.
   In Europe, the  favorite local application for relief  of pruritus is
a lotion  containing tar  in some  form.  Usually from five to ten per
cent, of glycerine is employed in  a spirit  lotion.   Salicylic acid is
often substituted for it:  e. g
         R. Acid, salicylic.
            Spts. vin. rectif.
            Aq.  dest.
         Lotion.
   ScliM-immer recommends :
         R. Alumin. hydrat.
            Glycerin. )
            Of.  oliv. J
            Ungt. moll.
        Sig.  Ointment

                    i Brit. Med.
3j;	4
.!i.i;	1)4
3"j;	96
M.
3jss;	6
fui 3v;	20
3x;	40
M
Journ., March 5, 1881, p. 328. 
588
DISEASES OF THE SKIN.
  Thin lotions  of starch-water or oatmeal gruel, iced or cooled in
hot weather, to  each pint of which a  drachm or more  of the  zinc
oxide, or subnitrate of bismuth may be added, are often of immediate
value.
  Iodoform, the oleate  and muriate of cocaine, the  latter in  from
two to four per ceut.  solutions; one ounce (32.) of the fluid  extract
of coca, to two  to four of water; and linseed  oil  (especially  for
pruritus ani), are also recommended.
  Jullieu recommends in pruritus of the vulva :
M.
  Cheron, in  pruritus  of the vulva attending the  menopause, has
successfully used:
        R.  Veratrise                 gr. iij ;             |266
            Axung.                     3j '■>           32       ^

  He also administers  in  pill form, one  one-hundred-and-twentieth
of a grain of veratria rubbed up with licorice.
  Squibb's formula is :

        R.  Acid, tannic.                Bj ;

            Spts. vin. rectif. j            °   '
            Aq.  dest.                ad fgiv ;
        Sig. Apply morning and evening on a rag.
R. Zinci oxid.	3yj;	24
Acid, salicylic.	gr. xv;	1
Glycerin.	3vj;	24
Sig. Apply as required.		
  1
 16
128
  Lastly, it should not be forgotten that many cases of intractable
pruritus are best managed  when  the  attention  of the patient  is
diverted from the malady by the distraction incident to travel, aided
by change of scene and climate.
  Prognosis.—Pruritus senilis is usually an intractable disorder, and,
when dependent  upon  senile alteration of  the  cutaneous tissues, is
incurable.   For all other forms of the disease a prognosis should be
formulated  with  reserve.   Under  the  influence  of systematic  and
appropriate treatment, the happiest results are often obtained.  Other
cases,  especially those associated  with  hypochondriasis,  may   bid
defiance to all remedial measures.   Relapse of the local forms of the
malady, especially of that  of the ano-genital region,  is sufficiently
common.  In many of these patients the treatment serves merely to
palliate the disorder,  which recurs with every renewal of the cause.

  Pruritus  Hiemalis, Prurigo Hyemalis, "Frost-itch"  or
Winter Prurigo.—Under  the  first title, Duhring1 described  a
harsh  and  pruritic  condition  of the skin,  essentially unattended by
structural alteration,  invading all  surfaces  of the body, but  chiefly

  1 Phila.  Med.  Times,  January 10,1874.  See, also, a later but independent observation by Mr.
Hutchinson : Lecture on Clinical Surgery, 1878, vol i., pt. 1, p.  100, and  Brit. Med. Journ Ibi^i  ii
p. 773. 
pruritus.
589
the inner faces of the thighs, the calves of the legs, and the neighbor-
hood of the joints of  the lower extremities, usually occurring in the
autumn, and  continuing until  the  following spring.   It possesses
many features in  common  M'ith the  forms of pruritus already de-
scribed, includiug variability in the subjective sensations awakened,
nocturnal exacerbation, and the absence of a primary eruption.  The
secondary  results  are  also similar, being sequelae  of  self-inflicted
injury iu the form of roughness, peri-follicular redness  and papula-
tion, torn  and  fractured  hairs, excoriations, blood-crusts,  and,  in
severe cases, an  induced dermatitis.  It, however, abates in  severity
with a rise of atmospheric temperature, though the author has occa-
sionally noted persistence of the  distress after such weather changes.
The affection, moreover, is one M'hich occurs in persons otherwise
enjoying perfect health, in those of every social grade, irrespective of
the character of the clothing worn and of  the habitual use or neglect
of the bath.   It is, without question, a disease of northern climates,
and more particularly of climates like our own where the variations
of temperature between the extremes of the summer and of the wiuter
range between one hundred and oue hundred and tM'enty-five degrees
Fahrenheit.   The careful description  by Duhring presents a picture
whose accuracy is verified by clinical observation, and which justifies
the recognition of the disease as a form  of  cutaneous pruritus.  Its
treatment is that detailed above, the author named laying stress upon
emollient unguents, glycerine in the form of lotion or ointment, and
alkaline baths.  In my experience, the  dusting powders,  when em-
ployed after the tepid bath, have proved more serviceable than any
fat-containing substances.

   Prairie Itch.—This is a  popular term applied  largely iu the
AVestern, Northwestern, and Southern States  of this country  to  a
cutaueous affection productive of itching sensations.   It is supposed
to be the disorder also popularly described as the "Texas Mange,"
" Ohio Scratches," " Swamp Itch," " Lumberman's Itch," etc.
A parasitic origin has been claimed for it  by several observers, who
also insist upon its  contagious  character and its curability by para-
siticides.
   The personal experience of the author has  led to the conviction
that these terms are loosely applied to a group of cutaneous symptoms
of diverse origin.  The most frequent  by far is a pruritus, of the kind
described  above as  pruritus  hiemalis, occurring  in the autumn,
M'inter,  or  spring  of the year, aud aggravated by  the coarse and
cheaply dyed woollen undergarments of the poor and hard-working
inhabitants of the lumber camps, mining districts, etc.  With these
causes iu full  operation, there is often aggravation after swallowing
drugs for relief of the pruritus based upon the idea of " purifying
the blood."
   With these  cases occur those of undoubted scabies, for  the study of
which the reader is referred to the  chapter devoted  to  that subject.
The proportion between the purely pruritic and purely parasitic cases 
590
DISEASES OF  THE  SKIN.
of this class cannot be definitely determined.  It probably differs in
different places and seasons, the proportion of cases of scabies increas-
ing in the lumber camps when they are reinforced by newly arrived
immigrants infested M'ith acari.   It  decreases to probably not more
than from one to two  per cent, of all skin diseases  in  the  interior
villages and towns of the \Vrest and Nortlnvest M'here there has been
no immigration for some length  of time, and M'here, after  the first
onset of sharply cold weather in the autumn, a large part of the inhab-
itants suffer from pruritic sensations in various degrees.
  A revieM' of the somewhat scanty literature ou this subject1 suggests
the conclusion that the disorder thus popularly designated  is far more
rare in Europe than in America.   It is possible that  the situation of
those parts of the United States where this group  of skin affections
seems to prevail  (at a great distance from  proximity to  the sea-shore
and  still further  separated from the Gulf Stream) may  play  an
important part  in the extraordinary  sensitiveness of  the  skin  to
climatic changes.  Certain it is  that a great number of these affections
are entirely relieved by removal to  a suitable climate, more particu-
larly to one of the Eastern, Southern, or extreme Western States.
  The therapy of this affection is that of pruritus  already described,
save M'here  a parasite is recognized  as  the efficient cause, as iu cases
of scabies.
  The prognosis is favorable,  though the disease is at times  intract-
able, persisting  or recurring with repeated thermometric variations
till the warm season is at hand.

                         [B.]  Dermatalgia.

  In this morbid state, the integument becomes the seat of painful
sensations, M'hich may and  may not be associated with a hyperses-
thetic condition.   This disorder is much more frequently  symptomatic
than idiopathic, and partial rather than general, being in the larger
number of  cases a  local  expression of some disease of the nervous
centres  or  tracts.   It is observed  usually in  middle  life,  and  in
women more than men.   Its symptoms vary iu severity and in char-
acter.  The pain is differently described  as comparable to that pro-
duced by friction, incision, penetration, contusion, or burning of the
integument,  as also to the passage over the part of  streams of very
hot or cold  water,  or the electric current.  With this  there is com-
monly associated  an  undue  sensitiveness to  contact   with  foreign
bodies.   The skin presents no objective signs  of disease.   The dis-
ordered sensations  may be  limited  to the scalp,  the region of the
spine, or the palmar aud  plantar surfaces.   In the latter situation it
is  often  significant of some obscurely  developed  systemic disease,
such  as  syphilis, rheumatism, or  locomotor ataxia.' In a  middle-

 i See two papers by the author, entitled "On the Affections of the Skin, Induced bv Temperature
Variations in Cold Weather." Chicago Med. Journ. and Examiner, Mar.h, 1885, and February 1886
Obersteiner: Wien. med. Wochenschrift, No. lfi, 1884: Brodie : Peninsul. Journ. of Medicine IkV?-^'
vol. i., p. 506; Jones: Kansas City Medical Index, 1S8G, with views of several Western  nV,'v=,vi.Jno'
Clark : Medical Age, 1886 ; Payne : British Medical Journal, May 3, 1887.             pnysicians , 
ANAESTHESIA.
591
 aged woman, lately under my charge, a persistent dermatalgia of the
 interscapular region Mas associated M'ith confirmed gastric dyspepsia.
 In other cases the disorder is dependent  upon  disturbance  of the
 uterine fuuetion.   It is occasionally observed as one of the rare signals
 of the occurrence of the menopause.
   It is to  be noted that the severe dermatalgia associated M'ith dis-
 orders  of the uterus in women, is occasionally succeeded by a cuta-
 neous lesion.  In a  middle-aged  dysmenorrhceic patient  under my
 charge, a pea-sized heemorrhagic  bulla  appeared  over  the forehead
 after several M'eeks of frontal suffering.   Buck,1 also, reports derma-
 talgia of the brow aud wrists in a  youug womau who had frequently
 miscarried,   followed  by recurrent formation  of a vesicle  which
 accomplished its career of rupture, crusting, and erosion, in a stadium
 of from five to seven days.
   The  disease is to be differentiated from pruritus and hyperesthesia
 of the  skin, as also  from the  affections  of deeper parts, muscular,
 nervous aponeurotic, and visceral.  Severe  pain, limited strictly to
 the skin of the lumbar region, M'ith hyperaesthesia, may precede the
 occurrence of periuephritic abscess.
   The  treatment  is  to be directed to the disorder, of  M'hich, in the
 great majority of cases, the dermatalgia is merely a  local symptom.
 Temporary relief may, however, be afforded by the local application
 of the rubber bag filled  with  very  hot or very cold water;  sometimes
 by an alternation of the two,  each for a  few moments at a  time.
 Sponging of the  part with very hot M'ater is  also useful, continued
 for  longer  periods,  and followed  by  swathing in  cotton batting
 covered with  the Lister protective.  The  anodynes  may also be
 used  topically with advantage; especially cocaine or the oils, com-
 bined M'ith  opium, aconite, belladonna, and stramonium.  In  some
 cases relief  is had by painting the part M'ith Squibb's oleate of mer-
 cury and morphia, a preparation  particularly M-ell adapted  to  meet
 the indications presented.  The skin should generally, in the interval
 of applications, be protected  by a  dusting  powder; and the clothing
 worn next the skin be of an uuirritating character.   Care should be
 taken in dermatalgias limited to the trunk of women, lest the corsets
 be responsible for tbe  mischief.   The  prognosis depends upon the
 nature of the cause of the abnormal sensations.  In  general  it may
 be said  that these cases are less persistent and annoying than those
 of confirmed cutaneous pruritus M'ith melancholia.

                          Anaesthesia.
                  Gi\ a, privitive ; a'toftr/aic, sensibility.
   In this condition  there  is [total  or partial  diminution  of sensi-
bility, with  and M'ithout structural  alteration of the skin.  As in the
affection just described,  the  disorder ■may be either idiopathic or
symptomatic, general  or partial, unilateral  or  bilateral, central or
peripheral, and  in varying grades of severity.   Illustrations of the
i Phila. Med. and Surg. Reporter, Jan. 18, 1881, p. 077. 
592                DISEASES  OF  THE  SKIN.
disease are furnished in the anaesthetic patches of leprosy, M'hich may
and may not  exhibit textural skin changes, the disorder resulting
from involvement of the nerves.   Other diseases and conditions may
be  accompanied by partial  or total  loss  of cutaneous sensibility,
including centric and eccentric paralyses; syphilitic,  hysterical, and
ataxic disorders ; partial or complete anaesthesia of artificial produc-
tion ; the several toxic  narcoses; traumatism of nerves by pressure,
wound, or contusion ; the local anaesthesia? induced by cold, frigorific
mixtures aud  substances capable of benumbing  the sensitiveness of
the  skin; coma, of whatever origin;  and  a  number of  idiopathic
cutaneous disorders, including certain of the atrophies, scleroderma,
and morphcea.
   A curious divorce occasionally obtains between the elements which
together constitute the  compound  sensory  impression derived from
the touch.   The recognition  of pain, of degrees of temperature,  as
also of the form, size, density, distance, weight, resistance,  and other
properties of  foreign bodies, is accomplished largely  by the sensory
nerves : and the power  to appreciate one or several of these objective
qualities may  be  in different degrees  impaired.   In  this  respect
several  forms  of  what, for want  of a better  term,  may  be named
cutaneous anaesthesia, are comparable to the conditions  recognized  in
color-blindness.  Thus, in  some cases, there is appreciation of heat,
but  not of  cold ;  of form, and not of weight; of pain, and  not  of
objective qualities;  and tbe reverse.  A curious illustration of this
occurred in  the person of a leper under my  observation, whose hands
were in all parts quite sensitive to the prick  of a lancet and  to contact
with  heated substances ; M'ho  yet  exposed  them for  hours, without
protection, to  an atmospheric temperature of ten degrees below zero,
without becoming aware of even slight discomfort.
   The neuroses described  above are those of sensibility.  Unques-
tionably there are,  beside these,  a number of  cutaneous  affections
popularly termed neuroses, M'hich require mention in this connection.
Unfortunately,  in  the  present state of science, it is not certainly
determined  to what special class these affections  should be definitely
and   permanently  assigned.   Some  of  them  have   already been
described  in  these  pages.   In M'hat  follows  there  is  attempted a
schematic classification  of the symptoms displayed iu all, without
attempting to  discriminate  between the parts severally played in each
by nerve, vessel, and tissue.

                 Vaso-motor and Trophic Neuroses.

   Under the first of these titles, Schwimmer discusses  erythema mul-
tiforme, herpes  iris, erythema  nodosum, urticaria, and the  medicinal
erythemata; under  the second,  prurigo and herpes  (simplex and
zoster).
   It is, however, to phenomena of a different character that in these
pages attention is  directed  by these terms.  These symptoms are, for
the most part, symmetrical in distribution, and largely limited to the 
NEUROSES.
593
hands  and feet, though in  some instances, with or M'ithout  implica-
tion of these organs, other  parts are invaded, most often the mouth,
next the  scalp, lastly the trunk.   The four groups named below are
readily recognized.
   in  the first group the symptoms  are functioual chiefly, invading
the feet  alone, or the hands alone, or both the hands  aud  feet, the
symptoms predominating either in the one or the other.  These are
symmetrical  hyperidrosis,  auidrosis, bromidrosis;  coldness of the
organs, and  symmetrical asphyxia ("dying" of the hands  or feet,
M'hen  immersed  in  cold water, digit! mortui).  With the local phe-
nomena may occur sudden  attacks of faintness or giddiness; a pulse
ranging from very sIom' to  very rapid action, aud rheumatoid pains.
Many of  these symptoms are associated M'ith those next described.
   Iu a second and larger  group may be collected the symmetrical
structural changes in the skin and its appendages M'ithout destructive
degeneration, cutaneous  or subcutaneous  in  situation.   With these
may be associated the blueness, coldness, or  wetness of the organs,
referred  to above.   One or several,  usually all, of the nails may be
here  involved, these  appendages  becoming  rough,  dry, lustreless,
friable, or gryphotic.  They are  usually tilted away anteriorly from
their nail-beds by a corneous deposit visible beneath the free border.
Here, also, may be enumerated,  symmetrically arranged,  livid or
reddish blotches; erythematous, vesicular, and scaling patches; local-
ized hypertrichoses  and  alopecias [of the legs chiefly]; tyloses of
palms and soles [in cases, M'ith recurrent slough of the callosity] ; and
local  anaesthesias.
   To this group belong the  Neurotic Excoriations of Sir Erasmus
Wilson,1 au example of M'hich M'as shoM'n at the International Med-
ical Congress of Loudon.   The Bleeding Stigmata M'hich attracted
the attention of the French aud Belgian  authorities  in  the years
l873-187o belong to the same category, as also the "Glossy Fingers"
of Paget  [q. v.].
   In  a  third  group  may  be  placed the  phenomena of Raynaud's
disease, the cases of symmetrical  ulceration  and gangrene, and the
other  ulcerative  aud  degenerating lesions, not  necessarily  fatal, in-
cluding the "perforating ulcer of the foot" [malum perforans pedis]
[q. v.].   Here are classed the cases described  by Atkinson as "mul-
tiple  cutaneous  ulceration," and  the well-known cases of  Eichoff,
Boeck, Simon, Weiss, and  Hutchinson.
   Leloir and  Dejerine  presented a  case of this character at a recent
meeting  of the  Societe  de  Biologie, in Paris.  A young girl, of  a
family, several members of which M'ere affected M'ith nervous diseases,
had, without  any apparent  cause,  several  patches of superficial  gan-
grene  developed" on the  cheeks;  the small  eschars soon separated,
leaving a  linear cicatrix, M'hich  gradually became transformed into
cheloid elevations.   The first happened three years before, and during
this period she had  suffered from  several similar lesions on the trunk

                 1 Lectures on  Dermatology. Loudon, 1875. p. 192. 
594
DISEASES OF THE SKIN.
 and  arms.  They  began  on the skin, by a sensation  of pricking,
 M'ith  slight redness  and  notable diminution of sensibility  at  this
 point; in nine hours a white patch, not  preceded  by phlyctenule,
 formed  and underwent,  after a short time, superficial  gangrene.
 Later the  spot  became brownish, detached at  tbe edges, and  Mas
 finally eliminated, leaving  au ulceration  and a cicatrix, the ansesthesia
 which existed around the part  finally disappearing.
   In a fourth and final group may be set the cases M'hich end fatally,
 in consequence of an apparently lethal tendency of the disease from
 the first.  Here may be cited Hutchinson's " Form of Inflammation
 of the Lips and Mouth, which sometimes ends Fatally, and is usually
 attended by some Disease  of the Skin;" and a list of affections Math
 cutaneous symptoms  chiefly studied by neurologists, including  the
 "pied tabetiqueJ'> of Charcot; cases of posterior spinal sclerosis,  and
 cases of syphilitic, tuberculous,  and rheumatic disease of the cord  and
 meninges.1
   The pathology of many of these disorders is clear, changes iu the
 central and peripheral nervous  tracts having  been found sufficient to
 account  for the  phenomena (absence of  axis-cylinder; thickening of
 neurilemma; increase of endoneurium).  In other cases, no lesions of
 the nerves have been recognized, and authors have not been wanting
 who regarded  some of the disorders named above as "purely local"
 in character.
   The subjoined bibliography is appended in view of the uncertainty
 respecting the proper distiuctiou  to  be  established with respect to
 several of the disorders named  above:
 Atkinsox.  Amer. Journ. Med. Sciences, 1884, p. 57.
 Atkin, Charles.   British Med. Journal, July 24, 1886.
 Anderson, McCall.   Treatise on Diseases of Skin.  London, 1887.
 Baker, Morrant.  Clin. Soc. Trans., vol. xviii.
 Bouchard.   Gaz. des Hopit., No.  112, 1884.
 Boeck, CAESAR.  Viertelj. f. Derm. u. Syph., 1881.
 Ball and Thibierge. Lancet, Oct. 21,1882.  Report to Int. Med. Congress.
 Brehier. These de Paris, 1874.
 Biggs.  Lancet, 1876, vol. vii. p. 735.
 Billroth.  Wien. med. Wochen., No. 23, 1878.
 Collander.  Clinical Society's Trans., April 12, 1878.
 Duplay.  Arch. gen. de Med., 1876, p. 346.
 Dejerine.  Le Progres Med., 1882, No. 6.
 ---- et Leloir.  Arch. gen. de Phys., 1881,  p. 1011.
 Eichoff. Deutsch. med. Woch., No. 34, 1880.
 Elliot.  Journ. of Cutan. and Gen.-Ur. Dis., May and June, 1887.
 Erichsen.  Surgery,  1879.
 Estlaxder.  Arch. f. klin. Chir.,  1870, xii. p. 453.
 Flynn.  N. Y. Med.  Record, March 28, 1885.
 Foulquier.  These de Paris, 1874.
 Hamilton, A. McLane.  N. Y. Med. Journ., Oct. 1874.
 Hastreiter.  Wiener med. Presse, 1882, No. 33.
 Hutchinson, J. British Med. Journ., June  18, 1887.
 ---.  British Med. Journ., May 7,  1887.
 Heusner.  Deutsch.  med. Woch.,  No. 16, 1885.

   1 See the author's paper on "Symmetrical Hand and Foot Disease," read before'the American
Dermatological Association, August :il, 1887. 
MYXEDEMA.
595
 Jones, S.  Path. Soc. Trans., No. 7, 1876.
 Kirmissox.  Arch. gen. de Med., January, 1885.
 Michaud.  Lyon Med., January, 1*70.
 Miles.   Amer. Journ. of the Med. Sci., October, 1878.
 Mitchell.  Amer. Journ. of the Med. Sci., July, 1878.
 Mougeot.  The.se  de Paris, 1867.
 Xelaton.  Gaz. des. Hopit., January 10, 1852.
 Ooston.  Lancet, 1878, p. 13.
 Pitres  et Yaillard.  Arch, de Phys., Feb. 15, 1885, p. 209.
 Petit et Verneuil.  Rev. de Chirurg., No. 19, 1883.
 Raynaud.  Arch. gen. de Paris, 1874.
 ---  These de Paris, No. 28, 1862.
 Simon,  Oscar.  Breslau Arzlische Zeitschft., No. 1, 1879.
 Schwimmer.  Art. Malum perforans Pedis—Ziemssen's Handbook of Diseases
  of Skin.
 Savory and Bdtlin.  Med.-Chir. Trans., vol. lxii., 1879 (illustrated).
 Starr.   Journ. of Nervous and Mental Dis., February, 1886.
 Tkkillox.  Revue Medic, 1886.  Report made to the Surgical Society of
  Paris.
 Tilden.  Journ. of Cutan. and Vener. Dis., October, 1886.
 Treves, Frederick.   Lancet, March 29, 1884, p. 950.
 Warren.  Boston Med. and Surg. Journ., No. 13, 1879.
 Weiss.   Wiener Klinik, 1878.
 Wilks.  Surgery of the Foot, p. 57.

                           Myxoedema.

                    Gr. fiv^a, humor; biSeu, to swell,
 Myxoedema is  a disease characterized by a  constitutional cachexia, which
  usually results in the  production of a cretinoid state, and is accompanied
  by a characteristic pachydermia.

   This disorder was first described by Sir Wm. Gull,1 in 1873;  and
 it has since been often observed, both abroad and in  this country, by
 competent observers,  including Ord,2 Mahomed,3 Hadden,4 Stokes,5
 Hammond,  Horsley,  aud  Ballet.   It   is  termed  by  the French
 " Cachexie  Pachydermique."   For thirteen  cases reported in  this
 country, the reader is referred to au interesting report by Dr.  A. B.
 Ball, of Now  York.6
  Symptoms.—The disease occurs  in  both acute aud chronic  mani-
 festations, usually after the fortieth year, aud in women more often
 than in men.   It  may, however, be first noticed in childhood.
  There is first observed a persistent and remediless anaemia, gradu-
 ally succeeded by  mental hebetude, sluggishness of bodily movements,
 and the characteristic change in the skin.  The latter becomes dry,
 waxy, translucent, thickened,  firm, and  refuses to pit on  moderate
 pressure, the  mucous  membranes  often  participating in the morbid
 process.   In the cheeks there is usually perceptible a brawny redness;
defined  at times as a sharply circumscribed pinkish  flush  extending
i|uite  to the lower lids, which  may be, as in  Ball's  cases, wrinkled,
boggy, and  swollen.   The eyes, for this reason, seem smaller than
1 Trans. Clin. Soc. London, 1874, vii. p. 170.
3 London Lancet, 1X81.
•"■ N. Y. Med. Record, July 10, 1886.
2 Med. Chir. Trans., 1878, v. p. 57.
* Brain, 1S82, 4.
o British Med. Journ., Oct. 16, 1886. 
596
DISEASES  OF  THE SKIN.
natural and more widely separated.   In consequence of the swelling
and immobility of the features, the facies is characteristic : the broad,
thick nose; swollen, pendulous, or even everted  lips; expressionless
eyes; and  leathery cheeks producing a mask-like impression upon
the observer.  The skin of the other regions of the body participates
in these changes.
   In the triangles at the side  of the neck, and also at its back, are
"bolsters" of fat.   The hair of the head becomes harsh and  scanty;
alopecia may be complete.  Pigment alterations readily occur; moles
increase in  size; and the general tint of the skin may vary from that
of dry parchment  to  the hue of Addison's disease.  The gait is
waddling and uncertain.   The thyroid gland atrophies.  Anaesthesia
is of common occurrence.  The tongue, uvula, and  fauces are often
so thickened  and immobile as to make the speech  both  slow and
indistinct.
   Stokes reports ten cases of acute myxoedema  following thyroid-
ectomy.  In these cases, beside the rapid occurrence of the symptoms
enumerated above, there were  convulsive seizures of an epileptiform
character.
   Etiology.—The cause of this  disease is imperfectly understood,
though its  association with the abolition of the thyroid gland (after
pathological change or ablation) is generally admitted.  The influence
of heredity is distinctly shown in cases reported by Ball, Ord, Saville,
aud Taylor.  One hundred and. one, of one huudred and twenty-one
cases collected by Ball, occurred in women.  The disease  may affect
children, but is more common in middle life.
   Pathology.—The disease seems to be due to the deposit of mucin,
or "animal gum,"  in  the meshes  of the connective tissue.  This
mucinoid  degeneration  may  involve  the  pneumogastric,  glosso-
pharyngeal, great  sympathetic, and  other  nerves.   The  psycho-
cortical centres are unquestionably similarly involved.   In the skin,
the fibrillse of connective tissue multiply, their nuclei becoming large
and distinct,   The  mucin-yielding cement substance between these
fibrillae appears in  large  amounts in  the  interstitial  spaces.  In a
post-mortem  examination  made by  Ord, it was  estimated  that  the
skin  contained fifty  times the normal amouut of mucin.
                     CLASS  Till.

                   PARASITIC AFFECTIONS.

  The cutaneous disorders of  this class  possess manv features ii
common with those already  described.  In  them, as  in others ai
observed the  hyperaemic and exudative  processes which result i
surface  lesions of similar type  and career.   They differ howevei 
TINEA FAVOSA.
597
from other affections of the  integument, iu that they are all induced
by parasites of either vegetable or animal  origin ;  and are, as a con-
sequence, commonly  characterized by certain special features.  They
involve the skin and its appendages, their symptoms being at times
displayed chiefly in  the integument proper, and at  others in oue or
more of the  cutaneous appendages, according to the mode of propa-
gation and attack, peculiar in each case to the parasite present.  They
are  all in different degrees  contagious; and being induced by local
and tangible  causes, are usually readily relieved  by external  treat-
ment.  Their importance in cutaneous medicine rests not only upon
the facts named above, but also upou the too general misconception
regarding  their  nature,  since  there  are  many patients treated  by
internal  remedies ingested vainly for long periods of time, who are
yet suffering from parasitic disorders often remediable by very simple
local measures.
   It should not be forgotten, however,  that, distinct though these
maladies  be in  an etiological  sense,  they are yet  practically often
commingled with others.  Thus an eczematous scalp in a child may
by accident become  the habitat of lice;  and  the  eczema  induced
originally by the acarus scabiei may long persist after the destruction
of the parasite.
   The term tinea, derived  from a  Latin word meaning  a moth or
worm, has by common consent been adopted  as a generic designation
of all the cutaneous disorders  induced by the  presence of vegetable
organisms.


                        1.  Vegetable.

                         Tinea Favosa.

                       Lat. favus, a honeycomb.
Tinea Favosa is  a contagious disease of the scalp, and less frequently of other
  portions of the surface of the  body,  characterized by pea- to coin-sized,
  sulphur-yellow, and umbilicated crusts commonly traversed  by hairs, and
  produced by the invasion of a vegetable organism, the achorion Schon-
  leinii.

   Symptoms.—Favus affects chiefly the scalp, but also occurs  upon
the so-called non-hairy portions of the skin  and the nails.  In  the
former situation  it  is usually first recognized by the development of
minute, sub-epidermic, yellowish or reddish puucta, visible through
the  translucent stratum corneum at the site of implantation of the
hairs.  A peripheral  circle  of  delicate vesicles may  surround  these
spots.  Puncture with a  needle usually  gives exit to  a puriform
matter.  In the  course  of a fortnight or  more, these develop  into
pea-sized and somewhat larger, friable, circular, aud elevated crusts,
having the yellowish tinge of the lemon or sulphur, and  a concavo-
convex shape,  with the free  concave face  of the disk exposed.   At 
598               DISEASES OF THE SKIN.
the centre of the  umbilication  thus  presented  to  the  eye, one or
several hairs usually make exit to the surface.  The inferior surface
of this disk or scutulum rests  upon the scalp, which is either moist
and deprived over a circumscribed area of its epidermis, or is smooth,
dry, reddened, and tender.   When the crust  is removed by traction
upon  the  hairs or otherwise, a minute  cup-shaped depression  is left
at the point where the lowest level of the favus crust was in intimate
connection with the epidermis.
   The subsequent features of the crusts, the hairs, and the scalp, are
subject to some variation.   The first  may acquire  a brownish  or
greenish tinge by  admixture with dirt or dried  pus ; may coalesce
(favus  squamosus), or may, by  gradual desiccation, exchange  the
yellowish hue for the dirty whitish shade of old  mortar,  a  substance
which they then  resemble in  dryness and  friability.   The hairs,
invaded both  in  sheath and  shaft, may lose their lustre; become
fragile; appear  as  fractured relics of  longer filaments;  be readily
extracted  from  their  follicles; and be finally shed,  leaving behind,
hair-sacs destined to fall into atrophy, and  incapable of reproducing
a pilary growth.  The scalp may be first the seat of an  extensive
hyperaemia or exudation going on to the formation of pus, when the
organism  is a source of acute irritation  in  consequence of  its  active
development.   Later, when its destructive  work may be said to have
been accomplished, the scalp surface is bald, irregularly atrophied, or
disfigured with minute cicatrices,  while  here and  there remain tufts
of hair which  have survived the attack.
  The lesions may  be discrete or  confluent, aud vary in  either case.
Occasionally but a few small and ill-developed crusts  form upon the
surface.   The entire scalp is not often covered with a confluent favus
crust.   The disease is usually chrouic  in  its course.  Untreated, it
may undergo  spontaneous involution  after total  destruction of all
hairs  and  production of general  follicular atrophy, but  this is rare.
It may last for fifteeu  or twenty years,  and even longer.   It is often
accompanied by adenopathy.
  The disease usually awakens a noteworthy degree of itching ; and,
as a result, it is not rare to find the favus crusts torn  and broken by
the comb  or the nails.
   The yellowish disks of the disease occur also in typical develop-
ment,  though more rarely, upon the surface of the face (including the
bearded cheeks, lips, and chin), and upon the  trunk and  extremities.
Dr. George Henry  Fox, of New  York, has photographed a patient's
knee which is covered on its extensor aspect with  favus crusts.
   When the nails are invaded, light or  deep yellowish, circumscribed
spots become visible through the nail structure, and by the extension
of these, inconsequence of the growth of the  parasite, the nail-tissue
may _ be thickened, irregularly split, laminated,  separated  from  its
matrix, or atrophied.   The complication is rare, and  supposed to be
due to the transfer of the organism from the scalp to the hands in the
act of scratching.   When it exists, the  epidermis fringing the nail is
usually also involved. 
TINEA  FAVOSA.
599
   The odor of fully developed  favus is so characteristic that  by it
alone a diagnosis has been established.   It is usually compared to'the
odor of  mice; also to that  of the urine of cats.   It should not be
confounded with  the peculiarly disgusting odor  of many neglected
scalps affected with lice  or covered with pustules and filth.   The
disease not infrequently coexists with other cutaneous, parasitic, and
non-parasitic diseases :  as, for example, seborrhoea, eczema, and tinea
tonsurans.
   Etiology.—Favus is always produced by the presence and develop-
ment of the vegetable organism which is named after  its discoverer,
the achorion Schonleinii.   It is a contagious disease, simply because
the parasite which  produces  it, is capable of transmission from man to
mau, as also from  animals to  man, and  vice  versa.  It  shares with
other diseases originating from vegetable parasites, the  peculiarity of
attacking certain  individuals specially predisposed to  the invasion,
either by physical  peculiarities of organization, or accidental and
fortuitous circumstances.  It  is most common from infancy to the
thirtieth year of life.  It is rare in the United States, Austria, and
Englaud ; and more common in France, Scotland, and Poland.  It
is said by Bergeron1 to  be a disease of  the country, while tinea tri-
chophytina prevails in  the cities.  This statement is certainly corrob-
orated by the author's experience.   Favus is more common in public
than  in  private practice, and  the larger number of clinical patients
with  favus come to the city  from the country.
   Evidences of contagion are exhibited in those  cases where several
members of the same household are affected with the disease; but in
other cases the absence of a  history of contagion after exposure indi-
cates  the relative difficulty experienced in propagating the contagious
element  in the case of favus.  Thus oue individual, exposed among
a dozen  who are diseased, will  fail  to exhibit any favus crusts; aud
the latter by no means  form in all situations of the same body where
the fungus cau be discovered  by  the microscope.   Aubert,2 indeed,
presents an  argument in favor of  the production of the disease by
traumatism, the resulting wounds,  excoriations,  etc.,  becoming by
accident the seat of the disease.
   Occasionally favus occurs  in  special  localities with  such develop-
ment among  men  and  the  inferior  animals  as to  constitute an
epidemic.  Girard3 reports  thus the simultaneous existence of the
disease  among sixteen  cows and  four  children  in  the  village of
Nantoin, in France.  It is propagated also upon the skin of rats and
mice, from which  it is transmitted to man, ofteu through the medium
of the domesticated cat  aud dog.
   Pathology.—Under the microscope, the fungus is readily recognized
in the root-sheaths, the  bulbs, and  the  shafts of the hairy filaments
near the scalp.  At a distance of about two inches  from  the  bulb it
ceases to appear iu the tissue of  the  hair.  It is also seen upon the

 1 Ktude sur la Geographic et la Prophylaxis des teignes, Paris, 1865.
 2 Role de traumatism dans l'etiologie de la teigne faveuse (Annal. de Derm, et de Syph., April, 1881).
 » Lyon Med., August 18, 1880, p. 547. 
600
DISEASES OF THE  SKIN.
free surface of  the skin.  The favus crust, softened  by the addition
of a little water or dilute liquor potassae, may be  placed  upon  the
slide  of the  microscope  without other  preparation  for its  study.
Under a good one-fourth  or one-sixth of an inch objective, the vege-
tation is seen to be composed of intricate masses of mycelium and
spores in great  quantity.

                             Fig. 79.
      Achorion Schonleinii.  a, spores ; b, c, sporophores. (After Cornil and Ranvier.)

  The former usually preponderate, and appear as narrow, flattened,
ramifying, short or elongated, thread-like cells or tubes.  These may
be simple and empty, or be divided more or less  regularly by trans-
verse partition walls,  transforming the longer and simple into shorter
and compound cells.  The latter often contain in their cavities spor-
ules clinging to either  side, in which  case the mycelial threads are
termed sporophores.  This is the vegetative part of the cryptogamous
fungus; and it develops by multiple subdivision into cells, which may
also  themselves similarly increase in number, or by the production,
at the terminal extremities of certain of the mycelial threads, of spores
or conidia.  The latter are encapsulated, or strung together like the
beads upon a necklace, and appear as round, oval-shaped, angular,
or very irregularly contoured  bodies,  often provided with partition
walls like the mycelia, constituting thus compound  cells.   At the
same time, an amorphous granular matter can usually be distinguished
in the mass of the fungus   According  to  Duhring, who  has  made
careful measurement of  these elements, the mycelia vary in width from
0.0023 to 0.0030 mm.;  and  the spores, from 0.0023 to 0.0052  mm.
   Examination of the invaded scalp reveals, according to Unna,1 the
presence of the fungus at the lower border of the upper three-fourths
of the root-sheaths, where chains of conidia appear among  the  histo-
logical elements.   His  view  is that the cuticle  of the hair offers a
relative resistance to  the  growth of the vegetation;  that  the  latter
first penetrates the stratum  corneum and  the follicular orifice, and
1 Viertelj f. Derm. u. Syph., vii. p 170. 
TINEA  FAVOSA.
601
then  stretches, upon the  one hand,  into  the cortex and medulla,
through the cuticle of the  hair; and, on the other, passes to the inner
root-sheaths, the outer remaining always intact.   In the  epidermis,
the fungus has a predilection for  the  tissues between the  superficial
and deep portions of the  stratum corneum, stopping as if before a
wall,  at the  living protoplasmic masses of  the rete.  The superior
pars vascularis of the corium exhibits enlarged vessels surrounded by
inflammatory elements.
   When the nail is involved, the parasite may be recognized in the
debris produced by scraping  the nail-substance; often  also in the
epidermis bordering the nail.  It exhibits here the same microscopical
features  as upon the scalp, though  in consequence of the denser
structure of the nail-substance, its vegetation is usually less luxuriant.
   Diagnosis.—The clinical  recognition of favus  is based  upon the
presence of the characteristic, yellowish, cup-shaped crusts, often aided
by a history of contagion,  and the peculiar odor  emanating from the
scalp.   The secondary effects upon the hairs, hair-follicles, and skin,
are also, when present, significant.  Dr.  White, of Boston, iu a valu-
able essay  on the "Vegetable  Parasites, and the Diseases  caused by
their  Growth upon  Man,-" calls attention to the stage  in  which the
disease is likely to be mistaken for ringworm.  It  exists  before the
formation  of the  crust, and  may be characterized  by hyperaemia,
vesiculation, or papulation, often  unnoticed  beneath the  hairs of the
scalp.
   The recognition of the  disease by the microscope is, however, the
most  certain method of  establishing a diagnosis;  and this is readily
accomplished.   Aubert,1 in the absence of the clinical features named
above, lays stress upon an intense redness of the  scalp where the hairs
have  been  cut and the crusts removed, this color being limited  to the
portions attacked by the disease.   The hairs, also, as a result of the
disintegration  of their  elements, are infiltrated  by air,  and  look
opaque and black  by transmitted light.   By  reflected  light, these
appear polished and stratified.  It should  uot be forgotten that, in
exceptional cases,  favus  crusts  coexist  upon the body  with other
diseases of prior or  subsequent origin, as indicated above.   The  dis-
ease should not  be  confounded with  seborrhcea, pustular  eczema, or
psoriasis of the scalp, none of which exhibits the special features  of a
parasitic fungus.
   Treatment.—The first indication in the treatment of favus is to
cleanse the surface thoroughly from  all  favus and  other  crusts  and
scales which mav be present.  For this purpose the scalp (if this be,
for example, the affected part)  is first shorn  of its hair with the
scissors, aud then thoroughly soaked  in olive, cod-liver, or other oil,
or glycerine.  After this,  all the  crusts are scraped away with  a  spa-
tula, and the scalp washed clean  with hot water and soap, the spirit
of green soap being here preferably used.  The scalp should be then
again anointed with oil,  or covered with au emollient poultice.  Once
i Annal. de Derm, et de Syph , 2m. ser., 11, p. 34. 
602
DISEASES  OF  THE  SKIN.
thoroughly  cleansed by repeated soakings in oil and ablutions, it is
necessary to resort  either to the  topical employment of parasiticides
(agents capable of destroying the fungus) or epilation (the extraction
of the hairs).   Often both  measures are required.   Without further
treatment, the scalp, however completely freed from all evidences of
the disease,  will not fail to  show fresh favus crusts iu  a fortnight or
somewhat longer time.
  Epilation is  practised  by the aid  of  epilating forceps.   These
should  be constructed with an  easy spring that will not tire  the
fingers of the  operator; with  blades that  are sufficiently broad to
grasp a few hairs at once; and with smooth, or slightly serrated faces
of the blades, as otherwise the hair is liable to fracture in the grasp of
the instrument.  The  surface to be operated upon should be  pre-
viously anointed with vaseline or olive oil, and the hairs  be entirely
removed, a  sufficient number, covering a  definite  space, upon  suc-
cessive days.
  The tediousuess of this process has led to several devices by which
it is sought  to do away with its necessity.   Originally  the "calotte"
was employed for the removal of  the hairs.  It was made by smearing
a disk of leather with pitch, and applying  it over the scalp.   When
the calotte was subsequently removed by a brisk motion of the hand,
the  hairs which adhered  were  forcibly uprooted  en masse; those
remaining being adherent  in  their sacs in consequence  of the  fact
that they had not been invaded  by the fungus.   As a substitute for
this somewhat  brutal  procedure, Bulkley1 has employed adhesive
masses, or sticks, which can be melted and made to adhere  at once
to large  numbers of the hairs.   When  cold they can  be withdrawn
from  the surface with the hairs attached.  These sticks are from  two
to three  inches in length, and from  one-fourth to three-fourths of au
inch  in  diameter.  The  hair  is first clipped so as to be about one-
eighth of an inch in length.  The eud of the stick  is theu heated in
an  alcoholic flame, and quickly  pressed upon  the  scalp.   It  is thus
left in  place  till quite cold, and  removed by  bending it over  aud
drawing  upon  the hairs successively  with slight  rotation.   When
free, it is found thickly set  with the extracted filaments,  which may
be  burned  off  in  the  alcohol flame, thus  destroying  both the hairs
aud any adherent fungous masses.   The stick is then carefully wiped
clean with paper, after  which it is again ready  for use.   The formula
for the mass of which these sticks are composed is as follows:

         R.
Cera? flavae	3nj ;	12
Laccae in tubulis	3iv;	16
Resinse	3vj;	24
Picis Burgundicse	3xj;	44
Gummi dammar.	Ijss;	48
                                                            M.
  The parasiticides in greatest favor are, corrosive sublimate in solu-
tion in the strength of one-half to four grains (0.033-0.266) to  the
ounce (32.); sulphite of sodium in saturated solution; pure or diluted
1 Favus and its Treatment by a Xew Method of Depilation, Arch, of Derm., vii. T$o. 2, April, 1881. 
TINEA  TRICHOPHYTINA.
603
sul phurous acid; spirit of green soap;  tar, croton  oil, carbolic and
salicylic acids;  petroleum, chloroform, ether, creasote, and the  oil of
cloves.   Ointments are also  useful containing mercury (citrine oint-
ment, yellow sulphate or white precipitate), naphthol, benzol, thymol,
sulphur, salicyl, pyrogallol, and carbolic acid.  Chrysarobin is very
effectual  in  an ointment, though  objectionable on  account of  the
staining of the  scalp, and, almost inevitably, of the face also.   Lenz-
berg1 generates  sulphur fumes in a dish of red-hot coals attached to a
frame, made of wood or paste-board, close to the head of the patient.
By means of a paper cap, the fumes are collected and  retained for
from five to ten minutes, in contact with the patient's hair.  During
ten years' trial of this  plan, he has never been compelled to  resort to
epilation.
   One  or more of the  methods may be  needed, either  at the same
time or by repetition or alteration, till the fungus is eutirely destroyed,
the  requisite  period usually extending  over three  months.  Treat-
ment should theu be discontiuued, in order to test the result by obser-
vation.   If, in  the course of a fortnight or  more, a relapse occurs,
the treatment is to be promptly renewed.  Upon the non-hairy por-
tions of the body, parasiticides thoroughly applied  usually procure a
radical  relief.  When the nail is involved, it should be cut short and
carefully scraped or  softened by repeated applications of a  strongly
alkaline lotion, after which a parasiticide  may be employed in oint-
ment or lotion.
   In general, it may  be remarked that patients long affected  with
rebellious favus, may need a  roborant course of treatment and nutri-
tious diet.   Cleanliness  here,  as  in all the parasitic disorders, is
essentially important.   As adjuvants  in the treatment of the scalp
and nails, it is well to remember  that  continuous applications of a
parasiticide are  aided by caps or cots of impermeable material, super-
imposed upon rags saturated  with the medicament employed.
   Prognosis.—The  prognosis is generally favorable  to the  ultimate
termination of the  disease ill all cases;  for eveu the most rebellious
and untreated forms  are relieved  when the hair  follicles atrophy.
Upon  the non-hairy portions  of  the  body, the disorder is rarely
severe if promptly and efficiently treated.  Upon the scalp, the prog-
nosis is proportioned  to  the extent, severity, and period  of  prior
invasion of the disease.  Early and vigorous treatment of the  scalp
in healthy children, is usually followed by satisfactory results.   Neg-
lect, filth,  and systemic malnutrition,  are  the  most  unfavorable
elements iu any case

                     Tinea  Trichophytina.

                   Gr. dpi!-, hair ; <pvr6v, a vegetation.

   Ringworm is a disease of the hairs and hair-follicles of the  scalp
and  beard, as also of  the non-hairy portions of the body.  Iu each
i Der. prakt. arzt., Feb. 1S81. 
604
DISEASES  OF  THE  SKIN.
case it is produced by the presence of the same vegetable fungus, the
trichophyton.  Inasmuch, however, as each of these regions of the
body, when  the  parasite is  present, displays lesions which are more
or less peculiar to itself, it is usual to consider each separately.  Ping-
worm  of the body is hence designated, Tinea Circinata ; of the
scalp, Tinea Tonsurans ;  of  the  beard, Tinea Sycosis.


                     [A.]  Tinea Circinata.

Tinea Circinata is a contagious disease  of the skin, characterized by macular
  vesicular, papular, squamous, and rarely  pustular lesions, having  usually
  a clearly defined, circular outline, and induced by the presence of the tri-
  chophyton.

   Symptoms.—Ringworm of the body  displays different  symptoms,
according to the temperature in which the vegetation flourishes, and
the various  external  irritants  to which the  skin, where it has once
been implanted, is subjected.
   The macular form  of the disease is characterized by the occurrence
of one or several pea- to large  coin-sized, circumscribed, reddish cir-
cles, usually  paling under pressure, often at the general level  of the
integument, occasionally slightly raised above it, forming then a flat-
tened disk.   The centre of the circle may be paler, or indeed to the
naked  eye quite unaffected, transforming  the  patch  to au annular
lesion, from which circumstance it originally received the name  " ring-
worm."   It  develops within certain  limits, rarely exceeding five  or
six inches in  diameter, by peripheral extension; and is  usually charac-
terized at the outer border by slight, whitish, furfuraceous desquama-
tion.   This form of lesion is usually seen upon exposed surfaces  of
the body where there is less heat,  moisture, and friction, than upon
others, as, for example, the forehead and  neck in moderate atmos-
pheric temperatures.   From it may be developed the  other forms
described below.  The  disease  may recur within  the  peripheral
border; in this way occasionally two,  three, and  more concentric rings
or parallel bands of crescentic outline may be visible in a single patch
of disease.   The subjective  sensations are a trifling degree of itching
or burning.   Should  these  rings extend to the beard  or scalp, the
circinate may coexist  with the other varieties of the disease.
   The vesicular lesions of ringworm appear as such at  the onset,  or
rise from the macular lesions described  above.   In the  former case,
pin-point sized, transitory, aud superficial vesicles or vesico-papules
spring from a central point  or  focus,  or speedily shrivel till they are
represented  merely  by minute,  whitish,  branny  scales.   To these
others succeed, always at the periphery, and to these again yet others,
the rosy  or  reddened base  on  which  they rest  being  sometimes
slightly in advance toward the outlying  skin.  The enlarging circlets
of disease proceed in their course to an evolution quite similar  to
that observed in the macular forms.  The difference, due chiefly to a
somewhat more active development of the fungus, is noted not merely 
TINEA TRICHOPHYTINA.
605
in the type of the lesion, but in the slightly  exaggerated  pruritic
sensations which are awakened.   Rarely, both of the forms described
are presented with acute symptoms and extensive development, in
multiple patches spreading over the face, neck, trunk, and extremi-
ties, accompanied by  a slight febrile movement and moderate tume-
faction of the affected surfaces.   xVs a rule, the eruption  is trifling;
and may, indeed, be  limited to  a single ring, or very few circlets
about  the neck, terminating in the  branny desquamation described ;
but in the severer forms the evolution of the disease may persist for
months, and crusts form, whose  fall  leaves annular pigineutations of
temporary duration.
   The papular  and  rare pustular forms of the disease observe the
same  peculiarities with  respect  to  the  clearing of the  centre, the
annular appearance of the advancing area  of involvement, and the
production finally of scales  and crusts.  They represent, however,
either a much more luxuriant vegetation of the fungus, or the irrita-
tion of the affected part by  friction and heat, or, what is probable,
the  cooperation  of  the  two.   They  are,  hence, most  commonly
observed  upon the back, the belly, the inter-  and infra-mammary
regions, and  the internal faces  of the  thighs  and arms, iu which
localities they occasionally occur with chronic manifestations.   The
papules are light or dull reddish, pin-head and larger, solid elevations,
roundish, oval-shaped, irregular, or confluent, forming  eventually
bean  to coin-sized, raised disks  with a  pale, exfoliating, or actively
inflamed centre, the so-called "nummular"  or  " discoid trichophytic
erythema" of French authors.   The  itching is sometimes in  these
forms severe; and the process may display  central recrudescence, as
noted  above.  Pustules  found at the periphery have the  size aud
distribution of the  other  lesions described.   They represent merely
an  aggravated exudative process awakened by the fungus, and the
scratching incident to the pruritic sensations excited.
   Partly because of the controversy which  the subject has aroused,
special attention has been directed for some  years to the disease which
Hebra  was first to  name,  Eczema  Marginatum.   It  is   most
marked upon the portions of the body which come  in contact  with
the saddle when a rider is mounted on a  horse—that is, the perineum
and the inner faces of the thighs, the  region well marked by the
reinforcing  patch in  the trowscrs of the cavalryman.  The disease,
as encouutered  here,  is termed  Tinea Trichopiiytina  Cruris,.
and occurs in both sexes.   It is characterized  by extensive exuda-
tion, in bright or lurid patches, with a very distinctly defined, raised
border, showing a sharp  contrast  with the healthy  skin  beyond,
from  which  peculiarity it has its name.   It  may extend  laterally
over  the groins, upward over the  pubes,  aud backward  over the
sacrum, being generally defined  at  the periphery by a crescentic
outline.  The centre   may be paler and less  involved,  or  actively
irritated, while the periphery still extends  in  one or  more annular
festoons down the  inside of the thigh  or  upward  over  the regions
indicated.  The itching is severe ; the course of the disease obstinate, 
606
DISEASES  OF  THE  SKIN.
persistent, and subject, in a remarkable degree, to relapse in the same
locality.  The fungus is always present, whether occurring as a cause
or epiphenomeuon of the disorder.  It was rightly named by Hebra ;
and deserves special recognition uuder whatever title it be classified.
It is a true eczema, with special features, complicated by the develop-
ment of the fungus, and aggravated  by heat, the moisture  of the
sweat, and the  friction of apposed  surfaces of the skin  in contact
with each other and the clothing.  After detecting the fungus in
scales scraped from the  surfaces thus involved, one is always in such
case impressed  with the  characteristic clinical  peculiarities  of the
disease.   It is usually of symmetrical distribution, due to the circum-
stances of its development, and in this respect differs from the other
manifestations of the disease.
   When the nails are affected, the disorder is termed Tinea Tricho-
phytina Unguium, or Onychomycosis.  These appendages  of the
skin then become friable, opaque, and  lamellated; and are clinically
indistinguishable from nails secondarily changed in eczema, psoriasis,
and similar  disorders of the  integument.   One or several   of the
nails of both  feet and  hands may be affected.  When all the nails
of both extremities are involved,  the  disease is rarely of parasitic
origin.   The  microscope is requisite for establishing the diagnosis in
such cases, the parasite being  detected in the fragments procured by
scraping the nail.

   Etiology.—The disease is caused by the  presence  of the parasite,
though the  latter may  be an  accident of other cutaneous disorders.
The trichophyton was first discovered by Gruby, in 1844 ; though
Malmsten, whose name  is often associated with that of the  fungus,
became identified with its recognition, by his observations during the
succeeding year.  As a contagious disease, it ranks higher  in the
scale than favus, being much more  readily communicated; and, as a
result, much  more common.   Occurring upon the non-hairy portions
of the body,  it is often spontaneously removed by the  desquamative
process which it excites  in the skin.
   Though the fungus is the essential cause of the disease, its develop-
ment is greatly favored or retarded by external  influences.  Attention
has been already called to its luxuriance under the influence of heat
and  moisture.  It  is, hence,  much more severe and  rebellious to
treatment in  tropical countries.  It  occasionally occurs in epidemic
forms.  Thus, Gerlier1  gives the  details  of  such  an  epidemic in
Ferney-Voltaire, where twenty-six  cases came under  his observation.
In  some of these the lesions  were pustular ; in others,  tuberculo-
pustular.  Aggravated forms of the. disease seem also to originate in
the  lower animals.   I  have  seen  certain mild  types  of ringworm
transmitted to man from cats and dogs.  Gerlier concludes that the
most rebellious and  persistent  forms are derived  from the  horse ■
those from the cow being of less formidable character.   Tilbury Fox
i Lyon Medical, April 24, 1881, p. 590, and May 1, p. 7. 
TINEA TRICHOPHYTINA.
607
reports an  especially aggravated  case originating iu the disease as it
existed upon a pony.   It occurs much more frequently in children
than in  adults, presumably  from the relatively tender conditiou of
the epidermis in these subjects.   It is particularly liable to occur in
men whose skins  are  especially moistened, as in those who work in
atmospheres saturated  with steam.   Several members of a  single
household  will often display ringworm of  the body at the same time,
having  transmitted it, the one to the other.   Duhring  and Fox are
in accord  respecting  a belief iu  the  need  of an appropriate soil for
the germination of the fungus, some  individuals being  thus predis-
posed to its invasion.   It is, however, encountered in both sexes and
in all social conditions.
   Pathology.—The seat of the  fungus in tinea circinata is between
the strata of the epidermis, that part of it  more particularly  which

                             Fig. 80.
 
608
DISEASES  OF THE  SKIN.
favorable to its development, it penetrates the layers of the epidermis
in every direction from the central point of invasion, the circle thus
produced being characteristic of many forms in both the higher and
the lower vegetable life.  The irritation excited by the presence of
this foreign  body produces  all the subsequent symptoms of a mild
grade of superficially seated inflammation;  erythema, exudation and
fine vesiculation, papulation, and, in  severe grades, the  production of
tubercles  and pustules.   The desquamative symptoms are exfolia-
tive ;  and represent, in a sense, the natural effort at relief; this effort,
as remarked above, being often successful when the spores and myce-
lia are thrown  off with the effete,  horuy  plates of the epidermis.
When the nails are affected, the same fungus can be  discovered  in
detritus of the nail-tissue, which has been macerated in dilute liquor
potassse.  Often, as  a  result of the impairment of the structure  of
this organ, and  owing  largely  to  the stratification of  its body, the
lamella? will be found in part to have undergone a caseous degenera-
tion.
   Diagnosis.—Ringworm of the body is  to be distinguished  clinic-
ally from eczema, psoriasis, seborrhcea, lupus erythematosus, herpes
iris, and  syphilis.   All  the varieties of eczema are noted  for their
greater degree of itching and  infiltration, their much less  defined
border, coarser  scales,  decided  absence of  a circular  coutour,  and
history of contagion.  Psoriasis does occur  in circular and  annular
patches, often with a clear centre and insignificant, subjective sensa-
tions.   But its scales are lustrous and the tissue beneath them readily
bleeds, showing deeper implication of the skin.  The disease is often
symmetrical in disposition ; occurs by preference upon certain  regions
of the body where ringworm is relatively infrequent; and its  history
is that of a chronic disorder.   Seborrhcea of the skin exhibits greasy
or fatty crusts, which are never characterized by the peculiarly  branny
condition of the scales seen in ringworm of  the body.   The distinct-
ion between these disorders on the scalp will be given later.   Lupus
erythematosus is often symmetrical, always chronic, and characterized
by the development of multiple, annular patches, enlarging centrifug-
ally from a clearing centre.   Herpes iris can be distinguished, first,
by its predilection for the extremities;  second, by the variegations in
color which it displays and  which are never seen in ringworm of the
hands.  Syphilis is  multiform  in  its lesions, usually preceded by a
history of infection ;  and its distinctly circular patches, eularging at
the periphery, all  exhibit  either atrophic,  ulcerative,  or distinctly
crusted symptoms, which suffice for their recognition.
   Pityriasis maculata et circinata is not characterized by vesicles; is
often  symmetrical in  development;  occurs in oval  rather than dis-
tinctly circular patches ;  and exhibits a characteristic tawny-yellowish
shade of color not seen in ringworm.  In eczema marginatum,  the
elevated border of the diseased surface, its situation (groins, armpits,
pubes, etc.), its  curved  outlines, and  the  occurrence of fresh rings
within the older, point to the nature of the trouble.
   But the microscopical discovery of the parasite is the chief and 
TINEA TRICHOPHYTIN A.               609
indeed, essential, method of diagnosis in tinea circinata.  By the aid
of a good fourth- or fifth-inch  objective,  the  spores  and mycelia
are readily recognized in  the scales  scraped  from the surface and
moistened  with dilute liquor  potassee.  Duhring  calls attention to
the care which should be had in distinguishing the fungous elements
from  cotton  or wool fibres,  fat  globules derived  from previously
applied unguents for the cure of the disease, sebum, pus, and the
nuclei  of the epithelia.   All confusion of this sort can be avoided by
a careful study of the anatomical peculiarities of  the  trichophyton,
recalling especially the parallelism seen in the double contours of the
threads, their jointed appearance, their contained  granules, and the
necklace-like or beaded arrangement of mauy spores.
   Treatment,—The  indication in the treatment of ringworm of the
body,  is  the  removal of the  superficial layers of the  epidermis, by
which means the spores aud mycelia are thrown off from the surface;
and, if possible, the simultaneous destruction of the latter.   Upou the
delicate skins of infants and  children, the simpler remedies are first
to be employed.   Scrubbing each patch with the spirit of green soap,
or merely soap and water,  will often suffice for its obliteration.   The
topical application of tincture of iodine is  a common and  usually
effective remedy.  The same may be said of dilute acetic, boric, and
carbolic acids.  Morris's solution of thymol,1 half a drachm to two
drachms (2.-8.) of chloroform, and six drachms (24.) of olive oil, is
equally available.  One may  also use thymol in  ointments, half a
drachm (2.) to the ounce (32.) of simple unguent, with good effect.
Of the mercurials,   ammoniated  mercury,  a  scruple  (1.33) to the
ounce  (32.)  of ointment;  corrosive sublimate, one  to two  grains
(0.066-0.133) to the ounce (32.) of solution; and the ointment of the
nitrate, one drachm  (4.) to the ounce (32.) of vaseline, are preferable.
Sulphurous  acid  from a freshly opened can, and saturated solutions
of the hyposulphite of sodium are as effective as any of the parasiti-
cides,  aud are often  used with advantage as  lotions to be followed by
an appropriate unguent, always providing against chemical decompo-
sition  of the ingredients of the latter.  Sulphur- and  tar-containing
lotions and unguents are useful in more obstinate cases.
   Chrysarobin and  pyrogallol, in ointment from five  to  ten grains
(0.33-0.66)  to  the  ounce  (32.), are  brilliantly effective in all  these
cases,  subject, however, to  the disadvantage  incidental to the staining
and irritative  effects they produce.   Thcv should be used with cau-
tion upon the skins of children,  and always tentatively at the onset.
In cases of ringworm on  the  face of male  adults, close to the beard
or  scalp,  one may employ these remedies with a  view to insure the
non-invasion of the pilary follicles by the fuugus,  whose prompt de-
struction  may become then a matter of urgency.  Wilkinson's oint-
ment,  recommended  by Kaposi,  is also  useful  in  the treatment of
aggravated forms of ringworm of the body, but should be restricted
to such cases.  For other aud more urgent  reasons,  caustic potash
1 Lancet, 1881, pp. 164 and 241.
          39 
610               DISEASES OF THE SKIN.
solutions should be reserved for exceedingly intractable cases.  Some-
times a combination of several of the simpler remedies named above
may be serviceable, as in the following formula:
R	Lac. sulphur.	3ijss;		10	
	Sapon. virid. spts. ) Lavandul. tr. }	aa. oyj;		24	
	Glycerin.	3ss;		2	M "Kaposi.
B	Iodin. pur.	3i.i;		64	
	01. picis [sp. gr. 0>'53]	3j;		32|	
Mix Avith care, gradually.					
R	Creasoti.	"Lxx ;		1	33
	Ol. cadini	f'3"j ;		12	
	Sulphuris prsecip.	fsfij;		12	
	Potass, bicarb.	3j;		4	
	Adipis	Sj;		32	M
To	be used in obstinate ringworm of adults.		[Van Harlingen		
  Dr. R. W. Taylor  applies the bichloride of mercury, four grains
to the ounce, in tincture  of myrrh.  Dr. Perry, of California, uses
the metal in one-half of the strength  last named, dissolved  in sul-
phuric ether.  Foulis, of Edinburgh, recommends iodine dissolved in
the oil of turpentine  or  benzine, the  fluids named penetrating with
greater ease  than others, to the deeper portions of the skin.
  Other articles advised  by authors  are the oleates of mercury and
copper (?), croton oil,  glacial acetic acid, cantharidal collodion, petro-
leum, and pyroligneous acid (Thomas).
  The thorough application of the remedy selected for use, upon the
integument quite freed  from its scales by scrubbing with soap and
water, is a matter of  some importance.  When the solution of sodic
hyposulphite is employed, the previous  application of dilute vinegar
and water by sponging, renders  the agent more effective, for evident
chemical reasons.   Overtreated  skins, or  those  to which too  strong
a  parasiticide has been  applied, require subsequent  relief  of the
induced irritation by the simpler bland dressings.  The inert dusting
powders, even when not thus indicated, are often  useful when there
is distinct vesiculation;  and in simple cases may be the sole remedies
required, as then the disease is self-limited in duration.
  Liborius, having observed in China that the tincture of an unknown
fibrous root was used  successfully as a remedy for ringworm, obtained
some  of the plant, which was found to be the Rhinacanthus communis,
whose leaves, bruised and  mixed with lime juice, are  used  iu India
as an  application for the same complaint.   Liborius has since ob-
tained from the  root a quinine like body, supposed to be the  active
constituent.   It resembles chrysarobin  in being antiseptic aud anti-
parasitic.   He  proposes  to call it rhinacanthin, and represents it by
the formula C1441804.
   The internal  treatment of- patients  affected  with  ringworm,  by
means of tonics and  roborant measures,  may be demanded  by the 
TINEA TRICHOPHYTIN A.
611
systemic condition, but has no recognized influence over the disease
itself.
   When  the  nail  is involved it should be thoroughly scraped, and
then kept moist by wearing over it the rubber cots sold iu the shops
for the use of sportsmen, fishermen, and others.   In this way a par-
tial maceration of the nail substance is secured, and the action of any
one of the parasiticides named above,  greatly aided.
   Prognosis.—The disease is  often  self-limited, and is  generally,
under the simplest treatment, satisfactorily  relieved.   Eczema mar-
ginatum, especially in the crural  region, may be obstinate; and  this
because it is  an eczema as well  as a parasitic disease, aud  therefore
subject to the relapses and chronic phases of the first-named disorder.
Other intractable forms of the malady do, however, occasionally occur
in adults, usually  in tropical climates and tropical temperatures.

   Tinea Imbricata.   Tokelau Ringworm.   Burmese Ring-
worm.   Malabar Itch.—Under these names and others of similar
character,  have been described  exaggerated forms  of a contagious
cutaueous disease  produced  by a  vegetable parasite  whose identity
with  the  trichophyton, though uot established, is probable.   Tinea
imbricata, as described by Manson; the Tokelau Ringworm, described
by Turner, and  the affection reported  by MacGregor as occurring in
the Soloman Islands  and the New Hebrides, may be identical.  The
parasite does  not  extend deeply within the corium,  but is found in
luxuriant vegetation  with preponderance of rather irregularly con-
toured spores.   The clinical symptoms are, exaggerated desquamation
of ichthyotic  flakes in large concentric circles even  a quarter of an
inch apart; the formation of these conceutric rings by recrudescence
of the disease within its annular limits; the production of  large fes-
toons of  lesions even upon the exposed surface of the face;  and
evidence,  at times,  of excessive irritation of the skin  excited by the
fungus, in the form of pustular and even furuncular aud tubercular
lesions.
   According to  Manson,  the fungus of tinea imbricata, differs from
that of ordinary ringworm in that the former is more abundant; its
threads louger, and its spores  more irregularly outlined.


                   [B.]   Tinea Tonsurans.

Tinea Tonsurans  is a cutaneous disease of the scalp,  characterized by the
  occurrence of one or several, circumscribed, non-elevated or tumid patches,
  over which the hairs  are usually fractured at a point near the integument,
  producing thus the effect of partial baldness, while  the scalp itself is the
  seat of vesiculation, scaling, or crusting, the disease being produced by the
  presence of the trichophyton.

   Si/mptoms.—The differences to be particularly noted between ring-
worm of the body and ringworm of the scalp, depend largely upon
the fact that  in the  latter, the  fungus makes  its way to the hair- 
612
DISEASES  OF  THE  SKIN.
follicles, and  there finds the nutriment  for  its  multiplication and
development.
  It  is usually first observed in the form of circumscribed, small
coin-sized, roundish patches upon the scalp, wholly or partly covered
by  minute,  whitish, slate-colored, grayish, or dirty yellowish scales.
Rarely, the  formatiou of the latter can be noted as consequent  upon
an hyperaemic and reddened condition.   Still more rarely, pin-point
sized, transitory vesicles  or pustules precede.  The hairs upon such a
patch seem irregularly clipped short near  the surface or, as it is fre-
quently styled,  "nibbled"  off, thus producing the effect of partial
baldness in  the involved area.  Among  them  may be often found
lustreless, dry, long, and fragile hairs, which break upon slight trac-
tion  or flexion.  The patches may increase in  number and spread
individually in area till,  in the course of weeks or months, the entire
scalp  is invaded.   In the older patches, youug  and downy hairs may
be seen here and  there, pushing up among the stumps left by those
that have fallen.   One or more of various phases of the disease may
be presented in  its subsequent evolution.   Thus a single patch may
extend  to the size of a large coin  or the palm, and the disease be
throughout  limited to that  area.   Again, as just related, almost the
entire scalp  may be covered by relatively small or enlarging patches,
or, even without the  occurrence of any distinct  patch, isolated  hairs
or tufts of  hairs here and  there over the entire scalp may exhibit
evidence of  impairment.   The disease may be acute or chronic in its
course.  Instead of assuming the dry and squamous type described,
acute  and exudative symptoms may develop, in which event the rare
vesicular  and  pustular  lesions are succeeded by the exudation of a
gummy secretion and the  formation of crusts.   Lastly, the variety
known as kerion may be produced, which is described below.
  Pruritus,  in  various  grades of severity, though usually mild, is
induced by  the disease;  and often the patches  are altered  in appear-
ance by the  traumatisms produced by the  finger-nails and the comb.
When the scalp is very generally invaded  by the squamous form of
the disorder, its appearance is very  similar to  that noted in diffuse
seborrhoea, chronic eczema, and psoriasis of the scalp, except that the
hairs  are  less  pasted to the surface; are more  lustreless, friable, aud
contorted in shape; and much more often represented by stubble or
stumps.   The disease may occur coincidently  with ringworm of the
body,  and indeed at times a ring  may  be detected, half of which
on the  neck presents the  typical aspect of tinea circinata, and the
other half involving the scalp exhibits the features here described.
Stowers,1  Saugster,2 as also Hutchinson,  Tay,  Hillier,  Baker, and
others have recorded cases in which the disease coexisted with alo-
pecia  areata.  The author has certainly observed this occurrence but
in oue case, where the  evidence was conclusive  that there was mere
coincidence  and no causal relation between the  disorders named.
   Geber  asserts that after exfoliation of patches of ringworm  the
1 Lancet, 1881, p. 326.
2 Id., 1880, p 303. 
TINEA  TRICHOPHYTINA.
613
 scalp may become absolutely bald, smooth, and glossy, but that hair-
 stumps and  scales  in  the environment indicate  the nature of the
 disease, which is thus  often  mistaken for area  Celsi,  or alopecia
 areata.
 .   Lastly, it is to be noted that here also at times the efforts of nature
 are successful in procuring  spontaneous relief.  With the defluvium
 capillitii and exfoliating epidermal plates, the  fungus may be  finally
 removed; the resulting alopecia be followed by a growth of healthy
 pilary  filaments; and, even though years  be required for this long
 process, in the end no trace of the disease  be discernible.
   Etiology.—Ringworm of the scalp is produced by the same fungus
 as that recognized in the etiology  of tinea circinata,'the trichophyton.
 It is frequently observed in children of both sexes, especially in those
 gathered together in schools and public charities, where it may spread
 very generally from oue to another, and require months  and years
 for its  extermination.  It is a highly contagious disease,  but yet re-
 quires  unquestionably a suitable  soil  for its  development.   I have
 been frequently impressed  with  a  fact  in this connection to which
 Dr. White1 calls attention.  When there is ringworm on  the face of
 au adult, even of rebellious form,  in the course of which the beard
 may be extensively affected, the scalp is usually spared.  Ringworm
 of the  scalp  in  the adult aud aged is, indeed, among the  rarest of
 cutaneous  accidents.  Among  the methods of transmission in chil-
 dren are, the use upon the heads of the unaffected, of brushes, combs,
 wearing apparel,  sponges, towels, etc.,  which  have been employed
 upon persons exhibiting ringworm  of the  body or  head.   It must
 be remembered that  tinea  circinata may transmit tinea  tonsurans;
 and it is by tracing the course of the two  forms of the disease, that
 the sources of contagion  can  be  ascertained  in any series of cases.
 The disease is one rather prevailing  in the cities than in the country;
 and in  this respect also differs from favus.
   Pathology.—The disease is  produced  in consequence of the inva-
 sion of the scalp, and follicles, bulbs, and  shafts of the hair, by the
 trichophyton,  the  fungus already described  as the  cause of tinea
 circinata.   This vegetable mould is much more abundantly developed
 about  the  hairs than the achorion  Schbnleinii, aud its presence is,
 hence, much more  readily demonstrated in  these structures.
   Robinson2  has  lately excised a portion  of  a scalp  affected with
 tinea tonsurans; and found the stratum corneum, especially in  its
 upper layers, largely iuvaded by spores, as also the rete, the external
 root-sheath of the hairs in its  upper  portion, the  corium, and sub-
 cutaneous tissues.   Mycelia were abundant in the mucous layer.   He
 concludes that  the  anatomical scat  of the disease differs in different
 cases.
   Under the microscope the hairs  themselves, in advanced cases, are
seen to  be  greatly  altered.   The bulbs are distorted, misshapen, or
withered, and often stuffed  with spores  which  greatly predominate
i Loc. cit.            2 Now York Medical Journal, 1881, vol. xxxiii. p. 289. 
614
DISEASES  OF  THE  SKIN.
over the mycelia.  At times the base of the bulb will show a brush-
like expansion, and  in this  respect resemble  the free ends of the
stumps  of the hairs above, which have a jagged, bristle-like appear-
ance, from the division of the shaft into  many  filaments between

                              Fig.  81.
Hair invaded by the trichophyton.
 which spores in abundance are visible.  The shaft is often longitu-
 dinally split, where the  parasitic  growth  has  mechanically forced
 apart its elements, and its cuticle may be peeled off, or curled above
 and below away from the axis, with spores protruding at such  points.
 Conidia can  be discovered much further upward along  the hair and
 distant from the scalp than  in  favus; often, indeed,  upon  its free
 surface.   Occasionally a  few  mycelial  threads  may be recognized,
 either longitudinally or transversely  arranged as  regards the axis.
 It  is probable,  however,  that the relative  preponderance of spores
 and mycelia in  these filaments is determined  by the stadium of the
 disease in any given case.  In the earlier stages of  the affection the
 elongated threads may be discovered in  larger quantity; and as they
 interfere less with the integrity of the fibrous tissue, the  hair  may
 usually at these times be extracted  from its  follicle without fracture.
 Later, the threads disappear and the conidia are infiltrated throughout
 every portion of the shaft which then  breaks, often upon  the slightest
 traction.  One unaccustomed to microscopical examinations,  with a
 view to the detection of the parasite, should be careful not to mistake
for these threads  the delicate lines traversing the surface of the shaft
exposed to the objective, and which represent the edges of the cuticle
of the hair.  The fungus,  though ordinarily refractory to the action
of coloring matters,  will  be stained  by  eosine and methyl-violet.
 The scales  found  upon the affected scalp also exhibit  traces of the
trichophyton under the microscope, though to  a  less  extent than  the
 invaded hairs.  In exceptional cases,  however, the epidermis of the
scalp seems  to suffer as much as  that of the non-hairy portions of
the bodv. 
TINEA TRICHOPHYTINA.
015
  Diagnosis.—The recognition of a typical patch of ringworm of the
head  is simple.  The branny scales, stumps of hairs, and distinct
contour of the invaded area, are always in the highest degree suspi-
cious  symptoms.   It has  been  stated, however,  that the general
development of tinea tonsurans over the scalp produces a condition
very like that seen in other diseases.   In  such cases the microscope
must  be employed  for a decision as to the nature of the  process.  I
have seen the whole vertex  unnecessarily epilated  in seborrhcea sicca,
when no parasite could be found.   But in  seborrhoea there is usually
a symmetry of involvement  which even  aggravated  cases of ring-
worm of the head  fail  to assume; and even  though  pasted  down,
atrophied, changed in color, and loosened in their follicles, the hairs
are rarely broken off near  the scalp in seborrhoea.   In seborrhoea,
psoriasis, and squamous eczema of the scalp, there is, moreover, no
history of contagion; the scales are in each  disease different in color
and  character;  and the hairs in  the two last-named affections are
firmly seated in their follicles, and only iu severe cases present nutri-
tional changes.  The diseases, moreover, are usually chronic in their
course.  In  any doubtful case, apart  from microscopical evidence,
thorough  removal of all  scales from the scalp by shampooing with
green  soap  and  hot water, will  reveal  the nature  of  the  disease
present.
  Alopecia areata, as has beeu noted above, may coexist with ring-
worm, but it is pathologically distinct  from it.  The  patches in the
first-named disease are uniformly smooth, and the hair falls from them
en masse, without lesions, stumps, or other traces of its former devel-
opment in the regions affected.  I have, however, often seen blackish
points or dots distributed over the areas which characterize this form
of alopecia, and which  certainly constitute  suspicious symptoms in
any case.   In such  event, one may be  able to pick out  with  a  fine
needle this  blackish point from  the patent  follicular orifice,  and
find  it  to be a  particle of dust  accidentally lodged  in  the depres-
sion.   It is not, as in comedo, free pigment which has found its  way
to the surface; nor, as in ringworm, the stump  of a  hair on a level
with  the  superficies of the scalp.   In favus, the cup-shaped crust
will sooner or later betray the character of the disease to the  naked
eye.
   Confirmatory evidence as to the nature of the disease will often be
furnished  bv a careful search for the source from which it was de-
rived ; and for obvious reasons this should be always attempted.
  Ringworm of the body occurring  upon the individual  patient
affected with tinea tonsurans, or other  members of the  same  house-
hold, and  suspicious " mangy"  patches  upon  horses,  dogs, cats,
rabbits, white mice, or other animals with  which the child may have
been in contact,  should always receive attention.
   Treatment.—The  indication for the  relief of the  disease  is  the
destruction of the parasite; and there  can be no question but  that
this may be accomplished in  some cases without having recourse to
epilation.   The parasiticides named in  counection with  ringworm of 
616
DISEASES  OF  THE  SKIN.
the body,  if thoroughly  applied  in  simple cases, after clippiug or
shaving the hair and au efficient scrubbing of the patch with spirit
of green soap and water,  will occasionally  be followed by permanent
relief.   Prominent among these parasiticides may be named : pyro-
ligneous acid, sulphurous and boric acids, saturated  solutions of the
sodic hyposulphite, acetum cantharidis, tincture of  iodine, Morris's
solution of thymol in chloroform  and olive oil (see  tinea  circinata),
ointments  of boric acid  and sulphur, of each a drachm (4.) to the
ounce  (32.) of vaseline,  and chrysarobin, the action  of the latter
being carefully limited to the patch of disease  by the aid of a skull-
cap.
   Epilation is, however, a valuable, aud occasionally essential, method
of treating the disease;  and may be  practised,  as  already recom-
mended, in considering the  treatment of  favus.  The scalp in each
case should be first oiled, and cleansed by the soap shampoo, and,
after the epilation is performed, an appropriate parasiticide should be
employed.   The calotte, made by spreading pitch plaster upon leather
or muslin, is a brutal substitute for epilation in order to remove the
hairs, but the sticks recommended by Bulkley  may be employed, the
formula  for  the preparation of which  has been already given.   In
each case, the epilation should remove a zone  of sound  hairs encir-
cling the diseased  patch,  that the  encroachments of  the fungus may
be in every possible way  limited.   It should not be forgotten, how-
ever, in the treatment of  tinea tonsurans by both epilation aud para-
siticides, that in chronic cases these methods, in the hands of the most
expert, have failed for consecutive months to  relieve  radically the
disease ;  that even the most inveterate cases, in  the course of time  and
as adult years are reached, are spontaneously relieved without perma-
nent alopecia;  and that no  remedy or procedure is ever justifiable
which is capable either of producing  follicular atrophy, or an effect
worse than that wrought  by the disease itself.
   Coster's paste is popular  among English practitioners, including
Stowers, Fox, Liveing, and others.   It contains two drachms (8.) of
iodine in crystals, slowly  dissolved in the oil of tar; and  is  painted
over the part at intervals  of a few days.  It is  most useful in  circum-
scribed patches of the  disease.   Among  other remedies  employed,
some of  which have been described in connection with ringworm of
the body, may be named, the corrosive chloride, ammonio-chloride,
red  oxide,  oleate,  and  ointment of the  nitrate of mercury; pure
carbolic  acid  and  carbolated glycerine;  aud sulphur,  chloroform,
ether, and  tar in ointment.
   In order to be effectual, the treatment pursued must be persistent,
thorough, and  always accompanied by frequent washings  and soap-
ings of the affected part.
   The induction of suppuration  in the hair-follicles (or a species of
artificial kerion) by the aid of croton oil  liniment, has  been praised
by Alder Smith and Wyndham Cottle, of London,  and lately,  in  a
modified form, by Magee Finny, of Dublin.   By the latter  process,
one hundred parts of the oil are mixed with  fifty each of cacao 
TINEA TRICHOPHYTINA.
617
 butter and white wax.  Sticks are made of the compound which
 can be thoroughly rubbed into the  part affected.   By both methods,
 it is claimed that no pain is produced, nor is permanent alopecia the
 result.   A solution  of  salicylic acid is applied after each treatment,
 and a subsequent poultice may be also  needed.   In these cases the
 parasite  is presumably  destroyed by the suppuration excited.
   Dr. James Foulis, of Edinburgh, claims to relieve the worst cases
 in a week by the following method : The patient (usually a child) is
 seated before a basin of warm  water with a towel fastened around the
 brow so as perfectly to protect the eyes from  the trickling into them
 of the fluids  used.  About the patches, the hair is cut short;  if the
 patches  are  numerous, the entire scalp is closely cropped.   The oil
 of turpentine is first thoroughly rubbed in with the finger, causiug
 the dirt  and greasy scales to disappear while the short  broken hairs
 are seen  to  stand up  like bristles.  The scalp  is then well sham-
 pooed with hot water and ten  per cent, carbolic soap.   The head is
 then  well dried  aud  two  or  three coats of iodiue  in tincture are
 painted  over each affected patch and  permitted to  dry.   Carbolic
 oil, one part to twenty, is then  rubbed  into all the hairs of  the head
 with  a view  to reaching any spores  among them.  The treatment is
 applied once or twice daily according to the  severity of the case for
 a week.
   As in the case of ringworm of  the  body, tinea tonsurans is  not
 remediable by internal treatment.  Such  internal medication, how-
 ever, may be indicated by the systemic condition of the little  patients,
 and should be in each instance such as that condition suggests.
   Prognosis.—The  ultimate prognosis  in  every judiciously treated
 case of tinea tonsurans is  favorable, since all patients ultimately re-
 cover from the disease per se.   Under the best treatment many cases
 will  prove tedious,  mouth after month  passing without marked im-
 provement.   The disease, however, in  a large proportion of cases
 among children  surrounded by proper hygienic conditions, especially
 as regards cleanliness, is readily relieved.

   Tinea  Kerion. — The occurrence  of active  inflammation in a
 usually circumscribed portion  of  the scalp affected with ringworm,
 is at  times followed by certain peculiar features, the assemblage of
 which has been  designated by this term.   This complication of the
 disease was recognized  early in the history of medicine, by Celsus,
 whose name has  since been associated with its lesions (Kerion Celsi,
 from  kvpiov, a honey-comb).   Tilbury Fox, in  1866, was first to recog-
 nize its identity  with tinea tonsurans;  and it has since been the sub-
ject of a number of interesting papers by Tauturri, Maiocchi, Schil-
 ling,  Bardazzi, Auspitz, and Wilson.   In this  country, Dr. I. E.
 Atkinson,1 of Baltimore, has  made it the subject of a valuable
 memoir.
  The symptoms are, the  occurrence of acute inflammation, usually
1 Arch, of Derm., vol. vii. Xo. 1, Jan. 1881. 
618
DISEASES  OF  THE  SKIN.
circumscribed, though occasionally diffuse, in a portion of the scalp
where a tumor forms  which may project to a considerable  distance
above the general level.  In  time the appearance presented  is quite
suggestive of anthrax, as from tumid orifices of numerous disteuded
follicles, a viscid, semi-transparent, and puriform fluid exudes.  The
latter is highly characteristic.  The hairs loosen and fall.  When the
view of the tumor is not obscured by the pilary growth, it appears as
a flattened hen's to turkey's  egg-sized, boggy, semi-globular tumor,
its  surface congested, reddened, glazed, and often exhibiting other
evidences of  inflammation, with split-pea sized, pustule-like lesions
distributed over its surface, or, when  these have ruptured, the gaping
apertures described above, from which the gummy secretiou is poured
in varying quantities.   Modifications of this condition occur, such as
the production of a true subcutaneous abscess with fistulous  sinuses.
The sensations awakened are usually  painful;  the course of  the dis-
ease is chronic.   It may begin with the usual symptoms of ringworm
of the head, though often there is no  history of the latter.  The com-
plication is a  rare one.   But five cases in all have come under  the
author's observation ;  two of  these were children in one  family,
brought to him from a neighboring State.
   The parasite  may and may  not  be found  in  patches of kerion,
according to the acuity of the present or precedent inflammatory pro-
cess.   If the latter be of high  grade and  suppuration  result,  the
fungus is destroyed, a  result whose attainment has been attempted in
the production of an " artificial kerion " by means of croton oil  for
the relief of tinea  tonsurans.   In the earlier stages, well described
by  Atkinson, and  represented by merely deep-seated follicular in-
flammation, with pustular  development about the hair-shafts,  the
latter  may be seen  microscopically to be invaded with spores.
  The treatment is either by  the  milder  parasiticides  or  by  the
methods proper for the relief of ordinary phlegmonous inflammation
of the scalp, according to the stage of the kerion.

                      [C] Tinea Sycosis.

Tinea Sycosis  is a  contagious disease of the region covered by the  beard of
  the adult male, in which the integument, hairs, hair-follicles, and subcu-
  taneous tissues may be involved, characterized by the occurrence of macu-
  lar, papular,  vesicular, pustular, or tubercular lesions, owing to the pres-
  ence of the trichophyton.

  Symptoms.—The disease is best studied at its onset, in the beard
of a blonde subject with relatively fine downy hairs, where  are pre-
sented the typical features of  tinea circinata, ringworm of the body.
One or several, reddish, pea- to small coin-sized rings become visible
with  pin-point sized vesicles,  branny scales,  and  often,  indeed, no
other  lesion  save an  hyperaemic,  scarcely elevated  margin  at  the
periphery.   The  hairs over the patch may be fragile, and  clusters 
TINEA TRICHOPHYTINA.
619
here and  there betray evidences of change.  With  proper treatment
the disorder may not progress beyond this point.
   In other cases the very slight  degree of itching awakened bv the
process just described, may be intensified, and  large plaques form, a
portion of which may extend from the region  of the beard over the
face and neck, or vice versa.  AVhen fully developed, a phlegmonous
disorder is produced which bears some analogy to the kerion just de-
scribed, and which may so  actively progress that it is  first seen in
typical development.  The skin is congested and reddened, with sub-
epidermic (or debris of ruptured) pustules at. the orifices of the pilary
follicles;  and is  studded  irregularly with firm,  pea-  to  nut-sized
papules and tubercles.   The latter are usually  aggregated iu masses
or lumps which involve the skin and subcutaneous  tissues;  and are
firm, often tender and painful, rarely boggy and furuncular.  AVhen
pierced, they give exit to a characteristic, muciform, gluey, yellowish,
aud sticky fluid, puriform yet differing from pure pus, which rapidly
dries iuto crusts.   These composite lesions are  usuallv circumscribed
in  a given area of involvement, very rarely covering the region of
the beard in symmetrical disposition, more often limited  to one cheek,
or  the cheek  and chin.   Duhring has an admirable portrait of this
disease in his Atlas,  one of the most faithful representations of a
cutaneous affection which it is possible to produce.
   The hairs in the invaded region are involved as in  ringworm of
the scalp.   These filaments break near the surface of the integument,
leaving  ragged stumps;  or spontaneously fall, after being loosened
in their follicles.
   The ease with which they may be epilated is  really one of the most
characteristic  features of the  disease;  they are slipped out of their
follicles  as  readily as  if they had beeu oiled;  or, as Anderson re-
marks, "as easily as a  pin  can  be  pulled out  of a pin-cushion."
They are then often whitish  because enveloped in the fungus  pro-
ducing the disease.  In either event, the resultiug, gradual thinning,
or removal of the hairs, renders  the disease of  the surface more con-
spicuous aud deforming.   At the edges of a patch thus exposed, de-
formed, lustreless, contorted, flattened, twisted,  or split hairs may be
found.   Occasionally the features of the patch are  changed  in conse-
quence of the unusual degree of suppuration excited.   In such case
the pustules burst, and their  contents concrete  into dry crusts about
the stumps of shafts of surviving hairs, from which circumstance the
disease has  received its  name (sycosis,  abnov, a  fig).   Rarely, a  con-
glomerate crust covers the entire  region  with an excoriated, inflamed,
and secreting surface beneath.
   During  the  last few years  the author has had the  opportunity of
treating a number of formidable  cases of tinea  sycosis in the persons
of farmers, resident in the  extreme western States, where  the disease
was loug untreated and  unrecognized.  A few of these severe cases
were produced after shearing sheep  having diseased pelts.   In these
cases the cheeks, lips, aud  chin were the seat of large-nut to small-
egg  sized, cutaneous and subcutaneous, soft,   boggy, and pus-filled 
620
DISEASES  OF  THE  SKIN.
tumors, accompanied  by excessive  soreness of the entire throat and
neck, the hair falling  from the follicles in  large  masses, and  as  if
lubricated to facilitate  their escape.
  Etiology.—The  disease is always produced by  the  trichophyton,
the fungus described as the  cause of ringworm of the body and scalp.
It was first discovered by Gruby,  in 1844.   Dr. AVhite,1 of Boston,
has  called special  attention to the frequency  of its  origin in the
barber's shop, a fact which common experience verifies.  It is usually
the irregular visitor to these establishments who is first to supply the
germs of the disease.   No individual  proprietorship in mug, soap,
brushes, and razor can secure, against danger of infection, the person
whose razor is drawn over a common strop, whose  cheek is handled
by unwashed fingers which  have been recently passed over an infected
face, or whose beard  is combed, brushed, or rubbed by the imple-
ments and  towels  in  common  use at these establishments.   The
remedy is twofold; first, the full beard should  be worn without
shaving, as it is very rare  to find bearded patients of this class affected
with tinea sycosis;  second, where the whole or any part of it is to be
removed, every adult male should learn how to  shave himself.  The
physician should, in this connection, be for medico-legal reasons put
upon his guard against hastily deciding both as to the nature of the
disease of his patieut and the source from which it was derived.   Of
the first, he can become certain by his microscopical investigations.
Of the second, he can only become  certain  by obtaining possession of
facts  far beyond the  reach of the  average practitioner.   A medical
gentleman  in a neighboring State recently sent  the author for exam-
ination some hairs  from  the beard of a male patieut affected with
tinea sycosis.   Before receiving a  report  confirming the diagnosis,
this physician was  sued by the barber in  whose  establishment the
disease had been probably acquired, on the ground of libel.
   It  is  difficult to determine  the frequency  of  the disease  from
statistics.   The  affection  is certainly  relatively rare, and  yet  more
common than is frequently supposed to be the case.   In the author's
practice it is of irregular occurrence, months passing without a single
case coming under observation, after which several  may be noted in
rapid succession.  The statistical returns of the American Dermato-
logical Association include eighty cases iu  the year 1885; ninety-
seven in the year 1886 ; and but twenty-two in the year 1887.
   The disease, being contagious, is one affecting men in all stations
of life, and these  usually at  a  period rather under than over the
fortieth year.   The author has certainly treated for this disease more
men  with  light hair  and eyes, and light brown, reddish, or sandy
beard, than  those  having darker shades of  hair and eyes, a fact to
which Mr. Morris has  called  attention  in connection with  tinea
tonsurans.2
   Pathology.—The disease is essentially a follicular and perifollicular
inflammation, induced  by the irritative  effects of the fungus, pre-
1 Loc. cit.
2 Lancet, 1881, pp. 164 and 241. 
TINEA  TRICHOPHYTINA.
621
ciscly as in the case of tinea tonsurans.  The reason for the difference
between the clinical aspects of the two diseases, may be  in part
explained by the habitual covering of the scalp with caps and hats,
while the face is left exposed ; and by the occurrence of tinea sycosis
in adult years, while  tinea  tonsurans is emphatically a  disease of
childhood.   As a  result of the induced inflammation, the  vesicles,
pustules, papules, and  tubercles  are  formed, while the perifollicular
inflammation may invade all portions of the skin and subcutaneous
tissues, gluing together the plastic nodules formed about the  individual
hair-sacs, into the  lumpy masses  which  are so characteristic  of the
disease.   The invasion of the hair-follicles aud hairs by the fungus,
is accomplished as in the case of ringworm of the scalp.   Under the
microscope, spores and mycelia are visible, the former preponderating
at the  stage where  the  disease first  comes under observation, but
probably preceded in most cases  by abundance of thread-like  forms.
  Filaments and spores of the trichophyton from the heard of a patient affected with tinea sycosis.

The identity of the disease  with ringworm of the body and  scalp,
does not, however, rest merely upon microscopical observation,  but is
demonstrable bv established  clinical facts.  Not only may ringworm
be seen to spread from the face to the beard, but  tinea tonsurans and
tinea circinata may transmit tinea sycosis, aud the reverse.  I  lately
treated  a physician for ringworm'of the bearded  chin and  cheek
derived from' the  face  of a  little patient under his care.   He  subse-
quently gave tinea circinata  to his wife, who suffered on the face and
shoulder, and  she, iu  turn, communicated  tinea tonsurans to  her
daughter.
  Diagnosis.—The distinction between the parasitic and non-parasitic
forms  of sveosis,   is of chief importance  in  this connection;  and, 
622                DISEASES  OF  THE SKIN
necessarily, the microscope must be employed to settle the question
definitely.   The  diseases, however, differ in their clinical features
The non-parasitic form always fails to exhibit the nodules, tubercles,
and composite cutaneous and subcutaneous agglutinations of the dis-
ease produced by the fungus.  The  disease in the former is a more
superficial  process, and, in the author's experience, exhibits to the eye
a more vivid redness as a result of the cutaneous hyperaemia.  Owing
to the same cause, the frequent  pus-containing lesions are developed
and elevated  above the general level of the  integument;  they  are
less commonly sub-epidermic  crypts filled with characteristic mucoid
puriform contents.   The  region  of the  bearded  upper lip, so often
involved in cases of chronic nasal  catarrh  with  coryza, is apt to be
spared by  the trichophyton.  AVhen  the latter is present, the hairs
are characteristically  loosened, distorted,  and  otherwise  changed.
This is uot seen in the non-parasitic form of the disease.   Exception,
however, in this particular is to be noted in some  long-standing cases
of non-parasitic sycosis.  AVhen the latter affection has persisted for
many years (and  one may often see such patients), the thinned and
starved condition of the pilary growth  is a striking symptom, the
scanty lustreless hairs often scarcely sufficing to conceal the deforming
redness and pustulation of the surface from which they spring.   In
another point, the author's personal experience seems  to differ  from
that of some other observers.  The diffuse symmetrical affection of
the hairy face, extending over both cheeks and chin, has been by him
more frequently  recognized as  unconnected with  the presence of a
parasite.    Lastly, the parasitic is, as a rule,  less  painful and tender
than the other form of sycosis; and is, without question, furthermore
of much  rarer occurrence.
   As distinguished  from syphilis,  it is to be  remarked  that the
papular or pustular syphiloderm developed  in the beard is, almost
without exception, to be discovered  in other parts of the body, espe-
cially the scalp.  Ringworm of the scalp and beard, existing at the
same time in one individual, the author has never  seen.  In syphilis,
there is  usually au offensive odor  to  the abundant crusts; shallow
ulcers are also apt to form beneath the pustules;  and there is often a
history of infection or a hint of the nature of the disease iu its poly-
morphic  character.
  Eczema of the bearded region may extend to or from other portions
of the face, as in  the case where it  sweeps down from the ear above.
The presence  of a stalactitic crust, depending from the lobe of the
ear of an affected side, would at once furnish a clew to the nature of
the disease in the beard.   In  eczema, the  interfollicular region  is
invaded ; uot  deeply, as in tinea, but superficially, as in non-parasitic
sycosis.  The itching is severe ;  the hairs not involved ; the infiltra-
tion diffuse ; the outline indeterminate ; and a halo of redness spreads
from the affected  part to the non-hairy surface in the vicinity.
   Treatment.—The treatment of tinea sycosis is generally conducted
as iu tinea tonsurans.  It  is' customary to  begin by anointing the
affected surface with an oily or fatty substance,  and to follow  this 
TINEA TRICHOPHYTINA.
623
with  a shampoo of soap and warm water for the removal of crusts,
after  which  shaving and  epilation  are  practised on alternate days;
aud parasiticides employed locally.  For the softening of the crusts,
the spray of the atomizer may be used.
   Epilation of the male beard is often  essential for the removal of
the disease, but  the author believes that  the results of the treatment
suggested below, are in the end often as satisfactory.  It is true, that
a month or more may be required for the removal of the disease, but
that is often the  period of time during which treatment by epilation
must be pursued.
   The patient for two successive days  keeps the affected part macer-
ated  with  almond or olive  oil.  On  the evening of the third day,
the shampoo with soap is employed, and the skin washed  free from
all crusts  and  scales.  The  part is then cleanly shaved.   The first
is more painful  than any subsequent similar operation.  After the
shaving, the affected surface is bathed for ten minutes iu water as hot
as can  be  tolerated, by which means the inflammatory  condition of
the perifollicular tissues is, in a brief  time, considerably reduced.
While the bathing is in progress, all sub-epidermic pustules or points
where a mucoid fluid is coming to the  surface, are opened with a fine
needle.  A solution of the hyposulphite of sodium  is then sponged
freely over the  surface  for  several minutes.   This may  contain  a
drachm (4.) to the ounce (-'52.) or even  more.  After a thorough and
final washing with the hot water, the  tender skin is carefully dried
and gently smeared with a sulphur ointment,  containing one or two
drachms (4.-8.)  to the  ounce (32.) of  vaseline.  The  patient then
retires to bed.  In the morning, the unguent is washed off with soap
and water, the sodium solution reapplied, and a salicylated powder
thoroughly dusted, and  kept over the part during the day.   In the
evening, the shaving may be repeated  or not,  according  to the vigor
with  which the  beard is  reproduced, but on the second day this is
imperative. As soon as the pustulation ceases  and the tubercles have
manifestly diminished in size, the ointment at night  is superseded by
the use, at that time also,  of the  dusting powder.  AVhether  the
shaving is  practised nightly or on alternate nights, the ablution with
very hot water and with the solution of  the hyposulphite of sodium,
is continued nightly until the inflammation excited  by the fungus is
practically limited  to the follicles which are invaded.  The dusting
powder is to be thoroughly'and constantly employed after the oint-
ment  is discontinued.  AVith care aud patience,  the author has suc-
ceeded by  these  measures  in saving a number of patients  from the
annoyance  of epilation.    The  treatment  should be continued  for
several weeks after the apparent relief  of the disease.
  The treatment  may be varied to suit the needs  of  individual cases,
Kaposi highly recommends,  for example, one per cent,  solutions  of
corrosive sublimate locally;  and the  other parasiticides considered
heretofore in connection  with the treatment of ringworm, may serve
here also a good purpose.   The author has used an ointment of thymol
in two cases with manifest advantage, and should not hesitate in others 
624
DISEASES  OF  THE SKIN.
to employ Mr. Morris's solution of the same  iu chloroform and oil.
The formula  for this  has  beeu already given.   In other cases, the
stimulating  spirit of green soap with sulphur; finely powdered sul-
phur, boric, acetic, and carbolic acids, or other topical applications of
recognized value may be employed.
   AVhen resort is had to epilation, and this is essential in all severe
cases, the hairs should be thoroughly removed from their follicles
over every lumpy nodule, and even over every suspicious patch cov-
ered with scales.  A zoue should be cleared about each such papule.
The results are prompt, and in the highest degree satisfactory.
   Prognosis.—This disease is always remedied sooner or later, though
at times tedious in its progress, and characterized by relapse.

   Precautions to be observed in the General Management
of Tinea Favosa and Tinea Trichophytina.—The physician,
consulted in the case of a patient affected with either of the diseases
thus far considered as resulting from  the presence of a vegetable
parasite,  should bear in mind that  they are the most highly conta-
gious of their class.   He  may not  only himself  suffer  from the
disease which  he is  attempting to relieve iu another, but also convey
it to others himself, or be consulted by others of his  patient's family,
actually infected during the course of the treatment pursued.
   Generally it may be said that the hands of the physician should
be carefully washed after each manipulation of the part, and prefer-
ably by  aid of a weak disinfecting solution.   AVhen  practicable,
infected  individuals  should  occupy  separate  beds; aud the  bed-
covering, clothing,  towels, toilet apparatus, and  dressing or  other
materials which have been  in contact with a diseased surface, should
be immersed in boiling water before they are again employed  for any
use in  common.  Thin recommends  covering every diseased  patch,
after the treatment appropriate to itself,  with an adhesive and imper-
meable dressing, for the sake, not of the  patient, but of those with
whom the latter may be brought into contact; and tbe suggestion seems
to the author both wise aud practicable.   A gentleman infected with
ringworm of  the beard  in a barber's shop which he has visited but
once, will often, when directed by his physician  to  shave, resort  to
some other establishment, where he is well known, and where he has
more confidence in the cleanliness of the operators.   In  this way  he
often thoughtlessly spreads the disease of which he is the victim.   In
his city, the author is in the habit of  sending patients M'ho cannot
shave themselves, to a particular barber, who, being instructed in the
manner of shaving so as not to communicate the disease, has thus far
failed to spread the disease in  any case. 
TINEA  versicolor.
625
                        Tinea Versicolor.
Tinea Versicolor is a cutaneous  disease occurring chiefly upon the trunk,
  neck, and upper extremities of adults, characterized by irregularly reticu-
  lated macular  lesions, yellowish or brownish in hue, over which the
  epidermis may exfoliate in delicate scales, owing to the presence of the
  microsporon furfur.

  Symptoms.—This disorder is also termed Pityriasis Versicolor, Der-
matomycosis Furfuracea, aud  Mycosis Microsporina.  The eruption
occurs iu the form  of few or many, irregular, roundish, circumscribed
or reticulated maculae, pin-head to small coin-sized, rarely occupying
an area of the  size of the palm or larger.   In color, it varies from
the most delicate  buff or  fawn shade to a reddish, deep brown, and
even  blackish  hue.  The  surface  of each lesion, when  closely in-
spected, is  usually seen to  be covered  by furfuraceous scales.  If the
latter are not visible,  slight erasion with the finger-nail will demon-
strate the fact that  the superficial layers of the stratum corneum are,
in the site of each  lesion,  readily separable from  the tissues beneath.
The eruption is most common upon the anterior surface of the thorax,
but it is also displayed upon the neck, the dorsum, and the other sur-
faces  of the  trunk, and the flexor aspects of the  upper extremities
(the hands only excepted).  It is rarely seen  upon the lower extrem-
ities;  still  more rarely  on the face; never on the  hands  and feet.
The eruption is either unproductive of any sensation, or accompanied
by a mild pruritus.  Patients  will usually declare, that after profuse
sweating, bathing in  warm water, or  brisk  friction of the surface,
minute epidermal rolls separate from the affected area.
  Exaggerated forms of the eruption are occasionally encountered.
In a young married woman presented to the author, who had been
the subject of the disease for many years, the  entire trunk, the axillae,
groins, upper portion  of the thighs, the neck to the level of the high
collar worn,  and the upper extremities to the wrists, M'ere encased in
a uniform sheet or cuirass of chocolate-tinted epidermis, in a condition
of exfoliation in finger-nail sized lamellated flakes.   Even in  these
extreme  cases  the  tendency of the disease to avoid the surfaces ex-
posed to the  light is distinctly manifested.   Unna1 describes another
anomalous feature  of the disease, in which the maculatious occur in
annular form M'ith  a clearing centre.   Rarely, also, a very few irregu-
larly distributed maculae  may be  seen as the  sole  evidences of the
existence of the parasite.  Thus a  patient  may exhibit a small coin-
sized patch on  the surface  of the chest, another on the shoulder, and
possibly  a third over the deltoid region of one arm.  These are
generally cases  partially relieved  of a more  diffuse  eruption.   More
commonly, the slightest manifestation of the malady is an irregular,
vertically arranged, somewhat  narrow band of lesions  immediately
over the sternum, and visible beneath the hairs of that region in the

                 i Viertelj. f. Derm. u. Syph., 1880, Nos. 2 and 3.
                                 40 
626
DISEASES  OF  THE  SKIN.
adult male, or upon the intermammary sulcus of  women.   The face,
hands, palms, soles, hairs, hair-follicles, and nails, are usually exempt
from the disease.
   Etiology.—The disease is produced by a vegetable mould discovered
by Eichstedt iu 1846, to which Robin gave the  name, microsporon
furfur.   In capabilities for contagion, it is far inferior to the vegetable
parasites already described, and illustrates well a point to which atten-
tion has been already directed, viz., that all these fungi flourish only
in soils suitable to their germination and fructification.   Members of
one family are  said to communicate  the disease occasionally, the one
to the other, and Lancereaux1 reports that in this way he accidentally
infected himself from scales collected for examination  from a patient
in hospital, and afterward unwittingly transmitted the affection to his
wife.  The author has never had personal knowledge of any instance
of such transmission.   The disease occurs in both sexes, rarely before
puberty and  after middle  life, and in persons of every social condi-
tion, irrespective of personal cleanliness.   It is  exceedingly common,
more so indeed, than statistics are capable of  demonstrating,  inas-
much as hundreds are  annually aunoyed  by it who  never seek pro-
fessional advice.  In the thousands of physical examinations made by
the author with a view to the enlistment of men in the  United States
service during  the late war, as also of many government  pensioners
since that date, he has been particularly impressed with  this  fact.
Being concealed  by the clothing  and unproductive of  much discom-
fort, many persons endure  its presence with complaceucy.
   By some it has been supposed that the fungus is particularly apt
to select the chest of the phthisical as its habitat, a supposition doubt-
less based upon the fact that  tuberculous men and women, more than
all others, expose the chest to the view of the medical  man in  order
to permit of  its auscultation  and percussion.
  Pathology.—The microsporon  furfur is readily recognized by the
aid of the microscope, as it exists in luxuriant profusion  upon every
affected surface.  The  scales  may be  scraped from the skin, aud  at
once examined, when innumerable clustered spores and  short mycelia
become visible; the former highly refractive and  resembling in their
circular and  oval contours,  droplets of oil.   Their aggregation  in
clusters is distinctive of this  among the other  forms of cryptogamic
vegetation.   They measure 0.0023 to 0.0084 mm., M'hile  the mycelia
vary  in  diameter from 0.0015 to  0.0038 (Duhring).   Among the
latter, sporophores are  distinguishable, with  contained conidia and
terminal elements emerging  at one extremity or the other of the
spore-case.  Both elements are more readily stained  by  eosine and
methyl-violet than those of the trichophyton or of favus.
  One of the strougest arguments against the claim for the identity
of all the vegetable parasites  is furnished by the history of this  inter-
esting mould.  It never by any possibility invades the hairs  or the
hair-follicles, though it may  be  seen flourishing  at the orifice  of a
Traite d'Anatomie Pathol., xi. p. 265, Paris,, 1875. 
TINEA  VERSICOLOR.
627
                      Microsporon furfur.  (After Kaposi.)

 follicular duct, and even beneath a vigorous  pilary growth upon the
 chest of a  male subject.  It avoids the light and the  air;  and singu-
 larly refuses to encroach upon certain covered  portions of the body,
 even preferring, in its extremest development, to linger unobtrusively
 at the neck near the verge of the collar.
   Diagnosis.—Here,  as  in  all  the  parasitic diseases  of vegetable
 origin, the microscope may be required to decide the diagnosis in any
 case M'here a doubt might arise.   In its simpler manifestations, the
 recognition of the affection is very readily assured.   The location of
 the eruption,  its irregular reticulations, its characteristic, yellowish or
 fawn-tinted shades of color due to the nature of the fungus ;  and the
 exfoliation of the epidermis which it excites by its superficial penetra-
 tion of  the  outer  layer of the stratum  corneum, producing thus a
 mealy, branny, flaky, or roll-like exuvium;  all this is significant.
 None of .the chloasmata due to pigment changes in the skin, however
 much they may resemble tinea versicolor in color, share with it this
 peculiarity of desquamation.   Chloasma  may involve, moreover, the
 face; tinea versicolor almost never.  Vitiligo may occur upon the
 scalp; tinea versicolor very rarely.  The macular syphiloderm may
 be mistaken for the disease under consideration, but when  developed
 to such au  extent  as to rival tinea  versicolor in its  diffuseness, the
 svphiloderm will creep out  over the  face, the  hands, and the  feet;
and will be  accompanied by  adenopathy, alopecia, mucous patches,
palatine  hvpenemia, or furnish evidence of a polymorphic tendency.
Often, indeed, with such an eruption,  the  survival of the initial 
628
DISEASES  OF  THE  SKIN.
sclerosis will at once  betray the nature  of the disease.  These are
important considerations, since in the mere  matter of subjective sensa-
tion, color, shape, and size of lesion, there  may be marked resemblance
between the two.  The author has treated several patients with tinea
versicolor who were suffering from syphilis; and  many having the
former disease M'ho, from the fact of exposure, believed they also  M'ere
infected by the latter, aud yet indeed were  not.   These incidents
serve to illustrate the importance of making an accurate diagnosis in
every case of cutaneous disease.
   The most vulgar error, however, committed  in this connection, is
based upon the fancied resemblance in  color between the patches of
tinea versicolor, and either the liver itself, or the color changes which
disease  of that  viscus is capable of producing in the skin.  The exist-
ence  of "liver-colored" spots on  the  skin  is  hence  erroneously
attributed to hepatic disease.  A remarkably comely, healthy-looking
woman, of high social standing, M'ho  had been vainly treated for tM'o
years by internal remedies addressed  to the liver, once consulted the
author, with a  view to the removal of large patches of tinea versi-
color from the surface of the chest.   She M'as  completely relieved of
her  disfigurement  in a single M'eek by the   employment of local
measures alone.  Few patients consult their physician  for the relief
of this disorder who have not a prejudice of similar sort.
   Treatment.—The author has always employed a single method of
relieving tinea versicolor, for the simple reason that that one has  been
invariably successful.   It is practically that given by Tilbury Fox,
and  requires merely vigorous  and intelligent cooperation on the part
of the patient.   A hot bath is taken,  if possible, for  three nights in
succession, and when the surface is well macerated by the hot M'ater,
the affected skin is  resolutely  scrubbed, either with the cheap yellow
soap of the grocer, or sapo viridis in substance or tincture.   AVhen
the disease is extensively developed, this process is aided  by friction
with  the flesh-brush  or a coarse towel.   The skin  is then M'ashed
clean with a surplus of hot water, the patient still  remaining in the
bath, after which the  affected patch  is first moistened  with  vinegar
and water, or dilute acetic acid, aud  afterward M'ell  sponged  with a
solution of the sodium  hyposulphite, one  drachm (4.) to the ounce
(32.) being  usually  sufficient.  As  a  rule, the last  vestiges  of the
eruption are  removed  with  the  third bathing.  Should there  be
recrudescence  in isolated patches, as is ofteu   the case, or  outlying
areas which have withstood the parasiticide employed, these  should
be subsequently attacked with a solution of the corrosive chloride of
mercury, one to two grains (0.066-0.133) to the ounce (32.).  Other
measures, however, are  popular  with physicians,  aud  among them
may be named the topical  use of boric,  carbolic,  and  sulphurous
acids;  the tincture of iodine ;  sulphur in  bath, ointment, or lotion;
calomel  in ointment; the  alkalies  in baths or lotions; sulphide of
potassium in  bath;  chrysarobin, pyrogallol, tar, Wilkinson's salve,
and the other parasiticides employed in the treatment of ringworm of 
ERYTHRASMA.
629
 the body.  The inner clothing should not be worn after  treatment
 till it has been immersed in boiling water.
   The following formula also is recommended :
         R. Hydrarg. chlor. corros.         J)j;            1 33
            Saponis viridis              ^ij;           64
            Spts. vin. rectif.              ^iv;          128
            01. lavandul.                i'3j;            4      ]\r
                             I                        (Anderson.)
   Prognosis.—The disease can be readily relieved by simple treat-
 ment.  Relapses often  occur, and require to  be radically  treated.
 Untreated,  the disease  may continue  for years without the slightest
 impairment of the general health.  It is probable that when untreated,
 the parasite undergoes spontaneous  exfoliation in advanced  years, a
 period when presumably the fungus fails to 'find in the epidermis the
 nutriment upon M'hich it thrives.

                         Myringomycosis.

   The spores of the aspergillus, being conveyed to the  external ear,
 occasionally develop  there, especially  if they come in  contact with
 fatty substances introduced for medicinal purposes.  Usually  M'hitish
 masses can be  recognized iu  the  canal, covered M'ith  greenish,
 browuish, or blackish spots.   There is usually some deafness, with a
 sensation of ringing in the  ears, and at times  a thin serous discharge
 from  the external auditory  meatus.  Lowenberg1  recommends the
 injection  of dilute alcohol into  the  canal for the destruction of the
 mould.

                           Erythrasma.
                           Gr. kpvdpdg, red.
 Erythrasma is a cutaneous disorder, affecting chiefly those regions of the body
  where exposed surfaces of the  skin are  in  contact, characterized by ery-
  thematous, rosette-shaped maculations,  and due to  the presence of the
  microsporon minutissimum.
   Buckhardt first described this disorder in 1859, but it received its
 name  from  v. Barensprung iu 1862.   It has  since been  carefully
 studied aud described by Balzer and Riehl.
   Symptoms.—The disease  first appears in punctiform to palm-sized,
 roundish, definitely  circumscribed  maculatious,  presenting  a sharp
 contrast in  color with that of the  adjacent  integument.  This  hue
 varies somewhat according to the  location  of the patches.  The
 younger lesions may  exhibit a vivid  redness over  the entire maculae,
 or  over their  borders  only.   The  older exhibit a  yellowish  or
 brownish tinge.  These  colors are  supposed to be compounds of
ordinary erythematous reduess and yellowish or  brownish discolor-
ation of the horny layer of the epidermis.
  The maculae are circular, or rosette-shaped, or display very irreg-

               ' Gaz. neb. d. Med. de Paris, 1880, 2me ser. xvii. p. 579. 
630
DISEASES  OF  THE  SKIN.
ular"outlines.   They are not raised  above the general level of the
skin to any extent, though  the finger pressed  over the surface can
recognize a slight elevation  of the border due to hyperaemia and sub-
sequent  moderate,  fine-flour-like, furfuraceous desquamation,  most
conspicuous also at the periphery.   Vesiculation  and papulation do
not occur.  The colors recognized in different  patches  may be  light
reddish-brown, pale reddish-yellow, and light or dark orange.
   The eruption is most commonly encountered when apposed surfaces
of the skin come in contact, such as  occurs in the axillae, the  groins,
the cleft of the anus, and tbe regions where the scrotum touches the
thigh.  The eruption spreads very slowly and in  serpiginous outline,
until the affected surfaces are completely invaded.   It  is said to be
much  more chronic in its  course than the other  dermato-mycoses,
lasting for months and years without apparent change.
   Etiology.—Erythrasma is produced by the growth in the superficial
layers of the epidermis,  of the  fungus described below.   Men  are
much  more often  affected than  women;  children not at all.  The
youngest patient whose case is recorded was sixteen years old;  the
oldest, fifty-five.
   Pathology.—The  fungus termed  microsporon minutissimum  to
which the disease is attributed, is chiefly remarkable for  the extra-

                             Fig. 84.
Microsporon minutissimum, from patches of erythrasma.
ordinary delicacy and fineness of its threads and spores.  The former
are either simple cylindrical bodies of variable sizes or  may exhibit
partition septa ;  they may divide dichotomously ; and  may terminate
in hooked or knobbed expansions.  They are inextricably interwoven
when occurring in large masses.   The largest transverse diameter is 
SCABIES.
631
0.6 of a micromillimetre; in length, the mycelia present the greatest
variation.   Bacteria aud  heaps  of zooglcea  are  visible among  the
scales.  The  granules  are piled  into  irregular heaps  according to
Buivkhardt, and give a dusty appearance  to  the  epidermal cells on
M'hich they  lie; often the  outline of these  granules  is  indistinct.
According to the same observer, the breadth of the mycelia is j^-jt
mm.; and the length from yL to ffo mm.
   Diagnosis.—From all ordinary chloasmata and pigment maculae,
the spots of erythrasma are  distinguishable  by the ease with  M'hich
the superficially embrowned epidermal layers are removed by erasion.
Tinea versicolor is distinguished from  erythrasma with greater diffi-
culty ; but the latter occurs  in different situations by preference;  its
patches are more vividly red ; and the parasite, under the microscope,
presents distinctive features.
   The Treatment is that of tinea versicolor; and the prognosis|favor-
able, subject to the disappointments arising from frequent relapses.

   La Perleche. — Under  this  title,  Dr. Justin  Lemaistre, of
Limoges,1  describes a contagious disease observed by himself in more
than three hundred children of his city.   It is characterized by dry-
ness, smarting, cracking, and excoriation of the lips, the epithelium
of  which  becomes  blanched,  macerated, and  readily  detached.
Haemorrhagic and painful fissures form in the  direction of the com-
missural folds.  Often plaques are visible suggesting mucous patches.
The disease  lasts for from  fifteen  days  to  a month, with possible
recurrences M'hich may lead  to a year's suffering.
   The disease is supposed to be of parasitic origiu, communicated by
drinking from cups used by  infected persons.   The author attributes
the  disease to a streptococcus plicatilis which  he has cultivated in
Pasteur flasks.  The microbes were originally found on  the borders
of epithelial cells of the lips of infected children.  The parasite lives
in stagnant M'ater, M'ells, and  springs  in the  form of a micrococcus.
The  disease  is oue of uncleauliness; and  readily  prevented  by
appropriate hygiene.


                          2.  Animal.

                             Scabies.
                        Lat.  scabere, to scratch.
Scabies is a contagious cutaneous affection, characterized chiefly by the for-
  mation of the cuniculus, or furrow, produced by the acarus  scabiei which
  is  the cause  of the disease,  as also  by  the occurrence of several of  the
  elementary lesions of the skin, accompanied by itching.
  Symptoms.—Scabies, or  " The Itch," is  a disease of  polymorphic
character, M'hich may be viewed as an  artificial eczema or dermatitis,
1 Le Progres Medical, October, 1884. 
632
DISEASES  OF  THE  SKIN.
produced by the invasion of the itch mite.   According to the extent
to M'hich the skin is primarily invaded by the parasite, or secoudarily
injured by  the traumatism  M'hich  follows severe scratching of its
surface, will its objective symptoms differ.
   Prominent  among the latter is  the  cuniculus, or acarian  furrow,
an elongated gallery excavated in the epidermis by the female acarus
soon after her impregnation  by the male.  The latter does not enter
the skin, but  is lodged beneath the crusts or other  exuviae M'hich
gather upon its surface.   This cuniculus or furrow, is a whitish or
yellowish, slightly arciform, linear lesion, covered with dots or specks
of blackish aspect, representing feces of the mite, with regular parallel
borders.   It terminates at the upper extremity, by a vesicle, pustule,
or exfoliatiou  of the surface at the site of an infundibuliform depres-
sion ;  and  at the  deeper extremity, by a  whitish  and  yelloM'ish,
shining and salient point, representing  always the acarus.   This is
the most characteristic symptom of scabies.
   The " head" of  the gallery is usually whitish, where the parasite
first entered the skin ; and  is  also more elevated  than the " tail,"
where the acarus rests after laying its  dozen or more of  eggs.   At
times, the entire cuniculus forms  an  elevated ridge, rather  than a
thread-like  depression, M'ith  white dots along its  summit.   When
the roof of the vesicle at " the head" is torn off by scratching, the
effect  is  to  produce  a  reddened spot at its  site,  surrounded  by a
whitish moat running around the spot to the entrance of the gallery.
   When the burrow exists, it can be most perfectly recognized in tbe
interdigital  spaces and on the skin of the penis, as a tangential  line,
running from a vesicle, papule, or pustule, to a distance of from one-
eighth of an inch to an inch.   It resembles a beaded, dotted, yellowish
or blackish  thread, the color being more pronounced in comparison
with  a fresh colored  and washed skin, and  less marked in contrast
with  a soiled surface; being,  in a soiled and subsequently washed
■integument, most conspicuous in proportion as the small puncta have
served to entrap particles of dirt.  The cuniculus may be  curved,
angular, or  tortuous; and occasionally may be seen well  nigh com-
pletely covered by a bulla,  pustule, or vesicle extending  its entire
length.  In such cases, hoMever, the female always peuetrates beyond
the peripheral wall of such lesion, Morking her gallery beyond it and
more deeply, lest she be lifted  by the exudation out of reach of the
succulent rete where she feeds.
   Hebra points to the fact that between two parallels, one drawn
through tbe nipples,  and another at a short distance above the knees,
on the anterior face of the body, can be recognized the greater part
of the eruptive lesions in every case of scabies.
   The disease is indeed  one peculiar to those classes M'hich are the
familiars of filth aud poverty, occurring among these at all ages and
in both sexes.  As a matter  of accident,  it  may  appear,  however
rarely, in individuals of high social station.  It is much more common
in Scotland, Austria, Prussia, Sweden, Norway, France,  and  the
Orient, thau in this country.  During the late civil M'ar, it prevailed 
SCABIES.
633
with relative frequency among the  masses of Americans associated
in regiments with  foreigners who had been  but a short time in the
country ; and since then, seems to have steadily decreased.  But few
cases are seen annually in the public clinics of large cities, though here
and there, chiefly among newly arrived immigrants, isolated " nests"
of the disease are discovered.
   In consequence of the irritation produced  by the parasite and the
traumatisms of scratching this furrow, all the symptoms of acute and
chronic eczema are presented in the region invaded.  These are vesi-
cles, pustules, wheals, small papules, hyperaemia of the skin upon M'hich
these rest, crusts formed by dried serum, pus and blood, excoriations,
fissures, and,  iu  cases of  long  standing,  pigmentation of the skin
where  the disease  has  existed.   These  lesions may coexist,  several
appearing at the same time upon the skin of an affected  individual;
small vesicles and pustules, with perhaps a few short cuniculi visible
upon  their  summits; excoriations;  larger and longer cuniculi inter-
spersed between inflammatory papules; a tumid skin, evidently the
seat of a mild grade of dermatitis; and crusts here and there, beneath
M'hich  male and young acari are ensconced.   Such is the composite
picture of a typical eruption in scabies.
   It M'ill  be  remembered that  the acarus  family find nutriment,
shelter, and all they require on the person  of the individual M'hose
skin they inhabit;  and there is  no inducement for them to colonize
at the instant  of the first opportunity offered.   The  transfer of  a
male acarus alone, from one person  to another, would  not insure a
generation of  the  young;  and the uuimpregnated female could not
alone do more.   As for the impregnated  female, Hebra, on  several
occasions, failed to induce scabies M'hen one such only M'as transferred
intentionally to a sound  skin and seen to penetrate  it.   Lastly, the
eggs alone would not suffice, for these have to be nicely planted within
the epidermis, in order to  be hatched safely to maturity. In brief,
only the more intimate  contacts of the bed at night, aud  the applica-
tion of nails charged M'ith acari of both  sexes, especially the  young,
are to be regarded as most effective for the transmission of the  disease.
That is one reason M'hile nearly seven men are found to be  affected
M'ith scabies to one woman.  Women are, as a rule, more inclined
to sleep alone, or M'ith those only to whom  thcv  have  family ties ;
M'hile laborers, boys, apprentices, aud persons of that class, including
those M'ho are strangers to each other, at times occupy the same beds,
especially in the large cities, where they are often huddled together at
night like swine.
   The intruder may be recognized always at the terminal extremity
of her gallery, for it is now  known that she does not in her lifetime
leave it for any purpose,  as Mas at one  time taught.   The female
acarus  here shows as a minute, whitish,  clearly defined  dot, present-
ing a contrast in this particular M'ith the blackish feces in the  gallery
behind;  and may be, iu a  good  light, by a person  of some dexterity
and fair eyesight, extracted  on  the point of a cambric needle, from
her lodging-point.   It is important to know that  this parasite may 
634
DISEASES OF THE SKIN.
be recognized by the unaided human eye.   Its characteristic tortoise-
like body exhibits  most of its anatomical peculiarities under a glass
enlargiug the figure but one hundred diameters.
Fig. 85.
      Female acarus, fecundated ; ventral surface. An ovum arrived at maturity is visible
                       within the body.  (After Kaposi.)

   The  regions affected by the eruption are the palms (especially of
women and children)  and dorsal surfaces  of the hands •  the flexor
aspects  of the wrist-joints; the  sides and  roots  of the fingers  and
toes; the feet (and, especially in women, the delicate skin of the feet
near the  instep,  partly dorsal, partly plantar  in situation); the but-
tocks (more  particularly in those who  are  seated in the trades and
occupations of life); the extensor faces of the joints;  the  belly the
penis and scrotum  in  men; the anterior  folds  of the axillae •'the
nipple and breast of women; the elbows and knees, rather than the
popliteal space and bend of the elbow ; and the anal region.   Scabies
prurigo, aud  pruritus  are  alike in  this, that in  each  the  face  and
posterior aspect of the  body display the fewest of any lesions visible
In  general, portions of the body subjected to  constant pressure by 
                                 SCABIES.                            635

the clothing, as,  for example, the regions pressed by the corset of the
woman, aud the  waistband of the trowsers iu man, are sites of predi-

                                  Fio. 86.
  Acarian|furrow, from the lumbar region   The female acarus is visible at the terminal extremity of
the furrow with ventral surface exposed, and containing a mature ovum ; two ova, next her, have
been laid during the day, as the third exhibits traces of the embryo ; the twelfth exhibits a mature
larva ;  twelve empty shells are also seen ; between these the feces are represented by blackish points.
(After Kaposi.)

lection.   Iu  other  cases,  the.  disease is encountered  in  the axillae,
groins, and, as a matter of rare exception, over the entire surface  of

the body. 
636
DISEASES  OF  THE  SKIN.
   The itching of scabies is occasionally severe, and  has in fact con-
ferred upon the  disease its familiar Euglish title, ''the itch."  This
sensation is usually worse at  night, when the parasite is  rendered
active by the heat of the  body in bed, retained by the  bed-clothing.
It differs somewhat in different cases,  being at times the cause of but
little complaint.   There  is nothing characteristic,  however,  in the
occurrence of this symptom, as equally severe pruritus accompanies
eczema  unconnected with  parasites.
   The itching M'hich results from the epidermic tunnelling in progress
is often noticeably more severe  than would  be suggested by the
moderate number of skin lesions visible. When these lesions (puncta,
vesicles, pustules, blebs, papules,  resulting crusts, furrows, excoria-
tions, etc.) are found upon the hands the itching becomes so great that
the infested person scratches also the accessible parts of the skin, where
there were originally no acari, such  as the inside of the thighs, the
lower belly, etc., as Hebra suggests, simply because they are " handy."
Hence it is that the picture comes to resemble that of all pruritic and
scratched skins.
   Several artificial forms of this polymorphic affection are occasionally
noted.   In children, the face may become diseased after contact with
the breast of the  mother, or the buttocks after contact with the flexor
aspect of the  nurse's arm.  Large vesicles, and even rupioid  bullae,
may result from  the irritation of their tender skins.  Again in sub-
jects predisposed  to eczema for any reasons, the invasion of the para-
site  in  one region of the  body, possibly a  region of preference, may
originate an  eczema  in another locality whither the parasite has not
wandered.  In other cases, the  most  exaggerated forms of eruption
are  seen, usually in persons of filthy  habits who have  long suffered
from the malady.  Thus  extensive epidermal  callosities form, filled
with debris of dead parasites  unable to find  nutriment  longer in the
cornified rete; or extensive greenish and blackish crusts cover colonies
of acari which survive beneath them  for  generations of their race.
The nails in  such extreme cases  may be involved.   The  so-called
Scabies Norvegica, or  Norwegian  itch, belongs without doubt  to
this class.  As a rule, however, the disease does not advance to these
severe grades.  The parasites having  gained lodgement in  the skin,
produce characteristic  symptoms of the disease  in  the average  of
cases, but even though unrecoguized, and persisting for M'eeks, are
the  sources of so much  annoyance that treatment of  some sort  is
instituted M'hich  is apt to restrict the extension of the malady, cer-
tainly in this  country, within  moderate limits.  Usually after lodge-
ment is effected, a week or fortnight elapses before the first character-
istic furrow is formed, though the pruritus  is of  earlier occurrence.
The extension of the disease by the maturing and ravages  of youug
acari requires  a few weeks more, so that in the course of from two  to
three months, the evolution  of the malady may be  considered  as
complete.  In the course of about three  months more, the disease,
unchecked may become generalized.
   Even the  animal  parasites elect the soil  upou which they thrive, 
SCABIES.
637
and indeed, after such election, thrive  well  or  ill, according to the
conditions present.   This is not only exemplified in the matter of
individual susceptibility, but in the conditions of health of an. affected
person.   Thus iu puerperal  and typhoid  fevers aud  other  grave
states  of systemic disturbance, the parasites  perish in the skin and
the resulting  eruption disappears; classical  symptoms recurring  in
convalescence if one or more acari have survived with sufficient vigor
to reproduce their kind.
   Etiology.—The disease is produced only by the acarus scabiei (or
sarcoptes scabiei) aud is thus contagious, the parasite being introduced
upon the surface of one individual,  mediately or immediately from
the skin of another infested  man or an animal.  All  persons are
supposed to be susceptible to the disease, but the  difficulty of inten-
tionally  transmitting it by contagion  is  greater than that of inducing
the leech to fasten itself indiscriminately upon any given skin.   The
brief shaking of the hand or transient personal contacts of the daytime,
are  certainly  in many  cases  quite insufficient  for contagion.   The
author has repeatedly bandied the skin of a patient affected with scabies
for half an hour at  a time, always with impunity; and never hap-
pened  to know of a practitioner of medicine M'ho .suffered  after the
most  careful examination of a patient.  When a case is  exhibited at
the clinic, it is minutely, and M'ithout ill results, examined by dozens
of students.   It is probable that the contacts of the night, incidental
to the  occupation of the same bed, or the  use of gloves and  other
articles of apparel containing parasites or their ova, is essential to the
transmission of the disease.
   Pathology.—The pathology of the eruption induced by the parasite
is that of the various phases of exudation.   The differences betrayed
between scabies and all  other eruptions of similar type, depend, in
the case  of the former, upon the peculiarities of  the exciting cause of
the disease.   In the  description 'of this, the acarus  scabiei, I shall
avail myself  of the  admirable chapter devoted  to  the subject by
Kaposi.
   The female acarus, visible as a yellowish-white dot at the cul-de-sac
of her subcutaneous gallery, and removed hence on the poiut of  a
fine needle, is visible to the naked eye, but best  examined under the
microscope.  The body is oval, with a short projecting  head and  a
convex dorsum transversely corrugated, with short spinous  processes
projecting for  the most part  backward, a direction  largely followed
also by the eight long bristles M'hich are most notable at the  posterior
extremity of the trunk.  The posterior portion of the dorsum also
exhibits  a series of recurved, short,  hook-like projections,  arranged
circle-wise, about the auo-vaginal orifice.
  The flat ventral surface  exhibits  eight short  claws or legs, four
anterior  and four posterior.   The former are set near the head, and
are provided   each  with  hairs, and a long, pedunculated sucker.
The latter  are armed solely  with long, straight bristles.   All  the
eight  have  five articulations.   The head  is oval  in shape, and pro-
vided M'ith four pairs of mandibles  and six palpi.   There are two 
638
DISEASES  OF  THE  SKIN.
ventral outlets; and a stomach, intestines, ovaries, muscles, and even
mature ova can be recognized internally.
   The  males are smaller than the  females  and  feM'er  in  number.
They differ also in this, that the posterior extremities are provided
with suckers and stalks, as are the anterior extremities of the female.
Situated between these and  the median line, is a  horse-shoe shaped
mass of chitiue ensheathing a fork-shaped penis.
   They are said to die in the course of from six to eight days after
copulation M'ith the female.   The latter survive from twenty to sixty
days.
   The female alone, as already said, penetrates  the epidermis.  This
act she  accomplishes by inserting the head first into the tissues of the
skin, the body disappearing afterward,  and depositing behind, in the
course of her progression downward, from one  to two eggs daily till
from  twenty  to  fifty have been  laid.  These are oval, their longi-
tudinal axes  placed transversely to  the  cuniculus.  In  the two or
three eggs fouud nearest the female, only a yelloM'ish color can be
distinguished; in the  third  to  the  fifth,  traces of the  embryo are
recognizable;  the sixth to  the ninth  contain  larvae;  and, in the
oldest, the head  and front legs can be.discerned.   There are six of
these  extremities when all are developed.   When mature, the shell
of the ovum  is ruptured, usually between  the  third and sixth day,
and the young acarus reaches the surface of the skin, either by making
exit at the original point of entry of the mother, or by the rupture
of the roof of the burrow.   It subsequently buries itself in  the skin
for a brief time, while the process of casting its slough is completed.
There are said to be three of these periods in its existence.   Before
the first is accomplished, the young acarus is provided with  but  two
pairs of posterior extremities, two  anal bristles, and ten dorsal spines.
After the  first, it is an octopod with four oval bristles  and twelve
dorsal  spines.   At the second, it gains two  dorsal spines, and after
the third, it possesses fourteen.  The acarus survives but a few days
when removed from the skin and  immersed in liquids which protect
it from  the air, such as water, oil, etc.
  The  transmission to man of tbe acarus peculiar to the horse, cat,
sheep,  rabbit, elephant,  etc.,  may be accomplished; but the colony
under these circumstances rarely thrives.   The same is  true of the
human  acarus when transferred to the lower animals.
  Diagnosis.—The diagnosis of scabies  must rest upon the  recogni-
tion of its special  features  described above.   There  are no lesions
peculiar to tbe disease save the cuniculi  or  furrows made by the para-
site, and these, it will be remembered,  do  not appear  till one or two
weeks have elapsed after infestation.   They may also be obliterated or
concealed by excoriations when the finger-nails plough them  open, or
by pustulation and subsequent crusting M'hen the irritation  induced
is  excessive.  In  every well-marked case, however, cuniculi can be
discovered, if not on the fingers, wrists, or foreams, at  least on the
penis, the breast near the nipple, or some other  covered portion of
the body.   With care and little dexterity, a fine cambric needle can 
SCABIES.
639
be then forced into the furrow well doM'n to aud a little beyond its
remote cul-de-sac, and the fons et origo mcdorum be thence extracted
and placed under the objective of the microscope.
  Next to the cuniculus, and its  inmate or inmates, the two most
important diagnostic features of scabies are, the polymorphism of the
eruption aud the sites of  its most frequent occurrence.  Possibly the
latter should be named first, as the more important of the two.  Few
skilled diagnosticians would fail  to entertain a suspicion of scabies in
a case of supposititious "eczema," existing upon the fingers, M-rists,
and  penis only, or on the breast of a mother, the face and  buttocks
of her infant, and the arms of its nurse.
  At the same time, it is a matter of great importance to remember
that eczema  is  often  attended M'ith very  severe itching;  that this
sensation  may be intensely aggravated after retiring to bed at night;
is often  limited to the hands; is not rarely characterized  by inter-
digital vesicles and pustules; and is, indeed, in this country very much
the more frequently encountered of the two  diseases.   The vulgar
conception of scabies holds to the belief that the disease is exceedingly
common; that every  severe itching with a cutaneous  exauthem is
produced by "insects" or  "worms" in the skin, and that transient
casual contacts are abundantly capable of transmitting the offending
parasite.  Many more cases of simple  eczema are  supposed to be
scabies than the reverse.  There are few villages in the country M'hich
cannot lay claim to an "itch,"  often known by a name of local sig-
nificance.  Among these  may be counted the so-called "prairie  itch"
of the West.  These are, as a rule, forms of eczema quite unconnected
with the existence of a parasite, and incurable generally by the  para-
siticides  too often  employed  to "kill" the  disease.  Iu  all  such
instances, the absence of the characteristic features of scabies described
above, the absence of a history of contagion, and the presence of that
of an alternating relief and aggravation of  the symptoms, M'ill  point
to the real character of the malady.
   In the severe pruritic affections of the West and Northwest, M'hich
the reader will find  described in the chapter devoted  to the several
forms of pruritus, it is noticeable that the patients are often  cleanly,
those M'ho are careful as to the hygieue of the body.   Scabies is really
a filth disease, and is  best  recognized among  the filthy classes.  Of
diagnostic importance is the relative proportion in frequency of cases
of scabies to all other cutaneous affections, pruritus included, observed
in this country.
  From the year  1878  to 1882, the statistical committee of  the
American Dermatological Association reported 58,617 cases  of skin
diseases of all kinds, and  the total number of cases of scabies included
in the list was  but 665, that  is 1.10  per  cent.  The  year 1883 to
1884 was au exceptional  one as regards scabies.  Out of 9329  cases
of cutaneous  disease reported  from  Boston,  New York, St. Louis,
Chicago, and  Canada, there were 339  cases  of scabies.  This rela-
tively o-reat increase Mas  largely due to local causes, however; for of
these cases Boston reported 179, and accompanied these  figures M'ith 
640
DISEASES  OF  THE  SKIN.
a note calling attention to the increase.  It  is interesting to specify
that of the cases collated in  the year  named, only  33 Mere seen in
private practice, the remainder, 306, being observed in dispensary or
public patients.
   During the succeeding year ending June 30, 1885, there were 442
cases of scabies reported from the several districts,  of M'hich 49
occurred in  private, and  393  in  public  practice.    This year, also,
Boston exhibited the largest increase, reporting three more than one-
half the entire number of cases of scabies registered  iu this country,
viz., 224.
   Treatment.—The treatment of scabies has in view the  destruction
of the parasite and  the relief of  the  cutaneous  disorder which the
former has induced.  Ordinarily the two indications are fulfilled at
the same time.  In such cases, the destruction  of  the  parasite is
followed by relief of the resulting cutaneous lesions; and the skin,
freed  from  the  burrowing  acari,  is  no  longer tormented  by the
scratching M'hich in extreme cases is  not only  irresistible  but  an
important element in the aggravation of the  lesions.  In  other cases,
however, the resulting eczema or dermatitis persists after the removal
of the original cause of the disease, and  demands special attention.
Care should always be had to avoid  treating the delicate  skin of the
infant with the severer remedies efficacious upon  the thicker integu-
ment of the adult.
   Sulphur,  in all  its forms and in various  combinations, has  long
held  the  highest  esteem  in the  treatment  of  the  disease.  Other
remedies, however, of acknowledged efficacy are employed M'ith satis-
factory results, most of them owing their usefulness to the  strong odor
which they emit.   Among these may be named carbolic acid ;  petrol-
eum ; naphthol; the oils of cloves, cinnamon, rosemary, and mint;
tar ; balsam  of  Peru and balsam  of  Tolu;  styrax;  staphysagria;
Vlemiuckx's solution, heretofore described;  and sapo viridis.
   Sulphur is commonly employed in the form of an ointment, one to
two drachms (4.-8.) to the ounce (32.), firmly, thoroughly, and  care-
fully rubbed, first into the  affected patches, especially between the
individual  fingers (or toes),  about the wrists, over the  palm  and
dorsum of the hand, into the axillae, about the nipples, penis, buttocks,
or other invaded  parts; and finally over the cutaneous surface in
general, the head alone excepted.   If no severe eczematous complica-
tions exist, the inunction  is  well  preceded by a  M'arm soap, or  soft
soap and  Mater bath.  But  in the event of such complication, the
bath should be deferred as decidedly injurious in  the inflamed condi-
tion  of the skin.
   This first inunction  is preferably performed at night,  after which
the patient retires  to his bed  enveloped in woollen  underclothing, or
wrapped in a blanket.  It  is  neither wise  nor necessary to induce
sudation by these measures, for the skin is best retained  in simply a
greasy condition, unmacerated by sweat. In England, it is customary
to bathe ou  the ensuing morning, but it is preferable to defer the
latter till the cure  is complete, however disagreeable the condition of 
SCABIES.
641
the integument may be to the sufferer.   The sulphur inunctions are
thus repeated for three successive nights, a thorough warm  soap aud
M'ater  bath being finally  employed  for  the purpose of cleanliness.
The clothing meantime should be either thoroughly disinfected M'ith
sulphur, immersed in boiling M'ater, or subjected in a stove or furnace
to a dry heat capable of destroying all  acari and ova which might
adhere to it.
   In France, the routine treatment of scabies is always preceded by a
thorough friction for twenty minutes M'ith soft  soap, special attention
being  as usual directed  to  the invaded  areas.   This is at  once
followed  by a bath  iu warm water, during which the  surface is also
thoroughly scrubbed  for from thirty minutes  to an hour.  Lastly,
the parasiticide is  M'ell rubbed  on  for  fifteen minutes, the patient
redressed iu the underclothing (disinfected during the progress of the
bathing) and the final cleansing of the  skin M'ith water is  practised
M'ithin twenty-four hours.
   When a resulting eczema demands attention, it is to be treated in
accordance  M'ith the  general principles considered in the chapter
devoted  to that subject.   In  such case the  dusting-powders, the
oleated lime-water, tbe  zinc, diachylon,  and eveu  more stimulating
ointments,  may  be employed with  advantage.  Generally, after a
vigorous  course  of  external treatment M'ith  sulphur, the patieut
should be instructed  to defer any further topical applications to the
skin for a week  or  more, in  order to test the efficaciousness of the
method pursued.
   One of the following formulae may be substituted for the ordinary
sulphur  ointment:

         R. Sulphur, flor.              oxij ;
            Potass, subcarb.             oyj;
            Adipis                     oix ;
         Hardy's modification of Helmerich's ointment.
R. Styracis liq.
   Petrol ei j
   01. olivae }
   Balsam. Peruv.
   Spts. sapon. virid.
R. Potass, sulphuret.
   Sapon. alb.
   01. oliv.
   01. thym.
    f 3j;
[aa f=ss;
  fSijss;
    fov;
   3v;
  oxx;
  i'oiv;
gtt. xv;
aa .->ss;
48	
24	
2SS	M.
4	
16	
10	
20	M.
(Kaposi.)	
20	
80	
16	
1 M.	
(Jadelot.)	
9	
32 M.	
0	Duhring.)
        R.  Sulphur, sublim.
            Balsam. Peruv.
            Adipis                      oj ;
        For use especially in the scabies of children.

  Hebra's modification of  Wilkinson's salve, Vlemiuckx's solution,
aud the balsam of Tolu  are employed for the same purpose.
                                 41 
642
DISEASES OF THE SKIN.
Kaposi's naphthol formula is :

      R. Naphthol               15 parts;
         Sapon. virid.            50 parts;
         Cret. alb. pulv.          10 parts ;
         Axung.                100 parts;                   M.

McCall Anderson much prefers, on account of its pleasant aroma

                                                          M.
R. Styracis liquid.
   Adipis
Melt and strain.
 sj;
3rj;
32!
64
or Schultze's modification of Pastav's formula
R. Styracis liquid.
   Spts. rectiticat.
   01. olivae
Ft. liniment.
 f.l.i;
f3ij;
 f3j;
M.
  Prognosis.—Scabies is an entirely curable  disease, even  after per-
sistence for long  periods  of  time.   When,  however, complications
exist, or severe eczema contiuues after the efficient action of a para-
siticide, the  patient  may  experience  some  delay before  attaining
complete restoration to health.
Fio.
                      Demodex Folliculorum.

  This parasite, known also as the steatozo5n, or acarus folliculorum,
was discovered by Simon, in  1842.  It is a microscopic creature in
                 the  form of an  elongated  and jointed worm, M'ith
                 head separated from the thorax, and eight legs, four
                 on a side, each with three articulations, and termi-
                 nating in three small hooklets.   The posterior ex-
                 tremity  of the body is  a  vermiform  appendage,
                 terminating in a conical point.
                   The demodex is found long after birth  upon the
                 free  surface of the skin,  those  parts particularly
                 M'here the sebaceous glands are large, and on patients
                 affected  M'ith  acne or seborrhcea oleosa, as well as
                 upon those free from  all evidence of disease.   It is
                 encountered  also in the substance  of the comedo
                 plug, where  at times from five  to  twenty may be
                 discovered in a single follicle.   It is, hoM'ever, in no
                 case  the source  of disease.  A  demodex, M'hich  is
                 considered to  be a variety of that discovered  upon
                 the skin of man, infests dogs, mice, and other lower
                 animals; and  may be, in the latter, the  source  of
Demodex folliculorum.  disease  characterized  by furuncular lesions, abscess,
                 and  even fatal  results.   None  of  these parasites
are, however, known to be transmissible to man. 
ANIMAL PARASITES.
643
  Pulex Penetrans (Rhinocoprion Penetrans, Sarcopsylla Westwood).

   The sand-flea is a minute, brownish-red, egg-shaped parasite which
 penetrates the skin of man and of the lower  animals, including rats
 and mice.  It is encountered chiefly in tropical countries, but is said
 also to exist in  higher latitudes, even in some of the  southern of the
 United States.   Fecundated females  only attack  the  skin, in man
 usually about the toes or near the nails, entrance being effected with
 scarcely painful pricking sensations.  In the course  of from  five to
 ten  days, a  painful  oedema  with pustulation  follows,  occasionally
 accompanied  by a lymphangitis or severer symptoms in the form of
 gangrenous abscesses.   These  sequelae are said to result  from the
 distention of the  ovary of the  parasite,  which may  exceed fivefold
 the origiual  dimensions of the  insect.  The treatment of the disease
 is the extraction of the  flea by the aid of  a heated needle, whereby
 it is simultaneously destroyed.  The resulting  wound  is often also
 cauterized.

        Filaria Medinensis (Filaria Sanguinis,  Guinea Worm).

   This parasite is encountered in the tissues only of  those who have
 resided iu tropical latitudes, more particularly iu  Egypt,  Persia,
 India, and Arabia.   It is occasionally encountered  in other countries
 after introduction by affected  individuals.   When it attacks the skin,
 it forms a painful, oedematous, furuncular or bullous lesion, which
 bursts; and  in the  fluid contents exuded, a portion of the worm
 becomes  visible.   Often  the systemic conditions which accompany
 this lesion are grave.  Febrile,  convulsive, or septicaemic phenomena
 may then be followed by fistulous or gangrenous results in the seat of
 the disease.
   It Mas long claimed  that the parasite entered  the skin from
 M'ithout, but there is reason to  disbelieve this assertion.  Observers
 have lately demonstrated the fact that the  parent worm  contains, in
 that part  of the body M'hich  is appended  to the head, thousands of
 minute worms contained  in a sarcodiform envelope.  These measure
 0.05  by  0.2  mm., each  exhibiting  a  thickened cephalic extremity
 M'ithout a buccal aperture, and a  ointed caudal  termination.   It is
 impossible for such a creature to penetrate  the skin by the accidents
 usuallv assigned as the occasion of its introduction; for example, by
 bathing in infested water, aud walking upon surfaces M'here the para-
 sites abound.   It is much more reasonable  to conclude that the latter
 are ingested,  either M'ith the food, or, more  probably, with the water,
 and  that  from the alimentary canal  they find their way to the other
 structures M'hich  they  attack.    They can  certainly traverse  the
 blood-vascular channels.  The worm has been photographed in situ,
 in the bloodvessels where it was discovered.  It is possible, hoM'ever,
 that the parasites may be, in rare instances, introduced into the skin
directlv through solutions of continuity produced in  walking, bath-
ing,  and  other  occupations, when the  foot or aukle  is accidentally 
644
DISEASES  OF  THE  SKIN.
abraded, or M'here indeed there has beeu a preexisting ulcer or sore.
Manson1 believes that the parent filaria inhabits the lymphatic trunks ;
and reports a case of lymph-scrotum in which a long slender M'orm,
resembling  catgut in appearance and of the thickness of a  medium-
sized  liorse-hair,  was found filled M'ith  embryos in different  stages of
development.  After the removal of about two inches of the  parasite,
the worm was broken.   It has also  been recognized iu the sac of  the
tunica vaginalis affected with hydrocele.
   The mosquito  is said to act as a carrier; sucking  the filaria M'ith
the blood of an  affected person, it afterward deposits the ova  or
embryos, which  have meantime hatched, in the M'ater where it lays
its own eggs.   These embryos are then swallowed with the drinking-
M-ater by another victim; and so the cycle of disease is completed.
It is a nocturnal  parasite.  During the day the filariae lie dormant at
some  point  in  the victim's circulation, but at night  they sally forth
aud rove the current of the blood the night long.
   The parent Morm,  fully developed, may measure two  feet or more
in length;  and, being usually packed full of young,  it is a matter of
great importance not to injure it in any efforts made  for the  purpose
of its extraction.   Forbes  Dick2 describes the four  methods chiefly
employed for the purpose  of obtaining  relief, as operating on  the
principle, either to "stink, coax, suck, or pull  the Morm out."  The
first is usually accomplished by the aid of assafcetida poultices, and
is the least desirable of all.  A combination of the others is pre-
ferred, the  Marmth, moisture, and protection afforded by the poultice
first attracting the worm to the surface.  When this result is obtained,
an incision is  made, and usually a foot  or more of the worm is at
once liberated.   According  to Dick, M'hen  the worm can be  felt at
two or more places, the point for incision is at the third part of its
anterior extremity, which  is  always furthest  from  the heart of  the
patient. After this the worm is carefully M'ound about an aneurismal
needle or similar  implement, and traction very gently made upon it
for from ten to fifteen hours.  If it cease to yield to this force,  the
traction should never be increased, lest the parasite seize the adjacent
tissues with its  mouth.   Suction   by the natives  is accomplished
through trumpet-shaped tubes.

                      Cysticercus Cellulosae.

   Cysticerci have been  recognized  in the  skin and subcutaneous
tissues by Rokitansky,  Lewin, Guttmann,  Schiff, Ferreol,  Duo-uet
and other  observers.   Iu such  cases, oue or several roundish  firm
elastic, cutaneous  or subcutaneous, pea to walnut-sized tumors isolated
or disseminated, unproductive of pain, project from the general  level
and are enveloped by an unaltered  integument.   They may remain
iu this condition M'ithout change  for  years;  and may  accompany
cysticerci of the brain and other portions of the body, productive of
1 Lancet, 1880, p. 10.
2 British Medical Journal, 1880, p 207. 
ANIMAL PARASITES.
645
the serious disturbance of the economy  which such  invasion  may
determine.   If the skin^tumors be opened and their contents exam-
ined, the parasite  will be  recognized as an ampulliform sac, with a
cephalic appendage, reentrant or projecting, and provided with four
suckers and  a  coronal of hooklets.   By no external characteristics
could such tumors be distinguished from others of similar size and
external appearance.  Only in,the rare case of nervous complication,
could a suspicion arise based upon the real character of the disorder.
Respecting this matter,  hoM'ever, the diagnostician is iu no  worse
position than when called upon to recognize cysticerci of the viscera.
On more than  one occasion, cysticerci  of the liver have beeu dis-
tinguished  during  life,  and  subsequently removed  by operative
procedures.
   The diagnosis is from gumma, lipoma, epithelioma, and sarcoma.
The first occurs only in the  syphilitic;  the second has a peculiarly
uneven surface and firm  feeling; the third is largely facial  in  situa-
tion ; and the last is of a plainly malignant character and relatively
rapid career.
                          Echinococcus.

   Weyl and  Geber state that this parasite,  not mentioned in derma-
tological treatises,  is found often  in  the human skin.   Of 336  cases
reported  by Davaine, the parasite occurred  thirty times  in  muscular
aud subcutaneous tissues,  more  often in women than in men.  The
vesicles produce a disagreeable  sensation  of tension, and undergo
fatty  or  other  metamorphosis after  the  death of  the encapsulated
parasite, M'hich usually occurs in from one to tMO  years.   Explora-
tion of the superficially seated fluctuating tumor, covered by unaltered
integument, usually demonstrates its nature.

                        Distoma Hepaticum.

   Kiichenmeister  (1. c.) reports three instances in which the embryos
of the large  liver fluke were encapsulated in subcutaneous tissue.
The tumors were painful or painless aud occurred on the head, trunk,
and extremities.
            Leptus.  (Leptus Autumnalis, Harvest Bug.)

   This is a minute, reddish, or yellowish-red  insect of the family of
the trombidae,  visible to the naked  eye, aud found in summer and
autumn clinging to bushes  and grasses.  It is  found both  in this
country and  in Europe.  It attacks man  only after its accidental
location upon the skin, where it perishes in the course  of a few hours.
In such situations, however, it induces considerable irritation, betrayed
in erythematous, urticarial, papular, and  even eczematous symptoms,
acconipaniedbv pruritus  of various grades.   It may  be seen in the
skin as an orange-reddish or brick-reddish point,  M'hich represents
often the bodv  of  the insect, its head being buried  in  the aperture of
a follicle beneath.  Examined after extraction, it is seen to have  a 
646
DISEASES OF THE SRIN.
 relatively large cephalic extremity.  It has a short, cylindrical, and
conical  haustellum, composed of  fused double maxillae;  and two
strong,  hooked, five-jointed palpi, which can  be rolled  up.  There
are also two  hatchet-like mandibles.   It  has a well-rounded body

          Fig. 88.
    Leptus.  (After Kuchenmeistee.)             Leptus autumnalis (harvest bug).

0.3558;mm. long, and 0.32 mm. broad, provided with three pairs of
legs.   It is found  upon the lower  limbs  particularly, but also upon
the scalp and every other part of the body.  According to Duhring,
children are particularly liable to its  encroachments.   The  disorder
is relieved by the application of a little balsam of Peru in  olive oil,
carbolated oil, spirit of camphor, or other mild stimulant or parasi-
ticide.
                    Kriptoptes Monunguiculosis.
                              Fig. 90.
Fig. 89.
Acarus hordei. 
ANIMAL  PARASITES.                  647
  Acarus hordei is the name given by Weyl and Geber to the larva
of a mite that annoys laborers in  barley.   It  is yellowish-M'hite,
oblong or oval in form, averaging 0.022 mm.  in length.  There is a
protrudible tubular haustellum,  enclosed by serrated mandibles.   On
each side are five-jointed  palpi.  There are four pairs of feet; two
on the cephalo-thorax; two, abdominal in  situation; all  articulated
to the epimeres.   The tarsus of the first pair terminates in hooked
claws; tbe  others have  haustellum  disks  on  steins.   BetM'een  the
first and second pairs are swinging clubs, indicating the larval condi-
tion.
          Dipterous Larvae in and beneath the Human Skin.

  There is no dipterous insect peculiar to man alone, but a number
of cases  are on  record where  the ova  of  several species of oestrus
have been deposited in the skin, and larvae been subsequently formed.
The oestrus bovis,'or gad-fly, is the most common of these.  Usually
after the ova are deposited  by the insect,  a painful swelling occurs

           Fig. 91.                               Fro. 92.

           <2ffi0>
<g^ 6
 (Estrus.  a, the larva, natural size ; 6, some
of the segments seen under a lens, and show-
ing the lines of minute projection ; c, and
d, the terminal ends of the insect.  (After
Abraham )

M'hich may change its place from one point to another.   When sup-
puration is induced, the larvae can be removed by pressure upon  the
boil.   Walter Smith,1 of Dublin, has lately  described  such a case,
M'here the swelling upon the ankle of a girl twelve years old, moved
to the elbow, and there discharged a M'hite grub nearly au inch in
leno-th.  BirdsalP has  described a specimen sent  him from Gaboon,
on &the West Coast  of  Africa,  in which two worms  escaped from
betM'een  the  middle aud  the ring  fingers of one  hand;  another
workman having had a similar accident occur upon the leg.  The
fly  whose ova had  been deposited  in these  two cases, Mas said to
attack the gorilla; aud the Pawnees, a tribe of Indians engaged in
capturing  these animals,  M'ere  reported as  being very commonly
troubled in the same way.   The worms sent to Dr.  Birdsall were

         i Sec TJoport of Internat.  Med. Congress, Arch, of Derm., January, 1882.
         2 N  Y. Sled, liecurd, March 18, 1SS2, p. 298.
 Larvae removed from the body of a child.  Of
the exact size, after several days in alcohol;
a, as seen from side ; 6, as seen from beneath. 
648
DISEASES  OF THE SKIN.
 respectively one-fourth and one-half of au inch in length, and about
 one-eighth of an inch in thickness.
   Abraham,  of Dublin,  has  also  examined  and reported upon a
 similar case,  the specimen having  been sent to  the  editor of the
 London Medical Press and Circular, from Portsalon, Letterkenny.
   Several specimens illustrating these accidents have been sent to the
 author from neighboring States.  The larvae represented in the sub-
joined sketch  Mere removed from the body of an infant in Nebraska.
 The muscidse (flesh, house, stable, dung, and other flies)  have  defec-
 tive maxillae, and are, therefore, unable to wound the uninjured skin.
 The pregnant female seeks, therefore, to deposit her ova M'here the
 larvae, equally unprovided  with developed jaws,  can most readily
 secure nutriment.   Hence,  open wounds and the tender  skins of
 newly born infants when exposed in the summer season, are liable
 to become the depots of such ova.
   The ova of other species of muscidae and cestridse  (according to
 Geber, of the former, Lucilia Caesar, in America; Stominis Calcitrans,
 in  Africa; and Sarcophila Wohlfati,  in  Russia;  of the  latter,
 Dermatobia Noxalis, Cutrebra, and Hypoderma) deposit ova or larvae
 in the skin by their special apparatus for puncture, occasionally also
 the hatched larva M'orks its May unaided from the epidermis to the
 subcutaneous  tissue.  Severe cases are  reported from  Texas,  where
 larvae have been expelled in great number from the  nares after
 inhalation of chloroform.

                       Ixodes (Wood-tick).

   Several  species  of  ticks are  recognized,  such as the  Ixodes
 Humantjs, Ixodes Bovis (cattle-tick), Ixodes American us, Ixodes
 Marginatus, Ixodes  Unipunctatus, and the  Ixodes  Ricinus
 (wood-beetle), the last-named  being  more  common in Europe.   In
 this country  they are found  in Mooded districts, especially those
 M'here pine and fir trees are growing.   The female attacks the skin
 by thrusting into it her beak, armed on either side with a  maxillo-
 labial projectiou having recurved hooklets, the mandibles  also pre-
 senting similar obstacles to the forcible extraction of the head.  After
 suction of the blood  from beneath, the  body of the tick  swells to
 the size of a pea or small  bean, and may remain for several days in
 this position.   At  such times the parasite  may be mistaken for a
 small pedunculated  tumor.  Forcible  attempts at extraction of the
 intruder are liable to detach the mandibles from the  body, and thus
 leave them as  the source of future irritation, and  even disagreeable
 inflammatory  symptoms, in  the site of the  punctured M-ound.  By
applying over it a  drop of the spirit of turpentine  or benzine, the
head is spontaneously retracted, and  the body falls from  its  position.
The soldiers on the plains of our own country, accomplish  the same
end m ith the juice of tobacco. The sensation produced at the moment
of the insertion of the beak of  the insect, is said to be so trifling as
often to pass unnoticed. 
pediculosis.
649
                           Pediculosis.

                      Lat. pediculus, a little foot.
Pediculosis is a contagious  affection, characterized by the  presence of lice
  upon the skin and hairs, by the wounds inflicted by the parasites, and by
  the scratching which the resulting pruritus excites.

   This disorder is also termed Phtheiriasis, Morbus Pediculosis, and
Lousiness.
   Symptoms.—Lice  belong  to the  order, rhynchotta; subdivision,
parasiUc; famil)-, pjediculidce.   They are apterous, provided each M'ith
two eyes,  and  have an oral  appendage capable of  both inflicting
M'ounds  and producing  suction.   The lice infesting the human body
are  recognized  as belonging to three varieties, those of the head, of
the body, and of the pubes.   Of the disorders to M'hich they give rise
it may be said in general, that the lesions presented differ somewhat
according  to the region invaded, the multiplicity of  the intruders,
and the  length of time during which their ravages have been inflicted.
Such lesions, however, are those which have been already studied in
connection with  eczema, urticaria, aud the similar disorders resulting
from external irritation.  Their special peculiarities  in pediculosis,
are owing solely to the  nature of the exciting cause aud the mode of
its operation.

         Pediculosis Capillitii (Parasite, the  Head Louse).

   The head louse is  usually  of a grayish color, but  differs slightly
with the hue of the hairs over the part which it frequents.  Its head
presents indistinctly the outline of a trefoil, and
is provided with two hairy antennae, each of five
articulations, and two eyes.   Its thorax is rela-
tively narrow, with six tracheal  stigmata and
three hairy legs on either side, the  latter pro-
vided  M'ith tarsal hooklets.   The abdomen is
divided into seven segments, defined by blackish
indentations on  either  side.   The  males  are
fewer  and smaller than the females,  and pre-
sent upon  the  dorsum  an  ano-genital  orifice
and  a large conoidal penis and testes.   The
females  are  provided with  ovaries,  oviducts
  i.i,    •  ,   •        •   i   •   „  „.,4.„,1  Pediculus capillitii—male.
which terminate in a vagina having a vential   (AfterKuclIEXMEisTER.)
orifice, aud  au anal aperture  in  the  terminal
abdominal segment.   Coupling is performed  with  the male beneath.
  The ova or " nits" are whitish  bodies of oval contour,  M'hich  are
glued to  the hairs by a  cylindriform sheath of chitine, M'hich com-
pletely encases the circumference of each filament.  They are deposited
in scries, as the female traverses the hair from  its insertion to its
distal extremity, so that the oldest  are in general the nearest to  the
scalp.  The voting escape from the ova  in from three to eight days,
 
650                DISEASES  OF  THE  SKIN.
and  arrive at maturity in from  eighteen to tMenty days.   A single
female can, according to Kaposi, lay fifty eggs in  six days, and thus
in eight M'eeks have an  entire progeny of five thousand lice.
   Head  lice usually limit their  habitat to the scalp, though, rarely,
in elderly  men  M'ith long hair  reaching to a full  beard, they may
encroach upon the latter.   They are found upon  every portion of
the scalp,  but find the region  of the greatest protection upon the
occiput.   They infest children and adults of both sexes, but are best
furnished with lodgement in  the scalps of  girls and women covered
by long and luxuriant hairs.
   The lesions observed upon a scalp thus  inhabited, vary according
to the age and vigor of the colony; and are feM' or numerous, discrete
or confluent pustules or bullae ; surfaces excoriated by scratching and
oozing M'ith  serum, pus, or blood;  crusts  varying  in character
according to  the  nature  of  the  desiccated exudate aud  sebaceous
                        matters.  Often the  picture presented is a
       Fig. 94.          conglomerate  of an  artificial eczema and
                        seborrhcea.
                          The ova, or " nits," are usually abundant
                        upon the hairs of an  infested head, and M'ill
                        scarcely escape the attention of  a close ob-
                        server.  They are not to be mistaken for the
                        exfoliated, epithelial,  and fatty plates seen in
                        seborrhcea  sicca,  disseminated  among' the
                        hairs, and  often perforated by hairy fila-
                        ments, since the former are firmly glued in
                        position, and resist the bristles of tbe  hair-
                        brush.  The peculiarly nauseating odor also
                        of  the  louse-infested,  pustule-  and  crust-
                        covered scalp is not to be  confounded M'ith
                        that perceived in favus of the same region.
                          In exaggerated cases,  the  post-cervical
                        ganglia express,  by  their  increase in size,

"I
                        the degree to M'hich the local irritation has
                        been pushed.  The itching is usually severe,
                        aud, in cases of long persistence in children,
                        may produce the usual  systemic  symptoms
                        of prolonged local irritation.  Children and
                        patients  of impoverished  health  and  M'ith
                        poor hygienic surrouudings, are thought to
                        exhibit  the disease in  severer  grades than
                        others;  but this, if indeed a fact, must be
                        at least in part due rather to the more favor-
                        able conditions for the development  and
                        multiplication  of  the  parasites,  M'hich are
                        presented  in filth  accumulation and lack of
cleanliness.   In the public charities of large cities, children are pre-
sented every week affected with pediculosis capillitii, who come from
Ova of the head-louse attached to
    hair. (After Kaposi.) 
PEDICULOSIS.
651
the very  loM'est  social grades of population and  from the filthiest
quarters.  Among these it cannot be observed that the general health
of the patients is a factor of weight  in the severity of the affection.
  The diagnosis  of  pediculosis capillitii is a matter of considerable
importance, however simple of accomplishment, since many cases  of
supposed  "pustular  eczema of the scalp " have beeu treated vainly by
one physician with internal remedies addressed to the systemic  vice
assumed to  be responsible for the disease which another has relieved
after the discovery of a feM' head-lice.   The hairs should always  be
raised and separated, the scalp carefully inspected, and the presence
of any parasites, and  especially ova or "nits" fastened to the hairs,
ascertained.   Whether the lice have preceded or folloM'ed the eczem-
atous state (and each of these conditions may be noted) is a matter of
minor importance.
   The indications in  the  treatment of  pediculosis capillitii  are the
destruction  of all parasites M'ith  their  ova, and the relief of the
induced inflammatory condition of the scalp.  Generally, the removal
of the former is followed  by the spontaneous  disappearance  of the
latter.
   For the destruction  of the lice, the  most popular remedy, iu this
country certainly, is petroleum [not kerosene], pure or with equal
parts of the balsam of Peru, M'hich gives it a more agreeable perfume,
poured over the scalp in quantity sufficient to cover it without overflow
upon the brow, temples, and neck. It should be rubbed in M'ith a piece
of white (undyed) flannel.  At the end of from  twelve to twenty-four
hours the lice are destroyed, and the ova rendered incapable of devel-
opment.  This treatment  is folloM'ed  by a thorough shampoo  with
tincture  of soap, or toilet soap and hot water; after this  operation
the tender scalp may require a bland unguent, such as vaseline, or a
small quantity of scented castor oil, either pure  or iu combination
with spirits of wine.   Kaposi employs petroleum as a parasiticide in
combination with olive oil and balsam of Peru : five parts  of the
first,  two and a half of the second, and one of the third.  Cutting
the hair  of women  and girls is quite unnecessary, as patience and
gentleness with the  use of the comb will finally disentangle the most
matted  masses after the lice  have  been destroyed.  Other remedies
are employed locally for  a  similar purpose,  of M'hich  the most
popular  are staphysagria, one drachm (4.) of the  powdered seeds to
the ounce (:32.) of vaseline, but especially in decoction ; the tincture of
cocculus Indicus; carbolic acid in oil or water; sabadilla; the ethereal
oils; and mercurials in ointment and solution, including the mercuric
oleates.    Iu cases where but a few parasites have found  their way
to the scalp, and that recently,  nothing  more  is requisite  than  a
careful use of the fine-tooth comb, scrubbing the scalp with  a strongly
scented  alcoholic perfume, and  a final  bathing  with  soap and hot
M'ater.
   The ova adhering firmly to the hairs can be removed  by soda or
borax lotions, alcoholic solutions,  or  dilute acetic acid, M-hich are 
652
DISEASES  OF  THE SKIN.
Fig. 95.
solvents for the gluey material by M'hich the " nits " are  secured  in
place.

          Pediculosis Corporis (Parasite, the Body  Louse).

  The parasite  in  this  disorder  inhabits exclusively  the  clothing
worn next the body,  and is hence often designated as  the Pedi-
culus Vestimenti.  In  anatomical  peculiarities it resembles the
pediculus capillitii already described, being, however, larger  in size,
the females also larger than the males.   The thorax is separated from
the abdomen, the latter  being  hairy, yellowish  at  the  margins, and
provided with eight segments.  The eyes are black, and very promi-
nent in both sexes;  and the periods requisite for the maturing  of
the ova and young are those named respectively in connection with
head lice.  In color they vary slightly from a dirty-white to a light
                       grayish hue, when uudistended M'ith blood.
                       In the reverse of this last-named condition,
                       they may  be  recognized  as  having  a dull
                       reddish or purplish  color, when they are
                       also  more indolent  in their movements.
                       They measure  2 to 3 mm.  in length, and 1
                       to 1.5 mm.  in breadth.   The female lays
                       from seventy to eighty eggs, from which the
                       young are produced in  from three  to eight
                       days, and are capable of reproduction in a
                       fortnight more.
                          They inhabit the seams of undergarments,
                       M'here  their ova  are  also deposited,  but  in
                       coarse  woollen or  flannel  shirts they  find
                       sufficient shelter in the  meshes of the mate-
                       rial  of which  the clothing is  made.  This
                       they leave temporarily, solely  for the pur-
                       pose of obtaining nutriment from the skin
of their host,  and  hence  are not  often  recognized  upon the  free
surface of the integument.   Upon rapid removal of the clothing  of
an infested individual, a few may occasionally be encountered,  hastily
seeking a place of refuge, though this is rather  the  exception to the
rule.  It thus may happen  that a louse-bitten patieut may not exhibit
the true  source of his troubles to  his physician after  a  recent and
complete change of clothing.  The greater then the importance  of
being  able to recognize  the  clinical features of the malady in the
absence of the parasite.  This is comparatively  easy to one who has
made himself familiar with the symptoms of the disorder.
  The manner in which the louse is enabled to supply itself with the
blood of man has been carefully studied by Swammerdam, Landois,
Schjodte, and Tilbury Fox.  The last-named author has summarized
the observations of tbe others, and the results he gives may be briefly
described as follows :
  Swammerdam's  original view that the  louse is not provided M'ith
Pediculus corporis — female.
 (After Kuchenmeister ) 
PEDICULOSIS.
653
mandibles by which it can  inflict a wound, but with an haustellum
by M'hich the blood is sucked up to the  head of the parasite, is con-
firmed by Schjodte.  This observer, examining the head of the louse
from behind M'ith reflected light, discovered  that the  parts  of the
head resembling mandibles in appearance, M'ere really situated beneath
its skin.   He  applied to the  integument lice which had been pre-
viously starved,  and M'atched  each as M'ith  retracted limbs, arched
back, and  head inclined  obliquely downward, it repeatedly projected
forward and retracted through  the extreme end of its head a " small,
dark, narrow organ," by which  it was finally firmly held in place.
A triangular blood-red point soon became visible in front of the eyes,
rapidly and alternately contracting and dilating, and  folloM'ed  by
energetic peristalsis of the gastro-intestinal tract.  If the  head then
be cut off in front of the eyes, and the haustellum carefully extracted,
the  latter can be recognized as a  brownish  protrusion, armed M'ith
terminal recurved hooks, from  which depends a delicate membranous
tube varying in length.
   " It seems that the mouth is like that in the rhynchotta generally,
but differs in the circumstance  that the  labium is capable of being
retracted into the upper part of the head, and has a fold  in it M'hen
so retracted.  In order to strengthen this part, a flat band of chitine
is placed  on the under surface;  and it  is thinner in the middle in
order that it may bend and  fold a little M'hen the skin is  not extended
by the  lower lip.  The latter consists of two hard lateral pieces, of
M'hich the fore ends are united by a membrane, so that they form, a
tube, of wdiich the internal  covering is a continuation of the elastic
membrane on the top of the head.   Inside its orifice are a number of
small hooks, which assume different positions according  to the degree
of the  protrusion ; and  if this is pushed to its highest point, they
form a collar of hooks curved  backward like barbs.  The pediculus
first inserts its labium into a sweat pore and protrudes the lip.  AVhen
the  hooks get  hold  of the  parts around, then the first pair of setae
(the real mandibles transformed) are protruded, and these are toward
the  point invested by membrane so as  to form a  closed tube, from
which again is exserted a second pair of setae or maxillae, which form
a  tube  and  end  in four  small lobes placed  crosswise.   The whole
forms a membranous tube,  along the Malls of M'hich retiform man-
dibles and maxillae are placed as long narrow bands of chitine.  This
tube can be lengthened or shortened at pleasure."
   This  explanation of the mode in which the louse attacks the skin,
is probably true of each of the  varieties M'hich infest the  human
body.   Fox well suggests that the invaded follicle, after the with-
drawal of the haustellum, becomes the seat of a circumscribed hemor-
rhage.  None of the  anatomical  peculiarities described above M'ill,
however completely explain, it seems to the author, the characteristic
pruritus of pediculosis corporis, for it can scarcely be questioned that
it is not merely  at the moment  of attack or  penetration that  the
sufferincr of the victim is greatest.  The pruritic condition of the
louse-wound persists, indeed usually attains  its maximum, after the 
654
DISEASES  OF  THE  SKIN.
M'ithdrawal of the pediculus, and is M'ithout doubt greater than that
awakened  by merely mechanical  puncture of the  epidermis.  Any
one who M'ill  compare the skin of a louse-infested patient M'ith  one
who has been subjected to the acupuncture process employed among
the lower classes of Germans, and by them known as " baunscheid-
tismus," can convince himself of this fact.
  The lesions seen on the skin thus invaded are  proportioned, as in
pediculosis  capillitii, to the size and age of the colony of parasites.
Excoriations,  usually linear,  occasionally circumscribed, varying in
depth and length, radiate irregularly from each  louse wound, and
may be commingled M'ith minute  papules, transitory  wheals, or,  in
rare, exaggerated cases, with the typical signs of diffuse eczema.  All
are produced  by scratching in order to relieve the pruritus.   Crusts,
more often composed of desiccated  blood, rarely of serum  or  pus,
minute and capping  the wounded  follicle, or linear and coextensive
with the excoriations produced by the scratching, are generally con-
spicuous.   In older  cases these  lesions are followed  by the usual
sequel, pigmentation, the latter being a partial indication of lousiness
which has  been long tolerated.
  In this country, it is rare to note  the severe and intense forms of
the malady resulting from long-continued neglect of the skin, which
occur in Germany.   In  such cases, dermatitis,  rupioid crusts, fur-
uncles,  abscesses,  carbuncles, and  ulcers  form,  bequeathing to  the
skin serious disorders, M'hich  may persist for weeks after the clothing
has  been freed  from lice, and finally  leave a  deep-tinted, diffuse
pigmentation of the surface, suggesting that of the negro or of  the
patient affected with Addison's disease.
  The  diagnosis  is  a  matter of  importance.   Patients will visit
physicians, claiming  that they have suffered from a "  humor of the
blood," who have been swallowing drugs for a long period  of time,
in the vain hope of obtaining relief, with lice, at the very moment of
uttering the complaint, crawling  over their persons.   Even those of
good social position  and habits of cleanliness, will occasionally suffer
after the accidental  contacts  in the street- or railway-car, the hotel,
the theatre, or other  places of public resort.   There are certain points
to be carefully noted in this connection.   Excoriations over the nucha,
about the shoulders, loins, buttocks, and external  faces  of the thighs,
all  visible at the same time, are highly suspicious symptoms ;  as au
eczema,  when  equally diffuse,  is sure to  be  accompanied at some
point by perfectly  classical   features; and generalized pruritus is
exceedingly rare, its  localized varieties concerning chiefly the regions
about the mucous outlets of  the body.   There  is a picture highly
suggestive  of  pediculosis exposed  to the eye when the trunk of an
infested patient is viewed from behind.  The lesions are more discrete,
more irregularly distributed, and more intermingled M'ith long scratch-
marks, reaching, for example, quite over the point of one shoulder,
than iu most disorders with M'hich  this could be confounded.  Here
and there minute blood specks tell a significant tale.  The author has
occasionally the opportunity  to exhibit patients  at the clinic M'ith 
PEDICULOSIS.
655
syphilodermata interspersed among characteristic lesions of pedicu-
losis corporis ; and often the students themselves in such cases point
out  the  particular  symptoms  referable to the  separate  disorders
present.
  In private practice it is usually advisable, for obvious reasons, to
secure the corpus delicti before informing the sufferer of the nature
of his or her complaint.   In the case of male patients, it is well to
take a position  in the rear, and when the underclothing  is drawn
Mell up  from the shoulders,  a careful  scrutiny of it may be made
M'hile the  applicant  for  relief supposes that attention is  directed
instead to his person.
  The treatment of  the disorder concerns largely the clothing.  The
latter requires  immersion in  boiling Mater, or may be wrapped in
paper and subjected to a high temperature in an oven, 160°-175° F.,
sufficient to destroy the lice aud their ova.   In case of recurrence of
the malady, the  clothing is to be again subjected to the same process.
Usually  the resulting  irritation  of the  skin  promptly  subsides.
When several members of one family suffer, all  clothing worn  must
be subjected to  similar treatment.   If the  skin  has been unusually
tormented by scratching, warm  alkaline baths will afford some  com-
fort, and may be followed by a bland unguent or one of the dusting
powders.   For  immediate use, before the clothing can be rid of the
intruders, a parasiticide ointment can be ordered  as recommended  by
Duhring, prepared by adding  two drachms (8.) of freshly poM'dered
staphysagria to the ounce (32.) of hot lard, strained and cooled.  The
surface of the skin may also be anointed with carbolic acid dissolved
in oil or water.

           Pediculosis Pubis (Parasite, the Pubic Louse).

  In this disorder the genital region is chiefly  involved, though in
exceptional cases all the  hairy portions of  the skin may be invaded,
including the eyebroM's, eyelashes,  axillae, and the moustache, beard,
hairy chest, and  hairy legs of the male.  The body of the  pubic
louse is  smaller than  either  of those described  above.  Its head is
also attached  more  closely to its  thorax, having  a  shape which  is
compared to that of a violin.   The thorax  is not distinctly separated
from the abdomen  and of the six stout legs that spring from it, the
second and third pair are conspicuously powerful, and armed with
relatively large  hooks  at the  tarsal extremity.   The  resemblance of
the  latter  to  the claws  of a crab, has given to this creature the
common name of "crab-louse."  The lateral abdominal indentations
are much less distinct than  in the other varieties; and the blackish
marginal marks of the latter are here, scarcely apparent.  The abdo-
men is  also much elongated, having a more  rounded  contour, aud
beino- provided  on  its lateral borders M'ith eight  short conical feet,
ternnuatino- in  bristles.  It is also distinguished  from the others of
its family by the length of its anal bristles, aud by the peculiar shield-
shaped  carapace M'hich covers  nearly one-half of the dorsum.  The 
656
DISEASES OF THE  SKIN.
Fig. 96.
male  is 0.8  and 1. mm. long, and 0.5 to 0.7 mm. in  width, being
thus from 1. to 1.5 mm. smaller than the  female.
  The pubic louse is  much more inactive than  the others, and does
not ordinarily escape its pursuer.   It buries its head deeply in a fol-
licular orifice, and steadies itself in  this position, M'here it may remain
for  some  time, by  grasping the  adjacent  hairs M'ith  its short and
powerful  claws.  A moderate  degree of force is required for its
dislodgement from this favorite position, and M'hen removed  its grasp
of the hair to which it clings is so firm that the latter usually slides
for  its entire length through the  claw of the louse.   Occasionally
thev may be found  creeping over the skin or  clinging  to hairs at a
distance from the surface.   The pyriform  ova  are smaller than those
of the head  louse,  though having  a similar color; and are, like the
latter, attatched to the hairs by a firm chitinous glue.
L  Pubic lice are usually acquired during the contacts incidental to
the sexual act; and are hence  more  frequently encountered among
                             adults, but may, without any question,
                             be, more rarely,  transmitted mediately
                             by  occupation of beds  and  covering
                             which have  been used  by infested per-
                             sons.   They  are  thus,  though very
                             rarely, found in  children of both sexes.
                               Tbe lesions induced are those pro-
                             duced by the Mounds  inflicted by the
                             parasites and by consequent scratching,
                             though the latter is rarely intense.  In
                             a few cases, one may see a severe eczema
                             folloM' the ravages of the lice, but in
                             such event the  complication is  chiefly
                             owing to  unnecessarily severe self-
                             treatment of the  disorder,  patients
                             being often  morbidly anxious in their
                             efforts to rid themselves  of the pests.
  The diagnosis of pediculosis pubis is betM'een eczema and pruritus
genitalium.   The disease last named  is, in  both sexes, accompanied
by  itching, and  that often  of intense  grade, but when this  is diffuse
and symmetrical  in distribution, it  is not limited particularly to the
hairy parts.  Eczema  of the genitals is not often produced  by para-
sites of that  region, and may be readily recognized by its character-
istic features.  Both disorders are often indeed  limited to symmetrical
patches upon the side  of the scrotum or one labium.  The discovery
of the parasite, however, in pediculosis pubis, is ahvays essential, and
requires  merely careful  inspection and a good light.   The lice may
be recognized either at or near the  point of implantation of the hairs,
which latter also display ova except  in very  recently infested indi-
viduals.   The  reddish  excrement  of the  parasites' mingled  with
scratch-marks and  excoriated  papules of small size,  may also be
observed.  Patients are often  made aware of their  condition by a
sensation  of craM'ling over  the parts.   Scratching  of the  pubic
Pediculus pubis.  (After Schmarda.) 
PEDICULOSIS.
657
region in adults of both sexes, should awaken some suspicion of the
disorder.
  The disease is commonly treated by the  topical application of
mercurial ointment, which is a disagreeable and rather filthy medica-
ment for  this locality.  The ten per cent, oleate may be substituted
for it, or, even preferably, corrosive sublimate in solution, three to
four  grains (0.266-32.) to the ounce.  Petroleum and olive oil with
the balsam of Peru, in the proportions given above in  connection
M'ith the  subject of pediculosis capillitii, is an effective  combination.
Staphysagria,  carbolic acid,  cocculus indicus, or  one  of the other
substances used in the  disorders occasioned  by the animal parasites,
may be substituted if desired.
   It  is usually  better to defer  bathing till  the  remedy selected for
the destruction of the lice has been applied on several occasions, after
which a  warm  water aud soap ablution M'ill  commonly  end the
trouble.   It is needless to clip the pubic hairs.  Should  an eczema-
tous disorder remain, it requires appropriate treatment,  including hot
bathing and the blander unguents.

   Pediculi and Acari transferred to Man from the Lower
Animals rarely thrive in  such uncongenial  soil, but as  a matter of
exception, occasionally survive such transfer.  Thus Goldsmith,1 of
Vermont, reports the case of a woman affected with intense pruritus,
who after sweating profusely observed numbers of pigeou- or hen-
lice emerging from the sweat-pores.   Megnin2  reports similar cases
under the title Prurigo Dermanyssique, the dermanyssus avium
or  gallinae being the acarus infesting domesticated fowls.   The dis-
order is  said to  be at  times epidemic iu the vicinity of aviaries and
pigeon-cotes, but is always  of trifling  severity.

    Cimex Lectularius (Acanthia Lectularia, Bugs, or Bed-bugs).

   Strictly speaking, the bug is  not a parasite of man, but finds its
congenial habitat  in  the  bed, bedding,  bed  covering,  M'alls  and
floors of  apartments occupied by persons of both sexes aud all  ages.^
 It  infests also furniture, including  chairs, sofas, aud  the  cushions of
seats occupied in  public  vehicles  and hotels.  From the  cracks,
crevices,  seams, folds, or  other protected points where  it  has found
lodgement, it emerges usually at night, for the purpose of securing its
nutriment in the blood of  its victims.   It is a pest as ancient as the
dav iu  which Dioscorides wrote, since he described it.
   The insect has a rusty or reddish color, this differing slightly
according as it  is or is not distended M'ith  blood.   It  is  an apterous
 member  of the order Cimicid.e;  and is  provided with a  blunt-
pointed   head, broadly attached to  the thorax; two  long  slender
antennae; and a  three-jointed haustellum capable of projection and

    i Louisville Med. News, Dec. 31, 1881, p. 320.
    2 Lea parasites et les maladies parasitairea chez l'homme, les animaux domestiques, etc., Pans,
1880.
                                 42 
658
DISEASES  OF  THE  SKIN.
 retraction beneath the head.   There are three pairs of long slender
 legs  by which it is  enabled  to  accomplish rapid movements,  two
 thoracic and four abdominal.  The abdomen is  broad, flattened,  and
 oval in shape, with nine segments.  The parasite emits a disgusting
 odor, which is much more distinct when it is crushed.
   The wound inflicted by the bug is accomplished with or without
 the consciousness  of its victim, who in the former case is made aware
 of a transitory prick or sting.  Soon after, decidedly pruritic burning
 or stinging sensations are experienced ;  and the wound becomes  the
 seat  of an  urticarial  wheal.   The lesion then, examined soon after
 the infliction of the wound, is seen to be small pea- to bean-sized,  and
 in the form of an elevated  and  circumscribed "button" or papulo-
 tubercle,  either whitish iu the centre,  or  exhibiting there also  the
 hyperaemia which distinguishes its peripheral  zone.  After  it  has
 begun to subside and  lose its acute features,  which may not occur for
 several hours  if it be irritated by rubbing or scratching,  a minute
 reddish puncture may be seen marking the original site of the M'ound.
   The lesions are usually multiple even when but a single assailant
 has been present, the insect taking apparent delight in  obtaining its
 nutriment  from several distinct  points upon one surface.  In this
 way  at times its  course  upon the integument may be for a  short
 distance traced.  In cases where the pests are numerous, as in filthy
 dwellings, prisons, ships,  and barracks, and when infants have been
 attacked, the resulting eruption  is often   greatly masked by  the
 scratching and  resulting  excoriations of the surface.  In  this way
 vesicles, pustules, crusts, purpuric blotches, and even  skin infiltra-
 tions may be found, iustead  of the rosy or  light  reddish  typical
 wheals of recent cases in  patients with fair  clean skins.   The diag-
 nosis is a matter of importance, and upon it may hang a professional
 reputation.   Physicians are  often  consulted respecting these lesions
 by patients  who believe themselves to be suffering from " humors,"
 exanthemata, and  even syphilis.   The insect attacks the parts of  the
 body to which access is easy as the patient sits or reclines on the back
 or side, including  the buttocks, thighs, shoulders, loins, and neck, in
 that order of frequency, rather more largely than the legs, much less
 frequently the scalp, face, and  genitalia.  The eruption is not to be
 confounded with urticaria ab ingestis, M'hich is more apt to be sym-
 metrical in disposition.
   It is best relieved by the topical application of spirits of camphor,
 alcohol,  weak  carbolated  lotions, or solutions of  boric  acid,  one
 drachm to the pint.   Untreated,  it disappears  spontaneously M'hen
 the source of the disorder is removed.   The most effective treatment
 is by prophylaxis, with soap and hot water,  of all accessories of  the
 dwelling-house inhabitable  by the insects.   Once discovered to be
 present, infested furniture should be scrubbed in all its crevices with
 a  saturated  solution  of  corrosive sublimate  in alcohol, and bed-
 clothing immersed in boiling water.

   Other insects,  which  may  persistently  or only  occasionally
attack the human skin, are: the mosquito and gnat (Culex Pipiens) 
PEDICULOSIS.
659
midges  (Tipulid.k, Simulia);  bees (Apes Mellifer^e) ;  wasps
(Yespidje), aud fleas (Pulex  Irritans).

                          Pulex Irritans.

  The Flea M'hich specially attacks  man  is a  brownish-red  insect,
having a laterally compressed body, an oral haustellum, serrated soft
mandibles, a tongue sheathed  in an  inferior labium, and  a  pair  of
labial, four-jointed palpi.   Each of the triple segments of the thorax
bears a pair of five-jointed, double-clawed legs.   The male is 2  to 5
millimetres in length, and  1 to 2 in breadth, the female being nearly
tM'ice that size.  The female deposits her eggs in any fissure, crevice,
or fold of garment or furniture which may be accessible, from M'hich
the larvae are produced in a week.   The  nyrapha is enfolded  in a
cocoon,  but the mature insect  only preys upon  man.   According to
Geber, it injects an irritating fluid into the skin at the moment of
attack.  The lesion it produces is a haemorrhagic punctum, followed
by a transitory hyperaemia and a haemorrhagic exudation which  may
persist for a few hours.

                        Culex Pipiens, etc.

  Mosquitoes, midges, etc., produce, by their bites or stings,  various
cutaneous  lesions, including urticarial M'heals, papules, ecchymoses,
and in rare cases even  ecchymomata.  Those  produced by the flea
are found more often on the legs, neck, or other covered portions  of
the body;  those of the midge and mosquito on  the  face, hands, and
exposed parts; though, when numerous and voracious, these insects
will   penetrate the clothing for the  purpose of obtaining  blood.
Severe eruptive lesions are often seen in this country on the faces and
extremities of infants and children exposed during  the night to the
incursions  of these  marauders.  They are usually treated  locally by
aqua  ammoniae or the spirits of camphor.
  The bodies of immigrants newly arrived during the summer season
in America, from countries M'here the mosquito is either rare or does
not exist, often present singular and even formidable evidences of the
attacks  of these  insects.   The skin, totally uuaccustomed to  such
depredations,  and quite unprotected, M'ill  often be found  greatly
swollen, and of a light  reddish hue, suggestive of erysipelas.   Here
and there bullae are conspicuous, M'hich add to the resemblance to the
last-named disease.   The features, iu consequence of the tumefaction,
vesiculation, and papulation, may be  so  swollen  as to present a con-
spicuous deformity,  and  the forearms,  and  even  the  arms, seem
greatlv increased  in size from the same cause. The feet and legs also
may be, in the unconsciousness of sleep, exposed in hot M'eather to
the depredations of these marauders, and in the same May the back,
buttocks, and, rarely, even  the genitalia present the same signs of
inflammation.  The matter of  chief moment is the correct diagnosis
of such cases, as  many patients seeking relief under such circum-
stances  have been mistakenly  treated for disorders  M'ith m hich  they
Mere  not affected. 
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I N  D  E X.
 4 CANTHIA lectularia, 657
A  Acari from lower animals, 657
Acarus folliculorum, 120, 642
    hordei, 647
    scabiei, 633
Achorion Schonleinii, 599
Acid mixture, Startin's, 114
Acne, 319
    artificialis, 319
    atrophica, 320
    cachecticorum, 320
    diagnosis, 323
    etiology, 322
    hvpertrophica, 320
    iiidurata, 320
    papulosa, 321
    pathology, 323
    punctata, 321
    pustulosa, 321
    rosacea, 329 _
         diagnosis, 331
         etiology,  330
         pathology, 330
         prognosis, 333
         symptoms, 329
         treatment, 331
     sebacea, 107
         symptoms, 319
         treatment, 323
     varioliformis, 321
     vulgaris, 321
 Aconite eruption, 179
 Acrochordon, 454
 Actinomycosis, 561
 Acute purulent oedema, 2Uo
 Addison's disease, 362
     keloid, 409
 Adenoma, 461
 Adenome sudoripare, 567
 Ainhum, 495
 Albinismus, 423
     symptoms, 423
 Albinoes, 423
 Aleppo evil, 202
 Alkaline baths, 80
     spirit of soap, 80
  Alopecia, 429 _
     areata, 435
          diagnosis, 437
Alopecia areata, etiology, 436
        pathology, 437
        prognosis, 439
        symptoms, 435
        treatment, 437
    congenital, 429
    furfuracea, 433
        diagnosis, 434
        etiology, 434
        pathology, 434
        treatment, 434
    neurotica, 440
    pityrodes capillitii, 433
    premature, 430
    presenile, 430
    senile, 430
         pathology, 431
         treatment, 431
 Alphos, 221
 Alveolar sarcoma, 577
 American Dermatological  Association,
|   classification of, 93
I Anaesthesia,  591
 Anatomical tubercle, 386
 Anatomy of the skin, 17
 Anderson's dusting powder, 158
 Anginose scarlet fever,  136
 Angioma, 464
     cavernosum, 467
     diagnosis, 466
     etiology, 468
     pigmentosum etatrophicum, 4bb
     pathology, 466
     treatment, 466,  468
 Angiomyoma, 463
 Anidrosis, 101
     treatment, 102
 Aniline rash, 173
 Animal parasites, 631
 Anthem ata, 57
 Anthrax, 198, 206
      diagnosis, 200
      etiology, 199
      pathology, 199
      prognosis, 201
      symptoms, 198
      treatment, 201
  Antipyrine eruption, 179
  Apes inelliferse, 65!) 
664
INDEX.
Argyria, 363
Armenian bole, 82
Arnica rash, 173
Arrectores pilorum, 32
Arsenic, 74
Arsenical eruption, 179
    habit, 231
Arteries, 27
Arthritic diathesis, 65
Asiatic pills, 75
Asphyxia of the extremities, 188
Asteatosis, 128
    symptoms, 128
    treatment, 129
Asthma and eczema, 262
Atheroma, 126
Atrophia cutis, 444
    maculosa et striata, 445
    pilorum propria, 440
    senilis, 444
    unguis, 443
Atrophy of hair, 429
    of hair of head, undescribed
      of, 440
    of nail, 443
    of skin, 444
Atropia eruption, 180
Auspitz's classification, 91
   BALDNESS, 429
     Barbadoes leg, 412
Baths, 79
Belladonna eruption, 180
     rash of, 139
Benzoate of sodium rash, 185
Benzoinated lard, 285
     sebum, 285
Biskra bouton, 202
Boils, 195
Borax eruption, 185
Boric acid  eruption, 180
Black-head, 119
Black herpes, 213
     measles, 143
Blanching  atrophy of skin, 446
Blebs,  53
Bleeding stigmata, 593
Bloody sweat, 106
"Bromidia" rash, 187
Bromidrosis, 102
     symptoms, 102
     treatment, 103
Bromine eruption,  180
Bronson's classification, 91 (note)
Bucnemia Tropica, 412
Bug, bed, 657
     harvest, 645
Bugs, 657
Bulb of the hair, 37
Bulkley's liquor picis alkalinus, 286
Bullae, 53
    haemorrhagicae, 354
Burmese ringworm, 611
Burns, 176
    treatment, 176
 rtACHEXIE pachydermique, 595
 \j  Cacotrophia folliculorum, 367
 Cadaveric  infection,  pustules  from,
   201
 Callositas, 374
 Callositas of hands with unusual com-
   plication, 375
 Calorimeter, 90
 Calotte, 602
 Calvities, 429
 Calx sulphurata, 77
 Cancer, 561
 Cancer en cuirasse, 573
     films, 573
     globes, 567
     hard, 573
     lenticular, 573
     melanotic, 574
 Cancer-" nests," 567
 Cancer of connective tissue, 573
     of extremities, 566
     of genital organs,  565
     of head, 564
     of lip, 565
     pigmented, 574
     scirrhous, 573
 Cancroid, 447
 Canities, 427
     etiology, 428
     pathology, 428
     symptoms, 427
     treatment, 428
 Cannabis Indica eruption, 181
 Carbolic acid, 77
 Carbuncle, 198
 Carcinoma, 561
     diagnosis, 569
     etiology, 566
     melanotic, 574
     pathology, 567
     pigmented, 574
    prognosis, 572
    treatment, 570
Carron oil, 158
Causes of diseases of the skin, 60
Caustics, 87
Cement-substance, 25
Chafed skin,  156
Chagres fever, 362
Chancre, 498
Chancrelle, 544
Chancre, simple, 544
    soft, 544
    vaccination, 151 
INDEX.
665
Chancroid, 544
Charbon, 198, 206
Cheiro-pompholyx, 105
Cheloid, 447
Chicken-pox, 146
Chilblains, 177
Chloasma, 361
    pathology, 364
    symptoms, 361
    treatment, 364
Chloasma uterinum, 361
Chloral-camphor, 87
Chloral eruption, 181
Chromidrosis, 103
Chronic erysipelas, 190
Chrysarobin, 77
Cicatrices, 56
Cicatrix, 449
    diagnosis, 451
    etiology, 451
    pathology, 451
    treatment, 451
Cimex lectularius, 657
Cimicidae, 657
Cinchona eruption, 184
Claret-stain, 465
Classification, 90
Clavus, 378
Cod-liver oil, 76
    eruption, 181
Coil-glands, 40
Collodion, 84
Coluinnae adiposae, 21
Columns, fat, 43
Comedo, 118
    diagnosis, 121
    double, 119
    etiology, 119
    extractor 89
    pathology, 120
    symptoms, 118
    treatment, 122
Condyloma, 3*1, 511
Confluent variola, 143
Congelatio, 177
Congenital syphilis, 521
Consecutive lesions, 53
Copaiba eruption, 182
Copper-nose, 417
Corium, 21
Corn, 378
Corn-salves,  379
Cornu cutaneum, 379
Corpuscles, Meissner,  31
    Pacinian, 30
    tactile, 31
    Vater, 30
    Wagner, 31
Cortex of hair,  38
Cosine's paste, 570
Cosmoline, 81
Cow-pox, 149
Crab-louse, 655
Crusta lactea,  109
Crustse, 54
Crusts, 54
Cubebs eruption, 182
Culex pipiens, 658, 659
Cundurango eruption, 182
Cuniculus,  632
Curettes, dermal, 88
Cutaneous hemorrhages, 353
    pruritus, 581
    punch, 90
Cuticle, 24
Cutisector,  89
Cutis testacea, 110
Cylindroma, 567
Cyst, 124
Cysticercus cellulosae, 644
UANDRUFF, 107
I'  Dartric myoma, 463
Dartrous diathesis, 65
Deep epithelioma, 563
Defluvium capillorum, 429
Delhi boil, 202
Demodex folliculorum, 642
Depilatories, 403
Derma, 21
Dermal curettes, 88
Dermanyssus avium, 657
Dermatalgia, 590
Dermatitis, 171
    calorica, 175
    exfoliativa, 240
        diagnosis, 242
        etiology, 242
        pathology, 242
        prognosis, 242
        treatment, 242
    exfoliativa infantum, 242
    gangraenosa, 188
    herpetiformis, 218
        symptoms, 219
    Kaposi, 466
    medicamentosa, 178
    multiformis, 218
    papillaris capillitii, 338
    traumatica, 172
    venenata, 172
Dermatological instruments, 89
Dermatomycosis furfuracea, 625
Dextrine pastes, 82
Diabetes and eczema, 304
Diab'etides g'enitales, 304
Diagnosis, general, 66
Diet, in diseases of the skin, effects of,
  63
Digitalis eruption, 182
Ditriti mortui, 593 
666
INDEX.
Dipterous larvae, 647
Diseases of connective tissue, 404
    epidermal and papillary layers, 3
    pigment, 422
    sebaceous glands,-107
    the skin, 95
Dissection tubercle, 386
Distoma hepaticum, 645
Donda Ndugu, 421
Donovan's solution, 75
"Driving in" cutaneous diseases, 78
"Driving out" cutaneous diseases, 78
Dyes, 429
''Dying" of feet and hands, 593
Dysidrosis, 105
  ECCHYMOMATA, 354
    Ecchymoses, 50, 354
Echinococcus, 645
Ecphyma mollusciforme, 454
Ecthyma, 345
    diagnosis, 346
    etiology, 346
    pathology, 346
    symptoms, 345
    treatment, 347
Eczema,  252
    acute, 260
    and asthma, 262
    chronic, 260
    diagnosis, 266
    erythematosum, 253
    etiology, 261
    fissum, 259
    intertrigo, 259
    lichenodes, 254
    local varieties, 291
    madidans, 258
    marginatum, 605
    of anus, 305
    of beard, 300
    of breast,  307
    of ears, 298
    of extremities, 308
    of face, 294
    of genitals, 302
    of hands and feet, 310
    of lids, 299
    of lips, 296
    of nails, 313
    of nipple, 307
    of nostrils, 297
    of scalp, 291
    of tropics, 314
    of umbilicus, 308
    papulosum, 254
    pathology, 264
    prognosis, 290
    pustulosum, 257
    rhagadiforme, 259
Eczema rubrum, 258
    sclerosum, 259
    solare, 314
    squamosum, 25!)
    symptoms, 252
    treatment, 273
    tuberculatum, 578
    verrucosum, 259
    vesiculosum, 256
Electrolysis in removal of hairs, 401
Elementary lesions, 49
Elephantiasis, 412
    Arabum, 412
    diagnosis, 415
    etiology, 414
    Graecorum, 549
    lymphangiectatica, 471
    pathology, 414
    prognosis, 416
    symptoms, 412
    treatment, 416
Elephant leg, 412
Ephelis, 360
Ephidrosis, 95
Epidermis, 24
Epilating forceps, 88
Epilation, 602
Epithelial cancer, 562
Epithelioma, 562
Erectores pilorum, 32
Ergot, 77
Erysipelas, 188
    ambulans, 189
    chronic, 190
    diagnosis, 192
    etiology, 191
    pathology, 192
    prognosis, 194
    symptoms, 188
    treatment, 193
Erythanthema syphiliticum, 521
Erythanthemata, 57
Erythema annularis, 159
    bullosum, 160
    caloricum, 154
    diphtheriticum, 160
    figuratum, 159
    gangraenosum, 154
    idiopathic, 153
    intertrigo, 156
        diagnosis, 157
        etiology, 156
        symptoms, 156
        treatment, 157
    iris, 159
    marginatum, 159
    multiforme, 159
        diagnosis, 162
        etiology, 161
        pathology, 161
        prognosis, 162 
INDEX.
667
Erythema multiforme, symptoms, 159
        treatment, 162
    nodosum, 159
    pa pu latum, 160
    papulosum, 160
    simplex, 153
        diagnosis, 155
        treatment, 155
    symptomatic, 154
    traumaticum, 153
    tuberculatum, 160
    tuberculosum, 160
    urticatum, 160
    variolosum, 140
    venenatum, 154
    vesiculosum, 160
 Erythematous syphilide, 504
 Erytheme centrifuge, 473
 Erythrasma, 629
    diagnosis, 631
    etiology, 630
    pathology, 630
    symptoms, 629
    treatment, 631
 Etiology, general, 60
 Exanthemata, 129
 Excoriations, 65
 Exfoliative dermatitis, 240
 Expansions and fissures of hairs, 442
 External treatment, 79
  FAT canals, 43
      columns, 43
Fat, subcutaneous, 20
Fats and oils, 81
Favus, 597
    squamosus, 598  .
Feigned disease of the skin, 154
Fetid sweat, 102
Fibroma, 452
    diagnosis, 455
    etiology, 454
    pathology, 454
    prognosis, 456
    symptoms, 452
    treatment, 456
Fibromyoma, 463
Fibrosarcoma, 577
Fibrous cancer, 573
Filaria medinensis, 643
    sanguinis, 643
Fish-skin disease, 390
Fissures, 55
Flea, 659
Follicle, hair, 35
Follicular vulvitis, 30.)
Forceps, epilating, 89
    grappling, 89
Fowler's solution, 75
Frambcesia, 419
Frambcesioid condylomatous  syphilo-
  derm, 510
Freckles, 154, 360
French measles, 133
Friction, effects of, 62
Frost-itch,  588
Fungous foot of India, 495
Furfuraceous desquamation, 54
Furunculosis, 195
Furunculus, 195
    diagnosis, 197
    etiology, 195
    pathology,  196
    prognosis, 198
    symptoms,  195
    treatment,  197
n AD-FLY, 647
U  Galactidrosis, 106
Galactorrhcea, producing intertrigo, 157
Gangrenefoudroyante, 205
Gangrenous dermatitis, 187
General diagnosis, 66
    etiology,  60
    prognosis, 71
    symptomatology, 48
    therapeutics, 73
German measles, 133
" Giant wheals," 51,164
Glands, coil,  40
    sebaceous, 39
    sudoriparous, 40
    sweat, diseases of, 95
Glossy fingers, 407, 446, 593
Glycerine, 81
Glycerolates, 81
    Squire's, 289
Glycerole of  lead, 81
Glyceroles, 81
Granular  layer, 26
Granuloma fungoides, 578
    sarcomatodes, 578
Green soap, spirit of, 80
Grutum, 124
Guinea worm, 643
Gum pastes,  82
Gutta rosea, 329, 417
  H.EMATIDROSIS, 106
    Haemophilia, 357
Hair-dyes, 429
Hair-follicle, 35
Hairiness, 398
Hairs, 33
Hard cancer, 573
Harvest bug, 645
Head louse,  649
Hebra's classification, 91
    diachylon salve, 284 
668
INDEX.
 Hebra's oriental lotion, 328
     spiritus saponis alkalinus, 80
 "Hedgehog" skin, 391
 Heliotrope rash, 174
 Helmerich's ointment, 641
 Hemiatrophia facialis, 407
 Henle's layer, 36
 Hereditary syphilis, 521
 Heredity, 64
 Herpes, 208
     circinatus bullosus, 219
     facialis, 208
     gestationis, 212, 219, 349
     iris, 159, 211, 219
     labialis, 208
     phlyctenodes, 219
     praeputialis, 209
     progenitalis, 209
     symptoms, 208
     treatment, 210
     zoster, 212
         diagnosis, 217
         etiology, 215
         pathology, 215
         symptoms, 212
         treatment, 217
 Herpetic diathesis, 65
     diseases, 208
 Hide-bound skin, 406
 Hirsuties, 398
 Hives, 163
 Horn-pox, 142
 Horns, 379
 Horny layer, 27
 Hot baths, 79
 " Humor of the blood," 529
 Hutchinson's  teeth in inherited  syph-
  ilis, 525
 Huxley's layer, 32
 Hybrid measles, 133
 Hydroa, 219
 Hydrosis, 95
 Hyperaesthesiae, 581
 Hyperhidrosis, 95
 Hyperidrosis,  95
     etiology, 96
     pathology, 97
     prognosis, 98
     symptoms, 95
     treatment, 97
 Hypertrichosis, 398
     etiology, 400
     treatment, 401
Hypertrophies of muscular tissue, 462
Hypertrophy of the hair, 398
        vessels, 464
Hypohidrosis, 101
 Ichthyosis congenita, 392
     diagnosis, 394
     etiology, 392
     hystrix, 390
     nacrea, 391
     nigricans, 391
     pathology, 393
     prognosis, 395
     sebacea, 110
     serpentina, 391
     simplex, 390
     treatment, 394
 Idrosis, 95
 Impetigo, 340
     contagiosa, 342
         diagnosis, 344
         etiology, 343
         pathology, 343
         symptoms, 342
         treatment, 344
     diagnosis,  341
     etiology, 341
     figurata, 258
     herpetiformis, 344
         pathology, 341
         symptoms, 340
         treatment, 342
Infection, cadaveric, pustules from,
  201
Inflammations of the skin, 129
Inflammatory  fungoid neoplasm, 57§
Inherited syphilis, 521
Insects, wounds inflicted by, 202
Internal treatment, 74
Intertrigo, 156
Iodide of potassium rashes, 182
Iodine, 76
Iodine eruption, 182
Iodized phenol of  Bellamy, 289
Itch, 631
     lumbermen's,  589
     Malabar, 611
     Norwegian, 636
     prairie,  589
    swamp,  589
Itching of the anus, 583
     of the genitals, 583
    of the nose, 583
    of the skin, 581
Ixodes, 648
    Americanus, 648
    bovis, 648
    humanus, 648
    marginatus, 648
    ricinis, 648
    unipunctatus,  648
TCHTHYOL, 77, 85
1  Ichthyosis, 390
 TABORANDI, 77
u     eruption, 183
Jequirity, 86 
INDEX.
669
   KAOLIN, 82, 123
     Kaposi's sulphur paste, 327
Kelis, 447
Keloid, 447
    diagnosis, 44!l
    etiology, 448
    pathology, 448
    prognosis, 449
    symptoms, 447
    treatment, 449
Keratoses, 366
    diagnosis, 367
    etiology, 367
    pathology, 367
Keratosis pilaris, 366
    senilis, 368
    treatment, 368
Kerion Celsi, 617
Klamann's dusting powder, 158
Kriptoptes monunguiculosis,  645
[ ACQUEK-WARE rash, 174
-Li  Lanolin, 84
La perleche, 631
Large pustular scrofuloderm, 493
La Rosa, 560
Lead pastes, 82
Leiomyoma, 462
Lenses, 88
Lenticular cancer, 573
Lentigo, 360
    etiology, 360
    pathology, 361
    symptoms, 360
    treatment, 361
Leontiasis, 549
Lepra, 221, 549
    anaesthetica, 553
    Arabum, 549
    diagnosis, 558
    etiology, 554
    maculosa, 552
    pathology, 556
    prognosis, 559
    symptoms, 54!)
    treatment, 558
    tuberosa, 549
Leprosy, 549
    Lombardy, 560
Leptus, 645
    autumnalis, 645
Lesions, consecutive, 53
    elementary, 49
    names descriptive of, 57
Leucoderma, 422
    symptoms, 422
Leucoplakia buccalis, 224, 247
Lichen   annulatus serpiginosus,  240
      (note)
    eczematodes, 254
Lichen pilaris, 366
    planus, 246
        diagnosis, 249
        etiology, 248
        pathology, 248
        prognosis, 249
        symptoms, 246
        treatment, 249
    ruber, 250
        diagnosis, 251
        etiology, 251
        moniliformis, 247
        pathology, 251
        prognosis, 252
        symptoms, 250
        treatment, 251
    scrofulosorum, 491
    tropicus, 314
    urticatus, 164
Liodermia cum melanosi  et telangiec-
  tasia, 466
Liquor picis alkalinus, 286
Lithaemia, 65
Lithaemic diathesis, 65
Livedo, 155
Liver-spots,  361, 628
Lombardy leprosy, 560.
Lotions, 80
IiOuse, crab, 655
    of body,652
    of head, 649
    of pubes, 655
Lousiness, 649
Lumbermen's itch, 589
Lunula, 47
Lupus disseminatus, 480
    erythematodes, 473
    erythematosus, 473
        diagnosis, 476
        etiology, 475
        pathology, 476
        prognosis, 479
        symptoms, 473
        treatment, 477
    exedens, 479
    exfoliativus, 480
    hypertrophicus, 480
    of ears,  486
    of extremities, 487
    of face,  485
    of genital region, 486
    of mucous membrane, 487
    of trunk, 486
    sclerosus, 480
    sebaceus, 473
    serpiginosus, 480
    superficialis, 473
    tubercftlosus, 480
    vegetans, 480
    verrucosus, 480
    vorax, 479 
670
INDEX.
Lupus vulgaris, 479
        diagnosis, 484
        etiology, 481
        pathology, 482
        symptoms, 47!)
        treatment, 487
Lycopodium, 83
Lymphadenectasia, 471
Lymphadenie cutanee, 578
Lymphangiectasic fibromyoma, 463
Lymphangioma, 470
    tuberosum multiplex, 470
Lymphatic currents,  29
    sarcoma, 577
    vessels, 28
Lymph-scrotum, 417
Lyomyoma, 462
   MACUL.E, 49
     Madura foot, 495
Malabar itch, 611
Malignant anginose scarlatina, 136
Malignant pustule, 205
Mal perforant du pied, 375
Malum perforans pedis, 375
Mange, lower animals, 615
Marsden's paste, 570
Martin bandage, 310
Matrix of nail, 45
Measles, 130
    black, 143
Medicated soaps, 81
Medicinal rashes, 178
Medulla of hair, 38
Medullated nerves, 30
Melanoderma, 361
    cachecticorum, 362
Melano-sarcoma, 577
Melanosis lenticularis progressiva, 466
Melanotic carcinoma, 574
Mellitagra, 258
Mentagra, 334
Mercury, 75, 87
    eruption, 183
Microsporon  furfur, 626
    minutissimum, 629
Midges, 659
Miliary fever, 100
Milium, 124
    diagnosis, 126
    etiology, 125
    needle, 89
    pathology, 125
    symptoms, 124
    treatment, 126
Milk-crust, 109
Mineral springs, 78
Molluscous corpuscles, 371
Molluscum contagiosum,  369
    epitheliale, 369, 370
Molluscum epitheliale, diagnosis, 372
         etiology, 370
         pathology, 371
         prognosis, 374
         symptoms, 369
         treatment, 374
    verrucosum, 373
Morbilli, 130
    diagnosis, 132
Morbus cceruleus, 155
    maculosus Werlhofii, 356
Morphcea, 409
    diagnosis, 411
    etiology, 411
    pathology, 411
    prognosis, 412
    symptoms, 409
    treatment, 411
Mosquitoes, 659
Mother's marks, 466
Mucous layer, 25
    patch, 511
Mulberry marks, 466
Mulls, 83
Multiple cachectic gangrene, 188
    cutaneous tumor, accompanied  by
      pruritus, 385
Murrain, 205
Muscles, 32
Muslins, salve, 83
Mycetoma, 495
Mycosis frambeesioides, 4] 9
    fungoides, 578
        etiology, 57!)
        prognosis, 581
        pathology, 580
        treatment, 580
    microsporina, 625
Myoma, 462
    telangiectodes, 463
Myringomycosis, 629
Myxoedema, 595
    etiology, 596
    pathology, 596
    symptoms, 595
Myxo-sarcoma, 577
  N^EVOID elephantiasis, 417
    Naevus aranaeus, 465
Naevus flammeus, 465
    lipomatodes, 387
    mollusciformis, 387
    pigmentosus, 387
        pathology, 388
    pilosus, 387
    spilus, 387
    unius lateris, 388
    vasculosus, 464
    verrucosus, 387
    vinosus, 466 
INDEX.
671
Nail-fold, 46
Nails, 45
Naphthol, 86
Needle-holders, 88
Needles, irido-platinum, 89
    milium, 89
Nerves, 29
Nervous papillae,  24
Nettle-rash, 163
Neuroma, 456
Neuropathic plica, 400
Neuroses, 581
    trophic, 592
    vasomotor, 592
Neurotic excoriations, 593
New growths, 447
    of connective tissue, 447
Nodose swellings of shafts of hairs, 442
Non-medullated nerves, 29
Non-striated muscular fibres, 32
Norwegian itch, 636
ABJECTIVE  symptoms, 48
v'  Odors of the skin, 44
GUstrus bovis, 647
Ohio scratches, 589
Oils and fats, 81
Oleates, 84
Oleum rusci, 85
Onychauxis, 395
    pathology,  397
    prognosis, 397
    symptoms,  395
    treatment, 397
Onychia, syphilitic, 396
Onychomycosis, 396, 606
Opium eruption, 184
Oriental lotion, 328
Osmidrosis,  102
'' Overflow " of bladder producing inter-
  trigo,  157
PACHYDERMIA, 412
-L   lymphangiectatica, 471
Pacinian corpuscles, 30
Paget's disease of nipple, 307, 506
Palmar and plantar syphilides, 512
Panniculus adiposus, 20
Papilhe, 23
Papillary epithelioma, 563
Papilloma, 385
Papular scrofuloderm, the, 491
Papules, 50
Parangi, 421
Parasitic affections, 596
Paronychia, 395
Pars papillaris, 22
    reticularis, 22
Pastav's salve, 642
Pastes, 81
Pediculi from lower animals, 657
Pediculosis, 649
    capillitii, 649
    corporis, 652
    pubis, 655
    symptoms, 649
Peliosis rheumatica, 355
Pellagra, 560
Pemphigus, 219, 348
    acutus contagiosus adultorum, 342
    aigu prurigineux, 219
    benignus, 348
    circinatus, 219, 348
    compose, 219
    diagnosis, 351
    disseminatus, 348
    diutinus, 348
    etiology, 350
    haemorrhagicus, 348
    hystericus, 212
    -like dermatitis, 219
    malignus, 349
    pathology, 350
    prognosis, 353
    prurigineux, 219
    pruriginosus, 349
    solitarius, 348
    symptoms, 348
    treatment, 352
    vulgaris, 348
Perforating ulcer of foot, 375
            diagnosis, 377
            pathology, 377
            prognosis, 377
            symptoms, 376
            treatment, 377
Permanent removal of superfluous hair
  by electrolysis, 401
Pernio, 177
Petechia', 50, 354
Phenol-camphor, 87
Phenol, iodized (of  Bellamy), 289
Phlegmona diffusa, 204
Phosphorus, 77
    eruption, 184
Phtheiriasis, 649
Phymata, 52
Physiology of the skin,  17
Pian, 419
Piebald skin, 422
Piedra, 443
Pied skin, 422
Pied tabetique, 594
Piffard's  acne lotion, 123
Pigment, 32
Pigmentary moles, 387
    syphilide, 506
Pigment disorders, 360,  422
Pigmented carcinoma, 574
Pills, Asiatic, 75 
672
INDEX.
Pilocarpine, 77
    eruption, 183
Pitting in variola, prevention of, 148
Pityriasis capitis, 433
    maculata et circinata, 239
        diagnosis, 240
        etiology, 239
        pathology, 239
        symptoms, 239
    pilaris, 366
    rubra, 243
        diagnosis, 245
        pathology, 244
        symptoms, 243
        treatment, 245
        tabescentium, 110
        versicolor,  625
Pix liquida, 85
Plantar and palmar syphilodermata, 512
Plaque muqueuse, 511
Plaster-mulls, 84
Plasters, 83
Pleximeter, 90
Plica neuropathica, 400
Podelcoma, 495
Podophyllin eruption, 184
Poison ivy, 172
Poliosis, 427
    circumscripta acquisita, 424
Polonica,  400
Polyidrosis, 95
Polypapilloma tropica, 419
Pomphi, 50
"Porcupine" skin,  121, 391
Pores, sweat, 42
Porrigo larvalis, 258
Port-wine mark, 465
Post mortem tubercle, 386
Potash soaps, 80
Powders, 83
Prairie itch, 589
Precautions in treating favus and ring-
  worm, 624
Prickle-cells, 25
Prickle layer, 25
Prickly heat, 61, 99, 314
Prognosis, general, 71
Prurigo, 316
    agria, 316
    der many ssique, 657
    diagnosis, 318
    etiology, 316
    ferox, 316
    hyemalis, 588
    mitis, 316
    pathology, 317
    symptoms, 316
    treatment, 318
    winter, 588
Pruritus, 581
    ani, 583
Pruritus, diagnosis, 584
    etiology, 583
    genitalium, 583
    hiemalis, 588
    narium, 583
    pathology, 584
    prognosis, 588
    senilis, 583
    symptoms, 581
    treatment,  585
Psora, 221
Psoriasis, 221
    buccalis, 247
    circinata, 221
    diagnosis, 227
    diffuse, 221
    etiology, 224
    figurata,  221
    guttata, 221
    gyrata, 221
    lingual, 224
    nummularis, 221
    orbicularis, 221
    pathology, 225
    prognosis, 238
    punctata, 221
    symptoms, 221
    treatment,  230
Ptomaines, 202
Pulex irritans,  659
    penetrans,  643
Punch, cutaneous, 90
Purpura, 354
    haemorrhagica, 356
    pathology, 358
    pulicosa, 357
    rheumatica, 355
    scorbutica, 357
    simplex, 354
    treatment,  359
    urticans, 355
    urticata, 164
Pustulae, 52
Pustula maligna, 205
        etiology, 206
        pathology, 206
Pustules, 52
    from cadaveric infection, 201
jULNINE, 76
,  eruption,  184
  RASHES, medicinal, 178
    Raspberry sore, 152
Ray-fungus, 561
Raynaud's disease, 188
Repercussion of exanthemata, 133
Reptiles and insects, wounds inflicted
  by, 202 
INDEX.
673
Resorcin, 86
Rete Malpighii, 25
    mucosum, 25
Rhagades, 55
Rhinocoprion penetrans, 643
Rhinophyma, 330
" Rhinosceros " skin, 391
Rhinoscleroma, 471
    diagnosis, 473
    etiology, 472
    pathology, 472
    prognosis, 478
    symptoms, 471
    treatment,  473
Rhus toxicodendron, 172
Ringworm, Burmese, 611
    of beard, 618
    of body, 604
    of scalp, 611
Risipola  Lombarda, 560
Rodent ulcer, 562
Root of  the hair, 37
Root-sheaths of the hair, 35
Rosacea, 329, 417, 465
    diagnosis, 419
    etiology, 418
    pathology, 418
    prognosis, 419
    symptoms, 417
    treatment, 419
Rosacea  erythematosa, 417
    hypertrophica, 418
Roseola, 154
    vaccinia, 152
    variolous, 140
Rotheln, 133
Rubella, 133
Rubeola, 130
Rumex salve, 327
Rupia, 516
  SALICYLIC acid eruption, 185
    "Salt rheum," 529
Salve muslins, 83
Sand flea, 643
Santonine eruption, 185
Sarcoma, 575
    alveolar, 577
    etiology, 576
    melanotic, 577
    pathology, 576
    symptoms, 575
    treatment, 577
Sarcopsylla Westwood, 643
Sarcoptes, 637
Sarg's fluid soap, 81
Saftian disease, the, 497
Scabies, 631
    diagnosis, 638
    etiology, 637
Scabies, Norwegian, 636
    pathology, 687
    prognosis, 642
    symptoms, 631
    treatment, 640
Scales, 53
Scarf-skin, 24
Scarlatina, 134
Scarlatiniform typhus, 137
Scarlet fever, 134
    rash, 134
Scars, 56
    vaccine, 150
Schultze's  modification   of  Pastav's
  formula, 642
Scirrhous cancer, 573
Sclerema, 405
Sclereme en placards, 405
Sclerema neonatorum, 404
    diagnosis, 405
    etiology, 404
    pathology, 404
    symptoms, 404
    treatment, 405
Scleriasis, 405
Sclerodactylia, 407
Scleroderma, 405
    diagnosis, 408
    etiology, 407
    pathology, 408
    prognosis, 409
    symptoms, 406
    treatment, 409
Scorbutus, 489
Scrofula, 489
Scrofulide tuberculev.se, 479
Scrofuloderm, large pustular, 493
    papular, 491
    small pustular, 492
Scrofuloderma, 489
    diagnosis, 493
    etiology, 493
    symptoms, 489
    treatment, 493
" Scrofulous ringworm," 473
    ulcers, 529
Scurvy, 357
Scutulum of favus, 598
Sebaceous cyst, 124
     glands, 39
        diseases of, 107
    secretion, 40
Seborrhcea, 107
    capillitii, 108
    congestiva, 113
    diagnosis, 112
    etiology, 111
    faciei, 109
    generalis, 110
    genitalium, 110
    oleosa, 111 
674
INDEX.
Seborrhoea, pathology, 112
     prognosis of, 118
     sicca, 108
     symptoms, 107
     treatment, 114
     trunci, 109
Septum lucidum, 26
Shaft of the hair, 37
Shingles, 212
Simulia, 659
Sirop de  Gibert, 541
Skin-grafting scissors, 89
Skin-worms, 119
Smallpox, 139
Small pustular scrofuloderm, 492
Smoker's patches, 224
Soaps, 80
     medicated, 81
Soda soaps, 80
Sodium benzoate eruption, 185
     biborate eruption, 185
Soft chancre, 544
Spender's formula, 85
" Spider-cancer," 465
Spiritus  saponis alkalinus (Hebra), 80,
  234  .
Splenic apoplexy, 206
     carbuncle, 206
     fever, 206
Spoons, dermal, 90
Spots, 49
Springs,  mineral, 78
Spud, 89
Squamae, 53
Stains, 49
Starch, 83
Startin's acid mixture, 114, 324
Steatoma, 126
    diagnosis, 127
    pathology, 127
    prognosis, 128
    symptoms, 126
    treatment, 127
Steatorrhoea, 107
Steatozoon folliculorum, 642
Stigmata, bleeding, 593
Stinking-sweat, 102
" Strait jacket," in eczema, 295
Stramonium eruption, 185
Stratum  corneum, 27
    granulosum, 26
    lucidum, 26
    mucosum, 25
Strawberry appearance of the tongue,
  135
Strawberry marks, 466
Striated muscular fibres, 32
Struma, 489
Strychnia eruption, 185
Subcutaneous tissue, 19
Subjective symptoms,  48
Sudamen, 99
     diagnosis, 100
     etiology, 100
     pathology, 100
     treatment, 100
     symptoms, 99
Sudatoria,  95
Sudden blanching of hairs, 427
Sudoriparous glands, 40
6'uette miliaire, 100
Sulphur, 86
     baths,  80
     hypochloride, 117
Sun-burn, 362
Superficial epithelioma, 562
Surgical appliances, 88
Swamp-itch, 589
Sweat, bloody, 106
     glands, 40
        diseases of, 95
Sweating, excessive,  99
Sweat-pore, 42
    stinking, 102
Swine-pox, 142
Sycosis, 334
    diagnosis, 336
    etiology, 335
    pathology, 336
    prognosis, 338
    symptoms, 334
    treatment, 337
Symmetrical dry gangrene, 188
Symmetry in eruptions, 68
Symptoms,  objective, 48
    subjective, 48
Synanthemata, 57
Synovial lesions of the skin, 496
Syphilis following vaccination, 151
Syphilitic treatment, "tonic," 534
Syphilitic roseola, 504
Syphiloderma, 497
    bullosum, 517
    diagnosis, 528
     etiology, 525
    gummatosum, 519
    hereditarium, 521
     infantile, 521
     maculosum, 504
     papulosum, 507
        large acuminate, 509
        large flat, 510
        small acuminate, 507
        small flat, 509
     pathology, 526
     prognosis, 543
    pustulosum, 514
        large acuminate, 515
        large flat, 516
        small acuminate,  514
        small flat, 515
    treatment, 530 
INDEX.
675
Syphiloderma tuberculosum, 517
    serpiginosum, 517
    vesiculosum, 513
Syphilodermata, 500
    general characteristics, 500
Tache cerebrate, 187
Tactile corpuscles, 31
Tan, 154, 360
Tanacetum eruption, 186
Tansy rash, 186
Tar, 77, 84
Tar-acne, 235
Tar eruption, 186
Tattooing, 49, 363
Telangiectasis, 465
Terms describing lesions of the skin, 57
Terra alba. 82
"Tetter," 529
Therapeutics, general, 73
Tinea circinata, 604
        diagnosis, 608
        etiology, 606
        pathology, 607
        prognosis, 611
        symptoms, 604
        treatment, 609
    favosa, 597
        diagnosis, 601
        etiology, 599
        pathology, 599
        prognosis, 603
        symptoms, 597
        treatment, 601
    imbricata,  611
    kerion, 617
    sycosis, 618
        diagnosis, 621
        etiology, 620
        pathology, 620
        prognosis, 624
        symptoms, 618
        treatment, 622
    tonsurans,  611
        diagnosis, 615
        etiology, 613
        pathology, 613
        prognosis, 617
        symptoms, 611
        treatment, 615
    trichophytina, 603
        cruris, 605
        unguium, 606
    versicolor, 625
        diagnosis, 527
        etiology, 626
        pathology, 626
        prognosis, 629
        symptoms, 625
        treatment, 628
Tipulidae, 659
Tokelau ringworm, 611
" Tonic treatment of syphilis," 534
Toxicants, 62
Traumaticine, 84
Traumatism, 62
Treatment, external, 79
    internal, 74
Trichophyton, 606
Trichorexis nodosa, 441
Trophic neuroses, 592
Tubercles, 51
Tubercula, 51
Tubercular epithelioma, 563
Tuberculosis of the skin, 494
Tuberose carcinoma, 573
Tumor cavernosus, 467
Tumores, 52
Tumors, 52
Turpentine eruption, 186
Tyloma, 374
Tylosis, 374
[TLCERS, 56
U  Unguentum Rochardi, 328
Uridrosis, 105
Urticae, 50
Urticaria, 163
    diagnosis, 167
    etiology, 165
    pathology, 166
    pigmentosa, 164
    prognosis, 171
    symptoms, 163
    treatment, 168
    tuberosa, 165
yACCINATION, 149
 »    chancre, 151
    syphilis, 151
Vaccine rashes, 152
Vaccinia, 149
Vaccinola, 152
Varicella, 146
    diagnosis, 147
Variola, 139
    diagnosis, 145
    etiology, 144
    hsemorrhagic, 143
    prognosis, 146
    treatment, 147
Varioliform acne, 370
Varioloid, 142
Variolous erythema, 140
    roseola, 140
Varix lymphaticus, 417
Vascular papillae, 24
Vaseline,  81
Vaso-motor neuroses, 592 
676                             i

Vegetable parasites, 597
Veins, 27
Vergetures, 446
Verruca, 381
    acquisita, 381
    acuminata, 381
    congenita, 381
    etiology, 382
    filiformis, 381
    glabra, 382
    necrogenica, 386
    pathology, 382
    plana, 382
    prognosis. 385
    senilis, 382
    treatment, 384
    vulgaris, 382
Vesicles, 52
Vesiculse, 52
Vespidae, 659
Vibices,  50, 354
Vitiligo, 424
    diagnosis, 426
    etiology, 426
    pathology, 426
    prognosis,  427
    symptoms, 424
    treatment, 426
Vitiligoidea, 458
Vleminckx's solution, 80;  note, 328
   WART-CURES, 384
     Warts, 381
Water, 79
Wen, 126
Wheals, 50
NDEX.

    White's  "strait-jackets" for  eczema-
      tous infants, 295
    Wilkinson's salve, 235
    Wilson's arsenical solution, 114
    Winter prurigo, 588
    Wool-fat, 84

    VANTHELASMA, 458
    A.   Xanthoma multiplex, 459
    Xanthoma planum, 458
        diagnosis, 461
        etiology, 459
        pathology, 460
        prognosis, 461
        symptoms, 458
        treatment, 461
        tuberosum, 459
    Xeroderma, 388
        pigmentosum, 466
    Xerosis, 388
        symptoms, 389

    V A WS, 419
7ONA, 212
/J  Zoster, 212
Zoster abdominalis, 215
    brachialis, 214
    capillitii,  214
    collaris, 214
    facialis, 214
    'femoralis, 215
    frontalis,  214
    nuchse, 214
    ophthalmicus, 214
    pectoralis, 215 
           LEA  BROTHEKS   <fc  CO.'S
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Lea Brothers & Co.'s Publications—Period.,  Manuals.        3
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THE MEDICAL NEWS  VISITING  LIST FOB 1888
Has  been revised  and  brought  thoroughly up to date in  every respect.   It con-
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a small special lot of same Ledger, with 300 pages.  Price, $4.00.
HARTSHORNB, HENRY, A. M., M. D., LL. D.,
      Lately Professor of Hygiene in the University of Pennsylvania.
    A Conspectus of the Medical Sciences; Containing Handbooks on Anatomy,
Physiology, Chemistry, Materia Medica,  Practice  of Medicine, Surgery and Obstetrics.
Second edition,  thoroughly revised  and greatly improved.  In one  large  royal 12mo.
volume of 1028 pages, with 477 illustrations.   Cloth, $4.25;  leather, $5.00.
 The object of this manual is to afford a conven-
ient work of reference to students during the brief
moments at their command while in  attendance
upon medical lectures.  It is a favorable sign that
it has  been found necessary, in a short space of
time, to issue a new and carefully revised edition.
The illustrations are very numerous and unusu-
ally clear, and each part seems to have received
its due share of attention.  We can conceive such
a work to be  useful, not only to students, but to
practitioners as  well.  It reflects credit upon the
industry and energy  of its able editor.—Boston
Medical and Surgical Journal, Sept. 3,1874.
  We can say with the strictest truth that it is the
best work  of the kind with  which we are ac-
quainted.  It embodies in a condensed form all
recent contributions to practical medicine, and is
therefore useful to every ousy practitioner through-
out our country, besides being admirably adapted
to the use of students  of medicine.  The book is
faithfully and ably executed.—Charleston Medical
Journal, April, 1875.
NEILL, JOHN, M. D.,  and SMITH,  E. G., M. D.,
   Late Surgeon to the Penna. Hospital.          Prof, of the Institutes of Med. in the Univ. of Perma.
    An  Analytical  Compendium of  the  Various Branches of Medical
Science for the use and examination of Students.   A new edition, revised and improved.
In one large royal 12mo. volume of 974 pages, with 374 woodcuts.  Cloth, $4; leather, $4.75.

LUDLOW,  J. L., M. D.,
       Consulting Physician to the Philadelphia Hospital, etc.
    A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of
Medicine Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics.  To which
is added a Medical Formulary.  3d edition, thoroughly revised, and greatly enlarged.  In
one 12mo. volume of 816 pages, with 370 illustrations.  Cloth, $3.25; leather, $3.75.
    The arrangement of this volume in the form of question and answer renders it espe-
cially suitable for the office examination of students, and for those preparing for graduation. 
4           Lea Brothers & Co.'s PrjuiauATiows—uictionanen.
DUNGLISON, ROBLEY, JI. D.f
       Late Professor of Institutes of Medicine m the Jefferson Medical College of Philadelphia.
     MEDICAL  LEXICON;  A Dictionary of Medical Science: Containing
a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol-
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris-
prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Officinal,
Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms,
and the French and other Synonymes,  so as to constitute a French as well as an  English
Medical Lexicon.  Edited by Richard  J.  Dunglison, M.D.  In one  very large and
handsome royal octavo volume oi 1139 pages.  Cloth, $6.50; leather, raised bands, $7.50;
very handsome half Russia, raised bands, $8.
    The object of the author, from  the outset, has not been to make the work a mere lexi-
con or dictionary of terms, but to afford  under each word a condensed view of its various
medical relations, and  thus to render the  work an epitome of the_ existing condition of
medical science.  Starting with this view, the immense demand which has existed for tbe
work has enabled him, in repeated revisions, to augment its completeness and usefulness,
until  at length it has attained the position of a recognized  and standard authority wherever
the language is spoken.  Special pains have been taken in the preparation of the present
edition to maintain this enviable reputation.   The additions to the vocabulary are more
numerous than in any previous revision, and particular attention has been bestowed on the
accentuation, which will be found marked on every word.  The typographical arrangement
has been greatly improved, rendering reference much more easy, and every care has been
taken with the mechanical execution.   The volume now contains the matter of  at least
four ordinary octavos.
  About tne first book purchased by the medical
student is the Medical Dictionary.  The lexicon
explanatory of technical terms is simply a sine qua
non.  In a science so extensive and with such  col-
laterals as medicine, it is as much a necessity also
to the practising physician. To meet the wants of
students and most physicians the dictionary must
be condensed while comprehensive, and practical
while perspicacious. It was because Dunglison's
met these indications that it became at once  the
dictionary of ssneral use wherever medicine  was
studied in the English language.  In  no former
revision have  the alterations and additions been
so great.  The chief terms have been set in black
letter, while the derivatives follow in small caps;
an arrangement which greatly facilitates reference.
—Cincinnati Lancet ana Clinic, Jan. 10, 1874.
  A book  of which every American ought to be
proud.  When the learned author of the work
passed away, probably all of us feared lest the book
should not maintain its place  in the advancing
science whose terms it defines.  Fortunately, Dr.
Richard J. Dunglison, having assisted his father in
the revision of several editions of the work, and
having been, therefore, trained in the methods
and imbued with the spirit of the book, has been
able to edit it as a work of the kind should be
edited—to carry it on steadily, without jar or inter-
ruption, along the grooves of thought it has trav-
elled during its lifetime.  To show the magnitude
of the task which Dr. Dunglison has assumed and
carried through, it is only necessary to state that
more than  six thousand new subjects have been
added iD the present edition.—Philadelphia Medical
Times, Jan. 3, 1874.
  It has the rare merit that it certainly has no rival
in the English language for accuracy and extent of
references.—London Medical Gazette.
HOBLYN, RICHARD D., M. D.
     A Dictionary  of the Terms Used in  Medicine and the Collateral
Sciences.   Revised, with numerous additions, by Isaac Hays, M. D., late  editor of
The American Journal of the Medical Sciences.  In one large royal 12mo. volume of 520
double-columned pages.  Cloth, $1.50; leather, $2.00.
  It is the best book of definitions we have, and ought always to be upon the student's table—Southern
Medical and Surgical Journal.

STUDENTS9  SERIES OF MANUALS.
     A Series of Fifteen Manuals, for the use  of Students and  Practitioners of Medicine
and  Surgery,  written by eminent Teachers  or Examiners, and issued in  pocket-size
12mo. volumes of 300-540 pages, richly illustrated and at a low price.  The following vol-
umes  are now ready:  Treves' Manual of Surgery, by various writers, in three  volumes,
each, $2;  Bell's  Comparative  Physiology and Anatomy, $2;  Gould's Surgical Diagno-
sis, $2; Robertson's  [Physiological  Physics, $2;  Bruce's Materia Medica and Therapeu-
tics (4th edition), $1.50; Power's Human Physiology  (2d edition), $1.50;  Clarke and
Lockwood's  Dissectors'  Manual,  $1.50;  Ralfe's  Clinical  Chemistry, $1.50;  Treves'
Surgical Applied Anatomy, $2; Pepper's Surgical Pathology, $2; and Klein's Elements of
Histology  (3d edition), $1.50.  The following are in  press: Bellamy's Operative Surgery,
Pepper's Forensic Medicine, and  Curnow's  Medical  Applied Anatomy.   For  separate
notices see index on last page.

SERIES  OF  CLINICAL MANUALS.
    In arranging for this Series it has been the design  of the publishers to provide the
profession with a collection of authoritative monographs on important  clinical subjects
in a cheap and portable form.  The  volumes  will contain about 550 pages and will be
freely  illustrated by  chromo-lithographs and  woodcuts.  The following  volumes are
now  ready:  Carter  &  Frost's Ophthalmic Surgery,  $2.25; Hutchinson on   Syphilis,
$2.25; Ball on the Rectum and. Anus, $2.25; Marsh on the Joints, $2; Owen on Surgical
Diseases of Children, $2;  Morris on  Surgical Diseases of the Kidney, $2.25;  Pick  on
Fractures  and  Dislocations, $2;  Butlin on  the Tongue, $3.50;  Treves  on  Intestinal
Obstruction, $2: and Savage on Insanity and  Allied  Neuroses, $2.  The following are in
active  preparation:   Broadbent on the Pulse, and Lucas  on Diseases of the  Urethra.
For separate  notices see index on last page. 
lea -Brothers  & Co.'s  Publications—Anatomy.              5
GRAY,  HENRY, F. R. S.,
       Lecturer on Anatomy at St. George's Hospital, London.
    Anatomy, Descriptive and Surgical.  The Drawings by H. V. Carter, M. D.,
and Dr. Westmacott.  The dissections jointly by the Author and Dr. Carter.  With
an Introduction on General Anatomy and Development by T. Holmes, M. A., Surgeon to
St. George's Hospital.  Edited by T. Pickering Pick, F. R. C. S., Surgeon to and  Lecturer
on Anatomy at St. George's Hospital,  London, Examiner in Anatomy, Royal College of
Surgeons of England.  A new American from the eleventh enlarged and improved London
edition, thoroughly revised and  re-edited by  William W. Keen, M. D., Professor of
Anatomy in the Pennsylvania Academy of the Fine Arts, etc.   To which is added  the
second  American from the latest English edition of  Landmarks, Medical and Surgi-
cal,  by  Luther Holden, F. R. C. S.  In   one  imperial  octavo volume  of  1098
pages, with 685 large and elaborate  engravings on wood.   Price of edition in black:
Cloth, $6;  leather, $7;   half Russia, $7.50.   Price of edition in colors (see  below):
Cloth, $7.25; leather, $8.25; half Russia, $8.75.
    This work covers  a more extended range of subjects than is customary in the ordinary
text-books, giving not  only the details necessary for the student, but also the application to
those details to the practice of medicine and surgery.  It thus forms both a guide for the
Learner and an admirable work of  reference for the active practitioner.   The engravingB
form  a special feature in  the work, many of  them  being the  size of nature, nearly all
original, and  having  the  names of the various  parts printed  on the body of the cut, in
place of figures of reference with descriptions at the foot.   In this edition  a new departure
has been taken by the issue of the work with the arteries, veins and nerves distinguished
by different colors.  The engravings thus form a  complete and splendid series, which will
greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh
the memory of those  who may find in the exigencies of practice the necessity of recall-
ing the details of the dissecting-room.   Combining, as  it  does, a  complete  Atlas of
Anatomy with  a thorough treatise on  systematic,  descriptive  and applied Anatomy,
the work will be found of great service to all physicians who receive students in  their
offices, relieving both  preceptor and pupil of much labor in laying the groundwork of a
thorough medical education.
     For the convenience of those who prefer not  to pay the slight increase in cost necessi-
tated by the use of colors, the volume will be  published also in black alone, and main-
tained in this style at the  price of former editions, notwithstanding the largely increased
Bize of the  work.
     Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden,
has  been appended to the present edition as it was to the previous one.   This work gives
in a clear, condensed and systematic way all the information by which the practitioner can
determine from  the external surface  of the body  the  position of internal  parts.  Thus
complete, the  work, it is  believed, will furnish  all the assistance that  can be  rendered
by type and illustration in anatomical study.
 The most popular work on anatomy ever written.
It is sufficient to say of it that this edition, thanks
to its American editor, surpasses all other  edi-
tions.— Jour, of the Amer. Mcl Ass'n, Dec. 31,1887.
 A work which for more than twenty years has
had the lead of all other text-books on anatomy
throughout the civilized world comes  to hand in
such beauty of execution and accuracy of  text
and illustration as more than to make good the
large promise of the prospectus.  It would be in-
deed difficult to name a feature wherein the pres-
ent  American  edition of Gray could be mended
or bettered, and it needs no prophet to see that
the royal work is destined for many years to come
to  hold the first place among anatomical text-
books.  The work is published with black and
colored plates.  It is a marvel of book-making.—
American Practitioner and News, Jan. 21,1888.
 Gray's Anatomy is the most magnificent work
upon anatomy which has ever been published in
the English  or any other language.—Cincinnati
Medical News, Nov. 1887.
 As the book now goes to the purchaser he is re-
ceiving the best work on anatomy that is published
in any language.— Virginia Med. Monthly, Dec. 1887.
      Also for sale separate—

HOLDEN,  LUTHER,  F.  R. C. S.,
      Surgeon to St. Bartholomew's and the Foundling Hospitals, London.
    Landmarks, Medical and Surgical.  Second American from the latest revised
English edition, with additions by W. W. Keen, M. D, Professor of Artistic Anatomy in
the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila-
delphia School of Anatomy.  In one handsome 12mo. volume of 148 pages.  Cloth, $1.00.
                                            cians and surgeons is much to be encouraged.  It
                                            inevitably leads to a progressive education of both
                                            the eye and the touch, by which the recognition of
                                            disease or the localization of injuries is vastly as-
  This little book is all that can be desired within
its scope, and its contents will be found simply in-
valuable to the young surgeon or physician, since
they bring before him such data as he requires at
every examination of a patient.  It is written  in
language  so clear and concise that one ought
almost to learn it by heart.  It teaches diagnosis  by
external examination, ocular and palpable, of the
bodv with such anatomical and physiological facts
as directly bear on the subject.  It is eminently
the student's and young practitioner's book.—Phy
                                            sisted. One thoroughly familiar with the facts her*
                                            taught is capable of a degree of accuracy and a
                                            confidence  of certainty which is otherwise unat-
                                            tainable. We cordially recommend the Landmarks
                                            to  the attention  of every physician who has not
                                            yet provided himself with a copy of this useful,
                                            practical guide to the correct placing of all th«
u.'° Dt""~T6uraeon" Nov~l*881                     anatomical  parts and organs.—Canada Medical and
11 The study of these Landmarks by both physi-  Surgical Journal,  Dec. 1881. 
6             Lea Brothers & Co.'s  Publications—Anatomy.
ALLEN, HARRISON, M. D.,
      Professor oj Physiology in the University of Pennsylvania.
    A System  of Human Anatomy, Including Its Medical and Surgical
Relations.  For the use of Practitioners and Students of Medicine.  With an Intro-
ductory  Section on Histology.  By E.  O. Shakespeare,  M. D.,  Ophthalmologist to
the Philadelphia  Hospital.  Comprising 813 double-columned  quarto pages, with 380
illustrations on 109 full page lithographic plates,  many of which are in colors, and 241
engravings in the text.   In six Sections, each in a  portfolio.  Section 1. Histology.
Section II.  Bones and  Joints.   Section III.  Muscles  and Fascia.   Section  IV.
Arteries, Veins and Lymphatics.   Section  V.  Nervous System.   Section  VI.
Organs of Sense,  op  Digestion and  Genito-TJrinary  Organs, Embryology,
Development, Teratology,  Superficial Anatomy, Post-Mortem Examinations,
and General and  Clinical Indexes.  Price  per Section, $3.50; also bound in one
volume, cloth, $23.00;  very handsome half Russia, raised bands and open back, $25.00.
For sale by subscription only.  Apply to the  Publishers.
  It is to be considered a study of applied anatomy
In its widest sense—a systematic presentation  of
such anatomical facts as can be applied to the
practice of medicine as well as of surgery.  Our
aitfhor is concise, accurate and practical in his
statements, and succeeds admirably in infusing
an interest into the study of what is generally con-
sidered a dry subject. The department of Histol-
ogy is  treated in a masterly manner,  and the
ground is travelled over by one thoroughly famil-
iar with it.  The illustrations are made with great
care, and are simply superb.  There is as much
of practical application of anatomical  points to-
the every-day wants of the medical clinician as
to those of the operating surgeon.  In fact,  few
general practitioners will read the work without a
feeling of  surprised gratification  that so many
noints, concerning which they may never have
thought before are so well presented for their con-
sideration.  It is a work which is destined to be
the best of its  kind in  any  language.—Medical
Record, Nov. 25,1882.
CLARKE,W.B.,F.R.C.S. &  LOCKWOOD,C.B.,F.R.C.S.
       Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London.

    The Dissector's  Manual.  In one pocket-size 12mo. volume of 396 pages, with
49 illustrations.   Limp cloth, red edges, $1.50.  See Students' Series of Manuals, page 4.
  Messrs.Clarke and Lockwood have written a book
that can hardly be rivalled as a practical aid to the
dissector.  Their purpose,which is "how to de-
scribe the best way  to display the  anatomical
structure," has been fully attained.  They excel in
a lucidity of demonstration and graphic terseness
of expression, which only a long training and
intimate association  with  students could have
 fiven.  With such a guide as this, accompanied
 y so attractive a commentary as Treves' Surgical
Applied Anatomy (same series), no student could
fail to be deeply and absorbingly interested in the
study of anatomy.—New Orleans Medical and Sur-
gical Journal, April, 1884.
TREVES,  FREDERICK,  F. R. C. S.,
      Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital
    Surgical Applied  Anatomy.  In one  pocket-size 12mo. volume of 540 pages,
with  61 illubtrations. Limp cloth,  red edges, $2.00.  See Students' Series  of  Manuals,
page 4.
                                           quickened by daily use as a teacher and practi-
                                           tioner, has enabled our author to prepare a work
                                           which it would be a most difficult task to excel.—
                                           The American Practitioner, Feb. 1884.
  He has produced a work which will command a
larger circle of readers than the class for which it
was written.  This union of a thorough, practical
acquaintance with these  fundamental branches,
CURNOW, JOHN, M. D.,  F. R. C. P.,
       Professor of Anatomy at King's College, Physician at King's College Hospital.
    Medical Applied Anatomy.  In one pocket-size 12mo. volume.
Students' Series of Manuals, page 4.
Shortly.  See
BELLAMY,  EDWARD, F. R. C. S.,
      Senior Assistant-Surgeon to the Charing-Cross Hospital, London.
     The Student's Guide  to  Surgical  Anatomy: Being  a Description  of the
most Important Surgical Regions of the Human Body, and intended as an Introduction to
operative Surgery.  In one 12mo. volume of 300 pages, with 50 illustrations.  Cloth, $2.25.

WILSON,  ERASMUS, F. R. S.
     A  System of Human Anatomy, General  and Special.   Edited by W.  H.
Gobrecht, M. D., Professor of  General and Surgical Anatomy in the Medical  College of
Ohio.  In one large and handsome octavo volume  of 616  pages, with 397  illustrations
Cloth, $4.00; leather, $5.00.

CLELAND,  JOHN, M. D.,  F.  R. S.,
      Professor of Anatomy and Physiology in Queen's College, Galway.
    A  Directory for  the  Dissection of the Human Body.
volume of 178 pages.  Cloth, $1.25.
In one 12mo.
HARTSHORNE'S handbook of  anatomy
  AND PHYSIOLOGY.  Second edition, revised.
  In one royal 12mo. volume of 310 pages, with 220
  woodcuts.  Cloth, 81.75.
HS^E^f SPECIAL ANATOMY AND HISTOL,
  0(jr¥:. Eighth edition, extensively revised and
  modified.  In two octavo volumes of 1007 raee.
  with 320 woodcuts. Cloth, $6.00.        P»ge*» 
Lea Brothers & Co.'s Publications—Physics, Physiol., Anat.     7
DRAPER,  JOHN C,  M. D., LL. D.,
       Professor of Chemistry in the University of the City of New York.
     Medical Physics.  A Text-book for Students and Practitioners of Medicine.  In
one octavo volume of 734 pages, with 376 woodcuts, mostly original.  Cloth, $4.

                                 FROM THE PREFACE.
     The fact that a knowledge of Physics is  indispensable to a thorough understanding of
Medicine has not been as fully realized in this country as in Europe, where the admirable
works of Desplate and Gariel, of Robertson and of numerous German writers constitute  a
branch of educational literature to which we can show no parallel.   A full appreciation
of this the author trusts will be sufficient justification for placing in  book form  the sub-
stance of his lectures on this department of science, delivered during many years  at  the
University of the City of New York.
     Broadly speaking, this work  aims to impart  a  knowledge  of the relations  existing
between Physics and Medicine in their latest state of development, and to embody  in  the
pursuit of this object whatever experience the author has gained during a long  period of
teaching this special branch of applied science.
  This elegant and useful work bears ample testi-
mony to the  learning and good judgment  of the
author. He has fitted his work  admirably to the.
exigencies of the situation by presenting  the
reader with brief, clear and  simple statements of
such propositions as he is by necessity required to
master.  The subject matter is well arranged,
liberally illustrated and carefuljy indexed. That
it will take rank at once among the text-books is
certain, and it is to  be  hoped that it will  find a
place upon the shelf of the  practical physician,
where, as a book of reference, it will be  found
useful and agreeable.—Louisville Medical  News,
September 26,1885
  Certainly we have no text-book as full as the ex-
cellent one he has prepared. It begins with a
statement of the properties of matter and energy.
After these the special departments of physics are
explained, acoustics, optics, heat, electricity and
magnetism, closing with  a section on electro-
biology. The applications of all these to physiology
and medicine are kept constantly in view.  The
text is  amply  illustrated and the many difficult
points of the subject are brought forward with re-
markable clearness and ability.—Medical and Surg-
ical Reporter, July 18,1885.
  That this work will greatly facilitate the study
of medical physics is apparent upon even a mere
cursory examination.   It is marked by that scien-
tific accuracy  which  always characterizes Di.
Draper's writings. Its peculiar value lies in the
fact that it is written from  the standpoint of the
medical man.  Hence  much is omitted that ap-
pears iira mere treatise on physical science, while
much is inserted of peculiar value to the physi-
cian.—Medical Record, August 22,1885.
ROBERTSON,  J.  McGREGOR,  M. A., M. B.,
       Muirhead Demonstrator of Physiology, University of Glasgow.
    Physiological Physics.   In one  12mo. volume of 537 pages, with 219 illustra-
tions.  Limp cloth, $2.00.  See Students' Series of Manuals, page 4.
  The title of this work sufficiently explains the I ments.  It will be found of  great value to the
nature of its contents.  It is designed as a man-  practitioner.  It is a carefully prepared book of
ual for the student of medicine, an auxiliary to  reference, concise and accurate, and as such we
his textbook in physiology, and it would be particu-  heartily recommend  it.—Journal of the American
larly useful  as a guide to  his laboratory experi- | Medical Association, Dec. 6, 1884.

DALTON,  JOHN C,  M. D.,
       Professor Emeritus of Physiology in the College of Physicians and Surgeons, New  York.
    Doctrines of the Circulation  of the Blood.   A  History of Physiological
Opinion and Discovery  in regard to the Circulation of the Blood.  In   one handsome
12mo. volume of- 293 pages.  Cloth, $2.
  Dr. Dalton's work is the fruit of the deep research
of a cultured mind, and to the bus/ practitioner it
cannot fail to be a source of instruction.   It will
inspire him with a feeling of gratitute and admir-
ation for those plodding workers of olden  times,
who laid the foundation of the magnificent temple
of medical science as it now stands.—New Orleans
Medical and Surgical Journal, Aug. 1885.
  In the progress of physiological study  no fact
was of greater  moment, none more completely
revolutionized the theories of teachers, than the
discovery of the  circulation  of  the blood.  This
explains the extraordinary interest it has to all
medical historians. The volume before us is one
of three or four which have been written within a
few years by American physicians.  It is in several
respects the most complete. The volume, though
small in size, is one of the most creditable con-
tributions from an American pen to medical history
that has appeared.—Med. ic Surg.  Rep., Dec. 6,1884.
BELL, F.  JEFFREY,  M.  A.,
       Professor of Comparative Anatomy at King's College, London.
    Comparative Physiology and Anatomy.  In one 12mo. volume of 561 pages,
with 229 illustrations. Limp cloth, $2.00.   See Students' Series of Manuals, page 4.
  The manual is preeminently a student's book-
clear and  simple in language and arrangement.
It is well and abundantly illustrated, and is read-
able and interesting.  On the whole  we consider
                          page-

it the best work in  existence in the English
language to place in  the hands of the medical
student.—Bristol Medico-Chirurgical Journal, Mar.,
1886.
ELLIS, GEORGE  VINER,
       Emeritus Professor of Anatomy in  University College, London.
    Demonstrations  of  Anatomy.   Being a Guide to the  Knowledge  of  the
Human  Body by Dissection.  From  the eighth and revised London edition.  In one very
handsome octavo volume of 716 pages, with 249 illustrations.  Cloth, $4.25; leather, $5.25.

ROBERTS,  JOHN B.,  A.  M.9 M. D.,
       Prof, of Applied Anat. and Oper. Surg, in Phila. Polyclinic and Coll. for Graduates in Medicine.
    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. 
8     Lea  Brothers  &  Co.'s Publications—Physiology, Chemistry.
CHAPMAN,  HENRY C, M.  D.,
       Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of
       Philadelphia.
    A Treatise on Human Physiology.   In one handsome  octavo volume of
925 pages, with 605 fine engravings.   Cloth, $5.50 ;  leather, $6.50.  Just ready.
  It represents  very fully  the  existing state of
physiology.  The present work has a special value
to the student and practitioner  as devoted more
to the practical application of well-known truths
which the advance of science  has given to the
profession in this department, which may be con-
sidered the foundation of rational medicine.—Buf-
falo Medical nnd Surgical Journal, Dec. 1887.
  Matteis which have a practical bearing on the
practice of medicine are lucidly expressed; tech-
nical matters are given in minute  detail; elabo-
rate directions are stated for the guidance of stu-
denfs in the laboratory.  In every respect the
work fulfils  its  promise, whether as a complete
treatise  for the student or for the physician ; for
the former it is so complete that he need look no
farther, and the latter will find entertainment and
instruction  in an admirable book of reference.—
North Carolina Medical Journal, Nov. 1887.

  The work certainly commends itself to both
student and practitioner. What is most demanded
by the progressive physician of to-day is an adap-
tation of physiology to practical therapeutics, and
this work is a decided improvement in this respect
over other works in the  market.  It will cerfainly
take place among the most valuable text-books.—
Medical Age, Nov. 25,1887.
  It is the production of an author delighted with
his work, and able to inspire students with an en_
thusiasm akin to his own.—American Practitioner
and Neivs, Nov. 12, 1887.
DALTON, JOHN C, M.  D.,
       Professor of Physiology in the College of Physicians and Surgeons, New York, etc.
     A Treatise  on  Human Physiology.   Designed for the use of Students and
Practitioners of Medicine.   Seventh edition, thoroughly revised and rewritten.   In one
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood.  Cloth,
$5.00; leather,  $6.00; very handsome half Russia, raised bands, $6.50.
                                             sands who have studied it in its various editions
                                             have never been in any doubt as to its sterling
                                             worth.—N. Y. Medical Journal, Oct. 1882.
                                               Professor Dalton's well-known and deservedly-
                                             appreciated work has long passed  the  stage at
                                             which it could  be reviewed in the ordinary sense.
                                             The work is eminently one for the  medical prac-
                                             titioner, since it treats most fully of those branches
                                             of physiology which have a direct bearing on the
                                             diagnosis and treatment of disease.  The work is
                                             one which we can highly recommend to all our
                                             readers.—Dublin Journal of Medical Science, Feb.'83.
  This edition of Dr. Dalton's well-known work
bears  evidence of having been  thoroughly and
careiuiiy revised.  From the first appearance of
the book it has been a favorite, owing as well to
the author's renown as an oral teacher .as to  the
charm of simplicity with which, as a writer, he
always succeeds in investing even intricate sub-
jects  It must be gratifying to him to observe the
frequency with which his work.written for students
and practitioners, is quoted by other writers on
physiology.  This  fact attests its value, and, in
great  measure, its originality. It now  needs no
such seal of approbation, however, for the thou-
FOSTER,  MICHAEL,  M.  D., F.  R.  S.,
       Prelector in Physiology and Fellow of Trinity College, Cambridge, England.
    Text-Book  of Physiology.  Third American from the fourth English edition,
with notes and additions by E. T. Reiohert, M. D., Professor of Physiology in the Uni-
versity of Pennsylvania.   In  one handsome royal 12mo. volume of 908 pages, with 271
illustrations.  Cloth, $3.25 ; leather,  $3.75.
  Dr. Foster's work  upon physiology is  so well-
known as a text-book in this country; thatitneeds
but little to be  said in regard to  it.   There is
scarcely a medical college in the  United States
where it is not in the hands of the students.  The
author, more than any other writer with whom
we are acquainted,  seems to understand what
portions of the science are essential for  students
to know and what may be passed over by them as
not important. From the beginning to the end,
physiology is taught in a systematic  manner. To
this third American edition numerous additions,
corrections  and alterations have been  made, so
that in its present form the usefulness of the book
will be found to be much  increased.—Cincinnati
Medical News, July 1885.
POWER,  HENRY,  M.  B., F. R.  C.  S.,
       Examiner in Physiology, Royal College of Surgeons of England.
     Human Physiology.   Second edition.  In one handsome pocket-size 12mo. vol-
ume of 396 pp., with 47 illustrations.  Cloth, $1.50.   See Students' Series of Manuals, p. 4.

SIMON,  W.,  Ph. D., M.  D.,
       Professor of Chemistry and Toxicology in the  College of Physicians and Surgeons, Baltimore, and
       Professor of Chemistry in the Maryland College of Pharmacy.
     Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners
in Chemistry.   A Text-book, specially adapted for  Students of Pharmacy and Medicine.
In  one  8vo. vol. of 410  pp.,  with  16 woodcuts and 7  plates, mostly of actual  deposits,
with  colors illustrating 56 of the  most important chemical reactions.  Cloth, $3.00; also
without  plates,  cloth, $2.50.
  This book supplies a want long felt by students
of medicine and pnarmacy, and is a concise  but
thorough treatise on the subject.  The long expe-
rience of the "author as a teacher in schools of
medicine ana  pharmacy is conspicuous  in  the
perfect adaptation of the work to the special needs
of the student of these branches.   The colored
plates, beautifully executed, illustrating precipi-
tates of various reactions, form  a novel and valu-
able feature of the book, and cannot fail to  be ap-
preciated by both student and  teacher as  a help
over the  hard places of the science.—Maryland
Medical Journal, Nov. 22, 1884.
     Wohler's Outlines of Organic Chemistry.  Edited by Fittig.   Translated
by Ira Remsen, M. D., Ph. P.  In one 12mo. volume of 550 pages.  Cloth, $3.

LEHMANN'S MANUAL  OF CHEMICAL  PHYS- I CARPENTER'3 PRIZE ESSAY ON THE USE AND
  IOLOGY.  In one octavo volume of 327 pages, |   Abuse or Alcoholic Liquors in Health and Dis-
  with 41 illustrations.  Cloth, $2.25.             I   ease. With explanations of scientific words Small
CARPENTER'S HUMAN PHYSIOLOGY.  Edited |   *2mo-  178 pages.  Cloth, fio cents.
  by Henry Power.  In one octavo volume. 
Lea Brothers & Co.'s  Publications—Chemistry.             9
FRANKLAND,E., D. C. L.,F.R.S.,&JAPP, F.R.,F.I. C,
        Professor of Cliemistry in the Normal School
                 of Science, London.

    Inorganic Chemistry.  In  one handsome octavo  volume of 677 pages with 51
woodcuts and 2 plates.  Cloth, $3.75 ; leather, $4.75.
  This work should supersede other works of its
class in the medical colleges. It is certainly better
adapted than any work upon chemistry.with which
we are acquainted, to impart that  clear and full
knowledge of the science whioh students of med-
icine should have. Physicians who feel that their
chemical knowledge is  behind the times, would
do well to devote some of their leisure time to the
study of this work. The descriptions and demon-
strations are made so plain that there  is no diffi-
culty in understanding them.—Cincinnati Medical
News, January, 188G.
Assist. Prof, of Chemistry in the Normal
     School of Science, London.
  This excellent treatise will not fail to take its
place  as one of the very best on the subject of
which it treats.  We have been much  pleased
with the comprehensive  and lucid  manner in
which the difficulties of chemical  notation and
nomenclature have been cleared up by the writers.
It shows on  every page that the problem of
rendering the obscurities of  this  science  easy
of comprehension has  long  and   successfully
engaged  the  attention of the authors.—Medical
and Surgical Reporter, October 31,1885.
FOWNES, GEORGE, Ph. D.

    A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  Em-
bodying  Watts'  Physical  Inorganic Chemistry.   New  American  edition.  In one  large
royal  12mo. volume of 1061  pages, with 168 illustrations  on wood and a colored plate.
Cloth, $2.75;  leather, $3.25.
  Fownes' Chemistry  has been  a standard text/
book upon chemistry for many years.  Its merits
are very fully known by chemist^ and physicians
everywhere in this country and  in England.  As
the science  has advanced by the making of new
discoveries, the work has been  revised  so as to
keep  it  abreast of the times.   It  has  steadily
maintained  its position as a text book with medi-
cal students. In this work are treated fully: Heat,
Light  and Electricity, including Magnetism.  The
influence exerted by  these  forces in chemical
action upon  health and disease, etc., is of the most
important kind, and  should be familiar to every
medical  practitioner.   We  can commend   the
work  as one of the  very best text-books  upon
chemistry extant.—Cincinnati Medical News, Oo-
tober, 1885.
  Of all the works on chemistry intended for the
use of medical students, Fownes' Chemistry ia
perhaps the most widely used.  Its popularity is
based upon its excellence.  This last edition con-
tains all of the material found in the  previous,
and it is  also enriched by the addition of Watts
Physical and Inorganic Chemistry.   All of the mat-
tor is brought to the present standpoint of chemi-
cal knowledge.  We may safely  predict for this
work a continuance of the fame and favor it enjoys
among medical students.—Neio  Orleans Medical
and Surgical Journal, March, 1886.
ATTFIELD, JOHN,  Ph.  D.,
      Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc.

    Chemistry,  General,  Medical and Pharmaceutical; Including the Chem-
istry of the  U. S.  Pharmacopoeia.   A Manual of the General Principles of the Science,
and their Application to  Medicine and Pharmacy.  A new  American, from the  tenth
English  edition, specially revised by the  Author for America.  In one handsome  royal
12mo. volume of 728 pages, with 87 illustrations.   Cloth, $2.50; leather, $3.00.

  It is a book on which too much praise cannot be
bestowed.  As a text-book for medical schools it
is unsurpassable in the present state of chemical
science,  and having been prepared with a special
view towards medicine and  pharmacy, it is alike
indispensable to all persons engaged in those de-
partments of  science.  It  includes the whole
chemistry of the last Pharmacopoeia.—Pacific Medi-
cal and Surgical Journal, Jan.  1884.            _
  A textbook which  passes through ten editions
in sixteen  years must  have good  qualities.  It
seems  desirable to point  out that feature of the
book which, in all probability, has made it so
popular.  There can be little doubt that it is its
thoroughly practical  character,  the  expression
being used in its best sense.  The author under-
stands what the student ought to learn, and is able
to put himself in the student's place and to appre-
ciate his state of mind.—American Chemical Jour-
nal, April, 1884.
BLOXAM, CHARLES L.,
       Professor of Chemistry in King's College, London.

    Chemistry, Inorganic and Organic.   New American from the fifth Lon-
don  edition  thoroughly revised and much  improved.  In one  very handsome octavo
volume of 727 pages, with 292 illustrations.   Cloth, $2.00;  leather, $3.00.
  Comment from us on this standard work is al-
most superfluous.  It differs widely in  scope  and
aim from that of Attfield, and in its  way is equally
beyond criticism.  It adopts the most direct meth-
ods in stating the principles, hypotheses and facts
of the science.  Its language is so terse and lucid,
and its arrangement of matter so logical in se-
quence that  tbe student never has occasion to
complain that chemistry is a hard study. Much
attention is paid to experimental  illustrations of
chemical  principles  and  phenomena,  and  the
mode of conducting these experiments  The book
maintains the position it has always held as one of
the best manuals of general chemistry In the Eng-
lish language.—Detroit Lancet, Feb. 1884.
  We know  of  no treatise on chemistry which
contains so  much practical information in  the
same number of pages.  The book can be readily
adapted not only to the needs of those who desire
a tolerably complete course of chemistry, but also
to the needs of those who desire only a general
knowledge of the subject.  We take pleasure in
recommending  this  work both as a satisfactory
text  book, and as a useful book of reference.— Bos-
ton Medical and Surgical Journal, June 19,1884.
GREENE,  WILLIAM H.,  M.  D.,
       Demonstrator of Chemistry in the Medical Department of the  University of Pennsylvania.
     A Manual of Medical Chemistry.  For the use of Students.  Based upon Bow.
     s Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus.  Cloth, $1.75:
m!lin."   „m,i» manual of three hundred pages, I the recognition of compounds due to pathological
  It is a conci. o    Bummarv 0f the best methods  conditions.   The detection of poisons is treated
giving an exoc        ^ 80,idsof the body, both  with sufficient fulness for the purpose of thestu-
   tl* estimation of their normal constituents and | dent or practitioner.—Boston Jl. of Chem. June,'80. 
10           Lea Brothers &  Co.'s Publications—Chemistry*
REMSEN, IRA, M.  D.,  Ph. D.,
       Professor of Chemistry in the Johns Hopkins University, Baltimore-
    Principles of Theoretical Chemistry, with special reference to the Constitu-
tion of Chemical Compounds.  New (third)  and thoroughly revised edition.  In one hand-
some royal 12mo. volume of 316  pages.   Cloth, $2.00.   Just ready.
  This work of Dr. Remsen is the very text-book | examination of college faculties as the text-book of
needed, and the medical student who  has it at
his fingers' ends, so to speak, can, if he chooses,
make himself familiar with any branch  of chem-
istry which he may desire to pursue.  It would be
difficult indeed to  find a more lucid, full, and at
the same time compact explication of the philos-
ophy of chemistry, than the book before us, and
we recommend it  to the careful and  impartial
chemical instruction.—&r. Louis Medical and Sur-
gical Journal. January, 1888.
  It is a healthful sign when we see a demand for
a third editk n of such a book as this.  This edi-
tion is larger than the last by about seventy-five
pages, and much of it has been rewritten,  thus
bringing it fully abreast of the latest investiga-
tions.—A. Y. Medical  Journal, Dec. 31,1887.
CHARLES, T.  CRANSTOUN, M. D., F.  C. S., M. S.,
      Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast.
    The  Elements of Physiological  and  Pathological  Chemistry.   A
Handbook for Medical  Students and Practitioners.    Containing a  general  account of
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and
Excretions of the Body in Health and in Disease.  Together  with the methods for pre-
paring or separating their chief constituents, as also for their  examination in detail, and
an outline syllabus of a practical course of instruction for students. In one handsome octavo
volume of 463 pages, with 38 woodcuts and 1 colored plate.  Cloth, $3.50.
                                           nowadays.  Dr. Charles  has devoted much space
                                           to the elucidation of urinary mysteries.  He does
                                           this  with much detail, and  yet in a practical and
  Dr. Charles is fully impressed with the import-
ance and practical reach  of his subject, and he
has treated it in a competent and instructive man-
ner.  We cannot recommend a better book than
the present.  In fact, it fills a gap in medical text-
books, and that is a thing which can rarely be said
intelligible manner. In fact, the author has filled
his book with many practical hints.—Medical Rec-
ord, December 20, 1884.
HOFFMANN, F.,  A.M., Ph.D.,  &  POWER  F.B., Ph.D.,
      Public Analyst to the State of New York.     Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy.
    A Manual of  Chemical Analysis, as applied to the Examination of Medicinal
Chemicals and their Preparations.  Being a Guide for the Determination of their Identity
and Quality,  and for the Detection of Impurities and Adulterations.  For the use of
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and
Medical  Students.  Third edition, entirely rewritten  and much enlarged.   In one very
handsome octavo volume of 621 pages, with 179 illustrations.  Cloth, $4.25.
  We congratulate the author on the appearance
of the third edition of this work, published for the
first time in this country also.  It is admirable and
the  information it undertakes to supply is both
extensive and trustworthy.  The selection of pro-
cesses for determining the purity of the substan-
ces of which it treats is excellent and the descrip-
tion of them singularly explicit.  Moreover, it is
exceptionally free from typographical errors. We
have no hesitation in  recommending it to those
who are engaged either in the manufacture or the
testing of medicinal chemicals.—London Pharma-
ceutical Journal and Transactions, 1883.
CLOWES, FRANK, D. Sc,  London,
      Senior Science-Master at the High School, Newcastle-under-Lyme, etc.
    An Elementary  Treatise on Practical  Chemistry  and  Qualitative
Inorganic Analysis.   Specially adapted for use in the Laboratories of Schools  and
Colleges and by Beginners.  Third American from the fourth and revised English edition.
In one very handsome  royal  12mo. volume of 387  pages, with 55 illustrations.  Cloth,
$2.50.
                                            It is the most readable book of the kind we have
  The style is clear, the language terse and vigor-
ous.  Beginning with a list of apparatus necessary
for chemical work, he gradually unfolds the sub-
ject from its simpler to its more complex divisions.
yet seen,  and is without  doubt a systematic,
intelligible and fully equipped laboratory guide
and text-book.—Medical Record, July 18,1885.
RALFE,  CHARLES H., M. D.,  F. R. C. P.,
       Assistant Physician at the London Hospital.
    Clinical Chemistry.  In  one pocket-size  12mo. volume of 314  pages, with 16
illustrations.  Limp cloth, red edges, $1.50.
  This is one of the most instructive little works
that we have met with in a long time.  The author
Is a physician and physiologist, as well as a chem-
ist, consequently the book is unqualifiedly prac-
tical, telling the physician just  what he ought to
know, of the applications of chemistry in medi-
 See Students' Series of Manuals, page 4.
cine.  Dr. Ralfe is thoroughly acquainted with the
latest contributions to his science, and it is quite
refreshing to find the subject dealt with so clearly
and simply, yet in such evident harmony with the
modern  scientific methods and spirit.—Medical
Record, February 2,1884.
CLASSEN,  ALEXANDER,
      Professor in the Royal Polytechnic School, Aix-la-Chapelle.
    Elementary Quantitative Analysis.  Translated, with notes and additions, by
Edgar F. Smith. Ph. D., Assistant Professor of Chemistry in the Towne Scientific School,
University of Penna.  In one 12mo. volume of 324 pages, with 36 illust.  Cloth, $2.00.
  It is probably the best manual of an elementary
nature extant, insomuch as its methods are the
best.  It teaches by examples, commencing with
■ingle  determinations, followed by separations,
and then advancing to the analysis of minerals and
such products as are met with in applied chemis-
try. It is an indispensable book for students in
chemistry.—Boston Journal of Chemistry. Oct. uwa 
^Lea Brothers & Co.'s Publications—Pharm., Mat. Med., Therap. 11


BRUNTON, T. LAUDER, M.D., D.Sc, F.R.S., F.R.C.P.,
       Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc.
    A Text-book of Pharmacology, Therapeutics and Materia Medica:
including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs
in  one handsome octavo volume  of 1033 pages, with 188 illustrations.  Cloth, $5 50-
leather, $6.50.
tw? jf.ascientific treatise worthy to be ranked with
the highest productions in physiology, either in
^LhW1 °/v.aD7 ot!?er languase.  Everything is
practical,  the dry, hard facts of physiology being
pressed into service and applied to the treatment
of the commonest complaints.  The information
Is  so systematically arranged that it is available
for immediate  use.   The index is so carefully
compiled that a reference to any special point is
at once obtainable. Dr. Brunton is never satisfied
with vague generalities, but gives clear and pre-
cise directions for prescribing the various drugs
and preparations.  We congratulate students on
being at last placed in possession  of a scientific
treatise of  enormous practical importance.—The
London  Lancet, June 27,1885.
MAISCH, JOHNM., Phar. D.,
       Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy.
    A Manual of Organic Materia Medica; Being a Guide to Materia Medica oi
the Vegetable  and Animal  Kingdoms.  For  the use of Students, Druggists, Pharmacists
and Physicians.   'New (3d)  edition, thoroughly revised.   In one handsome royal 12mo
volume of 523 pages, with 257 illustrations.   Cloth, $3.  Just Ready.
  Prof. Maisch is one of the most distinguished
pharmacists of this country.  He and Prof. Still©
are  the  authors of  The  National Dispensatory,
which is not excelled by any work of its kind ever
published. The learning and experience of the
author, therefore, is a guarantee that his manual
is well adapted for its purpose, viz.: a text- and
reference-book for students, pharmacists and phy-
sicians, containing the most recent and reliable
information in regard to drugs.—Cincinnati Medi-
cal News, Nov. 1887.
  This work has already met with so much favor
that there is little to do in noting the appearance
of a third edition besides saying that it is what
one would expect from its talented author.  The
arrangement of the subjects is systematic, accord-
ing to classes. The origin,  habitat, description,
constituents and properties of each drug are given
in a  clear and very succinct  manner; and the
whole book is full of valuable  information.  The
work of the publishers is as creditable  as that of
the author, the paper, printing  and binding being
of the highest order of excellence, while the illus-
trations are superb.—Medical and Surgical Report-
er, Nov. 19,1887.
BARTHOLOW, ROBERTS,  A. M., M. D., LL.  D.,
       Professor of Materii Medica an I General Therapeutics in the Jefferson Medical  College of Phila-
      . delphin.                                                               3  J
    New Remedies  of Indigenous Source:  Their Physiological Actions and
Therapeutical Uses.  In one octavo volume of about 300 pages.   Preparing.

PARRISH, EDWARD,
       Late Professor of the  Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy.
    A Treatise on Pharmacy: designed as a  Text-book for the Student, and as a
Guide for  the Physician and  Pharmaceutist.  With many Formulae  and  Prescriptions.
Fifth edition, thoroughly revised, by Thomas S. Wieoand, Ph. G.   In one handsome
octavo volume of 1093  pages, with 256  illustrations.  Cloth, $5; leather, $6.
                                            Each page bears  evidence of the  care bestowed
                                            upon it, and conveys valuable information from
                                            the rich store of the editor's experience.  In fact,
                                            all that relates to practical  pharmacy—apparatus,
                                            processes and dispensing—has been arranged and
                                            described with clearness in its various aspects, so
                                            as to afford  aid and advice alike to the student and
                                            to the practical  pharmacist.  The work is judi-
                                            ciously illustrated with good woodcuts—American
                                            Journal of Pharmacy, January, 1884.
                                             There is  nothing to equal  Parrish's Pharmacy
                                            in this or any other  language.—London Pharma-
                                            ceutical Journal.
  No thorough-going pharmacist will fail to possess
himself of so useful  a guide to practice, and no
physician who properly estimates the value of an
accurate knowledge of the remedial  agents em-
ployed  by  him  in daily  practice, so  far as their
miscibility, compatibility and most effective meth-
ods of combination are concerned, can afford  to
leave this work out of the list of their works  of
reference.  The country practitioner, who must
always be in a measure his own  pharmacist, will
find it indispensable.—Louisville Medical  News,
March 29, 1884.
  This well-known work presents itself now based
upon the  recently revised  new  Pharmacopoeia.
HERMANN, Dr. L.,
       Professor of Physiology in the University of Zurich.
     Experimental Pharmacology.  A Handbook of Methods for Determining the
Physiological Actions of  Drugs.  Translated, with  the Author's permission, and  with
extensive additions, by Robert Meade Smith, M. D.,  Demonstrator of Physiology in the
University of Pennsylvania.   In  one handsome  12mo. volume of  199  pages, with  32
illustrations.  Cloth, $1.50.

BRUCE,  J.  MITCHELL,  M. D.,  F. R.  C.  P.,
       Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London.
     Materia Medica  and Therapeutics.   An Introduction to  Rational Treat-
ment.   Fourth  edition.  In one pocket-size  12mo. volume  of 591 pages.  Limp  cloth,
$1.50.   See Students' Series of Manuals, page 4.

GRIFFITH, ROBERT EGLESFIELD, M.  D.
     A Universal Formulary, containing the Methods of Preparing  and Adminis-
tering Officinal and other Medicines.  The whole adapted to Physicians and Pharmaceut-
sits.  Third  edition, thoroughly revised, with numerous additions, by John M. Maisch,
Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy.
In one octavo volume of 775 pages, with 38 illustrations.  Cloth, $4.50; leather, $5.50. 
12     Lea Brothers & Co.'s Publicaxiuwb—luai. mea., rnerap.
8TILLE, A.,  M.D.,LL.D.,  & MAISCH, J.  M.,Phar.D.,
Professor Emeritus of the Theory and Prac-
tice of Medicine and of Clinical Medicine
in the University of Pennsylvania.
Prof, of Mat. Med. and Botany in Phila.
College of Pharmacy, Sec'y to the Ameri-
can Pharmaceutical Association.
                          NEW  (FOURTH) EDITION.


  The  National  Dispensatory.

CONTAINING THE NATURAL HISTORY.  CHEMISTRY, PHARMACY, ACTIONS AND  USES  OF
    MEDICINES,  INCLUDING THOSE RECOGNIZED IN THE PHARMACOPEIAS OF THE
         UNITED STATES, GREAT BRITAIN AND GERMANY, WITH NUMEROUS
                      REFERENCES  TO THE FRENCH CODEX.
            Fourth edition revised, and covering the new British Pharmacopada.
    In one magnificent  imperial  octavo volume of 1794  pages, with 311  elaborate
engravings.   Price in cloth,  $7.25 :  leather, raised bands,  $8.00; very handsome half
Russia, raised bands and open back, $9.00.
    *** This work will be furnished with Patent Ready Reference Thumb-letter Index for $1.00
in addition to the price in any style of binding.
    In this new edition of The National Dispensatory, all important changes in  the
recent British Pharmacopoeia have been  incorporated throughout the volume, while in
the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical
novelties which have been established  in  professional favor since the publication of  the
third  edition two years ago.  Detailed  information is  thus given of the following among
the many drugs treated:  Antipyrin, Cocaine Hydrochlorate, Cascara Sagrada, Fabiana,
Franciscea, various new  Glycerins, Gymnocladus, Hydroquinon, Hypnone, Iodol,  Jaca-
randa, Lanolin, Menthol,  Phormium, Sulphophenol, Thallin  and Urethan.   In this
edition, as always before, The National Dispensatory may be said to be the represent-
ative  of the most recent state of American, English,  German and French Pharmacology,
Therapeutics and Materia Medica.
  The National Dispensatory is so well and favor-
ably known  on both side* of the  Atlantic that
scarcely anything else is left to the reviewer than
to call attention to the  fact that another edition
of this valuable work has made its appearance.
This  last edition surpasses even its predecessors
in thoroughness and accuracy.  The fact that in
1884,  when tho third edition was published, no
revision  of the British Pharmacopoeia had been
made for seventeen years,  has necessitated a
thorough going over of the whole work in order
that references might correspond to the last re-
vision of the  work of our  British cousins. In
addition to these changes is a fairly full risumS, in
the form of addenda, of the more important drugs
which have come into general use in the last two
or three years.— The American Journal of the Med-
ical Sciences, April, 1887.
  We think it a matter for congratulation that the
profession of medicine and that of pharmacy have
shown such appreciation of this great work as to call
for four editions  within the comparatively brief
period of eight years. The matters with which it
deals are of so practical a nature that neither the
physician nor the pharmacist can do without the
latest text-books on them, especially those that are
so accurate and comprehensive as this one. The
book is in every way creditable both to the authors
and to the publishers.—New York Medical Journal.
May 21,1887.
EDES, ROBERT T., M. D.,
      Jackson Professor of Clinical Medicine in Harvard University, Medical Department.
    A Text-Book of Materia Medica and Therapeutics.  In one octavo volume
of 544 pages.  Cloth, $3.50 ; leather, $4.50.  Just ready.
  The treatise will be found to be concise and
practical, bringing the subject down to the latest
developments of therapeutics and pharmacology.
The student and practitioner will find the book a
valuable one for reference and study, the former
being facilitated by a full and excellent index.—
St. Louis Medical and Surgical Journal, Jan. 1888.
  The present work seems destined to take a prom-
inent place as a text-book on the subjects of which
it treats. It possesses all the essentials which we
expect in a book of its kind, such as conciseness,
clearness, a judicious classification, and a reason-
able degree of dogmatism. The style deserves
the highest commendation for its dignity and
purity of diction. The student and young practi-
tioner need a safe guide in this branch of medi-
cine. Such they can find in the present author.
All the  newest drugs of promise are treated of.
The clinical index at the end will be found very
useful.  We heartily commend the book and con-
gratulate the author on having produced so good
a one.— N. Y. Medical Jou> nal, Feb. 18,1888.
 Dr. Edes' book represents better than any older
book the  practical therapeutics of  the present
day.  The book is a thoroughly practical one.  The
classification of remedies has reference to their
therapeutic action, and such a classification will
always meet the approval of the student. The rela-
tive importance of different remedies is indicated
by the space devoted to each, and by the  use of
larger type in the titles  of the more important
articles.—Pharmaceutical Era, Jan. 1888.
FARQUHARSON, ROBERT,  M.  D.,
      Lecturer on Materia Medica at St. Mary's Hospital Medical School.
    A Guide to Therapeutics and Materia Medica.  Third American edition,
specially revised by the  Author.  Enlarged  and adapted to the U. S. Pharmacopoeia by
Frank Woodbury, M. D.  In one handsome 12mo. volume of 524 pages.  Cloth, $2.25.

STILLE, ALFRED,  M. D., LL. D.,
      Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna.
    Therapeutics and Materia Medica.   A Systematic Treatise on the Action and
Usee of Medicinal  Agents, including their Description  and  History.  Fourth edition-
revised and enlarged.   In two large and handsome octavo volumes, containing 1936 paces.
Cloth, $10.00; leather, $12.00; very handsome h?l* P.----.'   ..-.:.....T '  . ..-.  -.- - 
Lea Brothers & Co.'s Publications—Pathol., Histol.            13
COATS, JOSEPH, M.  D.,  F. F. P.  S.,
       Pathologist to the Glasgow Western Infirmary.
     A Treatise on  Pathology.  In one very handsome octavo volume of 829 pages,
with 339 beautiful illustrations.   Cloth, $5.50; leather, $6.50.
  The work before us treats the subject of Path-
ology more extensively than it is usually treated
In similar works.  Medical students as  well as
physicians, who desire a work for study or refer-
ence, that treats the  subjects in the various de-
partments in a very thorough manner, but without
prolixity, will certainly give this one the prefer-
ence to any with which we are acquainted. It sets
forth the most recent discoveries, exhibits, in an
interesting manner, the changes from a normal
condition  effected in structures by disease, and
points out the characteristics of various  morbid
agencies, so that they can be easily recognized. But,
not limited to morbid anatomy.it explains fully how
the functions of organs are disturbed by abnormal
conditions.  There is  nothing belonging to its de-
partment of medicine that is not as fully elucidated
as our present knowledge will admit.—Cincinnati
Medical News, Oct. 1883.
  One of the best features of this treatise consists
in the judicious admixture of foreign observation
with private experience.  Thus the subject is
presented  in a harmonious manner, facilitating
the study of single topics and making the entire
volume profitable and  pleasant reading.   The
author includes  in  his  descriptions, general
pathology as well as the special pathologicalhistol-
ogy of the different systems and organs. He has
succeeded in offering to students and practition-
ers a thoroughly acceptable work.—Medical Record,
Dec. 22,1883.
GREEN,  T.  HENRY,  M.  D.,
       Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London.
     Pathology and Morbid Anatomy.  New (sixth) American from the  seventh
revised and  enlarged  English  edition.   In one very handsome octavo volume of about
500 pages, with about 150 tine engravings.   Preparing.
     A notice of the previous edition is appended.
  The fact that this well-known treatise has so
rapidly reached its sixth edition is a strong evi-
dence of its popularity.  The author is to be con
gratulated upon the thoroughness with which  he
has prepared this work.  It is thoroughly abreast
with  all the most recent advances in pathology.
No work in the English language is so admirably
adapted to the wants of the student and practi-
tioner as this, and we would recommend it most
earnestly to every one.—Nashville Journal of Medi-
cine and Surgery,  Nov. 1884.
 WOOD HEAD,  G.  SIMS,  M.  D.,  F. R. C. P.  E.,
       Demonstrator of Pathology in the University of Edinburgh.
    Practical Pathology.   A Manual for  Students and Practitioners.   In one beau-
tiful octavo volume of  497 pages, with 136  exquisitely colored illustrations.  . Cloth, $6.00.
  It forms a real guide for the student and practi-
tioner who  is  thoroughly in earnest  in his en-
deavor to see for himself and do for himself. To
the laboratory  student it will be a helpful  com-
panion, and all  those who may wish to familiarize
themselves with modern methods  of examining
morbid  tissues are strongly urged  to provide
themselves  with this manual.   The  numerous
drawings are not fancied  pictures, or merely
schematic diagrams, but they represent faithfully
the actual images seen  under the microscope.
The author merits all praise for having produced
a valuable work.—Medical Record, May 31, 1884.
  We would heartily recommend it to any student
who desires to acquaint himself with the subject.
In the matter we can find nothing to criticise.
Every point is explained with perfect satisfaction,
so that the merest tyro may understand.—Physician
and Surgeon, December, 1883.
SCHAFER, EDWARD A.,  F. R. S.f
       Assistant Professor of Physiology in University College, London.
    The  Essentials  of  Histology.    In one octavo  volume of  246 pages, with
281 illustrations.   Cloth, $2.25.
  This admirable work was greatly needed.  To
those who are familiar with the author's former
"Course of Practical Histology," the book needs
no recommendation.  It has been written with the
object  of supplying the  student with directions
for the microscopical examination of the  tissues,
which  are given in a  clear and understandable
way.  Although especially adapted for laboratory
work, at the same time it is intended to serve as
an elementary text-book of histology, comprising
all the essential facts of the science, but omitting
unimportant  details.   The  author  has recom-
mended only those methods upon which long ex-
perience has proved that full dependence can be
placed.  The strict observance of this plan per-
mits of no doubt, and  makes the work eminently
satisfactory.—The Physician and Surgeon, July, 188T,
KLEIN,  E„  M. D., F.  R. S.,
     Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hosp., London.
     Elements  of  Histology.   Third edition.   In one pocket-size 12mo. volume of
360 pages, with 181  illus.  Limp cloth, $1.50.  See Students' Series of Manuals, page 4.
  This little volume, originally  intended by its
able  author as a  manual for medical students,
contains much valuable information, systematic-
ally  arranged, that will  be acceptable  to the
 General practitioner.  It gives a graphic and lucid
 escription of every tissue and organ in the hu-
man body;  and,  while small in size.it is full to
overflowing with important facts in regard to these
multiform and complex structures.  We know of
no book of its size that will prove of greater value
to  medical  students and practitioners of medi-
cine.— The Southern Practitioner, Nov. 1883.
PEPPER, A. J.,  M.  B.,  M.  S.,  F. R.  C. S.,
       Surgeon and Lecturer at St. Mary's Hospital, London.
     Surgical  Pathology.  In one pocket-size 12mo.  volume of 511 pages, with  81
illustrations.  Limp cloth, red edges, $2.00.  See Students' Series of Manuals, page 4.
  It is not pretentious,  but  it will serve exceed-
ingly well as a book of reference.  It embodies a
 freat deal of matter, extending over the whole
 eld of surgical pathology.  Its  form  is practical,
its  language is clear,  and the information set
forth  is  well-arranged,  well-indexed and well- [
illustrated.  The  student will find in it nothing
that is unnecessary.  The list of subjects coven
the whole range of surgery.  The book supplies a
very manifest want and should  meet with suc-
cess.—New York Medical Journal,  May 31, 1884.
     Cornil  and Ranvier's  Pathological  Histology. — Translated by  E. O.
Shakespeare, M. D., and J. Henry C. Simes, M. D.  Octavo, 800 pp., 360 illustration*. 
14         Lea Brothers & Co.'s Publications—Practice of Med.
FLINT,  AUSTIN, M.  D., LL. D.
   Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. Y.
    A Treatise on the Principles and Practice of Medicine.   Designed for
the use of Students and Practitioners of Medicine.   New (sixth) edition, thoroughly re-
vised and rewritten by the Author, assisted by AVilliam H. Welch, M. D.,  Professor of
Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D.,
Professor of Physiology, Bellevue Hospital  Medical College, N. Y.   In one very handsome
octavo volume of  1160 pages, with illustrations.   Cloth,  $5.50; leather, $6.50; very
handsome half Eussia, raised bands, $7.00.
  A new edition of a work of such established rep-
utation as Flint's Medicine needs but few words to
commend it to notice.  It may in truth be said to
embody the fruit of his labors in clinical medicine,
ripened by the experience of a long life devoted to
its pursuit.  America may well be proud of having
produced a man whose indefatigable industry and
gifts of genius have done so much to advance med-
icine; and all English-reading students must be
 frateful for the work which he has left behind bim.
 t has few equals, either in point of literary excel-
lence, or of  scientific learning, and no one can
6-tudy its pages without being  struck by the lu-
cidity and accuracy which characterize them.  It
is qualities such as these which render it so valu-
able for its purpose, and give  it a  foremost place
among the  text-books of this generation.—The
London Lancet, March 12,1887.
  No text-book on the principles and practice  of
medicine has ever met in this country with such
general approval by medical students and practi-
tioners as the work of Professor Flint.  In all the
medical  colleges of the United States it is the fa-
vorite work upon Practice; and, as we have stated
before in alluding to it, there is no other medical
work that can be so generally found  in  the libra-
ries of physicians.  In every state  and territory
of thisjvast country the book that will be most likely
to be found in the office of a medical man, whether
in city,  town, village, or at some cross-roads, is
Flint's Practice.  We  make this statement to  a
considerable extent from personal observation, and
it is  the testimony also of others.  An  examina-
tion shows that very considerable changes  have
been made in the sixth edition. The work may un-
doubtedly be regarded as fairly representing the
present state of the science of medicine, and as
reflecting the views of those who exemplify in
their practice the present stage of progress of med-
ical art.—Cincinnati Medical News, Oct. 1886.
HARTSHORNE, HENRY, M.  D.,  LL. D.,
       Lately Professor of Hygiene in the University of Pennsylvania.
     Essentials of the  Principles and Practice of Medicine.   A  Handbook
for Students and Practitioners.  Fifth edition, thoroughly revised and  rewritten.   In one
royal 12mo. volume of 669 pages, with 144 illustrations.  Cloth, $2.75; half bound, $3.00.
                                             this one;  and probably not one writer in our day
                                             had a better opportunity than Dr. Hartshorne for
  Within the compass of 600 pages it treats of the
history of medicine,  general pathology, general
symptomatology, and physical diagnosis (including
laryngoscope, ophthalmoscope, etc.), general ther-
apeutics, nosology, and special pathology and prac-
ticei • There is a wonderful amount of information
contained in this work, and it is one of the best
of its kind that we have seen.—Glasgow Medical
Journal, Nov. 1882.
  An indispensable book.  No work ever exhibited
a better average of actual practical treatment than
condensing all the views of eminent practitioners
into a 12mo.  The numerous illustrations  will be
very useful to students especially.  These essen-
tials, as the  name suggests, are not intended to
supersede the text-books of Flint and Bartholow,
but they are the most valuable in affording the
means to see at a glance the whole literature of any
disease, and the most valuable treatment.—Chicago
Medical Journal and Examiner, April, 1882.
BRISTOWE,  JOHN SYER, M.  D.,  F. R. C. P.,
       Physician and Joint Lecturer on Medicine at St. Thomas' Hospital, London.
    A Treatise on the Practice of Medicine.  Second American edition, revised
by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the
Pennsylvania Hospital.  In one handsome octavo volume of 1085 pages, with illustrations.
Cloth, $5.00;  leather, $6.00; very handsome half Eussia, raised bands, $6.50.
  The book  is a model of conciseness, and com-
bines, as successfully as  one could conceive it to
be possible, an  encyclopaedic character with the
.smallest dimensions.  It differs from other admi
rable text-books in  the completeness with which
it covers the whole field of medicine.—Michigan
Medical News, May 10,1880.
  His accuracy in the portraiture of disease, his
•care in stating subtle points of diagnosis, and the
faithfully given pathology of abnormal processes
have seldom been surpassed.  He embraces many
diseases not usually considered to belong to theory
and practice, as skin diseases, syphilis and insan-
ity, but they will not be objected to by readers, as
he has studied them conscientiously, and drawn
from the life.—Medical and Surgical Reporter, De-
cember 20, 1879.
  The reader  will  find every conceivable subject
connected with the practice of medicine  ably pre-
sented,  in a style at once clear, interesting and
concise.  The additions made by Dr.  Hutchinson
are appropriate and  practical, and  greatly add to
its usefulness to American readers.—Buffalo Med-
ical and Surgical Journal, March, 1880.
WATSON, SIR  THOMAS,  M.  D.,
       Late Physician in Ordinary to the Queen.
    Lectures on  the  Principles and Practice of Physic.  A new American
from  the fifth English edition.  Edited, with additions, and 190 illustrations, by Henry
Hartshorne, A. M., M. D., late Professor of Hygiene in  the University of Pennsylvania.
In two large octavo volumes ol 1840 pages.   Cloth, $9.00 ; leather, $11.00.
LECTURES ON THE STUDY OF FEVER.  By
  A. Hudson, M. D., M. R. I. A.  In one octavo
  volume of 308 pages. Cloth, 82.50.
A TREATISE ON  FEVER.  By Robeet D. Lyons,
  K. C. C.  In one 8vo. vol. of 354 pp.  Cloth, $2.26.
LA ROCHE ON YF.LLOW FEVER, considered in
  its  Historical,  Pathological,  Etiological and
  Therapeutical Relations. In two large and hand-
  some octavo volumes of 1468 pp.  Cloth. $7.00.
    A CENTURY OF AMERICAN  ME1>ICINE, 1776—1876.  By  Drs. E. H. Clabke  H. J.
Bioblow, 8. D. Gbosb, T. G. Thomas, and J. S. Billings.  In one 12mo. volume of 370 pages. 
Lea Brothers & Co.'s Publications—System of Med.         15
For Sale by Subscription  Only.
     A   System   of   Practical   Medicine.

                           BY AMERICAN AUTHORS.

             Edited  by WILLIAM  PEPPER, M. D.,  LL. D.,

   PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND  OF
              CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA,

Assisted by Louis Starr, M. D., Clinical  Professor of the Diseases of Children in th«
                     Hospital of  the University of Pennsylvania.

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is just ready.
     Price per volume, cloth, $5; leather, $6;  half Russia, raised bands and open back, $7.
    In this great work American medicine is for the first time reflected by its worthiest
teachers, and presented in the full development of the practical utility which is its pre-
eminent characteristic.   The  most able  men—from the  East and the West, from the
North and  the South, from all the prominent centres of education,  and from  all the
hospitals  which  afford  special  opportunities for study  and  practice—have united in*
generous rivalry  to bring together this vast aggregate of specialized experience.
    The distinguished editor  has so  apportioned the work that to each author has been
assigned the  subject which he is  peculiarly fitted to discuss, and in  which his views
will be accepted as  the latest expression of scientific and practical  knowledge.  The
practitioner will therefore find these volumes a complete, authoritative and unfailing work
of reference, to which he may at all times turn with full certainty of finding what he needs
in its most recent aspect, whether he seeks information on  the general principles of medi-
cine, or minute guidance in the treatment of special disease.  So wide is the scope of the
work  that, with the exception of midwifery and matters strictly surgical, it embraces the
whole domain of medicine, including the departments for which the physician is accustomed
to rely on special treatises, such as diseases of women and  children, of the genito-urinary
organs, of the skin, of the nerves, hygiene  and sanitary science, and medical ophthalmology
and otology.  Moreover, authors have inserted the formulas which they have found most
efficient in the treatment of the  various affections.  It may thus be truly regarded as a
Complete Library of Practical Medicine,  and the general practitioner possessing it
may feel secure that he  will require little ,else in the daily round of professional duties.
    In  spite of every effort to  condense the vast amount of practical information fur-
nished, it has been impossible to present it in less than 5 large octavo volumes, containing
about 5600  beautifully printed pages, and embodying the matter of about 15 ordinary
octavos.  Illustrations are introduced wherever requisite to elucidate the text.
    A detailed prospectus will  be sent to any address  on application to the publishers.
  These two volumes bring this admirable work
to a close, and fully sustain the high standard
reached by the earlier volumes;  we have only
therefore to echo the eulogium pronounced upon
them.  We would warmly congratulate the editor
and  his collaborators at the conclusion of their
laborious task on the admirable manner in which.
from first to last, they have performed their several
duties.  They have succeeded  in producing a
work which will long remain a standard work of
reference,  to  which practitioners will  look for
guidance,  and authors will resort to for  facts.
From a literary point of view, the work is without
any serious blemish, and in respect of production,
It has the beautiful  finish that Americans always
give their works.—Edinburgh Medical Journal, Jan.
1887.
  * * The greatest distinctively American work on
the practice of medicine, and, indeed, the super-
lative adjective would not be inappropriate were
even all other productions placed in comparison.
An examination of the five volumes is sufficient
to convince one of  the magnitude of the enter-
prise, and of the success which has attended its
fulfilment.— The Medical Age, July 26,1886.
  This huge volume forms a fitting close to the
great system of medicine which in so short a time
has won so high a place in medical literature, and
has done such credit to the profession in this
country.  Among the twenty-three contributors
are the  names of  the  leading neurologists in
America, and most of the work in the volume is of
the highest order.—Boston Medical and  Surgical
Journal, July 21,1887.
  We consider it one of the grandest works on
Practical Medicine in the English language.  It is
a work of which the  profession of this country can
feel  proud.  Written  exclusively  by American
physicians who are acquainted with all the varie-
ties of climate in the United States, the character
of the soil, the manners and customs of the  peo-
ple,  etc., it is peculiarly adapted  to the wants
of American practitioners of medicine, and  it
seems to us that every one of them would desire
to have it.  It has been truly called a " Complete
Library of Practical Medicine," and the general
practitioner will  require little else  in his round]
of professional duties.—Cincinnati Medical Newt,
March, 1886.
  Each of the volumes is  provided with a most
copious index, and the work altogether promises
to be one which  will add much to the medical
literature of the present century, and reflect great
credit upon the scholarship and practical acumen
of its authors.—The London Lancet, Oct. 3,1885.
  The feeling of proud satisfaction with which the
American profession sees this, its representative
system of practical medicine issued to the medi-
cal world, is fully justified by the character of the
work.  The entire caste of the system is in keep-
ing with the best thoughts of the leaders and fol-
lowers of  our home school of medicine, and the
combination of the scientific study of disease and
the practical application of exact and experimen-
tal knowledge to the treatment of human  mal-
adies, makes every one of us share in the pride
that  has welcomed Dr. Pepper's labors.  Sheared
of the  prolixity that wearies the readers of the
German school,  the articles glean  these same
fields for all that is valuable.  It is  the outcome
of American brains, and is marked throughout
by much of the sturdy independence of thought
and originality that is a national characteristic.
Yet nowhere is there lack  of study of the most
advanced views of the day.—North Carolina Medi-
cal Journal, Sept. 1886. 
16        Lea Brothers & Co.'s Publications—Clinical Med., etc.
FOTHERGILL, J. M.,  M. D.,  Edin,. M. R.  C. P., Loud.,
       Physician to the City of London Hospital for Diseases of the Chest.
    The Practitioner's Handbook of Treatment; Or, The Principles of Thera-
peutics.  New (third) edition.  In one octavo volume of 661 pages.  Cloth, $3.75; leather,
$4.75.  Just ready.
  Dr. Fothergill is always interesting and instruct-
ive, and in this  standard work  he shows his
 Eeculiar power as a writer on therapeutics to the
 est  advantage.  Everything he undertakes is
done conscientiously.   The book well sustains
the favorable impression which it  created at the
beginning  of its career, and in its  present im-
Eroved form it will be welcomed more than ever
 y the busy practitioner and the scientific student
of medicine.— The Medical News, July 23,1887.
  To have a description of the normal physiologi-
cal processes of an organ and of the methods of
treatment  of  its  morbid  conditions brought
together in a single chapter, and the relations
between the two clearly stated, cannot fail to prove
a great convenience to many thoughtful but busy
physicians.  The practical value of the volume is
greatly increased by  the introduction of many
prescriptions.   That the profession appreciates
that the author has undertaken an important work
and has accomplished it is shown by the demand
for this third edition.—New York Medical Journal,
June 11,1887.
  This is a wonderful book.  If there be such a
thing as  "medicine  made easy," this is the work
to accomplish this result. It imparts information
so agreeably, so smoothly, that the reader almost
thinks as he lays the book down that  he " knew
that before," when in reality he did not, or else he
could before have reconciled facts which now
become clear as daylight.  The author  deals with
the "Principles  of Therapeutics,"  the study of
which will give great vantage to the physician.—
Virginia Medical Monthly, June, 1887.
REYNOLDS, J.  RUSSELL, M.  D.,
       Professor of the Principles and Practice of Medicine in University College, London.
    A System of Medicine.  With notes and additions by Henry Hartshorne,
A. M., M. D., late Professor of Hygiene in the University of Pennsylvania.  In three large
and handsome octavo volumes, containing  3056 double-columned pages, with 317 illustra-
tions.  Price per volume, cloth, $5.00; sheep, $6.00; very handsome half Russia, raised bands,
$6.50.  Per set, cloth, $15; leather, $18; half  Russia, $19.50.  Sold only by subscription.


STILLE, ALFRED, M. D.,  LL. D.,
       Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna.
    Cholera:  Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat-
ment.  In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25.
FINLAYSON, JAMES, M. D.,  Editor,
       Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc.
    Clinical  Manual for  the  Study of Medical  Cases.   With  Chapters
by Prof. Gairdner on the  Physiognomy of Disease;  Prof. Stephenson on  Diseases of
the Female Organs;  Dr. Robertson  on Insanity;  Dr. Gemmell  on Physical Diagnosis;
Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by  the  Editor on Case-
taking, Family History and Symptoms of Disorder in the Various Systems.   New edition.
In one 12mo. volume of 682  pages, with  158 illustrations.  Cloth, $2.50.
  The profession cannot but welcome the second
edition of this very valuable work of Finlayson
and his collaborators. The size of the book has
been increased and the number of illustrations
nearly doubled.  The manner  in which the sub-
ject is treated is a most practical one.  Symptoms
alone  and  their  diagnostic indications form the
basis of discussion.  The text explains clearly and
thoroughly the methods of examination and the
conclusions to be drawn from the physical signs.—
The Medical News, April 23,1887.
  This manual is one of the most complete and
perfect of  its kind.  It goes thoroughly into the
question of diagnosis from every possible point.
It must lead to a thoroughness of observation, an
examination in detail of every scientific appliance,
and a study of means to the end which cannot
fail in laying an  excellent foundation for the
student for future success as an able diagnostician.
—Medical Record, August 13,1887.
  The second edition of  this  manual is a very
considerable improvement upon the first.  Much
new matter has been introduced and the work has
been brought up to the present time in all respects.
As it stands it is one of the best manuals of diag-
nosis in the English language for beginners. The
whole work is so complete and so simply written,
and yet contains such an amount of valuable
information, that it should be a part of the library
of every practitioner.—New York Medical Journal.
July 23, 1887.                                '
FENWICK, SAMUEL, M. D.,
       Assistant Physician to the London Hospital.
    The Student's Guide to  Medical Diagnosis.  From the third revised and
enlarged English edition.  In one very handsome royal 12mo. volume of 328  pages, with
87 illustrations on wood.  Cloth, $2.25.

HABERSHON, S.  O.,  M. D.,
       Senior Physician to and late Led. on Principles and Practice of Med. at Guy's Hospital London.

    On the Diseases of the  Abdomen;  Comprising those of the Stomach, and
other parts of the Alimentary Canal, CEsophagus, Caecum, Intestines and Peritoneum. Second
American  from third enlarged and revised  English edition.  In one handsome octavo
volume of 554 pages,  with illustrations.  Cloth, $3.50.

TANNER,  TH031AS^HAWKES,  M.  D.
    A Manual of Clinical Medicine and Physical Diagnosis. Third American
from the second London edition.   Revised  and  enlarged  by Tilbury Fox, M. D.
In one small 12mo. volume  of 362 pages, with illustrations.  Cloth, $1.50. 
Lea Brothers & Co.'s Publications—Hygiene, Electr., Pract.     17
BARTHOLOW, ROBERTS, A. M., M. D., LL. D.,
       Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc.

     Medical  Electricity.   A  Practical Treatise on the Applications of Electricity
to Medicine and Surgery.  New (third) edition.  In one very handsome octavo volume of
308  pages, with 110 illustrations.  Cloth, $2.50.
                                             should read it, especially when it is recalled what
                                             possibilities lie in the path of the further study of
                                             the therapeutics of electricity. Dr. Bartholow has
                                             here presented the profession with a concise work
                                             that, beginning with elementary descriptions and
                                             principles, gradually grows, page by page, into a
                                             magnificently practical treatise, describing opera-
                                             tions in detail, and giving records of successes
                                             that prove electricity to be marvellous as a curative
                                             agent in many forms of disease.  The doctor can-
                                             not now do better than to possess himself of Dr.
                                             Bartholow's treatise, just as it is.— Virginia Medi-
                                             cal Monthly, June, 1887.
  The fact that this work has reached its third edi-
tion in six years, and that it has been kept  fully
abreast with the increasing use and knowledge of
electricity,demonstrates its claim to be considered
a practical treatise of tried value to the profession.
The matter added to the present edition embraces
the most recent advances in electrical treatment.
The illustrations are abundant and clear, and the
work constitutes a full, clear and concise manual
well  adapted to the needs of both  student and
practitioner — The Medical News. May 14,1887.
  This "practical  treatise on the applications of
electricity to medicine and surgery" has grown to
be so important a work that every  practitioner
RICHARDSON, B. W.,  M.D.,  LL. D., F.R.S.,
       Fellow of the Royal College ot Physicians, london.
    Preventive Medicine.   In one octavo volume of 729 pages.   Cloth, $4; leather,
$5; very handsome half Russia, raised bands, $5.50.
                                             tive collection of data upon the diseases common
                                             Lo the race, their origins, causes, and the measures
                                             for their prevention.  The descriptions of diseases
                                             are clear, chaste and scholarly; the discussion of
                                             the question of disease is comprehensive, masterly
  Dr. Richardson has succeeded in  producing a
work which is elevated in conception, comprehen-
sive in scope, scientific in character, systematic in
arrangement, and which is written in a clear, con-
cise and pleasant manner. He evinces the happy
faculty of extracting the pith of what is known on
the subject, and of presenting it in a most simple,
intelligent and practical  form.  There is perhaps
no similar work written for  the general  public
thatcontains such acomplete, reliable and instruc-
and fully abreast with the latest and best knowl-
edge on the subject, and the preventive measures
advised are accurate, explicit and reliable.— The
American Journal of the Medical Sciences, April, 1884.
HARTSHORNE, HENRY, M. D., LL. D.,
       Formerly Professor of Hygiene in the University of Pennsylvania, and  Professor of Physiology and
       Diseases of Children in the Woman's Medical College of Pennsylvania.
    A Household Manual of Medicine, Surgery, Nursing  and Hygiene:
For Daily Use in the Preservation of Health and Care of the Sick and Injured, with an
Introductory Outline of Anatomy and Physiology.  In one very  handsome royal octavo
volume of 946 pages, with 8 plates and 283 engravings.  Cloth, $4.00; very handsome
full red leather, $5.00.        _____________________

THE  YEAR-BOOK OF  TREATMENT FOR  1887.
    A Comprehensive and Critical Review  for Practitioners of Medi-
cine.  In one 12mo. volume  of 341 pages, bound  in limp cloth, $1.25.  Just ready.


THE  YEAR-BOOK OF  TREATMENT FOR  1886.
    Similar to that of 1887 above.  12mo., 320 pages.  Limp cloth, $1.25.
  This "review" includes every  department of
medical and surgical as well as obstetrical practice.
It attempts nothing in the way of etiology,  diag-
nosis  or symptoms, but limits itself  to  the ad-
vances made in the treatment of diseases, injuries,
etc.  The  work seems to us  to be invaluable to
    **#  For special commutations with periodicals see page  3.

SCHREIBER, DR. JOSEPH.
    A Manual of  Treatment  by Massage  and  Methodical Muscle  Ex-
ercise.    Translated by Walter Mendelson,  M. D., of New York.   In one handsome
octavo volume of 274 pages, with 117 fine engravings.  Just ready. Cloth, $2.75.
                                             science of mechanical therapeutics, adapted to
                                             the  use of the general practitioner, this volume
                                             leaves nothing to be  desired.  The  text is fully
every practitioner, whether he be a general one or
a specialist.  It is a book to be kept on the office
table for continuous reference. An excellent in-
dex to  subjects, as well as  to authors quoted, is
appended.— Virginia Medical Monthly, April, 1887.
  The present volume will do much to establish
mechanical therapeutics upon a scientific basis.
The work is a very welcome addition to the library,
and we heartily recommend  it to our readers as
a step in the right direction.—New  York Medical
Journal, July 16, 1887.
  As a thorough and satisfactory exposition of the
illustrated by well-drawn woodcuts, leaving no
room for obscurity in the description of the vari-
ous manipulations  recommended.—Atlanta Medi-
cal and Surgical Journal, Aug. 1887.
STURGES' INTRODUCTION TO  THE STUDY
  OF CLINICAL MEDICINE.  Being a Guide to
  the Investigation of Disease.  In one handsome
  l2mo. volume of 127 pages.   Cloth, £1.25.
DAVIS' CLINICAL  LECTURES  ON  VARIOUS
  IMPORTANT  DISEASES.   By  N. S. Davis,
  M. D. Edited by Frank H. Davis, M. D. Second
  edition.  12mo. 287 pagws.  Cloth, 81.76.

TODD'S CLINICAL  LECTURES ON CERTAIN
  ACUTE  DISEASES.  In one  octavo volume of
  820 pages.  Cloth, $2.60.
PAW'S TREATISE ON THE FUNCTION OF DI-
  GESTION; its Disorders and their Treatment.
  Krom the second London edition.  In one octavo
  volume of 238 pages. Cloth. 82.00.
BARLOW'S MANUAL OF THE  PRACTICE OF
  MEDICINE.  With additions by D. F. Condm,
  M.D.  1  vol. 8vo., pp. 603.  Cloth, $2.50.
CHAMBERS'MANUAL OF DIET AND REGIMEN
  IN HEALTH  AND SICKNESS. In one hand-
  some octavo volume of 302 pp. Cloth, $2.76.
HOLLAND'S MEDICAL NOTES  AND REFLEC-
  TIONS. 1 vol. 8vo., pp. 493.  Cloth, $3.50. 
18      Lea Brothers & Co.'s Publications—Throat, Lungs, Heart.
FLINT, AUSTIN,  M. D.,
      Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y.
    A Manual of Auscultation and Percussion; Of the Physical Diagnosis of
Diseases of the Lungs and Heart, and of Thoracic Aneurism.  Fourth  edition.   In one
handsome royal  12mo. volume of 278 pages, with 14 illustrations. Cloth, $1.75.
 This admirable little book is too well known to
require any extended notice. That a third and
large edition has been exhausted in little more
than two years, is evidence that the book is appre-
ciated.  We ourselves have used a former edition
as a text-book in teaching the physical examina-
tion of the chest, and can consequently speak from
experience.—Boston Med. and Sur. Jour.,Feb. 11,'86.
                            BY THE SAME AUTHOR.
    Physical Exploration of the Lungs by Means of Auscultation  and
Percussion. Three lectures delivered before the Philadelphia County Medical Society,
1882-83.  In one handsome small 12mo. volume of 83 pages.  Cloth, $1.00.

    A Practical Treatise on the Physical Exploration of the Chest  and
the  Diagnosis of Diseases  Affecting the Respiratory Organs.  Second and
revised edition.  In one handsome octavo volume of 591 pages. Cloth, $4.50.

    Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events  and
Complications,  Fatality and Prognosis, Treatment and Physical  Diag-
nosis ; In a series of Clinical Studies. In one handsome octavo volume of 442 pages.
Cloth, $3.50.                          ----
    A Practical Treatise on the Diagnosis, Pathology and Treatment of
Diseases of the Heart.  Second revised and enlarged edition.  In one octavo  volume
of 550 pages, with a plate.  Cloth, $4.

    Essays on Conservative Medicine and Kindred Topics.  In one very hand-
some royal 12mo. volume of 210 pages.  Cloth, $1.38.

BROWNE,  LENNOX,  F. R.  C.  S., E.,
      Senior Physician to the Central London Throat and Ear Hospital.
    A Practical Guide to Diseases  of  the Throat and Nose, including
Associated Affections of the Ear.   With  120 illustrations in color, and  200 en-
gravings  on wood  designed and executed  by the Author.  New (second) and enlarged
edition.  In one imperial octavo volume of about 600 pages.  Cloth, $6.  Just ready.
  Among the points to which we would especially
draw the attention of the practitioner, is the sys-
tem followed  in describing  the symptoms and
methods of treatment in the various forms of
throat disease, the very valuable record of typical
cases  culled from the author's  practice,  and a
valuable appendix of formulse useful in treatment.
In this edition the letter-press has been trebled,
the engravingshaye been quadrupled, and twenty-
two  new colored  illustrations have been added.
We can cordially  recommend all our readers to
procure this work and avail themselves of the
rich treasures  of practical  experience therein
collected.—Provincial Medical Journal, Dec. 1,1887.
GROSS, S. D., M.D., LL.D., D.C.L.  Oxon.,  LL.D.  Cantab.
    A Practical Treatise on  Foreign Bodies in the Air-passages.  In one
octavo volume of 452 pages, with 59 illustrations.  Cloth, $2.75.

COHEN, J. SOLIS, M. D.,
      Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College.
    Diseases of the Throat and Nasal Passages.  A Guide to the Diagnosis and
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares.  Third
edition, thoroughly revised and rewritten, with a large number of new illustrations.  In
one very handsome octavo volume.  Preparing.

SEILER,  CARL, M. D.,
      Lecturer on Laryngoscopy in the University of Pennsylvania.
    A Handbook of Diagnosis  and Treatment of Diseases of the Throat,
Nose and Naso-Pharynx.  Second edition.  In one handsome royal 12mo.  volume
of 294 pages, with 77 illustrations.  Cloth, $1.75.

BROADBENT,  W.  H.,  M. D., F. R. C. P.,
      Physician to and Lecturer on Medicine at St. Mary's Hospital.
    The Pulse. In one 12mo. volume.  Preparing.  See Series of Clinical Manuals, page 4.
PULLER ON DISEASES OF THE LUNGS AND
 AIR-PASSAGES. Their Pathology, Physical Di-
 agnosis, Symptoms and Treatment. From  the
 second and revised English edition. In one
 octavo volume of 475 pages. Cloth, $3.50.
BLADE ON DIPHTHERIA; its Nature and Treat-
 ment, with an account of the History of its Pre-
 valence in various Countries. Second and revised
 edition.  In one l2mo. vol., pp. 158. Cloth. $1.25.
WALSHE ON THE DISEASES OF THE HEART
 AND GREAT VESSELS.  Third American edi-
 tion. In 1 vol. 8vo., 416 pp.  Cloth, $3.00.
SMITH ON CONSUMPTION; its Early and Reme-
  diable Stages.  1 vol. 8vo., pp. 253. Cloth, $2.25.
LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490
  pages.  Cloth, $3.00.
WILLIAMS ON PULMONARY CONSUMPTION;
  its Nature, Varieties and Treatment.  With an
  analysis of one thousand cases to exemplify its
  duration. In one 8vo. vol. of 303 pp.  Cloth, $2.50.
JONES' CLINICAL OBSERVATIONS ON FUNC-
  TIONAL NERVOUS DISORDERS. Second Am-
  erican edition. In one handsome octavo volume
  of 340 pages.  Cloth, $3.25. 
Lea  Brothers & Co.'s Publications—Nerv. and Ment. Dis., etc.   19
ROSS, JAMES, M.D., F.R.C.P., LL.D.,
       Senior Assistant Physician to the Manchester Royal Infirmary.
    A Handbook  on Diseases of the Nervous System.   In one  octavo
volume of 725 pages, with 184 illustrations.  Cloth, $4.50;  leather, $5.50
  This admirable work is intended for students of
medicine and for such medical men as have no time
for lengthy treatises.  In the present instance  the
duty of arranging the vast store of material at the
disposal of the author, and  of abridging the  de-
scription of the different aspects of nervous  dis-
eases, has been performed with singular skill,  and
the result is a concise and philosophical guide to
the department of medicine of which it treats.
Dr. Ross holds such a high scientific position that
any writings which bear his name are naturally
expected to have the impress of a powerful intel-
lect.   In every part  this handbook  merits tne
highest praise, and will no doubt be found of the
greatest value to the student as well as to the prac-
titioner.—Edinburgh Medical Journal, Jan. 1887.
MITCHELL,  S.  WEIR, M. D.,
       Physician to Orthopozdic Hospital and the Infirmary for Diseases of the Nervous System, Phila., etc.
    Lectures on  Diseases  of  the  Nervous  System;  Especially in Women.
Second edition.   In one 12mo. volume of 288 pages.  Cloth, $1.75.
  No work in our language develops or displays
more features of that many-sided affection, hys^
teria, or gives clearer directions for its differen-
tiation, or sounder  suggestions  relative to its
general management and treatment.  The book
is particularly valuable in  that it represents in
the main  the author's own clinical studies, which
have been so extensive and fruitful as to give his
teachings  the  stamp of authority all  over the
realm of medicine.  The work, although written
by a specialist, has no exclusive character, and
the general practitioner above all others will find
its perusal profitable, since it deals with diseases
which he frequently  encounters and must essay
to treat.—American Practitioner, August, 1885.
HAMILTON,  ALLAN McLANE, M. D.,
      Attending Physician at the Hospital for Epileptics and Paralytics, Blackwell's Island, N. Y.
    Nervous Diseases; Their Description and Treatment.  Second edition, thoroughly
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations.  Cloth, $4.
                                            characterized this book as the best of its kind in
  When the first edition of this good book appeared
we gave it our emphatic endorsement, and the
Eresent edition enhances our appreciation of the
 ook and its author as a safe guide to students of
clinical neurology.   One of  the best and most
critical of English neurologicaljournals, Brain, has
any language, which is a handsome endorsement
from an exalted source.  The improvements in the
new edition, and the additions to it, will justify its
purchase even by those who possess the old.—
Alienist and Neurologist, April, 1882.
TUKE, DANIEL HACK,  M.  D.,
      Joint Author of The Manual of Psychological Medicine, etc.
    Illustrations of the Influence of the Mind upon the Body in Health
and Disease.  Designed  to  elucidate  the Action of the Imagination.   New edition.
Thoroughly revised and rewritten.  In one handsome octavo volume of 467 pages, with
two colored plates.   Cloth, $3.00.
  It is impossible to peruse these interesting chap-
ters without being convinced of the author's per-
fect sincerity, impartiality, and thorough mental
grasp.  Dr. Tuke has exhibited  the  requisite
amount of scientific address on all occasions, and
the more intricate the phenomena the more firmly
has he adhered to a  physiological and rational
method of interpretation.  Guided by an enlight-
ened deduction,  the  author has reclaimed  for
science a most interesting domain in psychology,
previously abandoned to charlatans and empirics.
This book, well conceived and well written, must
commend itself to every thoughtful understand-
ing.—New York Medical Journal, September 6,1884.
CLOUSTON,  THOMAS S.,  M. D.,  F. R. C. P., L. R. C. S.,
       Lecturer on Mental Diseases in the University of Edinburgh.
    Clinical Lectures on Mental Diseases.   With an Appendix, containing an
Abstract of the Statutes of the Tjnited States and of the Several States and Territories re-
lating to the Custody of the Insane.  By Charles F. Folsom, M. D., Assistant Professor
of Mental Diseases, Med. Dep. of Harvard Univ.  In one handsome octavo volume of 541
pages, with eight lithographic plates, four of which are beautifully colored.  Cloth,
the general practitioner in guiding him to a diag-
nosis and indicating the treatment, especially in
many obscure and doubtful cases of mental dis-
ease.  To the American reader Dr. Folsom's Ap-
pendix adds greatly to the value of the work, and
will make it a desirable addition to  every library.
—American Psychological Journal, July, 1884.
  The practitioner as well as the student will ac-
cept the plain, practical teaching of the author as a
forward step in the literature of insanity.  It is
refreshing to find a physician of Dr. Clouston's
experience and high  reputation giving  the bed-
side notes upon which his  experience has been
founded and his mature judgment  established.
Such clinical observations cannot but be useful to
     flg^Dr.  Folsom's Abstract  may also be obtained separately in one octavo volume of
108 pages.  Cloth, $1.50.____________________________

SAVAGE,  GEORGE H., M. D.,
       Lecturer on Mental Diseases at Guy's Hospital, London.
     Insanity and  Allied Neuroses, Practical and Clinical
of 551 pages, with 18 illus
Cloth, $2.00
                           In one 12mo.
See Series of Clinical Manuals, page 4.
vol.
PLAYFAIR,  W.  S.,  M.  D.,  F. R.  C.  P.
     The  Systematic Treatment  of Nerve  Prostration and Hysteria.  In
one handsome small 12mo. volume of 97 pages.  Cloth, $1.00.

     Blandford on Insanity  and its Treatment:  Lectures on the  Treatment,
Medical and Legal, of Insane Patients.  In one very handsome octavo volume. 
20             Lea  Brothers &  Co.'s Publications—Surgery.
ASHHURST,  JOHN, Jr.,  M. D.,
       Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia.
    The Principles and  Practice  of Surgery.   New (fourth) edition, enlarged
and revised.   In one large and handsome octavo volume of 1114 pages, with 597 illustra-
tions.  Cloth, $6; leather, $7 ; half Eussia, $7.50.
  As with Erichsen so with Ashhurst, its position
in professional favor is established, and one has
now but to notice the changes, if any, in theory
and practice, that are apparent in the present
as compared with the preceding edition, published
three years ago.  The work has been brought well
up to date, and is larger and better illustrated than
before, and its author may rest assured that it will
certainly have a  " continuance of the favor with
which  it has heretofore  been  received."—The
American Journal of the Medical Sciences, Jan. 1886.
  Every advance in surgery worth notice, chroni-
cled in recent literature, has been suitably recog-
nized and noted in its proper place.  Suffice it to-
gay, we regard Ashhurst's Surgery, as now pre-
sented in the fourth  edition, as the best single
volume on surgery published  in the English lan-
guage, valuable alike to the student and the prac-
titioner, to the one as  a text-book, to the other as
a manual of practical surgery.  With pleasure we
give this volume our  endorsement in full.—-New
Orleans Medical and Surgical Journal, Jan., 1886.
GROSS,  S. D.,  M.  D., LL. D.,  D.  C.  L.  Oxon.,  LL. D.

           Cantab.,
      Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia.
    A System of Surgery:  Pathological,  Diagnostic,  Therapeutic and Operative.
Sixth edition, thoroughly revised and greatly improved.   In two large and beautifully-
printed imperial octavo  volumes containing  2382 pages,  illustrated by 1623 engravings.
Strongly bound in leather,  raised bands, $15;  half Russia, raised bands, $16
  Dr. Gross' System of Suraery has long been the
standard work on that subject for students and
practitioners.—London Lancet, May 10,1884.
  The work as a whole needs no  commendation.
Many years ago it earned for itself the enviable
reputation of the leading American work on sur-
gery, and it is still capable  of maintaining that
standard.  A considerable amount of new material
has been introduced,  and altogether the distin-
guished author has reason to be satisfied that he
has placed the work fully abreast of  the state  of
our knowledge.—Med. Record, Nov. 18,1882.
  His System of Surgery, which, since its first edi-
tion  in 1859, has been a standard work in  this
country as  well as in America, in "the whole
domain of surgery," tells how earnest and labori-
ous and wise a surgeon he was, how thoroughly
he appreciated the work done by men  in other
countries, and how much he contributed to  pro-
mote the science and practice of surgery in his
own.   There has been no man to whom America
is so much indebted in this respect as the Nestor
of surgery.—British Medical Journal, May 10,1884.
DRUITT, ROBERT,  M. R.  C.  S.,  etc.
    Manual of Modern Surgery.  Twelfth edition, thoroughly revised by Stan-
ley Boyd, M. B., B. S., F. R. C. S.  In  one 8vo. volume  of 965 pages, with 373  illustra-
tions.  Cloth, $4; leather, $5.
  It is essentially a new book, rewritten from be-
ginning to end.  The editor has brought his work
up to the  latest date, and nearly every subject  on
which the student and practitioner would desire
to consult a surgical volume, has found its place
here.  The volume closes witlj about twenty pages
of formulse covering a broad  range  of practical
therapeutics.  The student will find that the new
Druitt is to this generation what the old one was
to the former,  and no higher praise need  be
accorded to any volume.—North Carolina Medical
Journal, October, 1887.
  Druitt's Surgery has been an exceedingly popu-
lar work in the profession.  It is stated that 50,000
copies have been sold in England, while in the
United States, ever since its first issue, it has been
used as a text-book to a very large extent.  Dur-
ing the late war in  this country it was so highly
appreciated that a copy was issued by the Govern-
ment to each surgeon. The present edition, while
it has the same  features peculiar to the work at
first, embodies all  recent discoveries in surgery,
and  is fully up to  the times. Cincinnati Medical
News, September, 1887.
BALL, CHARLES B., M.  Ch., Dub., F. R.  C. S. E.,
       Surgeon and Teacher at Sir P. Dun's Hospital, Dublin.
    Diseases of the Rectum and  Anus.   In  one 12mo. volume of  417  pages,
with 54 engravings and 4 colored plates.  Cloth, $2.25.  Just ready.  See Series of Clinical
Manuals, page 4.
  It is a pleasure to read an exhaustive and well-
arranged book,  such  as the one before us.   It
covers all the ground, and yet is written in aterse
and concise style that  makes it exceedingly good
reading.  The work is far in  advance of the ordi-
nary text-book on this specialty.  It is very com-
plete, and the matter is all of practical importance
and well arranged. The writer has done for rectal
surgery  what Treves in the companion volume
has done for intestinal  obstruction, and both
works are alike creditable.—N. Y. Medical Journal,
Jan. 28, 1888.
GIBNEY,  V. P., M. D„
       Surgeon to the Orthopaedic Hospital, New York, etc.
     Orthopaedic Surgery.  For the use of Practitioners and Students.
some octavo volume, profusely illustrated.   Preparing.
In one hand-
ROBERTS, JOHN B.,  A. M.,  M. D.,
       Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy.
    The Principles and Practice  of Modern Surgery.  For the use of Students
and Practitioners of Medicine and Surgery.   In one very handsome octavo volume of about
500 pages, with many illustrations.  Preparing.

BELLAMY, EDWARD,  F. R. C. S.,
       Surgeon and Lecturer on Surgery at Charing Cross Hospital, London.
    Operative  Surgery.  Shortly.   See Students' Series  of  Manuals, page 4. 
Lea Brothers & Co.'s  Publications—Surgery.             21
ERICHSEN, JOHN E., F.  R. S., F.  R.  C. S.,
       Professor of Surgery in University College, London, etc.
    The  Science and Art  of Surgery;  Being a Treatise on Surgical Injuries, Dis-
eases and Operations.   From the eighth and enlarged English edition.  In two large and
beautiful  octavo  volumes of  2316  pages,  illustrated  with  984 engravings on  wood.
Cloth, $9; leather, raised bands, $11; half  Russia, raised bands, $12
  In noticing the eighth edition  of this well-
known work, it would appear superfluous to say
more than that it has, like its predecessors, been
brought fully up to  the times, and is in conse-
quence one of the best treatises upon surgery that
has ever been penned by one man.  We have  al-
ways regarded "The  Science and Art  of Surgery"
as one of  the best surgical  text-books  in  the
English language, and this  eighth edition only
confirms  our previous opinion.  We take great
pleasure in cordially commending it to our read-
ers.— The Medical News, April 11,1885.
  After being  before  the  profession for thirty
years and maintaining during that period a re-
putation as a leading work on surgery, there is not
much to be said in the way of comment or criti-
cism. That it still holds its own goes without say-
ing.  The author infuses into it his large experi-
ence and ripe judgment.  Wedded to no school,
committed to no theory, biassed by no hobby, he
imparts an honest personality in his observations.
and his teachings are the rulings of an impartial
judge. Such men are always safe guides, and their
works stand the tests of time and experience.
Such an author is Erich sen, and such a work is his
Surgery.—Medical Record, Feb. 21,1885.
BRYANT, THOMAS, F.  R.  C. S.,
       Surgeon and Lecturer on Surgery at Guy's Hospital, London.
    The Practice  Of Surgery.  Fourth American from the fourth and revised Eng-
lish edition.  In one large and very handsome imperial octavo volume of 1040 pages, with
727 illustrations.   Cloth, $6.50; leather, $7.50; half Russia, $8.00.
  The fourth edition of this work is fully abreast
of the times.  The author handles his  subjects
with that degree of judgment and skill which is
attained by years of patient toil and varied ex-
perience.  The present edition is a thorough re-
vision of those which preceded it, with much new
matter added.  His diction is so  graceful and
logical, and his explanations are so lucid, as to
place the work among the highest order of text-
books for  the  medical  student.  Almost  every
topic in surgery is.presented in such a form as to
enable the busy practitioner to review any subject
in every-day practice in a short time.  No time is
lost with useless theories or superfluous verbiage.
In short, the work is eminently clear, logical and
practical.—Chicago Medical Journal and Examiner,
April, 1886.
TREVES,  FREDERICK, F. R. C. S.,
       Hunterian Professor at the Royal College of Surgeons of England.
    A Manual  of  Surgery.   In Treatises by Various Authors.   In three  12mo.
volumes, containing 1866  pages, with 213 engravings.  Price per volume, cloth, $2.  See
Students' Series of Manuals, page 4.
  We  have  here the opinions of thirty-three
authors, in an encyclopsedic form for  easy and
ready reference.  The three volumes embrace
every variety of surgical  affections likely to  be
met with, the paragraphs are short and pithy, and
the salient points and the  beginnings of new sub-
jects are always  printed in  extra-heavy type, so
that a person may find whatever information  he
may  be  in  need of  at a moment's glance.—Cin-
cinnati Lancet-Clinic, August 21,1886.
  The hand of Mr. Treves is evident throughout
in the choice, arrangement and logical sequence of
the subjects. Every topic, as far as observed, is
treated with a fulness or essential detail, which is
somewhat surprising. Another characteristic of the
work is the well-nigh universal acceptance of mod-
ern and progressive views of pathology and treat-
ment.  The entire work is conceived and executed
in a scientific spirit. It contains the bone and mar-
row of modern surgery.—Annals of Surgery, Oct.
1880.
BUTLIN,  HENRY T., F.  R.  C.  S.,
       Assistant Surgeon to St. Bartholomew's Hospital, London.
     Diseases  of  the  Tongue.   In one 12mo. volume of 456 pages, with 8 colored
plates and 3 woodcuts.  Cloth, $3.50.  See Series of Clinical Manuals, page 4.
  The language of the text is clear and concise, veniently scattered through general works on sur-
The author has aimed to state facts rather than to gery and the practice of medicine. The physician
express opinions, and has  compressed within the and surgeon will appreciate its value as an aid and
compass of this small volume the pathology, etiol- guide.—Physician and Surgeon, Sept. 1886.
ogy, etc., of diseases of the tongue that are  incon-
TREVES, FREDERICK,  F. R. C. S.,
       Surgeon to and Lecturer on Surgery at the London Hospital.
     Intestinal Obstruction.  In one pocket-size 12mo. volume of 522 pages, with 60
illustrations. Limp cloth, blue edges, $2.00.  See Series of Clinical Manuals, page 4.
  A standard  work on a subject that has not been
■o comprehensively treated bj
English writer.  Its compl
review difficult, since every chapter deserves mi-
nute attention, and it is impossible to do thorough
ed by any contemporary
pleteness renders a full
justice to the author in a few paragraphs. Intes-
tinal Obstruction  is a work  that  will prove of
equal value to the  practitioner, the student, the
pathologist, the physician and the operating sur-
geon.—British Medical Journal, Jan. 31,1885.
GOULD,  A. PEARCE, M.  S.,  M. B., F.  R.  C. S„
       Assistant Surgeon to Middlesex Hospital.
     Elements  of Surgical  Diagnosis.   In one pocket-size 12mo. volume of  589
pages.  Cloth, $2.00.   See Students' Series of Manuals, page 4.

PIRRIE'S  PRINCIPLES  AND PRACTICE  OF  SKEY'S OPERATIVE SURGERY. In one vol. 8vo.
  SURGERY.  Edited by John Nkill, M. D.  In   of 661 pages, with 81 woodcuts.  Cloth, $3.26.
  oneSvo vol of784pp with 316 illus.  Cloth. $3.75.  MILLER'S PRINCIPLES OF SURGERY. Fourth
MILLER'S PRACTICE OF SURGERY.  Fourth   American from the third Edinburgh edition. In
  and revised American from the last  Edinburgh   one 8vo. vol. of 638 pages, with 340 illustrations
  edition.  In one large 8vo. vol. of 682  pages, with   Cloth, $3.75.
  364 illustrations.  Cloth, $3.75. 
22    Lea Brothers  &  Co.'s Publications—Surgery, Frac, Disloc
 HOLMES,  TIMOTHY, M.  A.,
       Surgeon and Lecturer on Surgery at St. George's Hospital, London
     A System of Surgery; Theoretical and Practical.   IN TREATISES BY
 VARIOUS  AUTHORS.  American edition, thoroughly revised  and re-edited
 by  John  H.  Packard, M. D., Surgeon to the Episcopal  and  St. Joseph's Hospitals,
 Philadelphia, assisted by a corps of thirty-three of the most  eminent American surgeons.
 In  three large and very handsome  imperial octavo volumes containing  3137 double-
coiumned pages, with  979 illustrations on wood and 13 lithographic plates, beautifully
colored.  Price per set, cloth, $18.00; leather, $21.00; half  Russia, $22.50.   Sold only by
subscription.

 HAMILTON, FRANK H., M. D., LL. D.,
       Surgeon to Bellevue Hospital, New York.
     A Practical Treatise on  Fractures  and Dislocations.  Seventh edition
thoroughly revised  and much improved.  In  one very  handsome octavo volume of 998
pages, with  379 illustrations.  Cloth, $5.50; leather,  $6.50;  very handsome half Russia,
open back, $7.00.
  It is about twenty-five years ago since the first
edition of this great work appeared.  The edition
now issued is the seventh, and this fact alone is
enough to testify to the excellence of it in all par-
ticulars. Books  upon  special subjects do  not
usually command extended sale, but this one is
without a rival in any language.  It is essentially
a practical treatise, and it gathers within its covers
almost everything valuable that has been written
about fractures and dislocations.  The principles
and methods  of treatment are very fully given.
The book is so well known that it does not require
any lengthened review.  We can only say that it
is still unapproached as a treatise, and that it is a
proof of the zeal and industry ana great ability of
its distinguished  author.— The Dublin Journal ol
Medical Science, Feb. 1886.
  His  famous treatise on Fractures and Disloca-
tions, published first in 1860, is justly regarded as
the best book on that subject in existence.  It has
now run through seven editions, and has been
translated  into French and  German.—Medical
Record, Aug. 14, 1886.
S3IITH, STEPHEN, M. D.,
       Professor of Clinical Surgery in the University of the City of New York.
    The Principles and Practice of Operative  Surgery.  New (second) and
thoroughly  revised  edition.  In one very handsome octavo  volume  of  892 pages, with
1005 illustrations.   Cloth, $4.00; leather, $5.00.   Just ready.
  We have never come across a work upon surgery
that we have considered better  adapted to the
wants of the medical man and  student.   It is
replete with information of the  most valuable,
practical character, of a kind just fitted to the
wants of the every-day practitioner.  Having been
thoroughly revised  and partly rewritten, it has
the merit of being fully abreast of the times in
presenting the latest accepted views on all surgical
matters.—Cincinnati Medical News,  March, 1887.
  This work is too well and too favorably known to
require any words of commendation, and its mer-
its effectually protect it from adverse criticism.
It is a treatise upon the principles as well as the
practice of mechanical surgery. The subject mafc-
ter is brought down to the very latest period, hence
we shall find the work to be a faithful exponent
of the art of surgery as practised now.  Stephen
Smith's Operative Surgery is one of the most com-
plete works in the English language.  The descrip-
tions  of  operative  procedures  are  plain.—The
American Journal of the Medical Sciences, April, 1887.
STIMSON, LEWIS A., B. A., M. D.,
       Surgeon to the Presbyterian and Bellevue Hospitals, Piofessor of Clinical Surgery in the Medical
       Faculty of the University of the City of New  York, Corresponding Member of the Societe de
       Chirurgie of Paris.
    A Manual of Operative Surgery.   New (second) edition.  In one very hand-
some  royal  12mo. volume of  503 pages, with 342 illustrations.  Cloth, $2.50.
  There is always room for a good book, so that
while many works on operative surgery  must be
considered  superfluous, that of Dr. Stimson has
held its own.  The author knows the difficult art
of condensation.   Thus the manual serves as a
work of reference,  and at the same time as  a
handy  guide. It teaches  what it professes, the
steps of operations.  In this edition  Dr. Stimson
has sought to indicate the changes that have been
effected in operative methods and procedures by
the antiseptic system, and has added an account
of many  new operations and variations in  the
steps of older operations.  We do not desire to
extol this manual above many excellent standard
British publications of the same class, still we be-
lieve that it contains much that is worthy of imi-
tation.—British Medical Journal, Jan. 22,1887.
                              By the same Author.
    A Treatise on  Fractures  and Dislocations.   In two handsome octavo vol-
umes.   Vol. I., Fractures,  582 pages, 360 beautiful illustrations.  Vol. II.,  Disloca-
tions, 540 pages, with  163 illustrations.  Complete work just ready, cloth, $5.50; leather,
$7.50.   Either volume separately, cloth, $3.00; leather, $4.00.
  The author has given to the medical profession
in this treatise on fractures what is likely to be-
come a standard work on the subject. Itis certainly
not surpassed by any work written in the English,
or, for that matter, any other language.  The au-
thor tells us in a short, concise and comprehensive
manner, all that is known about his subject.   There
Is nothing scanty or superficial about it, as in most
other treatises; on the contrary, everything is thor-
ough. The chapters on repair of fractures and their
treatment show him not only to be a profound stu-
dent, but likewise a practical surgeon and patholo-
gist. His mode of treatment of the different fract-
ures is eminently sound and practical. We consider
this work one of the best on fractures ; and it will
be welcomed not only as a text-book, but also by
the surgeon in full practice.—N. O. Medical and
Surgical Journal, March, 1883.
MARSH,  HOWARD,  F. R.  C.  S.,
       Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London.
     Diseases of the Joints.   In one 12mo. volume of 468 pages, with 64 woodcuts
and a colored plate.  Cloth, $2.00.  See Series of Clinical Manuals, page 4.

PICK,  T. PICKERING,  F. R. C. S.,
       Surgeon to and Lecturer on Surqery at St. George's Hospital, London.
     Fractures and Dislocations.   In one 12mo. volume  of 530  pages, with  93
illustrations.  Limp cloth, $2.00.  See Series of  Clinical Manuals, page 4. 
Lea Brothers & Co.'s Publications—Otol., Ophthal.         23
BURNETT,  CHARLES  H.,  A. M., M.  D.,
       Professor of Otology in the Philadelphia Polyclinic; President of the American Otological Society.
    The Ear, Its Anatomy, Physiology and Diseases.   A Practical Treatise
for the use of Medical Students and Practitioners. New (second) edition.  In one handsome
octavo volume of 580 pages, with 107 illustrations.  Cloth, $4.00; leather, $5.00.
  We note with pleasure the appearance of a second
edition of this valuable work.  When it first came
out it was accepted by the  profession as one of
the standard works on modern aural surgery in
the English language; and in his second edition
Dr. Burnett has fully  maintained his reputation,
for the book is replete with  valuable information
and suggestions.  The revision has been carefully
carried out, and much new matter added.  Dr.
Burnett's work must be regarded as a very valua-
ble  contribution to aural surgery, not only on
account of its comprehensiveness, but because it
contains the results of the careful personal observa-
tion and experience of this eminent aural surgeon.
—London Lancet, Feb. 21,1885.
POLITZER,  ADAM,
      Imperial-Royal Prof, of Aural Therap. in the Univ. of Vienna.
    A Text-Book of the Ear and its Diseases.  Translated, at the Author's re-
quest, by James Patterson Cassells, M. D., M. R. C. S.  In one handsome octavo vol-
ume of 800 pages, with 257 original illustrations.  Cloth, $5.50.
                                            section, and this again by the pathological physi-
                                            ology, an arrangement which serves to keep up the
                                            interest of the student by showing the direct ap-
                                            plication of what has preceded to the study of dis-
                                            ease. The whole work can be recommended as a
                                            reliable guide to the student, and an efficient aid
                                            to the practitioner in his treatment.—Boston Med-
 The work itself we do not hesitate to pronounce
the best upon the subject of aural diseases which
has ever appeared, systematic without being too
diffuse  on obsolete subjects, and eminently prac-
tical  in every sense. The anatomical descriptions
of each separate division of the ear are admirable,
and profusely illustrated by woodcuts. They are
followed immediately by the physiology  of the
ical and Surgical Journal, June 7,1883.
JULER, HENRY E.,  F. R.  C. S.,
       Senior Ass't Surgeon, Royal Westminster Ophthalmic Hosp.; la-te Clinical Ass't, Moorfields, London.
    A Handbook of Ophthalmic Science and Practice.   In one handsome
octavo volume of 460 pages, with 125 woodcuts,  27 colored  plates, selections from the
Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test.  Cloth, $4.50;
leather, $5.50.              _________________________

NETTLESHIP, EDWARD, F. R. C. S.,
       Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas' Hospital, London.
    The Student's  Guide to Diseases of the Eye.   New (third) edition, thor-
oughly revised.   With  a chapter on  the Detection of  Color-Blindness, by William
Thomson, M. D., Professor of Ophthalmology in the Jefferson  Medical  College.    In one
12mo. volume of 479 pages, with  164 illust., test-types and formulae. Cloth, $2.  Just ready.
  In the small work before us we have combined
simplicity  of  description with thoroughness of
instruction. It is such a book as any intelligent
student can read with profit to himself.—St. Louis
Medical and Surgical Journal, Oct. 1887.
  This excellent and trustworthy manual is ad-
dressed to students, but is equally suited to the
needs of practitioners, who will find in its pages
much valuable instruction.  The style of the au-
thor is pleasant, and the matter of  his book is
admirable.—Medical and Surgical  Reporter, Oct. 1,
1887.
NORRIS, WM. F.,  M. D.,  and  OLIVER, CHAS. A., M. D.
       Clin. Prof, of Ophthalmology in Univ..of Pa.
    A  Text-Book  Of Ophthalmology.   In one octavo volume of about 500 pages,
with illustrations.  Preparing.__________________________

CARTER, R. BRUDENELL,  &  FROST, W.ADAMS,
                                 F. R.  C. S.,                     F. R. C. S.,
                                                    Assistant Ophthalmic Surgeon to and Joint
                                                    Lecturer  on  Ophthalmic Surgery at St.
                                                    George's Hospital, London.
Ophthalmic Surgeon to and Lecturer on Oph-
thalmic Surgery at St. George's  Hospital,
       London.
     Ophthalmic Surgery.  In  one 12mo. volume of 559 pages, with 91 woodcuts,
color blindness test, test-types and dots and appendix of formulae.  Just ready.   Cloth,
$2.25.  See Series of Clinical Manuals, page 4._____________

WELLS, J. SOELBERG, F. R.  C. S„
       Professor of Ophthalmology in King's College Hospital, London, etc.
     A Treatise on Diseases  of the Eye.   New (fifth) American from the third
London edition.   In one large octavo volume.  Preparing.

BROWNE, EDGAR A.,
       Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skm Diseases.
     How to Use the Ophthalmoscope.  Being Elementary Instructions in Oph-
thalmoscopy, arranged for  the  use of Students.  In  one small royal 12mo. volume  of 116
pages, with 35 illustrations.  Cloth, $1.00.
LAURENCE AND MOON'S HANDY BOOK. OF
  OPHTHALMIC SURGERY, for the use of Prac-
  titioners.  Second edition.  In  one  octavo vol-
  ume of 227 pages, with 65 illust. Cloth, $2.75.
LAWSON ON INJURIES TO THE EYE, ORBIT
  AND EYELIDS: Their Immediate and Remote
  Effects. 8 vo., 404 pp., 92 illus.  Cloth, $3.50. 
24   Lea  Brothers & Co.'s Publications—Urin. Dis., Dentistry, etc.
ROBERTS,  WILLIAM, M. D.,
      Lecturer on Medicine in the Manchester School of Medicine, etc.
    A Practical Treatise on Urinary and Renal Diseases, including Uri
nary Deposits.   Fourth American from the fourth London edition.   In one  hand'
some octavo volume of 609 pages, with 81  illustrations. Cloth, $3.50.
  The previous editions of this book have made it
bo familiar to and so highly esteemed by the med-
ical public, that little more is necessary than  a
mere  announcement of the appearance of this,
their successor. But it is pleasant to be able to
say that, good as those were, this is still better
In fact, we think it may be said to be the best book
In print on the subject of which it treats.—The
American Journal of the Medical Sciences.—Jan. 1886.
  The peculiar value and finish of the book are in
a measure derived from its resolute maintenance
of a clinical and practical character.  It is an un-
rivalled  exposition  of everything which relates
directly  or indirectly to the diagnosis, prognosis
and treatment of urinary diseases, and possesses
a completeness not found elsewhere in our lan-
guage in its account of the different affections.—
The Manchester Medical Chronicle, July, 1885.
PURDY,   CHARLES  W., M.  D.
    Bright's Disease and Allied Affections of the Kidneys.   In one octavo
volume of 288 pages, with illustrations.  Cloth, $2.
                                           short space the theories, facts and treatments, and
  The object of this work is to "furnish a system-
atic,  practical and  concise description  of  the
pathology and treatment of  the  chief organic
diseases of the kidney associated with albuminu-
ria, which shall represent the  most  recent ad-
vances in our knowledge on these subjects ;" and
this definition of the object is a fair description of
the book. The work is a useful one, giving in a
going more fully into their later developments.
On treatment the writer  is particularly strong,
steering clear of  generalities, and seldom omit-
ting, what text-books usually do, the unimportant
items which are all important to the general prac-
titioner.— The Manchester  Medical Chronicle, Oct.,
1886.
MORRIS,  HENRY,  M.  B., F. R. C.  S.,
      Surgeon to and Lecturer on Surgery at Middlesex Hospital, London.
    Surgical Diseases of the Kidney.   In one 12mo. volume of 554 pages, with 40
woodcuts, and 6 colored plates. Limp  cloth, $2.25.  See <Smes of Clinical Manuals, page 4.
                                           he took in hand.   It is a full and  trustworthy
                                           book of reference, both  for students and  prac-
                                           titioners in search of guidance.  The illustrations
                                           in the text and the chromo-lithographs are beau-
                                           tifully executed.—The London Lancet, Feb. 26,1886.
  In  this manual we have a distinct addition to
surgical literature, which gives information riot
elsewhere to be met with in a single work.  Such
a book  was distinctly required, and  Mr. Morris
has very diligently and ably performed  the task
LUCAS,  CLEMENT,  M. B., B. S., F. R. C.  S.,
      Senior Assistant Surgeon to Guy's Hospital, London.
    Diseases  of the  Urethra.   In one  12mo.  volume.   Preparing.   See  Series
of Clinical Manuals, page 4.

THOMPSON,  SIR HENRY,
      Surgeon and Professor of Clinical Surgery to University College Hospital, London.
    Lectures on Diseases of the Urinary Organs.   Second American from the
third English edition.   In one 8vo. volume of 203 pp., with 25 illustrations.  Cloth, $2.25.

                              By the Same Author.
    On the Pathology and  Treatment of  Stricture of the Urethra and
Urinary Fistulae.   From the third English edition.  In one octavo volume of 359
pages, with  47 cuts and 3 plates.  Cloth, $3.50.

THE  AMERICAN  SYSTEM  OF DENTISTRY.
    In Treatises by Various  Authors.  Edited  by  Wilbur F. Litch, M. D.,
D. D. S.,  Professor of Prosthetic Dentistry, Materia Medica and  Therapeutics in the
Pennsylvania Collegeof Dental Surgery.  In three  very handsome  octavo volumes con-
taining  3160 pages, with 1863 illustrations and 9 full page plates.   Per volume, cloth, $6;
leather,  $7 ; half Morocco,  gilt top,  $8.  The complete work is now ready.  For sale by
subscription only.
  As an encyclopsedia of Dentistry it has no su-
 fierior.  It should form  a part of every dentist's
 ibrary, as the information it contains is of the
greatest value to all engaged in the practice of
dentistry.—American Journal of Dental Science,
September, 1886.
  A grand system, big enough and good enough
and handsome enough  for a monument (which
doubtless it is), to mark an epoch in the history of
dentistry.  Dentists will  be  satisfied with it and
proud of it—they must.  It is sure to be precisely
what the student needs to put him and  keep him
in the right track,  while the profession at large
will receive incalculable benefit from it.—Odonto-
graphy Journal, Jan. 1887.
COLEMAN,  A., L. R.  C.  P., F. R.  C.  S., Exam. L. D.  S.,
      Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London.
    A Manual of Dental Surgery and Pathology.  Thoroughly  revised  and
adapted to the  use  of American Students, by Thomas C.  Stellwagen, M. A., M. D.,
D. D. K., Prof, of Physiology at the Philadelphia Dental College.   In one handsome octavo
volume of 412 pages, with 331 illustrations.  Cloth, $3.25.
ESMARCH,  Dr.  FRIEDRICH,
       Professor of Surgery at the University of Kiel, etc.
    Early Aid  in Injuries  and Accidents.   Five Ambulance Lectures.  Trans-
lated by H. R. H. Princess Christian.  In one handsome  small 12mo. volume of 109
pages,  with 24 illustrations.   Cloth, 75 cents.

BASHAM  ON  RENAL  DISEASES : A Clinical  I  one 12mo. vol. of 304 pages, with 21 illustration*.
  Guide to  their Diagnosis  and  Treatment.  In  |  Cloth, 82.00. 
Lea  Brothers & Co.'s Publications—Venereal, Impotence.      25
GROSS,  SAMUEL  W.,  A.  M.,  M.  D„ LL. D.,
  Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Phila.

     u  Practical Treatise on Impotence, Sterility, and Allied Disorders
Of the Male Sexual Organs.  New (third) edition, thoroughly revised.  In one very
handsome  octavo volume of 163 pages, with 16 illustrations.   Cloth, $1.50.
  We must  congratulate the author that another i that it has been translated into Russian may indi-
fvT  i?n   •       made necessary.  The tone of | cate that it filled a void even in foreign literature.
the book is healthy, and a  cheerful prognosis is  His is a careful and physiological study of the
given of many of the affections of which it treats,  sexual act, so far as concerns the male, and all
We feel confident that the book will continue to  his conclusions are scientifically reached.  The
sell on its merits.—N.  Y. Med. Journal, June 18,1887.  book has  a place by itself in our literature, and
  It must be gratifying to both author and pub-  furnishes a large fund of information concerning
ushers that large first and second editions of this  important matters that are too often passed over
little work were so soon exhausted, while the fact  in  silence.—The Medical Press, June, 1887.
BUMSTEAD, F.  J.,
             M. D.,  LL.  D.,
       Late Professor of Venereal Diseases
       at  the College of Physicians  and
       Surgeons, New York, etc.
and         TAYLOR,  R.  W.,
                          A. M.,  M.  D.,
        Surgeon to Charity Hospital, New York, Prof, oj
        Venereal and Skin Diseases in the  University oj
        Vermont, Pres. of the Am. Dermatological Ass'n.
    The Pathology  and Treatment of Venereal Diseases.   Including  the
results of recent investigations upon the subject.  Fifth edition,  revised and largely re-
written,  by Dr. Taylor.   In one  large and handsome octavo volume of 898 pages with
139 illustrations, and thirteen chromo-lithographic figures.  Cloth, $4.75; leather, $5.75;
very handsome half Russia, $6.25.
  It is a splendid record of honest  labor, wide
research, just comparison,  careful scrutiny and
original experience, which will always be held as
a high credit to American medical literature. This
is not only the best work in the English language
upon the subjects of which it treats, but also one
which has no equal in other tongues for its clear,
comprehensive  and practical  handling of  its
themes.—Am. Jour, of the Med. Sciences, Jan, 1884.
  It is certainly the best single treatise on vene-
real in our own, and probably the best in any lan-
guage.—Boston Med. and Surg. Journal, April 3,1884.
  The character of this standard work  is so well
known that it would be superfluous here to pass in
review its general or special points of excellence.
The verdict of the profession has been passed; it
has been accepted as the most thorough and com-
plete exposition of the pathology and treatment of
venereal diseases in the language. Admirable as a
model of clear description, an exponent of sound
pathological doctrine, and a guide for rational and
successful treatment, itisanornamenttothe medi-
cal literature of this country.  The additions made
to the present edition are eminently judicious,
from the standpoint of practical utility.—Journal of
Cutaneous and Venereal  Diseases, Jan. 1884.
CORNIL,  V.,
       Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital.
    Syphilis, its Morbid Anatomy, Diagnosis and Treatment.   Specially
revised by the Author, and translated with notes and additions by J. Henry C. Simes,
M. D., Demonstrator of Pathological Histology in the  University of Pennsylvania, and
J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of  Surgery
in the University of Pennsylvania.  In one handsome octavo volume of 461 pages, with
84 very beautiful illustrations.   Cloth, $3.75.
                                            perusal without the feeling that his grasp of the
                                            wide and important subject on which it treats is
                                            a stronger and surer one.—The London Practv-
  The anatomy, the histology, the pathology and
the clinical features of syphilis are represented in
this work in their best, most practical and  most
instructive form, and no one will rise  from its
tioner, Jan. 1882.
HUTCHINSON,  JONATHAN,  F. R. S.,  F. R.  C. S.,
       Consulting Surgeon to the London Hospital.

    Syphilis.  In one 12mo. volume of 542  pages, with 8 chromo-lithographs.  Cloth,
$2.25.   See Series of Clinical Manuals, page 4.
  Those who have seen most of the disease and  and power of observation, but of his patience and
those who have felt the real difficulties of diagno-  assiduity in taking notes of his cases and keep-
sis and treatment will most highly appreciate the  ing them  in a form  available for such excellent
facts and suggestions  which  abound  in  these  use as he has put them to in this volume.—London
pages.  It is a worthy and  valuable record, not  Medical Record, Nov. 12, 1887.
only of Mr. Hutchinson's very large experience
GROSS,  S.  D.,  M.  D., LL.  D„  D. C. L., etc.
    A Practical  Treatise on the  Diseases,  Injuries  and Malformations
of the  Urinary  Bladder, the  Prostate Gland and  the  Urethra.  Third
edition, thoroughly  revised by Samuel W. Gross, M. D.  In one octavo volume of 574
pai;us, with 170 illustrations.   Cloth,  $4.50._____________

CULLERIER,  A., & BUMSTEAD, F. J., M.D., LL.D.,
      Surgeon to the Hopital du Midi.    Late Professor of Venereal Diseases in the College of Physician*
                                    and Surgeons, Neuo York.
    An Atlas of Venereal Diseases.  Translated and  edited by Freeman J. Bum-
BTEAii, M. D.  In one imperial 4to. volume of 328 pages, double-columns, with 26 plates,
containing about 150 figures, beautifully colored, many of them the size  of life.  Strongly
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts.

HILL ON SYPHILIS AND  LOCAL CONTAGIOUS FORMS OF   LOCAL  DISEASE  AFFECTING
  DISORDERS. In one8vo vol.of479p. Cloth.83.25. PRINCIPALLY  THE ORGANS OF GENERA-
LEE'S LECTURES ON SYPHILIS AND SOME | TION.  In one 8vo. vol. of 246 pages. Cloth, 82 26. 
26         Lea Brothers & Co.'s Publications—Venereal,  Skin.
TAYLOR,  ROBERT W.,  A.M.,  M.  D.,
      Surgeon 10 Charity Hospital, New York, and to the Department of Venereal and Skin Diseases of
      the New York Hospital.
    A Clinical Atlas of Venereal and Skin Diseases:  Including Diagnosis,
Prognosis and  Treatment.  In eight large folio parts,  measuring  14 x  18  inches, and
comprising  58  beautifully-colored  plates with 192 figures,  65 engravings and 400 pages
of text.  Price per part, $2.50.  Parts  I. and II. shortly.   For sale by subscription only.
Specimen plates sent on receipt of 10 cents.
    The early appearance of this great work will mark an era in the history of its subjects.
It will afford to all  English-speaking practitioners and specialists their first opportunity
of procuring a work in which life-like pictures  of all venereal and skin diseases are
accompanied by a text  altogether satisfactory on  the practical side of these  troublesome
affections.   Other distinguishing features  of  this Atlas will  be the abundance  and size
of its colored plates, and the  beauty of their execution.  Being chosen  with a view to
presenting typical  cases rather than mere medical curiosities, they will  furnish a vivid
and ready means of recognizing the various affections as they appear  in  life.  The text
will be principally confined to a terse and definite statement of diagnosis and treatment,
and it will be further illustrated by a large number of engravings executed in a size and
style  thoroughly in keeping with the nature of the work.   The Atlas_ will be sold by
subscription only, and  in due  course every member of the profession will be personally
visited and offered an  opportunity to procure this  most useful addition  to his  working
library.  A full prospectus is now ready for distribution  on application.


KAPOSI, MORIZ,
     Of Vienna.

    The Pathology  and  Treatment of Diseases  of the Skin.   For the use
of Practitioners and Students.   Translated, with the author's permission, by W.  Xavier
Sudduth, M. D., F.R.  M. S.   In one octavo volume of  about 600 pages, with 74 engrav-
ings and 8 colored plates.  Preparing.


HYDE, J. NEVINS,  A. M.,  M. D.,
       Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago.
    A Practical Treatise on Diseases  of the Skin.  For the use  of Students and
Practitioners.  New (second) edition.  In  one handsome  octavo  volume of about 600
pages, with  2  colored  plates  and 85 beautiful and elaborate illustrations.   Just ready.
Cloth, $4.50; leather, $5.50.
     A few notices of the previous edition are appended  :
  The author has given the  student and practi-
tioner a work admirably adapted to the wants of
each.  We can heartily commend the book as a
valuable addition to our literature and a reliable
guide to students and practitioners in their studies
by his detailed descriptions of therapeutic meas-
ures has adapted them to the needs of the physi-
cian in active practice.  In dealing with these
questions the author leaves nothing to the pre-
sumed knowledge of the reader, but enters thor-
and practice.—Am. Journ. of Med. Sci., July, 1883.    oughly into the most minute description, so that
  The aim of the author has been to present to his  one is not only told what should be done under
readers a work  not only  expounding  the most  given conditions but how to do it as well.  It is
modern conceptions of his subject, but presenting  therefore in the best sense "a practical treatise."
what is of standard value.  He has more especially  That it is comprehensive, a glance at the index
devoted its pages to the treatment of disease, and | will show.—Maryland Medical Journal, July 7,1883.
FOX,  T.,  M.D.,F.R.C.P.,andFOX,T.C.,B.A.,M.R.C.S.,
   Physician to the Department for Skin Diseases,         Physician for Diseases of the Skin to the
       University College Hospital, London.                  Westminster Hospital, London.

    An Epitome of Skin Diseases.  "With  Formulae.  For Students and Prac-
titioners.   Third edition, revised and enlarged.  In one very handsome 12mo. volume
of 238 pages.  Cloth, $1.25.
                                           manual to lie upon the table for instant reference.
                                           Its alphabetical arrangement is suited to this use,
                                           for all one has to know is the name of the disease,
                                           and here are its description and the appropriate
                                           treatment at hand and ready for instant applica-
                                           tion.  The present edition  has been very carefully
                                           revised and a number of new diseases  are de-
                                           scribed,  while most of the  recent additions to
                                           dermal therapeutics find mention, and the formu-
                                           lary at the end of the book has been considerably
                                           augmented.—The Medical News, December, 1883.
  The third edition of this convenient handbook
calls for notice owing to the revision and expansion
which it has undergone. The arrangement of skin
diseases in alphabetical order, which is the method
of classification adopted in this work, becomes a
positive advantage to the  student.  The book is
one which we can strongly recommend,  not only
to students but also to practitioners who require a
compendious summary of the  present  state of
dermatology.—British Medical Journal, July 2,1883.
  We cordially recommend Fox's Epitome to those
whose  time is  limited and who wish  a handy
WILSON,  ERASMUS,  F. R. S.
    The Student's Book of Cutaneous Medicine and Diseases of the Skin.
In one handsome small octavo volume of 535 pages.   Cloth, $3.50.
HILLIER,  THOMAS,  M.  D.,
       Physician to the Skin Department of University College, London.
     Handbook of  Skin Diseases; for Students and Practitioners.   Second Ameri-
can edition.  In one 12mo. volume of 353 pages, with plates.  Cloth, $2.25. 
Lea Brothers & Co.'s Publications—Dis. of Women.         27
The American  Systems  of Gynecology and  Obstetrics.
A«+?ystei?;s  of gynecology  and Obstetrics, in Treatises by American
  a  ^      gynecology edited by Matthew D. Manx, A.M., M.D., Professor of Obstetrics
ana  gynecology in  the Medical Department of the University of Buffalo; and Obstet-
rics edited by Barton Cooke Hirst, M. D., Obstetrician to the Philadelphia and to the
Maternity Hospitals, Philadelphia.   In four very handsome octavo volumes of about 800
pages each, fully illustrated by wood engravings and colored plates.  Volume I. of the
gynecology, containing 784 pages, with 201 engravings on wood and 3 colored plates, is
now ready.  Volume  I. of the Obstetrics ready shortly.   The subsequent volumes are to
follow at regular intervals.   Prices per volume:  Cloth, $5.00; leather, $6.00; half Russia,
|7.00.  For sale by subscription  only.  Address the Publishers.   Full descriptive circular
tree on application.
                              list of contributors.
       WILLIAM H. BAKER, M. D..
       ROBERT BATTEY, M. D.,
       SAMUEL C BUSEY, M. D.,
       JAMES C CAMERON, M. D.,
       HENRY C. COE, A. M., M. D.
       E. C. DUDLEY, A. B., M.  D .
       EDWARD S.  DUNSTER, M. D.,
       B. McE. EMMET, M. D.,
       GEORGE J. ENGELMANN, M. D..
       HAROLD C. ERNST, M. D.,
       HENRY J. GARR1GUES,  A. M., M. D.,
       WILLIAM GOODELL, A.  M., M. D.,
       EGBERT H.  GRANDIN, A. M., M. D.,
       CHARLES M. GREEN, M. D.,
       SAMUEL W.  GROSS, M. D.,
       ROBERT P. HARRIS, M.  D.,
       GEORGE T.  HARRISON, M. D.,
       BARTON C. HIRST, M. D.
       STEPHEN Y. HOWELL, M. D.,
       A. REEVES JACKSON, A. M., M. D.,
       W. W. JAGGARD, M. D ,
       EDWARD W. JENKS, M. D., LL. D.,
  In our notice of the "System of  Practical Medi-
cine by American Authors," we made the  follow-
ing statement:—"It is a work of  which the oro-
fession in this country can feel proud. Written
exclusively  by American physicians who  are ac-
quainted with all the varieties of climate in  the
United States, the character of the soil, the man-
ners  and customs of the people, etc., it is pecul-
iarly adapted to the wants of American practition-
ers of medicine, and it seems to us that every  one
of them would desire to  have it."  Every word
thus  expressed in regard to the "American Sys-
tem of Practical  Medicine" is applicable to  the
"System of  Gynecology by  American Authors,"
      HOWARD A. KELLY, M. D.,
      CHARLES CARROLL LEE, M. D.,
      WILLIAM T. LU8K, M. D., LL. D.,
      MATTHEW D. MANN. A. M., M. D.,
      H.  NEWELL MARTIN,  F. R.  S., M. D.,
          D.Sc, M.A.,
      RICHARD B. MAURY, M. D.,
      C. D. PALMER, M. D.,
      ROSWELL PARK, M. D.,
      THEOPHILUS PARVIN, M. D., LL. D.,
      R. A. F.  PENROSE, M. D., LL. D.,
      THADDEUS A. REAMY,  A. M., M. D.,
      J. C. REEVE,  M. D.,
      WILLIAM L. RICHARDSON, M. D.,
      A. D. ROCKWELL, A. M., M. D.,
      ALEXANDER J. C.  SKENE, M. D.,
      J. LEWIS SMITH,  M. D.,
      R.  STANSBURY  SUTTON, A.  M., M. D.,
          LL. D.,
      T. GAILLARD THOMAS, M. D.. LL. D.,
      ELY VAN DE WARKER, M. D.,
      W.  GILL WYLIE, M. D.
which we desire now to bring to  the attention of
our readers.  It, like the other, has been written
exclusively by  American   physicians who  are
acquainted with all the characteristics of American
people, who are  well  informed in regard to  the
peculiarities of American women, their manners,
customs, modes  of living, etc. As  every practis-
ing physician is called upon to treat diseases of
females,  and a-i they constitute a class to which
the familly physician must give attention, and
cannot pass over  to a specialist, we do not know of
a work in  any department  of medicine that we
should so strongly recommend medical men  gen-
erally purchasing.—Cincinnati Med. News, July,1887.
THOMAS, T. GAILLARD, M. D.,
       Professor of Diseases of Women in the College of Physicians and Surgeons,'N. Y.
    A Practical Treatise on the Diseases of Women.  Fifth edition, thoroughly
revised and rewritten.  In one large and handsome octavo volume of 810 pages, with  266
illustrations.  Cloth, $5.00; leather, $6.00; very handsome half Russia, raised bands, $6.50.
                                              That the previous editions of the treatise of Dr.
                                            Thomas were thought worthy of translation  into
                                            German, French,  Italian and Spanish, is enough
                                            to give it the stamp of genuine merit.  At home it
                                            has made its way into the library of every obstet-
                                            rician and gynaecologist as a safe guide to practice.
                                            No small number of additions have been made to
  The words which follow " fifth  edition" are in
this case no mere  formal announcement.  The
alterations and additions which have been made are
both  numerous and important.   The  attraction
and the permanent character of this book lie in
the clearness and truth of the clinical descriptions
of diseases; the fertility of the author in thera-
peutic resources and the fulness with which the
details  of treatment are described; the definite
character of the teaching;  and last, but not least,
the evident  candor which pervades it.—London
Medical Times and Gazette, July 30,1881.
the present edition to make it correspond to re-
cent improvements in treatment.—Pacific Medical
and Surgical Journal, Jan. 1881.
EDIS, ARTHUR  W., M.  D., Loud.,  F.R. C.P., M.R. C.S.,
       Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital.
     The Diseases  of Women.  Including their Pathology, Causation, Symptoms,
Diagnosis and Treatment.  A  Manual for Students and  Practitioners.  In one handsome
octavo volume of 576 pages, with 148  illustrations.  Cloth, $3.00; leather, $4.00.
  It is a  pleasure to read a book so thoroughly
good as this one.  The special qualities which are
conspicuous are  thoroughness in covering  the
whole ground, clearness of description and con-
ciseness of statement.  Another marked feature of
the book is the  attention  paid to the details of
many  minor surgical operations and procedures,
as, for instance,  the use of tents, application of
leeches, and use of hot water injections.  These ]
are among the more common methods of treat-
ment, and yet very little is said about them in
many of the textbooks.  The book is one to be
warmly recommended especially to students and
general practitioners, who need a concise but com-
plete resumt of the whole  subject. Specialists, too,
will find many useful hints in its pages.—Boston
Med. and Surg. Journ., March 2,1882.
BARNES, ROBERT, M. D., F. R.  C. P.,
       Obstetric Physician to St. Thomas' Hospital, London, etc.
    A Clinical Exposition of the Medical and Surgical Diseases of Women.
In one handsome octavo volume, with numerous illustrations.  New edition.  Preparing. 
28      Lea Brothers & Co.'s Publications—Dis. of Women, Midwfy.
EMMET,  THOMAS ADDIS,  M.  D., LL.  D.,
      Surgeon to the Woman's Hospital, New York, etc.
    The Principles and Practice of Gynaecology; For the use of Students and
Practitioners of Medici ne.   New (third) edition, thoroughly revised.  1 n one large and very
handsome octavo volume of 880 pages, with  150 illustrations.   Cloth, $5;  leather, $6;
very handsome half Russia, raised  bands, $6.50.
                                           only with honesty of purpose, but with a conscien-
                                           tious sense of responsibility, and a book that is at
                                           once a credit to its  author and to American med-
                                           ical literature.  We repeat that it is a book to be
                                           studied, and one that  is indispensable to every
                                           practitioner giving any attention to gynaecology.—
                                           American Journal of the Medical Sciences, April, 1885.
                                             The time has passed when Emmet's Gynaecology
                                           was to be regarded as a book for a single country
                                           or for a single generation.  It has always been his
                                           aim to popularize gynaecology, to bring it within
                                           easy reach of the general practitioner.  The orig-
                                           inality of the ideas compels our admiration and
                                           respect.  We  may   well take an honest pride in
                                           Dr. Emmet's  work and feel that his  book can
                                           hold its own against the criticism of two conti-
                                           nents.  It represents all that is most earnest and
                                           most thoughtful in American gynaecology.—Amer-
                                           ican Journal of Obstetrics, May, 1885.
  We are in douot whether to congratulate the
author more than the profession upon the appear-
ance of the third edition of this well-known work.
Embodying, as it does, the life-long experience of
one who has conspicuously distinguished himself
as a bold and successful  operator, and who has
devoted so much attention  to the specialty,  we
feel sure the profession will not fail to appreciate
the privilege thus offered them of perusing the
views and practice of the author. His  earnestness
of purpose and conscientiousness  are manifest.
He gives not only his individual experience but
endeavors to represent the actual state  of gynae-
cological  science and art.—British Medical Jour-
nal, May 16, 1885.
  No jot or tittle of the high praise  bestowed upon
the first edition is abated.  It is still a book of
marked personality, one based upon large clinical
experience, containing  large and valuable ad-
ditions to our knowledge, evidently  written not
DUNCAN, J. MATTHEWS, M.D., LL. D., I. R. S. E., etc.
    Clinical  Lectures on the Diseases of Women; Delivered  in  Saint Bar-
tholomew's Hospital.   In one handsome octavo volume of 175 pages.  Cloth, $1.50.
  They are in every way worthy ol their author ; I rule, adequately handled in the text-books; others
                                           of them, while bearing upon topics that are usually
                                           treated of at length in such works, yet bear such a
                                           stamp of individuality that they deserve to  be
indeed, we look upon  them as among the most
valuable of his contributions.  They are all upon
matters of great interest to the general practitioner.
Some of them deal with subjects that are not, as a
widely read.—N. Y. Medical Journal, March, 1880.
MAY,  CHARLES  H.,  M.  D.
       Late House Surgeon to Mount Sinai Hospital, New York.
    A Manual of the Diseases of Women.  Being a concise and systematic expo-
sition of the theory and practice  of gynaecology.   In one  12mo. volume of 342  pages;
Cloth,  $1.75.
  Medical students will find this work adapted to
their wants.  Also practitioners of medicine will
find it exceedingly convenient to consult for the
purpose of refreshing their minds upon the lead-
ing points of a gynaecological subject.  By syste-
matic condensation, the omission of disputed ques-
tions, and the presentation only of accepted views,
it constitutes a very satisfactory exposition of the
leading principles of gynaecology as they  are un-
derstood at the present time.—Cincinnati Medical
News, Nov. 1885.
HODGE, HUGHL.,  M.  D.,
       Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania.
    On Diseases Peculiar to Women j Including Displacements of the  Uterus.
Second edition, revised and enlarged.  In one beautifully printed octavo volume of 51
pages, with original illustrations.  Cloth, $4.50.

                              By the Same Author.
    The Principles and  Practice  of Obstetrics.  Illustrated with  large litho-
graphic plates containing 159  figures from original photographs, and with numerous wood-
cuts.   In one large  quarto volume  of 542 double-columned pages.   Strongly bound  in
cloth, $14.00.  Specimens of the plates and letter-press will be forwarded to any address,
free by mail, on receipt of six cents in postage stamps.

RAMSBOTHAM, FRANCIS H.,  M. D.
    The Principles  and Practice of  Obstetric Medicine and  Surgery:
In reference to the Process of Parturition.  A new and enlarged edition, thoroughly revised
by the Author.   With additions by W. V. Keating, M. D.,  Professor of Obstetrics, etc.,
in the Jefferson  Medical  College of  Philadelphia.   In one large and  handsome imperial
octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain-
ing in all nearly  200  beautiful figures.  Strongly  bound in leather, with raised bands, $7.

WINCKEL, F.
    A Complete Treatise  on the Pathology and Treatment of  Childbed,
For Students and  Practitioners.  Translated, with the consent of the Author, from the
second German edition, by J.  R. Chadwick,  M. D.  Octavo 484 pages.  Cloth, $4.00.

WEST,  CHARLESj, M. D.
    Lectures on the Diseases of Women.   Third American from the third  Lon-
don edition.   In  one  octavo volume of 543 pages.  Cloth, $3.75; leather, $4.75.
ASHWELL'S PRACTICAL TREATISE ON THE
  DISEASES PECULIAR  TO WOMEN.  Third
  American from  the third and  revised  London
  edition.  In one 8vo. vol., pp. 520.  Cloth, 83.50.
CHURCHILL  ON  THE  PUERPERAL FEVER
 AND OTHER DISEASES PECULIAR TO  WO-
 MEN.  In one 8vo. vol. of 464 pages.  Cloth, $2.50.
MEIGS ON THE NATURE, SIGNS AND TREAT-
 MENT OF CHILDBED FEVER.  In one 8vo.
 volume of 346 pages.  Cloth, $2.00. 
Lea  Brothers  &  Co.'s  Publications—Midwifery.
29
PAR VIN, THEOPHILUS, M.  D.,  LL.  D.,
       Prof, of Obstetrics and the Diseases of Women and Children in Jefferson Med. Coll., Phila.

     Th® ^£}fnce  and  Art of Obstetrics.  In  one  handsome 8vo. volume of 697
pages, with. 214 engravings and a colored plate.   Cloth, $4.25; leather, $5.25.

rnlnilf ri-ft! harTe8t ^at Dr. Parvin offers to his
r!^mL  .i! 1!Lno book that can be more safely
toft^ nde*d to,tl?e 8tudent or that can be turned
to in moments of doubt with greater assurance of
£ii\,   \-S a lbei-al digest of safe counsel that has
Jrf «  ^Jtienrty gathered.- The American  Journal
oj the Medical Sciences, July, 1887
.„I^erte iBJ^0i. in the Janguage 'a treatise on the
subject  which so completely  and intelligently
gleans the whole field of obstetric literature, giv-
ing the reader the winnowed wheat in concise and
well-jointed phrase, in  language  of  exceptional
purity and strength. The  arrangement of the
matter of this work is unique and exceedingly
favorable for an agreeable unfolding of the science
and art of obstetrics.  This new book is the easy
superior of any single work among its predeces-
sors for the student or  practitioner  seeking the
best thought of the day in  this department  of
medicine.—The  American Practitioner and News,
April 2,1887.
  This treatise maybe defined  as exact, concise
and scholarly.  Parvin's  distinguished position  as
a teacher,  his  scholarly  attainments,  and his
honest endeavor to do his best by both the student
and the physician, will secure for  his treatise
favorable recognition.—American Journal of Obstet-
rics, May, 1887.
BARNES,  ROBERT,  M. D.,  and  FANCOURT,  M. D.,
       Phys. to the General Lying-in Hosp., Lond.           Obstetric Phys. to St. Thomas' Hosp., Lond.
•   i   ^ystem  of Obstetric Medicine and Surgery, Theoretical and Clin-
ical.  For the Student and the Practitioner.  The Section on Embryology contributed by
Prof. Milnes  Marshall.   In one handsome octavo volume of 872 pages, with  231  illus-
trations.  Cloth, $5; leather, $6.
  This system will be eagerly sought for, not only
on account of its intrinsic merit, but also because
the reputation which the elder Barnes, in particu-
lar, has secured, carries with it the conviction that
any book emanating from him is necessarily sound
in teaching and conservative in practice.  It is in-
deed eminently fitting that a man who has done so
much towards systematizing the obstetric art, who
for so many years has been widely known as a capa-
ble teacher and trusted accoucheur, should embody
within a single treatise the system  which he has
taught and in practice tested,and which is the out-
come of a lifetime of earnest labor, careful obser-
vation and deep study.  The result of this arrange-
ment is the production ot a work which rises above
criticism and which in no respect need yield the
palm to any obstetrical treatise hitherto published.
—American Journal of Obstetrics, Feb. 1886.
PLAYFAIR,  W. S., M.  D.,  F.  R.  C.  P.,
       Professor of Obstetric Medicine in King's College, London, etc.
    A Treatise  on  the Science and  Practice of Midwifery.   New (fourth)
American, from  the fifth English edition.  Edited, with additions, by Robert P. Har-
ris, M. D.   In one handsome octavo volume of  654 pages, with 3 plates and 201 engrav-
ings.   Cloth, $4; leather, $5; half Russia, $5.50.
  This  still remains a favorite in America,  not
only because the author is recognized as a safe
guide and eminently progressive man, but also as
sparing no effort to make each successive edition
a faithful mirror of the latest and best practice.
A  work so frequently  noticed  as  the present
requires no further review. We believe that this
edition is simply the forerunner of many others,
and that the  demand will keep pace with  the
supply.—American Journal of Obstetrics, Nov. 1885.
  Since its first publication, only eight years  ago,
it has rapidly become the favorite text-book,  to
the practical exclusion of all  others.  A  large
measure of its popularity is' due to the clear and
easy style in which it is written.  Few text-books
for students have very much to boast of in this
respect.—Medical Record.
KING, A.  F.  A., M.  D.,
       Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer-
       sity, Washington, D. C, and in the University of Vermont, etc.
    A Manual Of Obstetrics.   New (third) edition.  In one very handsome 12mo.
volume of 376 pages, with 102 illustrations.   Cloth, $2.25.
  This little manual, certainly the best of its kind,
fully deserves the  popularity which  has made a
third edition necessary. Clear, practical, concise,
its teachings are so fully abreast with recent ad-
vances in  obstetric science that but few points
can be criticised.—American Journal of Obstetrics,
March, 1887.
  This volume deserves commendation. It is not
bulky—it is concise. The chapters are divided with
sub-headings, which aid materially in the finding
of any particular subject, and the definitions are
clear and explicit.  It fulfils its purpose admirably,
and we know of no better work to place in the stu-
dent's hands. The illustrations are good.—Arch-
ives of Gynecology, January, 1887.
BARKER,  FORDYCE, A. M.,  M. D.,  LL. D. Edin.,
       Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College,
       New York, Honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc.
     Obstetrical  and Clinical Essays.  In one handsome 12mo. volume of about
300 pages.  Preparing.                   _____________

BARNES, FANCOURT,  M. D.,
       Obstetric Physician  to St. Thomas' Hospital, London.
     A Manual of  Midwifery for Midwives and Medical Students.  In one
royal 12mo. volume of 197 pages, with 50 illustrations. Cloth, $1.25.

PARRY,  JOHN S., M.  D.,
       Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia.
     Extra - Uterine Pregnancy: Its Clinical  History,  Diagnosis,  Prognosis  and
Treatment.  In one handsome octavo volume of 272 pages.  Cloth,  $2.50.
TANNER ON PREGNANCY.  Octavo, 490 pages, 4 colored plates, 16 cuts.  Cloth, $4.25. 
30       Lea Brothers & Co.'s Publications—Midwfy., Dis. Childn.
LEISHMAN, WILLIAM, M.  D.,
       Regius Professor of Midwifery in the University of Glasgow, etc.
    A System of Midwifery, Including the Diseases of Pregnancy and the
Puerperal State.  Third American  edition, revised  by the Author, with additions by
John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc.  In one large and
very handsome octavo volume of 740 pages, with 205 illustrations.  Cloth, $4.50;  leather,
$5.50; very handsome half Russia, raised bands, $6.00.
                                             must prove admirably adapted. Complete in all its
                                             parts, essentially modern In its teachings, and with
                                             demonstrations noted for clearness and precision,
                                             it will gain  in favor and be recognized as a work
                                             of standard merit.  The work cannot fail to be
  The author Is broad in his teachings, and dis
cusses briefly the comparative anatomy of the pel-
vis  and the mobility of the pelvic articulations.
The second chapter is devoted  especially  to
the  study of the pelvis, while in the third the
female   organs  of  generation  are introduced.
The structure and development of the ovum are
admirably described. Then follow chapters upon
the  various subjects embraced in the study of mid-
wifery.  The descriptions throughout the work are
plain and pleasing.  It is sufficient to state that in
this, the last edition of this well-known work, every
recent advancement in this field has been brought
forward.—Physician and Surgeon, Jan. 1880.
  To the American student the  work  before us
popular  and is cordially recommended.—N.  O.
Med. and Surg. Journ.. March, 1880.
  It  has been  well and carefully written.  The
views of the author are broad and liberal, and in-
dicate a well-balanced judgment and matured
mind.  We  observe no spirit of dogmatism, but
the earnest teaching of the thoughtful observer
and lover of true science.  Take the volume as a
whole, and  it has  few equals.—Maryland Medical
Journal,  Feb. 1880.
LANDIS, HENRY G.,  A.  M., M.  D.,
       Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O.
     The  Management  of  Labor,  and of the  Lying-in Period.   In
handsome  12mo. volume of 334 pages, with 28  illustrations.  Cloth, $1.75.
  The author has designed to place in the hands
of the young practitioner a book in which he can
find necessary information in an instant.  As far
as we can see, nothing is omitted.  The advice is
sound, and the proceedures are safe and practical.
Cmtralblatt fur Gynakologie, December 4, 1886.
  This  is a  book we can heartily  recommend.
The author goes much more practically into the
details of  the management of labor  than  most
text-books, and is so readable throughout  as  to
one
tempt any one who should happen  to commence
the book to read it through.  The author pre-
supposes  a theoretical knowledge  of obstetrics,
and has  consistently excluded from this little
work everything that is not of practical use in the
lying-in room. We think that if it is as  widely
read as it deserves, it will  do much  to improve
obstetric  practice in general.—New Orleans Medi-
cal and Swgical Journal, Mar. 1886.
SMITH, J. LEWIS, M. D.,
       Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y.
    A Treatise on the Diseases  of  Infancy  and Childhood.  New (sixth)
edition,  thoroughly revised  and   rewritten.  In one  handsome  octavo volume of  867
pages, with 40 illustrations.   Cloth, $4.50; leather, $5.50 ;  half Russia, $6.00.
  Rarely does a pleasanter task fall to the lot of
the bibliographer than to announce the appearance
of a new pdition of a medical classic like Prof. J.
Lewis Smith's Treatise on the Diseases  of Infancy
and Childhood.  For years it has stood high in the
confidence of the profession, and with the addi-
tions and alterations  now made it may be said to
be the best book in the language on the subject of
which it treats.  An examination of the text fully
sustains the claims made in the preface, that "in
 fireparingthe  sixth edition the author has revised
 he text to  such  an  extent that a considerable
part of the book may be considered new."  If the
young pi actitioner proposes to place in his library
but one book on  the diseases  of children, we
would unhesitatingly say, let that book be the one
which is the subject of this notice.— The American
Journal of the  Medical Sciences, April, 1886.
  No better work on children's diseases could be
placed in the hands of the student, containing, as
it does, a very complete account of the symptoms
and pathology of the diseases of early life, and
possessing  the  furlher  advantage, in which it
stands alone amongst other works on  its subject,
of recommending treatment  in accordance with
the most recent therapeutical  views.—British and
Foreign Medico-Chirurgical Review.
  It is a pleasure to the busy  practitioner—inter-
ested in the advancement of his profession—to
meet, fresh from  the hands of its author, a medi-
cal classic such as Smith on Diseases of Children.
Those familiar with former editions of the work
will readily recognize the painstaking with which
this revision has been made.  Many of the articles
have been entirely rewritten.  The whole work is
enriched with a  research and reasoning which
plainly show that the author  has spared neither
time  nor labor in bringing it to its  present ap-
proach towards perfection. The extended table of
contents and the well-prepared index will enable
the busy practitioner to reach  readily and quickly
for reference the various subjects treated of in the
body of the work, and even those who are familiar
with former editions will  find the improvements
in the present richly worth the cost of the work.—
Atlanta Medical and Surgical Journal, Dec. 1886.
OWEN,  EDMUND,  M. B.,  F.  R.  C. S.,
       Surgeon to the Children's Hospital, Great Ormond St., London.
     Surgical Diseases  of  Children.
chromo-lithographic plates and  85 woodcuts
page 4.
  One is immediately struck on reading this book
with its agreeable style and the evidence it every-
where  presents of the practical  familiarity of its
author with his subject.  The book  may be
In  one 12mo. volume  of 525 pages, with 4
  Cloth,  $2.   See Series of Clinical Manuals,

honestly  recommended  to both students and
practitioners.   It is full of sound  information,
pleasantly given.—Annals of Surgery, May, 1886.
WEST,  CHARLES, M.  D.,
       Physician to the Hospital for Sick Children, London, etc.
    On Some Disorders  of the Nervous System in Childhood.
12mo.  volume of 127 pages.   Cloth, $1.00.
In one small
WEST'S LECTURES ON THE DISEASES OF IN-
  FANCY AND CHILDHOOD.  In one octavo vol.
CONDIE'S  PRACTICAL TREATISE ON  THE
DISEASES OF CHILDREN. Sixth edition, re-
vised and augmented.  In one octavo volume of
779 pages.  Cloth, $5.25; leather, 86.26.J 
Lea Brothers & (Jo.'s Publications—Med. Juris., Miscel.      31
TIDY, CHARLES MEYMOTT,  M. B., F.  C. S.,
       Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc.
     Legal  Medicine.   Volume II.   Legitimacy and  Paternity, Pregnancy, Abor-
tion, Rape, Indecent  Exposure, Sodomy, Bestiality, Live Birth,  Infanticide, Asphyxia,
Drowning, Hanging,  Strangulation, Suffocation.  Making a very handsome imperial oc-
tavo volume of 529 pages.  Cloth, $6.00; leather, $7.00.
     Volume I.   Containing  664  imperial  octavo pages, with  two  beautiful  colored
plates.  Cloth, $6.00;  leather, $7.00.
  The satisfaction expressed with the first portion
of this work is in no wise lessened by a perusal of
the second volume.  We find it characterized by
the same fulness of detail and clearness of ex-
pression which we had occasion so highly to com-
mend in our former notice, and which render it so
valuable  to  the medical  jurist.   The copious
tables of cases appended to each division of the
subject must have cost the  author a prodigious
amouni of labor and research, but they constitute
one of the most valuable features of the book,
especially for reference in medico-legal trials.—
A merican Journal of the Medical Sciences, April, 1884.
TAYLOR, ALFRED S., M. D.,
       Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London.
    A Manual of Medical Jurisprudence.  Eighth A merican from the tenth Lon-
don edition, thoroughly revised and rewritten.  Edited by John J. Reese, M. D., Professor
of Medical Jurisprudence  and  Toxicology  in  the University of Pennsylvanit.  In one
large octavo volume of 937  pages, with 70 illustrations.  Cloth, $5.00; leather, $6.00; half
Russia, raised bands, $6.50.
r-The American editions of this standard manual
have for a long time laid claim to the attention of
the profession in this  country: and  the eighth
comes before us as embodying the latest thoughts
and emendations of Dr. Taylor upon  the subject
to which he devoted his life with an assiduity and
success which made him Jacile princeps among
English writers on medical jurisprudence.  Both
the author  and the book have made a mark too
deep to be  affected by criticism,  whether  it be
censure or praise. In this case, however, we should
only have to seek for laudatory terms.—American
Journal of the Medical Sciences, Jan. 1881.
  This celebrated work has been the standard au-
thority in its department for thirty-seven years,
both in England and America, in  both the profes-
sions which it concerns, and it is improbable that
it will be superseded in many years.  The work is
simply indispensabl e to every physician, and nearly
so to every liberally-educated  lawyer, and we
heartily commend the present edition to both pro-
fessions.—Albany Law Journal, March 26,1881.
                               By the Same Author.
    The Principles and Practice of Medical Jurisprudence.  Third edition.
In two handsome octavo volumes, containing 1416 pages, with 188 illustrations.  Cloth, $10;
leather, $12.
  For years Dr. Taylor was the highest authority
In England upon the subject to which he gave
especial attention.  His experience was vast, his
Judgment excellent, and his skill beyond cavil. It
Is therefore well that the work of one who, as Dr.
Stevenson says, had an  "enormous grasp of all
matters connected with the subject," should be
brought up to the present day and continued in
its authoritative position.  To accomplish this re-
sult Dr. Stevenson has subjected it to most careful
editing, bringing it well up to the times.—Ameri-
can Journal of the Medical Sciences, Jan. 1884.
                               By the Same Author.
    Poisons in Relation  to Medical  Jurisprudence and Medicine.  Third
American, from the third and revised English edition.  In one large octavo volume of 788
pages.  Cloth, $5.50; leather, $6.50.

PEPPER,  AUGUSTUS  J.,  M. S., M. B., F. R. C. S.,
       Examiner in Forensic Medicine at the University of London.
    Forensic Medicine.  In one pocket-size  12mo. volume.  Preparing.  See Students'
Series of Manuals, page 4.    _______________________

LEA, HENRY C.
    Superstition and Force: Essays on The "Wager of Law, The Wager of
Battle, The Ordeal and Torture.  Third revised and enlarged edition
handsome royal 12mo. volume of 552 pages.   Cloth, $2.50.
In
one
  This valuable work is in reality a history of civ-
ilization as interpreted by the progress of jurispru-
dence. . .  In "Superstition and Force" we have a
 Ehilosophic survey of the long period intervening
 etween primitive barbarity and civilized enlight-
enment.  There is not a chapter in the work that
should not be most carefully studied; and however
well versed the reader may be in the science of
jurisprudence, he will find much in Mr. Lea's vol-
ume of which he was previously ignorant. The
book is a valuable addition to the literature of so-
cial science.— Westminster Review, Jan. 1880.
                          By the Same Author.
Studies in Church History.  The Rise of the Temporal Power—Ben-
efit of Clergy—Excommunication
octavo volume of 605 pages.  Cloth, $2.50.
  The author is pre-eminently a scholar.  He takes
nn every topic allied with the leading theme, and
traces it out to the minutest detail with a wealth
of knowledge  and impartiality of treatment that
compel admiration.   The amount of information
compressed into the book is extraordinary.  In no
other single volume is the development of  the
New edition.   In one very handsome royal


 primitive church traced with so much clearness,
 and with so definite a perception of complex or
 conflicting sources.  The fifty pages on the growth
 of the papacy, for instance, are admirable for con-
 ciseness and  freedom  from prejudice.—Boston
 Traveller, May 3,1883. 
Allen's Anatomy      ....
American Journal of the Medical Sciences
American Systems of Gynecology .
American System of Practical Medicine.
An American System of Dentistry
•Ashhurst's Surgery  ....
Ash well on Diseases of Women
Attfield's Chemistry   ....
Ball on the Rectum and Anus
Barker's Obstetrical and Clinical Essays,
Barlow's Practice of Medicine
Barnes' Midwifery     ....
•Barnes on Diseases of Women
Barnes' System of Obstetric Medicine
Bartholow on Electricity
Bartholow's New Remedies and their Uses
Basham on Benal Diseases .
Bell's Comparative Physiology and Anatomy
Bellamy's Operative Surgery
Bellamy's Surgical Anatomy
Blandford on Insanity
Bloxam's Chemistry  ....
•Bristowe's Practice of Medicine .
Broadbent on the Pulse
Browne on the Ophthalmoscope  .
Browne on the Throat, Nose and Ear
Brace's Materia Medica and Therapeutics
Brunton's Materia Medica and Therapeutics
♦Bryant's Practice of Surgery
♦Bumstead on Venereal Diseases .
•Burnett on the Ear   ....
Butlin on the Tongue  ....
Carpenter on the Use and Abuse of Alcohol
•Carpenters Human Physiology
Carter & Frost's Ophthalmic Surgery
Century of American Medicine
Chambers on Diet and Regimen
Chapman's Human  Physiology
Charles' Physiological and Pathological Chem
Churchill on Puerperal Fever
Clarke and Lockwood's Dissectors' Manual
Classen's Quantitative Analysis
Cleland's Dissector    ....
Clouston on Insanity  ....
Clowes' Practical Chemistry
Coats' Pathology      ....
Cohen on the Throat  ....
Coleman's Dental Surgery
Condie on Diseases of Children
Cornil on Syphilis     ....
•Cornil and Ranvier's Pathological Histology
Cullerier's Atlas of Venereal Diseases
Curnow's Medical Anatomy
Dalton on the Circulation
•Dalton's HumanPhysiology
Davis' Clinical  Lectures
Draper's Medical Physics
Druitt's Modern Surgery
Duncan on Diseases of Women
•Dunglison's Medical  Dictionary .
Edes' Materia Medica and Therapeutics
Edis on Diseases of Women  .
Ellis' Demonstrations of Anatomy
Emmet's Gynecology
•Erichsen's System  of Surgery
Esmarch's Early Aid in Injuries and Accid'ts
Farquharson's Therapeutics and Mat. Med.
Fenwick's Medical Diagnosis
Finlayson's Clinical Diagnosis
Flint on Auscultation and Percussion
Flint on Phthisis     ....
Flint on Physical Exploration of the Lungs
Flint on Respiratory Organs
Flint on the Heart    ....
Finn's Essays   ...
•Flint's Practice of Medicine
Folsom's Laws of U. S. on Custody of Insane
Foster's Physiology   ....
•Fothergill's Handbook of Treatment   .
Fownes' Elementary Chemistry
Fox on Diseases of the Skin  .
Frankland and Japp's Inorganic Chemistry
Fuller on the Lungs and Air Passages
Galloway's Analysis
Gibney's Orthopaedic Surgery
Gould s Surgical Diagnosis
•Gray's Anatomy .....
Greene's Medical Chemistry  .
Green's Pathology and Morbid Anatomy
Griffith's Universal Formulary
Gross on Foreign Bodies in Air-Passages
Gross on Impotence and Sterility  .
Gross on Urinary Organs
•Gross'System of Surgery
Habershon on  the Abdomen
•Hamilton on Fractures and Dislocations
Hamilton on Nervous Diseases
Hartshorne's Anatomy and  Physiology .
Hartshorne's Conspectus of the Med. Sciences
Hartshorne's Essentials of Medicine
Hartshorne's Household Medicine
Hermann's Experimental Pharmacology
Hill on Syphilis .....
Hillier's Handbook of Skin Diseases
Hoblyn's Medical Dictionary
Hodge on Women    ....
Hodge's Obstetrics    ....
Hoflmaun and Power's Chemical Analysis
Holden's Landmarks ....
Holland's Medical Notes and Reflections
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•Holmes' System of Surgery
Horner's Anatomy and Histology .
Hudson on Fever
Hutchinson on Syphilis
Hyde on the Diseases of the Skin  .
Jones (C. Handfield) on Nervous Disorders
Juler's Ophthalmic Science and Practice
Kaposi on Skin Diseases
King's Manual of Obstetrics .
Klein's Histology     ....
Landis on  Labor      ....
La Roche on Pneumonia, Malaria, etc. .
La Roche on Yellow Fever  .
Laurence and Moon's Ophthalmic Surgery
Lawson on the Eye, Orbit and Eyelid
Lea's Studies in Church History
Lea's Superstition and Force      .
Lee on Syphilis
Lehmann's Chemical Physiology  .
•Leishman's Midwifery
Lucas on Diseases of the Urethra .
Ludlow's Manual of Examinations
Lyons on Fever  ...
Maisch's Organic Materia Medica .
Marsh on the Joints
May on Diseases of Women .
Medical News
Medical News Visiting List .
Medical News Physicians' Ledger .
Meigs on Childbed Fever
Miller's Practice of Surgery .
Miller's Principles of Surgery
Mitchell's Nervous Diseases of Women .
Morris on  Diseases of the Kidney .
Neill and Smith's Compendium of Med. Sci.
Nettleship on Diseases of the Eye .
Norris and Oliver on the Eye
Owen on Diseases of Children
•Parrish's Practical Pharmacy
Parry on Extra-Uterine Pregnancy
Parv'ln's Midwifery
Paw on Digestion and its Disorders
Pepper's System of Medicine
Pepper's Forensic Medicine .
Pepper's Surgical Pathology
Pick on Fractures and Dislocations
Pirrie's System of Surgery .
Playfair on Nerve Prostration and Hysteria
•Piavfair's Midwifery .
Politzer on the Ear and its Diseases
Power's Human  Physiology .
Purdy on Bright's Disease and Allied A flections
Ralfe's Clinical Chemistry
Ramsbotham on Parturition
Remsen's Theoretical Chemistry  .
•Reynolds'System of Medicine
Richardson's Preventive Medicine
Roberts on Urinary Diseases
Roberts' Compend of Anatomy
Roberts' Principles and Practice of Surgery
Robertson's Physiological Physics
Ross on Nervous Diseases
Savage on Insanity, including Hysteria .
Schaier's Essentials of Histology,
Schreiber on Massage .
Seller on the Throat, Nose and Naso-Pharynx
Series of Clinical Manuals
Simon's Manual  of Chemistry
Skey's Operative Surgery
Slade on Diphtheria   ....
Smith (Edward) on Consumption .
•Smith <J. Lewis) on Children
Smith's Operative Surgery  .
Stllle on Cholera     ....
*Still<5 & Maisch's National Dispensatory
*Still€'s Therapeutics and Materia Medica
Stimson on Fractures and Dislocations,
Stimson's Operative Surgery
Stokes on Fever .....
Students'Series  of Manuals .
Sturges' Clinical Medicine
Tanner on Signs and Diseases of Pregnancy
Tanner's Manual of Clinical Medicine
Taylor's Atlas of Venereal and Skin Diseases
Taylor on Poisons    ....
•Tavlor's Medical Jurisprudence .
Taylor's Prin. and Prac. of Med. Jurisprudence
•Thomas on Diseases of Women
Thompson on Stricture
Thompson on Urinary Organs
Tidy's Legal Medicine....
Todd on Acute Diseases
Treves' Manual of Surgery .
Treves' Surgical Applied Anatomy
Treves on Intestinal Obstruction  .
Tuke on the Influence of Mind on the Body
Visiting List, The Medical News  .
Walshe on the Heart ....
Watson's Practice of Physic .
•Wells on the Eye    ....
West on Diseases of Childhood
West on Diseases of Women
West on Nervous Disorders in Childhood
Williams on Consumption .
Wilson's Handbook of Cutaneous Medicine
Wilson's Human Anatomy .
Winckel on Pathol, and Treatment of Childbed
Wohler's Organic Chemistry
Woodhead's Practical Pathology  .
 Year-Books of Treatment for 1886 and 1887
Books marked * are also bound in half Russia.
LEA  BROTHERS  &  CO.,  Philadelphia. 
 
 
 
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